Severe Acute Respiratory Syndrome

1. Severe Acute Respiratory Syndrome GROUP 23 - AbhijitKambalapally - Nimesh Das - Ginny Joshi - RidwanRahman - Eshan Shah

2. 10. Economic Impact 11. Medical Impact 12. WHO 13. Quarantine 14. Disease Control 15. Treatment 16. Diagnostic Tests 17. Vaccine Found 18. Preventive Measures What is SARS? Origins of SARS SARS Timeline Countries Affected SARS Cases Cause/ Effect Symptoms Social Impact Ethical Impact TABLE OF CONTENTS

3. “This syndrome, SARS, is now a worldwide health threat, ... The world needs to work together to find its cause, cure the sick and stop its spread.”  - Gro Harlem Brundtland

4. WHAT IS SARS? • The acronym “Sars” stands for, Severe Acute Respiratory Syndrome • Sars is a severe respiratory illness caused by a specific type of corona virus (SARS-CoV) • Another form of pneumonia, except more lethal • In the 2003 outbreak, several countries in Asia, Europe, North and South America were plagued by Sars • In total, 8098 people were infected, of which 774 died • 251 cases in Toronto, of which 44 died

5. The outbreak was contained by 2004 • Sars does not have a definite healing period; depends from person to person • older people, patients with weak immune systems and STD patients are targeted more frequently by the disease • Coronavirus • A type of virus that usually causes minor respiratory problems in humans but severe diseases in animals (neurologic, gastrointestinal, liver, respiratory) • As a result, it is believed that animals have caused the severe SARS-CoV virus among humans; real cause is still under investigation • incubation period is 2-7 days although infection may take up to 10+ days

6. FINDING THE CORONA • 13 Laboratories from 10 nations including Hong Kong, U.S and Germany confirmed the Coronavirus in March 2003 • Methods used to identify coronavirus: • isolation on cell culture • electron microscopy • polymerase chain reaction • microarray technology • immunofluorescent antibody tests (Peiris, Drosten, Kseizaek) • Proofs • Pathogen found • Isolated from host and grown in pure culture • Inoculation of of cynomolgus macaques with Vero-cell cultured virus (caused interstitial pneumonia akin to SARS coronavirus; isolated from nose/throat of monkeys)

9. GENOME SEQUENCE • Canadian researchers from Michael Smith Genome Sciences Centre in Vancounver, B.C. and National Microbiology Lab in Winnipeg, Manitoba uncovered the genome sequence • Related to murine, bovine, porcine and human coronavirus in the group HcoV – 229E • Since it is different, there’s another group (Marra) associated with the SARS virus • Sequence analysis reveals that it originated from an animal capable of infecting humans or crossing the species barrier

10. MORPHOLOGY • Through negative-stain transmission electron microscopy and cell culture supernatans, the coronavirus was determined to be 60 – 130 nm • Thin-section electron microscopy was used to examine particles of virus within cytoplasmic membrane-bound vacuoles and endoplasmic reticulum • Large Clusters of extracellular particles are present along surface of plasma membrane

11. ORGANIZATION • Sars-Cov genome has 5 reading frames (ORFs) that encode replicasepolyprotein; spike (S), envelope (E), membrane (M) glycoproteins; and nucleocapsid protein (N) • S protein • binds to species-specific host cell receptors • help fusion of viral envelope and cellular membrane • virulence factor • viral antigen that extracts the neutralizing antibody • M protein • major component of virion envelope • determinant of virion morphogenesis (uses S proteins to make virions) • selects genome for incorporation into virion

12. DETECTION • SARS-CoV detected in lungs and kidneys, bronchoalveolar lavage specimen, sputum (100 million molecules per millilitre), upper respiratory tract swab, aspirate and wash specimens • Detected in nasopharyngeal aspirates (32%) 3.2 days after onset of illness, and 68% in day 14 • Stool samples detected Viral RNA at 97% after 2 weeks; 42% of urin samples were positive for viral RNA • Detected in plasma

13. ORIGINS AND SPREAD OF SARS • 1st case of Sars: reported in November 2002, Shunde, Foshan (Guadong Province) China • Victim: a farmer; treated in Mckay Dennis Hospital • Result: Patient died and diagnosis on the cause was left unfinished • Chinese government worked hard to prevent word about outbreak • Once WHO reach epidemic proportions Chinese forced to admit

15. SARS TIMELINE • 27th November 2002 - Canada’s Global Public Health Intelligence Network (GPHIN), an electronic warning system, part of WHO’s Global Outbreak and Alert Response Network (GOARN) discovered reports about a “flu” epidemic in China through internet screening and notified WHO • 5th and 11th December - WHO requested intelligence from the Chinese government • In the process, weakness and holes in the system were highlighted as they were highly dependent on the Chinese government to respond • On 21 January, 2003 – first English report outlining the outbreak was disclosed; limited to only 1 other language (formed as an easily-avoidable barrier) • March 2003 – WHO released name, definition and activated a global outbreak response network team to raise awareness of Sars • When containment measures were finally taken, 500 deaths and 2000 cases had already been encountered • America’s Centre for Disease Control and Prevention took initiative and the disease soon became an international concern

16. COUNTRIES AFFECTED BY SARS Hong Kong, China Toronto, Ontario Vietnam Singapore Taiwan Thailand

17. HOW IT SPREAD

18. STATISTICS

19. SARS CASES Vietnam • February 2003 – An American businessman flying from China to Singapore reported having symptoms of pneumonia. • Plane stopped at Hanoi, Vietnam and the victim died in the Hospital of Hanoi • Shortly after, medical staff who treated the businessman became diagnosed with SARS • Carlo Urbani, an Italian doctor notified the Vietnamese government but became infected by SARS himself Hong Kong • Another trail had been traced back to a doctor from the 9th floor of Metropole Hotel in Kowloon Peninsula, who infected 16 hotel visitors • Visitors travelled to Singapore, Taiwan, Canada, Vietnam, spreading SARS there • Other places the disease spread – Toronto, Ottawa, San Francisco, Ulan Bator, Manila, Hanoi, Hong Kong, Jilin, Hebei, Hubei, Shaanxi, Jiangsu, Shanxi, Tianjin, Inner Mongolia

20. Amoy Gardens • A high concentration of cases were reported in a housing Estate called Amoy Gardens and said to be caused by poor sewage systems • Beijing Military System • Pressure from citizens prompted an investigation by Chinese government in this location • Problems included: decentralization, red tape, inadequate communication, basically revealing deteriorating health care system within the nation • Red Tape - A term used to describe explicit rigidness within a bureaucratic system; interfered with containment of Sars

22. CAUSES • On 16 April 2003, the World Health Organization issued a press release stating that a coronavirus identified by a number of laboratories was the official cause of SARS • Coronaviruses are species in the genera of animal virus belonging to the subfamily Coronavirinae in the family Coronaviridae • They are positive-strand, enveloped RNA viruses that are important pathogens of mammals and birds • many kinds of coronavirus, some of which cause the common cold • Experts say main way it spreads is through close contact with an infected person, spread through exhaled droplets and body secretions. • can come into contact with this when an affected person coughs or sneezes • experts also say SARS may also be spread when fecal matter containing the virus is ingested (ex. due to poor sewage treatment, contaminated food or water)

23. Virus was also later found in raccoon dogs, ferret badgers and domestic cats, and mainly the masked palm civet • Outbreak in Guangdong started when humans infected as they raised and slaughtered wild animals for food • Spread when people ate contaminate civets • Civets considered gourmet delicacy in China • Most if not all cases of SARS in Canada during the 2003 outbreak occurred in people who had recently travelled to Asia, health care workers who had cared for SARS patients and close family member of SARS patients

24. EFFECTS • Long term effects on survivors - effects on pulmonary function, exercise capacity, and health-related quality of life(according to a study of 86 survivors of SARS at the Chinese University of Hong Kong, in Hong Kong, PRC) • SARS also brought trauma to patients and their families, may require psychological, social and financial support • SARS has social impacts on countries who had the disease • combined with other factors, SARS heavily affected tourism industry; particularly destinations which registered highest numbers of victims

25. SYMPTOMS • The incubation period ranges from 2 to 10 days. This means that once someone has been exposed, it can take anywhere from 2 to 10 days for symptoms to occur • The initial indication of infection is a fever of 100.4 degrees Fahrenheit or more (38 degrees Celsius or more) • A dry, unproductive cough develops after 3 to 7 days • Other symptoms may include headaches, an overall feeling of discomfort, and body aches • Dry cough, chills and shivering, muscle aches and breathing difficulties • About 10 percent to 20 percent of patients have diarrhea • After 2 to 7 days, SARS patients may develop a dry cough • Most patients develop pneumonia • The most common symptom however appears to be a fever above 38 °C (100.4 °F)

27. SOCIAL IMPACT • What tends to occur in large epidemics with a magnitude like SARS, is a developed social stigma toward the community or region from which it originated • This led to ignorant individuals to ostracize members of the oriental community in fear of contracting the disease from them • This is reflected in the fall in business for Chinese enterprises, particularly restaurants. • Hatred toward the Chinese community an also stem from death of close relation due to SARS, as a means of blaming the death of them • Globalization and it’s link to social contexts played a factor in SARS as it socially deterred individuals from actively experiencing foreign cultures or environments, severely impacting tourism • As a result of the growing web of interconnections due to globalization, microbes have an easier ride than ever to cross countries, and span continents

28. For example, consider that in the Middle Ages, it took three years for the plague to spread from Asia to the western reaches of Europe. In perspective, the SARS virus, crossed from Hong Kong to Toronto in about 15 hours • A socio-ethical issue also refers to the privacy of one’s information versus the public need to know • The social impact of releasing confidential information for the betterment and safety of society can be detrimental on the individual it pertains to • For example, the name of the woman who was identified as accidentally bringing SARS to Canada is made public, Kwan Sui-chu. Upon her return home to Toronto, she passes it to her family, starting a chain of contamination. She dies at home, but her son goes to hospital for treatment of fever and a cough, beginning a series of infections in the city. • Socially, this would lead to the spread of stigma against those of Chinese origin, and further ostracise and isolate the son in social context

29. ETHICAL IMPACT • The most severe ethical issues that arose from the SARS outbreak concern quarantine and health care professionals • Quarantine: Individual freedom vs. Protection of public at large • Considering SARS’ highly contagious nature, thousands in Toronto were placed in quarantine, in order to protect millions of people in the city and around the world from possible exposure to a deadly disease • However this was often also considered an infringement on one’s individual freedoms, thus the issue’s ethical constraints • Officials should then be forced to consider whether the interest in protection of public health trumps the freedoms of an individual whom unintentionally poses a potential ‘threat’ to society • One must determine whether they value the honour of upholding an institutionally sound social freedom at the cost of affecting the safety of the health of many, including those outside our political borders

30. An ethical solution lies in adequately informing the individual of why there rights are being overridden and the degree to which they threaten the general health of the public, and to assist in reducing the impact of any collateral damages the quarantine may cause • Health care professionals: Public obligation vs. fear of one’s personal safety • Society is aware of the health care sector’s duty to provide for the sick, considering virtue ethics (to do good for others) and the professional oath they are obliged to carry out • However, doing so during an epidemic such as SARS puts them at risk of contracting the disease and making them prone to easily succumb to it’s effects • Thus to what extent should health care professionals be held in their line of duty as they balance the question to avoid health risks to themselves and their families, opposed by their obligation and need to maintain a salary on the line

31. public example of the sacrifice by health care worker was untimely and tragic death of Dr. Carlo Urbani, who was infected in Vietnam. • A solution to this would lie in institutions equally reciprocating what the health care workers are investing into the job at times like SARS. • Includes: providing information for staff so they can fully understand the risks, and policies supporting safety practices

32. ECONOMICAL IMPACT • There was significant collateral damage due to the waiting times, and constraints on hospital schedules • This was often directed towards patients who did not have SARS. Many people with other serious conditions had surgeries cancelled because some hospitals were considered contaminated areas, and some of these people died • At the University Health Network alone, which includes Toronto General, Toronto Western and Princess Margaret hospitals, 1,050 surgical procedures were cancelled because of SARS • Considering the social impacts and the build up of stigmatism toward China, there could also be severe impacts on trade relations and GDP for both China and it’s trading partners • This could stem from fear of foreign products (as globalization has increased the spread rate of disease) and resulting embargos

33. There was a decline in the tourism industry in the years SARS was active, where the industry lost more than $500 million and 28,000 jobs [Burns research] • also severe repercussions specifically for owners of oriental restaurants in the GTA area, during the height of the SARS hype as Ontario total restaurant receipts declined 1.6% in April 2003 [CRFA] • However in a country as well developed as Canada with a market economy, it has been concluded that the long term economical impacts from a pandemic such as SARS are relatively low • Eventually people adapt to the shock and shift spending across different sectors • One also found that spending was spread across time which allowed the economy as a whole to recover quickly.  While most sectors rebound rapidly, others, such as previously mentioned with tourism, did suffer more lasting effects

34. TRAVEL AND TOURISM

35. MEDICAL IMPACT • since outbreak it’s etiology, transmission route has received closer research attention • Toronto SARS crisis demonstrated, the current practice of housing large numbers of sick admitted patients for prolonged times in open, densely-populated EDs (Emergency Departments) is a potential public health hazard. • lack of long-term and acute-care hospital beds led to high hospital occupancy rates and cohosting of admitted patients in ED stretchers, holding areas or hallways • This impedes ED productivity, creates crowded waiting rooms and long care delays for patients, delays ambulance unloading, and spawns ambulance diversions and delayed ambulance responses. • overcrowding prevents appropriate application of infection control safety measures, increasing the likelihood of infectious disease transmission as it did in the Toronto SARS outbreak. • Infection control procedures introduced during the SARS epidemic

36. overcrowding prevents appropriate application of infection control safety measures, increasing the likelihood of infectious disease transmission as it did in the Toronto SARS outbreak. • Infection control procedures introduced during the SARS epidemic • Canada’s SARS outbreak showed how the ED has been deteriorating thus its need for urgent action • 50% attack rates of health- care workers • Health-care workers given gloves, surgical masks (N95), eye protection, gowns ands told to follow scruopulous hand hygiene • A study found that nurses most affected by outbreak, experiencing (to a greater degree than doctors, administrators or other hospital staff) symptoms such as trouble with sleep, difficulty making decisions and loss of confidence • A lot of stress was put on the Emergnecy Departments as well • WHO now created guidelines for alert, verification, and public health management of SARS on its website • SARS shows willingness of international community to form united front against shared threat

38. How was SARS controlled?

39. WHO • The first measure taken by the World Health Organization or WHO for the prevention of SARS was in March, 2003. • WHO set up a network for the doctors and researchers dealing with SARS. • consisted of a secure website where doctors and researchers could discuss, study chest x-rays of the patents affected by SARS and was done through teleconferencing.

40. QUARANTINE • The initial spread of SARS could not be stopped but attempts were made to prevent from further infection through the use of quarantine. • Quarantine is done to control the spread of a dangerous disease through complete isolation of the person. • 1200 people were quarantined in Hong Kong, 977 in Singapore and 1147 in Taiwan. Even Canada put thousands of people of under quarantine. • To stop the virus from spreading schools were also closed in Singapore and Hong Kong for a 10 days. • On 27 March 2003, the WHO recommended the screening of airline passengers for the symptoms of SARS.

42. INFECTIOUS DISEASES ACT AND HOME QUARANTINE • Singapore’s Ministry of Health implemented the Infectious Diseases Act on March 24. • According to it, home quarantined was imposed on all people who have come in contact with SARS patients. • Telephone surveillance and electronic picture camera, placed outside the door of the contact, were used to check upon them. Security officers from CISCO and a Singaporean auxiliary police force helped serve the quarantine orders to homes.

43. DISEASE CONTROL On 24 April, the Singaporean government made amendments to the Infectious Diseases Act and included penalties for the violation. These amendments included: • Suspected persons of the infectious disease were to be brought to the treatment centers. They were also prohibited from going to public places. • Access was restricted to certain designated contaminated areas. • Offenders were to be tagged using electronic wrist tags for breaking the home quarantine and fines were also imposed on them. • Anyone caught lying to the health officials about their travel to SARS-affected areas were subject to prosecution.

44. TREATMENT

45. TREATMENTS FAILED • It was found that antibiotics were ineffective since SARS is a viral disease. • Antipyretics, supplemental oxygen and ventilatory support were helpful in reducing the infection but not treating it. • Suspected cases of SARS were isolated and kept in negative pressure rooms. Strict nursing precautions were taken for any necessary contact between patients. • Initially, there was support for steroids and antiviral drug ribarivin but since there was no published evidence this treatment was dropped.

46. TREATING SARS • Treating SARS is difficult because by the time the symptoms in a patient appear, the infection would have spread and would have already greatly damaged the lungs. • Patients are given oxygen to help relieve their breathing difficulties, and physiotherapy is used to clear the fluid in the lungs. Patients may be even put on a ventilator in severe cases. • Antibiotics may be given but, as mentioned earlier, they are not to treat the virus, they are used to prevent any further infection by opportunistic bacteria. • Antiviral medicines can be used to block the replication of the virus in side lung cells. However, there was little benefit in using this treatment.

47. DIAGNOSTIC TESTS ELISA – enzyme-linked immunosorbent assay • Detects antibodies to SARS after 21 days Immunofluorescence Assay • Detects antibodies after 10 days • Time-consuming • Rigorous • Requires highly qualified operator, and a specialized microscope Polymerase Chain reaction • Detects SARS in blood, sputum, tissue samples, stools • Insensitive (probability of having SARS remains even after patients are tested negative)

48. VACCINE FOUND • Researchers started testing all antiviral treatments of other diseases on the SARS causing coronovirus. • Also, it was known that serious damage in • SARS was caused due cytokine storm (occurs when the body’s immune system overreacts to the virus). • Finally, in December 2004, a group of Chinese researchers had produced a SARS vaccine. Out of the 36 volunteers it was tested on, 24 developed antibodies against the virus. • how successful this vaccine would be remains unknown.

49. But Ultimately… “Prevention is better than cure”

50. PREVENTIVE MEASURES • Washing hands frequently: soaps or alcohol based hand rub containing at least 60% of alcohol prevent the bacteria and viruses getting onto the skin. Wearing infection controlled masks: WHO recommends standard masks or the N5 masks which are more effective than the surgical masks. These masks will protect you from 95% of the micro-organisms in the air.