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Clinical Aspects of Severe Acute Respiratory Syndrome (SARS), 2003

Clinical Aspects of Severe Acute Respiratory Syndrome (SARS), 2003. John A. Jernigan, MD, MS For the SARS Clinical/Infection Control Investigative Team National Center for Infectious Diseases. Clinical Aspects of Severe Acute Respiratory Syndrome (SARS). Incubation period 2-10 days

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Clinical Aspects of Severe Acute Respiratory Syndrome (SARS), 2003

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  1. Clinical Aspects of Severe Acute Respiratory Syndrome (SARS), 2003 John A. Jernigan, MD, MS For the SARS Clinical/Infection Control Investigative Team National Center for Infectious Diseases

  2. Clinical Aspects of Severe Acute Respiratory Syndrome (SARS) • Incubation period 2-10 days • Onset of fever, chills/rigors, headache, myalgias, malaise • Respiratory symptoms often begin 3-7 days after symptom onset

  3. Symptoms Commonly Reported By Patients with SARS1-5 Symptom Range (%) Fever 100 Cough 57-100 Dyspnea 20-100 Chills/Rigor 73-90 Myalgias 20-83 Headache 20-70 Diarrhea 10-67 1. Unpublished data, CDC. 2. Poutanen SM, et al. NEJM 3/31/03. 3. Tsang KW, et al. NEJM. 3/31/03 4. Peiris JSM, et al. Lancet 4/8/03 5. Lee N. et al NEJM 4/7/03

  4. Symptoms Reported by Patients With Diagnostic SARS-CoV Laboratory Testing, United States, 2003 *p=.07

  5. Common Clinical Findings in Patients with SARS1-5 1. Unpublished data, CDC. 2. Booth CM, et al. JAMA 5/6/03. 3. Tsang KW, et al. NEJM. 3/31/03 4. Peiris JSM, et al. Lancet 4/8/03 5. Lee N. et al NEJM 4/7/03

  6. Clinical Findings in Patients With Diagnostic SARS-CoV Laboratory Testing, United States, 2003 *p<.05

  7. Radiographic Features of SARS • Infiltrates present on chest radiographs in > 80% of cases • Infiltrates • initially focal in 50-75% • interstitial • Most progress to involve multiple lobes, bilateral involvement

  8. Lee N. et al NEJM 4/7/03

  9. Lee N. et al NEJM 4/7/03

  10. Clinical Outcome of Patients with SARS, 2003 1. Unpublished data, CDC. 2. Booth CM SM, et al. JAMA 5/6/03. 3. Tsang KW, et al. NEJM. 3/31/03 4. Peiris JSM, et al. Lancet 4/8/03 5. Lee N. et al NEJM 4/7/03

  11. Clinical Outcome of Probable SARS Cases*, 2003 * http://www.who.int/csr/sarscountry/2003_05_07/en/

  12. Clinical Features Associated with Severe Disease • Older Age • Underlying illness • ? Lactate dehydrogenase levels • ? Severe lymphopenia

  13. Analysis of Clinical Specimens of 20 Patients with RT-PCR positive Nasopharyngeal Aspirates (NPA) and Seroconversion to SARS-Associated Coronavirus Peiris et. al. www.who.int 5/1/03

  14. Transmission • Probable major modes of transmission • Large droplet aerosolization • Contact • Direct • Fomite • Airborne transmission cannot be ruled out • ? Role of aerosol-generating procedures • ? Fecal-oral • Transmission efficiency may vary among individuals

  15. Probable cases of severe acute respiratory syndrome, by reported source of infection,* --- Singapore, February 25--April 30, 2003 *Case 1 = 1; Case 2 = 6; Case 3 = 35; Case 4 = 130; and Case 5 = 127. Excludes 28 cases with either no or poorly defined direct contacts or who were cases translocated to Singapore with no further secondary transmission. MMWR 2003;52:405

  16. Diagnostic Approach to Patients with Possible SARS • Consider other etiologies • Diagnostic workup • Chest radiograph • Blood and sputum cultures • Pulse oximetry • Testing for other viral pathogens (e.g. influenza) • Consider urinary antigen testing for Legionella spp. and Streptococcus pneumoniae

  17. Diagnostic Approach to Patients with Possible SARS • Diagnostic workup (continued) • Save clinical specimens for possible additional testing • Respiratory • Blood • Serum • Acute and convalescent sera (>21 days from symptom onset) should be collected • Contact Local and State Health Departments for SARS-CoV testing

  18. Treatment of Patients with SARS • Most effective therapy remains unknown • Optimize supportive care • Treat for other potential causes of community-acquired pneumonia of unknown etiology

  19. Treatment of Patients with SARS • Potential Therapies Requiring Further Investigation • Ribavirin • ?other antiviral agents • Immunomodulatory agents • Corticosteroids • Interferons • Others?

  20. Infection Control • Early recognition and isolation is key • Heightened suspicion • Triage procedures • Transmission may occur during the early symptomatic phase • Potentially before both fever and respiratory symptoms develop

  21. Infection Control • Isolation • Hand hygiene • Contact Precautions (gloves, gown) • Eye protection • Environmental cleaning • Airborne Precautions (N-95 respirator, negative pressure)

  22. Acknowledgments The many CDC personnel involved in the response to the SARS outbreak. Members of all the CDC SARS Clinical/Infection Control Investigative Team: Sarah Reagan Marc Fischer Scott Harper Myrna Charles Dan Jernigan Matt Kuehnert Padmini Srikantiah Cliff McDonald Ben Park Maureen Sinclair Priti Patel Mathias Pletz Linda Chiarello Chesley Richards David Shay Tom Clark Todd Weber Susan Maloney

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