SARS Epidemic
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Severe acute respiratory syndrome (SARS) is a viral
respiratory disease Respiratory diseases, or lung diseases, are pathology, pathological conditions affecting the organs and tissues that make gas exchange difficult in Breathing, air-breathing animals. They include conditions of the respiratory tract including the t ...
of
zoonotic A zoonosis (; plural zoonoses) or zoonotic disease is an infectious disease of humans caused by a pathogen (an infectious agent, such as a bacterium, virus, parasite or prion) that has jumped from a non-human (usually a vertebrate) to a human. ...
origin caused by the
severe acute respiratory syndrome coronavirus Severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1; or Severe acute respiratory syndrome coronavirus, SARS-CoV) is a strain of coronavirus that causes severe acute respiratory syndrome (SARS), the respiratory illness responsible for th ...
(SARS-CoV or SARS-CoV-1), the first identified strain of the SARS
coronavirus Coronaviruses are a group of related RNA viruses that cause diseases in mammals and birds. In humans and birds, they cause respiratory tract infections that can range from mild to lethal. Mild illnesses in humans include some cases of the com ...
species, ''
severe acute respiratory syndrome–related coronavirus ''Severe acute respiratory syndrome–related coronavirus'' (SARSr-CoV or SARS-CoV)The terms ''SARSr-CoV'' and ''SARS-CoV'' are sometimes used interchangeably, especially prior to the discovery of SARS-CoV-2. This may cause confusion when some ...
'' (SARSr-CoV). The first known cases occurred in November 2002, and the syndrome caused the
2002–2004 SARS outbreak The 2002–2004 outbreak of SARS, caused by severe acute respiratory syndrome coronavirus (SARS-CoV or SARS-CoV-1), infected over 8,000 people from 29 countries and territories, and resulted in at least 774 deaths worldwide. The outbreak wa ...
. In the 2010s, Chinese scientists traced the virus through the intermediary of
Asian palm civet The Asian palm civet (''Paradoxurus hermaphroditus''), also called common palm civet, toddy cat and musang, is a viverrid native to South and Southeast Asia. Since 2008, it is IUCN Red Listed as Least Concern as it accommodates to a broad range ...
s to cave-dwelling
horseshoe bat Horseshoe bats are bats in the family Rhinolophidae. In addition to the single living genus, ''Rhinolophus'', which has about 106 species, the extinct genus '' Palaeonycteris'' has been recognized. Horseshoe bats are closely related to the Old ...
s in
Xiyang Yi Ethnic Township Xiyang Yi Ethnic Township (Yi script:?, ) is an ethnic township in Jinning District, Yunnan. Demographics and Languages Among its 10,155 residents, 78% (7,921) are ethnic minorities in China, chiefly Yi people (Lolo) and Hani people, as of 2006. ...
,
Yunnan Yunnan , () is a landlocked Provinces of China, province in Southwest China, the southwest of the People's Republic of China. The province spans approximately and has a population of 48.3 million (as of 2018). The capital of the province is ...
.The locality was referred to be "a cave in
Kunming Kunming (; ), also known as Yunnan-Fu, is the capital and largest city of Yunnan province, China. It is the political, economic, communications and cultural centre of the province as well as the seat of the provincial government. The headquar ...
" in earlier sources because the
Xiyang Yi Ethnic Township Xiyang Yi Ethnic Township (Yi script:?, ) is an ethnic township in Jinning District, Yunnan. Demographics and Languages Among its 10,155 residents, 78% (7,921) are ethnic minorities in China, chiefly Yi people (Lolo) and Hani people, as of 2006. ...
is administratively part of Kunming, though 70 km apart. Xiyang was identified on * For an earlier interview of the researchers about the locality of the caves, see:
SARS was a relatively rare disease; at the end of the epidemic in June 2003, the incidence was 8,469 cases with a
case fatality rate In epidemiology, case fatality rate (CFR) – or sometimes more accurately case-fatality risk – is the proportion of people diagnosed with a certain disease, who end up dying of it. Unlike a disease's mortality rate, the CFR does not take int ...
(CFR) of 11%. No cases of SARS-CoV-1 have been reported worldwide since 2004. In December 2019, another strain of SARS-CoV was identified as
severe acute respiratory syndrome coronavirus 2 Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) is a strain of coronavirus that causes COVID-19 (coronavirus disease 2019), the respiratory illness responsible for the ongoing COVID-19 pandemic. The virus previously had a No ...
(SARS-CoV-2). This new strain causes coronavirus disease 2019 (COVID-19), a disease that brought about the
COVID-19 pandemic The COVID-19 pandemic, also known as the coronavirus pandemic, is an ongoing global pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The novel virus was first identif ...
.


Signs and symptoms

SARS produces
flu-like symptoms Influenza-like illness (ILI), also known as flu-like syndrome or flu-like symptoms, is a medical diagnosis of possible influenza or other illness causing a set of common symptoms. These include fever, shivering, chills, malaise, dry cough, loss ...
which may include fever,
muscle pain Myalgia (also called muscle pain and muscle ache in layman's terms) is the medical term for muscle pain. Myalgia is a symptom of many diseases. The most common cause of acute myalgia is the overuse of a muscle or group of muscles; another likel ...
,
lethargy Lethargy is a state of tiredness, sleepiness, weariness, fatigue, sluggishness or lack of energy. It can be accompanied by depression, decreased motivation, or apathy. Lethargy can be a normal response to inadequate sleep, overexertion, overwo ...
, cough,
sore throat Sore throat, also known as throat pain, is pain or irritation of the throat. Usually, causes of sore throat include * viral infections * group A streptococcal infection (GAS) bacterial infection * pharyngitis (inflammation of the throat) * tonsi ...
, and other
nonspecific symptom Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showin ...
s. The only symptom common to all patients appears to be a fever above . SARS often leads to
shortness of breath Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing disc ...
and
pneumonia Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity ...
, which may be direct
viral pneumonia Viral pneumonia is a pneumonia caused by a virus. Pneumonia is an infection that causes inflammation in one or both of the lungs. The pulmonary alveoli fill with fluid or pus making it difficult to breathe. Pneumonia can be caused by bacteria, vir ...
or secondary
bacterial pneumonia Bacterial pneumonia is a type of pneumonia caused by bacterial infection. Types Gram-positive ''Streptococcus pneumoniae'' () is the most common bacterial cause of pneumonia in all age groups except newborn infants. ''Streptococcus pneumoniae'' ...
. The average
incubation period Incubation period (also known as the latent period or latency period) is the time elapsed between exposure to a pathogenic organism, a chemical, or radiation, and when symptoms and signs are first apparent. In a typical infectious disease, the i ...
for SARS is 4–6 days, although it is rarely as short as 1 day or as long as 14 days.


Transmission

The primary route of transmission for SARS-CoV is contact of the
mucous membrane A mucous membrane or mucosa is a membrane that lines various cavities in the body of an organism and covers the surface of internal organs. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. It is ...
s with
respiratory droplet A respiratory droplet is a small aqueous droplet produced by exhalation, consisting of saliva or mucus and other matter derived from respiratory tract surfaces. Respiratory droplets are produced naturally as a result of breathing, speaking, snee ...
s or
fomite A fomite () or fomes () is any inanimate object that, when contaminated with or exposed to infectious agents (such as pathogenic bacteria, viruses or fungi), can transfer disease to a new host. Transfer of pathogens by fomites A fomite is any ina ...
s. While
diarrhea Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin wi ...
is common in people with SARS, the
fecal–oral route The fecal–oral route (also called the oral–fecal route or orofecal route) describes a particular route of transmission of a disease wherein pathogens in fecal particles pass from one person to the mouth of another person. Main causes of fecal ...
does not appear to be a common mode of transmission. The
basic reproduction number In epidemiology, the basic reproduction number, or basic reproductive number (sometimes called basic reproduction ratio or basic reproductive rate), denoted R_0 (pronounced ''R nought'' or ''R zero''), of an infection is the expected number of ...
of SARS-CoV, R0, ranges from 2 to 4 depending on different analyses. Control measures introduced in April 2003 reduced the R to 0.4.


Diagnosis

SARS-CoV may be suspected in a patient who has: * Any of the
symptom Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showin ...
s, including a fever of or higher, and * Either a history of: ** Contact (sexual or casual) with someone with a
diagnosis Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...
of SARS within the last 10 days or ** Travel to any of the regions identified by the
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
(WHO) as areas with recent local transmission of SARS. * Clinical criteria of Sars-CoV diagnosis ** Early illness: equal to or more than 2 of the following:
chills Chills is a feeling of coldness occurring during a high fever, but sometimes is also a common symptom which occurs alone in specific people. It occurs during fever due to the release of cytokines and prostaglandins as part of the inflammatory r ...
, rigors,
myalgia Myalgia (also called muscle pain and muscle ache in layman's terms) is the medical term for muscle pain. Myalgia is a symptom of many diseases. The most common cause of acute myalgia is the overuse of a muscle or group of muscles; another likel ...
,
diarrhea Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin wi ...
,
sore throat Sore throat, also known as throat pain, is pain or irritation of the throat. Usually, causes of sore throat include * viral infections * group A streptococcal infection (GAS) bacterial infection * pharyngitis (inflammation of the throat) * tonsi ...
(self-reported or observed) ** Mild-to-moderate illness: temperature of > plus indications of lower respiratory tract infection (cough, dyspnea) ** Severe illness: ≥1 of radiographic evidence, presence of
ARDS Acute respiratory distress syndrome (ARDS) is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. Symptoms include shortness of breath (dyspnea), rapid breathing (tachypnea), and bluish skin color ...
, autopsy findings in late patients. For a case to be considered probable, a chest X-ray must be indicative for
atypical pneumonia Atypical pneumonia, also known as walking pneumonia, is any type of pneumonia not caused by one of the pathogens most commonly associated with the disease. Its clinical presentation contrasts to that of "typical" pneumonia. A variety of microorgan ...
or
acute respiratory distress syndrome Acute respiratory distress syndrome (ARDS) is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. Symptoms include shortness of breath (dyspnea), rapid breathing (tachypnea), and bluish skin colo ...
. The WHO has added the category of "laboratory confirmed SARS" which means patients who would otherwise be considered "probable" and have tested positive for SARS based on one of the approved tests (
ELISA The enzyme-linked immunosorbent assay (ELISA) (, ) is a commonly used analytical biochemistry assay, first described by Eva Engvall and Peter Perlmann in 1971. The assay uses a solid-phase type of enzyme immunoassay (EIA) to detect the presence ...
,
immunofluorescence Immunofluorescence is a technique used for light microscopy with a fluorescence microscope and is used primarily on microbiological samples. This technique uses the specificity of antibodies to their antigen to target fluorescent dyes to specif ...
or PCR) but whose chest X-ray findings do not show SARS-CoV infection (e.g. ground glass opacities, patchy consolidations unilateral). The appearance of SARS-CoV in chest X-rays is not always uniform but generally appears as an abnormality with patchy infiltrates.


Prevention

There is no vaccine for SARS, although immunologist
Anthony Fauci Anthony Stephen Fauci (; born December 24, 1940) is an American physician-scientist and immunologist serving as the director of the National Institute of Allergy and Infectious Diseases (NIAID) and the chief medical advisor to the president. ...
mentioned that the
CDC The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georgi ...
developed one and placed it in the Strategic National Stockpile. That vaccine, however, is a prototype and not field-ready as of March 2020. Clinical isolation and
quarantine A quarantine is a restriction on the movement of people, animals and goods which is intended to prevent the spread of disease or pests. It is often used in connection to disease and illness, preventing the movement of those who may have been ...
remain the most effective means to prevent the spread of SARS. Other preventive measures include: *
Hand-washing Hand washing (or handwashing), also known as hand hygiene, is the act of cleaning one's hands with soap or handwash and water to remove viruses/bacteria/microorganisms, dirt, grease, or other harmful and unwanted substances stuck to the hands ...
with soap and water, or use of alcohol-based hand sanitizer * Disinfection of surfaces of
fomite A fomite () or fomes () is any inanimate object that, when contaminated with or exposed to infectious agents (such as pathogenic bacteria, viruses or fungi), can transfer disease to a new host. Transfer of pathogens by fomites A fomite is any ina ...
s to remove viruses * Avoiding contact with bodily fluids * Washing the personal items of someone with SARS in hot, soapy water (eating utensils, dishes, bedding, etc.) * Avoiding travel to affected areas * Wearing masks and gloves * Keeping people with symptoms home from school * Simple hygiene measures * Isolating oneself as much as possible to minimize the chances of transmission of the virus Many public health interventions were made to try to control the spread of the disease, which is mainly spread through
respiratory droplet A respiratory droplet is a small aqueous droplet produced by exhalation, consisting of saliva or mucus and other matter derived from respiratory tract surfaces. Respiratory droplets are produced naturally as a result of breathing, speaking, snee ...
s in the air, either inhaled or deposited on surfaces and subsequently transferred to a body's mucous membranes. These interventions included earlier detection of the disease; isolation of people who are infected; droplet and contact precautions; and the use of personal protective equipment (PPE), including masks and isolation gowns. A 2017 meta-analysis found that for medical professionals wearing N-95 masks could reduce the chances of getting sick up to 80% compared to no mask. A screening process was also put in place at airports to monitor air travel to and from affected countries. SARS-CoV is most infectious in severely ill patients, which usually occurs during the second week of illness. This delayed infectious period meant that
quarantine A quarantine is a restriction on the movement of people, animals and goods which is intended to prevent the spread of disease or pests. It is often used in connection to disease and illness, preventing the movement of those who may have been ...
was highly effective; people who were isolated before day five of their illness rarely transmitted the disease to others. As of 2017, the CDC was still working to make federal and local rapid-response guidelines and recommendations in the event of a reappearance of the virus. It has been found that those with a Vitamin D deficiency were at a 19.61-fold higher risk of having a critical result from Covid-19 disease versus those with an adequate amount of vitamin D. Patients with low vitamin D levels had worse symptoms, were more likely to be hospitalized, and had a greater risk of death. It is believed the reason vitamin D supplementation helps with the prevention of Covid-19 is due to the fact that vitamin D combats cytokine storms that are brought on because of Covid-19. While vitamin D supplementation may be helpful in preventing Covid-19, it has been shown to have no effect after Covid-19 is contracted.


Treatment

As SARS is a viral disease,
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...
s do not have direct effect but may be used against bacterial secondary infection. Treatment of SARS is mainly supportive with
antipyretic An antipyretic (, from ''anti-'' 'against' and ' 'feverish') is a substance that reduces fever. Antipyretics cause the hypothalamus to override a prostaglandin-induced increase in temperature. The body then works to lower the temperature, which r ...
s, supplemental oxygen and
mechanical ventilation Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air ...
as needed. While ribavirin is commonly used to treat SARS, there seems to have little to no effect on SARS-CoV, and no impact on patient's outcomes. There is currently no proven
antiviral Antiviral drugs are a class of medication used for treating viral infections. Most antivirals target specific viruses, while a broad-spectrum antiviral is effective against a wide range of viruses. Unlike most antibiotics, antiviral drugs do no ...
therapy. Tested substances, include
ribavirin Ribavirin, also known as tribavirin, is an antiviral medication used to treat RSV infection, hepatitis C and some viral hemorrhagic fevers. For hepatitis C, it is used in combination with other medications such as simeprevir, sofosbuvir, pegin ...
,
lopinavir Lopinavir is an anti retroviral of the protease inhibitor class. It is used against HIV infections as a fixed-dose combination with another protease inhibitor, ritonavir (lopinavir/ritonavir). It was patented in 1995 and approved for medical ...
,
ritonavir Ritonavir, sold under the brand name Norvir, is an antiretroviral drug used along with other medications to treat HIV/AIDS. This combination treatment is known as highly active antiretroviral therapy (HAART). Ritonavir is a protease inhibitor a ...
, type I
interferon Interferons (IFNs, ) are a group of signaling proteins made and released by host cells in response to the presence of several viruses. In a typical scenario, a virus-infected cell will release interferons causing nearby cells to heighten the ...
, that have thus far shown no conclusive contribution to the disease's course. Administration of
corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involv ...
s, is recommended by the
British Thoracic Society The British Thoracic Society (BTS) was formed in 1982 by the amalgamation of the British Thoracic Association and the Thoracic Society. It is a registered charity and a company limited by guarantee. Function The society's main charitable objecti ...
/
British Infection Society British may refer to: Peoples, culture, and language * British people, nationals or natives of the United Kingdom, British Overseas Territories, and Crown Dependencies. ** Britishness, the British identity and common culture * British English, ...
/
Health Protection Agency The Health Protection Agency (HPA) was a non-departmental public body in the United Kingdom. It was an organisation that was set up by the UK government in 2003 to protect the public from threats to their health from infectious diseases and envi ...
in patients with severe disease and O2 saturation of <90%. People with SARS-CoV must be isolated, preferably in negative-pressure rooms, with complete barrier nursing precautions taken for any necessary contact with these patients, to limit the chances of medical personnel becoming infected. In certain cases,
natural ventilation Passive ventilation is the process of supplying air to and removing air from an indoor space without using HVAC, mechanical systems. It refers to the flow of external air to an indoor space as a result of pressure differences arising from natural ...
by opening doors and windows is documented to help decreasing indoor concentration of virus particles. Some of the more serious damage caused by SARS may be due to the body's own immune system reacting in what is known as
cytokine storm A cytokine storm, also called hypercytokinemia, is a physiological reaction in humans and other animals in which the innate immune system causes an uncontrolled and excessive release of pro-inflammatory signaling molecules called cytokines. Norma ...
.


Vaccine

Vaccines can help immune system to create enough antibodies and also it can help to decrease a risk of side effects like arm pain, fever, headache etc. According to research papers published in 2005 and 2006, the identification and development of novel vaccines and medicines to treat SARS was a priority for governments and public health agencies around the world. In early 2004, an early clinical trial on volunteers was planned. A major researcher's 2016 request, however, demonstrated that no field-ready SARS vaccine had been completed because likely market-driven priorities had ended funding.


Prognosis

Several consequent reports from China on some recovered SARS patients showed severe long-time
sequela A sequela (, ; usually used in the plural, sequelae ) is a pathological condition resulting from a disease, injury, therapy, or other trauma. Derived from the Latin word, meaning “sequel”, it is used in the medical field to mean a complication ...
e. The most typical diseases include, among other things,
pulmonary fibrosis Pulmonary fibrosis is a condition in which the lungs become scarred over time. Symptoms include shortness of breath, a dry cough, feeling tired, weight loss, and nail clubbing. Complications may include pulmonary hypertension, respiratory failu ...
,
osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone ...
, and femoral necrosis, which have led in some cases to the complete loss of working ability or even self-care ability of people who have recovered from SARS. As a result of quarantine procedures, some of the post-SARS patients have been diagnosed with
post-traumatic stress disorder Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
(PTSD) and
major depressive disorder Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introdu ...
.


Epidemiology

SARS was a relatively rare disease; at the end of the epidemic in June 2003, the incidence was 8,422 cases with a
case fatality rate In epidemiology, case fatality rate (CFR) – or sometimes more accurately case-fatality risk – is the proportion of people diagnosed with a certain disease, who end up dying of it. Unlike a disease's mortality rate, the CFR does not take int ...
(CFR) of 11%. The case fatality rate (CFR) ranges from 0% to 50% depending on the age group of the patient. Patients under 24 were least likely to die (less than 1%); those 65 and older were most likely to die (over 55%). As with
MERS Middle East respiratory syndrome (MERS) is a viral respiratory infection caused by ''Middle East respiratory syndrome–related coronavirus'' (MERS-CoV). Symptoms may range from none, to mild, to severe. Typical symptoms include fever, cough, ...
and
COVID-19 Coronavirus disease 2019 (COVID-19) is a contagious disease caused by a virus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first known case was COVID-19 pandemic in Hubei, identified in Wuhan, China, in December ...
, SARS resulted in significantly more deaths of males than females.


Outbreak in South China

The SARS epidemic began in the
Guangdong Guangdong (, ), alternatively romanized as Canton or Kwangtung, is a coastal province in South China on the north shore of the South China Sea. The capital of the province is Guangzhou. With a population of 126.01 million (as of 2020) ...
province of China in November 2002. The earliest case developed symptoms on 16 November 2002. The
index patient The index case or patient zero is the first documented patient in a disease epidemic within a population, or the first documented patient included in an epidemiological study. It can also refer to the first case of a condition or syndrome (not n ...
, a farmer from
Shunde Shunde District, also known as Shuntak, is a district of the city of Foshan, Guangdong province, located in the Pearl River Delta. It had a population of 2,464,784 as of the 2010 census. Once a traditional agricultural county, it has become one ...
,
Foshan Foshan (, ), alternately romanized as Fatshan, is a prefecture-level city in central Guangdong Province, China. The entire prefecture covers and had a population of 9,498,863 as of the 2020 census. The city is part of the western side of the ...
, Guangdong, was treated in the First People's Hospital of Foshan. The patient died soon after, and no definite diagnosis was made on his cause of death. Despite taking some action to control it, Chinese government officials did not inform the World Health Organization of the outbreak until February 2003. This lack of openness caused delays in efforts to control the epidemic, resulting in criticism of the People's Republic of China from the international community. China officially apologized for early slowness in dealing with the SARS epidemic. The viral outbreak was subsequently genetically traced to a colony of cave-dwelling
horseshoe bat Horseshoe bats are bats in the family Rhinolophidae. In addition to the single living genus, ''Rhinolophus'', which has about 106 species, the extinct genus '' Palaeonycteris'' has been recognized. Horseshoe bats are closely related to the Old ...
s in
Xiyang Yi Ethnic Township Xiyang Yi Ethnic Township (Yi script:?, ) is an ethnic township in Jinning District, Yunnan. Demographics and Languages Among its 10,155 residents, 78% (7,921) are ethnic minorities in China, chiefly Yi people (Lolo) and Hani people, as of 2006. ...
, Yunnan. The outbreak first came to the attention of the international medical community on 27 November 2002, when Canada's
Global Public Health Intelligence Network The Global Public Health Intelligence Network (GPHIN) is an electronic public health early warning system developed by Canada's Public Health Agency, and is part of the World Health Organization's (WHO) Global Outbreak Alert and Response Netw ...
(GPHIN), an electronic warning system that is part of the World Health Organization's
Global Outbreak Alert and Response Network The Global Outbreak Alert and Response Network (GOARN) is a network composed of numerous technical and public health institutions, laboratories, NGOs, and other organizations that work to observe and respond to threatening epidemics. GOARN works clo ...
(GOARN), picked up reports of a "flu outbreak" in China through Internet media monitoring and analysis and sent them to the WHO. While GPHIN's capability had recently been upgraded to enable Arabic, Chinese, English, French, Russian, and Spanish translation, the system was limited to English or French in presenting this information. Thus, while the first reports of an unusual outbreak were in Chinese, an English report was not generated until 21 January 2003. The first
super-spreader A superspreading event (SSEV) is an event in which an infectious disease is spread much more than usual, while an unusually contagious organism infection, infected with a pathogen, disease is known as a superspreader. In the human-to-human transmi ...
was admitted to the Sun Yat-sen Memorial Hospital in
Guangzhou Guangzhou (, ; ; or ; ), also known as Canton () and alternatively romanized as Kwongchow or Kwangchow, is the capital and largest city of Guangdong province in southern China. Located on the Pearl River about north-northwest of Hong Kon ...
on 31 January, which soon spread the disease to nearby hospitals. In early April 2003, after a prominent physician,
Jiang Yanyong Jiang Yanyong (born October 4, 1931) is a Chinese physician who publicized a coverup of the severe acute respiratory syndrome (SARS) epidemic in Mainland China. Born into the Zhejiang Xingye Bank family, Jiang was the chief physician of the 3 ...
, pushed to report the danger to China, there appeared to be a change in official policy when SARS began to receive a much greater prominence in the official media. Some have directly attributed this to the death of an American teacher, James Earl Salisbury, in Hong Kong. It was around this same time that Jiang Yanyong made accusations regarding the undercounting of cases in Beijing military hospitals. After intense pressure, Chinese officials allowed international officials to investigate the situation there. This revealed problems plaguing the aging mainland Chinese healthcare system, including increasing decentralization,
red tape Red tape is an idiom referring to regulations or conformity to formal rules or standards which are claimed to be excessive, rigid or redundant, or to bureaucracy claimed to hinder or prevent action or decision-making. It is usually applied to g ...
, and inadequate communication. Many healthcare workers in the affected nations risked their lives and died by treating patients, and trying to contain the infection before ways to prevent infection were known.


Spread to other regions

The epidemic reached the public spotlight in February 2003, when an American businessman traveling from China, Johnny Chen, became affected by pneumonia-like symptoms while on a flight to Singapore. The plane stopped in
Hanoi Hanoi or Ha Noi ( or ; vi, Hà Nội ) is the capital and second-largest city of Vietnam. It covers an area of . It consists of 12 urban districts, one district-leveled town and 17 rural districts. Located within the Red River Delta, Hanoi is ...
, Vietnam, where the patient died in Hanoi French Hospital. Several of the medical staff who treated him soon developed the same disease despite basic hospital procedures. Italian doctor
Carlo Urbani Carlo Urbani (; 19 October 1956 – 29 March 2003) was an Italian physician and microbiologist and the first to identify severe acute respiratory syndrome (SARS) as probably a new and dangerously contagious viral disease, and his early warn ...
identified the threat and communicated it to WHO and the Vietnamese government; he later died from the disease. The severity of the symptoms and the infection among hospital staff alarmed global health authorities, who were fearful of another emergent pneumonia epidemic. On 12 March 2003, the WHO issued a
global alert Global alert is used as the global radio-communications network during times of international crises or threats to international security. Global Alerts are also issued by agencies such as the World Health Organization (WHO), when there is a percei ...
, followed by a health alert by the United States
Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georgi ...
(CDC). Local transmission of SARS took place in
Toronto Toronto ( ; or ) is the capital city of the Canadian province of Ontario. With a recorded population of 2,794,356 in 2021, it is the most populous city in Canada and the fourth most populous city in North America. The city is the ancho ...
, Ottawa, San Francisco,
Ulaanbaatar Ulaanbaatar (; mn, Улаанбаатар, , "Red Hero"), previously anglicized as Ulan Bator, is the capital and most populous city of Mongolia. It is the coldest capital city in the world, on average. The municipality is located in north ce ...
,
Manila Manila ( , ; fil, Maynila, ), officially the City of Manila ( fil, Lungsod ng Maynila, ), is the capital of the Philippines, and its second-most populous city. It is highly urbanized and, as of 2019, was the world's most densely populate ...
, Singapore, Taiwan, Hanoi and Hong Kong whereas within China it spread to Guangdong,
Jilin Jilin (; alternately romanized as Kirin or Chilin) is one of the three provinces of Northeast China. Its capital and largest city is Changchun. Jilin borders North Korea (Rasŏn, North Hamgyong, Ryanggang and Chagang) and Russia (Prim ...
, Hebei,
Hubei Hubei (; ; alternately Hupeh) is a landlocked province of the People's Republic of China, and is part of the Central China region. The name of the province means "north of the lake", referring to its position north of Dongting Lake. The prov ...
, Shaanxi,
Jiangsu Jiangsu (; ; pinyin: Jiāngsū, Postal romanization, alternatively romanized as Kiangsu or Chiangsu) is an Eastern China, eastern coastal Provinces of the People's Republic of China, province of the China, People's Republic of China. It is o ...
, Shanxi,
Tianjin Tianjin (; ; Mandarin: ), alternately romanized as Tientsin (), is a municipality and a coastal metropolis in Northern China on the shore of the Bohai Sea. It is one of the nine national central cities in Mainland China, with a total popul ...
, and
Inner Mongolia Inner Mongolia, officially the Inner Mongolia Autonomous Region, is an autonomous region of the People's Republic of China. Its border includes most of the length of China's border with the country of Mongolia. Inner Mongolia also accounts for a ...
.


Hong Kong

The disease spread in Hong Kong from Liu Jianlun, a Guangdong doctor who was treating patients at Sun Yat-Sen Memorial Hospital. He arrived in February and stayed on the ninth floor of the Metropole Hotel in
Kowloon Kowloon () is an urban area in Hong Kong comprising the Kowloon Peninsula and New Kowloon. With a population of 2,019,533 and a population density of in 2006, it is the most populous area in Hong Kong, compared with Hong Kong Island and t ...
, infecting 16 of the hotel visitors. Those visitors traveled to Canada, Singapore, Taiwan, and Vietnam, spreading SARS to those locations. Another larger cluster of cases in Hong Kong centred on the
Amoy Gardens Amoy Gardens () is a private housing estate in the Jordan Valley area of Kowloon, Hong Kong completed from 1981 to 1987.Toronto Toronto ( ; or ) is the capital city of the Canadian province of Ontario. With a recorded population of 2,794,356 in 2021, it is the most populous city in Canada and the fourth most populous city in North America. The city is the ancho ...
was identified on 23 February 2003. Beginning with an elderly woman, Kwan Sui-Chu, who had returned from a trip to Hong Kong and died on 5 March, the virus eventually infected 257 individuals in the province of Ontario. The trajectory of this outbreak is typically divided into two phases, the first centring around her son Tse Chi Kwai, who infected other patients at the
Scarborough Grace Hospital The Birchmount Hospital, officially Scarborough Health Network, Birchmount Hospital, is a hospital in Toronto, Ontario, Canada. Located in the Agincourt neighbourhood along Birchmount Road, the hospital was opened in 1985 by The Salvation Army a ...
and died on 13 March. The second major wave of cases was clustered around accidental exposure among patients, visitors, and staff within the
North York General Hospital North York General Hospital (NYGH) is a teaching hospital in Toronto, Ontario, Canada. Primarily serving the North York district, as well as southern York Region, it offers acute care, ambulatory and long-term services at multiple sites. It is one ...
. The WHO officially removed Toronto from its list of infected areas by the end of June 2003. The official response by the Ontario provincial government and Canadian federal government has been widely criticized in the years following the outbreak. Brian Schwartz, vice-chair of Ontario's SARS Scientific Advisory Committee, described public health officials' preparedness and emergency response at the time of the outbreak as "very, very basic and minimal at best". Critics of the response often cite poorly outlined and enforced protocol for protecting healthcare workers and identifying infected patients as a major contributing factor to the continued spread of the virus. The atmosphere of fear and uncertainty surrounding the outbreak resulted in staffing issues in area hospitals when healthcare workers elected to resign rather than risk exposure to SARS.


Identification of virus

In late February 2003, Italian doctor
Carlo Urbani Carlo Urbani (; 19 October 1956 – 29 March 2003) was an Italian physician and microbiologist and the first to identify severe acute respiratory syndrome (SARS) as probably a new and dangerously contagious viral disease, and his early warn ...
was called into The French Hospital of Hanoi to look at Johnny Chen, an American businessman who had fallen ill with what doctors thought was a bad case of
influenza Influenza, commonly known as "the flu", is an infectious disease caused by influenza viruses. Symptoms range from mild to severe and often include fever, runny nose, sore throat, muscle pain, headache, coughing, and fatigue. These symptoms ...
. Urbani realized that Chen's ailment was probably a new and highly contagious disease. He immediately notified the WHO. He also persuaded the Vietnamese Health Ministry to begin isolating patients and screening travelers, thus slowing the early pace of the epidemic. He subsequently contracted the disease himself, and died in March 2003.
Malik Peiris Joseph Sriyal Malik Peiris ( Sinhala: ජෝසප් ශ්‍රියාල් මලික් පීරිස්, born 10 November 1949) is a Hong Kong-based British and Sri Lankan virologist, most notable for being the first person to ...
and his colleagues became the first to isolate the virus that causes SARS, a
novel coronavirus Novel coronavirus (nCoV) is a provisional name given to coronaviruses of medical significance before a permanent name is decided upon. Although coronaviruses are endemic in humans and infections normally mild, such as the common cold (caused by ...
now known as
SARS-CoV-1 Severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1; or Severe acute respiratory syndrome coronavirus, SARS-CoV) is a strain of coronavirus that causes severe acute respiratory syndrome (SARS), the respiratory illness responsible for ...
. By June 2003, Peiris, together with his long-time collaborators
Leo Poon Leo Poon Lit-man () is the Head of the Division of Public Health Laboratory Science of the University of Hong Kong. In July 2020, Professor Malik Peiris stepped down from the position of co-director of the joint research pole between Hong Kong Un ...
and
Guan Yi Guan Yi (; born 1962) is a Chinese virologist. In 2014, he was ranked as 11th in the world by Thomson Reuters (now known as Clarivate Analytics) among global researchers in the field of microbiology. He obtained his PhD in microbiology at th ...
, has developed a rapid
diagnostic Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engine ...
test for SARS-CoV-1 using
real-time polymerase chain reaction A real-time polymerase chain reaction (real-time PCR, or qPCR) is a laboratory technique of molecular biology based on the polymerase chain reaction (PCR). It monitors the amplification of a targeted DNA molecule during the PCR (i.e., in real ...
. The CDC and Canada's National Microbiology Laboratory identified the SARS
genome In the fields of molecular biology and genetics, a genome is all the genetic information of an organism. It consists of nucleotide sequences of DNA (or RNA in RNA viruses). The nuclear genome includes protein-coding genes and non-coding ge ...
in April 2003. Scientists at
Erasmus University Erasmus University Rotterdam (abbreviated as ''EUR'', nl, Erasmus Universiteit Rotterdam ) is a public research university located in Rotterdam, Netherlands. The university is named after Desiderius Erasmus Roterodamus, a 15th-century humanist ...
in
Rotterdam Rotterdam ( , , , lit. ''The Dam on the River Rotte'') is the second largest city and municipality in the Netherlands. It is in the province of South Holland, part of the North Sea mouth of the Rhine–Meuse–Scheldt delta, via the ''"N ...
, the Netherlands demonstrated that the SARS coronavirus fulfilled
Koch's postulates Koch's postulates ( )"Koch"
''
macaque The macaques () constitute a genus (''Macaca'') of gregarious Old World monkeys of the subfamily Cercopithecinae. The 23 species of macaques inhabit ranges throughout Asia, North Africa, and (in one instance) Gibraltar. Macaques are principally ...
s infected with the virus developed the same symptoms as human SARS patients.


Origin and animal vectors

In late May 2003, a study was conducted using samples of wild animals sold as food in the local market in Guangdong, China. The study found that "SARS-like" coronaviruses could be isolated from
masked palm civet The masked palm civet (''Paguma larvata''), also called the gem-faced civet, is a palm civet species native to the Indian subcontinent and Southeast Asia. It has been listed as least concern on the IUCN Red List since 2008 as it occurs in many p ...
s (''Paguma'' sp.). Genomic sequencing determined that these animal viruses were very similar to human SARS viruses, however they were
phylogenetically In biology, phylogenetics (; from Greek φυλή/ φῦλον [] "tribe, clan, race", and wikt:γενετικός, γενετικός [] "origin, source, birth") is the study of the evolutionary history and relationships among or within groups o ...
distinct, and so the study concluded that it was unclear whether they were the natural reservoir in the wild. Still, more than 10,000 masked palm civets were killed in Guangdong Province since they were a "potential infectious source." The virus was also later found in
raccoon dog The common raccoon dog (''Nyctereutes procyonoides''), also called the Chinese or Asian raccoon dog, is a small, heavy-set, fox-like canid native to East Asia. Named for its raccoon-like face markings, it is most closely related to foxes. Common ...
s (''Nyctereuteus'' sp.),
ferret badger Ferret-badgers are the six species of the genus ''Melogale'', which is the only genus of the monotypic mustelid subfamily Helictidinae. * Bornean ferret-badger (''Melogale everetti'') * Chinese ferret-badger (''Melogale moschata'') *Formosan fer ...
s (''Melogale'' spp.), and domestic cats. In 2005, two studies identified a number of SARS-like coronaviruses in Chinese bats. Phylogenetic analysis of these viruses indicated a high probability that SARS coronavirus originated in bats and spread to humans either directly or through animals held in Chinese markets. The bats did not show any visible signs of disease, but are the likely natural reservoirs of SARS-like coronaviruses. In late 2006, scientists from the Chinese Centre for Disease Control and Prevention of
Hong Kong University The University of Hong Kong (HKU) (Chinese: 香港大學) is a public research university in Hong Kong. Founded in 1887 as the Hong Kong College of Medicine for Chinese, it is the oldest tertiary institution in Hong Kong. HKU was also the fir ...
and the Guangzhou Centre for Disease Control and Prevention established a genetic link between the SARS coronavirus appearing in civets and in the second, 2004 human outbreak, bearing out claims that the disease had jumped across species. It took 14 years to find the original bat population likely responsible for the SARS pandemic. In December 2017, "after years of searching across China, where the disease first emerged, researchers reported ... that they had found a remote cave in
Xiyang Yi Ethnic Township Xiyang Yi Ethnic Township (Yi script:?, ) is an ethnic township in Jinning District, Yunnan. Demographics and Languages Among its 10,155 residents, 78% (7,921) are ethnic minorities in China, chiefly Yi people (Lolo) and Hani people, as of 2006. ...
, Yunnan province, which is home to horseshoe bats that carry a strain of a particular virus known as a coronavirus. This strain has all the genetic building blocks of the type that triggered the global outbreak of SARS in 2002." The research was performed by
Shi Zhengli Shi Zhengli (; born 26 May 1964) is a Chinese virologist who researches SARS-like coronaviruses of bat origin. Shi directs the Center for Emerging Infectious Diseases at the Wuhan Institute of Virology (WIV). In 2017, Shi and her colleague Cui ...
, Cui Jie, and co-workers at the
Wuhan Institute of Virology The Wuhan Institute of Virology, Chinese Academy of Sciences (WIV; ) is a research institute on virology administered by the Chinese Academy of Sciences (CAS), which reports to the State Council of the People's Republic of China. The institute ...
, China, and published in ''
PLOS Pathogens ''PLOS Pathogens'' is a peer-reviewed open-access medical journal. All content in ''PLOS Pathogens'' is published under the Creative Commons "by-attribution" license. ''PLOS Pathogens'' began operation in September 2005. It was the fifth journa ...
''. The authors are quoted as stating that "another deadly outbreak of SARS could emerge at any time. The cave where they discovered their strain is only a kilometre from the nearest village." The virus was ephemeral and seasonal in bats. In 2019, a similar virus to SARS caused a cluster of infections in
Wuhan Wuhan (, ; ; ) is the capital of Hubei, Hubei Province in the China, People's Republic of China. It is the largest city in Hubei and the most populous city in Central China, with a population of over eleven million, the List of cities in China ...
, eventually leading to the COVID-19 pandemic. A small number of cats and dogs tested positive for the virus during the outbreak. However, these animals did not transmit the virus to other animals of the same species or to humans.


Containment

The World Health Organization declared severe acute respiratory syndrome contained on 5 July 2003. The containment was achieved through successful
public health Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals". Analyzing the det ...
measures. In the following months, four SARS cases were reported in China between December 2003 and January 2004. While SARS-CoV-1 probably persists as a potential zoonotic threat in its original animal reservoir, human-to-human transmission of this virus may be considered eradicated because no human case has been documented since four minor, brief, subsequent outbreaks in 2004.


Laboratory accidents

After containment, there were four laboratory accidents that resulted in infections. * One postdoctoral student at the National University of Singapore in
Singapore Singapore (), officially the Republic of Singapore, is a sovereign island country and city-state in maritime Southeast Asia. It lies about one degree of latitude () north of the equator, off the southern tip of the Malay Peninsula, borde ...
in August 2003 * A 44-year-old senior scientist at the National Defense University in Taipei in December 2003. He was confirmed to have the SARS virus after working on a SARS study in Taiwan's only BSL-4 lab. The Taiwan CDC later stated the infection occurred due to laboratory misconduct. * Two researchers at the Chinese Institute of Virology in Beijing, China around April 2004, who spread it to around six other people. The two researchers contracted it 2 weeks apart. Study of live SARS specimens requires a biosafety level 3 (BSL-3) facility; some studies of inactivated SARS specimens can be done at biosafety level 2 facilities.


Society and culture

Fear of contracting the virus from consuming infected wild animals resulted in public bans and reduced business for meat markets in southern China and Hong Kong.


See also

*
2009 swine flu pandemic The 2009 swine flu pandemic, caused by the H1N1 influenza virus and declared by the World Health Organization (WHO) from June 2009 to August 2010, is the third recent flu pandemic involving the H1N1 virus (the first being the 1918–1920 Span ...
*
Avian influenza Avian influenza, known informally as avian flu or bird flu, is a variety of influenza caused by viruses adapted to birds.
*
Bat-borne virus The bat virome is the group of viruses associated with bats. Bats host a diverse array of viruses, including all seven types described by the Baltimore classification system: (I) double-stranded DNA viruses; (II) single-stranded DNA viruses; ...
*
Coronavirus disease 2019 Coronavirus disease 2019 (COVID-19) is a contagious disease caused by a virus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first known case was identified in Wuhan, China, in December 2019. The disease quickly ...
– a disease caused by
Severe acute respiratory syndrome coronavirus 2 Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) is a strain of coronavirus that causes COVID-19 (coronavirus disease 2019), the respiratory illness responsible for the ongoing COVID-19 pandemic. The virus previously had a No ...
*
Health crisis A health crisis or public health crisis is a difficult situation or complex health system that affects humans in one or more geographic areas (mainly occurred in natural hazards), from a particular locality to encompass the entire planet. Health cri ...
*
Health in China Health in China over the course of the twentieth century has gone from being a largely private and family concern, using traditional medicine, to being a major concern of the state as well. Beginning in 1905, the Qing dynasty established the ...
*
List of medical professionals who died during the SARS outbreak This is a list of medical professional A health professional, healthcare professional, or healthcare worker (sometimes abbreviated HCW) is a provider of health care treatment and advice based on formal training and experience. The field includes ...
*
Middle East respiratory syndrome Middle East respiratory syndrome (MERS) is a viral respiratory infection caused by ''Middle East respiratory syndrome–related coronavirus'' (MERS-CoV). Symptoms may range from none, to mild, to severe. Typical symptoms include fever, cough, ...
– a coronavirus discovered in June 2012 in Saudi Arabia *
SARS conspiracy theory The SARS conspiracy theory began to emerge during the severe acute respiratory syndrome (SARS) outbreak in China in the spring of 2003, when Sergei Kolesnikov, a Russian scientist and a member of the Russian Academy of Medical Sciences, first publ ...
*
Zhong Nanshan Zhong Nanshan (born 20 October 1936) is a Chinese pulmonologist. He was president of the Chinese Medical Association from 2005 to 2009 and is currently the editor-in-chief of the '' Journal of Thoracic Disease''. He is a recipient of Medal o ...


References


Further reading

* * * *


External links


MedlinePlus: Severe Acute Respiratory Syndrome
News, links and information from The United States
National Library of Medicine The United States National Library of Medicine (NLM), operated by the United States federal government, is the world's largest medical library. Located in Bethesda, Maryland, the NLM is an institute within the National Institutes of Health. Its ...

Severe Acute Respiratory Syndrome (SARS) Symptoms and treatment guidelines, travel advisory, and daily outbreak updates
from the
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
(WHO)
Severe Acute Respiratory Syndrome (SARS)
information on the international outbreak of the illness known as a severe acute respiratory syndrome (SARS), provided by the US
Centers for Disease Control The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georgi ...
{{Authority control Bat virome Zoonotic bacterial diseases Bird diseases Syndromes affecting the respiratory system Atypical pneumonias Sarbecovirus Viral respiratory tract infections Coronavirus-associated diseases