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SARS - PowerPoint Powered By Docstoc
					- Abhijit Kambalapally
- Nimesh Das
- Ginny Joshi
- Ridwan Rahman
- Eshan Shah
1.   What is SARS?        10. Economic Impact
2.   Origins of SARS      11. Medical Impact
3.   SARS Timeline        12. WHO
4.   Countries Affected   13. Quarantine
5.   SARS Cases           14. Disease Control
6.   Cause/ Effect        15. Treatment
7.   Symptoms             16. Diagnostic Tests
8.   Social Impact        17. Vaccine Found
9.   Ethical Impact       18. Preventive Measures
“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
 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
• 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
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)
 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
   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
Sars-Cov genome has 5 reading frames (ORFs) that encode replicase
  polyprotein; 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
   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
   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
 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
Hong Kong, China
                    Toronto, Ontario      Vietnam




    Thailand       Singapore           Taiwan
 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
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
• 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)
• 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
• 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
• 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)
 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
• 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
   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
• 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
   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
 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
• 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
• 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
• 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
• 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.
• 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.
• 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.
On 24 April, the Singaporean government made amendments to the
Infectious Diseases Act and included penalties for the violation. These
amendments included:

  1.   Suspected persons of the infectious disease were to be
       brought to the treatment centers. They were also prohibited
       from going to public places.
  2.   Access was restricted to certain designated contaminated
       areas.

  3.   Offenders were to be tagged using electronic wrist tags for
       breaking the home quarantine and fines were also imposed
       on them.

  4.   Anyone caught lying to the health officials about their travel
       to SARS-affected areas were subject to prosecution.
   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.
   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.
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)
• 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.
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.
Wearing disposable gloves, gowns, eye
protection: these minimize the opportunity for
the virus to gain internal access of the body by
contact.


                                Avoid skin contact with the patients
                                and family members, avoid touching
                                your eyes, nose or mouth, avoid
                                sharing food with those infected.


Disinfect surfaces: By using a household
disinfectant or diluted bleach, clean and
disinfect areas where patients have been
there, including furniture, toilet facilities etc.
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