Dr. Days .... - Muscat Private Hospital

ecent reports on SARS, the new severe pneumonia, which has spread from the far east to 17 other countries is still being closely monitored. As SARS is spreading, the health profession is learning more about it and below is a summary of the current known issues.

The first cases of Severe Acute Respiratory Syndrome (SARS) were identified in Guangdong Province, Mainland China in mid November 2002. It spread to Hong Kong and Hanoi, Vietnam and is now in Europe and America. The first suspected cases are now showing up in Southern Africa. So far, according to WHO figures, there have been 2781 known cases with 110 deaths. (The case-fatality rate among persons with illness meeting the current WHO case definition of SARS is approximately 4%.). The majority of those that have died from SARS have been people with a pre-existing chronic illness.

Confirmation of the causative organism still has to made, but so far it is thought that a mutant of a coronavirus causes SARS. Coronaviruses normally cause colds and 'flu, but this variant appears to be very virulent.

SARS affects all age groups although the majority of patients have been adults aged 25-70 years who were previously healthy. A few suspected cases of SARS have been reported among children aged <15 years. People at risk are those living or working in close contact to an infected individual. These are usually members of a household or healthcare workers. Community spread, as in public transport, is possible, but less likely.

The illness is thought to be transmitted by cough droplet infection. Since the virus survives outside the body for up to 3 hours, transmission by touching contaminated objects or by air transmission is possible. Some workers in Hong Kong, where SARS spread rapidly through a single housing complex, have hypothesized that the spread may have been through cockroaches carrying the organism. There is no scientific evidence for this.

The incubation period for SARS is typically 3-10 days. The virus is not transmitted during the incubation period, but only after symptoms appear. The illness begins with influenza-like symptoms such as fever (>38.0°C), myalgia, headache, sore throat, dry cough, shortness of breath, or difficulty breathing. Fever often is high, and is sometimes associated with chills and rigors, and might be accompanied by other symptoms, including headache, malaise, and myalgia. At the onset of illness, some people have mild respiratory symptoms. There is typically no rash, neurologic or gastrointestinal finding. Patients may progress to have an atypical pneumonia and in 10-20% of cases, this is severe enough to require intubation and mechanical ventilation.

Chest x-rays might be normal during the initial febrile stage and throughout the course of illness. However, in a substantial proportion of patients, the respiratory phase is characterized by early focal pneumonic changes on the x-ray progressing to a more generalized, patchy, pneumonia.

There is no current laboratory test that can test for SARS, although there are some research tests that identify the coronavirus thought to cause SARS. The diagnosis is made on clinical grounds, based on a set of diagnostic criteria. Patients must have a recently acquired respiratory illness. Their temperatures must exceed 38oC. They should have clinical findings of a respiratory disease, such as a cough, shortness of breath or chest X-ray changes. They should also have travelled to an affected area within the last 10 days or been in close contact within 10 days of onset of symptoms with a person with respiratory illness who travelled to a suspected area or a person known to be a suspect SARS case.

The severity of illness is highly variable, ranging from mild illness to death. Although a few close contacts of patients with SARS, including healthcare workers, have developed a similar illness, the majority have remained well. Some close contacts have reported a mild, febrile illness without respiratory signs or symptoms, suggesting the illness might not always progress to the respiratory phase.

There is currently no effective treatment regime. Antibiotics are used to presumptively treat the known bacterial agents of atypical pneumonia. Severely ill patients may need to be intubated and mechanically ventilated.

In an effort to suppress the spread of SARS health authorities are strongly advocating isolation of ill patients until 10 days after symptoms have resolved. This could be at home in mild cases, but in hospital for severe cases. Although quarantine of healthy exposed patients is not universally advocated, some health authorities may use this tool to limit spread.

In summary, SARS is a serious contagious disease. It is the individual's moral and civic duty to present to their health care provider if they think they have become infected so that the correct preventative measure can be put in place to safeguard the general public. It is recommended that travelers do not travel to areas with documented or suspected community transmission of SARS. These areas include:
-Peoples' Republic of China (i.e. mainland China)
-Hong Kong Special Administrative Region
-Hanoi, Vietnam
-Singapore

Global case counts are available at http://www.who.int.