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BREAKING NEWS – Severe Acute Respiratory Syndrome ( SARS ) Canadian Bacterial Surveillance Network

On March 13th a patient at a Toronto area hospital died of an unexplained respiratory illness. Initial investigation revealed that his mother had died of a similar illness the previous week after returning from Hong Kong. Epidemiological investigations rapidly identified six other cases of this illness, termed severe acute respiratory syndrome (SARS), all of whom had direct contact with the index case or other related cases. Of the eight cases, six were family members, two of whom had traveled together to Hong Kong. The other two cases involved a family doctor who had direct, unprotected exposure to three of the cases, and a patient on an adjacent stretcher in the ER to one of the cases before the outbreak was recognized and isolation precautions instituted. These cases were the beginning of the “Toronto SARS outbreak” and part of a country outbreak of pneumonia now known to be due to a new human coronavirus. Initial cases of this illness were reported from the Guangdong province of China, and related outbreaks have been recognized in Beijing, Hong Kong, Singapore, Taiwan and Hanoi. Experience with these outbreaks suggests that the incubation time of this illness is 2-10 days. The illness usually begins with fever and malaise, with or without myalgias, headache, and chills. Although sore throat may be present, other upper respiratory symptoms are notably absent. The fever may improve transiently on day 2, but then becomes persistent and usually >38.5C. On day 4 to 5, some chest tightness and/or a mild cough may develop; by day 7, chest x-ray infiltrates are usually present, and shortness of breath appears. On admission, the white cell count is usually normal but may be low, lymphopenia is common (but a non-specific finding), LDH is often elevated, about 40% of cases have a mildly elevated CPK, and nearly 60% are somewhat hypocalcemic. Although the first two Canadian cases died, the overall mortality has been reported to range between 3 and 10%. Age and underlying illness are strong predictors of mortality; however, deaths have been reported in healthy adults under the age of 50 (including one to date in Toronto). Treatment is generally supportive; ribavirin and steroids have been used, but whether they are efficacious is unknown. The most common means of transmission are droplet and/or contact spread. Although there has been no widespread community dissemination of this illness, transmission within household and health care settings has been substantial and very difficult to control. In particular, there has been explosive transmission from very ill patients in hospital to health care workers; contact with a single patient in Toronto with unrecognized disease over a three day period was associated with more than 20 cases of illness in health care providers and visitors. Strict isolation precautions has dramatically reduced the likelihood of spread in hospitals, but some transmission to health care workers in Toronto has occurred despite compliance with very strict precautions. Evidence is accumulating that this disease is caused by a novel coronavirus, although some variability in transmissibility and pathogenicity remains unexplained, and some experts believe that a co-pathogen may be involved. In the meantime, public health efforts are being directed towards raising public awareness, identifying contacts and assessing and managing probable or suspected cases. All health care workers should be aware of SARS and should consider SARS in the diagnosis of any patient presenting with a compatible clinical illness if they have recently returned from an area where disease has been reported to occur (e.g Hong Kong) or have had direct contact with a known probable case. Suspected cases should be put into contact and airborne isolation and local public health authorities contacted immediately. Additional information about this outbreak is being reported daily, and this report will likely be out of date prior to its publication. Updated information will be available on the Health Canada website as well as through the WHO and CDC. These sources, as well as public health, should be consulted for up to date information on case definitions and approaches to management. Donald E. Low, MD, FRCPC