# Presentation: 670172

## 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**** **
**Onset of fever, chills/rigors, headache, myalgias, malaise**** **
**Respiratory symptoms often begin 3-7 days after symptom onset**

## 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 Unpublished data, CDC. 2.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**

## Symptoms Reported by Patients With Diagnostic SARS-CoV Laboratory Testing, United States, 2003

| Symptom | Coronavirus Positive
(n=6) % | Coronavirus Negative
(n=28) % |
| --- | --- | --- |
| Fever | 100 | 96 |
| Cough | 100 | 93 |
| Dyspnea | 100 | 61* |
| Myalgias | 83 | 75 |
| Chills/Rigor | 83 | 68 |
| Headache | 67 | 68 |
| Diarrhea | 67 | 25* |
| Coryza | 17 | 43 |
| Sore Throat | 17 | 43 |

- *p=.07

## Common Clinical Findings in Patients with SARS1-5

| Finding | Range (%) |
| --- | --- |
| Examination
     Rales/Rhonci
     Hypoxia | 
38-90
60-83 |
| Laboratory
    Leukopenia
    Lymphopenia
    Low platelet
    Increased ALT
    Increased LDH
    Increased CPK | 
17-34
54-89
17-45
23-78
70-94
26-56 |

**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 Unpublished data, CDC. 2.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**

## Clinical Findings in Patients With Diagnostic SARS-CoV Laboratory Testing, United States, 2003

| Symptom | Coronavirus Positive
(n=6) % | Coronavirus Negative
(n=28) % |
| --- | --- | --- |
| Examination
   Rales/rhonci | 
83 | 
23* |
|    Hypoxia | 83 | 29* |
|    Infiltrates | 100 | 30* |
| Laboratory
    Leukopenia | 
17 | 
5 |
|     Lymphopenia | 83 | 53 |
|     Low platelets | 17 | 5 |
|     Increased ALT | 60 | 17 |

- *p<.05

## 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**

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

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

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

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

## Slide 10

## Slide 11

## Clinical Outcome of Patients with SARS, 2003

|  | 

n | Progression to Resp. Failure (%) |
| --- | --- | --- |
| U.S.1 | 6 | 17 |
| Canada2 | 144 | 14 |
| Hong Kong3 | 10 | 20 |
| Hong Kong4 | 50 | 38 |
| Hong Kong5 | 138 | 14 |
| Singapore1 | 178 | 12 |

**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**

## Clinical Outcome of Probable  SARS Cases*, 2003

|  | 

n | Case Fatality Proportion(%) |
| --- | --- | --- |
| U.S. | 65 | 0 |
| Canada | 146 | 15 |
| Hong Kong | 1654 | 12 |
| Singapore | 178 | 13 |

*** http://www.who.int/csr/sarscountry/2003_05_07/en/**

## Clinical Features Associated with Severe Disease

**Older Age**
**Underlying illness**
**? Lactate dehydrogenase levels**
**? Severe lymphopenia**** **

## Analysis of Clinical Specimens of 20 Patients with RT-PCR positive Nasopharyngeal Aspirates (NPA) and Seroconversion to SARS-Associated Coronavirus

| Day after onset of Symptoms | 10 | 13 | 16 | 19 | 21 |
| --- | --- | --- | --- | --- | --- |
| NPA
(Positivity rate) | 19 / 20 
(95%)
 | 18 / 20 
(90%)
 | 18 / 20
 (90%)
 | 15 / 20 
(75%)
 | 9 / 19 (47.4%)
 |
| STOOL
(Positivity rate) | 20 / 20 (100%)
 | 20 / 20 (100%)
 | 19 / 20 
(95%)
 | 12 / 15
(80%)
 | 10 / 15 (66.7%)
 |
| Urine 
(positivity rate)  | 10 / 20 
(50%)
 | 9 / 20 
(45%)
 | 7 / 20
 (35%)
 | 6 / 20
 (30%)
 | 4 / 19 (21.1%)
 |

**Peiris et. al. **_[www.who.int](http://www.who.int/)_** 5/1/03**

## 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**

## Probable cases of severe acute respiratory syndrome, by reported source of infection,* --- Singapore, February 25--April 30, 2003 

- 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

## 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***

## 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**

## 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**

## Treatment of Patients with SARS

**Potential Therapies Requiring Further Investigation**
**Ribavirin**
**?other antiviral agents**
**Immunomodulatory agents**
**Corticosteroids**
**Interferons**
**Others?**

## 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**

## Infection Control 

**Isolation**
**Hand hygiene**
**Contact Precautions (gloves, gown)**
**Eye protection**
**Environmental cleaning**
**Airborne Precautions (N-95 respirator, negative pressure)**

## 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**
**	**

**Notes:**
[Slide 10] Thank you.