Applying lessons from SARS to a newly identified coronavirus
Authors: Brian McCloskey, Alimuddin Zumla, Gwen Stephens, David L Heymann, Ziad A Memish
Journal: The Lancet Infectious Diseases (2013)

Human infection with a newly identified novel coronavirus has rapidly focused global attention on risk assessment1Pollack MP Pringle C Madoff LC Memish ZA Latest outbreak news from ProMED-mail: novel coronavirus–Middle East.Int J Infect Dis. 2013; 17: e143-e144Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 2WHOGlobal alert and response. Coronavirus infections.http://www.who.int/csr/disease/coronavirus_infections/en/index.htmlGoogle Scholar, 3Albarrak AM Stephens GM Hewson R Memish ZA Recovery from severe novel coronavirus infection.Saudi Med J. 2012; 33: 1265-1269PubMed Google Scholar, 4Zaki AM van Boheemen S Bestebroer TM Osterhaus AD Fouchier RA Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia.N Engl J Med. 2012; 367: 1814-1820Crossref PubMed Scopus (4190) Google Scholar, 5Malik M Mahjour J Opoka M Mafi AR Emergence of novel human coronavirus: public health implications in the Eastern Mediterranean Region.East Mediterr Health J. 2012; 18: 1084-1085PubMed Google Scholar, 6Chan JF Li KS To KK Cheng VC Chen H Yuen KY Is the discovery of the novel human betacoronavirus 2c EMC/2012 (HCoV-EMC) the beginning of another SARS-like pandemic?.J Infect. 2012; 65: 477-489Summary Full Text Full Text PDF PubMed Scopus (141) Google Scholar because its epidemic potential is not known. First detected in September, 2012, in a patient who had died of an acute respiratory illness in Saudi Arabia,4Zaki AM van Boheemen S Bestebroer TM Osterhaus AD Fouchier RA Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia.N Engl J Med. 2012; 367: 1814-1820Crossref PubMed Scopus (4190) Google Scholar it was soon confirmed in a Qatari patient with a similar illness in London, UK. These cases triggered collaborations between the Kingdom of Saudi Arabia Ministry of Health (KSA-MoH), Qatar, and other global partners. The immediate need was to ensure the safety of the 3 million pilgrims attending the Hajj pilgrimage in October, 2012. Testing of pilgrims before and after Hajj 2012, and case based surveillance for the novel coronavirus during Hajj, suggested that the virus was not in circulation at the time.7Gautret P Charrel R Belhouchat K et al.Lack of nasal carriage of novel corona virus (HCoV-EMC) in French Hajj pilgrims returning from the Hajj 2012, despite a high rate of respiratory symptoms.Clin Microbiol Infect. 2013; (published online Feb 11.)https://doi.org/10.1111/1469-0691.12174Crossref Scopus (77) Google Scholar Continued risk assessment of the global threat of the novel coronavirus involves close collaborations between KSA-MoH, WHO, the UK Health Protection Agency (HPA), and other global partners. As of March 12, 2013, 15 patients—eight from Saudi Arabia, four from UK, one from Germany, and two from Jordan—were reported with confirmed infections, and nine of these have died. Ascertainment of the country of initial infection remains unclear and at least three cases had a history of travel to another country (including Pakistan and Egypt). Eight cases occurred in three clusters, and 13 required intensive care. In the UK cluster, three members of the same family were infected: one individual had recently travelled to Pakistan and Saudi Arabia, whereas the other two had no recent travel history,8HPA update: Update on family cluster of novel coronavirus infection in the UK.http://www.hpa.org.uk/NewsCentre/NationalPressReleases/2013PressReleases/120319Updateoffamilyclusterofnovelcoronavirus/Google Scholar suggesting person to person transmission. Although two of the cases had severe respiratory symptoms, one had mild symptoms suggesting a range of clinical expression. Contacts of the UK cases have been identified by the HPA and KSA-MoH, and follow-up tests have so far been negative for the molecular targets of the novel coronavirus.8HPA update: Update on family cluster of novel coronavirus infection in the UK.http://www.hpa.org.uk/NewsCentre/NationalPressReleases/2013PressReleases/120319Updateoffamilyclusterofnovelcoronavirus/Google Scholar Coronaviruses are very common, and widely dispersed in animals and in human beings. They can infect the respiratory tract, gut, liver, and CNS, causing a range of illnesses. Sequence data have classified the virus as a β coronavirus similar to bat coronaviruses.9WHOLaboratory testing for novel coronavirus.http://www.who.int/csr/disease/coronavirus_infections/LaboratoryTestingNovelCoronavirus_21Dec12.pdfGoogle Scholar Not much is known about the novel coronavirus with respect to the source, mode of transmission, epidemiology, geographic distribution, predisposing factors for infection and disease, incubation period, immunopathogenesis, range of clinical manifestations, and epidemic potential. Previous WHO guidelines for screening of the novel coronavirus were determined by travel to, or residence in, the Arabian Peninsula.2WHOGlobal alert and response. Coronavirus infections.http://www.who.int/csr/disease/coronavirus_infections/en/index.htmlGoogle Scholar, 10WHOGlobal alert and response. Revised interim case definition—novel coronavirus. World Health Organization, Geneva2012http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/index.htmlGoogle Scholar, 11Perlman S Zhao J Human coronavirus EMC is not the same as severe acute respiratory syndrome coronavirus.MBio. 2013; (pii: e00002-13.10.1128/mBio.00002-13 published online Jan 15.)Google Scholar Although by definition these might indicate the pattern of diagnosed infections, the focus on the Middle East would have led to individuals with this viral infection in other geographical regions being missed. Latest WHO guidelines now recommend universal screening to define the epidemiology of this novel coronavirus.12WHOInterim surveillance recommendations for human infection with novel coronavirus.http://www.who.int/csr/disease/coronavirus_infections/InterimRevisedSurveillanceRecommendations_nCoVinfection_18Mar13.pdfGoogle Scholar Available molecular tests for detection of active cases of infection and screening of contacts are experimental and their sensitivity and specificity require definition. Serological tests for the novel coronavirus are urgently needed for accurate assessment of infection in asymptomatic contacts and for large-scale serosurveys to improve understanding of the epidemiology and global geographical distribution of this virus. Validated standard treatment protocols and case investigation forms are also needed. Findings of controlled studies of cases and contacts could provide information that leads to the source of infection. Lessons from the severe acute respiratory syndrome (SARS) epidemic showed the importance of rapid genetic sequencing, and these have been applied for study of the novel coronavirus,4Zaki AM van Boheemen S Bestebroer TM Osterhaus AD Fouchier RA Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia.N Engl J Med. 2012; 367: 1814-1820Crossref PubMed Scopus (4190) Google Scholar, 9WHOLaboratory testing for novel coronavirus.http://www.who.int/csr/disease/coronavirus_infections/LaboratoryTestingNovelCoronavirus_21Dec12.pdfGoogle Scholar enabling effective sharing of clinical, epidemiological, and microbiological information.2WHOGlobal alert and response. Coronavirus infections.http://www.who.int/csr/disease/coronavirus_infections/en/index.htmlGoogle Scholar, 7Gautret P Charrel R Belhouchat K et al.Lack of nasal carriage of novel corona virus (HCoV-EMC) in French Hajj pilgrims returning from the Hajj 2012, despite a high rate of respiratory symptoms.Clin Microbiol Infect. 2013; (published online Feb 11.)https://doi.org/10.1111/1469-0691.12174Crossref Scopus (77) Google Scholar, 8HPA update: Update on family cluster of novel coronavirus infection in the UK.http://www.hpa.org.uk/NewsCentre/NationalPressReleases/2013PressReleases/120319Updateoffamilyclusterofnovelcoronavirus/Google Scholar, 9WHOLaboratory testing for novel coronavirus.http://www.who.int/csr/disease/coronavirus_infections/LaboratoryTestingNovelCoronavirus_21Dec12.pdfGoogle Scholar, 10WHOGlobal alert and response. Revised interim case definition—novel coronavirus. World Health Organization, Geneva2012http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/index.htmlGoogle Scholar, 11Perlman S Zhao J Human coronavirus EMC is not the same as severe acute respiratory syndrome coronavirus.MBio. 2013; (pii: e00002-13.10.1128/mBio.00002-13 published online Jan 15.)Google Scholar, 12WHOInterim surveillance recommendations for human infection with novel coronavirus.http://www.who.int/csr/disease/coronavirus_infections/InterimRevisedSurveillanceRecommendations_nCoVinfection_18Mar13.pdfGoogle Scholar, 13Palm D Pereyaslov D Vaz J et al.Joint ECDC-WHO Regional Office for Europe Novel Coronavirus Laboratory Survey participantsECDC National Microbiology Focal PointsWHO European Region EuroFlu NetworkEuropean Network for Diagnostics of "Imported" Viral Diseases (ENIVD)Laboratory capability for molecular detection and confirmation of novel coronavirus in Europe, November 2012.Euro Surveill. 2012; 17 (published online Dec 6, DOI:pii: 20335)Google Scholar Another lesson was that although laboratory testing is important to confirm infection, it does not replace accurate case definitions, regular updates as information evolves for identifying and managing cases,14Peiris JS Chu CM Cheng VC et al.Members of the HKU/UCH SARS Study GroupClinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study.Lancet. 2003; 361: 1767-1772Summary Full Text Full Text PDF PubMed Scopus (1986) Google Scholar isolation of suspect cases, follow-up of contacts, and prevention of hospital-acquired infection—all essential for interruption of transmission.15Avendano M Derkack P Swan S Clinical course and management of SARS in healthcare workers in Toronto: a case series.CMAJ. 2003; 168: 1649-1660PubMed Google Scholar Although the novel coronavirus does not seem to be as readily transmissible between people as that which caused the SARS epidemic in 2003, vigilance and continued risk assessment are needed. One of the main goals of the Centre for Mass Gatherings Medicine16Al Rabeeah AA Memish ZA Zumla A et al.Mass gatherings medicine and global health security.Lancet. 2012; 380: 3-4Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar are collaborative risk assessment and surveillance for new and emerging infections. Because of the global nature of religious and sporting events, active surveillance of the participants is of paramount global importance. A unique opportunity now exists for global collaboration, with transparent sharing of information as was done during the SARS outbreak, to improve elucidation of the risks associated with the novel coronavirus so that another SARS-like epidemic does not begin to spread undetected. Collaborations with other consortia such as the International Severe Acute Respiratory and Emerging Infection Consortium will ensure that the lessons from the SARS epidemic are applied to provide a valuable resource for risk assessment, surveillance, and response in accordance with the international health regulations. We declare that we have no conflicts of interest.