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SARS: 1918 Revisited? The Urgent Need for Global Collaboration in Public Health

  • Dennis G. Maki
    Correspondence
    Address reprint requests and correspondence to Dennis G. Maki, MD, Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, Clinical Sciences Center, H4/574-5158, 600 Highland Ave, Madison, WI 53792
    Affiliations
    Department of Medicine Infection Control Department Center for Trauma and Life Support University of Wisconsin Hospital and Clinics University of Wisconsin-Madison
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      Humanity has but three great enemies: fever, famine and war; of these by far the greatest, by far the most terrible, is fever.
      Sir William Osler
      Humanity has been profoundly affected by plagues since the dawn of recorded history. The mother of all plagues, the Black Death, killed more than one third of the population of Europe in the 14th century.
      • Gottfried RS
      In more recent times, the great influenza epidemic of 1918, which had an inexplicably devastating mortality in persons between the ages of 20 and 40 years,
      • Pyle GF
      claimed the lives of 4 times as many soldiers as died on the battlefields of France at the height of World War I, and 25 to 50 million persons worldwide died of H1N1 influenza A.
      • Pyle GF
      • Crosby AW
      The world now faces a new apocalyptic horseman, severe acute respiratory syndrome (SARS), caused by a new human coronavirus (SARS-CoV). Genetic evidence suggests that SARS-CoV is a human-animal recombinant
      • Peiris JSM
      • Lai ST
      • Poon LL
      • SARS study group
      • et al.
      Coronavirus as a possible cause of severe acute respiratory syndrome.
      • Ksiazek TG
      • Erdman D
      • Goldsmith CS
      • SARS Working Group
      • et al.
      A novel coronavirus associated with severe acute respiratory syndrome.
      • Drosten C
      • Günther S
      • Preiser W
      • et al.
      Identification of a novel coronavirus in patients with severe acute respiratory syndrome.
      • Ruan Y
      • Wei CL
      • Ling AE
      • et al.
      Comparative full-length genome sequence analysis of 14 SARS coronavirus isolates and common mutations associated with putative origins of infection. Lancet [serial online].
      that made the leap, possibly from a civet or other smaller mammal, to humans in Guangdong Province, southern China.
      • Ruan Y
      • Wei CL
      • Ling AE
      • et al.
      Comparative full-length genome sequence analysis of 14 SARS coronavirus isolates and common mutations associated with putative origins of infection. Lancet [serial online].
      Between November 2002 and June 5, 2003, 8402 persons worldwide have acquired SARS, the vast majority in China (5329 infected; 334 deaths), Taiwan (678; 81), Hong Kong (1748; 283), Singapore (206; 31), Vietnam (63; 5), or Toronto, Canada (216; 31).
      • World Health Organization
      Cumulative number of reported probable cases of SARS.
      In keeping with its infamous historical predecessors, SARS has resulted in the deaths of 12% of patients with this disease,
      • World Health Organization
      Cumulative number of reported probable cases of SARS.
      many in some of the most advanced hospitals in the world.
      • Lee N
      • Hui D
      • Wu A
      • et al.
      A major outbreak of severe acute respiratory syndrome in Hong Kong.
      • Tsang KW
      • Ho PL
      • Ooi GC
      • et al.
      A cluster of cases of severe acute respiratory syndrome in Hong Kong.
      • Peiris JSM
      • Chu CM
      • Cheng VCC
      • et al.
      Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet [serial online].
      • Booth CM
      • Matukas LM
      • Tomlinson GA
      • et al.
      Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area.
      Mortality in persons older than 60 years has exceeded 40%.
      • Donnelly CA
      • Ghani AC
      • Leung GM
      • et al.
      Epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in Hong Kong. Lancet [serial online].
      SARS, which produces an unusually severe form of atypical pneumonia, is only the latest in a growing list of emerging infectious diseases detected and characterized since 1977, including legionnaires' disease; Clostridium difficile antibiotic-associated colitis; toxic shock syndrome caused by unique strains of Staphylococcus aureus or Streptococcus pyogenes; hemolytic uremic syndrome and thrombotic thrombocytopenic purpura deriving from food-borne infection caused by Escherichia coli O157:H7; human immunodeficiency virus infection and acquired immunodeficiency syndrome (AIDS); the blurring spectrum of human and animal prion diseases-Creutzfeld-Jakob disease, bovine spongiform encephalopathy, and chronic wasting disease of cervids; and in North America, Hantavirus pneumonitis and West Nile encephalitis.
      It has become clear that a large and highly developed country such as the United States not only has a powerful self-interest but also a moral obligation to invest in a world-class communicable disease center, such as the Centers for Disease Control and Prevention, to be able to detect and characterize new infectious diseases and contain their spread. The importance and impact of nationally funded organizations of excellence, staffed by the best and brightest and working in global concert with other like-minded organizations, also cannot be overstated. SARS was recognized as a distinct new infectious disease syndrome by Dr Carlo Urbani on February 28, 2003; the viral causation was identified and confirmed by scientists around the world within a month.
      • Peiris JSM
      • Lai ST
      • Poon LL
      • SARS study group
      • et al.
      Coronavirus as a possible cause of severe acute respiratory syndrome.
      • Ksiazek TG
      • Erdman D
      • Goldsmith CS
      • SARS Working Group
      • et al.
      A novel coronavirus associated with severe acute respiratory syndrome.
      • Drosten C
      • Günther S
      • Preiser W
      • et al.
      Identification of a novel coronavirus in patients with severe acute respiratory syndrome.
      International scientific collaboration, championed by epidemiologists and virologists at the World Health Organization, the US Centers for Disease Control and Prevention, and centers in Singapore, Hong Kong, Canada, and Germany, has been unprecedented
      • World Health Organization
      A multicentre collaboration to investigate the cause of severe acute respiratory syndrome.
      • Gerberding JL
      Faster…but fast enough? responding to the epidemic of severe acute respiratory syndrome [editorial].
      and has led to containment of SARS in most of the affected countries, particularly Vietnam, Singapore, and Hong Kong, at the time this editorial was written.
      • World Health Organization
      Cumulative number of reported probable cases of SARS.
      • World Health Organization
      Update 73 - No new deaths, but vigilance needed for imported cases.
      SARS is unique among the numerous types of community-acquired pneumonia: (1) it has a prohibitive mortality, considerably higher than most other viral or bacterial community-acquired pneumonias, with the exception of pneumonitis caused by Legionella pneumophila or Hantavirus; (2) mortality has been high in adults, especially those older than 60 years, but clinical disease has been uncommon and mild in children
      • Hon KLE
      • Leung CW
      • Cheng WTF
      • et al.
      Clinical presentations and outcome of severe acute respiratory syndrome in children. Lancet [serial online].
      ; (3) early microbiologic confirmation of SARS has been difficult because the virus is hard to culture in vitro, conventional DNA/RNA detection techniques such as reverse-transcriptase polymerase chain reaction have been relatively insensitive in the early phase of infection,
      • Peiris JSM
      • Lai ST
      • Poon LL
      • SARS study group
      • et al.
      Coronavirus as a possible cause of severe acute respiratory syndrome.
      • Ksiazek TG
      • Erdman D
      • Goldsmith CS
      • SARS Working Group
      • et al.
      A novel coronavirus associated with severe acute respiratory syndrome.
      • Drosten C
      • Günther S
      • Preiser W
      • et al.
      Identification of a novel coronavirus in patients with severe acute respiratory syndrome.
      • Tsang KW
      • Ho PL
      • Ooi GC
      • et al.
      A cluster of cases of severe acute respiratory syndrome in Hong Kong.
      • Peiris JSM
      • Chu CM
      • Cheng VCC
      • et al.
      Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet [serial online].
      • Booth CM
      • Matukas LM
      • Tomlinson GA
      • et al.
      Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area.
      and seroconversion, which ultimately occurs in nearly all infected individuals, takes up to 20 days
      • Peiris JSM
      • Chu CM
      • Cheng VCC
      • et al.
      Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet [serial online].
      ; (4) SARS can be extraordinarily contagious,
      • Centers for Disease Control and Prevention
      Severe acute respiratory syndrome—Singapore, 2003.
      • Centers for Disease Control and Prevention
      Severe acute respiratory syndrome—Taiwan, 2003.
      with more than one half of the early cases involving health care workers
      • Lee N
      • Hui D
      • Wu A
      • et al.
      A major outbreak of severe acute respiratory syndrome in Hong Kong.
      • Tsang KW
      • Ho PL
      • Ooi GC
      • et al.
      A cluster of cases of severe acute respiratory syndrome in Hong Kong.
      • Peiris JSM
      • Chu CM
      • Cheng VCC
      • et al.
      Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet [serial online].
      • Booth CM
      • Matukas LM
      • Tomlinson GA
      • et al.
      Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area.
      ; (5) the incubation period of SARS (mean, 6.4 days
      • Donnelly CA
      • Ghani AC
      • Leung GM
      • et al.
      Epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in Hong Kong. Lancet [serial online].
      ) is much longer than that for other respiratory viruses, and it appears that infected persons are not contagious until they become symptomatic; and (6) most cases probably become infected by droplet spread
      • Seto WH
      • Tsang D
      • Yung RW
      • Expert SARS Group of Hospital Authority
      • et al.
      Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS).
      (<10μM respiratory particles inhaled within 2 m of the source), but SARS-CoV can survive for hours on environmental surfaces,
      • World Health Organization
      First data on stability and resistance of SARS coronavirus compiled by members of WHO laboratory network.
      and, at least in theory, there appears to be potential for contact transmission and even fecal-oral spread.
      • Lee N
      • Hui D
      • Wu A
      • et al.
      A major outbreak of severe acute respiratory syndrome in Hong Kong.
      • Peiris JSM
      • Chu CM
      • Cheng VCC
      • et al.
      Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet [serial online].
      • Centers for Disease Control and Prevention
      Severe acute respiratory syndrome—Taiwan, 2003.
      • Hong Kong Department of Health Report
      Main findings of an investigation into the outbreak of severe acute respiratory syndrome at Amoy Gardens.
      In this issue of the Mayo Clinic Proceedings, Sampathkumar et al
      • Sampathkumar P
      • Temesgen Z
      • Smith TF
      • Thompson RL
      SARS: epidemiology, clinical presentation, management, and infection control measures.
      provide a succinct review of SARS and a valuable primer for clinicians and infection control practitioners. Although clinical features of SARS are nonspecific, with near-ubiquitous fever and cough, it must be emphasized that coryza and sore throat, which are common with most other human respiratory virus infections, are uncommon in SARS, and the cough is characteristically nonproductive.
      • Lee N
      • Hui D
      • Wu A
      • et al.
      A major outbreak of severe acute respiratory syndrome in Hong Kong.
      • Tsang KW
      • Ho PL
      • Ooi GC
      • et al.
      A cluster of cases of severe acute respiratory syndrome in Hong Kong.
      • Peiris JSM
      • Chu CM
      • Cheng VCC
      • et al.
      Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet [serial online].
      • Booth CM
      • Matukas LM
      • Tomlinson GA
      • et al.
      Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area.
      In contrast, gastrointestinal symptoms such as diarrhea are common and in some cases may predominate without respiratory symptoms.
      • Peiris JSM
      • Chu CM
      • Cheng VCC
      • et al.
      Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet [serial online].
      • Centers for Disease Control and Prevention
      Severe acute respiratory syndrome—Taiwan, 2003.
      Notably, several laboratory findings, rarely seen with other types of community-acquired pneumonia, may prove to be of considerable value as surrogate markers of early SARS: lymphopenia (<1000/μL); mild thrombocytopenia (<150,000/μL); evidence of disseminated intravascular coagulation with elevated D-dimer levels; low-grade rhabdomyolysis with elevated creatine phosphokinase levels; and especially an elevated lactic dehydrogenase level; 1 or more of these abnormalities are seen in up to 90% of patients, particularly in sicker patients.
      • Lee N
      • Hui D
      • Wu A
      • et al.
      A major outbreak of severe acute respiratory syndrome in Hong Kong.
      • Tsang KW
      • Ho PL
      • Ooi GC
      • et al.
      A cluster of cases of severe acute respiratory syndrome in Hong Kong.
      • Peiris JSM
      • Chu CM
      • Cheng VCC
      • et al.
      Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet [serial online].
      • Booth CM
      • Matukas LM
      • Tomlinson GA
      • et al.
      Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area.
      Until a sensitive, specific, and rapid confirmatory diagnostic test becomes available, for any febrile patient with cough, especially with radiological evidence of pneumonia or acute respiratory distress syndrome (ARDS), who has recently returned from a country where community transmission of SARS is occurring or has occurred or who has had recent close contact with another person suspected of having SARS, an immediate algorithmic approach must be initiated to prevent nosocomial spread. Specific measures include segregating patients with suspected SARS from other patients, ideally in a negative-pressure isolation room; masking the patient; and requiring all health care workers attending to the patient to wear a fit-tested N-95 respirator mask (or powered air-purifying system), a full-length long-sleeved gown and nonsterile gloves, and eye protection with goggles or a face shield.
      • Centers for Disease Control and Prevention
      Interim guidance on infection control precautions for patients with suspected severe acute respiratory syndrome (SARS) and close contacts in house-holds.
      • Centers for Disease Control and Prevention
      Updated interim domestic infection control guidance in the health-care and community setting for patients with suspected SARS.
      Suspicion of SARS must be recorded on all specimens sent to the diagnostic laboratory. As Sampathkumar et al point out, all health care workers attending to the patient must be noted and monitored closely for fever, the earliest sign of occupationally acquired infection.
      The importance of measures to prevent droplet airborne spread cannot be overemphasized. In a novel analysis of a large cohort of health care workers who had had extensive contact with patients with SARS in 5 Hong Kong hospitals, Seto et al
      • Seto WH
      • Tsang D
      • Yung RW
      • Expert SARS Group of Hospital Authority
      • et al.
      Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS).
      found that no health care worker who consistently used a mask, either an N-95 respirator mask or a high-quality surgical mask, became infected (P<.01), even if he or she did not always wear gloves. Hand washing and wearing a gown also appeared to be important in protection against occupationally acquired infection.
      To prevent spread of SARS in the community, public health authorities must strive to identify every contact of the presumed case, especially health care workers exposed without the benefit of barrier precautions, and place them on home quarantine.
      • Centers for Disease Control and Prevention
      Interim guidance on infection control precautions for patients with suspected severe acute respiratory syndrome (SARS) and close contacts in house-holds.
      • Centers for Disease Control and Prevention
      Updated interim domestic infection control guidance in the health-care and community setting for patients with suspected SARS.
      The epidemiological feature of SARS that gives greatest hope for containing spread is the prolonged incubation period, which allows case-contact investigation and quarantine to be instituted before contacts destined to become ill can spread SARS-CoV to others. Whereas quarantine was ineffective in preventing spread of influenza during the great epidemic of 1918
      • Pyle GF
      • Crosby AW
      because of its extremely brief incubation period, isolation of actively infected patients and stringent quarantine of those exposed have been the linchpin of control of SARS in Vietnam, Hong Kong, Singapore, Canada, and perhaps even China.
      • Lee N
      • Hui D
      • Wu A
      • et al.
      A major outbreak of severe acute respiratory syndrome in Hong Kong.
      • Tsang KW
      • Ho PL
      • Ooi GC
      • et al.
      A cluster of cases of severe acute respiratory syndrome in Hong Kong.
      • Peiris JSM
      • Chu CM
      • Cheng VCC
      • et al.
      Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet [serial online].
      • Booth CM
      • Matukas LM
      • Tomlinson GA
      • et al.
      Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area.
      • Donnelly CA
      • Ghani AC
      • Leung GM
      • et al.
      Epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in Hong Kong. Lancet [serial online].
      • World Health Organization
      Update 73 - No new deaths, but vigilance needed for imported cases.
      Beyond ruling out other treatable causes of community-acquired pneumonia and cutting-edge supportive care for critical illness,
      • Maki DG
      Management of life-threatening infection in the ICU.
      including lung-protective low-tidal-volume mechanical ventilatory support,
      • Acute Respiratory Distress Syndrome Network
      Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.
      stringent glycemic control,
      • van den Berghe G
      • Wouters P
      • Weekers F
      • et al.
      Intensive insulin therapy in critically ill patients.
      restrictive use of packed red blood cell transfusions,
      • Hebert PC
      • Wells G
      • Blajchman MA
      • Transfusion Requirements in Critical Care Investigators
      • Canadian Critical Care Trials Group
      • et al.
      A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care [published correction appears in N Engl J Med. 1999;340:1056].
      and uncompromising adherence to basic infection control precautions,
      • Maki DG
      Management of life-threatening infection in the ICU.
      it is still uncertain whether corticosteroids or antivirals, such as ribavirin, both recommended anecdotally by Hong Kong physician-investigators who have treated large numbers of patients,
      • Lee N
      • Hui D
      • Wu A
      • et al.
      A major outbreak of severe acute respiratory syndrome in Hong Kong.
      • Tsang KW
      • Ho PL
      • Ooi GC
      • et al.
      A cluster of cases of severe acute respiratory syndrome in Hong Kong.
      • Peiris JSM
      • Chu CM
      • Cheng VCC
      • et al.
      Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet [serial online].
      will improve outcome in terms of reducing mortality and length of hospitalization. The exuberant, proliferative inflammatory response with alveolar membrane formation seen histopatho-logically
      • Ksiazek TG
      • Erdman D
      • Goldsmith CS
      • SARS Working Group
      • et al.
      A novel coronavirus associated with severe acute respiratory syndrome.
      • Tsang KW
      • Ho PL
      • Ooi GC
      • et al.
      A cluster of cases of severe acute respiratory syndrome in Hong Kong.
      • Peiris JSM
      • Chu CM
      • Cheng VCC
      • et al.
      Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet [serial online].
      is extremely similar to that seen in gardenvariety ARDS but also not unlike desquamative interstitial pneumonitis or organizing pneumonia,
      • Cordier JF
      Organising pneumonia.
      with or without bronchiolitis obliterans,
      • Epler GR
      Bronchiolitis obliterans organizing pneumonia.
      conditions that usually respond favorably to corticosteroids. Evidence that moderate doses of corticosteroids may be of benefit in refractory late-phase severe ARDS
      • Meduri GU
      • Headley AS
      • Golden E
      • et al.
      Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial.
      and unequivocally improve survival in patients with AIDS and severe Pneumocystis carinii pneumonia
      • Gagnon S
      • Boota AM
      • Fischl MA
      • Baier H
      • Kirksey OW
      • La Voie L
      Corticosteroids as adjunctive therapy for severe Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome: a double-blind, placebo-controlled trial.
      further suggests that, in patients with SARS and progressive hypoxemic respiratory failure, early treatment with prednisone at a dose of 1 to 2 mg/kg per day may improve survival. In contrast, the efficacy of antivirals such as ribavirin, which has substantial toxicity,
      • Booth CM
      • Matukas LM
      • Tomlinson GA
      • et al.
      Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area.
      is far less clear, and no antiviral drug or drugs can be recommended at this time. Prospective multicenter randomized trials are urgently needed to determine conclusively the therapeutic role of early use of corticosteroids as well as ribavirin and other candidate antiviral drugs.
      However, the burning question remains: Will SARS continue to spread? Might it even explode on the world in the coming fall and winter months in the Northern Hemisphere (Table 1)? The huge negative economic impact of SARS in Asia and Canada to date has been sobering,
      • Simon B
      The cost of a virus.
      but the very real potential for uncontained global spread is even more sobering. Accelerated efforts to develop a vaccine, with trials in animal models under way, are encouraging. We can take heart that SARS has been successfully contained in most affected countries,
      • World Health Organization
      Cumulative number of reported probable cases of SARS.
      • World Health Organization
      Update 73 - No new deaths, but vigilance needed for imported cases.
      at least for now, but most importantly, SARS may have launched a new era of international cooperation in communicable disease control and public health in general.
      • World Health Organization
      A multicentre collaboration to investigate the cause of severe acute respiratory syndrome.
      • Gerberding JL
      Faster…but fast enough? responding to the epidemic of severe acute respiratory syndrome [editorial].
      It is no longer acceptable for countries to conceal their outbreaks or other health care problems.
      • Benitez MA
      Beijing doctor alleges SARS cases cover-up in China.
      Realizing that each day hundreds of thousands of people from every corner of the globe fly transcontinentally, the world is a rapidly shrinking global village in regard to infectious diseases. It is in every country's selfinterest to be forthcoming and work collaboratively toward a common goal-the prevention of communicable diseases and improvement of the health of every citizen of the world.
      Table 1Parallels Between 1918 Influenza and SARS
      CDC = Centers for Disease Control and Prevention; SARS = severe acute respiratory syndrome.
      Like more recent strains of the influenza A virus,
      • Treanor JT
      Influenza virus.
      the 1918 (H1N1) strain was almost certainly a human-animal recombinant that originated in southern China
      • Brownlee GG
      • Fodor E
      The predicted antigenicity of the haemagglutinin of the 1918 Spanish influenza pandemic suggests an avian origin.
      • Hilleman MR
      Realities and enigmas of human viral influenza: pathogenesis, epidemiology and control.
      In all likelihood, so is the SARS coronavirus (SARS-CoV)
      • Peiris JSM
      • Lai ST
      • Poon LL
      • SARS study group
      • et al.
      Coronavirus as a possible cause of severe acute respiratory syndrome.
      • Ksiazek TG
      • Erdman D
      • Goldsmith CS
      • SARS Working Group
      • et al.
      A novel coronavirus associated with severe acute respiratory syndrome.
      • Drosten C
      • Günther S
      • Preiser W
      • et al.
      Identification of a novel coronavirus in patients with severe acute respiratory syndrome.
      • Ruan Y
      • Wei CL
      • Ling AE
      • et al.
      Comparative full-length genome sequence analysis of 14 SARS coronavirus isolates and common mutations associated with putative origins of infection. Lancet [serial online].
      H1N1 influenza was extraordinarily contagious presumably because there was so little natural immunity in the general population worldwide
      • Hilleman MR
      Realities and enigmas of human viral influenza: pathogenesis, epidemiology and control.
      Serologic surveys by the CDC using specimens from US serum banks show no persons with preexisting antibodies to the new SARS virus
      • Ksiazek TG
      • Erdman D
      • Goldsmith CS
      • SARS Working Group
      • et al.
      A novel coronavirus associated with severe acute respiratory syndrome.
      H1N1 influenza A had high mortality among young and healthy individuals
      • Pyle GF
      • Crosby AW
      SARS has also had a prohibitive mortality
      • World Health Organization
      Cumulative number of reported probable cases of SARS.
      and has killed previously well health care workers, including the discoverer of SARS, Dr Carlo Urbani
      • Reilley B
      • Van Herp M
      • Sermand D
      • Dentico N
      SARS and Carlo Urbani.
      Influenza A classically spreads in the late fall and winter months and is rarely seen during the late spring and summer months
      • Treanor JT
      Influenza virus.
      ; in 1918, influenza continued to occur, inexplicably, all summer
      • Crosby AW
      SARS has caused epidemic disease all spring and will likely continue to spread slowly throughout the summer months
      In 1918, pandemic influenza surged worldwide in late August and the fall
      • Pyle GF
      • Crosby AW
      With SARS, we do not know what will occur, but we must be prepared for the worst; countries, regional and municipal health departments, hospitals, and individual practitioners must be informed and prepared
      * CDC = Centers for Disease Control and Prevention; SARS = severe acute respiratory syndrome.

      Acknowledgments

      We must hang together or assuredly we shall all hang separately.
      Benjamin Franklin

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      Linked Article

      • SARS: Epidemiology, Clinical Presentation, Management, and Infection Control Measures
        Mayo Clinic ProceedingsVol. 78Issue 7
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          Severe acute respiratory syndrome (SARS) is a recently recognized febrile respiratory illness that first appeared in southern China in November 2002, has since spread to several countries, and has resulted in more than 8000 cases and more than 750 deaths. The disease has been etiologically linked to a novel coronavirus that has been named the SARS-associated coronavirus. It appears to be spread primarily by large droplet transmission. There is no specific therapy, and management consists of supportive care.
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