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Introduction
A new disease, severe acute respiratory syndrome (SARS) gained worldwide notoriety in the spring of 2003. From November 2002 until July 2003, when the initial outbreak was declared controlled, the World Health Organization (who) reported the total number of cases world wide as 8,098 with 774 deaths in 30 countries. These numbers made SARS the most rapidly and widely traveled new lethal disease in recent times.1,2
Looking back at the SARS experience, it is obvious SARS demonstrated that the threat of an infectious disease is real, and in today’s closely interconnected and highly mobile world, every country is vulnerable. With no proven therapy available, clinicians reported using respiratory support, antiviral agents such as ribavirin, antibiotics, fever reduction, and hydration. Most deaths occurred among older patients and those with underlying health problems, such as diabetes or hepatitis B. Death rates varied substantially by age:
- Less than 1% in persons 24 years or younger;
- Up to 6% in persons 25 to 44 years;
- Up to 15% in persons 44 to 64 years; and
- Greater than 55% in persons aged 65 or older.3
Although SARS infected and killed far fewer people than other common infectious diseases, such as influenza, malaria, tuberculosis, and HIV– AIDS, its impact was disproportionately felt economically, because it spread in areas with broad international commercial links and received intense media attention. However, SARS demonstrated that with rapid communication, heightened awareness, facilitated by early detection, and isolation of suspected cases, SARS could be contained.
In order to contain SARS and other respiratory infections, Dr. Eddy Bresnitz, New Jersey’s state epidemiologist and then senior assistant commissioner for the New Jersey Department of Health and Senior Services, advocated an important new approach, universal respiratory precautions (URP). These precautions are analogous to universal blood-borne infection precautions that have been the standard of practice since HIV–AIDS first occurred in the early 1980s. The implementation of URP represents a paradigm shift in preventing disease in daily medical practice and assumes that every person with a respiratory illness is a potential source of serious respiratory infection that can be transmitted to others.4
The principles of URP include the early identification of individuals with respiratory illness at the time they present to medical facilities; provision of masks to these individuals, while they sit in waiting areas; separating these patients from patients without respiratory illness; and providing masks or respirators and gloves to health care providers and ensuring they are used when patients are examined. Meticulous hand washing with soap and water before and after contact with ill individuals is also emphasized. In addition, individuals who feel ill are advised to avoid exposure to others by staying home from work and places where vulnerable populations may congregate. All eligible persons should be immunized for influenza and pneumonia. These measures will minimize the transmission of respiratory illness, even without knowing whether the infectious agent is SARS, a common cold virus, or influenza virus.5,6
Scientists have demonstrated that SARS is caused by a novel coronavirus (SARS-CoV) that has been isolated from patients with SARS by several laboratories.7–10 The laboratory of the Centers for Disease Control and Prevention (CDC) sequenced the genome and confirmed that the SARS-CoV is a previously unrecognized coronavirus.11 However, with no point-of-care diagnostic test yet available for the early laboratory confirmation of SARS, it will be difficult to diagnose and differentiate SARS from other severe respiratory syndromes, including influenza.
SARS appears to spread by close person-to-person contact with an infected person. The virus is also transmitted by respiratory droplets. Droplet spread occurs when an infected person coughs or sneezes. The droplets can be propelled up to 3 feet through the air and deposited on the mucous membranes of a nearby person’s mouth, nose or eyes. It is also possible that the SARS virus might be spread from objects contaminated by infectious droplets.23
The lessons learned from the identification, surveillance, control, and containment of SARS have not been lost on those professionals entrusted with being vigilant for agents of bioterrorism. If SARS had not been identified as having an origin in nature, but, instead, had been a modified biological agent designed to cause terror, the methods used by the public health experts would be very similar, if not identical, to those used to contain and control SARS.
Whether naturally occurring or intentionally inflicted, microbial agents [infectious diseases can cause illness, disability, and death in individuals while disrupting entire population, economies, and governments. In the highly interconnected and readily traversed “global village” of our time, one nation’s problem soon becomes every nation’s problem as geographical and political boundaries offer trivial impediments to such threats.13
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