eMedicine Specialties > Infectious Diseases > Lower Respiratory Tract Infections

Severe Acute Respiratory Syndrome (SARS): Follow-up

Author: Richard L Oehler, MD, FACP, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases and Tropical Medicine, Univ of South Florida College of Medicine; Assistant Epidemiologist, Division of Infectious Diseases, Tampa VA Medical Center
Coauthor(s): Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants; Asim A Jani, MD, MPH, FACP, Hospital Epidemiologist, Orlando Regional Medical Center; Assistant Director, Infectious Diseases Fellowship Program, Internal Medicine Residency Program, Orlando Regional Healthcare System; Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Contributor Information and Disclosures

Updated: Oct 31, 2007

Follow-up

Further Inpatient Care

  • Severe acute respiratory syndrome (SARS) is a severe viral illness that requires prompt medical attention and hospitalization.
    • Isolation protocols described in this article must be followed.
    • Local, state, and federal health agencies must be notified.
    • Every attempt must be made to identify individuals who were in contact with a patient with possible or confirmed SARS within the 2 weeks before symptom onset.
    • Patients with SARS may require mechanical ventilation and ICU care.

Further Outpatient Care

  • Once the patient is discharged, confirm that the post–28-day convalescent serum has been collected (or is scheduled to be collected) for diagnostic confirmation.
    • Schedule follow-up care with the patient's primary care physician.
    • Confirm that all the patient's pre-illness contacts have been identified and evaluated.
    • Confirm that all the necessary patient samples have been collected per local, state, and federal health agency regulations.

Inpatient & Outpatient Medications

  • No medication protocols are currently approved for patients with SARS. All patients with SARS should be treated on a case-by-case basis in cooperation with an infectious disease specialist. Input from pulmonary specialists and critical care specialists may also be required.

Deterrence/Prevention

  • See Activity and Multimedia for material pertaining to CDC-recommended SARS isolation and infection-prevention procedures. Travel restrictions and recommendations issued by the WHO should also be reviewed.8
  • Airport screening measures include the following:
    • Airport screening for potentially sick and/or febrile passengers is being conducted in SARS-affected regions in Asia.
    • Infrared scanners designed for use by the military for night operations have been adapted for airport screening use in various locales (eg, Singapore). These scanners are used to identify potentially febrile passengers by measuring their body heat.
    • Individuals with positive screening results on these infrared scanners are then temporarily isolated and brought to a special cubicle, where temperatures are confirmed with an oral thermometer.
    • Any person with a skin temperature of 99.5°F (37.5°C) or greater glows bright red on the scanner. The software is color-coded in temperature ranges; as skin temperature increases, the colors on the scanner change (eg, black to green to yellow and, finally, to red).
    • Many other noninfectious causes can increase skin temperature, including sunburn, ingestion of alcoholic beverages, recent cigarette smoking, or brisk exercise. Thus, false-positive results are common with these scanners.

Complications

  • As with most viral illnesses, SARS encompasses a spectrum of disease severity.
    • Mortality statistics have shown a significant increase with advancing age. Mortality rates are approximately 4-5% in the third decade of life or younger and are approximately 50% in patients older than 65 years. The overall mortality rate is approximately 10%.
    • Recovery may be prolonged, including care in an ICU setting and mechanical ventilation. Complications related to a prolonged illness (eg, deep venous thrombosis, myocardial infarction, stroke) can occur.

Prognosis

  • See Mortality/Morbidity. Note that the evaluation criteria for this illness are largely based on data obtained during the original 2002-2003 outbreak.
  • Some data have suggested that certain risk factors—including older age, chronic hepatitis B infection, and laboratory features such as marked lymphopenia and elevated polymorphonuclear lymphocyte count, lactate dehydrogenase level, and alanine aminotransferase level—are associated with more progressive disease.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • No specific medicolegal pitfalls are associated with severe acute respiratory syndrome (SARS).

Special Concerns

  • Visit the CDC's SARS Information for Travelers Web page for the latest travel alerts and advisories. Details regarding CDC travel alerts versus travel advisories are as follows:
    • Definitions
      • Travel alert: These alerts notify the public that an outbreak of a disease is occurring in a geographic area. The purpose of an alert is to provide accurate information to travelers and resident expatriates about the status of the outbreak, how they can reduce their risk of infection, and what to do if they should become ill while in the area. The risk for the individual traveler is felt to be definable and limited; transmission has occurred in defined settings or is associated with specific risk factors (eg, transmission in a health care or hospital setting where ill patients are being treated). Nonessential travel to the area is not discouraged.
      • Travel advisory: These advisories notify the public that a disease is occurring in a geographic area. The purpose of an advisory is to provide accurate information to travelers and resident expatriates about the status of the outbreak and how they can reduce their risk of infection. They also serve to reduce the volume of traffic to the affected areas, which, in turn, can reduce the risk of translocating the disease to previously unaffected sites. Nonessential travel to the area is discouraged because the risk for the traveler is considered to be much higher than for a simple travel alert notice. For example, the risk is increased because of evidence of community transmission and/or inadequate containment.
    • Criteria for instituting alerts and advisories
      • Disease transmission: The magnitude and scope of the outbreak in the area will affect the decision to issue an advisory or an alert. Criteria that can be used include the presence or absence of community transmission and evidence that cases have been exported from the area.
      • Containment measures: The presence or absence of acceptable outbreak control measures in the affected area can influence the decision to issue a travel advisory or alert. Areas where the disease is occurring and that are considered to have poor or no containment measures in place may have the potential for a higher risk of transmission to exposed persons and translocation to other sites. (Note that isolation refers to the implementation of infection-control measures to isolate individuals who are sick, whereas quarantine refers to the restriction of individuals who are relatively well.)
      • Quality of surveillance: Criteria include whether health authorities in the area have the ability to accurately detect and report cases and to conduct appropriate contact tracing of exposed persons. Areas where the disease is occurring and that are considered to have poor surveillance systems may have the potential for a higher risk of transmission.
      • Quality and accessibility of medical care: Areas where the disease is occurring and that are considered to have suboptimal medical services or infection control procedures in place and remote locations without access to medical evacuation may be considered to present a higher level of risk for the traveler.
    • To downgrade a travel advisory to a travel alert, the following criteria should be met:
      • Adequate surveillance data from the area
      • No evidence of ongoing community transmission for 2 maximal incubation periods after the date of onset of symptoms for the last case (For SARS, this period would be 20 days.)
    • To remove a travel alert, the following criteria should be met:
      • Adequate surveillance data from the area: For example, with SARS, the area would be reporting both probable and suspected cases.
      • No evidence of new cases for 3 maximal incubation periods after the date of onset of symptoms for the last case: For SARS, this period would be 30 days.
      • Limited or no recent instances of unintentional exported cases from the area: This excludes intentional or planned evacuations.
  • WHO travel recommendations
    • Visit the WHO's Travel Web page for the most recent travel recommendations.
    • The most important message for international travelers concerning SARS is to be aware of the main symptoms of SARS: high fever (ie, 100.4°F [38°C]), dry cough, shortness of breath, or breathing difficulties. Persons who experience these symptoms and who have been in an area where recent local transmission of SARS has occurred in the last 10 days are advised to contact a doctor.
    • In the absence of effective drugs or a SARS vaccine, control of this disease relies on the rapid identification of patients and appropriate treatment, including the isolation of suspected and probable cases and the treatment of close contacts. In the great majority of countries, these measures have prevented imported cases from spreading the disease.
      • To further reduce the risk that travelers may carry the SARS virus to new areas, international travelers departing from areas with local transmission in the B or C categories should be screened for possible SARS at the point of departure.
      • Such screening involves answering 2-3 questions and may include a temperature check. Travelers with 1 or more symptoms of SARS who have a history of exposure, who have a fever, or who appear acutely ill should be assessed by a health care worker and may be advised to postpone their trip until they have recovered.
    • The WHO does not presently conclude that goods, products, or animals arriving from areas with SARS outbreaks pose a risk to public health. No restrictions in this regard are recommended.
      • The WHO further recommends that persons arriving from areas with recent local transmission should be aware of the main symptoms of SARS described above and should seek medical advice, initially by telephone, if they develop symptoms in the 10 days after they have left the outbreak area. Healthy persons who are not contacts of probable cases require no special measures and should be free to carry out normal activities.
      • Contacts of probable cases should not travel until 10 days after the last contact, assuming they themselves remain well. If, despite the advice above, a contact of a probable case travels to another country, the person should be placed in voluntary isolation and kept under active surveillance by the health authorities in the country of arrival.
    • Travelers are advised to contact their doctors or national health authorities for supplementary information because individual countries may adapt WHO recommendations to take into account national considerations. Many national health authorities have established Web sites with excellent information.
 


More on Severe Acute Respiratory Syndrome (SARS)

Overview: Severe Acute Respiratory Syndrome (SARS)
Differential Diagnoses & Workup: Severe Acute Respiratory Syndrome (SARS)
Treatment & Medication: Severe Acute Respiratory Syndrome (SARS)
Follow-up: Severe Acute Respiratory Syndrome (SARS)
Multimedia: Severe Acute Respiratory Syndrome (SARS)
References
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Further Reading

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Keywords

Coronaviridae, coronavirus, coronaviruses, SARS genome, SARS-associated coronavirus, SARS-CoV, human coronavirus 229E, HCV-229E, human coronavirus OC43, HCV-OC43, human metapneumovirus, HMP, respiratory syncytial virus, RSV, single-stranded RNA viruses, pneumonia, respiratory tract infection, respiratory failure, bronchiolitis obliterans-organizing pneumonia, BOOP, flulike syndrome, ribavirin, SARS virus, zoonotic virus transmission, zoonotic viral transmission, quarantinable disease, quarantinable communicable disease, communicable diseases

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Contributor Information and Disclosures

Author

Richard L Oehler, MD, FACP, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases and Tropical Medicine, Univ of South Florida College of Medicine; Assistant Epidemiologist, Division of Infectious Diseases, Tampa VA Medical Center
Richard L Oehler, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

Coauthor(s)

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

Asim A Jani, MD, MPH, FACP, Hospital Epidemiologist, Orlando Regional Medical Center; Assistant Director, Infectious Diseases Fellowship Program, Internal Medicine Residency Program, Orlando Regional Healthcare System
Asim A Jani, MD, MPH, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Public Health Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Charles V Sanders, MD, Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center
Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, Professor of Critical Care Medicine, Bioengineering, Cardiovascular Diseases and Anesthesiology, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center
Michael R Pinsky, MD, CM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, Shock Society, and Society of Critical Care Medicine
Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting

 
 
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