SARS-CoV-2 (COVID-19) and the teaching of Carlo Urbani in Vietnam: a lesson from history almost 20 years after SARS

Carlo Urbani was an infectious diseases expert for Health Organization (WHO), who in 2003, first identified Severe Acute Respiratory Syndrome (SARS) as a new and highly contagious disease. In February, 2003, an American businessman with an unknown lung disease was admitted to a hospital in Vietnam. Doctor Urbani immediately understood that it was a new virus and right after he alerted the WHO and the Vietnamese government; he involved also foreign doctors in the investigation of this case. He advised the authorities to immediately implement quarantine measures and thanks to his quick and unyielding response, the spread of the virus could be stopped quickly, many patients were identified and early isolated. His early warning to the World Health Organization triggered a swift and global response credited with saving numerous lives. He shortly afterwards himself became infected and died. The shut down of Vietnam’s first outbreak was really a very important step for the whole world community and the Urbani’s quick actions were crucial because ensured an early detection of SARS and an effective response from international community.

History for some or lesson for all? A systematic review and meta-analysis on the immediate and long-term mental health impact of the 2002-2003 Severe Acute Respiratory Syndrome (SARS) outbreak

BACKGROUND

The aims of this systematic review and meta-analysis are to examine the prevalence of adverse mental health outcomes, both short-term and long-term, among SARS patients, healthcare workers and the general public of SARS-affected regions, and to examine the protective and risk factors associated with these mental health outcomes.

METHODS

We conducted a systematic search of the literature using databases such as Medline, Pubmed, Embase, PsycInfo, Web of Science Core Collection, CNKI, the National Central Library Online Catalog and dissertation databases to identify studies in the English or Chinese language published between January 2003 to May 2020 which reported psychological distress and mental health morbidities among SARS patients, healthcare workers, and the general public in regions with major SARS outbreaks.

RESULTS

The literature search yielded 6984 titles. Screening resulted in 80 papers for the review, 35 of which were included in the meta-analysis. The prevalence of post-recovery probable or clinician-diagnosed anxiety disorder, depressive disorder, and post-traumatic stress disorder (PTSD) among SARS survivors were 19, 20 and 28%, respectively. The prevalence of these outcomes among studies conducted within and beyond 6 months post-discharge was not significantly different. Certain aspects of mental health-related quality of life measures among SARS survivors remained impaired beyond 6 months post-discharge. The prevalence of probable depressive disorder and PTSD among healthcare workers post-SARS were 12 and 11%, respectively. The general public had increased anxiety levels during SARS, but whether there was a clinically significant population-wide mental health impact remained inconclusive. Narrative synthesis revealed occupational exposure to SARS patients and perceived stigmatisation to be risk factors for adverse mental health outcomes among healthcare workers, although causality could not be determined due to the limitations of the studies.

CONCLUSIONS

The chronicity of psychiatric morbidities among SARS survivors should alert us to the potential long-term mental health complications of covid-19 patients. Healthcare workers working in high-risk venues should be given adequate mental health support. Stigmatisation against patients and healthcare workers should be explored and addressed. The significant risk of bias and high degree of heterogeneity among included studies limited the certainty of the body of evidence of the review.

COVID-19 and Other Pandemics: How Might They Be Prevented?

Pandemics such as influenza, smallpox, and plague have caused the loss of hundreds of millions of lives and have occurred for many centuries. Fortunately, they have been largely eliminated by the use of vaccinations and drugs. More recently, Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and now Coronavirus Disease 2019 (COVID-19) have arisen, and given the current absence of highly effective approved vaccines or drugs, brute-force approaches involving physical barriers are being used to counter virus spread. A major basis for physical protection from respiratory infections is eye, nose, and mouth protection. However, eye protection with goggles is problematic due to "fogging", while nose/mouth protection is complicated by the breathing difficulties associated with non-valved respirators. Here, we give a brief review of the origins and development of face masks and eye protection to counter respiratory infections on the basis of experiments conducted 100 years ago, work that was presaged by the first use of personal protective equipment, "PPE", by the plague doctors of the 17th Century. The results of the review lead to two conclusions: first, that eye protection using filtered eye masks be used to prevent ocular transmission; second, that new, pre-filtered, valved respirators be used to even more effectively block viral transmission.

Overview: The history and pediatric perspectives of severe acute respiratory syndromes: Novel or just like SARS

Many respiratory viral infections such as influenza and measles result in severe acute respiratory symptoms and epidemics. In the spring of 2003, an epidemic of coronavirus pneumonia spread from Guangzhou to Hong Kong and subsequently to the rest of the world. The WHO coined the acronym SARS (severe acute respiratory syndrome) and subsequently the causative virus as SARS-CoV. In the summer of 2012, epidemic of pneumonia occurred again in Saudi Arabia which was subsequently found to be caused by another novel coronavirus. WHO coined the term MERS (Middle East respiratory syndrome) to denote the Middle East origin of the novel virus (MERS-CoV). In the winter of 2019, another outbreak of pneumonia occurred in Wuhan, China which rapidly spread globally. Yet another novel coronavirus was identified as the culprit and has been named SARS-CoV-2 due to its similarities with SARS-CoV, and the disease as coronavirus disease-2019. This overview aims to compare and contrast the similarities and differences of these three major episodes of coronavirus outbreak, and conclude that they are essentially the same viral respiratory syndromes caused by similar strains of coronavirus with different names. Coronaviruses have caused major epidemics and outbreaks worldwide in the last two decades. From an epidemiological perspective, they are remarkably similar in the mode of spread by droplets. Special focus is placed on the pediatric aspects, which carry less morbidity and mortality in all three entities.

The deadly coronaviruses: The 2003 SARS pandemic and the 2020 novel coronavirus epidemic in China

The 2019-nCoV is officially called SARS-CoV-2 and the disease is named COVID-19. This viral epidemic in China has led to the deaths of over 1800 people, mostly elderly or those with an underlying chronic disease or immunosuppressed state. This is the third serious Coronavirus outbreak in less than 20 years, following SARS in 2002-2003 and MERS in 2012. While human strains of Coronavirus are associated with about 15% of cases of the common cold, the SARS-CoV-2 may present with varying degrees of severity, from flu-like symptoms to death. It is currently believed that this deadly Coronavirus strain originated from wild animals at the Huanan market in Wuhan, a city in Hubei province. Bats, snakes and pangolins have been cited as potential carriers based on the sequence homology of CoV isolated from these animals and the viral nucleic acids of the virus isolated from SARS-CoV-2 infected patients. Extreme quarantine measures, including sealing off large cities, closing borders and confining people to their homes, were instituted in January 2020 to prevent spread of the virus, but by that time much of the damage had been done, as human-human transmission became evident. While these quarantine measures are necessary and have prevented a historical disaster along the lines of the Spanish flu, earlier recognition and earlier implementation of quarantine measures may have been even more effective. Lessons learned from SARS resulted in faster determination of the nucleic acid sequence and a more robust quarantine strategy. However, it is clear that finding an effective antiviral and developing a vaccine are still significant challenges. The costs of the epidemic are not limited to medical aspects, as the virus has led to significant sociological, psychological and economic effects globally. Unfortunately, emergence of SARS-CoV-2 has led to numerous reports of Asians being subjected to racist behavior and hate crimes across the world.

Occupational health responses to COVID-19: What lessons can we learn from SARS?

On 31 December 2019, the World Health Organization (WHO) received reports of pneumonia cases of unknown etiology in the city of Wuhan in Hubei Province, China. The agent responsible was subsequently identified as a coronavirus-SARS-CoV-2. The WHO declared this disease as a Public Health Emergency of International Concern at the end of January 2020. This event evoked a sense of déjà vu, as it has many similarities to the outbreak of severe acute respiratory syndrome (SARS) of 2002-2003. Both illnesses were caused by a zoonotic novel coronavirus, both originated during winter in China and both spread rapidly all over the world. However, the case-fatality rate of SARS (9.6%) is higher than that of COVID-19 (<4%). Another zoonotic novel coronavirus, MERS-CoV, was responsible for the Middle East respiratory syndrome, which had a case-fatality rate of 34%. Our experiences in coping with the previous coronavirus outbreaks have better equipped us to face the challenges posed by COVID-19, especially in the health care setting. Among the insights gained from the past outbreaks were: outbreaks caused by viruses are hazardous to healthcare workers; the impact of the disease extends beyond the infection; general principles of prevention and control are effective in containing the disease; the disease poses both a public health as well as an occupational health threat; and emerging infectious diseases pose a continuing threat to the world. Given the perspectives gained and lessons learnt from these past events, we should be better prepared to face the current COVID-19 outbreak.

Taiwan's Experience in Hospital Preparedness and Response for Emerging Infectious Diseases

The Communicable Disease Control Medical Network (CDCMN), established in 2003 after the SARS outbreak in Taiwan, has undergone several phases of modification in structure and activation. The main organizing principles of the CDCMN are centralized isolation of patients with severe highly infectious diseases and centralization of medical resources, as well as a network of designated regional hospitals like those in other countries. The CDCMN is made up of a command system, responding hospitals, and supporting hospitals. It was tested and activated in response to the H1N1 influenza pandemic in 2009-10 and the Ebola outbreak in West Africa in 2014-2016, and it demonstrated high-level functioning and robust capacity. In this article, the history, structure, and operation of the CDCMN is introduced globally for the first time, and the advantages and challenges of this system are discussed. The Taiwanese experience shows an example of a collaboration between the public health system and the medical system that may help other public health authorities plan management and hospital preparedness for highly infectious diseases.

"To rid oneself of the uninvited guest": Robert Koch, Sergei Winogradsky and competing styles of practice in medical microbiology

Does an infectious disease have one, singular pathogenic cause, or many interacting causes? In the discipline of medical microbiology, there is no definitive theoretical answer to this question: there, the conditions of aetiological possibility exist in a curious tension. Ever since the late 19th century, the “germ theory of disease”–“one disease, one cause”– has co-existed with a much less well known theory of “multifactorality”–“one disease, many interacting causes”. And yet, in practice, it is always a singular and never a multifactorial aetiology that emerges once the pathogenic world is brought into the field of medical perception. This paper seeks to understand why. Performing a detailed, genealogical reading of the 2003 severe acute respiratory syndrome (SARS) outbreak, it foregrounds a set of links that connect the practical diagnostic tools at work within contemporary, 21st century laboratories to the philosophical assumptions at work within late-19th century understandings of the “germ theory of disease”.

Stigmatized ethnicity, public health, and globalization

The prejudicial linking of infection with ethnic minority status has a long-established history, but in some ways this association may have intensified under the contemporary circumstances of the "new public health" and globalization. This study analyzes this conflation of ethnicity and disease victimization by considering the stigmatization process that occurred during the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) in Toronto. The attribution of stigma during the SARS outbreak occurred in multiple and overlapping ways informed by: (i) the depiction of images of individuals donning respiratory masks; (ii) employment status in the health sector; and (iii) Asian-Canadian and Chinese-Canadian ethnicity. In turn, stigmatization during the SARS crisis facilitated a moral panic of sorts in which racism at a cultural level was expressed and rationalized on the basis of a rhetoric of the new public health and anti-globalization sentiments. With the former, an emphasis on individualized self-protection, in the health sense, justified the generalized avoidance of those stigmatized. In relation to the latter, in the post-9/11 era, avoidance of the stigmatized other was legitimized on the basis of perceiving the SARS threat as a consequence of the mixing of different people predicated by economic and cultural globalization.

Detection of a novel and highly divergent coronavirus from asian leopard cats and Chinese ferret badgers in Southern China

Since an outbreak of severe acute respiratory syndrome (SARS) was averted in 2004, many novel coronaviruses have been recognized from different species, including humans. Bats have provided the most diverse assemblages of coronaviruses, suggesting that they may be the natural reservoir. Continued virological surveillance has proven to be the best way to avert this infectious disease at the source. Here we provide the first description of a previously unidentified coronavirus lineage detected from wild Asian leopard cats (Prionailurus bengalensis) and Chinese ferret badgers (Melogale moschata) during virological surveillance in southern China. Partial genome analysis revealed a typical coronavirus genome but with a unique putative accessory gene organization. Phylogenetic analyses revealed that the envelope, membrane, and nucleoprotein structural proteins and the two conserved replicase domains, putative RNA-dependent RNA polymerase and RNA helicase, of these novel coronaviruses were most closely related to those of group 3 coronaviruses identified from birds, while the spike protein gene was most closely related to that of group 1 coronaviruses from mammals. However, these viruses always fell into an outgroup phylogenetic relationship with respect to other coronaviruses and had low amino acid similarity to all known coronavirus groups, indicating that they diverged early in the evolutionary history of coronaviruses. These results suggest that these viruses may represent a previously unrecognized evolutionary pathway, or possibly an unidentified coronavirus group. This study demonstrates the importance of systematic virological surveillance in market animals for understanding the evolution and emergence of viruses with infectious potential.

Toronto's Health Department in action: influenza in 1918 and SARS in 2003

This article compares the Toronto Health Department's role in controlling the 1918 influenza epidemic with its activities during the SARS outbreak in 2003 and concludes that local health departments are the foundation for successful disease containment, provided that there is effective coordination, communication, and capacity. In 1918, Toronto's MOH Charles Hastings was the acknowledged leader of efforts to contain the disease, care for the sick, and develop an effective vaccine, because neither a federal health department nor an international body like WHO existed. During the SARS outbreak, Hastings's successor, Sheela Basrur, discovered that nearly a decade of underfunding and new policy foci such as health promotion had left the department vulnerable when faced with a potential epidemic. Lack of cooperation by provincial and federal authorities added further difficulties to the challenge of organizing contact tracing, quarantine, and isolation for suspected and probable cases and providing information and reassurance to the multi-ethnic population. With growing concern about a flu pandemic, the lessons of the past provide a foundation for future communicable disease control activities.

Lessons from severe acute respiratory syndrome (SARS): implications for infection control

Severe acute respiratory syndrome (SARS), the first global epidemic in the 21^st century, affected over 8500 people in approximately 30 countries 1, 2, 3, 4, 5, 6, 7. With a crude mortality of 9%, its cause was quickly identified as a novel coronavirus that jumped species from animals to man. The SARS coronavirus epidemic, which began in the Fall of 2002, was related to the exotic food industry in southern China, initially involving disproportionate numbers of animal handlers, chefs, and caterers. Subsequently, person-to-person transmission spawned the outbreak. What distinguished this illness clinically was the fact that approximately half of the victims were health care workers (8), infected while caring for recognized or unrecognized patients with SARS. There are many curiosities and uncertainties surrounding the epidemic of SARS with lessons that may be useful to the community of infectious diseases physicians, especially when looking ahead to the next epidemic. Herein we relate our perspectives on useful lessons derived from a review of the SARS epidemic.

Emerging infectious diseases at the beginning of the 21st century

The emergence and re-emergence of infectious diseases involves many interrelated factors. Global interconnectedness continues to increase with international travel and trade; economic, political, and cultural interactions; and human-to-human and animal-to-human interactions. These interactions include the accidental and deliberate sharing of microbial agents and antimicrobial resistance and allow the emergence of new and unrecognized microbial disease agents. As the 21st century begins, already new agents have been identified, and new outbreaks have occurred. Solutions to limiting the spread of emerging infectious diseases will require cooperative efforts among many disciplines and entities worldwide. This article defines emerging infectious diseases, summarizes historical background, and discusses factors that contribute to emergence. Seven agents that have made a significant appearance, particularly in the 21st century, are reviewed, including: Ebola and Marburg hemorrhagic fevers, human monkeypox, bovine spongiform encephalopathy, severe acute respiratory syndrome (SARS), West Nile virus, and avian influenza. The article provides for each agent a brief historical background, case descriptions, and health care implications.

Godzilla in the corridor: The Ontario SARS crisis in historical perspective

Ontario nurses were employed as the front-line workers when SARS descended upon Toronto in March 2003. Once the crisis had subsided, many nurses remarked that SARS had forever altered their chosen profession; employment, which they once viewed as relatively safe, had been transformed into potentially life-threatening. This discussion provides descriptions of these expressions through nurses who experienced the crisis and chose to go on the public record. Secondly, it compares the subjective perceptions of those nurses to those held by nurses who worked through historical epidemics of unknown or contested epidemiology. The historical literature on nursing in yellow fever, cholera and influenza epidemics has been employed to offer insight. The goal is to determine whether the SARS outbreak was a unique experience for nurses or whether similar experiences were shared by nurses in the past? In summary, the reactions of nurses when confronted with the possibility of contracting a deadly disease remain altogether human, not dissimilar in past or present. Nurses’ responses to SARS can be usefully studied within a larger historical vision of crisis nursing, and information or impressions from earlier crises are potentially of interest to the nursing profession.

The concept of quarantine in history: from plague to SARS

The concept of ‘quarantine’ is embedded in health practices, attracting heightened interest during episodes of epidemics. The term is strictly related to plague and dates back to 1377, when the Rector of the seaport of Ragusa (then belonging to the Venetian Republic) officially issued a 30-day isolation period for ships, that became 40 days for land travellers.

During the next 100 years similar laws were introduced in Italian and in French ports, and they gradually acquired other connotations with respect to their original implementation.

Measures analogous to those employed against the plague have been adopted to fight against the disease termed the Great White Plague, i.e. tuberculosis, and in recent times various countries have set up official entities for the identification and control of infections.

Even more recently (2003) the proposal of the constitution of a new European monitoring, regulatory and research institution has been made, since the already available system of surveillance has found an enormous challenge in the global emergency of the severe acute respiratory syndrome (SARS). In the absence of a targeted vaccine, general preventive interventions have to be relied upon, including high healthcare surveillance and public information. Quarantine has, therefore, had a rebound of celebrity and updated evidence strongly suggests that its basic concept is still fully valid.

The international response to the outbreak of SARS in 2003

The sudden arrival of an internationally spreading outbreak of a newly identified infectious disease in early 2003, severe acute respiratory syndrome (SARS), provided an opportunity for a coordinated international response based on information and evidence obtained in real time through standard and electronic communications. Its containment represents a new way of working internationally, and demonstrates how intense collaboration in virology, clinical medicine and epidemiology can rapidly provide the information necessary to create and implement evidence-based control measures. The SARS outbreak serves as a reminder of the need for a strong national surveillance and response to infectious diseases, evidence-based international travel recommendations, and a global alert and response network to serve as a safety net when national surveillance fails.