View source for Medicine:SARS

{{short description|Disease caused by severe acute respiratory syndrome coronavirus}}
{{Infobox medical condition (new)
| name          = Severe acute respiratory syndrome<br />(SARS)
| synonyms      = Sudden acute respiratory syndrome<ref name="sudden">{{cite journal | vauthors = Likhacheva A | title = SARS Revisited | journal = The Virtual Mentor | volume = 8 | issue = 4 | pages = 219–22 | date = April 2006 | pmid = 23241619 | doi = 10.1001/virtualmentor.2006.8.4.jdsc1-0604 | url = https://journalofethics.ama-assn.org/article/sars-revisited/2006-04 | access-date = 26 April 2020 | url-status = live | quote = SARS—the acronym for sudden acute respiratory syndrome | archive-url = https://web.archive.org/web/20200507053554/https://journalofethics.ama-assn.org/article/sars-revisited/2006-04 | archive-date = 7 May 2020 | doi-access = free }}</ref>
| pronounce     = {{IPAc-en|s|ɑːr|z}}, {{IPAc-en|s|ɑː|z}}
| image         = SARS virion.gif
| caption       = Electron micrograph of SARS coronavirus virion
| field         = [[Medicine:Infectious disease (medical specialty)|Infectious disease]]
| symptoms      = Fever, persistent dry cough, headache, muscle pains, difficulty breathing
| complications = Acute respiratory distress syndrome (ARDS) with other comorbidities that eventually leads to death
| onset         = 
| duration      = 2002–2004
| types         = 
| causes        = [[Biology:Severe acute respiratory syndrome coronavirus|Severe acute respiratory syndrome coronavirus]] (SARS-CoV-1)
| risks         = 
| diagnosis     = 
| differential  = 
| prevention    = Hand washing, cough etiquette, avoiding close contact with infected persons, avoiding travel to affected areas<ref>{{cite web |url=https://www.nhs.uk/conditions/sars/ |title=SARS (severe acute respiratory syndrome) – NHS |publisher=National Health Service |date=24 October 2019 |access-date=22 April 2020 |archive-url=https://web.archive.org/web/20200309174230/https://www.nhs.uk/conditions/sars/ |archive-date=9 March 2020 |url-status=live }}</ref>
| treatment     = 
| medication    = 
| prognosis     = 9.5% chance of death (all countries)
| frequency     = 8,096 cases total {{when|date=October 2023}}
| deaths        = 783 known
| alt           = 
}}
'''Severe acute respiratory syndrome''' ('''SARS''') is a viral [[Medicine:Respiratory disease|respiratory disease]] of zoonotic origin caused by the virus [[Biology:SARS-CoV-1|SARS-CoV-1]], the first identified strain of the [[Biology:SARS-related coronavirus|SARS-related coronavirus]].<ref>{{Cite journal |last1=Al-Juhaishi |first1=Atheer Majid Rashid |last2=Aziz |first2=Noor D. |date=12 September 2022 |title=Safety and Efficacy of antiviral drugs against covid-19 infection: an updated systemic review |url=http://pharmacoj.com/ojs/index.php/Medph/article/view/8 |journal=Medical and Pharmaceutical Journal |language=en |volume=1 |issue=2 |pages=45–55 |doi=10.55940/medphar20226 |s2cid=252960321 |issn=2957-6067 |access-date=27 January 2023 |archive-date=20 February 2023 |archive-url=https://web.archive.org/web/20230220044327/http://pharmacoj.com/ojs/index.php/Medph/article/view/8 |url-status=live |doi-access=free }}</ref> The first known cases occurred in November 2002, and the syndrome caused the [[Medicine:2002–2004 SARS outbreak|2002–2004 SARS outbreak]]. In the 2010s, Chinese scientists traced the virus through the intermediary of [[Biology:Asian palm civet|Asian palm civet]]s to cave-dwelling [[Biology:Horseshoe bat|horseshoe bat]]s in Xiyang Yi Ethnic Township, Yunnan.<ref name=":1">The locality was referred to be "a cave in Kunming" in earlier sources because the Xiyang Yi Ethnic Township is administratively part of Kunming, though 70 km apart. Xiyang was identified on {{cite journal | vauthors = Wang N, Li SY, Yang XL, Huang HM, Zhang YJ, Guo H, Luo CM, Miller M, Zhu G, Chmura AA, Hagan E, Zhou JH, Zhang YZ, Wang LF, Daszak P, Shi ZL | display-authors = 6 | title = Serological Evidence of Bat SARS-Related Coronavirus Infection in Humans, China | journal = Virologica Sinica | volume = 33 | issue = 1 | pages = 104–107 | date = February 2018 | pmid = 29500691 | pmc = 6178078 | doi = 10.1007/s12250-018-0012-7 | url = https://www.ecohealthalliance.org/wp-content/uploads/2018/03/Virologica-Sinica-SARSr.pdf | access-date = 8 January 2020 | url-status = live | archive-url = https://web.archive.org/web/20201101125740/https://www.ecohealthalliance.org/wp-content/uploads/2018/03/Virologica-Sinica-SARSr.pdf | archive-date = 1 November 2020 }}
* For an earlier interview of the researchers about the locality of the caves, see: {{cite news|title=专访"病毒猎人"：在昆明一蝙蝠洞发现SARS病毒所有基因|newspaper=澎湃新闻|date=8 December 2017|last=吴跃伟|url=https://www.thepaper.cn/newsDetail_forward_1897724|access-date=10 April 2022|archive-date=14 March 2023|archive-url=https://web.archive.org/web/20230314180327/https://www.thepaper.cn/newsDetail_forward_1897724|url-status=live}}</ref>

SARS was a relatively rare disease; at the end of the epidemic in June 2003, the incidence was 8,469 cases with a [[Medicine:Case fatality rate|case fatality rate]] (CFR) of 11%.<ref name="Chan2003"/> No cases of SARS-CoV-1 have been reported worldwide since 2004.<ref name="nhssars">{{cite web |title=SARS (severe acute respiratory syndrome) |url=http://www.nhs.uk/conditions/SARS/Pages/Introduction.aspx |work=NHS Choices |publisher=UK National Health Service |access-date=8 March 2016 |date=3 October 2014 |quote=Since 2004, there haven't been any known cases of SARS reported anywhere in the world. |archive-url=https://web.archive.org/web/20160311232941/http://www.nhs.uk/Conditions/sars/Pages/introduction.aspx |archive-date=11 March 2016 |url-status=live }}</ref>

In December 2019, another strain of SARS-CoV was identified as [[Biology:Severe acute respiratory syndrome coronavirus 2|severe acute respiratory syndrome coronavirus 2]] (SARS-CoV-2).<ref>{{cite web |title=New coronavirus stable for hours on surfaces |url=https://www.nih.gov/news-events/news-releases/new-coronavirus-stable-hours-surfaces |website=National Institutes of Health (NIH) |publisher=NIH.gov |access-date=4 May 2020 |language=EN |date=17 March 2020 |archive-url=https://web.archive.org/web/20200323032520/https://www.nih.gov/news-events/news-releases/new-coronavirus-stable-hours-surfaces |archive-date=23 March 2020 |url-status=live }}</ref> This strain, which is related to SARS-CoV-1, caused [[Medicine:Coronavirus disease 2019|coronavirus disease 2019 (COVID-19)]], a disease that brought about the  COVID-19 pandemic.<ref>{{cite web |url=https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters |title=Myth busters |work=WHO.int |publisher=[[Organization:World Health Organization|World Health Organization]] |date=2019 |access-date=15 March 2020 |archive-url=https://web.archive.org/web/20200206055829/https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters |archive-date=6 February 2020 |url-status=live }}</ref>

== Signs and symptoms ==
SARS produces [[Biology:Influenza-like illness|flu-like symptoms]] which may include fever, muscle pain, lethargy, cough, sore throat, and other nonspecific symptoms. The only symptom common to all patients appears to be a fever above {{convert|38|C}}. SARS often leads to shortness of breath and [[Medicine:Pneumonia|pneumonia]], which may be direct [[Medicine:Viral pneumonia|viral pneumonia]] or secondary [[Medicine:Bacterial pneumonia|bacterial pneumonia]].<ref name="Peiris Chu Cheng Chan 2003 pp. 1767–1772">{{cite journal | vauthors = Peiris JS, Chu CM, Cheng VC, Chan KS, Hung IF, Poon LL, Law KI, Tang BS, Hon TY, Chan CS, Chan KH, Ng JS, Zheng BJ, Ng WL, Lai RW, Guan Y, Yuen KY | display-authors = 6 | title = Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study | journal = Lancet | volume = 361 | issue = 9371 | pages = 1767–1772 | date = May 2003 | pmid = 12781535 | pmc = 7112410 | doi = 10.1016/s0140-6736(03)13412-5 }}</ref>

The average [[Medicine:Incubation period|incubation period]] for SARS is 4–6 days, although it is rarely as short as 1 day or as long as 14 days.<ref name=":2">{{Cite report |publisher=World Health Organization |date=2003 |title=Consensus document on the epidemiology of severe acute respiratory syndrome (SARS) |language=en |type=none |hdl=10665/70863}}</ref>

== Transmission ==
The primary [[Medicine:Transmission|route of transmission]] for SARS-CoV is contact of the [[Biology:Mucous membrane|mucous membrane]]s with respiratory droplets or [[Medicine:Fomite|fomite]]s. While [[Medicine:Diarrhea|diarrhea]] is common in people with SARS, the [[Biology:Fecal–oral route|fecal–oral route]] does not appear to be a common mode of transmission.<ref name=":2"/> The [[Medicine:Basic reproduction number|basic reproduction number]] of SARS-CoV, R<sub>0</sub>, ranges from 2 to 4 depending on different analyses. Control measures introduced in April 2003 reduced the R to 0.4.<ref name=":2"/>

== Diagnosis ==
[[File:SARS xray.jpg|thumb|A chest X-ray showing increased opacity in both lungs, indicative of pneumonia, in a patient with SARS]]
SARS-CoV may be suspected in a patient who has:{{citation needed|date=June 2022}}
* Any of the [[Medicine:Symptom|symptom]]s, including a fever of {{convert|38|C}} or higher, and
* Either a history of:
** Contact (sexual or casual) with someone with a [[Medicine:Diagnosis|diagnosis]] of SARS within the last 10 days or
** Travel to any of the regions identified by the [[Organization:World Health Organization|World Health Organization]] (WHO) as areas with recent local transmission of SARS.
* Clinical criteria of Sars-CoV diagnosis<ref name="cdc.gov">{{Cite web|date=22 October 2019|title=SARS {{!}} Home {{!}} Severe Acute Respiratory Syndrome {{!}} SARS-CoV Disease {{!}} CDC|url=https://www.cdc.gov/sars/index.html|access-date=10 June 2020|website=www.cdc.gov|language=en-us|archive-url=https://web.archive.org/web/20200513133747/https://www.cdc.gov/sars/index.html|archive-date=13 May 2020|url-status=live}}</ref>
** Early illness: equal to or more than 2 of the following: [[Physics:Chills|chills]], rigors, [[Medicine:Myalgia|myalgia]], [[Medicine:Diarrhea|diarrhea]], sore throat (self-reported or observed)
** Mild-to-moderate illness: temperature of >{{convert|38|C}} plus indications of lower respiratory tract infection (cough, dyspnea)
** Severe illness: ≥1 of radiographic evidence, presence of [[Medicine:Acute respiratory distress syndrome|ARDS]], autopsy findings in late patients.

For a case to be considered probable, a chest X-ray must be indicative for [[Medicine:Atypical pneumonia|atypical pneumonia]] or [[Medicine:Acute respiratory distress syndrome|acute respiratory distress syndrome]].{{citation needed|date=November 2022}}

The WHO has added the category of "laboratory confirmed SARS" which means patients who would otherwise be considered "probable" and have tested positive for SARS based on one of the approved tests (ELISA, [[Biology:Immunofluorescence|immunofluorescence]] or [[Biology:Polymerase chain reaction|PCR]]) but whose chest X-ray findings do not show SARS-CoV infection (e.g. ground glass opacities, patchy consolidations unilateral).<ref name="cdc.gov"/><ref>{{cite journal | vauthors = Chan PK, To WK, Ng KC, Lam RK, Ng TK, Chan RC, Wu A, Yu WC, Lee N, Hui DS, Lai ST, Hon EK, Li CK, Sung JJ, Tam JS | display-authors = 6 | title = Laboratory diagnosis of SARS | journal = Emerging Infectious Diseases | volume = 10 | issue = 5 | pages = 825–31 | date = May 2004 | pmid = 15200815 | pmc = 3323215 | doi = 10.3201/eid1005.030682 }}</ref>

The appearance of SARS-CoV in chest X-rays is not always uniform but generally appears as an abnormality with patchy infiltrates.<ref>{{cite journal | vauthors = Lu P, Zhou B, Chen X, Yuan M, Gong X, Yang G, Liu J, Yuan B, Zheng G, Yang G, Wang H | display-authors = 6 | title = Chest X-ray imaging of patients with SARS | journal = Chinese Medical Journal | volume = 116 | issue = 7 | pages = 972–5 | date = July 2003 | pmid = 12890364 }}</ref>

==Prevention==
There is a vaccine for SARS, although in March 2020 immunologist [[Biography:Anthony Fauci|Anthony Fauci]] said the CDC developed one and placed it in the [[Social:Strategic National Stockpile|Strategic National Stockpile]].<ref>{{cite web |url=https://www.youtube.com/watch?v=DNXGAxGJgQI |title=Pandemic Preparedness in the Next Administration: Keynote Address by Anthony S. Fauci |publisher=YouTube video- see 27 min |date=14 February 2017 |access-date=22 April 2020 |archive-url=https://web.archive.org/web/20200411012314/https://www.youtube.com/watch?v=DNXGAxGJgQI |archive-date=11 April 2020 |url-status=live }}</ref>  That vaccine, is a final product and field-ready as of March 2022.<ref name=nbcnews1/> [[Medicine:Isolation (health care)|Clinical isolation]] and [[Biology:Vaccination|vaccination]] remain the most effective means to prevent the spread of SARS. Other preventive measures include:
* Hand-washing with soap and water, or use of alcohol-based [[Chemistry:Hand sanitizer|hand sanitizer]]<ref>{{Cite book| author = National Center for Biotechnology Information |url=https://www.ncbi.nlm.nih.gov/books/NBK144054/|title=WHO-recommended handrub formulations |date=2009|publisher=World Health Organization|language=en|access-date=25 March 2020|archive-url=https://web.archive.org/web/20200321142741/https://www.ncbi.nlm.nih.gov/books/NBK144054/|archive-date=21 March 2020|url-status=live}}</ref>
* Disinfection of surfaces of [[Medicine:Fomite|fomite]]s to remove viruses
* Avoiding contact with bodily fluids
* Washing the personal items of someone with SARS in hot, soapy water (eating utensils, dishes, bedding, etc.)<ref>{{cite web|url=http://www.mayoclinic.com/health/sars/DS00501/DSECTION=prevention|title=SARS: Prevention|date=6 January 2011|publisher=MayoClinic.com|access-date=14 July 2013|archive-url=https://web.archive.org/web/20130531024849/http://www.mayoclinic.com/health/sars/DS00501/DSECTION=prevention|archive-date=31 May 2013|url-status=live}}</ref>
* Avoiding travel to affected areas
* Wearing masks and gloves<ref>{{Cite web|url = https://www.nhs.uk/conditions/sars/|title = SARS (Severe acute respiratory syndrome)|date = 19 October 2017|access-date = 1 December 2017|archive-date = 9 March 2020|archive-url = https://web.archive.org/web/20200309174230/https://www.nhs.uk/conditions/sars/|url-status = live}}</ref>
* Keeping people with symptoms home from school
* Simple hygiene measures
* Distancing oneself at least 6 feet if possible to minimize the chances of transmission of the virus

Many public health interventions were made to try to control the spread of the disease, which is mainly spread through respiratory droplets in the air, either inhaled or deposited on surfaces and subsequently transferred to a body's mucous membranes. These interventions included earlier detection of the disease; isolation of people who are infected; droplet and contact precautions; and the use of personal protective equipment (PPE), including masks and isolation gowns.<ref name=Chan2003/> A 2017 meta-analysis found that for medical professionals wearing N-95 masks could reduce the chances of getting sick up to 80% compared to no mask.<ref>{{cite journal | vauthors = Offeddu V, Yung CF, Low MS, Tam CC | title = Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis | journal = Clinical Infectious Diseases | volume = 65 | issue = 11 | pages = 1934–1942 | date = November 2017 | pmid = 29140516 | pmc = 7108111 | doi = 10.1093/cid/cix681 }}</ref> A screening process was also put in place at airports to monitor air travel to and from affected countries.<ref>{{cite web|title=SARS (severe acute respiratory syndrome)|url=https://www.nhs.uk/conditions/sars/|website=nhs.uk|access-date=1 December 2017|date=19 October 2017|archive-url=https://web.archive.org/web/20200309174230/https://www.nhs.uk/conditions/sars/|archive-date=9 March 2020|url-status=live}}</ref>

SARS-CoV is most infectious in severely ill patients, which usually occurs during the second week of illness. This delayed infectious period meant that [[Medicine:Quarantine|quarantine]] was highly effective; people who were isolated before day five of their illness rarely transmitted the disease to others.<ref name=":2"/>

As of 2017, the CDC was still working to make federal and local rapid-response guidelines and recommendations in the event of a reappearance of the virus.<ref>{{cite web|title=SARS|url=https://www.cdc.gov/sars/about/fs-sars.pdf|access-date=1 December 2017|archive-url=https://web.archive.org/web/20171017071031/https://www.cdc.gov/sars/about/fs-sars.pdf|archive-date=17 October 2017|url-status=live}}</ref>

== Treatment ==
[[File:Acte de courage et de dévouement.jpg|thumb|Award to the staff of the Hôpital Français de Hanoï for their dedication during the SARS crisis]]
As SARS is a viral disease, [[Chemistry:Antibiotic|antibiotic]]s do not have direct effect but may be used against bacterial secondary infection. Treatment of SARS is mainly supportive with [[Chemistry:Antipyretic|antipyretic]]s, supplemental oxygen and [[Medicine:Mechanical ventilation|mechanical ventilation]] as needed. While ribavirin is commonly used to treat SARS, there seems to have little to no effect on SARS-CoV, and no impact on patient's outcomes.<ref>{{Cite book|title=Harrison's Internal Medicine, 17th ed.|publisher=Parisianou Publications|pages=1129–1130}}</ref> There is currently no proven [[Biology:Antiviral drug|antiviral]] therapy. Tested substances, include [[Chemistry:Ribavirin|ribavirin]], [[Chemistry:Lopinavir|lopinavir]], [[Chemistry:Ritonavir|ritonavir]], type I [[Biology:Interferon|interferon]], that have thus far shown no conclusive contribution to the disease's course.<ref>{{cite journal | vauthors = Stockman LJ, Bellamy R, Garner P | title = SARS: systematic review of treatment effects | journal = PLOS Medicine | volume = 3 | issue = 9 | pages = e343 | date = September 2006 | pmid = 16968120 | pmc = 1564166 | doi = 10.1371/journal.pmed.0030343 | doi-access = free }}</ref> Administration of [[Biology:Corticosteroid|corticosteroid]]s, is recommended by the British Thoracic Society/British Infection Society/Health Protection Agency in patients with severe disease and [[Medicine:Oxygen saturation|O2 saturation]] of <90%.<ref>{{cite journal | vauthors = Lim WS, Anderson SR, Read RC | title = Hospital management of adults with severe acute respiratory syndrome (SARS) if SARS re-emerges—updated 10 February 2004 | journal = The Journal of Infection | volume = 49 | issue = 1 | pages = 1–7 | date = July 2004 | pmid = 15194240 | pmc = 7133703 | doi = 10.1016/j.jinf.2004.04.001 }}</ref>

People with SARS-CoV must be isolated, preferably in [[Physics:Negative room pressure|negative-pressure rooms]], with complete barrier nursing precautions taken for any necessary contact with these patients, to limit the chances of medical personnel becoming infected.<ref name="cdc.gov"/> In certain cases, [[Physics:Natural ventilation|natural ventilation]] by opening doors and windows is documented to help decreasing indoor concentration of virus particles.<ref>{{cite news |url=https://www.washingtonpost.com/archive/politics/2003/05/05/vietnam-took-lead-in-containing-sars/b9b97e91-b325-42f9-98ef-e23da9f257a0/ |title=Vietnam Took Lead In Containing SARS | vauthors = Nakashima E |newspaper={{wipe|The Washington Post}} |date=5 May 2003 |access-date=6 March 2020 |archive-url=https://web.archive.org/web/20200131124205/https://www.washingtonpost.com/archive/politics/2003/05/05/vietnam-took-lead-in-containing-sars/b9b97e91-b325-42f9-98ef-e23da9f257a0/ |archive-date=31 January 2020 |url-status=live }}</ref>

Some of the more serious damage caused by SARS may be due to the body's own immune system reacting in what is known as [[Medicine:Cytokine storm|cytokine storm]].<ref name="PMID 16322745">{{cite journal | vauthors = Perlman S, Dandekar AA | title = Immunopathogenesis of coronavirus infections: implications for SARS | journal = Nature Reviews. Immunology | volume = 5 | issue = 12 | pages = 917–27 | date = December 2005 | pmid = 16322745 | pmc = 7097326 | doi = 10.1038/nri1732 }}</ref>

===Vaccine===
{{See also|Economics of vaccines|COVID-19 vaccine}}Vaccines can help immune system to create enough antibodies and also it can help to decrease a risk of side effects like arm pain, fever, headache etc.<ref>{{cite journal | vauthors = Jiang S, Lu L, Du L | title = Development of SARS vaccines and therapeutics is still needed | journal = Future Virology | volume = 8 | issue = 1 | pages = 1–2 | date = January 2013 | pmid = 32201503 | pmc = 7079997 | doi = 10.2217/fvl.12.126 }}</ref><ref>{{cite web |title=SARS (severe acute respiratory syndrome) |url=https://www.nhs.uk/conditions/sars/ |website=nhs.uk |access-date=31 January 2020 |language=en |date=19 October 2017 |archive-url=https://web.archive.org/web/20200309174230/https://www.nhs.uk/conditions/sars/ |archive-date=9 March 2020 |url-status=live }}</ref> According to research papers published in 2005 and 2006, the identification and development of novel vaccines and medicines to treat SARS was a priority for governments and public health agencies around the world.<ref name="PMID 15655773">{{cite journal | vauthors = Greenough TC, Babcock GJ, Roberts A, Hernandez HJ, Thomas WD, Coccia JA, Graziano RF, Srinivasan M, Lowy I, Finberg RW, Subbarao K, Vogel L, Somasundaran M, Luzuriaga K, Sullivan JL, Ambrosino DM | display-authors = 6 | title = Development and characterization of a severe acute respiratory syndrome-associated coronavirus-neutralizing human monoclonal antibody that provides effective immunoprophylaxis in mice | journal = The Journal of Infectious Diseases | volume = 191 | issue = 4 | pages = 507–14 | date = February 2005 | pmid = 15655773 | pmc = 7110081 | doi = 10.1086/427242 | s2cid = 10552382 }}</ref><ref name="PMID 15885812">{{cite journal | vauthors = Tripp RA, Haynes LM, Moore D, Anderson B, Tamin A, Harcourt BH, Jones LP, Yilla M, Babcock GJ, Greenough T, Ambrosino DM, Alvarez R, Callaway J, Cavitt S, Kamrud K, Alterson H, Smith J, Harcourt JL, Miao C, Razdan R, Comer JA, Rollin PE, Ksiazek TG, Sanchez A, Rota PA, Bellini WJ, Anderson LJ | display-authors = 6 | title = Monoclonal antibodies to SARS-associated coronavirus (SARS-CoV): identification of neutralizing and antibodies reactive to S, N, M and E viral proteins | journal = Journal of Virological Methods | volume = 128 | issue = 1–2 | pages = 21–8 | date = September 2005 | pmid = 15885812 | pmc = 7112802 | doi = 10.1016/j.jviromet.2005.03.021 | doi-access = free }}</ref><ref name="PMID 16453264">{{cite journal | vauthors = Roberts A, Thomas WD, Guarner J, Lamirande EW, Babcock GJ, Greenough TC, Vogel L, Hayes N, Sullivan JL, Zaki S, Subbarao K, Ambrosino DM | display-authors = 6 | title = Therapy with a severe acute respiratory syndrome-associated coronavirus-neutralizing human monoclonal antibody reduces disease severity and viral burden in golden Syrian hamsters | journal = The Journal of Infectious Diseases | volume = 193 | issue = 5 | pages = 685–92 | date = March 2006 | pmid = 16453264 | pmc = 7109703 | doi = 10.1086/500143 | doi-access = free }}</ref> In early 2004, an early clinical trial on volunteers was planned.<ref>{{cite web |title=China in SARS vaccine trial |work=The Scientist Magazine |date=20 January 2004 |url=https://www.the-scientist.com/news-analysis/china-in-sars-vaccine-trial-50553/ | vauthors = Miller JD |access-date=31 January 2020 |archive-url=https://web.archive.org/web/20200217080053/https://www.the-scientist.com/news-analysis/china-in-sars-vaccine-trial-50553 |archive-date=17 February 2020 |url-status=live }}</ref> A major researcher's 2016 request, however, demonstrated that no field-ready SARS vaccine had been completed because likely market-driven priorities had ended funding.<ref name=nbcnews1>{{cite web |url=https://www.nbcnews.com/health/health-care/scientists-were-close-coronavirus-vaccine-years-ago-then-money-dried-n1150091 |title=Scientists were close to a coronavirus vaccine years ago. Then the money dried up |date=8 March 2020 |publisher=NBC News |access-date=3 May 2020 |archive-url=https://web.archive.org/web/20200501010544/https://www.nbcnews.com/health/health-care/scientists-were-close-coronavirus-vaccine-years-ago-then-money-dried-n1150091 |archive-date=1 May 2020 |url-status=live }}</ref>

==Prognosis==
Several consequent reports from China on some recovered SARS patients showed severe long-time [[Medicine:Sequela|sequela]]e. The most typical diseases include, among other things, [[Medicine:Pulmonary fibrosis|pulmonary fibrosis]], [[Medicine:Osteoporosis|osteoporosis]], and [[Medicine:Avascular necrosis|femoral necrosis]], which have led in some cases to the complete loss of working ability or even self-care ability of people who have recovered from SARS. As a result of quarantine procedures, some of the post-SARS patients have been diagnosed with [[Medicine:Post-traumatic stress disorder|post-traumatic stress disorder]] (PTSD) and major depressive disorder.<ref name="PMID 15324539">{{cite journal | vauthors = Hawryluck L, Gold WL, Robinson S, Pogorski S, Galea S, Styra R | title = SARS control and psychological effects of quarantine, Toronto, Canada | journal = Emerging Infectious Diseases | volume = 10 | issue = 7 | pages = 1206–12 | date = July 2004 | pmid = 15324539 | pmc = 3323345 | doi = 10.3201/eid1007.030703 | doi-broken-date = 22 January 2024 }}</ref><ref>{{cite news |language=zh |url=http://www.infzm.com/content/31372 |title=(Silence of the Post-SARS Patients) |publisher=Southern People Weekly | vauthors = Jinyu M |date=15 July 2009 |access-date=3 August 2013 |archive-url=https://archive.today/20130126090839/http://www.infzm.com/content/31372 |archive-date=26 January 2013 |url-status=live }}</ref>

==Epidemiology==
{{Main|Medicine:2002–2004 SARS outbreak}}
SARS was a relatively rare disease; at the end of the epidemic in June 2003, the incidence was 8,422 cases with a [[Medicine:Case fatality rate|case fatality rate]] (CFR) of 11%.<ref name="Chan2003">{{cite journal | vauthors = Chan-Yeung M, Xu RH | title = SARS: epidemiology | journal = Respirology | volume = 8 | issue = s1 | pages = S9-14 | date = November 2003 | pmid = 15018127 | pmc = 7169193 | doi = 10.1046/j.1440-1843.2003.00518.x }}</ref>

The case fatality rate (CFR) ranges from 0% to 50% depending on the age group of the patient.<ref name=":2"/> Patients under 24 were least likely to die (less than 1%); those 65 and older were most likely to die (over 55%).<ref>{{Cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK92458/|title=SARS: Down But Still a Threat| vauthors = Monaghan KJ |date=2004|publisher=National Academies Press (US)|language=en|access-date=6 February 2018|archive-url=https://web.archive.org/web/20200212145528/https://www.ncbi.nlm.nih.gov/books/NBK92458/|archive-date=12 February 2020|url-status=live}}</ref>

As with [[Medicine:MERS|MERS]] and [[Medicine:COVID-19|COVID-19]], SARS resulted in significantly more deaths of males than females.

[[File:2003 Probable cases of SARS - Worldwide.svg|400px|thumb|2003 Probable cases of SARS – worldwide]]
{| class="wikitable sortable" style="width:430px;"
|+Probable cases of SARS by country or region, <br />1 November 2002 – 31 July 2003<ref>{{cite web |title=Summary of probable SARS cases with onset of illness from 1&nbsp;November 2002 to 31&nbsp;July 2003 |date=21 April 2004 |publisher=World Health Organization |url=https://www.who.int/csr/sars/country/table2004_04_21/en/ |access-date=4 February 2020 |archive-url=https://web.archive.org/web/20200319162659/https://www.who.int/csr/sars/country/table2004_04_21/en/ |archive-date=19 March 2020 |url-status=live }}</ref>
|-
! Country or region
! style="text-align:right;" | Cases
! style="text-align:right;" | Deaths
! style="text-align:right;" | Fatality (%)
|- align=right
|align=left|{{Flagu|China}}{{efn|name=fn1|Figures for China exclude Hong Kong and Macau, which are reported separately by the WHO.}}||5,327||349||6.6
|- align=right
|align=left|{{Flagu|Hong Kong}}||1,755||299||17.0
|- align=right
|align=left|{{Flagu|Taiwan}}{{efn|After 11 July 2003, 325 Taiwanese cases were 'discarded'. Laboratory information was insufficient or incomplete for 135 of the discarded cases; 101 of these patients died.}}||346||81|| 23.4<ref>{{Cite web|title=衛生署針對報載SARS死亡人數有極大差異乙事提出說明|url=https://www.cdc.gov.tw/Bulletin/Detail/epPvhTanl4S984qYmcaMXA?typeid=9|access-date=1 December 2021|website=www.cdc.gov.tw|language=zh-Hant|archive-date=20 March 2020|archive-url=https://web.archive.org/web/20200320075731/https://www.cdc.gov.tw/Bulletin/Detail/epPvhTanl4S984qYmcaMXA?typeid=9|url-status=live}}</ref>
|- align=right
|align=left|{{Flagu|Canada}}||251||43||17.1
|- align=right
|align=left|{{Flagu|Singapore}}||238||33||13.9
|- align=right
|align=left|{{Flagu|Vietnam}}||63||5||7.9
|- align=right
|align=left|{{nowrap|{{Flagu|United States}}}}||27||0||0
|- align=right
|align=left|{{Flagu|Philippines}}||14||2||14.3
|- align=right
|align=left|{{Flagu|Thailand}}||9||2||22.2
|- align=right
|align=left|{{Flagu|Germany}}||9||0||0
|- align=right
|align=left|{{Flagu|Mongolia}}||9||0||0
|- align=right
|align=left|{{Flagu|France}}||7||1||14.3
|- align=right
|align=left|{{Flagu|Australia}}||6||0||0
|- align=right
|align=left|{{Flagu|Malaysia}}||5||2||40.0
|- align=right
|align=left|{{Flagu|Sweden}}||5||0||0
|- align=right
|align=left|{{Flagu|United Kingdom}}||4||0||0
|- align=right
|align=left|{{Flagu|Italy}}||4||0||0
|- align=right
|align=left|{{Flagu|Brazil}}||3||0||0
|- align=right
|align=left|{{Flagu|India}}||3||0||0
|- align=right
|align=left|{{Flagu|South Korea|1997}}||3||0||0
|- align=right
|align=left|{{Flagu|Indonesia}}||2||0||0
|- align=right
|align=left|{{Flagu|South Africa}}||1||1||100.0
|- align=right
|align=left|{{Flagu|Colombia}}||1||0||0
|- align=right
|align=left|{{Flagu|Kuwait}}||1||0||0
|- align=right
|align=left|{{Flagu|Ireland}}||1||0||0
|- align=right
|align=left|{{Flagu|Macao}}||1||0||0
|- align=right
|align=left|{{Flagu|New Zealand}}||1||0||0
|- align=right
|align=left|{{Flagu|Romania}}||1||0||0
|- align=right
|align=left|{{Flagu|Russia}}||1||0||0
|- align=right
|align=left|{{Flagu|Spain}}||1||0||0
|- align=right
|align=left|{{Flagu|Switzerland}}||1||0||0
|- align=right
| style="text-align:left;" | {{nowrap|Total excluding China{{efn|name=fn1}}}}||2,769||454||16.4
|-  style="text-align:right; font-weight:bold;"
| style="text-align:left;" | Total (29 territories) || 8,096 || 782 || 9.6
|-
| colspan=5 style="font-size: smaller;" | {{notelist}}
|}

=== Outbreak in South China ===
The SARS epidemic began in the Guangdong province of China in November 2002. The earliest case developed symptoms on 16 November 2002.<ref>{{cite journal | vauthors = Feng D, de Vlas SJ, Fang LQ, Han XN, Zhao WJ, Sheng S, Yang H, Jia ZW, Richardus JH, Cao WC | display-authors = 6 | title = The SARS epidemic in mainland China: bringing together all epidemiological data | journal = Tropical Medicine & International Health | volume = 14 | issue = s1 | pages = 4–13 | date = November 2009 | pmid = 19508441 | pmc = 7169858 | doi = 10.1111/j.1365-3156.2008.02145.x }}</ref> The index patient, a farmer from Shunde, Foshan, Guangdong, was treated in the First People's Hospital of Foshan. The patient died soon after, and no definite diagnosis was made on his cause of death. Despite taking some action to control it, Chinese government officials did not inform the World Health Organization of the outbreak until February 2003. This lack of openness caused delays in efforts to control the epidemic, resulting in criticism of the People's Republic of China from the international community. China officially apologized for early slowness in dealing with the SARS epidemic.<ref>{{cite news |url=http://www.cnn.com/2003/HEALTH/04/05/sars.vaccine/index.html |title=WHO targets SARS 'super spreaders' |publisher=CNN |date=6 April 2003 |access-date=5 July 2006 |url-status=dead |archive-url=https://web.archive.org/web/20060307182402/http://www.cnn.com/2003/HEALTH/04/05/sars.vaccine/index.html |archive-date=7 March 2006 }}</ref>

The viral outbreak was subsequently genetically traced to a colony of cave-dwelling [[Biology:Horseshoe bat|horseshoe bat]]s in Xiyang Yi Ethnic Township, Yunnan.<ref name=":1"/>

The outbreak first came to the attention of the international medical community on 27 November 2002, when Canada's [[Medicine:Global Public Health Intelligence Network|Global Public Health Intelligence Network]] (GPHIN), an electronic warning system that is part of the World Health Organization's [[Organization:Global Outbreak Alert and Response Network|Global Outbreak Alert and Response Network]] (GOARN), picked up reports of a "flu outbreak" in China through Internet media monitoring and analysis and sent them to the WHO. While GPHIN's capability had recently been upgraded to enable Arabic, Chinese, English, French, Russian, and Spanish translation, the system was limited to English or French in presenting this information. Thus, while the first reports of an unusual outbreak were in Chinese, an English report was not generated until 21 January 2003.<ref name="Mawadeku and Blench">{{cite web |url=http://www.mt-archive.info/MTS-2005-Mawudeku.pdf | vauthors = Mawudeku A, Blench M |title=Global Public Health Intelligence Network |year=2005 |publisher=Public Health Agency of Canada |access-date=7 June 2007 |archive-url=https://web.archive.org/web/20070616003532/http://www.mt-archive.info/MTS-2005-Mawudeku.pdf |archive-date=16 June 2007 |url-status=live }}</ref><ref name="PMID 15040346">{{cite journal | vauthors = Heymann DL, Rodier G | title = Global surveillance, national surveillance, and SARS | journal = Emerging Infectious Diseases | volume = 10 | issue = 2 | pages = 173–5 | date = February 2004 | pmid = 15040346 | pmc = 3322938 | doi = 10.3201/eid1002.031038 }}</ref> The first [[Medicine:Super-spreader|super-spreader]] was admitted to the Sun Yat-sen Memorial Hospital in Guangzhou on 31 January, which soon spread the disease to nearby hospitals.<ref>{{cite book | vauthors = Abraham T |date=2004 |title=Twenty-first Century Plague: The Story of SARS |publisher=Johns Hopkins University Press |isbn=9780801881244 |url=https://archive.org/details/twentyfirstcentu00thom |url-access=registration |access-date=6 November 2019 |archive-url=https://web.archive.org/web/20200226203419/https://archive.org/details/twentyfirstcentu00thom |archive-date=26 February 2020 |url-status=live }}</ref>

In early April 2003, after a prominent physician, [[Biography:Jiang Yanyong|Jiang Yanyong]], pushed to report the danger to China,<ref name="China Status 2007">{{cite news | vauthors = Kahn J | url=https://www.nytimes.com/2007/07/13/world/asia/13iht-13doctor.6640426.html | title=China bars U.S. trip for doctor who exposed SARS cover-up | newspaper=The New York Times | date=12 July 2007 | access-date=3 August 2013 | archive-url=https://web.archive.org/web/20141216095838/http://www.nytimes.com/2007/07/13/world/asia/13iht-13doctor.6640426.html | archive-date=16 December 2014 | url-status=live }}</ref><ref name="award 2004">{{cite web | url=http://www.rmaf.org.ph/Awardees/Citation/CitationJiangYan.htm | title=The 2004 Ramon Magsaysay Awardee for Public Service | publisher=Ramon Magsaysay Foundation | date=31 August 2004 | access-date=3 May 2013 | archive-url=https://web.archive.org/web/20070614083317/http://www.rmaf.org.ph/Awardees/Citation/CitationJiangYan.htm | archive-date=14 June 2007 | url-status=dead }}</ref> there appeared to be a change in official policy when SARS began to receive a much greater prominence in the official media. Some have directly attributed this to the death of an American teacher, James Earl Salisbury, in Hong Kong.<ref>{{cite news |url=http://www.cnn.com/2003/HEALTH/04/10/sars/index.html |title=SARS death leads to China dispute |publisher=CNN |date=10 April 2003 |access-date=3 April 2007 |url-status=dead |archive-url=https://web.archive.org/web/20071128060248/http://www.cnn.com/2003/HEALTH/04/10/sars/index.html |archive-date=28 November 2007 }}</ref> It was around this same time that Jiang Yanyong made accusations regarding the undercounting of cases in Beijing military hospitals.<ref name="China Status 2007"/><ref name="award 2004"/> After intense pressure, Chinese officials allowed international officials to investigate the situation there. This revealed problems plaguing the aging mainland Chinese healthcare system, including increasing decentralization, [[Social:Red tape|red tape]], and inadequate communication.<ref>{{Citation |last=Huang |first=Yanzhong |title=THE SARS EPIDEMIC AND ITS AFTERMATH IN CHINA: A POLITICAL PERSPECTIVE |date=2004 |url=https://www.ncbi.nlm.nih.gov/books/NBK92479/ |work=Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary |access-date=19 May 2023 |publisher=National Academies Press (US) |language=en}}</ref>

Many healthcare workers in the affected nations risked their lives and died by treating patients, and trying to contain the infection before ways to prevent infection were known.<ref>{{cite news | vauthors = Fong K |title=They risked their lives to stop Sars |url=https://www.bbc.com/news/magazine-23710697 |work=BBC News |date=16 August 2013 |access-date=31 January 2020 |archive-url=https://web.archive.org/web/20200209132716/https://www.bbc.com/news/magazine-23710697 |archive-date=9 February 2020 |url-status=live }}</ref>

===Spread to other regions===
The epidemic reached the public spotlight in February 2003, when an American businessman traveling from China, Johnny Chen, became affected by pneumonia-like symptoms while on a flight to Singapore. The plane stopped in [[Place:Hanoi|Hanoi]], Vietnam, where the patient died in Hanoi French Hospital. Several of the medical staff who treated him soon developed the same disease despite basic hospital procedures. Italian doctor [[Biography:Carlo Urbani|Carlo Urbani]] identified the threat and communicated it to WHO and the Vietnamese government; he later died from the disease.<ref>{{cite web|title= Dr. Carlo Urbani of the World Health Organization dies of SARS|url=https://www.who.int/csr/sars/urbani/en/|website=WHO |access-date=29 November 2017|archive-url=https://web.archive.org/web/20170704000323/http://www.who.int/csr/sars/urbani/en/ |date=29 March 2003 |archive-date=4 July 2017|url-status=dead}}</ref>

The severity of the symptoms and the infection among hospital staff alarmed global health authorities, who were fearful of another emergent pneumonia epidemic. On 12 March 2003, the WHO issued a global alert, followed by a health alert by the United States Centers for Disease Control and Prevention (CDC). Local transmission of SARS took place in Toronto, Ottawa, San Francisco, [[Place:Ulaanbaatar|Ulaanbaatar]], [[Place:Manila|Manila]], Singapore, Taiwan, Hanoi and Hong Kong whereas within China it spread to Guangdong, Jilin, Hebei, Hubei, Shaanxi, Jiangsu, Shanxi, [[Place:Tianjin|Tianjin]], and [[Place:Inner Mongolia|Inner Mongolia]].{{citation needed|date=November 2017}}

====Hong Kong====
[[File:Hotel Metropole 9th floor layout SARS 2003.svg|thumb|upright=1.4|9th-floor layout of the Hotel Metropole in Hong Kong, showing where a [[Medicine:Super-spreader|super-spreading]] event of severe acute respiratory syndrome (SARS) occurred]]
The disease spread in Hong Kong from Liu Jianlun, a Guangdong doctor who was treating patients at Sun Yat-Sen Memorial Hospital.<ref>{{cite news |date=27 March 2003 |title=Inside the hospital where Patient Zero was infected |url=http://www.scmp.com/article/410652/inside-hospital-where-patient-zero-was-infected |work=South China Morning Post |access-date=23 May 2018 |archive-url=https://web.archive.org/web/20180524082337/http://www.scmp.com/article/410652/inside-hospital-where-patient-zero-was-infected |archive-date=24 May 2018 |url-status=live }}</ref> He arrived in February and stayed on the ninth floor of the Metropole Hotel in Kowloon, infecting 16 of the hotel visitors. Those visitors traveled to Canada, Singapore, Taiwan, and Vietnam, spreading SARS to those locations.<ref>{{cite journal | vauthors = Griffiths S |title=SARS in Hong Kong |journal=Oxford Medical School Gazette |volume=54 |issue=1 |url=http://www.medsci.ox.ac.uk/gazette/previousissues/54vol1/Part21/ |access-date=10 November 2008 |url-status=dead |archive-url=https://web.archive.org/web/20081010223237/http://www.medsci.ox.ac.uk/gazette/previousissues/54vol1/Part21/ |archive-date=10 October 2008 }}</ref>

Another larger cluster of cases in Hong Kong centred on the Amoy Gardens housing estate. Its spread is suspected to have been facilitated by defects in its bathroom drainage system that allowed sewer gases including virus particles to vent into the room. Bathroom fans exhausted the gases and wind carried the contagion to adjacent downwind complexes. Concerned citizens in Hong Kong worried that information was not reaching people quickly enough and created a website called sosick.org, which eventually forced the Hong Kong government to provide information related to SARS in a timely manner.<ref>{{cite news|url=https://www.npr.org/templates/story/story.php?storyId=1264207|title=Hong Kong Residents Share SARS Information Online|website=NPR.org|access-date=11 May 2016|archive-url=https://web.archive.org/web/20160605115053/http://www.npr.org/templates/story/story.php?storyId=1264207|archive-date=5 June 2016|url-status=live}}</ref> The first cohort of affected people were discharged from hospital on 29 March 2003.<ref>{{cite web|url=http://www.news-medical.net/news/2004/04/24/821.aspx|title=Severe Acute Respiratory Syndrome (SARS) overview|date=24 April 2004|website=News Medical Life Sciences|publisher=AZO network|archive-url=https://web.archive.org/web/20160604124901/http://www.news-medical.net/news/2004/04/24/821.aspx|archive-date=4 June 2016|url-status=live}}</ref>

====Canada====
The first case of SARS in Toronto was identified on 23 February 2003.<ref>{{cite web|url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5223a4.htm|title=Update: Severe Acute Respiratory Syndrome – Toronto, Canada, 2003|website=www.cdc.gov|access-date=11 May 2016|archive-url=https://web.archive.org/web/20160513181309/http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5223a4.htm|archive-date=13 May 2016|url-status=live}}</ref> Beginning with an elderly woman, Kwan Sui-Chu, who had returned from a trip to Hong Kong and died on 5 March, the virus eventually infected 257 individuals in the province of Ontario. The trajectory of this outbreak is typically divided into two phases, the first centring around her son Tse Chi Kwai, who infected other patients at the Scarborough Grace Hospital and died on 13 March. The second major wave of cases was clustered around accidental exposure among patients, visitors, and staff within the North York General Hospital. The WHO officially removed Toronto from its list of infected areas by the end of June 2003.<ref>{{cite book | vauthors = Low D |date=2004 |title=Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary}}</ref>

The official response by the Ontario provincial government and Canadian federal government has been widely criticized in the years following the outbreak. Brian Schwartz, vice-chair of Ontario's SARS Scientific Advisory Committee, described public health officials' preparedness and emergency response at the time of the outbreak as "very, very basic and minimal at best".<ref>{{cite news|url=http://www.cbc.ca/news/health/mers-outbreak-3-lessons-canada-learned-from-sars-1.3109550|title=Is Canada ready for MERS? 3 lessons learned from SARS|website=www.cbc.ca|access-date=11 May 2016|archive-url=https://web.archive.org/web/20160513160311/http://www.cbc.ca/news/health/mers-outbreak-3-lessons-canada-learned-from-sars-1.3109550|archive-date=13 May 2016|url-status=live}}</ref> Critics of the response often cite poorly outlined and enforced protocol for protecting healthcare workers and identifying infected patients as a major contributing factor to the continued spread of the virus. The atmosphere of fear and uncertainty surrounding the outbreak resulted in staffing issues in area hospitals when healthcare workers elected to resign rather than risk exposure to SARS.{{citation needed|date=November 2017}}

===Identification of virus===
In late February 2003, Italian doctor [[Biography:Carlo Urbani|Carlo Urbani]] was called into The French Hospital of Hanoi to look at Johnny Chen, an American businessman who had fallen ill with what doctors thought was a bad case of [[Medicine:Influenza|influenza]]. Urbani realized that Chen's ailment was probably a new and highly contagious disease. He immediately notified the WHO. He also persuaded the Vietnamese Health Ministry to begin isolating patients and screening travelers, thus slowing the early pace of the epidemic.<ref name="who_2004_04_21">{{cite web |url=https://www.who.int/csr/sars/country/table2004_04_21/en/index.html |title=Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003 |date=31 December 2003 |publisher=[[Organization:World Health Organization|World Health Organization]] (WHO) |access-date=31 October 2008 |archive-url=https://web.archive.org/web/20110624025825/http://www.who.int/csr/sars/country/table2004_04_21/en/index.html |archive-date=24 June 2011 |url-status=live }}</ref> He subsequently contracted the disease himself, and died in March 2003.<ref>{{cite news | url=http://www.timesonline.co.uk/tol/comment/obituaries/article1129034.ece | location=London | work=The Times | vauthors = Coates S, Anushka A | title=Dr Carlo Urbani Health expert who identified the Sars outbreak as an epidemic, and was killed by the virus | access-date=21 May 2020 | archive-url=https://web.archive.org/web/20110605002200/http://www.timesonline.co.uk/tol/comment/obituaries/article1129034.ece | archive-date=5 June 2011 | url-status=live }}{{subscription required}}</ref><ref>{{cite news| url=https://www.who.int/csr/sars/urbani/en/| date=29 March 2003| access-date=23 January 2020| work=WHO| title=Dr. Carlo Urbani of the World Health Organization dies of SARS| archive-url=https://web.archive.org/web/20200611054924/https://www.who.int/csr/sars/urbani/en/| archive-date=11 June 2020| url-status=dead}}</ref>

[[Biography:Malik Peiris|Malik Peiris]] and his colleagues became the first to isolate the virus that causes SARS,<ref>{{cite journal |title=Coronavirus as a possible cause of severe acute respiratory syndrome |journal=The Lancet |volume=361 |issue=9366 |pages=1319–1325 |year=2003 |pmid=12711465 |doi=10.1016/S0140-6736(03)13077-2 |pmc=7112372 |first1=JSM |last1=Peiris |first2=ST |last2=Lai |first3=LLM |last3=Poon |first4=Y |last4=Guan |first5=LYC |last5=Yam |first6=W |last6=Lim |first7=J |last7=Nicholls |first8=WKS |last8=Yee |first9=WW |last9=Yan |first10=MT |last10=Cheung |first11=VCC |last11=Cheng |first12=KH |last12=Chan |first13=DNC |last13=Tsang |first14=RWH |last14=Yung |first15=TK |last15=Ng |first16=KY |last16=Yuen|last17=SARS study group }}</ref> a [[Biology:Novel coronavirus|novel coronavirus]] now known as [[Biology:Severe acute respiratory syndrome coronavirus 1|SARS-CoV-1]].<ref>{{cite journal |title=Pathogenesis of severe acute respiratory syndrome |journal=Current Opinion in Immunology |volume=17 |issue=4 |pages=404–410 |year=2005 |pmid=15950449 |doi=10.1016/j.coi.2005.05.009 |pmc=7127490 |first1=Yu Lung |last1=Lau |first2=JS Malik |last2=Peiris }}</ref><ref>{{cite journal |last1=Normile |first1=Dennis |title=Up Close and Personal With SARS |journal=Science |date=2003 |volume=300 |issue=5621 |pages=886–887 |doi=10.1126/science.300.5621.886 |pmid=12738826 |url=https://www.science.org/doi/10.1126/science.300.5621.886 |s2cid=58433622 |access-date=27 October 2022 |archive-date=27 October 2022 |archive-url=https://web.archive.org/web/20221027084348/https://www.science.org/doi/10.1126/science.300.5621.886 |url-status=live }}</ref> By June 2003, Peiris, together with his long-time collaborators Leo Poon and Guan Yi, has developed a rapid [[Organization:Laboratory diagnosis of viral infections|diagnostic]] test for SARS-CoV-1 using [[Biology:Real-time polymerase chain reaction|real-time polymerase chain reaction]].<ref>{{cite journal |last1=Poon |first1=Leo LM |last2=Wong |first2=On Kei |last3=Luk |first3=Winsie |last4=Yuen |first4=Kwok Yung |last5=Peiris |first5=Joseph SM |last6=Guan |first6=Yi |title=Rapid Diagnosis of a Coronavirus Associated with Severe Acute Respiratory Syndrome (SARS) |journal=Clinical Chemistry |date=2003 |volume=49 |issue=6 |pages=953–955 |doi=10.1373/49.6.953 |pmid=12765993 |pmc=7108127 }}</ref> The CDC and Canada's National Microbiology Laboratory identified the SARS [[Biology:Genome|genome]] in April 2003.<ref>{{cite web |url=https://www.cdc.gov/about/history/sars/feature.htm |title=Remembering SARS: A Deadly Puzzle and the Efforts to Solve It |date=11 April 2013 |access-date=3 August 2013 |publisher=Centers for Disease Control and Prevention |archive-url=https://web.archive.org/web/20130801143131/http://www.cdc.gov/about/history/sars/feature.htm |archive-date=1 August 2013 |url-status=live }}</ref><ref>{{cite web |url=https://www.who.int/mediacentre/releases/2003/pr31/en/ |title=Coronavirus never before seen in humans is the cause of SARS |publisher=United Nations World Health Organization |date=16 April 2006 |access-date=5 July 2006 |archive-url=https://web.archive.org/web/20040812124322/http://www.who.int/mediacentre/releases/2003/pr31/en/ |archive-date=12 August 2004 |url-status=dead }}</ref> Scientists at Erasmus University in Rotterdam, the Netherlands demonstrated that the SARS coronavirus fulfilled [[Medicine:Koch's postulates|Koch's postulates]] thereby suggesting it as the causative agent. In the experiments, [[Biology:Macaque|macaque]]s infected with the virus developed the same symptoms as human SARS patients.<ref name="PMID 12748632">{{cite journal | vauthors = Fouchier RA, Kuiken T, Schutten M, van Amerongen G, van Doornum GJ, van den Hoogen BG, Peiris M, Lim W, Stöhr K, Osterhaus AD | display-authors = 6 | title = Aetiology: Koch's postulates fulfilled for SARS virus | journal = Nature | volume = 423 | issue = 6937 | pages = 240 | date = May 2003 | pmid = 12748632 | pmc = 7095368 | doi = 10.1038/423240a | bibcode = 2003Natur.423..240F }}</ref>

==== Origin and animal vectors ====
In late May 2003, a study was conducted using samples of wild animals sold as food in the local market in Guangdong, China.<ref name="pmid12958366">{{cite journal |vauthors=Guan Y, Zheng BJ, He YQ, Liu XL, Zhuang ZX, Cheung CL, Luo SW, Li PH, Zhang LJ, Guan YJ, Butt KM, Wong KL, Chan KW, Lim W, Shortridge KF, Yuen KY, Peiris JS, Poon LL |title=Isolation and characterization of viruses related to the SARS coronavirus from animals in southern China |journal=Science |volume=302 |issue=5643 |pages=276–8 |date=October 2003 |pmid=12958366 |doi=10.1126/science.1087139 |bibcode=2003Sci...302..276G |s2cid=10608627 |url=https://zenodo.org/record/3949022 |access-date=4 April 2022 |archive-date=19 March 2023 |archive-url=https://web.archive.org/web/20230319035007/https://zenodo.org/record/3949022 |url-status=live |doi-access=free }}</ref> The study found that "SARS-like" coronaviruses could be isolated from masked palm civets (''Paguma'' sp.). Genomic sequencing determined that these animal viruses were very similar to human SARS viruses, however they were [[Biology:Phylogenetic tree|phylogenetically]] distinct, and so the study concluded that it was unclear whether they were the natural reservoir in the wild. Still, more than 10,000 masked palm civets were killed in Guangdong Province since they were a "potential infectious source."<ref name="pmid16140765">{{cite journal |vauthors=Kan B, Wang M, Jing H, Xu H, Jiang X, Yan M, Liang W, Zheng H, Wan K, Liu Q, Cui B, Xu Y, Zhang E, Wang H, Ye J, Li G, Li M, Cui Z, Qi X, Chen K, Du L, Gao K, Zhao YT, Zou XZ, Feng YJ, Gao YF, Hai R, Yu D, Guan Y, Xu J |title=Molecular evolution analysis and geographic investigation of severe acute respiratory syndrome coronavirus-like virus in palm civets at an animal market and on farms |journal=J Virol |volume=79 |issue=18 |pages=11892–900 |date=September 2005 |pmid=16140765 |pmc=1212604 |doi=10.1128/JVI.79.18.11892-11900.2005 |url=}}</ref> The virus was also later found in [[Biology:Raccoon dog|raccoon dog]]s (''Nyctereuteus'' sp.), ferret badgers (''Melogale'' spp.), and domestic cats.{{citation needed|date=June 2022}}

In 2005, two studies identified a number of SARS-like coronaviruses in Chinese bats.<ref name="PMID 16195424">{{cite journal | vauthors = Li W, Shi Z, Yu M, Ren W, Smith C, Epstein JH, Wang H, Crameri G, Hu Z, Zhang H, Zhang J, McEachern J, Field H, Daszak P, Eaton BT, Zhang S, Wang LF | display-authors = 6 | title = Bats are natural reservoirs of SARS-like coronaviruses | journal = Science | volume = 310 | issue = 5748 | pages = 676–9 | date = October 2005 | pmid = 16195424 | doi = 10.1126/science.1118391 | url = https://zenodo.org/record/3949088 | s2cid = 2971923 | bibcode = 2005Sci...310..676L | access-date = 30 September 2020 | archive-date = 11 November 2020 | archive-url = https://web.archive.org/web/20201111110805/https://zenodo.org/record/3949088 | url-status = live | doi-access = free }}</ref><ref name="PMID 16169905">{{cite journal | vauthors = Lau SK, Woo PC, Li KS, Huang Y, Tsoi HW, Wong BH, Wong SS, Leung SY, Chan KH, Yuen KY | display-authors = 6 | title = Severe acute respiratory syndrome coronavirus-like virus in Chinese horseshoe bats | journal = Proceedings of the National Academy of Sciences of the United States of America | volume = 102 | issue = 39 | pages = 14040–5 | date = September 2005 | pmid = 16169905 | pmc = 1236580 | doi = 10.1073/pnas.0506735102 | bibcode = 2005PNAS..10214040L | doi-access = free }}</ref> Phylogenetic analysis of these viruses indicated a high probability that SARS coronavirus originated in bats and spread to humans either directly or through animals held in Chinese markets. The bats did not show any visible signs of disease, but are the likely natural reservoirs of SARS-like coronaviruses. In late 2006, scientists from the Chinese Centre for Disease Control and Prevention of Hong Kong University and the Guangzhou Centre for Disease Control and Prevention established a genetic link between the SARS coronavirus appearing in civets and in the second, 2004 human outbreak, bearing out claims that the disease had jumped across species.<ref>{{cite news |url=http://www.chinadaily.com.cn/china/2006-11/23/content_740511.htm |title=Scientists prove SARS-civet cat link |work=China Daily |date=23 November 2006 |access-date=14 March 2011 |archive-url=https://web.archive.org/web/20110614103319/http://www.chinadaily.com.cn/china/2006-11/23/content_740511.htm |archive-date=14 June 2011 |url-status=live }}</ref>

It took 14 years to find the original bat population likely responsible for the SARS pandemic.<ref>{{cite web |title=The 'Occam's Razor Argument' Has Not Shifted in Favor of a Lab Leak |url=https://www.snopes.com/news/2021/07/16/lab-leak-evidence/ |website=Snopes.com |date=16 July 2021 |publisher=Snopes |access-date=19 July 2021 |archive-date=6 August 2021 |archive-url=https://web.archive.org/web/20210806232609/https://www.snopes.com/news/2021/07/16/lab-leak-evidence/ |url-status=live }}</ref> In December 2017, "after years of searching across China, where the disease first emerged, researchers reported ... that they had found a remote cave in Xiyang Yi Ethnic Township, Yunnan province, which is home to horseshoe bats that carry a strain of a particular virus known as a coronavirus. This strain has all the genetic building blocks of the type that triggered the global outbreak of SARS in 2002."<ref name=":1"/> The research was performed by Shi Zhengli, Cui Jie, and co-workers at the [[Organization:Wuhan Institute of Virology|Wuhan Institute of Virology]], China, and published in ''[[Biology:PLOS Pathogens|PLOS Pathogens]]''. The authors are quoted as stating that "another deadly outbreak of SARS could emerge at any time. The cave where they discovered their strain is only a kilometre from the nearest village."<ref name=":1"/><ref>{{Cite journal| vauthors = Cyranoski D |date=1 December 2017|title=Bat cave solves mystery of deadly SARS virus — and suggests new outbreak could occur|journal=Nature|language=en|volume=552|issue=7683|pages=15–16|doi=10.1038/d41586-017-07766-9|pmid=29219990 |bibcode=2017Natur.552...15C|doi-access=free}}</ref> The virus was ephemeral and seasonal in bats.<ref>{{Cite web|title=How China's 'Bat Woman' Hunted Down Viruses from SARS to the New Coronavirus|url=https://www.scientificamerican.com/article/how-chinas-bat-woman-hunted-down-viruses-from-sars-to-the-new-coronavirus1/|url-status=live|archive-url=https://web.archive.org/web/20200423004810/https://www.scientificamerican.com/article/how-chinas-bat-woman-hunted-down-viruses-from-sars-to-the-new-coronavirus1/|archive-date=23 April 2020|access-date=16 May 2020|website=Scientific American|vauthors=Qiu J}}</ref> In 2019, a similar virus to SARS caused a cluster of infections in [[Place:Wuhan|Wuhan]], eventually leading to the COVID-19 pandemic.

A small number of cats and dogs tested positive for the virus during the outbreak. However, these animals did not transmit the virus to other animals of the same species or to humans.<ref>{{cite web|date=4 March 2020|title=Coronavirus: Italy and Iran close schools and universities – BBC News|url=https://www.bbc.co.uk/news/live/world-51747782|url-status=live|archive-url=https://web.archive.org/web/20200305181343/https://www.bbc.co.uk/news/live/world-51747782|archive-date=5 March 2020|access-date=31 March 2020|publisher=Bbc.co.uk}}</ref><ref>{{cite web|title=Expert reaction to reports that the (Previously reported) pet dog in Hong Kong has repeatedly tested 'weak positive' for COVID-19 virus &#124; Science Media Centre|url=https://www.sciencemediacentre.org/expert-reaction-to-reports-that-the-previously-reported-pet-dog-in-hong-kong-has-repeatedly-tested-weak-positive-for-covid-19-virus/|url-status=live|archive-url=https://web.archive.org/web/20200312203015/https://www.sciencemediacentre.org/expert-reaction-to-reports-that-the-previously-reported-pet-dog-in-hong-kong-has-repeatedly-tested-weak-positive-for-covid-19-virus/|archive-date=12 March 2020|access-date=5 March 2020}}</ref>

===Containment===
The World Health Organization declared severe acute respiratory syndrome contained on 5 July 2003. The containment was achieved through successful public health measures.<ref name=":3">{{cite journal | vauthors = Morens DM, Fauci AS | title = Emerging Pandemic Diseases: How We Got to COVID-19 | journal = Cell | volume = 182 | issue = 5 | pages = 1077–1092 | date = September 2020 | pmid = 32846157 | pmc = 7428724 | doi = 10.1016/j.cell.2020.08.021 }}</ref> In the following months, four SARS cases were reported in China between December 2003 and January 2004.<ref name=":0">{{cite web| url=http://www.huffingtonpost.ca/2013/03/11/sars-2013_n_2854568.html| title=SARS 2013: 10 Years Ago SARS Went Around the World, Where is It Now?| date=11 March 2013| access-date=15 January 2015| archive-url=https://web.archive.org/web/20150116020750/http://www.huffingtonpost.ca/2013/03/11/sars-2013_n_2854568.html| archive-date=16 January 2015| url-status=live}}</ref><ref>{{cite web|title =  SARS outbreak contained worldwide|url =https://www.who.int/mediacentre/news/releases/2003/pr56/en/|website = WHO |date=5 July 2003 |access-date = 16 October 2015|archive-url = https://web.archive.org/web/20151017052222/http://www.who.int/mediacentre/news/releases/2003/pr56/en/|archive-date = 17 October 2015|url-status = dead}}</ref>

While SARS-CoV-1 probably persists as a potential zoonotic threat in its original animal reservoir, human-to-human transmission of this virus may be considered eradicated{{citation needed|date=March 2023}} because no human case has been documented since four minor, brief, subsequent outbreaks in 2004.<ref name=":3" />

=== Laboratory accidents ===
After containment, there were four laboratory accidents that resulted in infections.
* One postdoctoral student at the National University of Singapore in [[Place:Singapore|Singapore]] in August 2003<ref name=":4">{{cite journal|vauthors=Senior K|date=November 2003|title=Recent Singapore SARS case a laboratory accident|journal=The Lancet. Infectious Diseases|volume=3|issue=11|pages=679|doi=10.1016/S1473-3099(03)00815-6|pmc=7128757|pmid=14603886}}</ref>
* A 44-year-old senior scientist at the National Defense University in Taipei in December 2003. He was confirmed to have the SARS virus after working on a SARS study in Taiwan's only BSL-4 lab. The Taiwan CDC later stated the infection occurred due to laboratory misconduct.<ref>{{Cite web|url=https://www.cidrap.umn.edu/news-perspective/2003/12/taiwanese-sars-researcher-infected|title=Taiwanese SARS researcher infected|date=17 December 2003 |access-date=13 May 2021|archive-date=13 May 2021|archive-url=https://web.archive.org/web/20210513005241/https://www.cidrap.umn.edu/news-perspective/2003/12/taiwanese-sars-researcher-infected|url-status=live}}</ref><ref>{{Cite web|url=https://www.cdc.gov.tw/En/Category/ListContent/bg0g_VU_Ysrgkes_KRUDgQ?uaid=u1D6dRGtmP4Q5YA1GmSKIw|title=SARS (Severe Acute Respiratory Syndrome)|access-date=13 May 2021|archive-date=13 May 2021|archive-url=https://web.archive.org/web/20210513005244/https://www.cdc.gov.tw/En/Category/ListContent/bg0g_VU_Ysrgkes_KRUDgQ?uaid=u1D6dRGtmP4Q5YA1GmSKIw|url-status=live}}</ref>
* Two researchers at the Chinese Institute of Virology in Beijing, China around April 2004, who spread it to around six other people. The two researchers contracted it 2 weeks apart.<ref name=":5">{{Cite web|title=SARS escaped Beijing lab twice|url=https://www.the-scientist.com/news-analysis/sars-escaped-beijing-lab-twice-50137|url-status=live|archive-url=https://web.archive.org/web/20200514073727/https://www.the-scientist.com/news-analysis/sars-escaped-beijing-lab-twice-50137|archive-date=14 May 2020|access-date=16 May 2020|website=The Scientist Magazine®}}</ref>

Study of live SARS specimens requires a biosafety level 3 (BSL-3) facility; some studies of inactivated SARS specimens can be done at biosafety level 2 facilities.<ref>{{cite web|url=https://www.cdc.gov/sars/guidance/f-lab/app5.html|title=SARS {{!}} Guidance {{!}} Lab Biosafety for Handling and Processing Specimens {{!}} CDC|website=www.cdc.gov|language=en-us|access-date=11 September 2017|archive-url=https://web.archive.org/web/20170911204827/https://www.cdc.gov/sars/guidance/f-lab/app5.html|archive-date=11 September 2017|url-status=live}}</ref>

==Society and culture==
Fear of contracting the virus from consuming infected wild animals resulted in public bans and reduced business for meat markets in southern China and Hong Kong.The WHO declared the end of the pandemic on March 24 2004. <ref>{{cite journal | vauthors = Zhan M | title = Civet Cats, Fried Grasshoppers, and David Beckham's Pajamas: Unruly Bodies after SARS | journal = American Anthropologist | volume = 107 | issue = 1 | pages = 31–42 | date = March 2005 | pmid = 32313270 | pmc = 7159593 | doi = 10.1525/aa.2005.107.1.031 | url = http://www.escholarship.org/uc/item/6sk8w3xk | access-date = 22 January 2019 | url-status = live | jstor = 3567670 | archive-date = 12 March 2020 | archive-url = https://web.archive.org/web/20200312182523/https://escholarship.org/uc/item/6sk8w3xk }}</ref>

== See also ==
* [[Biology:2009 swine flu pandemic|2009 swine flu pandemic]]
* [[Chemistry:Aerosol|Aerosol]]
* [[Biology:Avian influenza|Avian influenza]]
* [[Biology:Bat-borne virus|Bat-borne virus]]
* [[Medicine:Coronavirus disease 2019|Coronavirus disease 2019]] – a disease caused by [[Biology:Severe acute respiratory syndrome coronavirus 2|Severe acute respiratory syndrome coronavirus 2]]
* Health crisis
* Health in China
* [[Biology:Healthy building|Healthy building]]
* [[Earth:Indoor air quality|Indoor air quality]]
* List of medical professionals who died during the SARS outbreak
* [[Medicine:Middle East respiratory syndrome|Middle East respiratory syndrome]] – a coronavirus discovered in June 2012 in Saudi Arabia
* [[Social:SARS conspiracy theory|SARS conspiracy theory]]
* [[Earth:Sick building syndrome|Sick building syndrome]]
* [[Biography:Zhong Nanshan|Zhong Nanshan]]

== References ==
{{reflist|colwidth=30em}}

== Further reading ==
{{refbegin}}
* {{cite journal | vauthors = Sihoe AD, Wong RH, Lee AT, Lau LS, Leung NY, Law KI, Yim AP | title = Severe acute respiratory syndrome complicated by spontaneous pneumothorax | journal = Chest | volume = 125 | issue = 6 | pages = 2345–51 | date = June 2004 | pmid = 15189961 | pmc = 7094543 | doi = 10.1378/chest.125.6.2345 }}
* {{cite journal | vauthors = Enserink M | title = War stories | journal = Science | volume = 339 | issue = 6125 | pages = 1264–8 | date = March 2013 | pmid = 23493690 | doi = 10.1126/science.339.6125.1264 }}
* {{cite journal | vauthors = Enserink M | title = SARS: chronology of the epidemic | journal = Science | volume = 339 | issue = 6125 | pages = 1266–71 | date = March 2013 | pmid = 23493691 | doi = 10.1126/science.339.6125.1266 | bibcode = 2013Sci...339.1266E }}
* {{cite journal | vauthors = Normile D | title = Understanding the enemy | journal = Science | volume = 339 | issue = 6125 | pages = 1269–73 | date = March 2013 | pmid = 23493692 | doi = 10.1126/science.339.6125.1269 | bibcode = 2013Sci...339.1269N }}
{{refend}}

== External links ==
{{Library resources box
 |onlinebooks=no
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}}
* [https://www.nlm.nih.gov/medlineplus/severeacuterespiratorysyndrome.html MedlinePlus: Severe Acute Respiratory Syndrome] News, links and information from The United States National Library of Medicine
* [https://www.who.int/csr/sars/en/ Severe Acute Respiratory Syndrome (SARS) Symptoms and treatment guidelines, travel advisory, and daily outbreak updates], from the [[Organization:World Health Organization|World Health Organization]] (WHO)
* [https://web.archive.org/web/20160412085632/http://www.cdc.gov/ncidod/sars/ Severe Acute Respiratory Syndrome (SARS)]: information on the international outbreak of the illness known as a severe acute respiratory syndrome (SARS), provided by the US Centers for Disease Control

{{Medical resources
| DiseasesDB     = 32835
| ICD10          = {{ICD10|U|04||u|00}}
| ICD9           = {{ICD9|079.82}}
| ICDO           =
| OMIM           =
| MedlinePlus    = 007192
| eMedicineSubj  = med
| eMedicineTopic = 3662
| MeshID         = D045169
}}
{{Respiratory pathology}}
{{Viral diseases}}
{{Health in the People's Republic of China}}

[[Category:Severe acute respiratory syndrome| ]]
[[Category:Zoonotic bacterial diseases]]
[[Category:Sarbecovirus]]

{{Sourceattribution|SARS}}