https://www.cdc.gov/coronavirus/mers/downloads/Isolation2007.pdf

2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings.

As a transmissible infectious disease, severe acute respiratory syndrome (SARS) was successfully contained globally by instituting widespread quarantine measures. Although these measures were successful in terminating the outbreak in all areas of the world, the adverse effects of quarantine have not previously been determined in a systematic manner. In this hypothesis-generating study supported by a convenience sample drawn in close temporal proximity to the period of quarantine, we examined the psychological effects of quarantine on persons in Toronto, Canada. The 129 quarantined persons who responded to a Web-based survey exhibited a high prevalence of psychological distress. Symptoms of posttraumatic stress disorder (PTSD) and depression were observed in 28.9% and 31.2% of respondents, respectively. Longer durations of quarantine were associated with an increased prevalence of PTSD symptoms. Acquaintance with or direct exposure to someone with a diagnosis of SARS was also associated with PTSD and depressive symptoms.

SARS Control and Psychological Effects of Quarantine, Toronto, Canada

ContextSevere acute respiratory syndrome (SARS) is an emerging infectious disease
that first manifested in humans in China in November 2002 and has subsequently
spread worldwide.ObjectivesTo describe the clinical characteristics and short-term outcomes of
SARS in the first large group of patients in North America; to describe how
these patients were treated and the variables associated with poor outcome.Design, Setting, and PatientsRetrospective case series involving 144 adult patients admitted to 10
academic and community hospitals in the greater Toronto, Ontario, area between
March 7 and April 10, 2003, with a diagnosis of suspected or probable SARS.
Patients were included if they had fever, a known exposure to SARS, and respiratory
symptoms or infiltrates observed on chest radiograph. Patients were excluded
if an alternative diagnosis was determined.Main Outcome MeasuresLocation of exposure to SARS; features of the history, physical examination,
and laboratory tests at admission to the hospital; and 21-day outcomes such
as death or intensive care unit (ICU) admission with or without mechanical
ventilation.ResultsOf the 144 patients, 111 (77%) were exposed to SARS in the hospital
setting. Features of the clinical examination most commonly found in these
patients at admission were self-reported fever (99%), documented elevated
temperature (85%), nonproductive cough (69%), myalgia (49%), and dyspnea (42%).
Common laboratory features included elevated lactate dehydrogenase (87%),
hypocalcemia (60%), and lymphopenia (54%). Only 2% of patients had rhinorrhea.
A total of 126 patients (88%) were treated with ribavirin, although its use
was associated with significant toxicity, including hemolysis (in 76%) and
decrease in hemoglobin of 2 g/dL (in 49%). Twenty-nine patients (20%) were
admitted to the ICU with or without mechanical ventilation, and 8 patients
died (21-day mortality, 6.5%; 95% confidence interval [CI], 1.9%-11.8%). Multivariable
analysis showed that the presence of diabetes (relative risk [RR], 3.1; 95%
CI, 1.4-7.2; P = .01) or other comorbid conditions
(RR, 2.5; 95% CI, 1.1-5.8; P = .03) were independently
associated with poor outcome (death, ICU admission, or mechanical ventilation).ConclusionsThe majority of cases in the SARS outbreak in the greater Toronto area
were related to hospital exposure. In the event that contact history becomes
unreliable, several features of the clinical presentation will be useful in
raising the suspicion of SARS. Although SARS is associated with significant
morbidity and mortality, especially in patients with diabetes or other comorbid
conditions, the vast majority (93.5%) of patients in our cohort survived.Published online May 6, 2003 (doi:10.1001/jama.289.21.JOC30885).

https://jamanetwork.com/journals/jama/articlepdf/196681/JOC30885.pdf

Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area.

background Severe acute respiratory syndrome (SARS) is a condition of unknown cause that has recently been recognized in patients in Asia, North America, and Europe. This report summarizes the initial epidemiologic findings, clinical description, and diagnostic findings that followed the identification of SARS in Canada. methods SARS was first identified in Canada in early March 2003. We collected epidemiologic, clinical, and diagnostic data from each of the first 10 cases prospectively as they were identified. Specimens from all cases were sent to local, provincial, national, and international laboratories for studies to identify an etiologic agent. results The patients ranged from 24 to 78 years old; 60 percent were men. Transmission occurred only after close contact. The most common presenting symptoms were fever (in 100 percent of cases) and malaise (in 70 percent), followed by nonproductive cough (in 100 percent) and dyspnea (in 80 percent) associated with infiltrates on chest radiography (in 100 percent). Lymphopenia (in 89 percent of those for whom data were available), elevated lactate dehydrogenase levels (in 80 percent), elevated aspartate aminotransferase levels (in 78 percent), and elevated creatinine kinase levels (in 56 percent) were common. Empirical therapy most commonly included antibiotics, oseltamivir, and intravenous ribavirin. Mechanical ventilation was required in five patients. Three patients died, and five have had clinical improvement. The results of laboratory investigations were negative or not clinically significant except for the amplification of human metapneumovirus from respiratory specimens from five of nine patients and the isolation and amplification of a novel coronavirus from five of nine patients. In four cases both pathogens were isolated. conclusions SARS is a condition associated with substantial morbidity and mortality. It appears to be of viral origin, with patterns suggesting droplet or contact transmission. The role of human metapneumovirus, a novel coronavirus, or both requires further investigation.

/pdf/identification-of-severe-acute-respiratory-syndrome-in-14ufb20pnh.pdf

Identification of Severe Acute Respiratory Syndrome in Canada

Crimean-Congo haemorrhagic fever (CCHF) is an often fatal viral infection described in about 30 countries, and it has the most extensive geographic distribution of the medically important tickborne viral diseases, closely approximating the known global distribution of Hyalomma spp ticks. Human beings become infected through tick bites, by crushing infected ticks, after contact with a patient with CCHF during the acute phase of infection, or by contact with blood or tissues from viraemic livestock. Clinical features commonly show a dramatic progression characterised by haemorrhage, myalgia, and fever. The levels of liver enzymes, creatinine phosphokinase, and lactate dehydrogenase are raised, and bleeding markers are prolonged. Infection of the endothelium has a major pathogenic role. Besides direct infection of the endothelium, indirect damage by viral factors or virus-mediated host-derived soluble factors that cause endothelial activations and dysfunction are thought to occur. In diagnosis, enzyme-linked immunoassay and real-time reverse transcriptase PCR are used. Early diagnosis is critical for patient therapy and prevention of potential nosocomial infections. Supportive therapy is the most essential part of case management. Recent studies suggest that ribavirin is effective against CCHF, although definitive studies are not available. Health-care workers have a serious risk of infection, particularly during care of patients with haemorrhages from the nose, mouth, gums, vagina, and injection sites. Simple barrier precautions have been reported to be effective.

/pdf/crimean-congo-haemorrhagic-fever-1mjnt47obh.pdf

Crimean-Congo haemorrhagic fever

ObjectiveTo develop consensus-based recommendations for measures to be taken
by medical and public health professionals if hemorrhagic fever viruses (HFVs)
are used as biological weapons against a civilian populationParticipantsThe Working Group on Civilian Biodefense included 26 representatives
from academic medical centers, public health, military services, governmental
agencies, and other emergency management institutionsEvidenceMEDLINE was searched from January 1966 to January 2002 Retrieved references,
relevant material published prior to 1966, and additional sources identified
by participants were reviewedConsensus ProcessThree formal drafts of the statement that synthesized information obtained
in the evidence-gathering process were reviewed by the working group Each
draft incorporated comments and judgments of the members All members approved
the final draftConclusionsWeapons disseminating a number of HFVs could cause an outbreak of an
undifferentiated febrile illness 2 to 21 days later, associated with clinical
manifestations that could include rash, hemorrhagic diathesis, and shock
The mode of transmission and clinical course would vary depending on the specific
pathogen Diagnosis may be delayed given clinicians' unfamiliarity with these
diseases, heterogeneous clinical presentation within an infected cohort, and
lack of widely available diagnostic tests Initiation of ribavirin therapy
in the early phases of illness may be useful in treatment of some of these
viruses, although extensive experience is lacking There are no licensed vaccines
to treat the diseases caused by HFVs

https://jamanetwork.com/journals/jama/articlepdf/194908/JST20006.pdf

Hemorrhagic Fever Viruses as Biological Weapons: Medical and Public Health Management

Concern for potential bioterrorist attacks causing mass casualties has
increased recently. Particular attention has been paid to scenarios in which
a biological agent capable of person-to-person transmission, such as smallpox,
is intentionally released among civilians. Multiple public health interventions
are possible to effect disease containment in this context. One disease control
measure that has been regularly proposed in various settings is the imposition
of large-scale or geographic quarantine on the potentially exposed population.
Although large-scale quarantine has not been implemented in recent US history,
it has been used on a small scale in biological hoaxes, and it has been invoked
in federally sponsored bioterrorism exercises. This article reviews the scientific
principles that are relevant to the likely effectiveness of quarantine, the
logistic barriers to its implementation, legal issues that a large-scale quarantine
raises, and possible adverse consequences that might result from quarantine
action. Imposition of large-scale quarantine—compulsory sequestration
of groups of possibly exposed persons or human confinement within certain
geographic areas to prevent spread of contagious disease—should not
be considered a primary public health strategy in most imaginable circumstances.
In the majority of contexts, other less extreme public health actions are
likely to be more effective and create fewer unintended adverse consequences
than quarantine. Actions and areas for future research, policy development,
and response planning efforts are provided.

Large-scale quarantine following biological terrorism in the United States: scientific examination, logistic and legal limits, and possible consequences.

Marci Layton

Papers

Hemorrhagic Fever Viruses as Biological Weapons: Medical and Public Health Management

Large-scale quarantine following biological terrorism in the United States: scientific examination, logistic and legal limits, and possible consequences.