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Coronavirus Biology and Pathogenesis
On the Front Lines
Clinical Spectrum of SARS Infection
Clinical Experience in Toronto
SARS: An Update from China
Panel 2 Discussion
Approaches to Vaccines and Drug Development
Future Perspectives on Emerging Infections
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SARS in the Context of Emerging Infectious Threats SARS in the Context of Emerging Infectious Threats
On the Front Lines
Clinical Experience in Toronto

Donald Low, Mt. Sinai Hospital, Toronto
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Highlights

First Toronto SARS Cases
• Toronto's Index Case stayed at the Hotel M in Hong Kong on February 21, returned to Toronto February 23, died at home on March 5.
• Index Case's son became ill, went to hospital March 7, and died on March 13.
• The rest of the family was brought in for isolation on March 13.
• Case B was admitted without protection and was the first sign that spread outside families had occurred, primarily among hospital workers and visitors.
• Case B's wife became ill, indicating a need to remember the family members before they can spread the virus.
• Case C was misdiagnosed early with congestive heart failure, causing spread to cardiac health care workers.
• The close-knit BLD community was the only case of community outbreak in Toronto.

Clinical Features and Outcomes from 144 Toronto Patients
• Among the first 144 patients at Toronto's Mt. Sinai hospital, females were prevalent, as are health-care workers (51 percent), and median age is 45.
• Clinical symptoms begin with aches and pains and fever within three to ten days of known exposure. Diarrhea and cough follow.
• Patients under home isolation often left the home, causing new infections.
• Emergency departments, doctors' offices, and occasionally hospitals recognize the disease most often.
• Median time from visit to admission is three days, so many people were sent home.
• Chest X-rays are normal in 25 percent of early patients, pneumothorax occurred in 4 out of 144 patients, and about 30 percent showed infiltrates in both lung fields.
• LDH is high in 90 percent of patients, perhaps reflecting lung disease, and creatine kinase was abnormal in 40 percent of patients.
• Ribavirin and steroids need to be evaluated in clinical trials for effectiveness; in a small sample, they did not appear to affect viral load.
• Artus RT-PCR system was used to detect virus in lungs from autopsy and all 11 samples taken were positive.
• Duration of illness before death was 20 days; those who died sooner were more likely to have high viral load.
• Mortality rate is going up, likely because of the denominator used in determining probable cases.

Infection Control
• Contact and droplet spread is the most likely mode of transmission, and possibly occasionally airborne contact.
• Precautions used include a N95 face shield, hairnet, gloves, gowns, and hand-washing.
• The order of removal of protective gear is important.

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