eLetters to:

ELECTRONIC ARTICLE: Ari Bitnun, Upton Allen, Helen Heurter, Susan M. King, Mary Anne Opavsky, Elizabeth L. Ford-Jones, Anne Matlow, Ian Kitai, Raymond Tellier, Susan Richardson, David Manson, Paul Babyn, and Stanley Read Children Hospitalized With Severe Acute Respiratory Syndrome-Related Illness in Toronto Pediatrics 2003; 112: e261 [Abstract] [Full text] [PDF]

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Title: No more SARS please

KLE Hon, Kam-lun Ellis Hon FAAP, Man-chim Albert Li MRCP, Ting-fan Leung MRCP   (19 November 2003)

Re: Title: No more SARS please

Ari Bitnun, Upton Allen MBBS, Susan Richardson MD, and Stanley Read MD PhD   (24 December 2003)

Title: No more SARS please 19 November 2003
KLE Hon, Doctor Chinese University of Hong Kong, Kam-lun Ellis Hon FAAP, Man-chim Albert Li MRCP, Ting-fan Leung MRCP Send letter to journal: Re: Title: No more SARS please ehon{at}hotmail.com KLE Hon, et al.	Letter to the Editor: Title: No more SARS please Kam-lun Ellis Hon FAAP, Man-chim Albert Li MRCP, Ting-fan Leung MRCP Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China Correspondence to: Prof. Kam-lun Ellis Hon, Department of Paediatrics, The Chinese University of Hong Kong, 6/F, Clinical Sciences Building, Prince of Wales Hospital, Shatin, Hong Kong SAR, China. Tel: (852) 2632 2859. Fax: (852) 2636 0020. E-mail: b103892@cuhk.edu.hk. We read the article by Bitnun et al with interest.1 They described 25 children with SARS and SARS-related illness in Canada. They were quite right to point out the insensitivity of the WHO case definitions. Indeed, when we first reported the clinical features of SARS in children2, all patients had fever (> 380C), positive contact history and radiographic changes of pneumonia. Yet, we quickly realized how useless the term SARS was apart from scaring parents and subjecting children to immediate isolation. In order to better classify the clinical illness, we suggested the use of the term epidemic viral pneumonia.3 We subsequently reported a number of cases with clinical and radiographic features of suspect or probable SARS but who were indeed false alarms.4 During the isolation and management of these children, we had to be careful not to label them as having SARS immediately in the midst of the epidemics because of the adverse psychosocial consequences associated with this stigmatization. Many of the cases reported in the Canadian paper1 were ¡®pseudo¡¯- SARS and none of the clincial features were specific enough for making the diagnosis of SARS. In our opinion, their observations do not add mcuh up- to-date new information to this new coronavirus (CoV) infection in children. The authors concluded that the presence of fever in conjunction with a history of SARS exposure should prompt one to consider SARS as a possible diagnosis in children irrespective of whether they have any respiratory symptom. A close contact does not guarantee SARS.4,5 What closer contact than to be born from mothers who died of SARS. We reported five such neonates without evidence of vertical transmission of CoV infection.5 Indeed, a person with SARS does not have to have Severe or Respiratory symptoms. We have heard about asymptomatic or silent carriers with CoV; SARS with and without contact history; SARS with and without fever; SARS with and without diarrhea; SARS with positive isolation of CoV and those without CoV; and CoV infection with and without SARS. Asking the question ¡®What is SARS¡¯ or ¡®has this patient got SARS¡¯ is like requesting a one dollar note from a person. It depends on where (country-specific) and when (time-specific) you ask the question. One US dollar is obviously different from one Canadian dollar or a Hong Kong dollar. Therefore, the WHO surveillance definition for SARS may be different from the local definition.3 Also, one US dollar may have more purchasing power a few months ago, given the hugh depreciation of the dollar lately. Similarly, the WHO definition in October is different from its definition six months ago.6 WHO currently identifies SARS according to either ¡®clinical¡¯ or ¡®laboratory¡¯ case definitions, and the category of ¡®suspect¡¯ SARS is removed. At one stage, the Hospital Authority in Hong Kong defined ¡®suspect¡¯ cases as those with SARS infection that were serious enough to warrant ribavirin treatment. This modification did not stand the test of time and was quickly scrapped. Currently, SARS equates proven CoV infection in Hong Kong, regardless of contact history, symptomatology and so on. The corollary follows: a patient is not considered to have SARS no matter how Severe, Acute or Respiratory the clincial picture is if repeated molecular, serologic studies or virus culture did not reveal any evidence of coronavirus. The term SARS has served its historical purpose and we should use precise terms such as coronavirus pneumonia and cornavirus infection instead. References 1. Bitnun A, Allen U, Heurter H et al. Children hospitalized with severe acute respiratory syndrome-related illness in Toronto. Pediatrics 2003; 112: e261. 2. Hon KLE, Leung CW, Cheng WTF et al. Clinical presentations and outcome of severe acute respiratory syndrome in children. Lancet 2003; 361: 1701- 3. 3. Hon KLE, Li AM, Cheng FWT et al. Personal view: Confusing definition, Confusing diagnoses! Lancet 2003; 361: 1984-5. 4. Li AM, Hon KLE, Cheng WT et al. Severe acute respiratory syndrome: ¡®SARS¡¯ or ¡®Not SARS¡¯. J Paediatr Child Health 2003 (In press). 5. Shek CC, Ng PC, Fung GPG et al. Infants born to mothers with severe acute respiratory syndrome. Pediatrics 2003; 112: e254. 6. Case definition for surveillance of severe acute respiratory syndrome SARS. Geneva: World health Organization, April 10, 2003: http://www.who.int/csr/sars/casedefinition.
Re: Title: No more SARS please 24 December 2003
Ari Bitnun, MD Hospital for Sick Children, University of Toronto, Toronto, Upton Allen MBBS, Susan Richardson MD, and Stanley Read MD PhD Send letter to journal: Re: Re: Title: No more SARS please ari.bitnun{at}sickkids.ca Ari Bitnun, et al.	Dear Sir; We note the comments by Hon KLE and colleges and thank them for their letter. Fortunately, the Severe Acute Respiratory Syndrome (SARS) outbreak was limited to a relatively small number of centres around the world. As one of the centres in the epicenter of the SARS outbreaks in Canada, we are pleased to have had the opportunity of sharing the largest North American pediatric experience with readers of the Journal. In our paper we described the clinical, laboratory, and epidemiologic features of children admitted to the Hospital for Sick Children, Toronto, with a diagnosis of suspect or probable SARS[1]. In our setting, we felt that the most useful "screening test" was the epidemiologic link, be it direct contact with a suspect or probable SARS case, travel from a SARS- affected region or having been in a SARS-affected hospital at a time when secondary SARS spread had occurred. In this regard, we used a "screening test" that would enable us to minimize the chances of missing cases of SARS-associated coronavirus infection. We fully concur that close contact does not guarantee SARS. Since serology is a late diagnostic test, and since RT-PCR assays performed early in infection do not have the sensitivity to rule out disease[2], a clinical screening test, however imperfect, will for the foreseeable future, be required in order to permit timely institution of appropriate infection control precautions. In the context of an outbreak, one has no choice but to use a clinical/epidemiologic case definition as the starting point. Finally, we are in the process of completing the serologic and second generation RT-PCR assays on available samples. Although preliminary, our data suggest good concordance between serologically confirmed SARS- associated coronavirus infection and probable SARS as classified by us. Sincerely, Ari Bitnun, Upton Allen, Susan Richardson, Stanley Read 1. Bitnun A, Allen U, Heurter H, et al. Children hospitalized with severe acute respiratory syndrome-related illness in Toronto. Pediatrics. 2003; 112:e261. 2. Peiris JS, Chu CM, Cheng VC, et al. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet. 2003; 361:1767-72.