SARS: The Pandemic that Never Was: Part 1

0:00:02 Narrator: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. This episode is part of a series of special editions of our podcast focusing on the ongoing Coronavirus pandemic. This week, we're doing something a little different. A group of undergraduate students at the University of Michigan School of Public Health recently created a three-part podcast series, looking back at the 2003 SARS epidemic and how it relates to the coronavirus pandemic.

SARS and COVID-19 are both caused by coronaviruses and share a lot of similarities, but they have had very different effects on the world. In this episode, the students focus on the history of the SARS outbreak, the similarities between SARS and the current pandemic and the key differences that have caused COVID-19 to take hold as a global pandemic.

1:05 Anjali Vaishnav: Hello everyone, and welcome to SARS: The Pandemic that Never Was. My name is Anjali, and today I'm accompanied by four different guests, and we are all undergraduate students at the University of Michigan School of Public Health. If you're interested in infectious disease and how it's shaped by different social factors you're in the right place. In this episode, we'll be talking about the biology of the pathogen SARS.

So diving into what exactly SARS is. SARS stands for Severe Acute Respiratory Syndrome, and it's a viral respiratory disease that is caused by a type of Coronavirus. Yes, another kind of Coronavirus. Transmission of SARS is primarily from person to person through respiratory droplets, much like the common cold, influenza, and COVID-19, so when a person sneezes or coughs. And it can also be indirectly spread through surfaces touched by an infected person and later an uninfected person.

The clinical presentation of this acute infection resembles a lot of what viral pneumonia looks like, and patients develop a lot of flu-like symptoms including fever, dry cough and a headache. And in fact, when the virus was first identified, the Chinese actually thought that it was some type of a typical pneumonia.

And so when it was first recorded from the November 2002 outbreak all the way leading to July 2003, there were approximately 8,000 cases of this disease reported worldwide, over 700 deaths, and a case fatality ratio of 9.6% which made SARS very, very fatal. And the largest burden of this disease was concentrated in Asia.

And so a lot of this information may sound incredibly familiar as we are living through a very parallel Coronavirus pandemic right now. SARS COV 1, which refers to the first SARS strain I've been discussing has been followed by SARS COV 2, which is more commonly known today as COVID-19. And so I'm joined today by Maddie Malvitz who will help us to better understand the similarities and differences between these two similar yet different devastating diseases. So, thanks for being here Maddie.

0:03:05 Madelyn Malvitz: Hi. Awesome, thanks for having me.

0:03:08 Vaishnav: So I was wondering if you would be able to dive into the basics of what exactly the epidemiology of COVID-19 is and how it's similar to SARS.

0:03:17 Malvitz: Yeah, absolutely. So SARS and COVID have a genome that's about 79% similar. So we're gonna find a lot of similarities between the two. With COVID, there's going to be 64.3 million cases as of now, at 1.49 million deaths and the United States alone has 13.9 million cases and 273,000 deaths. So almost all the parts of the United States are showing an increase in these cases recently as well, and even though people may think this problem is declining, it's not. Although there are a lot of these cases, there is data that 41.3 million of those worldwide cases have been recovering from the illness, so there is hope in the aspect.

0:04:03 Vaishnav: I'm really surprised, given the very similar genomes of these two viruses, their effect around the globe has been drastically different. Do you think that these are due to differences in the transmission of COVID-19 versus SARS?

0:04:16 Malvitz: Yes, I absolutely agree with that statement. There's one very known reason would be the fatality rate between the two. So COVID has about a 3.4 fatality rate, and the one you said before, SARS is almost triple that. So the high number of cases themselves would be because that transmissibility is higher. It's also transmitted directly through contact with an infected individual with that coughing, sneezing, talking, breathing, which is the same as SARS, but there are many other theories on why the training visibility could be higher.

0:04:49 Vaishnav: Got it. And could you maybe dive into what one of those theories may be?

0:04:53 Malvitz: Yeah, for sure. So COVID-19 has a higher viral load earlier on in the infection, which means that they are more infectious during this period. So they're just as their symptoms are developing, but before they're beginning to worsen. They can still be transmitting that disease, which shows those asymptomatic infections that we weren't able to do with SARS before. Yeah, and also that means we're not able to isolate those patients and then they're able to even create a larger outbreak with that.

There's also the biology behind the disease, which I can explain really quickly, it's a little complex, but there's just...there's a receptor that's present on our lung cells and many other parts of the body, and that's what the pathogen is going to be attacking. So with COVID-19 we're seeing this pathogen attack at 10 to 20 times more effective rate than SARS, so that could explain the difference as well.

0:05:49 Vaishnav: That's really interesting. Okay, so then given that similar biological background, a similar transmission, what is probably the most recognizable types of symptoms between the two diseases?

0:06:02 Malvitz: Yeah, So symptoms would be obviously a common factor between the twO. There's the common fever, chills, cough, shortness of breath, fatigue, the muscle aches, the headache, kind of all that running nose congestion, all the typical signs of illness. It’s a problem because they are so diverse in their symptoms, with us tracking into the cold season, it's gonna be very difficult on top of those asymptomatic cases.

0:06:36 Vaishnav: Definitely, and I think we can see how that's playing out even now. So thank you much for that information and on the topic of what's happening right now, we're in the midst of this really unprecedented rush for developing a COVID-19 vaccine. And I’m thinking, given that SARS was so similar and was also a coronavirus, was there anything that during the SARS epidemic, any type of vaccine development, that would help for the COVID-19 vaccine to be built off of?

0:07:05 Malvitz: Right, that's kind of a tough one. So after the 2002, 2003 pandemic of SARS, there was a lot of experimental vaccines that went under development, but there was no known vaccine or prophylaxis that was able to prevent SARS. And a big reason of that is because there was this disappearance of SARS that halted the vaccine creation for most of the coronavirus family. And that really brings the question to light if we would have had this vaccine already from SARS if we would have been able to come up with one faster for COVID-19. But as of now, we're still seeing that development of new and promising vaccines for COVID-19 from multiple pharmaceutical companies. It’s kind of a question we'll never know.

0:07:49 Vaishnav: Definitely, I think the vaccine coming up is very great news, and maybe we're reaching that final closing chapter in the history of this COVID-19 pandemic. I think though it's also important, a lot of our listeners may be informed about what the history of the SARS epidemic looked like, given that it was so short-lived. So I was wondering if we'd be able to dive more into the progress of that SARS epidemic in 2002 and 2003, what the history was during the time period, how did cases spread, all of that?

0:08:22 Malvitz: Absolutely. For SARS, the first case was in Guangdong, China, which is the southern part of the country. So it's believed that there was a 74-year-old doctor there, and he traveled to Hong Kong and he unknowingly spread the virus through that. He was then admitted into a hospital at Hong Kong and unknowingly infected the other hospital guests. The virus also found its way to Singapore, Toronto, and Hanoi. International Corporation was really important during this time, and they were able to catch the disease early and isolate those people that were infected. So although that toll of the virus was still high and absolutely horrible, there were many efforts that were able to stop this outbreak from being much bigger than it could have been.

0:09:11 Vaishnav: That's really great news. And it's much different from, I think, what we're seeing today. I was wondering, you talked a little bit about one of these events that led to probably a contact tracing nightmare. If you could dive into, are there other events that were similar to this during the SARS epidemic?

0:09:30 Malvitz: Yeah, so there were many super spreader events and that’s a term that we use when there's an influx in cases due to an infective individual in that location. So there were many that happened throughout this disease. One reason that I spread out of mainland China would be because of the, it was called the Metropole Hotel in Hong Kong. There was a professor from Guangdong that had been treating many patients with atypical pneumonia, which is one of those symptoms that we talked about before. So very similar to SARS. And he then stayed in the Metropole Hotel on February 21, 2003 and he was already feeling unwell. He then traveled to Hong Kong. He was admitted at a hospital there and inspected many other people, so that was one case.

There was also just a timeline of it all. It's right during the Chinese Lunar New Year in January, so many people are going to be traveling to go see family and in those really infected places and crowded areas. So that would be another situation.

The last big one that we saw was there was an apartment complex in Hong Kong that was known as the Amoy Gardens. And with the living situations in this place, they were very, very crowded. There was about 19 blocks of these houses and they were ranging from 30 to 40 floors. So, very many people were crowded in these places. The multitude of people living in these places in such close proximity, resulted in 300 infections and 42 deaths. Which if you think about the whole epidemic as a full, it really is a high area of cases.

0:11:20 Vaishnav: That's absolutely insane to think that that just happened in one apartment complex. Wow. So these superspreader events must have been so critical. But from the stories that you've been telling, it sounds like the greatest burden of disease remained in mainland China and surrounding areas then?

1:37 Malvitz: Yes, there was. So there was Hong Kong and mainland China that were hit the hardest. China had 5,000 cases about and 349 deaths, whereas Hong Kong had about 1,700 cases and 300 deaths. So looking at those numbers, immediately you may think that China had the larger burden, and it does depend on your definition of what burden is, but China is 866,000% larger than Hong Kong. So even though they had those more cases, you have to remember there was all that space to spread out the cases, so personally, I believe Hong Kong’s impact was more burdensome because they were so dense on those hospitals and the society in general there.

0:12:24 Vaishnav: Definitely. That density does probably play such a huge factor in what actually ended up, what the disease burden actually ended up looking like. Given this high burden, what were people doing in these regions to help control the spread?

0:12:38 Malvitz: Yeah, there were many preventative measures being taken by the city to stop the spread of the disease. There were the contact tracing of the infected individuals, they also said they developed a lot of testing equipment during this period, and there were these five major control measures that they spoke of: there was the isolation and surveillance of the community, the stopping of high school classes and universities, the exchange of information between Hong Kong and mainland China, and they also did temperature checks for travelers that we're entering and exiting the country, and the last would be these district-wide cleansing campaigns for the whole country.

13:20 Vaishnav: Go it. Soyou mentioned travelers, I was wondering, aside from this epicenter, did the disease move elsewhere?

13:25 Malvitz: Absolutely. China and Hong Kong and Taiwan had roughly 91% of the cases, so it was pretty compact there. But Singapore and Canada came in second. Canada had about 2.9% of the cases and Singapore had 2.8%. So it still did have that spread. The United States itself only estimated around 33 cases. There was a hundred that were maybe, but again, they weren't able to diagnose those people. But these Americans had been proving to those countries where SARS was spreading. But fortunately for us, SARS did not become a significant transmission for the United States.

0:14:09 Vaishnav: Got it. Okay, so then given the intensity and the globalization of the outbreak, where those other countries like Singapore, like Canada, really prepared to handle the consequences?

0:14:22 Malvitz: I would not say so. Many of the countries, their health system was really in the infancy stages. The 2003 outbreak was absolutely a wake-up call for these countries to realize the gravity of that occupational risk that they had for those healthcare workers and the first responders that were with the emergency response time. So we're able to see that countries like Canada, the epidemic underscored a lack of preparedness to be able to protect those healthcare settings and the first responders and socially vulnerable populations. And Canada was able to research and understand that it was due to overcrowding and poor housing conditions, lack of access to clean water, and low socioeconomic status. So they were able to find these out before, and it really begs the question is, since the United States was not hit so hard with the SARS epidemic, would we have been able to be more prepared, like Canada we have seen is today with COVID, if we had had these things in the past with SARS? And the question will never know, be answered, but it's something we have to think about.

0:15:34 Vaishnav: That's definitely an interesting question. It's something that's been on my mind too, is how did we end up here? Would there have been another event that would have let us to be more prepared, like the SARS epidemic? But from my understanding and what you've been saying it sounds like it was a very short lived outbreak. What happened to cause the end of SARS? Clearly there wasn't a vaccine or anything like that, but it seems like a kind of a mystery of how it disappeared.

0:16:00 Malvitz: Right. Yeah. It was kind of mysterious the way it disappeared. SARS itself isn't a reoccurring epidemic, as far as we know today. There was the last noted transmission of the original stars outbreak in July of 2003, and after that, we did see SARS appear on four different occasions, one of them being a re-introduction due to a reservoir, and then the other three just being laboratory acquired infections. So it is not common anymore and it has disappeared and it's kind of uncertain the way it did. But these instances really do highlight the importance of bio-safety procedures and the risk that could result from improper safety measures that could be taken. But SARS itself truly has not been seen recently or should be seen in the future.

0:16:51 Vaishnav: So maybe a silver lining out of all this, getting us to be more prepared ideally and recognizing that importance of biosafety.

0:16:57 Malvitz: Absolutely agree.

0:16:58 Vaishnav: Well, thank you so much for all your help, Maddie. This was really insightful I'm sure for all of our listeners to really understand how the history of SARS evolved and what the biology behind this disease was and its similarities to the very, very similar Coronavirus that we're seeing plague our society today. So thank you again, and that will conclude our first episode of SARS: The Pandemic that Never Was. Be sure to keep listening for our next episode where we'll discuss some of the more social factors that drove disease burden of this epidemic. We really appreciate all of your time here and looking forward to you listening with us next upside.

0:17:48 Narrator: Be sure to listen next time for Part Two of this three-part series produced by students at the University of Michigan School of Public Health.

This has been a special edition of Population Healthy, a podcast from the University of Michigan School of Public Health. During the ongoing coronavirus pandemic, we’ll work to bring you analysis from our community of experts to help you understand what this public health crisis means for you. To stay up-to-date in between special edition episodes, be sure to check out our website publichealth.umich.edu, subscribe to our Population Healthy newsletter at publichealth.umich.edu/news/newsletter and follow us on Twitter, Instagram, and Facebook @umichsph.