European Respiratory Society
SARS, MERS and other Viral Lung Infections

Viral respiratory tract infections are important and common causes of morbidity and mortality worldwide. In the past two decades, several novel viral respiratory infections have emerged with epidemic potential that threaten global health security. This Monograph aims to provide an up-to-date and comprehensive overview of severe acute respiratory syndrome, Middle East respiratory syndrome and other viral respiratory infections, including seasonal influenza, avian influenza, respiratory syncytial virus and human rhinovirus, through six chapters written by authoritative experts from around the globe.

  • ERS Monograph
  1. Page v
  2. Page vii
  3. Page ix
  4. Page 1
    David S. Hui, Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong. E-mail:

    SARS, caused by a novel CoV, first emerged in Southern China in November 2002 before spreading to 29 countries/regions within a few weeks in 2003. Bats are natural reservoirs of SARS-like CoVs. The presence of SARS-like CoVs in horseshoe bats raised the possible role of bats in previous and future SARS outbreaks in humans. Tracheal intubation, manual ventilation before intubation, tracheotomy and noninvasive ventilation increased the risk of nosocomial SARS transmission to healthcare workers; a bed distance of <1 m apart, staff working while experiencing symptoms and high flow oxygen >6 L·min−1 increased the risk of super-spreading events. The unexpected emergence, rapid spread and high morbidity and mortality of SARS made it impossible to set up RCT of any antiviral agents and other therapies against SARS-CoV infection. Retrospective analyses of non-RCT data suggested that protease inhibitors, IFN and convalescent plasma might have some beneficial effects, whereas ribavirin led to significant haemolysis without any clinical benefit.

  5. Page 21
    Yaseen M. Arabi, Intensive Care Dept, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, P.O. Box 22490, Riyadh 11426, Saudi Arabia. E-mail:

    Since June 2012, MERS-CoV has been reported in more than 1600 individuals, some of whom have developed severe acute respiratory illness and multiorgan dysfunction. Most reported cases in Saudi Arabia have occurred as community-acquired sporadic infections and from human-to-human transmission in healthcare facilities. Cases in countries outside the Arabian Peninsula have been linked to travel to the Arabian Peninsula. Transmission from dromedary camels has been identified in several primary infections with MERS-CoV, with some of these leading to clusters of human-to-human transmissions, especially within healthcare facilities. The case-fatality rate in reported cases approaches 35%, but this does not take into account milder cases or asymptomatic infections that remain unrecognised. Strict adherence to infection prevention and control practices in healthcare is pivotal in preventing transmission in healthcare settings. At present, there is no specific therapy of proven effectiveness against MERS-CoV, and treatment is largely supportive. Further epidemiological studies and trials on potential therapies are needed for a better understanding and management of this disease.

  6. Page 35
    Jonathan S. Nguyen-Van-Tam, Room A28b, Clinical Sciences Building, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK. E-mail:

    Influenza viruses belong to the family Orthomyxoviridae and are of four types: A, B, C and D. Types A and B cause measurable public health impact via regular epidemics in human populations. Influenza is seasonal in the temperate zones, but less so in the tropical and subtropical areas, where it can be found more or less all year round. A number of hypotheses have been proposed to explain the seasonality of influenza in temperate zones, but the exact causes remain unknown. Interpandemic influenza causes substantial morbidity and mortality globally, especially in the elderly ≥65 years of age and in children <6 months of age. Influenza classically presents as an ARI with fever, and can potentially lead to a number of pulmonary and extrapulmonary complications. National and international guidelines for the control of interpandemic influenza include vaccination of population groups at risk of increased morbidity and mortality, and treatment with antiviral drugs in at-risk patients and in those who present or become severely unwell.

  7. Page 65
    Bin Cao, No. 2 Ying-hua Dong-jie, Chao-yang district, Beijing, 100029, China. E-mail:

    Avian influenza (AI) viruses have caused great worldwide concern. So far, more than 13 strains of AI viruses have been shown to cross the species barrier and infect humans. Among them, the H5N1 and H7N9 strains have caused the highest mortality and morbidity worldwide. Clinical manifestations may range from asymptomatic, mild or moderate upper respiratory tract infection, to severe pneumonia and ARDS. Severe outcomes of AI infection in humans are the synergistic result of the intrinsic virulence of the virus and host factors. When treating severe AI infection, antiviral drug therapy is of great importance. However, drug resistance has emerged during treatment. More potent antiviral agents need to be isolated and investigated. In the meantime, ways to deal with the emergence of antiviral resistance, such as combining antiviral therapies with different modes of action, should be investigated. Immunopathology mediated by the inappropriate production of cytokines contributes to complicated influenza. Therefore, as well as antiviral drug therapy, the effectiveness of immunomodulators needs to be explored further.

  8. Page 84
    Peter J.M. Openshaw, National Heart and Lung Institute, Imperial College London (St Mary's Campus), Norfolk Place, Paddington, London, W2 1PG, UK. E-mail:

    RSV infection has an estimated global incidence of 33 million cases in children <5 years of age, with 10% requiring hospital admission and up to 199 000 dying of the disease. There is growing evidence that severe infantile RSV bronchiolitis, a condition characterised by an inflammatory reaction to the virus, is associated with later childhood wheeze in some vulnerable children; however, a direct causal relationship with asthma has not yet been established. RSV infection is also increasingly recognised as a cause of morbidity and mortality in those with underlying airway disease, the immunocompromised and frail elderly persons. Novel molecular-based diagnostic tools are becoming established, but treatment remains largely supportive, with palivizumab the only licensed agent currently available for passive prophylaxis of selected pre-term infants. While effective treatments remain elusive, there is optimism about the testing of novel antiviral drugs and the development of vaccines that may induce long-lasting immunity without the risk of disease augmentation.

  9. Page 110
    Stephen Oo, Respiratory and Sleep Dept, Princess Margaret Hospital, Roberts Road, Subiaco, Perth, Western Australia, 6008, Australia. E-mail:

    Rhinovirus (RV) PCR techniques have been refined in the past two decades. They have redefined the epidemiology of this virus and have resulted in the discovery of a third species, Rhinovirus C (RV-C), in addition to the species Rhinovirus A (RV-A) and Rhinovirus B (RV-B). Alterations in the RV genome have allowed insight into the evolution of RV strains. The surface structure and cellular receptors differ among RV species, particularly for RV-C. For RV-C, the differences compared with RV-A and RV-B in these attributes suggest that the host immune responses against this virus may also differ from the other species. RV has long been associated with acute asthma, and RV-C has been found to be more common in acute severe asthma in children. The discovery of CDHR3 as the probable receptor for RV-C opens the way for biological and mechanistic studies. Genome-wide association studies have identified childhood asthma risk genes, namely GSMDB, ORMDL3 and CDHR3. The demonstration of RV relevance to these genes supports previous theories about RV in asthma pathogenesis.