Study offers first picture of effects of SARS

CTV.ca ^ | May 28, 2003 | CTV.ca News Staff

[Judith Anne]

A new study, released early by the Canadian Medical Association Journal, shows that the toll SARS takes on health care workers is more profound than many doctors expected.

The research is based on 14 Toronto-area health care workers, many of them nurses, who developed SARS in late March. They suffered from fatigue, pneumonia, and in some cases severe life threatening anemia.

Of the 14 studied, 13 have still not returned to work, weeks after they were released from hospital. And many may be suffering from Post Traumatic Stress Disorder, similar to soldiers returning from war.

The study is the most detailed clinical analysis of what happens to people hit by the new and mysterious illness. It was released on the CMAJ website about a month before the paper's appearance in the print version of CMAJ.

CMAJ STUDY:Clinical course and management of SARS in health care workers in Toronto

The study found that the disease usually developed within four four days of exposure. It often caused full pneumonia in less than three days. Patients remained in hospital for a mean of 14 days.

Many suffered temporary heart problems and long term breathing problems that still persist up to eight weeks later, leaving them breathless and exhausted.

"These are healthy health care workers. The mean age was 42, so they are not old people," explains Dr. Monica Avendano, one of the authors of the study.

Another key finding from the study is the high number of patients who developed severe hemolytic anemia. Some required lifesaving blood transfusions.

The doctors aren't certain whether the anemia is a results of the SARS itself or a complication of treatment, possibly associated with the use of ribavirin, an anti-viral drug doctors were testing on patients at the time. The drug is no longer in use.

Most striking of all the effects were the deep psychological and emotional problem, including insomnia and nightmares. Most of the patients expressed feelings of fear, depression and anxiety at the time of the acute illness.

Pat Tamilin, one of those studied, was "sicker than I've ever been ... it's worse than any pneumonia." And she's concerned about going back to work. "I don't want to be the first health care worker to get SARS twice," she said.

In addition, many of those in the study expressed frustration at being in isolation and without contact with family and loved ones. This was particularly the case for those patients with young children, and especially the two patients whose children developed SARS.

"We are convinced that they have some sort of post traumatic stress disorder," says Dr. Avendano

There was one bright bit of news. The study found that the 14 subjects had contact with 33 family members. Of them, only two developed SARS, and both were mild cases. But disturbingly, one didn't develop symptoms until 12 days after the last contact with the family member -- suggesting that the 10-day quarantine period currently recommended may not be long enough.

The conclusion of the doctors is that SARS is a fast moving disease that if survived, results in a long slow recovery once the acute phase of the disease ends -- as long as two months.

Only one of the 14 subjects has returned to work. If that trend continues and more health care workers are similarly affected in this second wave of cases, it could seriously deplete the health care system.

"The disease continues to linger, the inflammatory process stays for a long time, and we don't know how long," says Dr. Peter Derkach, another of the study's authors.

That's why researchers plan to follow these health care workers for some time to come, to get the clearest picture of the long-term effects of the disease.

[John O]

Just following the discussion. I see a lot of worry about a fall outbreak. Why? Why would the disease revive in fall as opposed to sooner? Wouldn't the extra time between now and then give us better chances to find controls and/or cures?

And lastly, I don't remember seeing any speculation on whether this was a failed (botched) attempt at producing a bio weapon by the Chinese that escaped the lab. Any links to that sort of discussion? (I work in the chem/bio detection field and haven't seen anything on it from this end but it's amazing how fast FR is at finding the real story)

[Judith Anne]

I'm not sure that making such a rule about the nails is going to be helpful--there are other issues, such as rings (I only wear a plain wedding band to work, but others wear more)...for one thing, although there's been a lot of publicity about the artificial nails, gloves are mandated to be worn anytime there is a possibility of touching any body fluid. Gloves are, in my experience, worn in almost every patient's room, with handwashing before and after.

The rule you cite, though, is gathering steam. In my school, it was that nails must not extend beyond the end of the finger, which still leaves room for germs to hide. Gloves are the best bet, in my opinion.

[Judith Anne]

One of the reasons we (and health authorities, AFTER the folks on FR did) are speculating about a fall outbreak is that during the Spanish flu epidemic, there was a spring "herald wave" of a relatively few cases, then in the fall, a huge number--millions.

Typically, influenza strains begin each year in China, where the dominant strain is identified and then the flu vaccines are manufactured for the US cases which inevitably result the following fall and winter. SARS is a coronavirus, not the flu, but you can see the logic.

That's the reason for the concern about this fall...

As far as whether or not this is a failed Chinese biowar experiment gone amock, I personally have no idea. China's farming and restaurant meat procurement practices, however, are sufficient to account for SARS in my opinion.

If it was a biowarfare catastrophe on China's part, then they will indeed pay an almost unbelievable price, in terms of economics but most of all in terms of humanity. It may well bring down the government there. Just guessing.

[Judith Anne]

PS, there've been FR discussions about the possibility that SARS is biowar, you might find links in backhoe's or flutters' threads that link and title most of the articles...

[EternalHope]

You're right about the SARS incubation period giving us time to identify the people who have been exposed, but it is difficult to get compliance with quarantine for extended periods.

The WHO (and the U.S. CDC) is saying the quarantine period should be 10 days. Unfortunately, there are numerous examples of SARS incubation periods that are even longer, and it is possible they are common enough that the quarantine period should be longer as a result.

Another issue is whether people are still contagious after they seem to have recovered. SARS virus in feces has been found for months after a person is released from the hospital.

[jacquej]

I agree with you about gloves! I read somewhere that the virus is suspected of surviving on metals for three days. Is that correct?

Does every worker in a hospital wear gloves all the time? I am wondering about all the metal touched... door handles, etc... I am thinking of the husband in the post above who contacted it while visiting his wife. She was in an orthopedic ward, I am guessing. What did he touch with ungloved hands? IIRC, he was masked and gowned.

Here in the states, the last hospital stay for my husband a couple of years ago, not all workers wore gloves all the time and in all areas. It must be impossible to clean all metals over the entire hospital... Could the virus be transferred by hands from one metal surface to another, extending it's "life" with every transfer? Perhaps from hand lotions or normal skin cells? I do not even want to think about the possibility of fecal materials being the means of transfer!!!

Maybe it is silly to wonder about all this. I am sure the researchers are far better than I at figuring it all out, and eventually will discover the various means of transmission.

[Judith Anne]

I think you have good questions.

And you're right. Not all healthcare workers are diligent.

[Judith Anne]

My practice, since my hospitals have alcohol gel on the walls outside each door:

Wash hands with gel before going into the room. Determine the intervention needed. Don gloves before touching patient. Do intervention. Remove gloves and wash hands, lathering for 15 seconds, before leaving the room. If I'm rushed, I use the gel immediately after leaving the room. Studies show it's very effective.

[jacquej]

Uh-oh!

From this link...

http://www.canada.com/edmonton/edmontonjournal/story.asp?id=CCF39353-674C-4896-8AB0-40F30523CD36

"A second 11th-grader was being assessed for signs of the illness."

This is from the same HS as the first boy....

[-YYZ-]

"Toronto has done a good job with this, compared to Cascadia (The Vancouver/Wasington State Metro Areas, sorta), as the quarantining in Toronto has been agressive. Now, we suspect it isn't long enough, but I do not think it is fair to single out Canada for criticism for the following reason."

And just to say a little more in defense of our response here, I've seen many paranoid and insulting comments on these threads about the "communist" Canadians response to and reporting on SARS. While it is true that it appears that public health officials here could have done a better job, and are inclined to downplay the number of cases and likelihood of transmission, there is one big difference between Canada and say, the PRC: we have a free press. Any lies, obfuscations and cover-ups by officials here are uncovered eventually, and reported in the media. This tends to (eventually, at least) force our officials to come clean and change their approach. This is happening today, in fact, when the reporting of cases of SARS will change to using the WHO's standards, which err more on the side of caution than Health Canada's standards. So when you suddenly see the numbers of suspected, possible or probable cases go up, be aware that these are cases which were already known but reported differently. Also there's good reason to believe these differences in reporting were based on reasonable differences of scientific opinion about this disease which is still not very well understood.

As I say, as a Canadian who lives less than an hour away from Toronto I am not so impressed with how this has been handled so far, but I do believe some of the criticisms leveled at our handling of it by posters here has been hyperbolic, to say the least.

[Bluewave]

I agree that US hospitals are not prepared for even a mild and limited outbreak of SARS. I made some guesses a few weeks back that there are approximately 20,000 vacant intensive care beds available and not all of those beds have negative airflow systems.

There is also the fact that health care workers are among the first disabled by the disease and personnel shortages will be evident in an already stressed system.

I've been working on my own home health care plan and I think if I were really scared and serious, I would buy a home ventilator and an oxygen generator. I haven't done so because of the cost and my optimistic hope that the disease can be contained.

I hove toyed with a plan for self isolation if necessary and have the infection control products that I think might be needed to keep us from spreading the virus to others.

I do not expect the hospitals to do much once the disease spreads in the community.

We are seeing a 15% mortality rate with the best medicine has to offer. I wonder what the mortality rate will be for self care?

[Bluewave]

I think the suggestion that SARS is a hospital disease is absurd. It is a hospital disease because that is where seriously ill people go for help.

[Fury]

I believe that Canada did not handle the situation as well as they could have, as evidenced by the most recent cluster of cases. Even some of the health care professionals involved stated that protocols developed were not being followed. If the US finds itself in the same situation, then shame on them as well.

[Judith Anne]

Home ventilation on a respirator is not possible. Using oxygen with a face mask might be, with a doctor's help...user would need to be trained, special equipment (masks, lines) provided.

Of course, in a worst case scenario, who knows what will happen?

[Judith Anne]

Ordinary bleach/alcohol/peroxide, are good disinfectants. So is vinegar full strength. Latex and vinyl gloves can be bought at any drugstore or (surprise!) hardware store.

[GOPJ]

Thanks for an important observation:

Which means patients need a lot of human contact and help to make it through. Isolating them from fellow patients is a bad idea. Seeing others make it boosts your own will to recover and resume an active life. That's one of the lessons of SARS.

[Judith Anne]

I'm headed out to the yard for some gardening. I'll check in later.

[GOPJ]

Is SARS like the common cold in that you can get it several times a year?

[Judith Anne]

Except, of course, if the others die...

(Sorry, I couldn't help posting this...I've seen it happen...patients always worry if there's someone else in the room. CERTAINLY any isolated patient needs a lot of support and human contact...I myself would personally want anything that let me sleep through the majority of it.)

[Judith Anne]

I don't know, and I don't know if science knows. There were some people who seemed to have relapses, but they are now said to have had other conditions, not SARS. I'm not sure if those reports are accurate or not.