Posted on 05/09/2003 1:54:44 AM PDT by FreepForever
The Prince of Wales Hospital (PWH) has been at the forefront of the outbreak of severe acute respiratory syndrome (SARS) in Hong Kong.1 We relate our experience at this hospital. A working definition of SARS is important,2 although clinical conditions rarely remain within artificial boundaries. Some patients might not have all features, others may present unusually. Fever is a cardinal symptom but not always so, and is sometimes absent in elderly patients. Some patients have presented with diarrhoea or, in at least two cases, with severe acute abdominal pain requiring exploratory laparotomy. All these patients developed typical SARS. Patients presenting with other respiratory infections must now all be regarded as potential SARS cases until proven otherwise. Contact with a known case is an important discriminator but, if emphasised too strongly in the diagnostic process, may lead to false positives or negatives.
The difficulty of making a firm diagnosis until chest radiographic changes appear has important implications for health-care personnel and for surveillance. Three major reasons for spread of infection to health-care workers have been: failure to apply isolation precautions to cases not yet identified as SARS, breaches of procedure, and inadequate precautions. Every patient must now be assumed to have SARS, which has major long-term implications for the health-care system. Another reason for spread among health-care workers is infected workers continuing to work despite symptoms, such as mild fever. Such individuals must now cease working. However, staying at home can also have disastrous consequences for exposed family members. Potential cases therefore require early isolation from both workplace and household. Extreme measures are required to protect health-care workers, who account for about 20% of cases.
Early diagnosis by virus isolation or serological testing is essential to halt the spread of SARS. Progress has been made with the isolation of the coronavirus.3-5 A metapneumovirus was also identified in Canada4 and in many of the cases at PWH. Coronavirus appears to be the main pathogen, but dual infections may be possible. Such situations are uncommon in human disease, apart from HIV-related infections, but in veterinary medicine combined infections with coronavirus and other agents have been described.6,7
The first cases probably occurred in Guangdong Province in southern China in November, 2002.8 The term SARS appears to have been first used for a patient in Hanoi who became ill on Feb 26, 2003, and was evacuated back to Hong Kong where he died on March 12. The physician who raised the alarm in Hanoi, Carlo Urbani, subsequently contracted SARS and died. The first case in Hanoi had stayed at a hotel in Kowloon, Hong Kong, at the same time as a 64-year-old doctor who had been treating pneumonia cases in southern China. This doctor was admitted to hospital on Feb 22, and died from respiratory failure soon afterwards.9 He was the first known case of SARS in Hong Kong and appears to have been the source of infection for most if not all cases in Hong Kong as well as the cohorts in Canada, Vietnam, Singapore, USA, and Ireland, and subsequently Thailand and Germany.10
The index patient at PWH was admitted on March 4, 2003, and had also visited this hotel. He had pneumonia which progressed initially despite antibiotics, but after 7 days he improved without additional treatment.1 On March 10, 18 health-care workers at PWH were ill and 50 potential cases among staff were identified later that day. Further staff, patients, and visitors became ill over the next few days and there was subsequent spread to their contacts. By March 25, 156 patients had been admitted to PWH with SARS, all traceable to this index case.1 One important factor in the extensive dissemination of infection appears to have been the use of nebulised bronchodilator, which increased the droplet load surrounding the patient. Overcrowding in the hospital ward and an outdated ventilation system may also have contributed.
The second major epicentre in Hong Kong, accounting for over 300 cases, has been an apartment block called Amoy Gardens. The source has been attributed to a patient with renal failure receiving haemodialysis at PWH who stayed with his brother at Amoy Gardens.11 He had diarrhoea, and infection may have spread to other residents by a leaking sewage drain allowing an aerosol of virus-containing material to escape into the narrow lightwell between the buildings and spread in rising air-currents. Sewage also backflowed into bathroom floor drains in some apartments. Spread to people in nearby buildings also occurred, probably by person-to-person contact and contamination of public installations.
Although the rapid spread of the disease in some situations may have been explained, many uncertainties remain. Why the disease spread in the Kowloon hotel has not been clarified, and there are many other important issues. "Super-spreaders" may be prone to carry a high viral load because of defects in their immune system, as could be the case in the patient with end-stage renal failure implicated in the Amoy Gardens outbreak and another with renal failure at the centre of an outbreak in Singapore. Subclinical infections may also occur and will not be recognisable until reliable diagnostic tests are available. Procedures causing high risk to medical personnel include nasopharyngeal aspiration, bronchoscopy, endotracheal intubation, airway suction, cardiopulmonary resuscitation, and non-invasive ventilation procedures. Cleaning the patient and the bedding after faecal incontinence also appears to be a high-risk procedure.
Treatments have been empirical. Initial patients were given broad-spectrum antibiotics but, after failing to respond for 2 days, were given ribavirin and corticosteroids. Patients who continued to deteriorate with progression of chest radiographic changes or oxygen desaturation, or both, were given pulsed methylprednisolone.1 Steroids were used on the rationale that progression of the pulmonary disease may be mediated by the host inflammatory response, similar to that seen in acute respiratory distress syndrome, and produced by a cytokine or chemokine "storm". The clinical impression is that pulsed steroids sometimes produce a dramatic response. However, apparent benefits of steroid treatment have proven to be incorrect before, as in infection with respiratory syncytial virus.12
Lack of knowledge of SARS' natural history adds to the difficulty of determining the effectiveness of therapy. Some patients have a protracted clinical course with potential for relapses continuing into the second or third week, or beyond. Long hospital stays, even in less ill patients, are required, and the high proportion of patients requiring lengthy intensive care, with or without ventilation (23% in the 138 cases from PWH1), and the susceptibility of health-care workers bodes ill for the ability of health-care systems to cope. Even when the acute illness has run its course, unknowns remain. Continued viral shedding and the possible development of long-term sequelae, such as pulmonary fibrosis or late post-viral complications, means that patients will require careful surveillance.
This Commentary is dedicated to the frontline health-care staff who have shown courageous devotion to duty throughout this epidemic.
*Brian Tomlinson, Clive Cockram
Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, People's Republic of China
If SARS ever becomes endemic in the USA I doubt that many managers will react well to people staying home from a mild fever or a cough.
May 10 2003
Taipei
The World Health Organisation has advised against travel to two more Chinese provinces and the capital of Taiwan, as its experts headed to China's hinterland where they fear SARS is beginning to spread rapidly.
The WHO extended its SARS-related travel warning to the provinces of Tianjin and Inner Mongolia, as well as Taipei. The United Nations health agency had already advised against travel to Beijing, the provinces of Guangdong and Shanxi and Hong Kong.
WHO experts say China is the key to containing the global spread of the virus. Severe acute respiratory syndrome has now killed more than 500 people and infected more than 7300.
The WHO has turned its attention to the country's poorer provinces, dispatching four experts to Hebei province, which surrounds Beijing. The team, which arrived in the city of Baoding on Thursday, will inspect hospitals, talk to medical workers and visit rural areas.
In recent days an estimated million migrant workers have returned to Hebei from Beijing and other SARS-stricken areas. Eight officials in the Hebei city of Zhouzhou were fired for allowing a SARS-infected woman returning from Beijing to infect her family, state media reported.
Compounding concerns about the outbreak, Cambodian officials reported the death of seven people from an unidentified form of pneumonia in two impoverished regions near the country's border with Vietnam. WHO and Cambodian officials said there was no evidence yet the deaths were linked to SARS.
But the worst news came from Taipei, where officials reported at least six new cases of SARS that could not be traced to foreign travel or to other SARS victims. Such instances of so-called community infection have been a harbinger of much larger outbreaks to come in other countries that have been affected.
Authorities also were investigating the death of a 63-year-old man in the southern city of Kaohsiung, which represented the first SARS case outside Taipei.
Taiwan now has 132 probable cases and 14 deaths. The island trails only mainland China and Hong Kong with its case load. "It is a grim situation at the moment," said Dr Lee Ming-liang, who was recently appointed to head a SARS taskforce. "Our most important task at this point is to track down the sources of community infections."
The increases have been especially bitter for Taiwan, which has imposed some of the most draconian measures of any country in its efforts to control the disease.
Authorities require all passengers on trains and buses to wear masks, and visitors to buildings with more than 100 workers must have their temperatures taken before entering. The country also is imposing mandatory 10-day quarantines on all visitors from China, Hong Kong, Singapore and Toronto - a step that is devastating its economy.
Taiwanese President Chen Shui-bian told his cabinet on Thursday night that he would order the army and police to take a more active role in enforcing the quarantine and pursuing violators.
The initial assessment of a WHO epidemiological team - the first representatives of that agency to visit the island in 30 years - did not provide any comfort, criticising the country's initial efforts at containment.
"There is some concern that they are not taking proper infection control measures and that, when a case is identified, they do not have the procedures to make sure that person is isolated," said Maria Cheng, a WHO spokeswoman.
Not only managers, but workers. I have found it very frustrating when sick people come to work and then spread their sickness among their fellow workers.
A lot of people nowadays refuse to stay home when they are sick. They either don't want to lose the money or they don't have any "sick days" left. In the meantime, they get everybody else sick and the cycle goes round and round.
I'll take a guess. At some point, after all sick days are used up, the employee will be placed on a 'no pay' authorized absence. The company is not penalized by having to pay excessive sick days and the employee is not penalized for excessive absentism.
With 1,600 cases and 200 deaths, Hong Kong is the second hardest hit area in the world, just next to China. We peaked at 80 new cases/day. Today, the new case/day hit a new low, just 6. New cases per day had been single digit for the past 5 days. We went through a lot of hardship but we did come through the crises. Yes, many families are ruined, many children are orphaned, thousand of jobs are losts, hundreds of businesses went bankrupt. But we survived.
After all, there is not one death case in Ameica, yet. So, don't cry, Betty. Face it. Does worry and fear help to fight to disease? If you want detail of how we deal with it, just ask. I will summarize our experience here. I am not saying Hong Kong is a successful model. The casualty is just second to China, but we did survive. And, that matters a lot to me.
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