Outbreak of severe acute respiratory syndrome in Hong Kong Special Administrative Region: case report
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7394.850 (Published 19 April 2003) Cite this as: BMJ 2003;326:850All rapid responses
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Data on the outbreak of severe acute respiratory syndrome (SARS) are
very important, especially when rapid spread and high morbidity indicates
high virulence of the agent involved. Unfortunately, data on health care
workers do not specify their duties at the hospital. The question arises
whether infection has also been transmitted to, e.g., laboratory personnel
which only is handling contaminated body fluids or excretions without
direct contact to affected patients.
Dietmar Fuchs
Institute of Medical Chemistry and Biochemistry,
University of Innsbruck
Competing interests:
None declared
Competing interests: No competing interests
Individuals with SARS (severe acute respiratory syndrome)seem to
recover or succumb, largely to respiratory complications. Empirical
treatment with corticosteroids is apparently being tried on the basis that
much of the damage is related to pro-inflammatory cytokine release. It
would seem sensible to consider use of agents other than corticosteoids,
also empirically. Specific blockade of the pro-inflammatory cytokine
tumour necrosis factor-alpha with infliximab, adalimumab or etanercept
would be one empirical approach. Use of DFMO (difluoromethylornithine) to
provide blockade of ornithine decarboxylase which converts ornithine to
putrescine would be another. (Putrescine causes increased capillary
permeability in several circumstances and would potentiate lung damage).
David Bullimore
Competing interests:
None declared
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In a world taking different sides on questions of war, it is
refreshing that the medical profession at least is taking a responsibly
open approach to the impending SARS pandemic.
As a former submarine medical officer, I note the observation that
the use in hospital of a nebuliser in the index patient, leading to
atomisation of infected secretion might have been involved in
transmission. The report does not comment on the use of positive pressure
ventilation (PPV) systems in this outbreak but it seems reasonable to
assume that these were present in the locations of rapid spread in Hong
Kong (a hotel and a major public hospital). Since passenger airlines also
use positive pressure ventilation systems and are implicated in the spread
of this new disease, it follows that positive pressure ventilation systems
should be addressed to assess their effectiveness in removal of aerosol
particles. It is possible to use electrostatic filters to remove aerosols
from PPV systems but it is unlikely that these are widespread or well
maintained in commercial civilian applications.
An initial public health measure that could be taken would be to
switch off PPV systems in hospitals until effective filtering of the air
to remove aerosol droplets can be confirmed or retrofitted. Such a measure
would be uncomfortable for those losing the benefits of air conditioning
but might help to contain a lethal pathogen. The airline industry is set
to lose vast sums in the light of this outbreak: it would make commercial
sense to ensure that aeroplanes filter passenger atmospheres effectively.
Competing interests:
None declared
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I would like to echo Dr.Teik E Tan's opinion that the documented
management guideline of Hospital Authoriy (HA) make us feel
uneasy.
The convalescent SARS patient is cohorted for up to 3 weeks
from onset of illness, or at least 7 days since convalescence,
whichever is longer. Then he will be self-quarantine at home for
10 days. And he will return to work if there is no deterioration
of condition.
From some published paper of Human respiratory syncytial virus
(HRSV), the patient may be contagious for at least 3 weeks after
signs and symptoms subsided. Some microbiologists in Hong
Kong even reported that the excreta, oral and nasal secretions
from recovered patient can be contagious for half an year.
Since, the acumulative number of discharge patients is 233 on
18 Apr., 2003. Some of them are already or pending to return
working soon according to the reent HA guideline. It may be
possible that those patients may bring along the contagious viruses
back to work and aggravate the virus spreading into the Hong
Kong community.
Competing interests:
None declared
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I thank Prof. Chan-Yeung and Dr. Yu for their case report on the
severe acute respiratory syndrome (SARS) outbreak in Hong Kong. What
worries me deeply is the guideline on management of SARS authored by the
Hong Kong Hospital Authority Working Group on SARS and the Central
Committee on Infection Control, published on-line in the Lancet on 8th
April 2003 (http://image.thelancet.com/extras/03cmt89web.pdf).
In the flow chart on management, for a definite contact, those
patients who are symptomatic but having a normal chest radiograph (and
normal or low-normal lymphocyte count) are presumably sent home on sick
leave and home charting of temperature. Would this not contribute to the
spread of the infection to members of the patient's household, and from
them to the community? Surely one cannot trust lay people to be
scrupulous with their personal hygiene. Shouldn't all definite contacts
with symptoms be isolated until asymptomatic?
Competing interests:
None declared
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I read with amazement that Genetic Engineering has been used to breed
more virulent strains of the Coronavirus
(click here for PubMed FullText) [1].
This paper particularly
notes "The assembled cDNA has allowed the rescue of a virulent virus that
replicates both in the enteric and the respiratory tracts of swine".
Isn't that so very similar to what SARS is turning out to be? Are the
clinicians going to be given the benefit of insights into potential
treatment methodologies from those involved in these earlier studies?
Are the scientists working to isolate the DNA of the SARS
epidemic being helped by the scientists that worked on enhancing the
coronavirus's virulence?
Totally amazing...
1. Almazan F, Gonzalez JM, Penzes Z, Izeta A, Calvo E, Plana-Duran J,
Enjuanes L: Engineering the largest RNA virus genome as an infectious
bacterial artificial chromosome. Proc Natl Acad Sci U S A 2000 May
9;97(10):5516-21 [PubMed Full Text]
2. Lai MM: The making of infectious viral RNA: No size limit in
sight. Proc Natl Acad Sci U S A 2000 May 9;97(10):5025-7 [PubMed Full Text]
Competing interests:
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I read Dr KP Chan's article with interest.
I have some observations to add.
I have seen many case of URI coming in these few weeks.Though eventually
they did not end up in hospital, and they did not have positive XRay, they
did have features unusual , quite unlike the common URIs seen before.
The first cases were seen in early March.They made the patient very
ill,with high swinging fever.Many of them were quite healthy people
before,as I know them quite well for years for other complaints.
One private radiologist looking at CXR from this region told me that she
observed around 5-10 cases of very mild nonspecific pnueumonia. Though
these all eventually did not end up in hospital,she regarded the
occurrence as unusal,as she used to see only one or two of such films pre
year for her many years of practise.
These horde of cases lasted around two weeks, at early March. They
then disappeared,and were followed by another batch of URI with symptoms
of mild colic, and frequency of bowel motion,but not amounting to watery
diarrhoea.
These lasted around half to one week.
Then another batch of URI appeared with intense pain and coldness of
the forehead.There was also very strong foul smell of breath from deep
down the airways,somewhat like kerosine.Such patients felt that the breath
from deep inside is very cold. I had feel such breath, it was really very
cold.Such patients felt very much improvement by having hot water shower
over the forehead and chest. Some did it for continuously 30 plus minutes
and felt completely cured after that. Some of them said that it was better
than my antibiotics and analgesics.
These cases. though stormy, usually ended up only as bronchitis,and
lasted only one to two days.
There was then one night of intense thunderstorm.There was little
case after that night for a few days.
Then later that week,cases like the first batch of intense fever
reappeared. But they are milder and patients felt less ill.
During the last week,cases like those 'cold' cases reappeared. But
the coldness was milder. They seemed more resilient,and lasted more than
three days. Though milder,many of them ended eventually to mild
bronchiolitis to mild pneumonia,but no typical SARS XRC.Again they have
this cold air from inside,foul smell,and response to hot water shower.But
unlike the 'first'batch,hot shower relieved but could not 'cure' the
discomfort.It still lingered on after half a day of relieve.
I have not been able to do viral tests for everyone. But my patients
of these sort promised to come back later for reassesment their viral
status.
My impression is that they may be two types ,coming in two batches. The
later batch seems milder than the first batch for both.One seems hot,while
the later 'cold' cases response to 'physical therapy'with hot water
shower.
Of course these may not be the corona virus.But they were what
presented to us recently,and quite unlike the URI we used to see.Are they
'relatives'or 'peers'?
I cannot tell until they have their viral studies back.
I just want to share these observations with other front line workers in
cases it may be of some hint in tackling SARS.
PS. My last response on SARS and the direction of east,I forget to
mention that Macao. She is so close to Hong Kong and China, with in fact
nonstop travellers between them. She also have a less powerful medical and
health setup. Yet their cases are nearly nil compare to HK. HK is again on
Macao's east.I heard that WHO is going to study this problem too,and hope
that their research worker also put this factor into their consideration.
Competing interests:
None declared
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Kong, SAR from March 14th to April 1st 2003
Date |
Healthcare workers |
Patients, families, visitors |
Total |
||
Hospital where outbreak started |
Other healthcare workers |
Total |
|||
March 14 March 15 March 16 March 17 March 18 March 19 March 20 March 21 March 22 March 23 March 24 March 25 March 26 March 27 March 28 March 29 March 30 March 31 April 1 |
36 36 38 44 + 16* 47 + 17* 54 + 17* 58 + 17* 66 + 17* 68 + 17* 73 + 17* 78 + 17* 82 + 17* 88 + 18* NA NA NA NA NA NA |
7 11 11 12 20 21 24 27 29 32 34 35 37 NA NA NA NA NA NA |
43 47 49 72 84 92 99 110 114 122 129 134 143 149 153 156 162 164 168 |
0 0 0 23 39 58 74 93 108 125 136 156 176 221 272 314 368 446 517 |
43 47 49 95 123 150 173 203 222 247 265 290 319 370 425 470 530 610 685 |
* Medical students; NA=not available
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Dear Sir,
Prof. DC Hooper, Division of Infectious Diseases, Infection Control
Unit, Massachusetts General Hospital, Harvard Medical School warned
September 2002:
"Fluoroquinolone resistance has arisen in multidrug-resistant clones and
its prevalence has been especially high in Hong Kong and Spain." (1)
Case 7-2003 of the Massachusetts General Hospital shows the
problems of non-bactericidal treatment with azithromycin and levofloxacin
in a patient with a bacterial superinfection of a viral respiratory
process:
Symptoms vanished, but the patient died.
Bactericidal therapy (like penicillin) is advocated. (2)
Penicillin therapy should be discussed in SARS.
Streptococci are the killer in common cold.
Sincerely Yours
Friedrich Flachsbart
1. Hooper DC: Fluoroquinolone resistance among Gram-positive cocci.
Lancet Infect Dis 2002;2:530-8
2. Rubin RH, King ME, Mark EJ: Case 7-2003: A 43-Year-Old Man with
Fever, Rapid Loss of Vision in the Left Eye, and Cardiac Findings. N Engl
J Med 2003;348:834-43
Competing interests:
None declared
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Citation
This article has been cited:
Yu WC, Tsang THF, Tong WL, et al. Prevalence of subclinical infection by
the SARS coronavirus among general practitioiners in Hong Kong. Scand J
Infect Dis 2004; 36:287-90
Competing interests:
None declared
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