Severe Acute Respiratory Syndrome (SARS)|
by Tom Buckley - 18th Mar 2003
Severe Acute Respiratory Syndrome (SARS)
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Centers for Disease
Control and Prevention
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Atlanta, GA 30333
Guidance about Severe Acute Respiratory Syndrome
for Americans Living Abroad
The Centers for Disease Control and Prevention, HHS, has
received reports of outbreaks of a severe form of pneumonia
(also being referred to as Severe Acute Respiratory Syndrome,
or SARS) in Hong Kong SAR, Vietnam, and Guangdong Province in
China, Canada, Singapore, Thailand, Germany and Switzerland.
Approximately 170 suspected cases had been reported as of
March 17. Cases appear to primarily involve health-care
workers caring for patients with SARS and close family
contacts. CDC is working closely with WHO and country partners
in efforts to define the etiology of this infection, to track
patterns of its transmission, and to determine effective
strategies for its control and prevention. At the present
time, a CDC travel advisory recommends that persons with
elective or non-essential travel to Hong Kong SAR, Guangdong
Province and Hanoi, Vietnam consider postponing such travel.
Additional information is available at http://www.cdc.gov
... This is a warning of a possible near term pandemic which
may be highly lethal and result in serious disruption of
civil order and normal daily life. As most of you probably
know from news reports there has been an unusual communicable
form of "pneumonia" which does not respond to any treatment
currently available including antivirals and antibiotics.
What you may not know is that the media is severely (in my
opinion) underreporting the gravity of the situation in
general, and the severity of this illness in particular.
I first became aware of this problem about 6 months ago when
reports came out of China that a new flu had emerged and the
local population was "overreacting" according to the Chinese
government. One of my Internet medical colleagues in China
advised me that the disease was quite serious, virulently
communicable (had failed containment using standard
Universal Precautions and cloth and disposable surgical
masks). I was also told that heath care workers were heavily
affected and that draconian containment measures were being
used in the province where the disease began. I was also
told that it was *rumored* that the area where the epidemic
began was in proximity to military installations involved
in defensive nuclear-chemical-biological (NBC) research.
Shortly afterward, he died, possibly of the new illness.
His last message indicated that all attempts he knew of
(i.e., civilian) to isolate the etiologic agent responsible
for the disease in China had failed. In short, it did not
appear to be an influenza, although the province where it
originated is in the heart of the world influenza
generation zone (which, BTW, is in China).
On 15 March, the World Health Organization (WHO) issued
an alert and gave the illness a name: SARS, or
Severe Acute Respiratory Syndrome. My contacts in
other areas of epidemiology and medicine have informed
me that the CDC has also so far failed completely to
characterize the etiologic agent for SARS.
[...] As a sidebar, unfortunately, I currently work at a
facility that services travelers and tourists, so, unless
my timing is flawless in the face of a US epidemic of SARS,
all my precautions may have been futile.
Several things are clear:
1) SARS patients who require hospitalization do not seem
to improve and those who become ventilator dependent remain
so. It is not known how many people recover from the illness
who do not reach hospital, but in well nourished urban
populations it appears that the mortality rate may be as
2) SARS is *extremely* infectious; those physicians
treating it in Hong Kong report that it is about as
infectious as influenza. So that you can understand
the gravity of this statement this would mean that
SARS is more infectious than Ebola or the other
hemorrhagic fevers and would require the highest
level of biosafety containment for handling in the
laboratory. *For practical purposes it means that
complete civilian protection can best be achieved
by complete isolation until the epidemic is over.*
Masks (respiratory) and conjunctival protection
(eye shields) coupled with gloves will probably
provide a significant degree of protection against
casual exposure. A principal purpose of the gloves
is to remind you not to touch your face. However,
these methods of protection will likely fail if
contact with infected person(s) is prolonged in
indoor or contained spaces (homes, vehicles,
3) SARS is likely to spread rapidly and public health
officials are likely to react too slowly to contain it.
Only draconian measures would allow any significant
degree of protection and these measures are likely to
be so severe that normal commerce and travel would be
severely or completely disrupted. SARS may well behave
much like the 1918 Flu. For an excellent and comprehensive
review of this pandemic I highly recommend Gina Kolata's
FLU: THE GREAT INFLUENZA PANDEMIC OF 1918 AND THE
SEARCH OF THE AGENT THAT CAUSED IT (ISBN: 0374157065
Publisher: Farrar, Straus & Giroux, LLC). Used copies are
available from bookfinder.com for as little as $1.00 (US).
The 1918 Flu killed more people than W.W.I. Estimates for
deaths in the US are as high as 18 million.
4) I suggest that if you have not done so already, you
stockpile emergency food, water, and minimal protective
equipment for you and your loved ones. It is impossible
to be comprehensive here, but other measures such as having
bleach and dispensing equipment available for disinfection
of surfaces should you have to care for someone infected
with SARS should also be undertaken Many websites for
disaster and NBC preparedness exist, and many of these sell
supplies which may be useful. Frankly, these are supplies
you should *all* have in any event as a routine part of
preparedness for life. *Anyone seriously concerned about
their survival should have these kinds of preparations in
place. * Survival Unlimited.com is one such website. There
are many others.
5) The elderly and immunocompromised appear to be particularly
hard hit by SARS and appear to constitute a disproportinate
number of those who've died.
6) I emphasize that media coverage is not accurately reflecting
the severity of the disease or the extent of SARS in China,
although the media is beginning to report that SARS "is of concern
to healthcare agencies."
7) Those involved in healthcare, cryonics care, and those who
deal with tourists (freeway related businesses, tourist centers,
and hotels/motels) are IMHO likely to be at very high risk of
exposure to the initial wave of infection with SARS should it
become epidemic in the United States and Europe.
A disproportinate number of sentinel provincial Chinese cases
were in hoteliers and shopkeepers at trade hubs. If you are
involved in such a business it would probably be wise to cease
operation (where possible) at such time as the first cases are
reported in your country or region of your country.
Healthcare and cryonics workers should acquire active
full-head HEPA protection for all staff and impermeable
full-body protective suits. In the case of cryonics
personnel, Standby staff who deal with the patient while
alive will be at very high risk. Volunteers for these high
risk positions should be sought at the earliest opportunity
and training to minimize the risk of SARS transmission
(using influenza as a model) should begin at once.
Cryonics organization should also, in my opinion,
modify handling and operative procedures to deal
with this illness. The external surfaces of all
patients who arrive should be scrubbed with detergent
and 2% sodium hypochlorite.
Finally, impending war is likely to provide a fertile
opportunity for rapid spread of SARS since it mandates
movement of manpower and material across multiple
borders even the presence of disease, concentrates
people in barracks and shelters, and results in
immunocompromise from stress (even in healthy and well
nourished soldiers and civilians) from increased
glucocorticoid secretion. War is the handmaiden of
epidemic disease and in this case the timing could not
be worse in my opinion.
Thank you for your consideration of this message. The
communication from Tom Buckley, as posted to the
Critical Care Medicine Forum (CCM-L), is reproduced
The implications of SARS for the cryonics community are overwhelming.
I will close this message with a communication from Tom Buckley,
an Intensivist in Hong Kong. Tom's is a superb physician and
Intensivist and his communication below should give you snap
shot of what is happening in a major, highly sophisticated
medical center in Hong Kong.
I have not read all of the below because we seem to be close
too or are the centre of this form of atypical pneumonia.
So just a brief summary of our experience.
Male arrives on the medical ward having been admitted
thru A & E. Other patients and STAFF start to develop
symptoms - fever, headache, dry cough.
Unresponsive to various combinations of cefotaxime,
chlarithromycin, levofloxacin, doxyclycline and Tamiflu.
All microbiology is NEGATIVE (after one week).
Physicians have started patients on ribovarin and steroids.
As of yesterday there were 64 patients with "atypical pneumonia"
in the hospital - a large number of whom are staff.
Patient visitors, medical consultation staff, medical students
visiting patients have all developed symptoms and to a large
degree CXR signs.
While most of our cases revolve around the patient admitted
to the medical ward we have admitted (to ICU) another patient
from another hospital with atypical pneumonia.
In ICU we have twelve patients admitted so far
Five are ventilated. Seven breathing spontaneously but
very oxygen dependent.
My impressions CXR reveal progressive bilateral infiltrates
starting at the bases. Patients invariably have a low WCC and
maybe thrombocytopenic. Patients invariably have an elevated
CPK. No ECG changes and Troponin T negative. Post mortem on
an Indonesian maid (not in our hospital) showed evidence of
ARDS and myocarditis.
So far 2-3 of our older patients with chronic disease have
deteriorated fastest. Medical staff - younger and fitter
have faired better. Their radiological findings have
deteriorated in all but one case.
We receive 2-3 admissions per day. So far no-one has shown
any improvement. Once intubated however they remain
relatively static but very oxygen and PEEP dependent.
Those ventilated have solid lungs. Interestingly one
patient developed a pneumothorax on the medical ward and
after chest drain and re-expansion his pneumonia involves
only the side without a chest drain. Another patient
(ventilated) has developed surgical emphysema.
ICU is now closed for all but atypical pneumonias. All our
other "clean cases" have been transferred to other ICUs.
All elective surgery is being cancelled and wards are
being closed and evacuated. Al ambulances are being
We are taking strictest possible isolation procedures
available to us including hand washing, gloves, gowns,
N95 masks and visors.
Masks are worn throughout the hospital.
Staff are not going home to children.
Please take the warning below seriously. My impression
is that even with minimal contact with an infected person
people have been becoming ill.
Staff morale in ICU is high but If ICU staff start
developing symptoms then this is a big problem as we
have instituted isolation procedures earliest.
Other hospitals in Hong Kong are admitting sporadic cases.
I am off to a noon update.
Any suggestions will be gratefully received.
Department of Anaesthesia and Intensive Care,
Prince of Wales Hospital