Severe Acute Respiratory Syndrome (SARS)
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http://www.cdc.gov/ncidod/sars/

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 Centers for Disease
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 (404) 639-3311

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 
and http://www.who.int 
 http://www.cdc.gov/ncidod/sars/
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http://groups.yahoo.com/group/transhumantech/message/15859
... 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 
high 10%-20%.

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, 
aircraft, etc.).

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 
below.

Mike Darwin

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.
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Dear All,

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
diverted. 

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.


Tom Buckley
Consultant Intensivist
Department of Anaesthesia and Intensive Care,
Prince of Wales Hospital
Shatin, 
Hong Kong
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