Posted on 05/01/2003 1:06:47 PM PDT by sarcasm
ONG KONG, May 1 — Some SARS patients who appear to recover are actually late in suffering the worst effects of the disease, while many recovered patients may still have some of the live virus in their bodies when they are discharged from hospital, doctors said here today.
Both phenomena could create problems in controlling the spread of SARS, severe acute respiratory syndrome, and underline how little is known about the later stages of the disease.
Hong Kong's health director, Dr. Margaret Chan, said at a news conference today that "even after recovering, a recovered patient can still excrete a small load of virus."
But Dr. Chan said that she did not know how infectious the discharged patients might be and for how long they might be infectious. "It is important for us to do more tests and studies," she said.
The relapses are a public health issue of potentially enormous importance, as a single discharged patient could reignite the outbreak here if the patient started moving around the community while still infectious. The Hong Kong Hospital Authority announced late Wednesday that a dozen SARS patients had suffered relapses following their discharge from hospital.
Yet at a news conference today, Dr. Chan and Dr. Liu Shao-haei, a senior Hong Kong Hospital Authority manager, were vague about the details of the problem and how they would handle it.
Dr. Chan said that she did not know the minimum time that patients were spending in hospital before they were discharged. "My sense is they would stay there more than three weeks, as the rule rather than the exception," she said.
Dr. Liu said that in deciding when to discharge a patient, doctors looked mostly at that patient's current health. "They are discharged upon their convalescence," he said, adding that he also did not have details like the breakdown between men and women among the relapsed patients.
While Dr. Chan said that discharged patients were still excreting virus, she said that officials did not know how much virus or for how long, and that further tests and studies would be needed to determine this.
Doctors here said on Wednesday and today that relapses were occurring as late as the third week after a patient was discharged, yet hospitals have been telling patients to stay home for only two weeks after their discharge. Dr. Chan said only that hospitals impressed upon patients the importance of following precautions during this period to avoid infecting others.
Falling ill again does not necessarily mean that a patient becomes infectious again. Dr. Brian Tomlinson, a clinical pharmacologist at Prince of Wales Hospital, who has just written a paper about SARS for the British medical journal Lancet, said that relapses, including those that had happened before a patient was discharged, typically represented a late and excessive immune-system response to the virus.
They do not necessarily include an increase in the actual quantity of the virus present, Dr. Tomlinson said.
One source of confusion about the relapses appears to be that they have only occurred among patients of less well-known hospitals. Almost all the initial SARS cases in Hong Kong were treated at Prince of Wales Hospital, the teaching hospital for the Chinese University of Hong Kong.
Chinese University medical professors have been working closely with the W.H.O. and with Hong Kong government officials to come up with responses to SARS, and have written pioneering medical journal articles about the ailment. But not one of the more than 300 patients from Prince of Wales has had a relapse.
Instead, the relapses have occurred among patients of Princess Margaret Hospital, which specializes in respiratory diseases, and United Christian Hospital, two hospitals whose medical staffs are less well known and that only began taking SARS patients after Prince of Wales started to become overwhelmed.
Public hospitals in Hong Kong are run as practically independent fiefs, and SARS specialists at Prince of Wales like Dr. Tomlinson and Dr. David Hui, the chief of respiratory medicine, said they had been given fairly little information about the relapses.
Dr. Hui said a few patients had appeared to recover early, only to fall very ill later.
That pattern raises the possibility that a small number of patients may have been discharged from hospitals only to become sick later, Dr. Hui said. The relapses have occurred at hospitals that may not be holding patients as long as Prince of Wales, which usually keeps patients for at least three weeks from the onset of fever.
In three-quarters of the more than 300 SARS cases treated at Prince of Wales, the patients' pneumonia has worsened significantly and has spread to both lungs 7 to 10 days after the onset of fever, Dr. Hui said. In most of the remaining cases, the pneumonia and fever gradually disappear without the disease ever taking a sudden turn for the worse.
But for three patients at Prince of Wales, all women, the illness did not worsen until the 18th day, Dr. Hui said. At least one of the women had shown considerable signs of recovery, including the disappearance of fever, before her condition abruptly deteriorated; all three women have since recovered, Dr. Hui said.
The delayed onset of the worst symptoms may be part of the natural course of the disease or it may be a result of heavy use of steroids, which suppress the immune system's response to the disease so as to limit inflammation of the lungs, he added.
Dr. Mark Salter, a medical officer with the World Health Organization, said the agency had not been informed of the late onset of the most serious stage of the illness in the cases that Dr. Hui described. The W.H.O. recommends that SARS patients be kept in the hospital for 21 days, which should be long enough, Dr. Salter added.
Dr. Hui said that even though the policy of the Prince of Wales was to release patients only after 21 days, some patients had been released as many as four or five days earlier. These patients were very fit men and women who had clearly gone through the most serious flaring up of pneumonia — with inflammation in both lungs and quite widespread — and then recovered fully, he said.
Doctors elsewhere should be aware that "if you don't observe the flare, keep them a little bit longer," Dr. Hui advised.
Dr. Chan said that the usual regimen of treatment for SARS here made it unlikely that many patients would be released sooner than 21 days. Patients are sent from pneumonia wards to convalescent wards if their blood tests are normal, their chest X-rays show they have little sign of pneumonia and they have been free of fever for 48 hours. Patients must then spend another five days in the convalescent ward before going home.
Today's concerns about relapses came as the number of new cases in the past 24 hours dropped to 11, the lowest in a single day since officials here began announcing daily figures nearly seven weeks ago. Five SARS patients died here today, bringing Hong Kong's death toll to 162, more than in any other city. But 43 patients were discharged today.
In a new worry, however, Dr. Chan said a 13-year-old girl had come down with a suspected case of SARS on April 28, and her high school had been ordered closed until May 8. No illnesses have been found so far among the girl's classmates or instructors.
High schools reopened here last week and junior high schools reopened this week, despite some concerns from parents, while most elementary schools remain closed.
I figured it was the flu because my husband who had a flu shot only got mildly ill. The rest of us didn't get the shot this year and were sick as dogs for about 8 or 9 days.
But, prior to this-no, I never relapsed after a cold or flu.
Gee, such optimism. ;) But I agree, it's not an easy one. I read the doctors are having problems even considering a vaccine, because they say it mutates too fast. Is this natural, i.e. do viruses "Normally" mutate this fast?
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