Study offers first picture of effects of SARS

CTV.ca ^ | May 28, 2003 | CTV.ca News Staff

[Judith Anne]

A new study, released early by the Canadian Medical Association Journal, shows that the toll SARS takes on health care workers is more profound than many doctors expected.

The research is based on 14 Toronto-area health care workers, many of them nurses, who developed SARS in late March. They suffered from fatigue, pneumonia, and in some cases severe life threatening anemia.

Of the 14 studied, 13 have still not returned to work, weeks after they were released from hospital. And many may be suffering from Post Traumatic Stress Disorder, similar to soldiers returning from war.

The study is the most detailed clinical analysis of what happens to people hit by the new and mysterious illness. It was released on the CMAJ website about a month before the paper's appearance in the print version of CMAJ.

CMAJ STUDY:Clinical course and management of SARS in health care workers in Toronto

The study found that the disease usually developed within four four days of exposure. It often caused full pneumonia in less than three days. Patients remained in hospital for a mean of 14 days.

Many suffered temporary heart problems and long term breathing problems that still persist up to eight weeks later, leaving them breathless and exhausted.

"These are healthy health care workers. The mean age was 42, so they are not old people," explains Dr. Monica Avendano, one of the authors of the study.

Another key finding from the study is the high number of patients who developed severe hemolytic anemia. Some required lifesaving blood transfusions.

The doctors aren't certain whether the anemia is a results of the SARS itself or a complication of treatment, possibly associated with the use of ribavirin, an anti-viral drug doctors were testing on patients at the time. The drug is no longer in use.

Most striking of all the effects were the deep psychological and emotional problem, including insomnia and nightmares. Most of the patients expressed feelings of fear, depression and anxiety at the time of the acute illness.

Pat Tamilin, one of those studied, was "sicker than I've ever been ... it's worse than any pneumonia." And she's concerned about going back to work. "I don't want to be the first health care worker to get SARS twice," she said.

In addition, many of those in the study expressed frustration at being in isolation and without contact with family and loved ones. This was particularly the case for those patients with young children, and especially the two patients whose children developed SARS.

"We are convinced that they have some sort of post traumatic stress disorder," says Dr. Avendano

There was one bright bit of news. The study found that the 14 subjects had contact with 33 family members. Of them, only two developed SARS, and both were mild cases. But disturbingly, one didn't develop symptoms until 12 days after the last contact with the family member -- suggesting that the 10-day quarantine period currently recommended may not be long enough.

The conclusion of the doctors is that SARS is a fast moving disease that if survived, results in a long slow recovery once the acute phase of the disease ends -- as long as two months.

Only one of the 14 subjects has returned to work. If that trend continues and more health care workers are similarly affected in this second wave of cases, it could seriously deplete the health care system.

"The disease continues to linger, the inflammatory process stays for a long time, and we don't know how long," says Dr. Peter Derkach, another of the study's authors.

That's why researchers plan to follow these health care workers for some time to come, to get the clearest picture of the long-term effects of the disease.

[twntaipan]

I'm living in Taipei, and having watched the SARS epidemic spread here I have a few observations (strictly from a layman's perspective).

1. Quarantines are easy to announce, not easy to enforce. They depend fully on the willingness of people to comply, and I doubt a majority of Americans will be willing to strictly quarantine themselves if they are determined to have had contact with a known SARS case.

2. Swings from massive over confidence to almost raw panic are very rapid; they give you whiplash. Taiwanese rush to these extremes (we have nothing to worry about, it's out of control, we have it contol...oops), but as the Canadians have shown, it is not an exclusive Asian phenomenon.

3. There are powerful economic forces at play that put huge pressures on the health care system--from the CEOs of hospitals to public health officials. Toronto is a case in point; China is a case in point; and Hong Kong will be a case in point.

4. The hospital outbreaks make taking an injured or sick family members all the more difficult. People get SARS far too easily in hospitals who quite easily misdiagnose SARS.

5. Public sanitation improves, at least in Taipei (I have heard the same in Hong Kong).

6. It is the social impact, at least here, that is the most nerve wracking. Things go crazy quickly here (see item two above).

7. Increased sales of N95 masks will add to 3M's quarterly profits. (Did you know they make them in children's sizes?)

[Judith Anne]

Bluewave, I'm wrong of course. There are people on home respirators/mechanical ventilation, but (evidently I have limited knowlege and freely admitted ignorance) they have to be in a hospital to be put on one...mostly they are spinal injury patients.

I'm sorry for passing along misinformation, I really try not to do that.

[GOPJ]

Thanks for being here. This situation might get much worse and we'll all need caring, accurate information. You're a treasure.

[jacquej]

I absolutely agree with you! I am not in favor of a health care system here in the states similar to that used in Canada, but it has nothing to do with SARS.

I am not at all sure the states are capable of doing any better a job. Our health care system here is failing, too, and much of the criticism of Canadian Health Care is simply part of a political food fight over what to do about it.

Those here who would use SARS to make a political point about the costs/benefits regarding health care are focusing on their distrust of government health care ideas, and not thinking deeply enough about the myriad contributing factors to health care/insurance issues.

(I personally favor a medical insurance savings account, as a start to a solution, but have no idea what to do about the lawsuit/insurance costs. Right now we are paying $750 a month for two people (Blue Cross standard group policy from a self-employed businesses group).

Our grown children have joined HMOs through their places of employment, and have to face paying out of pocket if they go beyond the incredible restrictions placed on coverage! And, I am assuming they wouldn't be breaking the law by doing so, and that is probably wrong!

I do not want to even get into the deterioration in care happening in our own hospitals in the states because of skyrocketing costs, excessive regulation, fear of litigiation, paperwork, and resulting economic red ink.

I know it is pretty hard to take the uncalled for Canadian bashing, but realize I think and it is the result of people taking sides in a liberal/conservative ideology battle over what to do about our own problems here in the states.

Do I get my flame suit on now? Call my Belgian Malinois buddies to come sit by my side at the computer just in case someone goes after me for being too honest?

[Judith Anne]

Never have I been so aware of my limitations...:-(

[aristeides]

I wonder if this news will persuade the students in Toronto to observe the quarantine.

[jacquej]

Well, I think this is making us all aware of our limitations. We have enjoyed a brief respite during the past 50 to 60 years from death and disability from infectious diseases and degenerative illnesses.

Along with the incredible advances in medical knowledge and technology has come the notion that we all are "entitled" to a solution to just about any medical catastrophe we can think of, and if we do not get it, by gum, we are gonna sure sue someone as fast as we can, for as much as we can.

And, then we complain about the inevitable consequences of our own foolishly unrealistic expectations!

[jacquej]

This is interesting about the length of time it takes to incubate with SARS, from an article in Toronto's Globe and Mail, but, I wonder how the reporter can be sure the kids weren't contagious to others... the rest of the article is good reading too...

A 14-year-old girl developed SARS a week after her parent was hospitalized, and a 17-year-old came down with symptoms 12 days after her parent was hospitalized. Neither got very sick.

While the long incubation period is worrisome, the researchers found the lack of spread among family members reassuring.

"We can only hypothesize that not all patients with SARS are as infectious as has been reported previously. This fact gives us some hope that this disease will not spread in a totally uncontrolled manner in the community," Dr. Avendano said."

http://www.globeandmail.com/servlet/story/RTGAM.20030529.uquar0529/BNStory/Front/

[First Amendment]

There needs to be an open intercom system in these SARS rooms. If voice contact is ingoing it might help alleviate some of the isolation stress.

Hearing classical/favorite music should help, books on tape if conscious enough... Once I was very sick, basically alone (and sleepless from pain) for a week, and I survived because my tape player was within reach - I listened to two favorite tapes over and over for a week, and the sound kept me alive.

[jacquej]

More from the Globe and Mail about the kids breaking the quarantine, as some of us who have raised kids knew they would...

Teens rebel against quarantine
Students straying after 1,500 ordered to remain at home

By CAROLINE ALPHONSO
EDUCATION REPORTER
Thursday, May 29, 2003 - Page A13


Public health officials struggled to keep about 1,500 teenagers in quarantine yesterday, a task that proved insurmountable when some left their confinement to have fun.

On the first day of quarantine for students of Father Michael McGivney Catholic Academy, just north of Toronto, one was already out shopping, while another invited friends to a concert where he was going to be playing last night.....

Murray McQuigge, a spokesman for York Region's public health department, knows all too well that grounding an entire school without any supervision is far from easy.

(snip)


The school closed its doors yesterday because a Grade 11 student attended the school for three days last week with symptoms of SARS.

(snip)

In the meantime, students and staff at the school located in Markham are in quarantine till Tuesday. If another person shows symptoms, this quarantine period could be extended, health officials said.

Reached at their homes yesterday, many students were sleeping in, playing video games or surfing the Internet. A few were even catching up on homework.

But news quickly spread that some had broken quarantine. One girl, for example, took a shopping trip to the city.

"You can't expect people to be isolated for 10 days. We have quite the social life," said 15-year-old Rachel Gunasingham, whose friend went shopping. "It's very difficult. It's summer now, and we're off school early."


The enitre article is interesting reading. Apparently the hospitalized boy's father is now feeling "unwell"...

http://www.globeandmail.com/servlet/ArticleNews/TPStory/LAC/20030529/USCHOM/National/Idx

[Bluewave]

No problem.

I was simply trying to illustrate my belief that the health care system will break down early in an outbreak. Everyone I talk to about SARS, believes the disease is under control and people simply go to the hospital and get well.

I don't expect the general public to be knowledgeable but some health care professionals are equally ignorant. I was talking to an RN friend of mine yesterday. She said SARS would not be a problem because we have good hospitals. She is evidently not a FREEPER.

[harpseal]

It is clear that health care workers and hospital patients are a lot easier to quarantine then a bunch of high school students who feel fine and are convinced they are not going to be the one who come down with it. This could be very significant of the course of this disease's course.

[Judith Anne]

Thanks for your understanding, I felt like an idiot.

One fellow nurse was adamant that the borders would be closed. She is sure of it. I'm not, at all. Plus, consider the coastlines...

If there is a serious wave of outbreaks this fall, I suspect that a number of people will be on their own, at least for a good while...it concerns me, too.

[aristeides]

The people who get the sickest seem to be the most infective. Young people tend to do well with SARS, and so are likely to be less infective.

[riri]

We have far too many people living from paycheck to paycheck who will resist sensible quarantine, if we ever figure out what that is

I said the same thing a few days ago. Also, we have many people who work the type of jobs where if you don't work, you don't get paid. To make it worse, many of these jobs are in the service sector where would-be patients come into contact with the public.

Can you imagine trying to quarantine after, say, a Super Wal-mart checker has come down with SARS and went to work with symtoms for two days, as the high school student in Toronto did?

[Judith Anne]

That's an excellent point...

All quarantines rely on voluntary compliance, in the last analysis, unless we are going to execute people the way the Chicoms do...

How are we going to solve this problem, friends? Let's give the CDC and WHO some help on this, if we can--we already think they're reading our threads, let's see if we have any good ideas for them...

[jacquej]

I hope you are right about them being less infective, as it seems to take them longer to come down with the illness. The hs outbreak in Toronto will be very educational for all of us.

Given that several of the teenagers had some pretty long incubation periods, it could be even up to a month before we know much about how infective they are to each other, if i am calculating correctly.

Do you know something about the infectious period that I haven't seen somewhere? I have been researching pretty carefully, but haven't seen any conclusive evidence pinning down exactly when the contagious period begins and ends, nor have I read anything suggesting that sicker patients are more infective than those less sick. I have seen speculation, but it hasn't eased my mind.

I would love to see some links that would help me get a clearer handle on who is most infective, and exactly how long it takes for them to be "clear"...

[riri]

and exactly how long it takes for them to be "clear"

I would really like to know if they actually clear the virus. In all the things I have read about SARS, I have never read a concrete statement that says that. Has anyone here?

[Judith Anne]

I haven't.

[jacquej]

I took your advice earlier, Judith Anne, and went out to the garden to check on the progress of my flowers, tomatoes, and peppers. Then picked some fresh lettuce and spinach for tonight's dinner salad.

I have lots of good ideas about how to stop this, and I am sure they do too! The problem is that they all are economically disastrous, and politically radioactive.

Never mind the total riot and breakdown of civil discourse we would see on the floor of the General Security Council! (That is my pathetic attempt to be funny, and I admit I am humor-impaired...)

I imagine nothing but martial law would be effective, and you know what a horrible flame-war regarding which conspiracy theory was correct could be started start amongst some in our midst.

Reynolds doesn't make enough aluminum foil to cover the heads on that one. I wouldn't like it much either, since we are among the self- employed who do not get paid if we do not work!

Even our Amish friends no longer could manage without a weeklytrip to the supermarket. I know many of them, and they are losing their self-reliance in all but the strictest branches.