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.

[riri]

About two months ago, I saw an older company in the Albertson's buying, seriously, about 30 bottles of vinegar. It was before the SARS thing was really even making the news but I wondered if they were up on it.

[Judith Anne]

Hmmmm....

[jacquej]

I have used vinegar for years as a disinfectant. Also use it for a lot of other things. I do not buy any cleaning junk but bleach, hydrogen peroxide, and vinegar. And hydrogen peroxide will kill what vinegar doesn't! Just the regular store kind...

Don't use pesticides or fungicides in my house or garden or on my pets. We have a kitchen garden and eat out infrequently.

There are so many good uses for vinegar. One is in the rinse water of your washing machine, especially if you have hard water. Used to rinse our hair with it (mixed in water, of course, not straight) when we were kids to make sure we got all the soap out and to make it shine.

[jacquej]

Wonder if they have a lot of windows to wash, and are using that instead of Windex?

[TaxRelief]

The medical profession "knows" transmission can occur through the eyes, but there is a lot of denial about it within hospital walls. They just can't keep their hands off their faces. Gloves do nothing if you put a gloved, contaminated finger near you face.

[riri]

Yeah, I don't know. It was very early on in the SARS news and in fact, it was around the time that you would occasionally hear reports of the Chinese using vinegar to disinfect the air in their homes. That was what made me take notice.

Whatever the reason, they had a grocery cart full of vinegar.

I remember reading my older sister's Glamour magazines. They would give the tip to rinse your hair with vinegar and I would try it when I was about 8 or 9. LOL. Along with the Avocado masks, oatmeal and eggwhite masks, etc.

[TaxRelief]

Culturally, chinese people use vinegar as their number one choice of disinfectant. I thought grocery store vinegar targeted fungus more than bacteria. And I was under the impression that it did not cause "instant death" like alcohol or bleach.

[TaxRelief]

Could they convince me my illness was not SARS? I would also pay for an autopsy is I suspected a family member died of SARS. There is no way would my private doctor would keep it from me. He is a conservative activist, too!

[jacquej]

I was told a long time ago that the proper way to kill mold and fungus was to wash the surface first with vinegar, for this would kill the crud, but wouldn't clean the stain.

After that, assuming the surface could tolerate bleach, that would eliminate the stain. But, most people do not realize that bleach doesn't actually eliminate the mold, just the discoloration. The mold will then grow back. Eliminating the source of the mold is very important, of ocurse.

Now, hydrogen peroxide is good for other stuff ya want to eliminate... so it pays to do your homework before just taking anything you read about as the gospel truth.

Bleach fumes are pretty tough, and alcohol is harsh as a disinfectant.

A vinegar wipe-down, followed by a spray of hydrogen peroxide is a pretty good and cheap solution for most domestic uses. Hydrogen peroxide is good for cleaning the surfaces of produce and meats, for example. But proper food handling is always important.

Maybe this old business had a mold problem?

[TaxRelief]

Have you hired a knew tag line writer? You're killing me! ROFLMAO

[TaxRelief]

There are so many reliable sources of better, less interpreted SARS information, it really is not worth the time to check the validity of vanity sites. Refer to my post above. Dr. Preiser is one of the key researchers, and he is in the immediate loop.

[jacquej]

Thanks for the link, TaxRelief, I am off to do just that.

But, I wish you would give me your informed opinion the validity of his understanding about how the US is calculating the cases given on that site. I do not think it would take you all that long. And you seem to be pretty thoughtful on this issue.

[jacquej]

I have downloaded the pdf doc... is that the one you mean?

[jacquej]

Oops! That was supposed to be addressed to TaxRelief. I hit the wrong message in replying, so sorry!

[BartMan1]

May want to check out this ref in Lancet:

http://pdf.thelancet.com/pdfdownload?uid=llan.361.9368.original_research.25515.1&x=x.pdf

Its a retospective study of SARS infected Hong Kong healthcare workers-looked at what protective gear they wore, and determined what measures were most likely to protect against infection.

Turns out that simple surgical mask and gowning ( N 95 mask not necessary) was probably sufficient protection.

This is valuable info going forward as we look for sensible and economical means to deal with suspect cases.

[jacquej]

Thanks for that link! I had no idea how much information was available there. Is there an update available? It seems to stop at around May 7th.

I skipped to the section on Categorization and found nothing there that contradicted my doubts about the accuracy and validity of US Reporting. But, that could be my inadequacy, as I am not skilled in any of these areas.

The comments made by the author of "vanity" site still bother me, and I realize your time is valuable, so I will post the most troublesome paragraph there to save you the time. I have no idea whether these comments are more up-to-date than the PDF document in your link...

"The US numbers are difficult to clearly interpret.  Results of PCR testing for the coronavirus are not used to confirm cases - instead, cases are suspect and probable based on clinical presentation and history. California (having gateways to Asia and large Asian populations) has the largest number of probable cases.



Source: WHO, CDC (CDC and WHO are often 1 day out of sync, CDC and WA Department of Health figures (higher) are also out of sync often).

CDC issues reports irregularly and several states have unusual reporting patterns (i.e. announcing "probable cases" only after the individual has recovered);

There is the prospect of business influence on the reported numbers. The past non-conformity with the WHO definition makes US statistics difficult to compare."

[jacquej]

Wah! Bartman1! I can't get in without a password!

[TaxRelief]

http://www.cdc.gov/ncidod/sars/casedefinition.htm

CDC definition: SARS areas are limited to those with suspected or documented community transmission; this differs from the WHO definition as it excludes areas where secondary transmission has been limited to only health care workers or direct household contacts. Note: the list of SARS areas will be updated as new information becomes available.

SARS Home >

Updated Interim U.S. Case Definition of Severe Acute Respiratory Syndrome (SARS)
May 23, 2003, 10:00 PM ET

Download PDF version formatted for print (126 KB/3 pages)

The previous CDC SARS case definition (published May 20, 2003) has been updated as follows:

• In the Epidemiologic Criteria, the last date of illness onset for inclusion as reported case for Toronto, Canada is now "ongoing."
  

Clinical Criteria

• Asymptomatic or mild respiratory illness
• Moderate respiratory illness
  • Temperature of >100.4º F (>38º C)*, and
  • One or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, or hypoxia).
• Severe respiratory illness
  • Temperature of >100.4º F (>38º C)*, and
  • One or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, or hypoxia), and
    • radiographic evidence of pneumonia, or
    • respiratory distress syndrome, or
    • autopsy findings consistent with pneumonia or respiratory distress syndrome without an identifiable cause.

Epidemiologic Criteria

• Travel (including transit in an airport) within 10 days of onset of symptoms to an area with current or previously documented or suspected community transmission of SARS (see Table), or
• Close contact§ within 10 days of onset of symptoms with a person known or suspected to have SARS

Travel criteria for suspect or probable U.S. cases of SARS
Area	First date of illness onset for inclusion as reported case‡	Last date of illness onset for inclusion as reported case†
China (mainland)	November 1, 2002	Ongoing
Hong Kong	February 1, 2003	Ongoing
Hanoi, Vietnam	February 1, 2003	May 25, 2003
Singapore	February 1, 2003	Ongoing
Toronto, Canada	April 23, 2003	Ongoing
Taiwan	May 1, 2003	Ongoing

Laboratory Criteria¶

• Confirmed
  • Detection of antibody to SARS-CoV in specimens obtained during acute illness or >21 days after illness onset, or
  • Detection of SARS-CoV RNA by RT-PCR confirmed by a second PCR assay, by using a second aliquot of the specimen and a different set of PCR primers, or
  • Isolation of SARS-CoV.
• Negative
  • Absence of antibody to SARS-CoV in convalescent serum obtained >21 days after symptom onset.
• Undetermined
  • Laboratory testing either not performed or incomplete.

Case Classification**

• Probable case: meets the clinical criteria for severe respiratory illness of unknown etiology and epidemiologic criteria for exposure; laboratory criteria confirmed, negative, or undetermined.
• Suspect case: meets the clinical criteria for moderate respiratory illness of unknown etiology, and epidemiologic criteria for exposure; laboratory criteria confirmed, negative, or undetermined.

Exclusion Criteria
A case may be excluded as a suspect or probable SARS case if:

• An alternative diagnosis can fully explain the illness***
• The case was reported on the basis of contact with an index case that was subsequently excluded as a case of SARS (e.g., another etiology fully explains the illness) provided other possible epidemiologic exposure criteria are not present

Also see:

• MMWR: Updated Interim Surveillance Case Definition for Severe Acute Respiratory Syndrome (SARS)— April 29, 2003

__
* A measured documented temperature of >100.4º F (>38º C) is preferred. However, clinical judgment should be used when evaluating patients for whom a measured temperature of >100.4º F (>38º C) has not been documented. Factors that might be considered include patient self-report of fever, use of antipyretics, presence of immunocompromising conditions or therapies, lack of access to health care, or inability to obtain a measured temperature. Reporting authorities should consider these factors when classifying patients who do not strictly meet the clinical criteria for this case definition.

§ Close contact is defined as having cared for or lived with a person known to have SARS or having a high likelihood of direct contact with respiratory secretions and/or body fluids of a patient known to have SARS. Examples of close contact include kissing or embracing, sharing eating or drinking utensils, close conversation (<3 feet), physical examination, and any other direct physical contact between persons. Close contact does not include activities such as walking by a person or sitting across a waiting room or office for a brief period of time.

&#8225; The WHO has specified that the surveillance period for China should begin on November 1; the first recognized cases in Hong Kong, Singapore and Hanoi (Vietnam) had onset in February 2003. The dates for Toronto and Taiwan are linked to CDC&#8217;s issuance of travel recommendations.

&#8224; The last date for illness onset is 10 days (i.e., one incubation period) after removal of a CDC travel alert. The case patient&#8217;s travel should have occurred on or before the last date the travel alert was in place.

¶Assays for the laboratory diagnosis of SARS-CoV infection include enzyme-linked immunosorbent assay, indirect fluorescent-antibody assay, and reverse transcription polymerase chain reaction (RT-PCR) assays of appropriately collected clinical specimens (Source: CDC. Guidelines for collection of specimens from potential cases of SARS. Available at http://www.cdc.gov/ncidod/sars/specimen_collection_sars2.htm). Absence of SARS-CoV antibody from serum obtained <21 days after illness onset, a negative PCR test, or a negative viral culture does not exclude coronavirus infection and is not considered a definitive laboratory result. In these instances, a convalescent serum specimen obtained >21 days after illness is needed to determine infection with SARS-CoV. All SARS diagnostic assays are under evaluation.

** Asymptomatic SARS-CoV infection or clinical manifestations other than respiratory illness might be identified as more is learned about SARS-CoV infection.

*** Factors that may be considered in assigning alternate diagnoses include the strength of the epidemiologic exposure criteria for SARS, the specificity of the diagnostic test, and the compatibility of the clinical presentation and course of illness for the alternative diagnosis.

[IncPen]

Courtesy ping...

[GOPJ]

bump