Cybermed Update Feb 2003

The future is much like the present, only longer.

Dan Quisenberry

Severe Acute Respiratory Syndrome (SARS)

It has been some time since my last article and these episodes (of not writing) between articles seem to be getting frequent and longer apart! Guess when one puts it off once or twice it becomes easier to do so the third and fourth time. I recently, met up with some colleagues and they have noted my absence. That is motivation enough.

We recently had over the last year or so several outbreaks such as the anthrax, west nile fever, bird flu, to name a few and now we seem to be in for another outbreak - Severe Acute Respiratory Syndrome or SARS for short.

WHO had issued two travel advisory's ...I have included the links below..

The case definition given by WHO is as follows...

Case definitions for Surveillance of Severe Acute Respiratory Syndrome (SARS)

Revised 16 March 2003

Suspect Case

A person presenting after 1 February 2003 with history of :


AND one or more of the following:


Probable Case

A suspect case with chest x-ray findings of pneumonia or Respiratory Distress Syndrome


A person with an unexplained respiratory illness resulting in death, with an autopsy examination demonstrating the pathology of Respiratory Distress Syndrome without an identifiable cause.


In addition to fever and respiratory symptoms, SARS may be associated with other symptoms including: headache, muscular stiffness, loss of appetite, malaise, confusion, rash, and diarrhea.

*Close contact means having cared for, having lived with, or having had direct contact with respiratory secretions and body fluids of a person with SARS.

Some information on the events so far...

An epidemic of atypical pneumonia had previously been reported by the Chinese government starting in November 2002 in Guangdong Province. This epidemic is reported to be under control.

Hanoi, Viet Nam

On the 26 February 2003, a man (index case) was admitted to hospital in Hanoi with a high fever, dry cough, myalgia and mild sore throat. Over the next four days he developed increasing breathing difficulties, severe thrombocytopenia, and signs of Adult Respiratory Distress Syndrome and required ventilator support. Despite intensive therapy he died on the 13 March after being transferred to Hong Kong Special Administrative Region of China.

On 5 March, seven health care workers who had cared for the index case also became ill (high fever, myalgia, headache and less often sore throat). The onset of illness ranged from 4 to 7 days after admission of the index case.

As of 15 March, 43 cases have been reported in Viet Nam. At least five of these patients are currently requiring ventilator support. Two deaths have occurred. With the exception of one case (the son of a health care worker) all cases to date have had direct contact with the hospital where the index case had first received treatment.


15 March 2003 | GENEVA -- During the past week, WHO has received reports of more than 150 new suspected cases of Severe Acute Respiratory Syndrome (SARS), an atypical pneumonia for which cause has not yet been determined. Reports to date have been received from Canada, China, Hong Kong Special Administrative Region of China, Indonesia, Philippines, Singapore, Thailand, and Viet Nam. Early today, an ill passenger and companions who travelled from New York, United States, and who landed in Frankfurt, Germany were removed from their flight and taken to hospital isolation.

Due to the spread of SARS to several countries in a short period of time, the World Health Organization today has issued emergency guidance for travellers and airlines.

“This syndrome, SARS, is now a worldwide health threat,” said Dr. Gro Harlem Brundtland, Director General of the World Health Organization. “The world needs to work together to find its cause, cure the sick, and stop its spread.”

There is presently no recommendation for people to restrict travel to any destination. However in response to enquiries from governments, airlines, physicians and travellers, WHO is now offering guidance for travellers, airline crew and airlines. The exact nature of the infection is still under investigation and this guidance is based on the early information available to WHO.



Four new patients with SARS have been admitted since the MOH Press Release yesterday. As at 16 March 2003, we have a total of 20 patients of SARS. Other than the initial three cases, there are an additional 17 patients who have been admitted to hospital. All these have been in close contact with patients of SARS. Ten are family members and friends, and seven are hospital staff who had attended to the patients when they were first admitted to the hospitals. All these patients are stable. Patients are being isolated and the hospital staff have been informed to observe enhanced infection control procedures when attending to suspected cases.

Number of Healthcare Workers Infected

The following is jointly issued by the Department of Health and the
Hospital Authority:

As at 1pm today (16 Mar 2003), the admission statistics of healthcare
workers who suffered from respiratory tract infection are as follow:

Total Admissions (The numbers in bracket are those with Pneumonia Symptoms)

Staff of Prince of Wales Hospital admitted to:
    Prince of Wales Hosptial 36 (29)
    Kwong Wah Hospital 1 (1)
    Princess Margaret Hosptial 1 (1)
Staff of Kwong Wah Hospital admitted to:
    Kwong Wah Hosptial 2 (2)
Staff of Pamela Youde Nethersole Eastern Hospital  admitted to:
    Pamela Youde Nethersole Eastern Hospital  6 (6)
Staff of Private Clinic admitted to:
    Princess Margaret Hospital 3 (3)

Total  admissions  49 (42)

Toronto, Canada: from Promed

Update re Severe Acute Respiratory Syndrome - Toronto Experience ------ There are now 6 probable and 2 suspect adult cases of severe acute respiratory syndrome (SARS) of unknown etiology in the Greater Toronto Area (GTA). (See Health Canada's preliminary definitions of probable and suspect cases at the end of this report.) The first 6 cases involved 6 adults in one family (composed of 7 adults and 3 children) who have been admitted to hospitals in the GTA with probable/suspect SARS. The index case and her husband had traveled to Hong Kong 13 Feb 2003 to 23 Feb 2003. She had respiratory symptoms upon her return to Toronto and died at home on 5 Mar 2003. Four of her adult children/children-in-law (3 of whom lived with her) and her husband ultimately developed symptoms and were diagnosed with probable(4)/suspect(1) SARS. None of the 3 young children in the family have shown signs of SARS although one (5 months old) has been admitted to hospital for observation. This child was noted to have a rash described as erythema multiforme minor after exposure to probable cases in his family noted by his family doctor on 6 Mar 2003 but which resolved by 10 Mar 2003. Two probable cases from this family have died. One probable case from this family is requiring mechanical ventilation but is stable. The remaining probable/suspect cases from this family are stable on medical wards. The seventh case involves the family physician who assessed at least one probable and one suspect case from this family. She has also been diagnosed with suspect SARS and has been admitted to a medical ward and is currently stable. She saw these patients on 6 Mar 2003 for approximately 45 minutes and on 9 Mar 2003 she developed a temperature of 40 C (104 F) which has persisted to date (16 Mar 2003). On 14 Mar 2003, she developed a dry non-productive cough with adventitious sounds in the left lower lobe but has had a normal chest x-ray. The eighth case has been diagnosed on 16 Mar 2003 with probable SARS. He is not related to the first 6 cases and is the first non-Asian case in Toronto. For the first 2 weeks of Mar 2003, he was traveling in Southeast Asia (including Hong Kong on 10 Mar 2003). He developed symptoms on 12 Mar 2003 with pleuritic chest pain, sore throat and light headedness that developed into productive cough with hemoptysis [coughing up blood] and shortness of breath on 14 Mar 2003. He was assessed and noted to have a temperature of 40 C (104 F) on 15 Mar 2003 and is requiring 40 percent oxygen by mask. Pulmonary embolism has been ruled out. Clinical specimens from all cases, including autopsy specimens from one of the probable cases that died have been sent to local, regional, and national laboratories for diagnostic testing. Initial results have revealed no etiology. Histological examination of lung from one of the deceased patients was compatible with adult respiratory distress syndrome. Description of the Toronto SARS Cases: In 3 probable cases where there was a defined exposure, the estimated incubation period ranged from 2-5 days. In all 8 cases, the initial symptoms were primarily fever and malaise. Some, but not all also had headache and myalgias [muscle pains]. While respiratory symptoms were common to all cases (primarily dry cough and shortness of breath), it is worth noting that respiratory symptoms occurred later in the illness in some patients. At presentation to hospital, most have been febrile, short of breath and hypoxic. However, some have not had a fever in hospital. Several patients have had gastrointestinal upset and diarrhea. The chest x-ray abnormalities have been subtle initially, and despite respiratory symptoms, some have had normal chest x-rays. As illness progressed, most developed bilateral and symmetrical pulmonary infiltrates. Total white blood cell counts have been slightly abnormal and 4 patients have been lymphopenic [low number of lymphocytes]. Most patients have had some elevation in transaminases (AST/ALT/GGT 1- 3x upper limit of normal) [these are indicative of liver abnormalities - Mod.MPP]. Three patients have had elevations in creatine kinase [this is indicative of muscle cell damage - Mod.MPP].

For further updates - Severe Acute Respiratory Syndrome (SARS) - VADS CORNER .

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With that I let your "mouse" or your "keyboard" do the "talking".

Till next month, "Happy Surfing".

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