Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Correction of Table 1
- Moira Chan-Yeung (15 April 2003)
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Coronavirus may be killed by a higher body temperature
- Chan Kam Ping (15 April 2003)
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Are levofloxacin and macrolides the best treatment in pneumonia?
- Friedrich Flachsbart (16 April 2003)
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Correction of Table 1 - 2nd Version
- Moira Chan-Yeung (17 April 2003)
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SARS and Temperature
- Y L Yip (17 April 2003)
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Genetically Engineered Coronavirus more potent in Enteric and Respiratory tracts of swine
- Trevor G Marshall (18 April 2003)
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Contributing factor to deadly SARS outbreak in HK?
- Teik E Tan (18 April 2003)
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Convalescence & discharge management of Hospital Authorityy in Hong Kong.
- Edward Lai (19 April 2003)
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Is PPV a common link?
- Andrew J Ashworth (19 April 2003)
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Empirical therapy in SARS
- David W Bullimore (21 April 2003)
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SARS transmission to health care workers
- Dietmar Fuchs (23 April 2003)
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Citation
- Wai C YU (22 May 2005)
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Moira Chan-Yeung, Chair Professor of Respiratory Medicine Department of Medicine, The University of Hong Kong, Hong Kong
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Table 1: Number of reported cases of SARS to the Department of Health, Hong Kong, SAR from March 14th to April 1st 2003
Competing interests: None declared |
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Chan Kam Ping, medical practioner Hong Kong
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May I postulate this deadly virus has the following characteristics : 1. It is highly infectious because it infects by air-borne.
Supports of this hypothesis are :
Therefore, I would like to suggest a simple test to confirm this hypothesis : Incubate the virus at different temperature in human tissue media, say below 36C, 36.5C, 37C, and above 37C. If the hypothesis is correct, then control is straight forward :
Let me tell you a legend happened in HK over a hundred years ago. HK was infected by an unknown epidemic. In frustration, people (including the sick) came to the street and watched the "Fire Dragon" dance. As a miracle or due to the intense heat, many sick recovered and the epidemic disappeared. Competing interests: None declared |
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Friedrich Flachsbart, General medicine 37085 Göttingen
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Dear Sir, Prof. DC Hooper, Division of Infectious Diseases, Infection Control Unit, Massachusetts General Hospital, Harvard Medical School warned September 2002: "Fluoroquinolone resistance has arisen in multidrug-resistant clones and its prevalence has been especially high in Hong Kong and Spain." (1) Case 7-2003 of the Massachusetts General Hospital shows the problems of non-bactericidal treatment with azithromycin and levofloxacin in a patient with a bacterial superinfection of a viral respiratory process: Symptoms vanished, but the patient died. Bactericidal therapy (like penicillin) is advocated. (2) Penicillin therapy should be discussed in SARS. Streptococci are the killer in common cold. Sincerely Yours
1. Hooper DC: Fluoroquinolone resistance among Gram-positive cocci. Lancet Infect Dis 2002;2:530-8 2. Rubin RH, King ME, Mark EJ: Case 7-2003: A 43-Year-Old Man with Fever, Rapid Loss of Vision in the Left Eye, and Cardiac Findings. N Engl J Med 2003;348:834-43 Competing interests: None declared |
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Moira Chan-Yeung, Chair Professor of Respiratory Medicine Department of Medicine, The University of Hong Kong
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Table 1: Number of reported cases of SARS to the Department of Health, Hong
Kong, SAR from March 14th to April 1st 2003
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Y L Yip, Honorary Asst. Professor, Dept of Family Medicine, Faculty of Medicine, HKU St Teresa's Hospital, Argyle Street ,Kowloon ,Hong Kong
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I read Dr KP Chan's article with interest. I have some observations to add. I have seen many case of URI coming in these few weeks.Though eventually they did not end up in hospital, and they did not have positive XRay, they did have features unusual , quite unlike the common URIs seen before. The first cases were seen in early March.They made the patient very ill,with high swinging fever.Many of them were quite healthy people before,as I know them quite well for years for other complaints. One private radiologist looking at CXR from this region told me that she observed around 5-10 cases of very mild nonspecific pnueumonia. Though these all eventually did not end up in hospital,she regarded the occurrence as unusal,as she used to see only one or two of such films pre year for her many years of practise. These horde of cases lasted around two weeks, at early March. They then disappeared,and were followed by another batch of URI with symptoms of mild colic, and frequency of bowel motion,but not amounting to watery diarrhoea. These lasted around half to one week. Then another batch of URI appeared with intense pain and coldness of the forehead.There was also very strong foul smell of breath from deep down the airways,somewhat like kerosine.Such patients felt that the breath from deep inside is very cold. I had feel such breath, it was really very cold.Such patients felt very much improvement by having hot water shower over the forehead and chest. Some did it for continuously 30 plus minutes and felt completely cured after that. Some of them said that it was better than my antibiotics and analgesics. These cases. though stormy, usually ended up only as bronchitis,and lasted only one to two days. There was then one night of intense thunderstorm.There was little case after that night for a few days. Then later that week,cases like the first batch of intense fever reappeared. But they are milder and patients felt less ill. During the last week,cases like those 'cold' cases reappeared. But the coldness was milder. They seemed more resilient,and lasted more than three days. Though milder,many of them ended eventually to mild bronchiolitis to mild pneumonia,but no typical SARS XRC.Again they have this cold air from inside,foul smell,and response to hot water shower.But unlike the 'first'batch,hot shower relieved but could not 'cure' the discomfort.It still lingered on after half a day of relieve. I have not been able to do viral tests for everyone. But my patients of these sort promised to come back later for reassesment their viral status. My impression is that they may be two types ,coming in two batches. The later batch seems milder than the first batch for both.One seems hot,while the later 'cold' cases response to 'physical therapy'with hot water shower. Of course these may not be the corona virus.But they were what presented to us recently,and quite unlike the URI we used to see.Are they 'relatives'or 'peers'? I cannot tell until they have their viral studies back. I just want to share these observations with other front line workers in cases it may be of some hint in tackling SARS. PS. My last response on SARS and the direction of east,I forget to mention that Macao. She is so close to Hong Kong and China, with in fact nonstop travellers between them. She also have a less powerful medical and health setup. Yet their cases are nearly nil compare to HK. HK is again on Macao's east.I heard that WHO is going to study this problem too,and hope that their research worker also put this factor into their consideration. Competing interests: None declared |
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Trevor G Marshall, Research Director Sarcinfo, Thousand Oaks, California, 91360
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I read with amazement that Genetic Engineering has been used to breed more virulent strains of the Coronavirus (click here for PubMed FullText) [1]. This paper particularly notes "The assembled cDNA has allowed the rescue of a virulent virus that replicates both in the enteric and the respiratory tracts of swine". Isn't that so very similar to what SARS is turning out to be? Are the clinicians going to be given the benefit of insights into potential treatment methodologies from those involved in these earlier studies? Are the scientists working to isolate the DNA of the SARS epidemic being helped by the scientists that worked on enhancing the coronavirus's virulence? Totally amazing... 1. Almazan F, Gonzalez JM, Penzes Z, Izeta A, Calvo E, Plana-Duran J, Enjuanes L: Engineering the largest RNA virus genome as an infectious bacterial artificial chromosome. Proc Natl Acad Sci U S A 2000 May 9;97(10):5516-21 [PubMed Full Text] 2. Lai MM: The making of infectious viral RNA: No size limit in
sight. Proc Natl Acad Sci U S A 2000 May 9;97(10):5025-7 [PubMed Full Text]
Competing interests: None declared |
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Teik E Tan, Consultant Anaesthetist Penang Adventist Hospital, 10350 Penang, Malaysia.
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I thank Prof. Chan-Yeung and Dr. Yu for their case report on the severe acute respiratory syndrome (SARS) outbreak in Hong Kong. What worries me deeply is the guideline on management of SARS authored by the Hong Kong Hospital Authority Working Group on SARS and the Central Committee on Infection Control, published on-line in the Lancet on 8th April 2003 (http://image.thelancet.com/extras/03cmt89web.pdf). In the flow chart on management, for a definite contact, those patients who are symptomatic but having a normal chest radiograph (and normal or low-normal lymphocyte count) are presumably sent home on sick leave and home charting of temperature. Would this not contribute to the spread of the infection to members of the patient's household, and from them to the community? Surely one cannot trust lay people to be scrupulous with their personal hygiene. Shouldn't all definite contacts with symptoms be isolated until asymptomatic? Competing interests: None declared |
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Edward Lai, Physiotherapist North District Hospital, Hong Kong
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I would like to echo Dr.Teik E Tan's opinion that the documented management guideline of Hospital Authoriy (HA) make us feel uneasy. The convalescent SARS patient is cohorted for up to 3 weeks from onset of illness, or at least 7 days since convalescence, whichever is longer. Then he will be self-quarantine at home for 10 days. And he will return to work if there is no deterioration of condition. From some published paper of Human respiratory syncytial virus (HRSV), the patient may be contagious for at least 3 weeks after signs and symptoms subsided. Some microbiologists in Hong Kong even reported that the excreta, oral and nasal secretions from recovered patient can be contagious for half an year. Since, the acumulative number of discharge patients is 233 on 18 Apr., 2003. Some of them are already or pending to return working soon according to the reent HA guideline. It may be possible that those patients may bring along the contagious viruses back to work and aggravate the virus spreading into the Hong Kong community. Competing interests: None declared |
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Andrew J Ashworth, GP Non-prinicpal Bonhard House, Bo'ness, West Lothian, EH51 9RR
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In a world taking different sides on questions of war, it is refreshing that the medical profession at least is taking a responsibly open approach to the impending SARS pandemic. As a former submarine medical officer, I note the observation that the use in hospital of a nebuliser in the index patient, leading to atomisation of infected secretion might have been involved in transmission. The report does not comment on the use of positive pressure ventilation (PPV) systems in this outbreak but it seems reasonable to assume that these were present in the locations of rapid spread in Hong Kong (a hotel and a major public hospital). Since passenger airlines also use positive pressure ventilation systems and are implicated in the spread of this new disease, it follows that positive pressure ventilation systems should be addressed to assess their effectiveness in removal of aerosol particles. It is possible to use electrostatic filters to remove aerosols from PPV systems but it is unlikely that these are widespread or well maintained in commercial civilian applications. An initial public health measure that could be taken would be to switch off PPV systems in hospitals until effective filtering of the air to remove aerosol droplets can be confirmed or retrofitted. Such a measure would be uncomfortable for those losing the benefits of air conditioning but might help to contain a lethal pathogen. The airline industry is set to lose vast sums in the light of this outbreak: it would make commercial sense to ensure that aeroplanes filter passenger atmospheres effectively. Competing interests: None declared |
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David W Bullimore, Consultant Physician Barnsley DGH, S75 2EP
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Individuals with SARS (severe acute respiratory syndrome)seem to recover or succumb, largely to respiratory complications. Empirical treatment with corticosteroids is apparently being tried on the basis that much of the damage is related to pro-inflammatory cytokine release. It would seem sensible to consider use of agents other than corticosteoids, also empirically. Specific blockade of the pro-inflammatory cytokine tumour necrosis factor-alpha with infliximab, adalimumab or etanercept would be one empirical approach. Use of DFMO (difluoromethylornithine) to provide blockade of ornithine decarboxylase which converts ornithine to putrescine would be another. (Putrescine causes increased capillary permeability in several circumstances and would potentiate lung damage). David Bullimore Competing interests: None declared |
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Dietmar Fuchs, University of Innsbruck A-6020 innsbruck
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Data on the outbreak of severe acute respiratory syndrome (SARS) are very important, especially when rapid spread and high morbidity indicates high virulence of the agent involved. Unfortunately, data on health care workers do not specify their duties at the hospital. The question arises whether infection has also been transmitted to, e.g., laboratory personnel which only is handling contaminated body fluids or excretions without direct contact to affected patients. Dietmar Fuchs
Competing interests: None declared |
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Wai C YU, Consultant Physician Princess Margaret Hospital, Hong Kong
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This article has been cited: Yu WC, Tsang THF, Tong WL, et al. Prevalence of subclinical infection by the SARS coronavirus among general practitioiners in Hong Kong. Scand J Infect Dis 2004; 36:287-90 Competing interests: None declared |
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