X-Message-Number: 21445
From:
Date: Fri, 21 Mar 2003 22:36:20 EST
Subject: Personal Protection Steps
I have been asked by a number of people for updates about the spread of SARS
and for information on personal protection and prophylaxis. I am providing
the following information for guidance purposes only. We know so little about
SARS (in part because experience with it is short) it is hard to be definite.
Having said this, I think the following recommendations and observations are
reasonably solid.
1) The spread of SARS is still linear rather than exponential. This may well
be a result of vigorous efforts at isolation and containment. It also may be
an artifact of reporting. It is also often the case that early in an epidemic
the disease has a smoldering phase, perhaps until a critical number of hosts
are infected which give the impression of linearity. In Hong Kong (HK) they
are now beginning to admit secondary cases such as General Practitioners and
family members who came into contact with SARS. When Hugh Hixon and I were
trying to determine if AIDS (HIV) was infectious in early 1980 we were
greatly hampered by not knowing the incubation time. We still have no
definite incubation time for SARS, including maximum times and the
possibility of carrier status. This greatly impact understanding the gravity
of the current situation. Also, SARS may have an animal carrier or reservoir.
Pigs are the usual transmitting animal and "reservoir" for influenza since
influenza occurs as a result of viral recombination of bird respiratory
viruses with porcine viruses (housing pigs and birds together is the prime
reason for this happening; standard proactive in China and Indochina).
2) The situation continues to worsen in HK as detailed in the post from Dr.
Buckley below.
3) On the basis of Dr. Buckley's experience it seems wise to recommend that
you acquire a stock of masks for personal use. The N950 mask which is
available at most hardware stores (standard 3M dust mask) seems to have been
fairly effective in Dr. Buckley's hospital. However, these masks are ill
fitting and allow a fair amount of air leak around the edges. Also, a serious
problem is that N950 masks are uncomfortable, make breathing difficult, and
fog eyeglasses in cool environments. Much better are the N100 masks which are
true HEPA masks. These are also sold in Home Depot and similar outlets and
cost about $10.50 each US. The N100 masks provide 100% filtration of
particles 0.2 microns or above. This should be highly protective. While
viruses are much smaller than this, in practice they are always attached to a
particle which is *much* larger (sputum or secretion droplet). Thus, masks
such as N950 or N100 should be, and apparently are, highly effective. Once
cases occur in your community masks should be worn at all times when outside
the home, and obviously at all times in the presence of an infected person.
the N100 mask has an exhalation valve on it which makes breathing easier and
in normal use should last a week or two. N100 masks may be ordered online
from:
https://www.onlineallergyrelief.com/masks/masks.html
Please note there are now major shortages of masks in Indochina and China.
4) Gloves are strongly suggested. Nitrile rubber gloves are preferred and
these can be washed while on the hands so that they do not need to be
discarded after each time you come into contact with a potentially infectious
object (door handle, subway pole, etc.).
5) Home air cleaners with high output and HEPA rating are suggested to reduce
airborne viral load in community dwellings. Apartment houses and other
structures which have common air handling systems, or situations where a
family member is sick with SARS and being cared for at home would examples of
where these units would be most effective. Also, if you have roommate or
share a dwelling with someone insensitive to taking precautions having a HEPA
air purifier would seem wise. The Honeywell Enviracare is the best home HEPA
air cleaner on the market. Germicidal UV lights in the "safe room" (sleeping
room) or in the room of an infected person is also suggested.
6) Avoid the following starting now, or whenever you feel the threat level is
significant to you personally:
*Crowded public places except when absolutely necessary.
*Highly cosmopolitan venues where this crowding and/or common air
handling facilities. Examples would be Las Vegas (casinos, etc.), NYC,
sporting events, movie theaters, and any place where people congregate.
*Public transportation. If you must use it, wear a mask. Let them laugh.
Better safe than sorry and you can always tell nosy people you've just had
chemotherapy or an organ transplant and don't want to talk about it.
* Minimize shopping and other activities where exposures can be
consolidated into a single trip.
*Have food reserves and reserves of other things you may need (toilet
paper, hygiene items, dish soap, etc.).
7) Ribavirin *may* be of some help according to a recent unreferenced BBC
media report. Unfortunately, stocks of Ribavirin in Mexico along the border
are very low and most of what was there has been purchased already (no, not
by me; I laid in my stock of Ribavirin several years ago after returning from
the Middle East and realizing serious conflict was *inevitable*).
8) Network with others. If anyone with expertise would care to establish a
users group this would be a good idea if there is enough interest. This would
allow rapid exchange of information and suggestions and ideas.
Let us all hope this is a "false alarm" and tat SARS does not spread and is
contained.
Mike Darwin
----------------------
Date: Fri, 21 Mar 2003 06:07:15 +0800
From: Tom Buckley <>
Subject: Re: SARS
Dear Les,
We are using routine community acquired antibiotics but all our cases who
have had contact with ward have not responded. We are now only admitting
cases to our hospital who have had contact with our original case.
We are now seeing the second wave - relatives of primary contacts.
So far no staff have been infected once isolation procedures were put in
place. No one is wearing ordinary surgical masks. There have been some
close calls with some nurses being reported as having atypical pneumonia
after precautions have been taken but in all cases our contact tracing team
has established that there was an earlier contact. Everyone has been
wearing N95 masks and while I think (though don't know for sure) that N95 is
satisfactory staff have not been wearing them properly or they do not fit.
We are switching to the N100 masks not because they are ~ 5% more efficient
but because the nurses have found them more comfortable to breath through
(less resistance) and they fit more comfortably on the face. The N95
masks, despite a variety of brands and sizes have been uncomfortable and
difficult to breath through. There is also the psychological aspect as well.
We are going to try BIPAP. I do not expect it to work (hypoxic respiratory
failure only) but because of the higher flow rates (along the lines of the
nebulized ventolin in the Index Case) and potential for environmental spread
I want it to be as safe as possible. So besides all our "usual" precautions
we are going to do this in one of our isolation rooms - increased
ventilation flow rates and personal HEPA units. If the staff can tolerate
them we will distribute to all staff. Many problems with these but I cannot
afford to lose one nurse. Mind you haven't made a final decision about the
BiPAP.
Last night senior nurse rang me to say she was resigning. She is petrified.
HK Government is down playing the whole thing presumably because of the
economic implications but own hospital has been taken over completely by
this infection. We currently have 24 cases of atypical pneumonia in ICU -
now is that impressive or what.
It also appears to be out in the community. GPs are being admitted.
All of our patients in ICU are either on 100% O2 or they are ventilated
(some prone).
Pulse steroids have been given by the physicians to patients on the general
ward. They initially improve but are now septic and being referred to ICU.
They claim some patients are better on the ward but I think these patients
would have improved anyway. While I was able to dissuade them from using
pulse steroids in ICU patients I had no control over the general wards.
Sorry to ramble. I am very tired but hope this is helpful
Tom Buckley
On 3/21/03 4:04 AM, "Les Galler" <> wrote:
> Dear Tom
>
> Thank you very much for the continuing updates.
> It is hard to really imagine how it must be for yourself, your colleagus,
> and everybody's families.
>
> We have a couple of cases described as "suspect" cases coralled in a couple
> of the Auckland Hospitals, bith patients at this stage relatively well.
>
> We are trying to assemble the appropriate masks and have taken your
> suggestion regarding N100 masks for the staff taht are likely to be exposed
> to such patients over long periodss (eg a nursing shift) and N95 masks for
> "casual" contact.
> There appears to be a problem with small portabel HEPA filters - they are
> thought to be extremely inefficient even for a standard ICU bedspace (I am
> cynical of this) and the big HEPA filters are in short supply and will take
> some time to come (even if they were ordered).
>
> I take it that your patients are being treated with "community-acquired
> pneumonia" antibiotics plus ribavirin and that you are discouraging the use
> of steroids?
>
> Once again we are all immensely grateful for your ongoing updates.
>
> Please convey our admiration and bestw ishes to yourself, your colleagues,
> and the nursing/ancillary staff having to deal with this dreadful problem
>
> Cheers
>
>
> Les Galler
>
>> -----Original Message-----
>> From: Tom Buckley [SMTP:]
>> Sent: Thursday, 20 March 2003 23:27
>> To:
>> Cc: Carol Dembe
>> Subject: Re: SARS
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