SARS: experience at Prince of Wales Hospital, Hong Kong
Identifieur interne : 000A02 ( Pmc/Corpus ); précédent : 000A01; suivant : 000A03SARS: experience at Prince of Wales Hospital, Hong Kong
Auteurs : Brian Tomlinson ; Clive CockramSource :
- Lancet (London, England) [ 0140-6736 ] ; 2003.
Url:
DOI: 10.1016/S0140-6736(03)13218-7
PubMed: 12737853
PubMed Central: 7134636
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">SARS: experience at Prince of Wales Hospital, Hong Kong</title><author><name sortKey="Tomlinson, Brian" sort="Tomlinson, Brian" uniqKey="Tomlinson B" first="Brian" last="Tomlinson">Brian Tomlinson</name><affiliation><nlm:aff id="aff1">Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, People's Republic of China</nlm:aff></affiliation></author><author><name sortKey="Cockram, Clive" sort="Cockram, Clive" uniqKey="Cockram C" first="Clive" last="Cockram">Clive Cockram</name><affiliation><nlm:aff id="aff1">Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, People's Republic of China</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">12737853</idno><idno type="pmc">7134636</idno><idno 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id="aff1">Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, People's Republic of China</nlm:aff></affiliation></author></analytic><series><title level="j">Lancet (London, England)</title><idno type="ISSN">0140-6736</idno><idno type="eISSN">1474-547X</idno><imprint><date when="2003">2003</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Lee, N" uniqKey="Lee N">N Lee</name></author><author><name sortKey="Hui, D" uniqKey="Hui D">D Hui</name></author><author><name sortKey="Wu, A" uniqKey="Wu A">A Wu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="World Health Organization" uniqKey="World Health Organization">World Health Organization</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Centers For Disease Control And Prevention" uniqKey="Centers For Disease Control And Prevention">Centers for Disease Control and Prevention</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Poutanen, Sm" uniqKey="Poutanen S">SM Poutanen</name></author><author><name sortKey="Low, De" uniqKey="Low D">DE Low</name></author><author><name sortKey="Henry, B" uniqKey="Henry B">B Henry</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Peiris, Jsm" uniqKey="Peiris J">JSM Peiris</name></author><author><name sortKey="Lai, St" uniqKey="Lai S">ST Lai</name></author><author><name sortKey="Poon, Llm" uniqKey="Poon L">LLM Poon</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Storz, J" uniqKey="Storz J">J Storz</name></author><author><name sortKey="Lin, X" uniqKey="Lin X">X Lin</name></author><author><name sortKey="Purdy, Cw" uniqKey="Purdy C">CW Purdy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Yu, M" uniqKey="Yu M">M Yu</name></author><author><name sortKey="Ismail, Mm" uniqKey="Ismail M">MM Ismail</name></author><author><name sortKey="Qureshi, Ma" uniqKey="Qureshi M">MA Qureshi</name></author><author><name sortKey="Dearth, Rn" uniqKey="Dearth R">RN Dearth</name></author><author><name sortKey="Barnes, Hj" uniqKey="Barnes H">HJ Barnes</name></author><author><name sortKey="Saif, Ym" uniqKey="Saif Y">YM Saif</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="World Health Organization" uniqKey="World Health Organization">World Health Organization</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Tsang, Kw" uniqKey="Tsang K">KW Tsang</name></author><author><name sortKey="Ho, Pl" uniqKey="Ho P">PL Ho</name></author><author><name sortKey="Ooi, Gc" uniqKey="Ooi G">GC Ooi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Centers For Disease Control And Prevention" uniqKey="Centers For Disease Control And Prevention">Centers for Disease Control and Prevention</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hong Kong Department Of Health Report" uniqKey="Hong Kong Department Of Health Report">Hong Kong Department of Health Report</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Buckingham, Sc" uniqKey="Buckingham S">SC Buckingham</name></author><author><name sortKey="Jafri, Hs" uniqKey="Jafri H">HS Jafri</name></author><author><name sortKey="Bush, Aj" uniqKey="Bush A">AJ Bush</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="discussion"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Lancet</journal-id><journal-id journal-id-type="iso-abbrev">Lancet</journal-id><journal-title-group><journal-title>Lancet (London, England)</journal-title></journal-title-group><issn pub-type="ppub">0140-6736</issn><issn pub-type="epub">1474-547X</issn><publisher><publisher-name>Elsevier Ltd.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">12737853</article-id><article-id pub-id-type="pmc">7134636</article-id><article-id pub-id-type="publisher-id">S0140-6736(03)13218-7</article-id><article-id pub-id-type="doi">10.1016/S0140-6736(03)13218-7</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>SARS: experience at Prince of Wales Hospital, Hong Kong</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Tomlinson</surname><given-names>Brian</given-names></name><email>btomlinson@cuhk.edu.hk</email><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author"><name><surname>Cockram</surname><given-names>Clive</given-names></name><xref rid="aff1" ref-type="aff">a</xref></contrib></contrib-group><aff id="aff1"><label>a</label>Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, People's Republic of China</aff><pub-date pub-type="pmc-release"><day>1</day><month>5</month><year>2003</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="ppub"><day>3</day><month>5</month><year>2003</year></pub-date><pub-date pub-type="epub"><day>1</day><month>5</month><year>2003</year></pub-date><volume>361</volume><issue>9368</issue><fpage>1486</fpage><lpage>1487</lpage><permissions><copyright-statement>Copyright © 2003 Elsevier Ltd. All rights reserved.</copyright-statement><copyright-year>2003</copyright-year><copyright-holder>Elsevier Ltd</copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions></article-meta></front><body><p id="para10">The Prince of Wales Hospital (PWH) has been at the forefront of the outbreak of severe acute respiratory syndrome (SARS) in Hong Kong.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> We relate our experience at this hospital. A working definition of SARS is important,<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> although clinical conditions rarely remain within artificial boundaries. Some patients might not have all features, others may present unusually. Fever is a cardinal symptom but not always so, and is sometimes absent in elderly patients. Some patients have presented with diarrhoea or, in at least two cases, with severe acute abdominal pain requiring exploratory laparotomy. All these patients developed typical SARS. Patients presenting with other respiratory infections must now all be regarded as potential SARS cases until proven otherwise. Contact with a known case is an important discriminator but, if emphasised too strongly in the diagnostic process, may lead to false positives or negatives.</p><p id="para20">The difficulty of making a firm diagnosis until chest radiographic changes appear has important implications for health-care personnel and for surveillance. Three major reasons for spread of infection to health-care workers have been: failure to apply isolation precautions to cases not yet identified as SARS, breaches of procedure, and inadequate precautions. Every patient must now be assumed to have SARS, which has major long-term implications for the health-care system. Another reason for spread among health-care workers is infected workers continuing to work despite symptoms, such as mild fever. Such individuals must now cease working. However, staying at home can also have disastrous consequences for exposed family members. Potential cases therefore require early isolation from both workplace and household. Extreme measures are required to protect health-care workers, who account for about 20% of cases.</p><p id="para30">Early diagnosis by virus isolation or serological testing is essential to halt the spread of SARS. Progress has been made with the isolation of the coronavirus.<xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref> A metapneumovirus was also identified in Canada<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref> and in many of the cases at PWH. Coronavirus appears to be the main pathogen, but dual infections may be possible. Such situations are uncommon in human disease, apart from HIV-related infections, but in veterinary medicine combined infections with coronavirus and other agents have been described.<xref rid="bib6" ref-type="bibr">6</xref>, <xref rid="bib7" ref-type="bibr">7</xref></p><p id="para40">The first cases probably occurred in Guangdong Province in southern China in November, 2002.<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref> The term SARS appears to have been first used for a patient in Hanoi who became ill on Feb 26, 2003, and was evacuated back to Hong Kong where he died on March 12. The physician who raised the alarm in Hanoi, Carlo Urbani, subsequently contracted SARS and died. The first case in Hanoi had stayed at a hotel in Kowloon, Hong Kong, at the same time as a 64-year-old doctor who had been treating pneumonia cases in southern China. This doctor was admitted to hospital on Feb 22, and died from respiratory failure soon afterwards.<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> He was the first known case of SARS in Hong Kong and appears to have been the source of infection for most if not all cases in Hong Kong as well as the cohorts in Canada, Vietnam, Singapore, USA, and Ireland, and subsequently Thailand and Germany.<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref></p><p id="para50">The index patient at PWH was admitted on March 4, 2003, and had also visited this hotel. He had pneumonia which progressed initially despite antibiotics, but after 7 days he improved without additional treatment.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> On March 10, 18 health-care workers at PWH were ill and 50 potential cases among staff were identified later that day. Further staff, patients, and visitors became ill over the next few days and there was subsequent spread to their contacts. By March 25, 156 patients had been admitted to PWH with SARS, all traceable to this index case.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> One important factor in the extensive dissemination of infection appears to have been the use of nebulised bronchodilator, which increased the droplet load surrounding the patient. Overcrowding in the hospital ward and an outdated ventilation system may also have contributed.</p><p id="para60">The second major epicentre in Hong Kong, accounting for over 300 cases, has been an apartment block called Amoy Gardens. The source has been attributed to a patient with renal failure receiving haemodialysis at PWH who stayed with his brother at Amoy Gardens.<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> He had diarrhoea, and infection may have spread to other residents by a leaking sewage drain allowing an aerosol of virus-containing material to escape into the narrow lightwell between the buildings and spread in rising air-currents. Sewage also backflowed into bathroom floor drains in some apartments. Spread to people in nearby buildings also occurred, probably by person-to-person contact and contamination of public installations.</p><p id="para70">Although the rapid spread of the disease in some situations may have been explained, many uncertainties remain. Why the disease spread in the Kowloon hotel has not been clarified, and there are many other important issues. “Super-spreaders” may be prone to carry a high viral load because of defects in their immune system, as could be the case in the patient with end-stage renal failure implicated in the Amoy Gardens outbreak and another with renal failure at the centre of an outbreak in Singapore. Subclinical infections may also occur and will not be recognisable until reliable diagnostic tests are available. Procedures causing high risk to medical personnel include nasopharyngeal aspiration, bronchoscopy, endotracheal intubation, airway suction, cardiopulmonary resuscitation, and non-invasive ventilation procedures. Cleaning the patient and the bedding after faecal incontinence also appears to be a high-risk procedure.</p><p id="para80">Treatments have been empirical. Initial patients were given broad-spectrum antibiotics but, after failing to respond for 2 days, were given ribavirin and corticosteroids. Patients who continued to deteriorate with progression of chest radiographic changes or oxygen desaturation, or both, were given pulsed methylprednisolone.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> Steroids were used on the rationale that progression of the pulmonary disease may be mediated by the host inflammatory response, similar to that seen in acute respiratory distress syndrome, and produced by a cytokine or chemokine “storm”. The clinical impression is that pulsed steroids sometimes produce a dramatic response. However, apparent benefits of steroid treatment have proven to be incorrect before, as in infection with respiratory syncytial virus.<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref></p><p id="para90">Lack of knowledge of SARS' natural history adds to the difficulty of determining the effectiveness of therapy. Some patients have a protracted clinical course with potential for relapses continuing into the second or third week, or beyond. Long hospital stays, even in less ill patients, are required, and the high proportion of patients requiring lengthy intensive care, with or without ventilation (23% in the 138 cases from PWH<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref>), and the susceptibility of health-care workers bodes ill for the ability of health-care systems to cope. Even when the acute illness has run its course, unknowns remain. Continued viral shedding and the possible development of long-term sequelae, such as pulmonary fibrosis or late post-viral complications, means that patients will require careful surveillance.</p></body><back><ref-list id="bibl10"><title>References</title><ref id="bib1"><label>1</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Lee</surname><given-names>N</given-names></name><name><surname>Hui</surname><given-names>D</given-names></name><name><surname>Wu</surname><given-names>A</given-names></name></person-group><article-title>A major outbreak of severe acute respiratory syndrome in Hong Kong</article-title><source>N Engl J Med</source><year>2003</year><ext-link ext-link-type="uri" xlink:href="http://content.nejm.org/cgi/reprint/NEJMoa030666v1">http://content.nejm.org/cgi/reprint/NEJMoa030666v1</ext-link><comment>(accessed April 7, 2003)</comment></element-citation></ref><ref id="bib2"><label>2</label><element-citation 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Dis</source><volume>185</volume><year>2002</year><fpage>1222</fpage><lpage>1228</lpage><pub-id pub-id-type="pmid">12001038</pub-id></element-citation></ref></ref-list><ack><p>This Commentary is dedicated to the frontline health-care staff who have shown courageous devotion to duty throughout this epidemic.</p></ack></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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