UNDER SIEGE
Doctors and other health workers fighting SARS find themselves victims and spreaders of the virus
By Lucio Victor Jr.
With reports from AFP
On February 26, 48-year-old Chinese-American businessman Johnny Chen was admitted to the French Hospital in Hanoi, Vietnam after developing high-grade fever, dry cough, malaise, and myalgia while on a business trip. Chen had traveled to Shanghai and while in Hong Kong en route to Vietnam stayed at the Metropole Hotel at the same time that a medical professor allegedly fell ill of a disease initially labeled as atypical pneumonia.
Chen's case caught the clinical eye of WHO representative and infectious disease expert Dr. Carlo Urbani who visited the hospital on request of the hospital staff two days into Chen's confinement. Urbani immediately suspected a new disease and alerted the WHO. Severe acquired respiratory syndrome (SARS) was coined to refer to the still unknown disease, and the WHO later issued its first worldwide alert on the mysterious virus.
Urbani's early detection of SARS triggered heightened global surveillance, identification, and isolation of cases, and a concerted effort to contain the infection.
At the French Hospital, Dr. Urbani set to work, collecting specimens and further investigating the killer pneumonia-like disease, finding ways of containing the causative organism. He tightened infection control measures in the hospital imposing such measures as disinfection, handwashing, wearing of protective paraphernalia, and isolation of cases. Unfortunately, about a week later, 10 doctors and nurses attending to the patient developed similar symptoms and fell victim to SARS.
Chen, who was flown back to Hong Kong, died soon after. At about this time, two-thirds of the nurses and half of the nurse-aides in the Hanoi hospital have become infected with SARS. On March 11, Dr. Urbani developed symptoms of SARS after a meeting in Bangkok, Thailand. On March 29, at the age of 46, he died from complications secondary to SARS. A Vietnamese and a French doctor and two nurses also died.
Out of Control
The death of Urbani and several other health workers in Vietnam, China, Hong Kong, Singapore, and Taiwan not only highlighted the reality that health-care personnel are not immune to the diseases they are working to treat, but exposed certain weaknesses in the infection control measures supposed to be in place in hospitals. Likewise it served strong notice of the danger of hospitals becoming centers of viral or bacterial transmission and doctors and health-care workers becoming spreaders of disease.
Consider the following:
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Guangdong medical professor Dr. Liu, Hong Kong's first recorded and most famous SARS case, was believed to have infected 13 hotel guests of various nationalities at the Metropole Hotel and was seen as the "index case" of the worldwide epidemic. The 13 guests went on to infect people in Vietnam, Singapore, Germany, Canada, and Hong Kong, according to the US Centers for Disease Control and Prevention.
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Around 80 percent of all SARS cases in Toronto (the city hit hardest outside Asia) and Singapore were transmitted in hospitals. At least 100 medical staff were infected in Singapore.
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The rapid and massive spread of SARS in China was largely blamed by the WHO on the unpreparedness of hospitals whose lack of control measures made them a breeding ground for the disease. The WHO pointed in particular to fever clinics, which became major areas of transmission. Fever clinics are sections in Beijing hospitals and emergency wards where patients with fever are initially diagnosed. "The fever clinics were not prepared for the number of cases they saw, they did not take adequate precautions in screening and isolating SARS patients, and they didn't have the capacity-so there were more transmissions in the fever clinics," WHO virologist James Maguire noted. At the height of the epidemic in China when Beijing was reporting more than 100 cases a day, 60 of the 123 fever clinics in the city were shut down.
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Several hospitals in China had to be sealed off, and thousands of their workers quarantined along with their patients, after outbreaks went out of control. Among these were the Ditan Hospital where the 600-strong medical staff was quarantined along with 100 SARS patients; the People's Hospital where 1,000 doctors, nurses, other hospital personnel, and patients were put in isolation; the 600-bed Dongzhimen Hospital with 800 staff members.
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Thousands of medical workers in China were put under severe stress, not only because of the magnitude of the problem they had to attend to but because of the threat SARS posed to their own well-being and their being put in isolation themselves. Said 27-year-old Dr. Li Jing of Dongzhimen Hospital: "It's very cruel. Once you enter the hospital, you might not come out. Your family might never see you again. Many of our colleagues are also patients." Added Wang Kerong, nurse at Ditan Hospital: "Some of us work a full shift without eating a meal or even getting a drink of water. We are too afraid the virus will get into our system."
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Of the 2,304 SARS cases as of May 12 in Beijing, 384 (16.6 percent) involved health workers.
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In one cluster case in Hong Kong, 112 doctors, nurses, and medical students in one hospital alone were infected by a 26-year-old Chinese man. By May 4, at least 362 health workers made up nearly one-fourth of total Hong Kong cases. Four of the fatalities were a doctor and three front-line health workers.
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Taiwan's health system was plunged into crisis as mass hospital infections and staff resignations nearly crippled hospitals already hard put at containing the surge in SARS cases. Five hospitals have reported mass infections. At least 114 SARS cases have been linked to the Taipei Municipal Hoping Hospital, which had to be sealed off on April 24 following the first mass infection. Among the fatalities in this facility was 28-year-old Dr. Lin Chung-wei. About 200 patients were put in isolation and the hospital's 900 workers were quarantined for two weeks. Five other health workers have died as of May 18. Other hospitals which closed totally or partially were Jen Chi, where eight nurses contracted the virus; Chang Gung, where 15 members of the staff were infected and 600 patients had to be quarantined; and Taiwan University Hospital, where 250 members of its staff were quarantined.
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The Philippines' first imported case involved a returning Filipina nurse from Canada who died after infecting her father, who also died later.
Paramount
There were, however, some that learned the lessons early and avoided the same fate.
Like Guangzhou No. 8 People's Hospital in southern China where 150 cases were immediately confined at the height of the SARS epidemic. When 10 doctors and 10 nurses were infected, the hospital took immediate action and responded with practical measures.
Hospital deputy director Dr. Yin Chibiao said the hospital staff took personal protection measures like wearing masks and gloves when dealing with patients and handling body secretions. They also practiced frequent cleansing and disinfecting of the wards and ensured the proper handling of contaminated materials and waste.
The hospital also improved ventilation by installing more exhaust fans and ensuring a steady flow of fresh air. Since many of the patients' family members became infected with SARS while caring for their relatives, the hospital limited visits and educated patients on proper hygiene and safety measures. The efforts paid off. Cases dropped to 32 by April with only 11 fatalities, none of them a member of the staff. Ying said the mortality rate would have been higher without the precautions adopted.
The WHO has stressed that disease controls in hospitals were paramount to fighting SARS. "Although we don't know a lot about SARS, we know that the fight in the hospital needs to be done well," Henk Bekedam, WHO resident director in China, said. "If we are not able to treat patients in such a way that we can protect our health-care workers, then I think we have lost the battle. We know that hospital infection control is paramount."
Local Daily Fare
But with or without SARS, occupational hazards surround hospital staff and health-care personnel everyday, and nosocomial infection can strike in several ways.
Laboratory technicians working in serology laboratories or blood banks face exposure to biological hazards like blood-borne pathogens (HIV, hepatitis B and C). Personnel who take blood samples like physicians, nurses, and phlebotomists are equally at risk of exposure with a simple needle prick. Likewise, laboratory technicians who process body fluids of TB patients are at risk unless they take such precaution as using masks, lab gowns, and gloves when handling and processing slides and cultures.
Orderlies, housekeeping, and clean-up crew are constantly exposed to chemical hazards like ethylene oxide, glutaraldehyde, and phenol-based cleansers which they use to clean, disinfect, and sterilize. Other chemical hazards like nitrous oxide pose a threat to anesthesiologists who constantly use and handle the anesthetic. Pathologists and morgue attendants are exposed to the carcinogenic effects of formalin. Radiologists and radiology technicians get exposed to high doses of radiation.
The occupational hazard list in a hospital does not end here.
Violence from psychiatric inpatients, psychosocial issues like depression and adjustment disorders, and hypersensitivity to latex gloves and antiseptic cleansers are also dangers hospital staff face.
But none is more pressing than the biological hazards and the risk of acquiring a nosocomial infection.
At the San Lazaro Hospital, one of two designated SARS centers in Metro Manila, members of the staff are constantly made aware of the health hazards and adequately prepared for these.
According to Dr. Abelardo Alera, head of the hospital's infection control committee, safety measures against biohazards are not the same for all members of the hospital staff. "Different individuals are exposed at different levels depending on which part of the hospital they work." Some face higher risk and have to be appropriately donned with protective masks, latex gloves, and laboratory gowns. But for secretaries and administrative staff who work behind desks, these are unnecessary.
Alera adds that hospital personnel are frequently reminded of practicing safety measures. This, Alera says, has helped San Lazaro escape any problems with outbreaks or hospital infections among the staff .
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