Learning from SARS

PUBLIC HEALTH | During the height of Hong Kong’s SARS epidemic, even the elevator buttons in Dr. Gabriel Leung’s apartment building were covered in protective plastic. “They would change it every day and wipe it down with diluted bleach every hour,” he recalled.

Dr. Sophia Siu-Chee Chan saw people “frantically washing their hands” and noted that neither kindergartners nor nursing-school students could attend classes without first checking their temperatures. Quick community response to public-health initiatives helped bring the epidemic under control in Hong Kong, she said.

With the last case of SARS documented there on June 6, Leung—clinical assistant professor in public-health medicine at the University of Hong Kong—and Chan—head of its nursing-studies department—finally had a chance to step back from the frontlines of the fight to share what they learned during a late July visit to Penn’s Nursing School, hosted by the Hartford Center of Geriatric Nursing Excellence and the RAND/Hartford Center for Interdisciplinary Geriatric Health Care Research.

“The SARS epidemic in Hong Kong has taught us that nursing, public health, and clinical medicine must and can work together to combat an epidemic,” Leung said. “Because that is the only way that we came through this epidemic. And it’s the only way we can do so should it come back. Of course the million-dollar question is, ‘Is it coming back?’ We don’t know.”

Leung played a critical role in organizing an international database to better understand the virus. Chan mobilized students and colleagues to support nurses in developing protocols for dealing with SARS patients. And both were involved in crafting strategies to send public-health messages to the elderly and schoolchildren.

According to Leung, one of the key questions that epidemiologists had about SARS was, “How quickly was it spreading?” Of some comfort was the fact that the spread rate was fairly low to begin with (even lower than for the common flu), with the exception of rare “super-spreading events.” (In one of those, more than 300 people were infected in the same apartment complex.) Through public-health interventions, Hong Kong managed to bring the viral “reproduction rate”—the number of cases brought on by one infected person—close to zero by April.

Here’s what else the numbers for Hong Kong showed:

More women got infected than men, due to the fact that more nurses in Hong Kong are women, and the disease spiked in the 20-to-34 age bracket, reflecting the large number of junior medical workers exposed to the virus.

Young people infected with SARS almost always survived, but elderly patients succumbed to the disease in large numbers. Four-fifths of those over 75 who were infected died.

The mean incubation period for the disease was 4 days, but SARS has “a very long tail”—up to 10 or 11 days, according to some estimates—making it difficult to determine how long people who had been exposed to infected persons should be quarantined.

Hong Kong reduced the interval between the onset of disease symptoms to a patient’s hospital admission from four or five days to two days. “That was key in controlling the spread of the epidemic in the community,” Leung said. “The flip side is that the sooner you get people in, the more you get in, the greater the hazard to health-care workers. So how do you balance that?”

According to Chan, a survey of nurses in eight public hospitals in Hong Kong showed that SARS posed “a lot of occupational stress to health-care workers.” Nurses who lived with elderly relatives were especially concerned about spreading infection. Yet the same survey showed nurses as a whole coping better than the ordinary population in response to SARS.

Leung pointed out that physicians and nurses in Taiwan “protested and walked out en masse and resigned. So we shouldn’t take for granted the very good stable work force in Hong Kong that stood up to the challenge and did what they were trained to do.” —S.F.