Introduction. The authors of these bulletins are infectious diseases physicians on the front line in the epidemic of severe acute respiratory syndrome (SARS) in Hong Kong. They are affiliated with the Division of Infectious Disease, Department of Microbiology, at Queen Mary Hospital and the University of Hong Kong, and they are also caring for patients in the Pamela Youde Nethersole Eastern Hospital, Princess Margaret Hospital, and Kwong Wah Hospital. Their bulletins are being published in the News section of the electronic edition of Clinical Infectious Diseases within 1–2 days after receipt in our office; below is the most recent bulletin, from 5 May 2003.—Sherwood Gorbach and Michael Barza
Bulletin. More than 1600 cases of SARS with 180 related deaths have occurred in the Hong Kong Special Administrative Region of China. This has hit Hong Kong like the September 11th terrorist attacks hit the United States. The practice of medicine and the way of life in Hong Kong will never be the same. Since the number of new cases per day in Hong Kong has decreased to single digits, it is now the time to begin to reflect on how we might have done better during the initial stages of the epidemic.
In retrospect, the news of an outbreak of atypical pneumonia in Guangzhou should have been handled with greater vigilance. Information exchange should have started between health officials, frontline doctors, and academics when it first became apparent that there was an unusual outbreak of illness. An immediate response regarding the necessary infection- control procedures in the hospital and public health measures in the community should have been formulated and disseminated to all levels. When the index case that came from Guangzhou was identified in Hong Kong, these hospital infection- control measures should have been heightened, and the border controls for all visitors from mainland China (i.e., obligatory health declaration and core temperature checking) should have been implemented. Subsequent epidemiological tracing showed that spread had occurred at a hotel, which resulted in dissemination of the disease to all parts of the world. When the first amplification of the outbreak occurred at a major teaching hospital in Hong Kong, closure of this hospital and a rapid outbreak investigation to identify the amplification mechanism should have been performed. Contact tracing and quarantine should have been very thorough, to prevent spillage of the outbreak into the community. The outbreak amplification mechanism was later traced to the use of a nebulizer by the index patient and occasional lapses in infection-control measures by health care workers.
When the second amplification of the outbreak occurred in the community at the Amoy Garden housing development, immediate evacuation and quarantine measures should have been instituted. The faulty sewage system and all similar architectural designs at housing developments should have undergone inspection and repair, as indicated.
In future outbreaks, it must be realized that amplification can occur in old peoples' homes and in nurseries, where good hygienic practice is difficult. Workers at these premises must undergo the necessary training to prevent acquisition and dissemination of the hardy SARS coronavirus, which can survive for quite some time in the environment and in excreta. The facilities in these premises must be upgraded to ensure that they do not become the next amplifiers for SARS.
In the long run, Hong Kong must set up rapid-response teams like those of the Centers for Disease Control and Prevention (Atlanta, GA), with regard to both epidemiological investigation and research, so that this nightmare will not recur. Because it is the most densely populated part of the world, Hong Kong must be cleaner and better prepared for outbreaks of infection than are any other cosmopolitan cities. This must be our first step in the revival of the Pearl of the Orient.—V. C. C. Cheng, M. Peiris, and K. Y. Yuen