Treatment of severe acute respiratory syndrome in health-care workers

Sir

There is still no proven therapy for severe acute respiratory syndrome (SARS). The protocol reported by Loletta So and colleagues¹ emphasised the combination use of ribavirin and high-dose cortico-steroid. However, if given very early in the course of the disease, this approach could suppress the generation of host immunity to the novel coronavirus. We observed a biphasic pattern of illness in SARS and postulated that the first stage represents a viraemic phase and the second phase is an immune phase.² Acute respiratory distress syndrome seems to be a complication in the second phase.² If this hypothesis is true, antiviral agents will be most beneficial in the first phase, whereas corticosteroids should be delayed until the onset of the second phase to maximise benefit and keep the negative effects of immune suppression to a minimum.

We, therefore, developed a treatment protocol³ that emphasises early use of ribavirin but delayed introduction of corticosteroids until the second week, if possible. One oral 2000 mg loading dose of ribavirin was given to patients as soon as they received medical attention, followed by 600 mg ribavirin twice daily for patients with a bodyweight greater than 75 kg or 1000 mg daily for those with a bodyweight of 75 kg or less (400 mg in morning, 600 mg in evening) for 10 days. For patients who developed pneumonia, intravenous methylprednisolone (2 mg/kg daily for 5 days) was started on day 8 of fever or later. If rapid deterioration occurred before day 8, steroid treatment was started upon development of dyspnoea. If respiratory distress was not responsive to this dose, 500 mg methylprednisolone daily for 3 days was given. Upon improvement, the dose of steroid was tapered off over the next 2 weeks as recovery warranted.

In Taipei between April 23 and May 31, 2003, 17 health-care workers at our hospital contracted SARS.⁴ PCR of serum or nasopharyngeal swab proved positive in seven of the 17 health-care workers, and convalescent serum antibodies were positive in 13 health-care workers. All 17 health-care workers received our treatment protocol (table ). The median starting day of ribavirin was day 2 of fever (range 1–7 days). Only one health-care worker needed subsequent intubation and respiratory support. All 17 individuals recovered without major sequelae or subsequent relapse. With prompt identification and early treatment, mortality from SARS can be avoided among previously healthy health-care workers.

Table.

Characteristics and timing of treatment for 17 health-care workers with SARS

	Age (years)/sex/occupation	Protection used	SARS category	Ribavirin started*	Steroid started†	Minipulse started‡	ICU stay	Maximum oxygen demand	Discharge
Patient number
1	33/M/doctor	N95 mask	Probable	D1	D7	–	No	Room air	D24
2	28/F/nurse	N95 mask	Suspected	D2	–	–	No	Room air	D18
3	26/F/nurse	N95 mask	Probable	D3	D9	–	No	Room air	D28
4	45/F/nurse	N95 mask	Probable	D3	D10	–	No	Nasal cannula 3 L/min	D27
5	26/F/nurse	N95 mask	Probable	D2	D8	D13	No	Nasal cannula 2 L/min	D28
6	49/F/register	Surgical mask	Probable	D2	D6	D15	Yes	Intubated with FiO2 0·6	D52
7	51/F/porter	Surgical mask	Probable	D7	D13	–	No	Nasal cannula 3 L/min	D33
8	49/F/porter	Surgical mask	Probable	D4	D7	–	No	Nasal cannula 3 L/min	D25
9	34/M/doctor	N95 mask	Suspected	D6	–	–	No	Room air	D6
10	53/F/doctor	N95 mask	Suspected	D2	–	–	No	Room air	D14
11	41/F/nurse	N95 mask	Probable	D1	D10	–	No	Room air	D20
12	27/F/nurse	N95 mask	Suspected	D4	–	–	No	Room air	D10
13	35/F/nurse	N95 mask	Probable	D2	D9	–	No	Room air	D20
14	28/F/nurse	N95 mask	Suspected	D3	–	–	No	Room air	D12
15	30/F/doctor	N95 mask	Probable	D2	D8	–	No	Room air	D26
16	42/M/technician	N95 mask	Probable	D2	D11	–	No	Nasal cannula 3 L/min	D29
17	57/F/porter	N95 mask	Probable	D3	D13	–	No	Room air	D23

F=female. M=male. D=day since onset of fever. ICU=intensive care unit; FiO₂=fractional concentration of oxygen in inspired gas.

^*Oral ribavirin 2000 mg loading then 600 mg twice daily.

^†Intravenous methylprednisolone 2 mg/kg daily.

^‡Intravenous methylprednisolone 500 mg daily.