Thu, May 15, 2003 page8

• Start with the most basic measures

  • By Sung Fung-chang 宋鴻樟
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  The mass transmission of SARS in Taipei Municipal Hoping Hospital and Jen Chi Hospital have shown that the fight against this disease is no longer something that can be managed by public health agencies and medical personnel alone. It requires a consensus among the entire population and cooperation all around. Teaching the public how to protect themselves should be a matter of the utmost urgency.

  It is gradually becoming clear how SARS is transmitted, but there is no consensus about methods of prevention. People still aren't acting in unison.

  The primary method of transmission is believed to be via respiratory droplets or other bodily fluids. The wearing of surgical masks has become most people's primary prevention measure. In fact, the theory of transmission through the air is rather questionable. As a result, the issue of who should wear surgical masks has become a matter for debate.

  Since the typical symptoms of SARS are a high fever, cough and diarrhea, coughing in a public place creates tension, especially on public transportation. It is almost as though the person coughing should be the one wearing a mask in order to avoid spraying the others.

  Since respiratory droplets are considered an important path of transmission, there is a need for a consensus in favor of using designated spoons and chopsticks to serve food at banquets. It would also be appropriate for those under quarantine to eat their meals separate from others. According to the analysis in the April 25 Morbidity and Mortality Weekly Report by the US Centers for Disease Control and Prevention (USCDC), the primary mode of transmission is to family mem-bers and other "close contacts."

  It is rather difficult to determine the definition of a "close contact." Would it include an unsuspecting carrier of the disease with whom you shook hands? This was the question people pondered when AIDS first began to spread and SARS is no different. In interpersonal contacts, will the traditional Chinese greeting of saluting with folded hands replace the handshake? We will have to wait and see.

  Speaking of transmission by airborne droplets, the SARS virus is rated by the Center for Disease Control (CDC) at biosafety level 3 (BSL-3), ie, on a par with tuberculosis. The morbidity and acute severity of the SARS virus in fact surpass tuberculosis but are less serious than Ebola hemorrhagic fever, which is rated BSL-4. Hence SARS' is listed as BSL-3 and the slightly easier to implement control mechanisms.

  It is still appropriate, however, for items disposed of by SARS hospitals or patients to be sterilized prior to any further handling. How should items disposed of by quarantined individuals be handled? This will require consideration. The CDC currently regards quarantined individuals as BSL-2. Public health authorities must publicly provide further information about what this means. Items discarded by such individuals must be sealed in sturdy, government-provided plastic bags and handled like medical waste.

  Only after the viral incubation period has passed and the quarantine has been lifted may these bags be disposed of as regular garbage. I would recommend that, if the quarantined individual becomes ill, authorities are notified and the waste is handled according to BSL-3 guidelines.

  To prevent the spread of enterovirus, public health authorities have in the past often urged the public to wash their hands frequently. In the SARS epidemic, they are telling people both to avoid unnecessary group activities and to wash their hands frequently. That hand-washing can prevent the spread of SARS need no longer be debated.

  Unfortunately, however, many public places do not provide liquid soap for hand washing or, needless to say, paper towels. Some even lack water. If the authorities believe hand-washing can reduce infection, the Ministry of Transportation and Communications must demand that all airport and bus-station restrooms maintain cleanliness and provide liquid soap for hand-washing -- not just the major stations in Taipei, Taichung, Tainan and Kaohsiung. The Ministry of Education must issue orders for schools at all levels to comply as well.

  The habit of spitting should also be prohibited. The plaza in front of the Taichung Train Station is covered with red betel nut stains and is in particular need of improvement.

  Lin Reuy-shiung (林瑞雄) of National Taiwan University's Institute of Preventative Medicine made a trip last month to Hong Kong's Amoy Gardens apartment complex to investigate the characteristics of the mass outbreak there. Looking at the way the infections occurred there, Lin believed the virus spread through the building's sewage system. Later, researchers in Hong Kong did further analysis, and recently the WHO released a report showing that every patient's feces contained the virus. This confirmed Lin's judgement.

  The handling of feces, therefore, like that of other waste, must be listed among important prevention measures. It would appear that we should design special tools for eradicating the virus. At the very least, toilets should be disinfected with appropriate quantities of bleach, and not flushed until sufficient time has passed for it to kill the virus. Another headache will be the problem of septic tanks.

  Lin has also specially considered the path of SARS infection in the cases of certain male patients. He reasoned that some men infected in China got the disease through sexual contact. This theory was first criticized, but it caught the attention of China's CDC. At an international conference on SARS on April 23 and 24 in Beijing, Chinese epidemiologists acknowledged Lin's conclusion that SARS could be spread by sexual contact. The conference chairman believed Lin made a point of thanking him for this contribution.

  The underground sex industry could be one important source of transmission and it would be best to take preventative measures before the problem gets worse. Whether it is sex or respiratory droplets that is the most important transmission route remains to be seen.

  The panic surrounding the outbreak of SARS is very similar to what happened 20 years ago when AIDS first broke out. In both cases, the origins of the disease are a mystery, and the transmission routes of the SARS virus are even more complex than those of AIDS.

  Public awareness and restraint -- especially self-restraint on the part of suspected SARS cases and cooperation with measures developed by the public health authorities -- will help control the epidemic. Calming the public's fears will also be a great challenge that requires every sort of wisdom.

  Sung Fung-chang is a professor in the College of Public Health at National Taiwan University.

  Translated by Ethan Harkness
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