I think of her often, the innocent victim of a disease she brought home with her. She was 78 years old and was visiting family in Hong Kong before she became the index, or first, case of SARS (severe acute respiratory syndrome) in the Western hemisphere.
Her illness 10 years ago highlighted another aspect of our shrinking world. Just days after the first case of SARS was identified in Hong Kong, it had circled the globe with one airplane ride.
The old woman became symptomatic shortly after returning home and was dead in less than two weeks. This anonymous woman was Toronto’s first victim of the terrible disease.
She died at home, and one of the sons taking care of her was the next victim. Five days after he was checked into a Toronto hospital the World Health Organization issued an alert for an atypical pneumonia that was mainly affecting health-care workers and their patients. It was spreading from Hong Kong throughout Southeast Asia.
They didn’t realize that it also was spreading in Toronto. The son appeared at a hospital complaining of a high fever, severe cough and shortness of breath. The emergency department was busy, and he was placed in an open ward while waiting – for 18 to 20 hours. He was admitted to the Intensive Care Unit and placed on a ventilator. Hospital workers suspected tuberculosis.
By the time his test came back negative six days later, he was dead and several family members were symptomatic. The physician who placed him on the ventilator and three nurses caring for him were ill, as were two of the other patients in the emergency department.
One of those patients was admitted with this new illness and died, but not before infecting his wife and three other members of the family. Canadian public-health investigators know that his wife infected seven visitors to the emergency department, six hospital staff members, two patients, two paramedics, a firefighter and a housekeeper. You see where this is going.
In 2003, 8,000 people worldwide contracted SARS, and 10 percent of them died. In Toronto, of the 251 people who became ill, 44 died – for an 18 percent mortality rate.
There were eventually 153 Toronto health-care workers diagnosed with the disease. The hospitals were full. Health-care workers, patients and visitors were becoming infected, and the disease was continuing to spread. The real tragedy of what happened with SARS in Toronto – no plan for containing the spread of an unknown infectious disease. We would have faced a similar tragedy in Denver, New York or Chicago.
It could have been Durango. According to my friend Joe Fowler, epidemiologist at San Juan Basin Health, the department searched its records after the warning to identify how many locals were immunized for travel to Asian countries. The health department immunizes dozens of people every month for international travel.
All of our plans to this point looked at dealing with a known infectious disease threat. How do you protect yourself from something you never suspect?
Some basic infection prevention concepts led to the development of respiratory etiquette. Although the formal title may have been coined by a Miss Manners wannabe, the common name is Cover Your Cough. Many serious respiratory illnesses are spread by coughing or sneezing, and touching something contaminated by the droplets produced. If you cough into your bare hands, anything you touch before washing them is contaminated.
Cover Your Cough is the all-important first step in preventing the spread of respiratory illness – whether it be influenza, whooping cough or SARS. Many of these same measures helped stop the spread of SARS a decade ago.
The basic elements are to cover your mouth and nose with a tissue when you cough or sneeze. Put the tissue in a wastebasket (so no one else handles your war-torn wad of tissue). And then clean your hands with soap and water, or with an alcohol-based hand cleaner. You’ll notice that whenever directions are given about disease prevention, the mantra “wash your hands, wash your hands, wash your hands” rings like a chorus in the background.
Few of us walk around with tissues at the ready. So an alternative method of covering the cough is to aim it into the crook of your elbow. Only a contortionist is likely to contaminate anything from that angle. Many preschoolers already have learned this technique, instead of coughing into their hands as most of us have done since childhood.
We have additional resources in hospitals and clinics, including surgical-type masks. These are offered to any patient or visitor who comes in with a cough or sneeze.
They are for use throughout the year, not just during flu and cold season. This is for the protection of health-care workers, other patients and visitors – and is pretty standard now throughout health care. The masks, along with tissues and hand cleanser, are in Respiratory Hygiene Stations at Mercy Regional Medical Center entrances and near patient-care areas.
We don’t really know if respiratory etiquette would have completely stopped SARS from becoming an epidemic in Toronto. We do know that when these steps were enacted the number of new cases dropped dramatically. And we’ve learned this type of prevention doesn’t require you know which infectious disease you are trying to prevent to be effective.
So cover your cough, and wash your hands, wash your hands, wash your hands.
guywalton@centura.org. Guy Walton is the infection preventionist at Mercy Regional Medical Center.
