This e-mail received from Tim Rainer in Hong Kong last night, may be of
interest becuase of his experience:


Dear John

It was great to receive your e-mail.  Please let me know if you have any
specific questions.  Do you have any cases yet?

A member of the local press asked me a few questions by e-mail and my
response is included below.  Please let me know if you have any further
questions.


1.      Why so many frontline health care workers continue to be infected
with Sars?

There is no test to diagnose SARS so we cannot tell who has it at an early
stage, which may also be the time when people are most infectious.  SARS
patients generally gravitate towards hospital so the infectious load is
concentrated in hospitals.  Some patients appear not to have SARS and are
triaged to a low risk ward where protection may not be so high but later
SARS appears.  Whilst in the ward they may infect other patients and staff.
It is hard to maintain strict barrier techniques for all staff 24 hours a
day and staff may unwittingly be caught out.  Staff are also tired and
stressed which again reduces their standard of care.  In the early phase,
many staff went down, the very people who were needed to treat others.
Ideally all staff should have been laid off work until the SARS disappeared
but this was impossible and impractical.

2.      What is it about the virus that barrier control measures are not
proving effective?

The virus is hard to differentiate from other causes of cough, fever,
malaise, loss of appetite etcetera.  We simply cannot diagnose the illness
accurately and early enough.  Hospitals is Hong Kong have generally been
overcrowded and basic standards of hygiene may have been a little lax.
Reduced funding has meant that outdated hospitals, structures and equipment
may have not been replaced so there are weaknesses in the system.

Everyone needs to scratch their nose, wipe their brow etcetera sometime and
if you happen to have touched an infected area just before, then the barrier
is breached.

Staff have been without proper leave and rest for many weeks all of which
add up to reducing heightened care.

Very high levels of barrier controls (spacesuits) are expensive, unpleasant
to work in and to date have been thought unnecessary, especially as every
health worker would have to wear one, because we cannot predict where the
next source is hiding.

3.      What is the critical point where the infection is most often spread?
i.e intubation

Very few staff seem to get the infection in our ICU probably because the
awareness is so high.  Most staff get it who are working in medical wards.

4.      Why is intubation so dangerous, what happens?

Intubation may be dangerous because the practitioner gets up close to the
patient's mouth.  Intubation sometimes is required in an emergency when
tight barrier precautions are not in place and protective gear may not be
immediately available.  Sometimes there may be very simple problems such as
the stock of protective gear is temporarily exhausted at just the time that
the patients requires intubation etcetera.  It is hard for staff who are
overworked and tired to foresee every eventuality such as acquiring more
stock before it runs out.  Sometimes we may be overrun with an unexpected
rush of cases which noone could predict.

5.      How can we better protect our frontline workers? What measures need
to be urgently taken?

Frontline workers need adequate rest, shorter shifts, heightened awareness,
better, faster, diagnostic tests, and more spaced out wards with fewer
patients.  Patients need to be nursed in individual cubicles especially when
first admitted and when most infectious.  We need larger wards with fewer
patients.

Staff need large areas where they can change clothes and shower.  At present
they are squashed into little changing rooms with inadequate showering
facilities.

Unfortunately there are not enough staff to do the work and not enough
space.

In the long term we need newer hospitals, with better infectious control
planning.

That's it for now.

Tim Rainer