The Pharmaceutical Journal
Vol 270 No 7243 p469
5 April 2003

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SARS — a worldwide threat

Severe acute respiratory syndrome is the name given to an atypical pneumonia of unknown cause, which is reported to have killed 64 people. Over 1,800 cases have been reported from 15 countries. Lin-Nam Wang (on the staff of The Journal) looks at current recommendations

Although there have been no deaths from severe acute respiratory syndrome (SARS) in the United Kingdom, three probable cases have been reported and as media coverage of the global spread of this disease continues, pharmacists may find themselves being asked about it.

Some community pharmacies have already experienced an increase in the demand for personal protective equipment, such as surgical masks, from people travelling to affected areas, although this increase could partly be due to general fears about terrorism. Hazel Angus, store manager of John Bell & Croyden pharmacy in London, told The Journal that the pharmacy was inundated with requests for surgical masks last Saturday and was waiting for new stocks to arrive. The pharmacy has also seen an increase in demand for anti-pollution masks — the kind that cyclists wear, she added.

Although the infecting organism has not been confirmed, a coronavirus has been found in specimens from patients and genetic analysis indicates that it is a new strain. Patterns have suggested droplet or contact transmission, but more recently 213 people living on the same residential estate in Hong Kong were admitted to hospital with suspected SARS. This indicates an environmental mode of transmission and epid- emiologists are investigating whether or not bodily secretions containing the virus could have entered a system that links apartments.

World Health Organization guidelines for infection control when caring for a patient with probable SARS include using personal protective equipment and frequent hand washing. In clinics, the guidelines say that outpatients presenting with suspected SARS should be given a mask to wear. There are no recommendations for international passengers to wear masks, but last week, Taiwanese officials handed out 100,000 masks to employees and travellers at CKS international airport. Dr David Heyman, executive director, communicable diseases, said at a press briefing in Geneva: "The best prevention for any disease is information and understanding by people of what that disease looks like and what they should do if they become sick. With that information, people can decide whether or not they want to expose themselves to what they consider a risk."

The mask recommended by both WHO and the Centre for Disease Control is the N95 mask. However, according to Richard Howgill, marketing manager for the 3M Occupational Health and Safety group, a major global supplier of respiratory protective equipment to industry, N95 is an American standard and there is no absolute direct equivalent in Europe, which uses the CE system. "In most instances, surgical masks are used to protect the patient from the health care worker and are generally not CE marked. In this case, we are talking about masks that protect the wearer from an infectious person. The current 3M position is that an FFP2 mask would offer a similar level of protection to the N95. If a customer wants a higher level of product, the FFP3 mask is recommended," he explained.

Mr Howgill told The Journal that 3M had seen an increase in orders for masks, but not a significant one. However, "we have certainly seen an increase in enquiries on our technical helpline, from both pharmacists and the general public, about the level of protection that should be aimed for. 3M is extremely aware of the situation in Asia," he said.

Hong Kong has been affected by over 600 cases of SARS; many of these are health workers. Close contact with others in this densely populated area is made more likely by the large number of skyscrapers — getting into and out of lifts is necessary. Pharmacist Winham Lok, who works at the Hong Kong Hospital Authority's head office, told The Journal that surgical masks, rubbing alcohol (surgical spirit), alcohol swabs, antiseptics, vitamins, thermometers and surgical gloves are in high demand in Hong Kong. Mr Lok himself has been wearing a surgical mask all day in the office, until he gets home. "People here are worried and the lives of everyone is being affected," he said. Dispensing to patients isolated in the community is being co-ordinated through the Department of Health.

Guidelines issued to hospital pharmacy staff in Hong Kong recommend that infection control training classes are provided. Phar-macy working practices are also affected. For example, pharmacies are advised to give 5ml spoons to patients instead of allowing them to help themselves. Physical contact between high risk wards and pharmacies is minimised (eg, orders should be faxed and top up services should be conducted for wards at no risk before those at low and high risk).

The Hong Kong Hospital Authority guideline on the management of SARS proposes a treatment regimen that includes broad spectrum antibiotics, corticosteroids and the antiviral ribavirin, but WHO says that antibiotics do not appear to be effective in treating SARS and at this time, no drug can be recommended for prophylaxis or treatment. According to Dr Mark Salter, SARS clinical management network, the use of ribavirin to treat SARS has been unremarkable to date. "Clinicians have been working through standard therapeutic approaches, which they would normally apply if patients were presenting with a disease that they wouldn't initially know the cause of." Getting a handle on the virus would provide an opportunity to start looking at experiments in tissue cultures to see what effectiveness therapies might have on blocking the replication of the virus in those tissues, he added.

To prevent international spread, WHO says that all persons leaving affected areas should be screened for SARS symptoms. Anyone suspected of having SARS will be asked to postpone their travel until they feel better. Risk areas listed by WHO are Hanoi (Vietnam), Singapore, Hong Kong, Taiwan, Beijing and Guangdong and Shanxi provinces (China) and Toronto (Canada). In addition, WHO recommends that travellers consider postponing non-essential trips to Hong Kong and Guangdong province, but this does not apply to transit passengers. This advice will be reviewed daily and warnings may extend to other countries.

This news feature is based on information available as The Journal went to press, but guidelines and recommendations are likely to change as we learn more about SARS. Daily updates on the disease are available on the websites of WHO (www.who.int/en) and the Public Health Laboratory Service (www.phls.co.uk).

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