When SARS first began to spread in Taiwan in March, there were relatively few cases. Moreover, most of those at risk were travellers from the areas where SARS originated or those affected by those outbreaks. Thus the prevention strategy in that initial period was one of containing imported cases.
As the number of cases rapidly increased, however, the original containment policy had to be systematically reconsidered and more comprehensive rapid- response measures had to be implemented.
The reason is very simple: When the scope of any communicable disease expands continuously, mortality will rise -- as was seen last summer with the spread of dengue hemorrhagic fever -- and once the number of serious cases grows, it becomes more difficult to control the epidemic.
At that point, it requires even more thorough thinking and close cooperation to consider SARS prevention as the No. 1 priority for every citizen.
In the first place, as the SARS epidemic spreads, what's most needed is strong leadership in crisis management, professional handling of epidemiological investigations, and efficient disease control and problem-solving.
Unfortunately, after the Taipei Municipal Hoping Hospital was sealed off, a scheduled conference of specialists was suddenly cancelled. Many specialists did what they could to bring the situation under control, but they were unable to convey their expert judgements to higher authorities and participate in the policymaking process. The loss of such a good opportunity to systematize epidemic prevention work is regrettable.
Next, in a democratic society, reports about SARS should consider the social responsibility to educate the public as a higher priority than just presenting news. For example, when SARS was spreading in Hong Kong, the mistaken information in many news reports in Taiwan left the public not knowing what to believe.
In fact, the key aspects of epidemic prevention are to reduce opportunities for transmission of the virus and reduce the quantity of the virus in an environment. The former requires educating the public to cut back on all unnecessary activities for about a month, not just quarantining SARS patients. Government leaders should set an example by reducing the number of visits and interviews. In this way opportunities for transmission can be reduced.
It is especially important to ensure that patients with respiratory symptoms receive the best medical care directly and rapidly so that they no longer move from one hospital to another.
In terms of reducing the quantity of the virus in an environment, public transportation must immediately install variable direction electric fans and create an open air environment. After two taxi drivers got SARS, all drivers were immediately required to wear surgical masks. An even more important measure, however, is that all cab windows be left open to reduce the amount of virus per cubic unit of air.
As for the hospitals, why did cases of hospital transmission mushroom after a SARS outbreak exploded at Hoping Hospital? At the level of implementation, it is necessary for us to understand how to reduce the possibility of infection for nurses, nurses' aides, janitors, laundry workers, X-ray technicians and lab technicians.
When a problem is discovered, clinics and hospitals should im-mediately be instructed via computer networks on how to avoid the same kind of danger. In emergency wards, for example, it is necessary to consider how ventilation and hospital architecture can be systematically renovated to reduce transmission of the virus.
While SARS is spreading, all visitors to hospitals should be banned and patients' contact histories must be carefully filled out. The excrement of all patients should be immediately sterilized by high-pressure steam autoclave.
In epidemic prevention, universal precautions should be taken for all possible patients to minimize risk rather than waiting until SARS patients show clear clinical symptoms.
Attention should also be paid to the following minor points: All flush toilets in hospitals should be flushed only after the lid has been lowered. Before people enter a hospital emergency room, they should first be asked to drink some hot water, which will reduce the quantity of virus they disseminate. Medical personnel should drink hot water every one to two hours to reduce SARS viral load with which they may have become infected.
Patients should not be allowed to crowd together in waiting rooms. All emergency rooms and outpatient examination rooms for fever patients should be closed at night and sterilized with ultraviolet light.
We must consider all methods to reduce the amount of virus in an environment and ways by which the virus might be trans-mitted. At the same time, head nurses and hospital directors should pay attention to where patients have gathered in large numbers or if medical personnel are overworked. They should visit the wards to show their concern and seize any opportunity to improve operations.
The spirit of public health is to make building local infrastructure the first priority, to gather suggestions widely, and to undertake bottom-up planning. One absolutely must not blindly defer to authority or only follow orders coming down from the top.
When the US Centers for Disease Control and Prevention were first confronted with Legionnaires' disease in Pennsylvania, they not only immediately sent specialists to conduct epidemiological investigations, but also spent even more time understanding local difficulties and what practical help was needed. In this way they established two-way communication channels and feasible control strategies.
Without a doubt, the spread of SARS is testing our humanitarian concern as well as our scientific attitude.
King Chwan-chuen is a professor at the Institute of Epidemiology, College of Public Health of National Taiwan University.
Translated by Ethan Harkness
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