SARS and Occupational Health in The

EDITORIAL 539 Occup Environ Med: first published as 10.1136/oem.60.8.539 on 25 July 2003. Downloaded from Infectious diseases steps to issue masks to passengers and ...... their crew and begun wiping down the interior of the plane with disinfectant. Some are issuing surgical gloves for SARS and occupational health in flight attendants to handle trash from the air people who seem sick. “The best sources of information M K Lim, D Koh are the WHO and US Center for ...... Disease Control websites” Educational efforts aimed at communicating the facts and There has been rapid progress in the understanding of the nature of the dispelling the myths about SARS are required disease, but many unanswered questions remain; for example: Are asymptomatic evere acute respiratory syndrome sought medical advice and was cleared patients infectious? Are N-95 masks suf- (SARS) first surfaced in Guang- by a New York physician to fly. However, ficiently protective? Is aircraft cabin air Sdong, China in November 2002. It Singapore’s Ministry of Health got wind quality an issue? Until we know more, it simmered there for three months, under of it through a medical colleague he had would seem prudent to follow the stand- a shroud of secrecy, before arriving in spoken to over the phone just before ard recommended precautions based on Hong Kong, Vietnam, Singapore, and boarding the flight, and contacted SIA the assumption of possible spread by Canada on modern jet planes. Thirty and the health authorities in Germany to droplet and contact. Hand washing, for countries are now affected. As of 10 inform them of the situation. instance, is perhaps the single most June, WHO has reported 8430 probable When the plane landed in Frankfurt important personal hygiene measure. An SARS cases and 789 deaths, giving a case the doctor and his two asymptomatic excellent guideline on infection control fatality rate of 10.7%.1 travelling companions were admitted to guidance for airline personnel, including The illness is caused by a novel hospital for treatment and observation. infection control guidelines for air flight coronavirus (SARS-CoV) measuring be- The remaining Singapore bound passen- cabin crew, aircraft cleaning crew, airport tween 0.1 and 0.2 microns.23 Clinical gers were put on board another SIA air- staff, and quarantine officers can be features are those of atypical pneumo- craft and flown to Singapore the next found at http://www.hc-sc.gc.ca/pphb- nia, with the common presenting symp- day. Subsequently, the Singapore doc- dgspsp/sars-sras/prof_e.html. As the toms being fever greater than 38°C and a tor’s mother-in-law and wife also devel- SARS situation changes very rapidly, the dry cough.4 Empirical treatment consists oped SARS in Frankfurt and were best sources of information are the WHO of corticosteroids, broad spectrum anti- treated. Fortunately, all three recovered and US Center for Disease Control viral agents, and antibacterial cover.5 The uneventfully. But the female flight at- websites (http://www.who.int/csr/sars/ primary mode of transmission is tendant, who had worked in the rear en/ and http://www.cdc.gov/ncidod/sars/). through droplets, as when an infected section of the plane where the trio was The WHO posts a daily situation update, person sneezes or coughs. World Health seated, developed SARS after arriving in while the CDC website has a fact sheet Organisation (WHO) officials have ac- Singapore. The entire crew had to be and frequently asked questions page, http://oem.bmj.com/ knowledged that air travellers “within quarantined, and the aircraft thoroughly both of which are updated regularly. two rows of an infected person could be disinfected. There is no doubt that tightened SARS in danger”.6 However, the virus has also In-flight, passenger to passenger screening measures taken by airlines and been found to survive for days in the transmission has also been implicated. airports have lessened the risk of catch- environment,7 giving rise to the possi- When a cluster of 13 passengers became ing SARS on board a plane. Airports on bility of spread by contact with surfaces infected with SARS Co-V during Hong high alert are in fact beginning to look such as armrests and tray tables. Kong to Beijing Air China Flight 112 on more like hospitals—as 24 hour frontline Coming close on the heels of inter- 15 March,8 a 73 year old passenger was staff, armed with thermometers, masks, on September 27, 2021 by guest. Protected copyright. national terrorism and the Iraq war, believed to be the source. However, that disinfectants, declaration forms, and SARS has all but dashed the hopes of an was not the end of the matter, for subse- health alert notices, take no chances. It early recovery for the ailing airline quently, the Hong Kong authorities had was Singapore that first introduced industry. As panic stricken travellers stay to trace all passengers and crew who walk-through infrared thermal scanners at home, anxious aircrew are clamouring travelled on 21 March from Beijing to at Changi Airport for outbound travellers for protection from occupational expo- Hong Kong on Air China Flight 111, or as well as inbound passengers from sures. from Hong Kong to Taipei on Cathay SARS affected countries. This technol- In the first documented case of in- Pacific Flight 510, as four passengers ogy, aimed at detecting individuals with flight, occupationally related transmis- from Taiwan who developed symptoms fever, has since caught on in several air- sion of the disease, a Singapore Airlines of SARS during their stay in Beijing (and ports in Asia. (SIA) flight attendant has been diag- who were believed to have contracted the No screening method, however, is nosed with SARS after working on a 14 disease while on board the 15 March Air foolproof. Illustrative of the pandemo- March flight between New York and China Flight 112), had returned to nium that can result from a single breach Frankfurt, Germany, which had carried Taiwan on the two flights. is the case of the 48 year old man who an infected doctor, his pregnant wife, Needless to say, flight attendants have boarded a Lufthansa flight on 28 March and mother-in-law, all of whom it is now been on edge. The US Association of and flew to Europe, where he criss- known, were incubating the SARS virus. Flight Attendants has petitioned the crossed the continent. He had flown on The 32 year old Singapore doctor had in Federal Aviation Administration to issue seven Lufthansa passenger jets in all, early March treated two SARS patients an emergency order requiring airlines to from Hong Kong to Munich, Barcelona, in Singapore. He subsequently attended offer gloves and surgical masks to airline Frankfurt, London, Munich again, a medical conference in New Yorkbut fell attendants, or at least allow them to Frankfurt again, and then back to Hong ill there with fever and symptoms bring their own.9 Some airlines flying Kong before entering a hospital.10 It was suggestive of atypical pneumonia. He Asian routes have on their own taken in Barcelona, on 31 March, where he

www.occenvmed.com 540 EDITORIAL Occup Environ Med: first published as 10.1136/oem.60.8.539 on 25 July 2003. Downloaded from began showing symptoms of SARS. On security concerns relating to terrorist Available at: http://content.nejm.org/cgi/ 10 April, the Hong Kong Department of actions and rumours of layoffs) are real. reprint/NEJMoa030781v3.pdf. 3 Drosten C, Gunther S, Preiser W, et al. Health issued a worldwide appeal for Passengers have legitimate fears too, like Identification of a novel coronavirus in passengers and air crews from all seven sitting next to a SARS infected person. patients with severe acute respiratory flights to consult their doctors. All too often, rumours outpace official syndrome. N Engl J Med. Available at: Earlier, on 5 April, Qantas airline staff information. Educational efforts aimed http://content.nejm.org/cgi/reprint/ had their turn to frantically contact 310 at communicating the facts and dispel- NEJMoa030747v2.pdf. 4 Hsu L-Y, Lee C-C, Green JA, et al. Severe passengers of Flight QF 094 from Los ling the myths about SARS, and the acute respiratory syndrome (SARS) in Angeles to Melbourne because three proactive steps to allay commonly per- Singapore: clinical features of index patient children they shared the flight with were ceived fears, backed by sensible and and initial contacts. Emerg Infect Dis [serial suspected of having SARS (which later reassuring preventive measures, are online] 2003 Jun [date cited];9. Available at: http://www.cdc.gov/ncidod/EID/vol9no6/ turned out not to be the case). There therefore needed. 03-0264.htm. have also been other false alarms, as To the extent that on-board spread of 5 Chan-Yeung M, Yu WC. Outbreak of severe when the American Airlines flight the disease is a possibility that poten- acute respiratory syndrome in Hong Kong carrying 125 passengers from Tokyo was tially endangers aircrew and passengers Special Administrative Region: case report. BMJ 2003;326:850–2. detained for more than two hours on the alike, SARS is an occupational and pub- 6 Koubek C, Loose C, Sottili C. Protecting tarmac at San José, California. lic health concern which the airline yourself as SARS fears increase. Washington In probable overreaction, Sudanese industry cannot ignore or simply wish Post, 13 April 13 2003. authorities on 26 April disallowed 72 away. The safety and wellbeing of air- 7 World Health Organisation. First data on stability and resistance of SARS coronavirus Chinese nationals from disembarking at crew and passengers must be accorded compiled by members of WHO laboratory Khartoum’s airport for fear that they priority. At the same time, there is no network. Available at: http://www.who.int/ might be infected with SARS. The need for the fear of SARS to be more csr/sars/survival_2003_05_04/en/ Chinese passengers were forced to return contagious than the illness itself. index.html. Anon on the same Gulf Air flight that brought 8 . World’s airports step up measures to Occup Environ Med 2003;60:539–540 fight SARS. International Herald Tribune,29 them to Khartoum after other passen- March 2003. gers were let out of the plane and into ...... 9 The Association of Flight Attendants. the country.11 On the other hand, Air AFL-CIO press release. Flight attendants Authors’ affiliations demand protection from SARS. Washington, India has had to suspend 45 pilots who M-K Lim, D Koh, Department of Community, DC, 3 April 2003. refused to fly to destinations where Occupational and Family Medicine, Faculty of 10 CNN.com. Frequent flyer takes SARS on SARS is prevalent, or with flight crew Medicine, National University of Singapore board. 13 April 2003. 11 AFP .Sudan rejects 72 Chinese passengers on who had been in these countries within Correspondence to: Professor D Koh, the past 10 days.12 The issue has since SARS fears: airline. 26 April 2003. Department of Community, Occupational and 12 Radio Australia Asia Pacific. Air India pilots been resolved—it turned out that the Family Medicine, Faculty of Medicine, National suspended over SARS ban. Available at: pilots’ actions were motivated by other University of Singapore; [email protected] http://www.abc.net.au/asiapacific/news/ non-SARS related grouses as well.13 GoAsiaPacificBNA_843103.htm. The above instances, however, serve to REFERENCES 13 Press Trust of India. Air India pilots call off 1 World Health Organisation. Cumulative stir. New Delhi, 2 May 2003. Available at: emphasise the psychosocial dimensions http://www.hindustantimes.com/news/ 14 number of reported probable cases of severe of the SARS problem which, if not acute respiratory syndrome (SARS). Available 181_244662,0008.htm. managed, could easily blow out of at: http://www.who.int/csr/sarscountry/ 14 Maunder R, Hunter J, Vincent L, et al.The proportion. Aircrew are human and their 2003_06_10/en/ immediate psychological and occupational http://oem.bmj.com/ 2 Ksiazek TG, Erdman D, Goldsmith C, et al.A impact of the 2003 SARS outbreak in a fears of contagion, and of infecting fam- novel coronavirus associated with severe teaching hospital. www.cmaj.ca, 16 April ily, friends, and colleagues (on top of acute respiratory syndrome. N Engl J Med. 2003. on September 27, 2021 by guest. Protected copyright.