Interview on COVID-19 with SARS Expert Dr. Sarah Borwein

Feb 28, 2020

The internet is currently flooded with information about the Corona virus, some informative others not so much (and possibly fake news!). Below is an article extracted from the website of Hong Kong based healthcare experts, AD Medilink, which gives some good insights into the virus. Originally from Canada, Dr. Sara Borwein has been practicing in Hong Kong for over 15 years, and prior to that she ran the Infection Control program for the only expatriate hospital in Beijing during the SARS period, also serving as liaison with the World Health Organisation (WHO) there.

What would you say are the main differences between COVID-19 and SARS? 

COVID-19 and SARS do share some common features: they belong to the same family of viruses,  they both seem to have jumped from animals to humans, they both originated in China and both can cause severe pneumonia.

But there are some important differences. SARS was more lethal than COVID-19, but less easily transmitted. It went straight for the lungs, and caused severe pneumonia which became transmissible only when patients were quite severely ill and usually by then in hospital. About 10% died.

COVID-19, on the other hand, seems to be more likely to replicate in the upper respiratory tract and it seems like individuals might produce a lot of virus when they are only mildly symptomatic. It’s not known how many people with COVID-19 develop pneumonia, but of the ones who do, about 20% get severely ill and fewer than 2% die. Overall death rates are still not known for sure, but are probably less than 1%.

So COVID-19 is a lot less lethal than SARS, but harder to control because it spreads more easily and by people with milder symptoms. That’s why, despite being considerably less likely to kill you than SARS was, COVID-19 has still in total killed more people in 6 weeks than SARS did in eight months.

Another important difference is that medical science has advanced considerably in the 17 years since SARS. In 2003, it took months to identify the virus and develop a test. For COVID-19 that happened within a couple of weeks. That has made identifying patients a great deal easier. In addition, there are newer treatments and some vaccine prospects already in the works.

Which lessons can be learnt from SARS to best manage the current outbreak?

The most important thing we learned from SARS was that infectious diseases do not respect borders or government edicts, and cannot be hidden. It requires international cooperation, transparency and sharing of information to control an epidemic.

We also learned the importance of providing good, balanced, reliable information to the public. In any epidemic, there is the outbreak of disease and then there is the epidemic of panic. And nowadays, there is also what the WHO has termed the Infodemic, the explosion of information about the epidemic. Some of it is good information, but some of it is rumour, myth, speculation and conspiracy theory, and those things feed the anxiety. It can be hard to sort out which information to believe, so it is important to choose trustworthy sources. Panic and misinformation make controlling the outbreak more difficult.

Finally, SARS was the first time we realized that acute respiratory illnesses (other than TB) could be spread to healthcare workers. When the SARS epidemic started in 2003, the hospital I worked at had two N95 masks, in case of the occasional case of active tuberculosis. Many people had never even heard of an N95 mask! Now we do recognize that healthcare workers, the very people we depend on to help us if we get sick, are particularly vulnerable. Although this risk appears to have been considerably worse for SARS than it is for COVID-19, it does appear that there is an elevated risk to our frontline care-givers in hospitals, and special care has to be taken to protect them.

How serious is the situation in Hong Kong now relative to other places in Asia?

The situation is much less serious in Hong Kong than in mainland China, especially Wuhan and Hubei. We are quite exposed here, because of our close ties with the mainland, but we have a very strong public health system, good resources, and deep experience in managing epidemics. After SARS, Hong Kong set up the Centre for Health Protection (CHP), which is our version of the CDC in the United States. When COVID-19 emerged, there was already an epidemic management plan in place that just had to be activated. The four best prepared places in Asia are probably Hong Kong, Singapore, Thailand and South Korea.

A lot is being said and written about masks. How important is it to wear one?

The shortage of masks has many people feeling quite anxious and unprotected. But masks are NOT very effective at preventing transmission of viral infections, particularly when worn by healthy people. They are by no means the most important measure you can take to protect your health. In fact, if you wear a mask incorrectly, touch or adjust it frequently, re-use it, or fail to wash your hands before putting it on and after taking it off, you may actually increase your risk.

Who should wear a mask:

– People who are sick, to prevent them spreading their viral droplets when they cough or sneeze.

– People caring for sick people at close quarters.

– In a health-care setting.

– People whose occupation requires them to have close contact with clients.

As it has become socially unacceptable in Hong Kong to NOT wear a mask, there may be situations in which you might choose to wear a mask simply to make other people feel comfortable. But in general, healthy people do not need to wear masks, except when they need to be in crowded places, or with possibly sick people.

Which precautions are the most critical to stay safe? 

Other more important measures for protecting yourself are hand washing, social distancing (avoiding crowds), and staying at least 3-feet away from people with fever or cough. Hand-washing is the most important. Alcohol-based hand sanitizer is an acceptable alternative, except when your hands are visibly soiled.

Get enough sleep, eat well, and get some exercise. In other words, look after your general health.

Do not travel, go to work or socialize when you are feeling unwell yourself. It won’t be appreciated!

And if you haven’t already done so, get a Flu shot. It won’t protect you against COVID-19, but it will prevent Influenza, which is a nasty illness in its own right, and can land you in hospital or quarantine, and overburden the system at a time when the resources are needed elsewhere. 

How does the climate influence the virus? We read that with warmer weather the virus may go away but there are cases in countries like Singapore.

We really don’t know the answer to this question. It is true that some viruses that are spread by respiratory droplets, as COVID-19 is believed to, spread more easily when the air is cold and dry. In warm, humid conditions, they fall to the ground more easily and that makes transmission harder.

But there is still a lot we don’t know about exactly how COVID-19 is spread and the effects climate may have on it. We do see it spreading in Singapore, which is warm and humid, so who knows?

Should any international travel be postponed for the time being?

Avoid travel to mainland China, especially Hubei province! And I think I’d stay away from cruise ships for now.

It’s important to note that some countries that report few or no cases have limited testing ability, meaning that it is hard to know what is actually going on.

In some countries, it is possible you might be asked to self-isolate or even quarantined, and rules seem to be changing all the time, so stay informed and be flexible about your travel.  Interestingly, airplanes do not seem to have been places where people have become infected.

What are the questions that you hear the most from your patients? 

The most common questions are “how serious do you think this is ?” and “should I be worried ?”

The answer is that from an individual point of view, there is no reason to worry. The disease is probably not that severe for most people, certainly much less severe than SARS was. Early indications are that the illness may be no worse than a flu-like illness for the majority. The elderly, and those with other health problems, especially diabetes or heart disease, do seem to be at higher risk of becoming seriously ill.

But from a public health point of view, this could be very serious. A highly transmissible disease, even with low fatality rates, can cause huge disruption to the healthcare system and can actually end up killing more people than a less contagious disease with higher case fatality rates. That’s why so much effort is being made to stop it.

Which psychological impacts do you see so far on the community in Hong Kong?

The mental health effects of this outbreak are the most serious impact of this outbreak so far.  The school closures, the cancellation of many events, the working from home, the isolation and the uncertainty about how and when this will end are creating an atmosphere of fear and sadness that is taking a toll on many people. Especially coming on the heels of the months of protests we had beforehand.

We see a range of reactions, all the way from “the sky is falling” to “this is a huge over-reaction”. But actually, I’ve been impressed at how many people seem to take a calm and sensible approach.

The outbreak brought anxiety to many parents. As a mother yourself, what tips can you share to help parents cope with work, home schooling, and epidemic fear?

During SARS, there was no such thing as Google Classroom or Zoom. Online learning was limited to sending assignments back and forth by email. In some ways, I think that was less stressful than trying to have a full online classroom, especially as many kids are now on different time zones.  On the other hand, it does help to try to maintain normal routines insofar as possible.

Children’s reactions will be influenced by your reaction, so model a calm, common-sense approach. Reassure them that they are safe and, in an age-appropriate way, answer their questions. Find ways for them to socialize and exercise, and do the same for yourself!

Remember that as far as we know so far, this virus does not cause severe disease in children, even if they do get it. The same was true of SARS.

Some good resources are:

– Calming kids’ fears about Coronavirus:

– Supporting children through the healthcare crisis:

Looking at the evolution of the epidemic so far, how optimistic are you on its future path?

I am optimistic that this will be contained. China has taken unprecedented quarantine and social distancing measures, on a scale never seen before. These do seem to be limiting international spread. Here in Hong Kong, we are fortunate to have one of the best public health systems in the world, strong epidemic planning and deep experience. There are few places better equipped to deal with an epidemic of this sort.

Any final advice to best manage this difficult period? 

The most important thing is to remember that this will pass. Epidemics always do. And the massive control efforts made by China as well as here and in other places, are likely to speed up that process. So while it’s no fun, it’s not forever.

In the meantime, keep calm, wash your hands and try to keep it all in perspective.


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