SARS and H1N1: The past is prelude

Crisis met, but a troubling obsession with N95s

Allison McGeerAfter some 20 years in infection prevention, Allison McGeer, MD, has weathered both the 2003 Toronto outbreak of SARS and the 2009-2010 H1N1 influenza A pandemic.

"I'm really hoping that this is it," says McGeer, a microbiologist and infectious disease consultant at Mount Sinai Hospital in Toronto. "But we have learned that emerging infectious diseases are with us to stay. There is no question that both SARS and pandemic flu — from the perspective of our ability to protect patients, our recognition of infectious disease risks — have been enormously valuable. But I've had enough for a while."

Coming swiftly out of Hong Kong as a severe infection of unknown etiology, SARS hit Toronto hard. Thousands were quarantined, and health care workers were among those who died. Even then, McGeer knew that the bitter struggle could pay off later when pandemic flu inevitably emerged.

"We had really very little public health infection prevention strength at a provincial level in Ontario," she recalls. "We had done very little pandemic planning, and it was hard to get people organized. SARS really galvanized that. We went from being way behind other jurisdictions in Canada in pandemic planning to being equal to or ahead of them. And that was an enormous benefit."

Postmortems of the global outbreak, which seemed to dissipate as quickly as it appeared, included the conclusion that more infection preventionists were needed in Toronto hospitals. They are there now.

"Also [after SARS], really for the first time in Canada, people started looking at health care workers as potentially having occupational risks," McGeer says. "We had largely ignored that, and that was a benefit for public planning too because people could talk about the potential risks to health care workers and about the need to protect them."

Infection preventionists everywhere did not know what to expect when H1N1 emerged last year as a novel pandemic strain, but in Toronto McGeer and colleagues had to fight the perception that it was the return of SARS.

"When you live through SARS, people tend to see all respiratory infections as the same," she says. "It's really hard to get people focused on [the fact] that influenza is completely different. It actually caused some problems in that sense because people tended to resort to 'this is what we did during SARS.'"

In the aftermath of SARS, health care worker unions pushed hard for N95 respirators for medical workers treating H1N1 patients. The old controversy about droplet and airborne spread had long since tipped the balance to respirators instead of surgical masks, and there was no going back in the wake of SARS.

"Basically, it has become completely a political issue in Ontario," McGeer says. "I don't mind [them] fighting for N95 respirators. Whatever I think of them, I can see that the argument is necessary. What I can't fathom is why [they] are doing that and not arguing that we have to have antiviral stockpiles. If you see it as your role to be out there on the front line protecting your workers, that's great; I have no objection to that. But what you really want are antiviral stockpiles."

While the relatively mild H1N1 pandemic has not been a major problem for well-stocked and well-staffed Toronto hospitals, the fixation on N95 respirators was disturbing and could spell trouble during a more severe pandemic in the future, she notes.

"If this had been a more severe pandemic, if there had really been significant risks to health care workers, that resonance of SARS would have been a very significant problem for us," McGeer says. "This resolute focus on a single thing — whether or not it is useful — would have significantly detracted from our capacity as a system to do what we needed to do to best protect health care workers. The second piece is, if we had actually run out of N95s, then this complete dependence on them as a security blanket in the absence of evidence would have done us a lot of harm."