Report paints a dark picture of SARS in U.S.

Think tank gives CDC strong warning

With visions of overrun, bankrupt hospitals and workers dying or refusing to treat patients, a recent government-commissioned study of an epidemic of severe acute respiratory syndrome (SARS) in the United States had everything but a nightmarish cover painting by Hieronymus Bosch.

The SARS epidemic demonstrated the lack of surge capacity for isolation and treatment in hospitals and the lack of adequate residential facilities for quarantine. Because SARS was, in large measure, a hospital-based epidemic, it was necessary to close hospitals in every jurisdiction where SARS appeared, the report found.

"Closing a hospital for a month or more because of quarantine and isolation would be extremely costly to a hospital both in terms of the costs incurred in treating the patients and staff, and in the lost revenue from other patients," the report stated.

"It is quite possible that some hospitals would go bankrupt. Hospitals concerned about these consequences also might be reluctant to treat individuals in an epidemic," it added. "A public hospital later designated as the SARS hospital may be the only place that was providing health care to indigents."

The report by public health researchers at the University of Louisville, KY, was commissioned by the Centers for Disease Control and Prevention (CDC). The researchers looked at the global outbreaks of SARS and projected the impact of an epidemic on the U.S. health care system.

"The loss of hospital beds prevented many elective procedures, and it is difficult to calculate the overall health effects of this lack of access to health care," the analysis noted. "In addition, there were frequent shortages of essential supplies, including gowns, gloves, masks, protective eyewear, and ventilators as well as inadequate laboratory capacity and infection control measures.

Designate standby hospitals

In China, new hospital facilities were built rapidly to respond to SARS, but this approach is unlikely to be effective in the United States. It probably would be much better to have standby hospital facilities that could be used in the event of any emergency, the group recommended.

Measures need to be taken at once to ensure the continued financial viability of institutions taking care of patients in an epidemic. Similarly, there must be a plan for the allocation of financial responsibility among local, state, and federal governments in the event of a public health emergency. There also needs to be a plan to ensure uninterrupted health care in the event of a hospital closure.

The SARS epidemic also is likely to have long-term repercussions for health care staffing. For example, some health care workers who went through quarantine have had a residual psychological burden and have found it difficult to treat patients with any type of infection, the report found.

"In Toronto, a substantial number of health care workers have left the profession, and there has been a decline in enrollment in training programs," the researchers found. "Perhaps the most troubling aspect of health care staffing in the SARS epidemic was the widespread reluctance of physicians and nurses to treat infected patients due to concerns for their own health. This phenomenon was experienced in every country we studied."

For example, in Taiwan, 160 health care workers quit or refused to work on SARS wards. Three physicians were fined $2,600 and three hospitals were fined $43,000 for covering up or delaying the reporting of possible cases of SARS. In China, the government fired at least six physicians for refusing to treat SARS patients and banned them from practicing medicine for life.

Besides punishing health care workers who refused to care for SARS patients, the governments in affected countries adopted a range of financial incentives to encourage health care workers.

In Vietnam, health care and public health personnel were given an allowance of five times their regular salary. In Toronto, the hospitals doubled the salaries of nurses handling SARS patients. In Taiwan, physicians caring for SARS patients were given "danger pay" of $300 per day, and nurses were given $150 per day.

Epidemics also place tremendous burdens on health care providers, and SARS, by infecting health care providers at a high rate, presented even greater challenges. The first challenge was to maintain adequate staffing levels during the epidemic.

"Deaths and illnesses of health care workers and quarantine of others limited the availability of physicians and nurses," the report continued.

"For example, in Hong Kong, 22% of the deaths were among health care workers, and in Taiwan, more than 90% of the infections occurred in hospitals. There were other aggravating factors as well.

"Even where there were adequate supplies, working with personal protective equipment, including gloves masks, and respirators, was physically and psychologically difficult, which required even more frequent staff rotation."

(Editor’s note: The full version of "SARS Report for CDC" is available on-line at www.louisville.edu/medschool/ibhpl/.)