SARS presents challenges to hospitals, public health
Weighing ethics and public safety
If an outbreak of severe acute respiratory syndrome (SARS) were to occur in the United States this year, our health care and public health systems might have a significantly harder time detecting and containing spread of the virus than the countries that experienced cases last year, experts say.
But a recent federal preparation plan developed by the Centers for Disease Control and Prevention (CDC) in Atlanta offers guidance on how health officials can balance individual freedoms and safety at the same time.
"I think it is a very valuable document for people to look at, to digest, and to consider the implications of what they are proposing and what steps may be necessary should an event similar to what occurred last year in Asia and Canada occurs here," says Steven Opal, MD, professor of medicine and infectious diseases at Brown Medical School in Providence, RI. "It gives people a good point of reference and allows time to reflect on how difficult it would be to control the situation here in the United States, an the sometimes draconian measures that might be required should a serious outbreak occur."
The CDC’s draft plan (available on its web site at: www.cdc.gov/ncidod/sars) advocates a tiered approach in SARS preparations for health care facilities and local public health officials. The first tier, in effect as long as there are no currently reported cases of SARS transmission anywhere in the world, involves enhanced surveillance for possible SARS based on clinical symptoms combined with epidemiologic links between suspect patients and areas of the world that reported cases in the last outbreak.
Hospitals are encouraged to ensure their clinicians, particularly in outpatient clinics and emergency departments, are alert for possible signs of SARS in patients who present for care. They are also urged to develop close contacts and communication procedures with local public health officials so that information can be shared quickly.
For example, because spread of SARS was so closely tied to health care facilities in the last outbreak, it now is recommended that hospital providers report any potential cases to the public health department. The public health department also should be on heightened alert for any evidence of clusters of respiratory illnesses, particularly among health care workers from the same facility.
Once SARS cases have been reported again, the CDC recommendations gradually ramping up the number and intensity of precautions to be taken.
If SARS is reported again anywhere, for example, hospitals are urged to implement a plan for isolating patients with respiratory symptoms from other patients in hospital and physician waiting rooms. If SARS transmission is evident in a particular community, the CDC plan advocates a system of voluntary quarantine by the cancellation of public events and gatherings and requesting that contacts of people with SARS confine themselves to their homes.
"In the United States, containing SARS will be more difficult than in countries with have a state-supported health care system and a more autocratic view of controlling their citizens," Opal says. "I was amazed at how well the WHO [World Health Organization] and other countries were able to keep a lid on this. Whether we could do the same here in the U.S., with [the risk of] violating people’s civil rights and trying to control the population and the spread of pathogens in the community, is less clear."
In the United States, a fragmented, private health care system and a patchwork of public health quarantine laws, which vary state to state, will make a coordinated response to SARS very difficult, Opal predicts.
Public health officials will largely have to rely on good communication with the public to ensure its willingness to comply with containment measures, he adds.
"You are going to have to have a measured approach consistent with the level of the outbreak in order to try to do this with an informational and voluntary process as opposed to coming through with the National Guard forcing people to stay in their homes," he says.
Put a plan in place
It’s important that U.S. health care systems have a plan of action in place so that they can respond calmly and logically should a SARS outbreak occur, adds Michael Vaughn, president and CEO of Nashai Biotech LLC, a technology transfer company that has major operations in both Nashville, TN, and Shanghai, China.
Vaughn was traveling in southern China in November of 2002 during the time of the initial SARS outbreak there.
"At that time, it was referred to as severe upper respiratory flu," he notes.
Over the course of his trip, Vaughn had his temperature taken 30 times in four days, encountered a panicked public encouraged to wear small face masks at all times, and SARS reporting enforcement measures that threatened the execution of anyone who had SARS and failed to report to authorities, or failed to report if their neighbor had SARS.
China’s experience should be a lesson to the United States about the need for advance planning that provides appropriate precautions but minimizes panic, he says.
"Communication, or the lack thereof, will determine how successful the U.S. policy for SARS is implemented when we have an outbreak," Vaughn notes. "The public should be informed, with reinforced education via the media, on the basics of public health hygiene, especially during the flu season. The message should include references to the possibility of a serious outbreak of SARS, or a terrorist weaponization of an infectious agent, and emphasize the need to wash our hands, cover when sneezing and coughing, and see a doctor or nurse when we have flulike symptoms."
If they feel informed, the public will respond appropriately, he says. But if they don’t trust the messages they are given or feel that information is being withheld, then panic and overreactions may result, Vaughn adds.
If the CDC’s plans are implemented effectively, then an outbreak here should be able to be contained relatively quickly, says Opal.
The SARS virus, so far, is an example of a pathogen that can be contained by relatively easy means, he notes. Unlike influenza or tuberculosis, it appears to be spread primarily through human contact, or by contact with a contaminated object. And it appears that people are most at risk of transmitting the virus when they are having severe symptoms.
"It could have been much worse," he says. "Severe influenza or measles would have been worse. With this disease, the sicker you get, the more contagious you are. It puts health care workers at risk, but it makes it less likely that it will spread out of control before you realize what is going on, the way other respiratory viruses can. With other viruses, people are transmitting it before they even know they are sick, but that has not been the case with SARS. Very strict isolation and control measures will work. The [challenge] is how to best implement them so that people will comply."
The real nightmare scenario for hospitals and other health providers is the re-emergence of SARS in the middle of winter, prime season for a number of respiratory ailments, including influenza and respiratory synctial virus.
There currently are no rapid diagnostic tests available for SARS. Blood samples must be sent to public health authorities for testing and are most accurate if taken after the patient has been sick for some time.
As a result, a SARS patient could be at a hospital for days before a definitive diagnosis of suspect SARS is made. Determining whether suspect cases should be isolated individually and when or whether they can be safety cohorted, will be a key challenge for health care facilities, Opal says.
"It is very likely that people with undiagnosed respiratory illnesses will have different diseases and they may end up transmitting them to each other if they are cohorted together," he explains. "It will be a major challenge for health care systems, colleges, and the military — anywhere people are together in a closely defined space."
Like Vaughn, Opal says it is essential for hospitals and public health authorities to work together to develop effective communication plans and strategies that can convey accurate, reliable information to the public in the event an outbreak occurs.
"With China, it was difficult enough trying to quarantine people in certain municipalities and regions. I think in the U.S., you can just imagine how difficult it would be," he says. "Let’s face it, you are talking about violating people’s civil rights and freedom of movement. It will be difficult to do without significant buy-in from the community that quarantine and isolation is the logical thing to do — and that they are not being persecuted. It would be interesting to see how this would work. I hope we don’t have to find out."
The anthrax attacks that began in September 2001 provided a glimpse at how public perceptions can overtake clinical realities and cause significant problems, Opal adds.
"With people receiving mixed information about anthrax and the ensuing huge demand for Cipro, it became obvious that you want to have a very specific message that the local department of health, local doctors and health care administrators are going to give to the public," he says. "The messages have to be accurate and consistent. It is vital to get people to buy into the plan because you may be asking them to voluntarily defer themselves from school or work or stay home, etc."
In addition to making plans for managing patients, medical centers and universities also should consider policies for reminding faculty and staff that travel to SARS-affected areas could have consequences, not just for their health, but for their activities abroad and their freedom of movement and activity once they return home, he adds.
"At Brown, we have a number of people who travel to endemic areas for research or to visit family," he notes. "They need to be aware that if they travel there during the time a travel advisory is in place, they are subject to the same public health protections as the citizens of that country. If they are quarantined and not allowed the fly home, then that is just the situation they are in. And if they choose to travel to an affected area, then they may be asked to take a leave of absence for a period of time when they return. That is something people need to be made aware of."
The CDC’s effort has helped craft a national response that should be effective yet preserve as much local autonomy as possible, Opal says.
"I think they did us a favor by having us consider national guidelines on what you should do, as opposed to each state coming up with their own system, which could yield quite dissimilar plans, with some being overkill and some underkill," he says. "Now we have federal guidelines. You don’t have to follow them, but you know what they suggest and you can decide how to implement them in the most appropriate way locally to deal with local situations."
- Steven Opal, MD, Professor, Brown Medical School, Brown University, Box G-MHRI, Providence, RI 02912.
- T. Michael Vaughn, President and CEO, Nashai Bioetch, 209 10th Ave. S., Suite 332 Nashville, TN 37203.