August 29, 2003

SARS: IT'S NOT TOO LATE TO TURN LEMONS INTO LEMONADE
By Saul B. Wilen

This past year, 2002-2003, brought the emergence of SARS (Severe Acute Respiratory Syndrome) caused by a corona virus and spread human-to-human via droplet infection. The world outbreak began in Guangdong Province of mainland China in November 2002. The four month silence about the existence of the epidemic by the Chinese government until February 2003 played a significant role in the uncontrolled spread of the disease. Open communication and cooperation with health care entities like the World Health Organization could have proven successful in alleviating the ensuing epidemic and its consequences. Health care workers unwittingly played a significant role in the spread of SARS throughout the world, and closing health care facilities helped bring the epidemic under control.

SARS infected 8,439 people in 30 countries on five continents with a death rate of 10 percent (812 people). The United States was not hard hit, with only 73 cases and no deaths. In Toronto, Canada, there were 247 cases with 39 deaths. Twenty five percent of the Canadian cases were among health care workers. Few U.S. health care workers contracted the disease in contrast with large numbers of infected health care workers around the world.

No vaccine or specific treatment presently exists. No rapid laboratory identification testing presently exists to help in the early identification of SARS. The disease has primarily been controlled by isolating patients and quarantining those in close contact with them. Re-training of hospital doctors and health care workers in infection control measures (proper use of gloves, masks, face shields, barrier techniques, strict isolation) was necessary because hospital workers were exposing others. SARS may yet prove to be a seasonal disease that returns in the winter each year. There is a need to develop predictive models in preparation for its return should a reservoir exist as many experts believe. The application of techniques like patterning will be most helpful.

Public health officials and health care workers struggle with SARS, a disease that is both difficult to diagnose and difficult to treat. It is difficult to separate SARS, an atypical pneumonia, from other pneumonias. In the early days of the epidemic, the illness was passed from person to person. The transmission became amplified when health care workers became infected, and when "super spreaders," people who for unknown reasons are extremely contagious, were involved they infected hundreds.

The case definition from the Centers for Disease Control (CDC) focuses on symptoms common to many diseases and is therefore too broad to be clinically practical. SARS symptoms are nonspecific, including fever, chills, rigors, headache, myalgia and malaise. The respiratory symptoms of dry cough and shortness of breath usually start three to seven days into the course.

The two break-outs in July 2003 of a mild upper respiratory infection at unrelated nursing homes in Vancouver, British Columbia, Canada, has complicated the SARS epidemic even further. The first nursing home outbreak involved 68 percent of the residents, or 143 people, and 29 percent of the staff, or 46 people. The second outbreak started when the first was ending; nine residents contracted the illness.

Preliminary testing results indicate that these illnesses seem to be caused by a SARS-like virus. Definitive testing is continuing and can take eight to 10 weeks. Questions are raised as to whether the SARS virus causes a wide spectrum of illness previously undetected, or if the virus has mutated and now causes a disease which is milder. Last spring the National Microbiology Laboratory in Winnipeg, Manitoba, Canada, found evidence of SARS virus in 150 people who had mild or no symptoms.

Rethinking approach
All approaches to SARS are presently focused on response, reaction and recovery. They should be equally focused on prevention so that preparedness is developed for prevention simultaneously with preparedness to respond and recover. The SARS epidemic, its rapid progression and worldwide public health and economic impact provide a unique opportunity to use the SARS experiences in developing controls for future disease epidemics.

Significant errors recognized in the SARS epidemic include: impeded, limited and slow international communication, consultation and commitment; minimal cooperation and absence of consistency; and the active role of health care workers in the transmission and spread of the infection. The control of borders and points of entry were and are particularly problematic in the management of the international spread of SARS. As one who traveled to Toronto during the SARS epidemic, I participated in the entry monitoring process in place. I was given a SARS Health Alert Notice (in multiple languages) that included a self-assessment questionnaire.

The concluding statement read, "This Health Alert Notice will be given back to you by the Custom's Agent." After reading the notice, completing the questionnaire, and disembarking the airplane, I tried approximately 15 times to give the responses to someone in authority, including the "Custom's Agent." All of these individuals very politely rejected my request stating that they had no knowledge of any such procedure. No officially designated individual on or off the airplane was available to answer questions about the Health Alert Notice.

In evaluating the SARS epidemic, significant questions have been raised relating to the seasonal variation of SARS, the risk of household transmission (important since many patients were sent home for isolation and quarantine), evaluation for optimal diagnostic tools, the potential mutation of the corona virus that causes SARS, the existence of a SARS reservoir (as is the case for Influenza viruses) to support recurrence, and identification of potential "super spreaders." These and other components of SARS experiences and processes can be used for the development of predictive modeling for recurrence, in modeling for future disease epidemics, and for bioterrorism and terrorism prevention planning.

Dire consequences
The exporting of contagious infectious disease cases to other countries is a criterion the World Health Organization (WHO) uses to impose travel advisories. This was a major consideration applied in the SARS epidemic. Governments are always eager to avoid these advisories due to the impact on their tourist industries. Travel advisories were imposed on a number of countries primarily in Asia and also on Canada. The estimated economic costs in Canadian dollars to Toronto as of the end of May 2003, were $900 million for health care, the loss of $570 million in tourism, and a $1 billion loss to the GNP of Toronto. The CDC and WHO advisories against non-essential travel due to the SARS epidemic affected and disrupted international student programs.

A report released in July 2003 by the General Accounting Office (GAO) indicated that preparation is underway by national and local health officials for a possible SARS outbreak when colder weather returns at the end of the year. The preparedness of U.S. hospitals to deal with a SARS recurrence is brought into serious question due to the findings of the lack of key personnel and equipment.

The GAO warned that a widespread outbreak would overwhelm hospitals; large SARS isolation facilities might be needed; and in conjunction with the Influenza season, all medical resources would be stretched far beyond their capabilities to respond. The report stated further, "Most hospitals lack the capacity to respond to large-scale infectious disease outbreaks. ...Few hospitals have adequate equipment such as N-95 respirators -- needed to care for a large number of these patients, facilities for isolation and quarantine, and adequate air-handling and filtering equipment."

The GAO study of 2,000 plus U.S. hospitals demonstrates that few had the equipment and supplies needed for an extensive infectious disease outbreak. This would include infectious biological agents like Smallpox and others that could be used for bioterrorism. Local, regional and national planning is necessary to respond to a potential large-scale outbreak like SARS. This approach to planning and preparedness is similar to the approaches necessary for preventing and preparing to react to bioterrorism. The findings of this GAO study, put America's preparedness for terrorism -- especially bio-terrorism -- almost two years after Sept. 11, into a grave perspective.

Dr. Saul B. Wilen is president and CEO of International Horizons Unlimited (www.intlhorizons.com, 210-692-1268) a national consultation and resources consortium based in San Antonio. Dr. Wilen has a background in medicine and education, and is a recognized authority in prevention strategies, problem solving, systems dynamics and informatics.