SARS prompts added vigilance, worry over spread of infection

Doctors across the country are taking steps to help contain a virus that is continuing to create havoc in parts of Asia.

By Susan J. Landers, AMNews staff. April 28, 2003.

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Washington -- Office-based physicians are being urged to take 10 seconds to help stop a pandemic and protect themselves, their co-workers and patients from severe acute respiratory syndrome.

That's about the amount of time it takes to ask patients who call or come into the office with a respiratory illness and a fever about recent trips out of the country or trips taken by family members or close associates who are also ill, noted Mark Metersky, MD, a pulmonologist and an associate professor at the University of Connecticut School of Medicine.

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As the SARS threat entered its second month with about 3,000 cases reported worldwide, Julie Gerberding, MD, MPH, director of the Centers for Disease Control and Prevention, reported a mixed pattern among nations battling the disease. While the outbreak seemed to be slowing in the United States, Canada and Taiwan, it was still raging in Hong Kong, China and Singapore.

She cautioned the U.S. public health community to remain vigilant, reminding them that it takes only one highly transmissible case to infect many. "Now is not the time to take a deep breath and relax a little bit here."

Dr. Gerberding also reported April 14 that both the CDC and Canadian scientists had sequenced the genome of the strain of coronavirus that is believed to be causing SARS. The hope is that a rapid diagnostic test, effective treatment, or even a vaccine, could come from the breakthrough.

Until then, physicians whose patients have traveled to areas where the illness is rampant, or have been in close contact with someone who has recently returned from such an area, are being urged by the CDC to take precautions when treating them for respiratory illnesses.

Patients suspected of having SARS should be met at the office door, supplied with a surgical mask and quickly brought to an exam room. In addition, those examining the patient should wear an N-95 respirator, gloves, gowns and eye protection, and exercise good hand hygiene.

Scheduling suspected cases for the last appointment of the day when no other patients are waiting also would be a wise precaution. Physicians who do suspect SARS in a patient are being advised to report the case to a local health department.

Defensive tactics

The precautions are particularly important because physicians and other health care workers have, in some cases, fallen prey to the illness. SARS proved lethal for Carlo Urbani, MD, the World Health Organization expert on communicable diseases who first sounded the alert that a puzzling and dangerous disease was emerging from Guangdong province in China.

A family physician in Toronto also became infected after treating an elderly Chinese couple who had recently returned from Hong Kong. The couple and a son died. The physician recovered. Nearly half the SARS cases in Canada were reported in health care workers who were not using protective measures, said Andrew Simor, MD, who heads the Dept. of Microbiology and Infectious Diseases at Sunnybrook and Women's College Health Sciences Centre in Toronto. "I've not seen an agent spread with such ease and rapidity before."

The United States has benefited from the experiences of other countries. Warnings from China, Hong Kong, Hanoi, Singapore and Toronto have been taken seriously by many physicians in the United States, where, at press time, close to 200 people were suspected of having SARS.

AMA Trustee Nancy Nielsen, MD, PhD, an internist in Buffalo, N.Y., noted that the nearly two dozen cases of SARS in her state had sent her to the Internet for up-to-the-minute facts on the rapidly evolving epidemic.

Jonathan Temte, MD, a family physician in Wisconsin, ordered numerous extra tests when he thought there was a possibility that a patient had SARS. The patient had been in close contact with several associates from Southeast Asia while attending a professional meeting in the United States. Dr. Temte was treating him for an acute respiratory illness, a fever and shortness of breath.

"If this had been six weeks ago, I would have said this looks like influenza and I would probably have stopped there," Dr. Temte said. But given the present situation, he went much further and obtained a chest x-ray, among other things, and decided to hold onto an extra vial of blood in case his patient's condition worsened and a diagnostic test for SARS became available.

Dr. Temte also counsels couples who are adopting children from foreign countries, many from China. In those cases, travel warnings may not be heeded because, "when they call and tell you it's time for you to come, it's time for you to go." For such travelers, Dr. Temte is advising the frequent use of alcohol-based hand washes and good judgment.

Mary Frank, MD, a family practice physician in northern California, has yet to see a patient suspected of having SARS but noted that Sonoma County, where she practices, has had one identified case.

If a patient matching the SARS criteria does call her office, Dr. Frank is planning to follow the precautions she takes when a patient is suspected of having chicken pox. "We have a back door, and the patient goes there rather than through the waiting room."

The fright factor

Meanwhile, public apprehension about SARS seems to vary depending on community and location. An April 15th poll released by Gallup Tuesday Briefing indicates a certain level of awareness among American respondents. More than a third, or 37%, said they are either very worried or somewhat worried that they or a family member would be exposed.

But Dr. Frank marveled at how little panic there seemed to be among her patients compared with the anthrax scare of 2001. At that time, patients who had simply passed through Florida, the site of the first identified anthrax case, called the office with concerns. She theorized that the reason for the lower level of fear could be related to the lower fatality rate for SARS, at about 4%, and the distraction of the war in Iraq.

Of course panic is not what anyone needs. The illness is causing extreme anxiety among the populations of the nations most affected. Kim Yu, MD, a family physician in Dearborn Heights, Mich., has friends and relatives in Singapore and Hong Kong whose lives have been disrupted.

In those cities, "Business is down 75%, they've closed schools for weeks, a physician has died," she said. "Physicians and nurses are not living with their families because they are afraid of spreading the disease to them."

People in Asia are also turning to an herbal remedy to try to protect themselves from SARS, said Dr. Yu, an outcome she would not welcome here. "I don't want to scare other physicians or patients, but it could become a very bad situation," she said. "Now it's really a localized epidemic. It could become a pandemic without proper procedures."

Toronto epidemiologist Mark Loeb, MD, knows firsthand the disruption SARS can wreak. He was among the 9,000 people quarantined in Canada. Dr. Loeb was exposed while working with a group of infectious disease specialists on SARS. One member contracted the disease, sending the rest into quarantine.

"The last thing we'd want was to infect our colleagues," Dr. Loeb said via speakerphone at a SARS briefing held at a meeting of the Society for Healthcare Epidemiology of America. Dr. Loeb restricted himself to his home, sending his wife and children away. For diversion, Dr. Loeb reported that he passed the 10 days by participating in conference calls and taking his temperature.

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