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Cold-and-flu seasonal spread suggests new burst of SARS

Vigilance is today's watchword -- whether for emerging infections or obesity and smoking. Integration of the exam room and public health has never been so important.

By Victoria Stagg Elliott, AMNews staff. July 7, 2003.

Chicago -- Severe acute respiratory syndrome, the dreaded atypical pneumonia that sickened thousands and killed hundreds, may return in the months ahead.

"Although the epidemic appears to be coming under containment now, we have no idea what to expect in the fall," said Centers for Disease Control and Prevention Director Julie Gerberding, MD, MPH. "It would not be surprising if we had a re-emergence."

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Dr. Gerberding spoke during the American Medical Association's Annual Meeting last month and underscored to physicians that the SARS experience is still unfolding. Seasonal coughs and colds that come with cooler weather may foreshadow new complications.

The syndrome could reappear in autumn much like other respiratory illnesses, including influenza, and it may be spread by people who don't even know they are infected. There is increasing evidence that some who contract SARS have mild versions or experience no symptoms at all. And still unknown is whether the virus can be transmitted by those who are asymptomatic.

Thus, there's absolutely no way to predict what the future holds.

"We may have an easier ride because we know what's going on and can act more quickly. On the other hand, it may have the pattern of pandemic flu where the first year out there was a small blip in cases, and the second year we have a crisis," she said.

Her bottom line: "We have to be very, very vigilant."

Overall, vigilance has become an even greater necessity because of what Dr. Gerberding and other health officials refer to as "the new normal." The SARS experience is just one scenario that illustrates its implications.

The emergence of infectious agents -- whether natural, as in the recent outbreak of monkeypox, or deliberate, as in the 2001 anthrax exposures -- is no longer the exception. It is now the rule that new or unfamiliar pathogens emerge and then spread rapidly via international travel or the transport of goods.

"The new normal is emerging infectious diseases, and emerging infectious diseases that are almost instantaneously a global concern because of the speed with which people, animals and products move around the world," said Dr. Gerberding.

Adapting to this reality has imposed several lessons on the public health system -- the need for speed, the need to consider public health problems from a global view, and the need to incorporate physicians in the processes as much as possible.

For starters, in the context of the "new normal," the public health infrastructure has begun to move faster. In the past, public health agencies were criticized for taking so long to issue information that when findings were finally available, they were no longer relevant. Officials say they have learned people need data as soon as possible, even if that information is still evolving.

"It's almost like there [was a belief in] some kind of miracle that occurs between the information that comes in and the guidelines that go out," said Dr. Gerberding. "But the lesson we learned from anthrax was that we couldn't wait until we could dot every 'i' and cross every 't.' "

When SARS appeared as a threat, the agency issued a health alert and clinical guidelines for detection, isolation and infection control within 24 hours and held its first-ever Saturday media briefing, something the agency continued to do throughout the outbreak and again to release early information about monkeypox.

"When you have a case of SARS, or any other communicable disease, it is bold action that matters most," said Dr. Gerberding. "There is no time to sit around in committee. Successful containment efforts occurred in places where the individual clinicians and the public health system were able to act very quickly."

The realization that the public health system is only as strong as its weakest link, anywhere in the world, has taken on a new imperative. To tackle this complex challenge, the CDC is increasing collaboration with international health agencies such as the World Health Organization, although Dr. Gerberding stresses that the agency has no intention of becoming an international public health sentinel.

"We have profound deficiencies in our global surveillance network that we are working very hard to address. We have to figure out how to avoid a recurrence of a disease incubating in a population for a long period of time before we know about it," said Dr. Gerberding. "But I don't think we are the world's public health agency. Our role in the global health arena is to work with the WHO."

Physicians and the "new normal"

There is also a greater recognition of the vital role that physicians play in public health preparedness. As a result, the CDC is increasingly emphasizing clinician involvement in investigating outbreaks. During last summer's West Nile flare-up, the agency for the first time established a clinician team to accompany epidemiologists. This step led to expanded knowledge of the disease course, particularly the neurological impact.

"I do not believe there is a difference between public health and health care delivery," said Dr. Gerberding. "I profoundly believe that the more we integrate into a health system, the better we will all be able to do our jobs."

Physicians also are more aware of this two-way street. At the AMA meeting, delegates reaffirmed that bettering the public health was the group's highest goal and also adopted policy that state health departments should be led by physicians. It's all part of an ongoing effort to close the historical gulf between these disciplines.

And public health officials warned that while controlling novel infectious disease outbreaks is important, the old standards, including influenza and HIV, are ever-present threats. In addition, there are non-infectious factors that significantly shorten life and lessen its quality.

Dr. Gerberding and Surgeon General Richard H. Carmona, MD, MPH, who also spoke at the Annual Meeting, warned we shouldn't forget that the top killers in the United States are still diseases linked to tobacco, obesity and alcohol. Obesity is a particularly acute problem because, although still ranked second, it is rapidly closing the gap and may soon overtake tobacco-related illness in the No. 1 spot.

"Too often we are forced to rely on great medicine to undo people's bad choices," said Dr. Carmona. "Poor eating habits and inactivity erode America's quality of life, shorten our life spans, and burden our health care system."

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