U.S. SARS cases still rare, but worries are more common

The illness may not have spread in the United States to the same degree as in some other nations, but fear of it has.

By Victoria Stagg Elliott, AMNews staff. June 16, 2003.

The woman was coughing and short of breath. She had a fever. And she was also positive she had severe acute respiratory syndrome.

But here's the rest of the story. The woman had never traveled more than 10 miles from her home in rural Arkansas -- never, that is, before being hospitalized as a result of this very condition. Thus, her doctor had to break the news to her. She was sick, that was true. But her problem was much more mundane. She had community-acquired pneumonia.

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SARS: Did it fall from space?

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"That was a 20-minute conversation," said Robert Hopkins, MD, associate professor of internal medicine and pediatrics at the University of Arkansas for Medical Sciences in Little Rock.

The emergence of SARS in Asia and Canada is testing the communication skills of physicians here. With only a few dozen U.S. cases of SARS, nearly all linked to international travel, many physicians report that while they're not dealing with SARS infections, they are dealing with SARS anxiety.

"On a daily basis, we get at least one or two questions about SARS," said Sharon Allison-Ottey, MD, an internist and geriatrician at COSHAR Medical in Baltimore. "It does take a bit of hand-holding because every night, if they watch the nightly news, they hear something about SARS. You've got to address their fears with facts."

Physicians are saying that those with regular seasonal allergies or bronchitis are showing up in their offices worried about SARS. They don't meet the Centers for Disease Control and Prevention criteria for the disease, but they know there is something wrong.

43% of Americans say they are worried about SARS.

"The concern is legitimate and realistic," said Dr. Hopkins. "But the devil is in the details."

According to an April poll by CNN/USA Today and the Gallup Organization, 43% of Americans said they were worried about SARS, an increase from the 37% noted at the beginning of that month. And they are taking those fears to their doctors and asking not just about respiratory conditions but also for travel advice.

"Patients are calling even about interstate travel, like to Florida," said Dr. Allison-Ottey.

In many ways, SARS is provoking the same patient anxieties brought on by last summer's West Nile virus outbreaks or the 2001 anthrax attacks. In both situations, there was more fear than actual reported cases. Anthrax was particularly scary because of the possible criminal link. West Nile was a new beast on American soil.

But with SARS, physicians will face a diagnostic challenge similar to these two episodes. There is not yet a good test to confirm a case quickly or exclude it as a possibility.

"If we could develop an accurate, relatively rapid diagnostic test, we could weed through those who are truly affected with SARS and effectively quarantine and treat those patients," said Michael Greene, MD, a family physician in Macon, Ga. "That's an urgent need in the short term."

An experimental rapid-result test is being distributed by the CDC to 100 laboratories nationwide.

Doctors also point out that the fear is not all bad. One doctor suggested that his bronchitis patients may have come in earlier in the course of their infection because they were afraid that their respiratory illnesses were something beyond the norm.

A concern close to home

In addition to their patients' anxieties, doctors are also dealing with their own, because many of those infected with SARS have been health care workers.

"You're a sitting duck, and you never know what you're going to encounter in any interaction with a patient," said Antonio Carbayo, MD, staff physician at the Western Medical Center in Santa Ana, Calif. "I just hope that I'll be among the lucky ones who have a strong immune system that will not collapse so quickly."

SARS appears to be petering out in some areas, but the CDC warns that it may cycle through again in the fall.

"The bottom line is we don't know," said CDC Director Julie Gerberding, MD, MPH. "This is a respiratory illness. Most respiratory illnesses are worse in the winter months and improve or disappear over the summer months, but it is anybody's guess what's going to happen in the fall. We need to be prepared for the possibility that we'll see a resurgence or even expansion of SARS next fall."

Physicians are particularly concerned about how SARS and anxiety related to it may impact the coming flu season, particularly if SARS becomes endemic here.

"If this starts spreading in the next two or three months and then we start getting into cold and flu season in the fall -- good Lord -- how in the world do you differentiate between somebody who has SARS and somebody with the common variety viral upper respiratory or lower respiratory illnesses?" said Dr. Greene. "It's going to be a nightmare."

ADDITIONAL INFORMATION:

SARS: Did it fall from space?

With the cause of severe acute respiratory syndrome pegged to a coronavirus, researchers are now struggling to figure out where it came from and how it jumped to humans.

A University of Hong Kong research team working with the Center for Disease Control and Prevention of Shenzhen, China, announced last month that the virus has been isolated in civet cats sold at local markets.

The World Health Organization said the discovery was important, but that there were too many unanswered questions to definitively conclude that these animals were the source.

"It cannot be ruled out that these animals might have been a source of human infection," according to a WHO statement. "However, many fundamental questions remain. Samples were taken from one market only. Studies need to determine how widespread the SARS virus might be in animals in Guangdong and elsewhere, and if these animals can excrete virus in an amount sufficient to infect humans."

Other researchers suggest a very different origin. Scientists at Cardiff University in Wales suggested in a letter in the May 24 The Lancet that the virus may have come from outer space -- a small but important part of the biological material that falls to Earth every day.

But public health officials appear to be leaning toward the animal theory.

"I think what we're seeing is a situation that is most explainable by natural evolution of coronaviruses either from an animal or a poultry source, or possibly a coronavirus that's evolved in a human," said Julie Gerberding, MD, MPH, director of the U.S. Centers for Disease Control and Prevention. "We don't know the source of the coronavirus, but we have many hypotheses that are far more plausible than meteorites."

Weblink

Information on severe acute respiratory syndrome from the Centers for Disease Control and Prevention (www.cdc.gov/ncidod/sars)

Information on SARS from the World Health Organization (www.who.int/csr/sars/en)

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