The SARS outbreak and community paediatrics

In March 2003, paediatricians returned from March break to news of the first outbreak in the Greater Toronto Area of Severe Acute Respiratory Syndrome (SARS). For the community, the social, psychological and economical consequences during the SARS outbreaks were enormous, as was the toll on many health care workers dealing with them. A number of large community hospitals providing both paediatric and maternal and newborn care became the epicenters of the outbreak. Community paediatricians in office practice who provide on-call hospital coverage faced a number of difficult challenges. Provincially mandated restrictions on hospital activity, which included limiting physicians to working in one hospital, placed pressure on a system with an already strained paediatric workforce. Many paediatricians were required to go into quarantine while patient volumes in offices, ambulatory clinics and emergency departments decreased by 70% as families avoided medical services out of fear of coming into contact with the illness. In the first outbreak, the cancellation of elective surgery and ambulatory appointments for children with developmental and behavioural problems created additional pressure on already long waiting lists. While SARS affected primarily the adult population, initial provincial recommendations did not take into account the effect that restrictions on patient movement would have on the delivery of services for children, mothers and newborns. An established Child Health Network for the Greater Toronto Area of tertiary, secondary and community providers was able to deal rapidly with a number of complex issues such as paediatric-specific guideline development, facilitation of patient transfers and the dissemination of information. This included the redirecting of a large obstetrical caseload from a community hospital to other Network hospitals for a three month period during the second SARS outbreak in May 2003. Many health care workers, including primary care physicians, became ill, and some tragically died. The lack of clear guidelines and policies relating to the community health care setting and weaknesses in the communication process placed paediatricians in a vulnerable situation. Physicians and office staff were required to screen patients and provide care using infection control equipment such as goggles, masks, gloves and gowns, which proved to be both physically demanding and stressful. The normal visual cues used to counsel patients and families were lost behind the new outfit, although some commented that the bizarre appearance of the paediatrician often kept the young child engaged long enough to perform an examination! One casualty was the sudden reversal of family-centered practices both in hospitals and offices resulting from the restriction of visitors and the number of accompanying siblings and family members. This created significant problems for families trying to attend appointments. Maintaining a family-centered philosophy in this new environment will continue to be a challenge. Paediatricians, like many others in the health care field, rose to the occasion to help contain the SARS outbreak. SARS is but one example of emerging infectious diseases, including West Nile virus, that are increasing in incidence and geographic range, especially in an interconnected and mobile society. SARS occurred in the seasonally quiet period for infectious diseases, but a similar outbreak during respiratory syncytial virus and influenza season will undoubtably cause greater logistical challenges for the paediatrician in office practice. Practical protocols to assist paediatricians in decision-making are urgently required (1,2). Paediatricians will need to remain both vigilant and educated, particularly in the areas of screening and infection control in the office environment, to protect their patients, staff and themselves. Children and their families will require support as they deal with concerns over the threat of global catastrophes such as infectious disease outbreaks and bioterrorism. As new coordinated federal and local public health strategies unfold, paediatricians will need to help ensure that these measures will meet the needs of children and their families. This should also include the implementation of a national immunization strategy for Canadian children. Finally, as front line care-givers, paediatricians must play an important role in disease surveillance, a vital component in helping to understand, control and treat new infectious diseases (3).

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