Concerns about SARS Could Complicate Patient Diagnoses

Ferreting out whether a patient has influenza or severe acute respiratory syndrome (SARS) is complex diagnostic puzzle that tests emergency departments. As concerns about a new outbreak of SARS mount, emergency physicians are wondering how they will cope in already-strained EDs. The federal Centers for Disease Control and Prevention (CDC) recently released an aggressive draft response plan for SARS control in the event of a U.S. outbreak. It calls for prompt isolation of any patient who presents with respiratory symptoms until he is accurately diagnosed. (A draft of the SARS response plan is available at www.cdc.gov/ncidod/sars.) SARS emerged in China last November, and caused an epidemic in Toronto, Canada, last spring, subsequently being identified as a new coronavirus. In July, Julie L. Gerberding, MD, the director of the CDC, said SARS could reappear, much like other respiratory illnesses such as influenza, and be spread by people who don't know they are carriers of the virus. “It would not be surprising if we had a resurgence,” said Dr. Gerberding. Current worries about SARS are exacerbated by the fact that influenza immunization is not 100 percent effective, and can't be relied on as a triage tool. While the CDC supports flu shots, especially for high-risk Americans such as the elderly, it does not recommend them for the sole purpose of reducing the number of patients who need to be evaluated for SARS, as detailed in the Oct. 3, 2003 issue of the CDC's Morbidity and Mortality Weekly Report. If a patient who had a flu shot subsequently develops a febrile respiratory illness, warned the CDC, neither SARS nor influenza can be automatically ruled out. The CDC has released criteria for making a diagnosis of SARS (see box). Widespread concerns about SARS were evident at a recent forum in Washington, D.C., sponsored by the Institute of Medicine (IOM). In terms of a serious outbreak in the United States, “I don't think we're any better prepared to deal with SARS than we were 12 months before it even existed,” warned Michael T. Osterholm, PhD, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “It's going to take more than just talk. I'm afraid we're going to have to write this book as it's unfolding.” No Masks One specific concern: an adequate supply of N-95 masks. Dr. Osterholm pointed out that at the height of the SARS epidemic last year, the 3M Co., which makes the masks, was backlogged by years. “SARS is a very nonspecific syndrome. This is not a good time to have a cough,” commented Martin S. Cetron, MD, an infectious disease specialist in the CDC's National Center for Infectious Diseases (NCID), Division of Global Migration and Quarantine. He urged hospitals to plan for “surge capacity” in the event of a major SARS outbreak. For emergency physicians, this is a particularly difficult time to be saddled with worries about SARS. New census data show that 2.4 million more Americans were uninsured in 2002 than in 2001 (43.6 million in 2002), which places more strain on EDs, said George Molzen, MD, the immediate past president of the American College of Emergency Physicians. “The increased demand from uninsured patients can push many emergency departments past their capacity,” he said. Ill patients will wait longer for hospital admissions, which means that undiagnosed patients will wait longer in the waiting room as well, he noted. If they do have SARS, they could expose other patients while they wait.Table: Signs of SARS: CDC GuidelinesCrowded waiting rooms or not, ultimately a diagnosis of SARS will be made by savvy clinicians, said Dan Rutz, a special assistant for communications to the CDC's NCID. “It's the astute physician or other front-line provider who's going to catch cases of SARS,” said Mr. Rutz. “Their importance can't be overstated.” To contain a SARS outbreak, the country should reinvent the time-honored concept of quarantine and use it in a nonstigmatizing, nonpunitive way, said Dr. Cetron. Quarantine, as defined by the CDC, is separating exposed people who appear well but may be infected and restricting their movements. Dr. Cetron said isolation separates sick patients who have a specific illness from healthy people to stop the spread of illness. During the 2003 SARS outbreak, infected U.S. patients were isolated until they were no longer infectious. If they were isolated at home, patients were asked to remain there 10 days following the resolution of their fever, provided that their respiratory symptoms were gone or improving. “It would not be surprising if we had a resurgence.” Dr. Julie Gerberding “I don't think we're any better prepared to deal with SARS than we were 12 months before it even existed.” Dr. Michael Osterholm “This is not a good time to have a cough.” Dr. Martin Cetron Real-World Delay “Quarantine is an ancient public health tool,” said Dr. Cetron. “We want to reinvent this tool and use it in modern times in a way that gets rid of the negative connotations but retains effectiveness.” A real-world delay in diagnoses gives rise to a time when SARS can propagate, said Dr. Cetron. “How many contacts will at-risk people have?” he asked. “How many of these contacts will become infected? Quarantine reduces that period of time. Quarantine is a delicate balance between individual liberties and the public good.” Modern quarantine, he said, is a form of self-preservation that “leverages the public's instinct for self-shielding. Even a partial or ‘leaky’ quarantine can reduce disease spread.” Dr. Cetron said a modern quarantine might include canceling public events, encouraging non-essential personnel to stay home from work, adopting “snow day” restrictions on activities, following holiday work schedules, and providing those in quarantine with all available disease-preventing interventions. According to the CDC, states generally have the authority to enforce quarantine within their borders, but this authority varies widely depending on the laws of each state. The CDC, through its Division of Global Migration and Quarantine, has the power to detain, medically examine, and release those suspected of carrying certain communicable diseases.

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