Getting ready for SARS. Officials consider tough measures to contain outbreaks should deadly virus return.

Officials consider tough measures to contain outbreaks should deadly virus return

Health officials around the world are preparing for the possible return of severe acute respiratory syndrome (SARS). The viral infection that emerged in southern China last year quickly spread around the world, and before disappearing caused more than 8425 cases including 813 deaths.

In preparation of the return of the virus or the emergence of another new disease, WHO has issued new guidelines that, among other things, call for the cautious use of diagnostic testing (weighing up the impact that false positives will cause panic and the need to detect an outbreak quickly); stringent laboratory safety standards to protect staff; and better public education. WHO has proposed a three-zone strategy for testing, which advises testing for SARS in all cases of atypical pneumonia in areas where the virus is thought likely to re-emerge—namely southern China—but less aggressive testing protocols in “nodal areas” where SARS was previously transmitted, such as Toronto and parts of Hong Kong, and in regions where there were no major outbreaks, such as the USA.

There were only eight documented cases of SARS in the USA; nevertheless, the US Centers for Disease Control (CDC) and Prevention is urging caution. A SARS preparedness committee has issued draft guidelines that suggest tough measures in the event of an outbreak. These include immediate masking and segregation of all patients with cough or other respiratory symptoms; mass quarantine of people exposed to SARS (initially on a voluntary basis, but could be made mandatory); temperature monitoring in public places; closure of schools, mass transit system, and businesses; bans on large public gatherings; and even curfews (http://www.cdc.gov/ncidod/sars/sarsprepplan.htm).

“Some of the proposed measures may seem extreme, but Barry R Bloom, dean at the Harvard School of Public Health, Boston, USA, says the CDC's proposed plan makes “appropriate and important recommendations that are basically about planning how to respond to an epidemic before it happens—especially in the case of SARS, for which diagnostics or vaccines are not currently available”.

The CDC's emphasis on isolation and quarantine are “classic public-health” measures, says Bloom. “The focus of public-health systems is first and foremost to block disease transmission, and these two major tools —old and crude as they are—work.” Where the document falls short, Bloom says, is in failing to provide strategies to make the public understand and support the proposed quarantine measures. “The message has to be that it's a matter of civic responsibility and individual obligation, which is a different message than ‘you are a risk’, and putting a red tag on their door.”

Meanwhile, Health Canada has issued recommendations that call for the development of a comprehensive plan for infectious-disease control, including the establishment of a national infectious-disease surveillance and reporting agency similar to the USA's CDC—an initiative that would cost a projected Can$700 million over the next 3 years. Other recommendations include hiring more local public-health officials, including nurses, doctors, microbiologists, and infection-control experts; a central computerised laboratory to manage information and facilitate data sharing during a major outbreak or epidemic; increased funding for SARS research; and a national vaccine strategy (http://www.hc-sc.gc.ca/english/protection/warnings/sars/learning/index.htm).

Because it is difficult to distinguish SARS from influenza, WHO is urging all groups at high risk for influenza—such as children, elderly people, individuals with weakened immune systems, those with underlying chronic diseases, and health-care workers who have frequent contact with vulnerable populations—to make sure they have the yearly influenza vaccination. If vaccination coverage is good, it is more likely that SARS cases will be detected than if they appeared during a major influenza epidemic.

Health-care systems tool up

Several places that were hit hard by SARS, such as China and Toronto, seem to have learned from their run-in with the virus and are gearing up for their next encounter. In China, health officials have instituted extensive programmes to train health-care workers to identify and isolate SARS cases. A SARS surveillance system has been put in place, with 16 teams assigned to the field by the Ministry of Health to assess local preparedness and to supervise case detection and outbreak control in 31 provinces. Chinese officials have also started to implement an enhanced surveillance system to monitor health- care workers, laboratory workers, and wildlife handlers in Guangdong province. China has also established an internet-based system that will allow more than 13 000 health-care facilities and more than 10 000 township hospitals to report cases directly to the Ministry of Health. During the last outbreak, slow and inconsistent case reporting hampered control efforts. But communication and reporting within China and between Chinese officials and international health organisations is now improving, says WHO's representative in Beijing, Henk Bekedam.

At Toronto's The Scarborough Hospital, officials have set up a preparedness plan that includes doubling the number of isolation beds, enhanced surveillance, and better patient and staff tracking. “We've hired more infectious-disease-control staff, who are looking and listening for fever presentation and are responsible for the timely institution, discontinuation, and reinstatement of measures”, says David Rose, chair of the infection-control committee at The Scarborough Hospital. Signs are now also permanently posted at hospital entrances urging people not to enter unless they absolutely must. “You have to find a fine line, though, to decide when to exclude patients or have them self-exclude, since it impacts on what level of care you are able to provide, when you are essentially discouraging patients from seeking hospital care”, he says.

The Scarborough Hospital has also put together a team to help should SARS return. Starting in September, a programme called Infection Control Associates was introduced, comprising five registered nurses on modified duty, who have been trained in some infection-control practices. As hospital watchdogs, they collect temperature logs, make sure isolation signs are prominent, ensure personal protective equipment is available to staff, and work to enhance staff communication.

Toronto's Mount Sinai Hospital has adopted some of the practices initiated during the SARS emergency as standard protocols to be activated in the case of a future outbreak, says Allison McGeer, director of infection control at Mount Sinai Hospital. For example, during the outbreak, to keep potentially infected staff out of the facility, staff had to check in on a computer using an electronic identity card and answer an on-screen symptom questionnaire before they would be allowed to enter. “It's not something we are using now, but we would if another outbreak started. In the meantime, we are doing surveillance for staff respiratory illness”, says McGeer.

There have also been enhancements to the hospital's database for managing patients with febrile respiratory illness. “Since April, we have had a tracking system for these patients, which also enables us to study patterns developing”, McGeer says. But the emphasis remains case detection and isolation. “The fundamental principles of how to manage an outbreak of any kind haven't changed since SARS.”

Frontline concerns

Frontline health-care workers who work directly with patients say there are three priorities that need to be addressed in preparation for another outbreak: infection-control education; the establishment of reliable lines of communication; and an increase in staff—especially nurses. Mary Ferguson-Paré, vice president of professional affairs and chief nurse executive at the University Health Network, which comprises three Toronto hospitals—Toronto General, Toronto Western, and Princess Margaret—says efforts are underway at their facilities to address such issues. During the first SARS outbreak, she initiated the launch of a communication project called “MFP (Mary Ferguson-Paré) TV” using the hospitals' intranet system. Each week a 5 minute video was broadcast to provide staff, many of whom were isolated from one another because of infection-control measures, with updates and support. The goal of the programme was to provide support, share information, and seek input from staff on how best we could meet their needs, says Ferguson-Paré.

The hospitals also started education for all staff about infectious-disease control and how to screen patients. “It makes staff an effective alert system”, says Ferguson-Pare. The hospitals have also added extra staff in several areas, including a new assistant director of infection control for education and development; extra occupational health and safety workers for more effective tracking of employee illness; and more respiratory therapists. “We're also maximising full-time nursing staff wherever possible, rather than relying as much on casual or agency staff. It not only creates more full-time jobs, but acts as an infectious-disease-control measure by minimising movement of staff between units and facilities”, says Ferguson-Paré.

Meanwhile, at all Toronto hospitals, signs are now posted at all entry points, listing a handful of questions to help staff and visitors screen themselves for SARS symptoms. And alcohol-gel dispensers are placed throughout the buildings with directions that all staff, patients, and visitors should sanitise their hands as they enter and leave hospitals, nursing units, patients' rooms, and outpatient departments. Such changes, says The Scarborough Hospital's David Rose, have become the “new normal”.