With the potential for severe acute respiratory syndrome to re-emerge this winter in the U.S. and abroad, federal health officials are asking hospitals to consider initiating a major policy change in the diagnosis and care of individuals who come to healthcare facilities with respiratory symptoms.
The Centers for Disease Control and Prevention, Atlanta, is encouraging hospitals, physicians' offices and other providers to issue surgical masks to all incoming patients who show evidence of a respiratory illness and to isolate them in a private area as soon as possible until a diagnosis can be made.
"It's good common-sense practice for any respiratory disorder that a person may be experiencing-particularly if that disorder is contagious-be it influenza or anything that can easily be passed to others through respiratory droplets," a CDC spokesman said.
The new strategy, a throwback to infection-control procedures not widely used in hospitals since the days of tuberculosis, is part of a "universal respiratory etiquette" outlined in a comprehensive, far-reaching draft plan released Oct. 17 identifying general principles to guide the U.S. in responding to a potential SARS outbreak.
"It's a radical departure from business as usual if we do follow all of these guidelines, which are draft guidelines," said Daniel Lucey, director of the Center for Biologic Counter- terrorism and Emerging Diseases, a private facility at Washington (D.C.) Hospital Center. "Frankly, for some hospitals, clinics and healthcare settings it's going to be very difficult to implement all of these recommendations."
A team of physicians and administrators at Washington Hospital Center is reviewing the new SARS strategy, said Lucey, who attended CDC development meetings for the plan. State and local health departments, hospitals and other public health providers will be given an opportunity to comment on the draft plan, which the CDC has been refining for several months in close collaboration with partners abroad and in the U.S., including the American Hospital Association.
"The CDC has done a valuable service to provide a road map of suggestions that institutions, physicians in offices and community public health agencies can take to make sure we don't turn into Toronto," said James Bentley, vice president of strategic policy planning at the AHA, referring to Toronto's spring 2003 SARS outbreak. "Clearly no one wants to have that happen."
On March 12, the World Health Organization issued a global alert for SARS, the potentially deadly new respiratory illness thought to be primarily spread by close person-to-person contact and transmitted most readily by respiratory droplets produced when an infected person coughed or sneezed. By the time the global transmission of SARS was halted last July, 8,098 cases and 774 deaths had been reported to the WHO, many of them contracted in hospitals.
In Toronto, 77% of patients in the outbreak's first phase were infected in the hospital; half of all SARS cases in Toronto were healthcare workers. In Canada, 43 of the 251 infected people died. The U.S. reported 29 cases but no fatalities, according to the WHO.
Last week, an independent advisory panel composed of more than 30 leading SARS researchers convened in Geneva, for the first meeting of the WHO's SARS scientific research advisory committee. The panel recommended limited routine diagnostic testing for SARS and is preparing to issue formal testing guidelines for physicians and healthcare workers.
The CDC is directing all U.S. hospitals to equip themselves for a limited number of SARS patients as part of routine operations and a large number of patients in the case of an outbreak. Hospitals should develop a written preparedness-and-response plan that includes procedures for surveillance and triage, patient placement, exposure reporting and staffing needs, according to the SARS draft plan.
Currently, many decisions must be made before SARS is officially diagnosed because no specific clinical or laboratory finding can reliably distinguish SARS from other respiratory illnesses in the early stages, the CDC said.
The AHA's Bentley said infection-control staffs at hospitals nationwide should rely on the document as a resource as they shore up isolation and disaster preparedness procedures already in place.
"We've had a casual attitude about infections that may have allowed us to spread more than we need to," he said. "Maybe the healthcare system and individuals will learn from SARS; far fewer people can get the flu if we improve things. The flu kills roughly 35,000 people in this country every year; it's right up there with traffic accidents."
In addition to distributing surgical masks for patients with respiratory symptoms, the CDC's public health guidance also includes installing Plexiglas barriers at triage or registration stations to protect healthcare workers from respiratory droplets.
If no barriers are present, patients with respiratory symptoms should be segregated by at least three feet in waiting areas.
Washington Hospital Center, which last week held a meeting on surge capacity issues in SARS containment for more than 200 healthcare officials from the District of Columbia, Maryland and Virginia, is preparing to begin fitting all its hospital employees-not just healthcare workers-for N-95 respirators. The N-95 is the CDC-recommended mask for protection from airborne pathogens.
"It's easily a few thousand people and from every profession," says Lucey, who spent two weeks in Toronto in June conducting daily surveillance of patients with fevers at Scarborough Hospital, where SARS was epidemic. The experience, he said, changed him as a physician.
"It made all of this theory real," he said.