If you think the term SARS is merely ancient history, you may want to read this column. Yes, severe acute respiratory syndrome arrived out of nowhere in China in November 2002, wreaked havoc around the world, and then disappeared by July 2003. Its lessons, however, should not have been lost to the textbooks, which I am afraid has been the case.
Thankfully, the newly released SARS Commission report, published by the government of Ontario, is a sobering list of what hospitals in U.S. cities need to do to protect all of us.
For those who may have forgotten, on March 7, 2003, two middle-aged men with undiagnosed cases of SARS went to the hospital in two different Canadian cities. In Toronto, this event caused an outbreak of disease that killed 44 people, infected another 330, and forced hospitals to close. Across the country, a robust worker safety and infection control culture enabled Vancouver (British Columbia) General Hospital to prevent the disease from spreading to a single other patient or hospital visitor, the report found.
One city thwarted an epidemic, while another made deadly mistakes.
Mr. C (the report omits full names) arrived in Vancouver, after a trip to Asia. He felt so ill that he went to the emergency room at Vancouver General at 4:55 p.m. Because of his high fever and difficulty breathing, the staff removed him from the crowded room within five minutes and placed him in a cubicle. By 5:10 p.m., he was put on full respiratory precautions. Caregivers wore tight N95 masks (disposable respirators) to filter out microbial particles. Hospital staff had been fitted for these masks and trained to use them. By 7 p.m., Mr. C had been moved to a negative pressure room to prevent infectious agents from flowing to other parts of the hospital
That evening, Mr. T (no, not that Mr. T) was taken to Scarborough Hospital, Grace campus, in Toronto. Mr. Ts mother had come home from Hong Kong two weeks earlier, and died from what everyone thought was heart disease. Mr. T waited in Scarborough Graces crowded emergency room for 16 hours, despite his high fever and respiratory distress. Two patients waiting with him contracted SARS. Infection control was not a high priority in Ontario hospitals, says the report. Of the people who contracted SARS in Ontario, 77% got it while working in, visiting or being treated in a hospital.
Hospital administrators at Scarborough insisted that ordinary surgical masks, instead of N95 masks, were enough to protect the staff. In Vancouver, the staff was ordered to don N95 masks until there was proof less protection was needed.
On March 18, 2003, the Ontario Ministry of Health and Long-Term Care recommended gloves, gowns, N95 masks, and eye protection when treating SARS patients. Healthcare workers had to fend for themselves. Doctors at Torontos Lapsley Family Doctors Clinic bought goggles and masks from Home Depot, but three of four doctors there still caught SARS.
Many SARS patients needed to be intubated. During intubation, mucous sometimes is expelled with force onto nurses faces, equipment, and walls. Mr. C was intubated at Vancouver General without anyone present becoming infected. Not so in Toronto, where doctors and nurses who performed the procedure without N95 masks caught the disease.
Hospital workers were also exposed to SARS by contaminated equipment (the virus can live on objects for several hours) and visitors whose relatives were being treated for SARS. Mrs. M, whose husband was in intensive care with SARS, was allowed to walk around the hospital without a mask, on the false assumption that without symptoms she posed no risk. She died of SARS in April 2003.
The SARS report is a tale of different hospital culturesVancouvers robust infection control and Ontarios laxity. James Young, Ontarios commissioner of public safety and security, said that Ontario hospitals did not have doctors and nurses who were used to getting in and out of gloves, and gowns and masks; who were used to working in these situations; who knew and thought about infection control every day of their lives.
The SARS Commission report shows that if avian flu or another virus made its way to the U.S., the death toll would depend largely on what hospitals did when the first victims were admitted. If hospitals have effective infection controls in place, an epidemic might be stopped. Vancouver proved it. U.S. cities can learn from it.
Some preparations have been made, such as stockpiling N95 masks. The dangerous shortcoming is hospital culture, and in this sense, most hospitals in the U.S. are underprepared. One out of every 20 patients contracts an infection in the hospital. Methicillin-resistant Staphylococcus aureus is racing through hospitals, spread by dirty hands and unclean equipment. How can hospitals that are failing to prevent ordinary infections spread by touch contain a new, unknown virus that can spread not only by touch but also invisibly in the air?
In Toronto, doctors and nurses unknowingly brought SARS home to their families. In U.S. cities, hospital workers wear contaminated uniforms home, and even into restaurants.
Such shoddy practices are poor preparation for the challenge of an unknown disease from a faraway place. Travelers pour into U.S. cities every day. Our best defense against a sudden, new contagion is rigorous hospital hygiene and routine infection prevention. That is the lesson of SARS.