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Cold-and-flu season confusion: Bracing for SARS -- and false alarms

Some physicians say differentiating this emerging infection from regular coughs and colds could take a great deal of time and resources.

By Victoria Stagg Elliott, amednews staff. Oct. 6, 2003.

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Physicians around the world are sounding the alarm about the great burden that severe acute respiratory syndrome may have on the health care system this fall.

"We look to the upcoming flu season with anxiety," said Dr. Gro Harlem Brundtland, former director-general of the World Health Organization, at the Interscience Conference on Antimicrobial Agents and Chemotherapy in Chicago last month.

Her sentiments were echoed by many others. And the reason why is clear. Traditional respiratory illnesses will crop up in the next months, as they do every year. But the newfound awareness and threat of SARS will make treating patients who present with these usual flu-season symptoms more complicated. Physicians will face the challenge of distinguishing garden-variety respiratory illnesses from SARS -- whether the ailment returns or not. The task may be expensive, time-consuming and even chaotic as the various viruses and bacteria that cause the aches, pains, fevers and chills are sorted out.

"It's going to be tough," said Susan Balter, MD, an infectious disease specialist from River Forest, Ill., who attended the meeting. "You can't be putting everyone in isolation over the long haul."

The situation is foreboding because, as yet, there is no rapid point-of-care test for the coronavirus that causes SARS. Currently available tests do not confirm the presence of the virus until at least 10 days or more have passed -- time that allows the virus to spread because health care workers may not know to take greater precautions. It is also a long time to quarantine patients waiting to see if they are infected.

"In Canada, anyone who comes in with fever and respiratory symptoms is admitted and gets automatically put in isolation," said Mona Loutfy, MD, a research fellow at McGill University in Montreal. She presented a late-breaking paper suggesting possible treatments for the disease. "But our concerns are what burden that is going to be on the health care system. What are primary care physicians going to do in their offices? Until we have a diagnostic test, if this disease isn't gone, it's going to be a problem."

The Singapore experience

Confusing SARS with other respiratory illnesses already has been an issue confounding its control. For example, when it hit Singapore, several cases were initially believed to be dengue fever, which is endemic to the area. This diagnosis delay is believed to be one factor contributing to the initial spread of the virus and earliest SARS deaths. The outbreak there eventually killed 33 and sickened more than 200.

According to a study presented at the Chicago conference, SARS' economic and resource impact on Singapore was significant. More than 600 patients at Singapore's National University Hospital were isolated during the outbreak in March for fever and flu-like symptoms. Only 39 turned out to have SARS. But more than 6,000 N95 masks and nearly 40,000 gloves were used daily at a cost of $13,000 per day at this facility alone.

"We responded to any requests, no matter how irrational," said Dr. Paul Tambyah, an infectious disease consultant at National and lead author on the study. "Protection is expensive, but missed cases can be devastating."

But those who have experienced SARS outbreaks have suggestions that might make the upcoming cold-and-flu season a little easier. First and foremost, a point-of-care test is needed urgently, but until that is available, the best way to avoid SARS confusion might be widespread flu vaccination.

"SARS is clinically nonspecific," said Allison McGeer, MD, director of infection control at Mount Sinai Hospital in Toronto. "If you deliver your flu shots, it'll be a lot easier to deal with patients because there will be less respiratory illness around."

A lot has been learned about SARS in a short time, and this knowledge might make future re-emergence easier to contain. For instance, certain procedures such as intubation make transmission more likely and should be carried out on suspected SARS patients only with extreme caution. Masks, gloves and gowns provide protection, and duration and proximity to someone with the infection seems to be the leading risk factor for contracting it. There is also suspicion that contact with an infected surface might cause transmission.

But it is epidemiology, in most cases, that provides the crucial pieces of the puzzle distinguishing SARS infections from other respiratory illnesses.

"Where have they been? Have they had travel to affected areas? Have they been around other people with pneumonia?" said John Jernigan, MD, chief of the intervention and evaluation section of the Centers for Disease Control and Prevention division of health care quality promotion. "These are going to be the critical flags."

Meanwhile, advanced age seems to increase the risk of fatality. Younger adults get it, though their infections tend to be milder. Children don't seem to be affected much, if at all. A small number of adults also appear to have contracted SARS while remaining asymptomatic and not contributing to its spread. And, while a handful of people seem to transmit to dozens of people who cross their paths, most don't seem to spread the disease.

"If asymptomatic people were able to spread the infection, controlling the outbreak would have been much harder," Dr. McGeer said.

Physicians also learned what not to do. In Singapore, one hospital was initially designated a "SARS hospital" -- handling all such cases. Patients with other conditions were sent elsewhere. "That turned out to be a very efficient means of disseminating the infection to other hospitals," Dr. Tambyah said. "Now we know to button down the ward. No in. No out."

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