 |
|
Severe Acute Respiratory Syndrome
Providing Care in the Face of Uncertainty
Henry Masur, MD;
Ezekiel Emanuel, MD;
H. Clifford Lane, MD
JAMA. 2003;289:(doi:10.1001/jama.289.21.JED30036).
Severe acute respiratory syndrome (SARS) has captured the attention of health care professionals and the public worldwide.1-7 Compared with human immunodeficiency virus (HIV), tuberculosis, malaria, and even influenza, there have been relatively few cases of SARS and a limited number of deaths. However, the ultimate course and global impact of this new illness is currently unknown. Much like concern about anthrax, West Nile disease, and new strains of influenza, most segments of society have been appropriately concerned about how they will be affected.
In this issue of THE JOURNAL, Booth and colleagues report the clinical features and outcomes of 144 cases in the SARS outbreak in Toronto, Ontario.8 The authors deserve enormous credit for developing their comprehensive description of this outbreak so rapidly during a period when health care professionals in Toronto have been overwhelmed with clinical and public health responsibilities. The medical press and governmental health authorities also deserve considerable credit for recognizing the importance of expeditiously publishing facts about the outbreaks.1-8 These efforts have enabled the medical community and the public to make more rational decisions about how their communities should respond to SARS based on solid data rather than on sound bites or personal testimonials in the media.
The characteristics of the outbreak in Toronto8 are quite similar to what has been reported in 2 separate series of 138 and 50 patients, respectively, from different institutions in Hong Kong.7, 9 Consistent with a novel coronavirus as the etiologic agent, the illness shares clinical and laboratory characteristics with many other respiratory infections; neither series could elicit clues other than exposure that were highly suggestive of SARS as opposed to other infectious disorders. Lymphopenia and elevated lactate dehydrogenase may be helpful clues. However, the full spectrum of the clinical manifestations of this disease process are not yet fully recognized or appreciated. In the 3 series, 6% to 20% of patients presented with diarrhea. Such atypical manifestations might lead SARS to be excluded from the differential diagnosis at least initially, with unfortunate epidemiological consequences.
The epidemics in Toronto and Hong Kong involved relatively young adults (median age of 45 years and mean ages of 39-42 years, respectively) and both involved a startling percentage of health care workers (51% and 28%-50%). Intensive care unit admission (21% and 23%-38%), requirement for mechanical ventilation (14% and 14%-38%), and death (6% and 2%-4%) occurred with similar frequencies in these 2 areas. Older age and certain factors such as a history of smoking or diabetes or other comorbid conditions may predispose patients to more severe disease. These associations need to be confirmed by more careful definitions and larger case series composed of laboratory-validated cases.10-13 Differences in reported antecedent illnesses, symptoms, and disease manifestations were not major, and differences that have been reported may reflect either differences in data collection, definition, or intensity of follow-up or differences in concurrent illnesses that were either confused with disease caused by SARS-associated coronavirus or that coinfected patients. For assessment of the clinical and epidemiological data, it must be emphasized that the cases are defined syndromically; dramatically more useful data will be available when sensitive and specific diagnostic tests such as serologic tests for antibody and direct detection systems for the etiologic agent become available that allow clinicians to differentiate those who are infected by the etiologic agent (presumably the SARS-associated coronavirus10-13).
Much of the attention and concern that SARS has appropriately elicited is because current knowledge regarding the transmission of this disease is rapidly evolving and clinicians must provide patient care while dealing with a degree of uncertainty. The Centers for Disease Control and Prevention have published and regularly update logical recommendations for preventing the spread of the causative agent. The causative organism appears to spread predominantly by contact and by droplets and may spread by airborne routes as well.14-15 The use of N-95 masks, hand hygiene, gowns, double gloves, and eye protection seem well advised and appear to have substantially curtailed spread within hospitals.
Accounts circulating from health care workers who have seen colleagues stricken and who have themselves developed this syndrome are reasons for concern. There is also concern that these workers represent a risk to their families in terms of spreading this nosocomial pathogen. Whether these health care workers were infected while taking proper precautions or whether they were inadvertently infected when the risk of exposure was not apparent or when the pressure of events precluded meticulous precautions remains to be determined.
The best strategy to limit in-hospital transmission is to focus on clear indications for outpatient and inpatient care. If patients are not sick enough to warrant admission, the community may be best served by sending such patients home, provided patients can restrict their activities in a responsible manner until they are asymptomatic and less likely to be infectious. For those who must be hospitalized, current recommended procedures provide a high degree of safety. However, health care professionals are already recognizing that certain high-risk procedures, such as intubation, bronchoscopy, and positive pressure mechanical ventilation, should be performed only by a highly experienced staff using the most stringent precautions that are feasible in the institution. The role for N-99 masks, personal air-powered respirators, and special high-efficiency particulate air–filtered travel tents remains to be determined.
In the article by Booth et al,8 the authors acknowledge the work and dedication of health care professionals who risked their lives and the lives of their families to care for these patients with SARS. More than 15 years ago, the medical profession was debating physicians' obligations to treat patients with HIV/AIDS. Legitimate concern for one's personal health, exacerbated by uncertainty, fueled the debate then and have led to similar debates now.16-17
The clear and widely recognized resolution from that time is that physicians and nurses have an obligation to treat sick and potentially infectious patients because they are members of a profession whose primary goal is an ethical calling: caring for the sick. This obligation to serve the sick is constitutive of medicine as a profession and is what uniquely distinguishes physicians, nurses, and other clinicians from other professionals. This duty is not optional, but comes with being a health care professional. This profession, like that of police, fire, rescue, and military personnel, is voluntarily chosen.
The duty to treat is strong, and health care professionals are expected to take some personal risk to do their duty. This has been quite clear when physicians care for patients with tuberculosis or influenza or certain viral hemorrhagic fevers or when surgeons operate on patients with hepatitis B or HIV. The duty to treat is not, however, absolute. Countervailing considerations, including a high potential for serious injury or even death, need to be evaluated. If the danger of serious injury or death is too high, such risk could and should limit that primary duty.
Assessment of the degree of risk should be measured against the risks health care professionals assume in other aspects of caring, such as the risks of morbidity and mortality from other infectious agents, such as influenza, meningococcus, drug-resistant bacteria, and Ebola virus, entities that are not always amenable to therapy and that can cause death. Health care professionals are recognizing more and more clearly that their patient care facilities harbor a host of dangerous infectious agents, some of which are difficult or impossible to treat. Patients and health care professionals have come to accept that such facilities do pose risks for acquiring potentially dangerous pathogens, but through vigilant infection control practices, such risk can be reduced to acceptable levels but not to zero. While there is no explicit level at which risks become excessive, physicians and other health care professionals must recognize that their roles and responsibilities cannot always be successfully carried out in a risk-free environment.
Health care leaders, like the frontline caregivers, must also recognize their responsibilities. They must provide equipment and environmental controls that maximize the safety of their health care staff. While much can be done with appropriate equipment in existing facilities, the issue of whether the United States needs better containment facilities for patients with SARS and those with other contagious pathogens must be carefully reexamined.
Global efforts have described this new syndrome with dramatic speed and identified and sequenced the apparent etiologic agents. With expedited efforts to develop a specific diagnostic test for SARS-associated coronavirus, effective infection-control techniques, and concentrated efforts to develop effective therapies and vaccines, there is much reason for optimism. Only time will tell whether the disease will reappear when seasons again change or when the virus is reintroduced by some unexpected vector. To be prepared for that challenge, health care professionals must not forsake their patients, the research community must help provide answers to the unanswered questions, and health care leadership must take the knowledge from that research to rapidly implement whatever strategies might be necessary to better combat this newly emerging infectious disease.
AUTHOR INFORMATION
|
Corresponding Author and Reprints: Henry Masur, MD, Critical Care Medicine Department, National Institutes of Health, 10 Center Dr, Bldg 10, Room 7D43, Bethesda, MD 20892-1662 (e-mail: hmasur{at}cc.nih.gov).
Editorials represent the opinions of the authors and THE JOURNAL and not those of the American Medical Association.
Author Affiliations: Critical Care Medicine Department and Department of Bioethics, Clinical Center, and Office of the Clinical Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
REFERENCES
|
1. World Health Organization. WHO issues a global alert about cases of atypical pneumonia. Available at: http://www.who.int/csr/sarsarchive/2003_03_12/en/. Accessed April 29, 2003.
2. World Health Organization. Cumulative number of reported probable cases of severe acute respiratory syndrome (SARS). Available at: http://www.who.int/csr/sarscountry/2003_04_28/en. Accessed April 29, 2003.
3. Centers for Disease Control and Prevention. Update: outbreak of severe acute respiratory syndrome—worldwide, 2003. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5212a1.htm. Accessed April 29, 2003.
4. Ksiazek TG, Erdman D, Goldsmith CS, et al. A novel coronavirus associated with severe acute respiratory syndrome. N Engl J Med. Available at: http://content.nejm.org/cgi/reprint/NEJMoa030781v4.pdf. Accessed May 1, 2003.
5. Poutanen SM, Low DE, Henry B, et al. Identification of severe acute respiratory syndrome in Canada. N Engl J Med. Available at: http://content.nejm.org/cgi/reprint/NEJMoa030634v3.pdf. Accessed May 1, 2003.
6. Tsang KW, Ho PL, Ooi GC, et al. A cluster of cases of severe acute respiratory syndrome in Hong Kong. N Engl J Med. Available at: http://content.nejm.org/cgi/reprint/NEJMoa030666v3.pdf. Accessed May 1, 2003.
7. Lee N, Hui D, Wu A, et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med. Available at: http://content.nejm.org/cgi/reprint/NEJMoa030685v2.pdf. Accessed May 1, 2003.
8. Booth CM, Matukas LM, Tomlinson GA, et al. Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area. JAMA. 2003;289:1-9.
9. Peiris JS, Lai ST, Poon LL, et al. Coronavirus as a possible cause of severe acute respiratory syndrome. Lancet. 2003;361:1319-1325.
PUBMED
10. Drosten C, Gunther S, Preiser W, et al. Identification of a novel virus in patients with severe acute respiratory syndrome. N Engl J Med. Available at: http://content.nejm.org/cgi/reprint/NEJMoa030747v2.pdf. Accessed May 1, 2003.
11. British Columbia Genome Sciences Centre. SARS associated coronavirus. Available at: http://www.bcgsc.ca/bioinfo/SARS/. Accessed April 29, 2003.
12. Centers for Disease Control and Prevention. SARS coronavirus sequencing. Available at: http://www.cdc.gov/ncidod/sars/sequence.htm. Accessed April 29, 2003.
13. Centers for Disease Control and Prevention. Severe acute respiratory syndrome and coronavirus testing—United States, 2003. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5214a1.htm. Accessed April 29, 2003.
14. Centers for Disease Control and Prevention. Interim guidance on infection control precautions for patients with suspected severe acute respiratory syndrome (SARS) and close contacts in households. Available at http://www.cdc.gov/travel/other/sars_can.htm.
15. Centers for Disease Control and Prevention. Updated interim domestic guidelines for triage and disposition of patients who may have severe acute respiratory syndrome (SARS). Available at: http://www.cdc.gov/ncidod/sars/triage_interim_guidance.htm. Accessed May 1, 2003.
16. Emanuel EJ. Do physicians have an obligation to treat patients with AIDS? N Engl J Med. 1988;318:1686-1690.
PUBMED
17. Freedman B. Health professions, codes, and the right to refuse to treat HIV-infectious patients. Hastings Cent Rep. 1988;18:suppl 20-5.
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati
What's this?
RELATED ARTICLE
Clinical Features and Short-term Outcomes of 144 Patients With SARS in the Greater Toronto Area
Christopher M. Booth, Larissa M. Matukas, George A. Tomlinson, Anita R. Rachlis, David B. Rose, Hy A. Dwosh, Sharon L. Walmsley, Tony Mazzulli, Monica Avendano, Peter Derkach, Issa E. Ephtimios, Ian Kitai, Barbara D. Mederski, Steven B. Shadowitz, Wayne L. Gold, Laura A. Hawryluck, Elizabeth Rea, Jordan S. Chenkin, David W. Cescon, Susan M. Poutanen, and Allan S. Detsky
JAMA. 2003;289(21):2801-2809.
ABSTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Caring for risky patients: duty or virtue?
Tomlinson
J. Med. Ethics 2008;34:458-462.
ABSTRACT
| FULL TEXT
Planning for Avian Influenza
Bartlett
ANN INTERN MED 2006;145:141-144.
ABSTRACT
| FULL TEXT
The Occupational and Psychosocial Impact of SARS on Academic Physicians in Three Affected Hospitals
Grace et al.
Psychosomatics 2005;46:385-391.
ABSTRACT
| FULL TEXT
Persevering Through a Difficult Time During the SARS Outbreak in Toronto
Bournes and Ferguson-Pare
Nurs Sci Q 2005;18:324-333.
ABSTRACT
Ethical and Legal Challenges Posed by Severe Acute Respiratory Syndrome: Implications for the Control of Severe Infectious Disease Threats
Gostin et al.
JAMA 2003;290:3229-3237.
ABSTRACT
| FULL TEXT
Acute Respiratory Distress Syndrome in Critically Ill Patients With Severe Acute Respiratory Syndrome
Lew et al.
JAMA 2003;290:374-380.
ABSTRACT
| FULL TEXT
|
