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Severe Acute Respiratory = Syndrome=20

Providing Care in the Face of Uncertainty=20

= Henry=20 Masur, MD; Ezekiel Emanuel, MD; H. = Clifford Lane, MD

JAMA. 2003;289:(DOI=20 10.1001/jama.289.21.JED30036).

Severe=20 acute respiratory syndrome (SARS) has captured the = attention=20 of health care professionals and the public = worldwide.1-7=20 Compared with human immunodeficiency virus (HIV), = tuberculosis, malaria, and even influenza, there = have=20 been relatively few cases of SARS and a limited = number of=20 deaths. However, the ultimate course and global = impact of=20 this new illness is currently unknown. Much like = concern=20 about anthrax, West Nile disease, and new strains = of=20 influenza, most segments of society have been = appropriately=20 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=20 SARS outbreak in Toronto, Ontario.8=20 The authors deserve enormous credit for = developing their=20 comprehensive description of this outbreak so = rapidly=20 during a period when health care professionals in = Toronto=20 have been overwhelmed with clinical and public health=20 responsibilities. The medical press and governmental=20 health authorities also deserve considerable = credit for=20 recognizing the importance of expeditiously = publishing=20 facts about the outbreaks.1-8=20 These efforts have enabled the medical community and = the=20 public to make more rational decisions about how = their=20 communities should respond to SARS based on solid = data=20 rather than on sound bites or personal = testimonials in=20 the media.

The characteristics of the outbreak in Toronto8=20 are quite similar to what has been reported in 2 = separate=20 series of 138 and 50 patients, respectively, from = different institutions in Hong Kong.7,=20 9=20 Consistent with a novel coronavirus as the etiologic=20 agent, the illness shares clinical and laboratory=20 characteristics with many other respiratory = infections;=20 neither series could elicit clues other than = exposure=20 that were highly suggestive of SARS as opposed to = other=20 infectious disorders. Lymphopenia and elevated = lactate=20 dehydrogenase may be helpful clues. However, the = full=20 spectrum of the clinical manifestations of this disease = process are not yet fully recognized or appreciated. = In=20 the 3 series, 6% to 20% of patients presented = with=20 diarrhea. Such atypical manifestations might lead = SARS to=20 be excluded from the differential diagnosis at = least=20 initially, with unfortunate epidemiological=20 consequences.

The epidemics in Toronto and Hong Kong involved = relatively=20 young adults (median age of 45 years and mean = ages of=20 39-42 years, respectively) and both involved a = startling=20 percentage of health care workers (51% and = 28%-50%).=20 Intensive care unit admission (21% and 23%-38%),=20 requirement for mechanical ventilation (14% and = 14%-38%),=20 and death (6% and 2%-4%) occurred with similar=20 frequencies in these 2 areas. Older age and certain=20 factors such as a history of smoking or diabetes = or other=20 comorbid conditions may predispose patients to = more=20 severe disease. These associations need to be = confirmed=20 by more careful definitions and larger case = series=20 composed of laboratory-validated cases.10-13=20 Differences in reported antecedent illnesses, = symptoms,=20 and disease manifestations were not major, and=20 differences that have been reported may reflect = either=20 differences in data collection, definition, or = intensity=20 of follow-up or differences in concurrent illnesses = that=20 were either confused with disease caused by = SARS-associated=20 coronavirus or that coinfected patients. For = assessment of=20 the clinical and epidemiological data, it must be = emphasized that the cases are defined = syndromically;=20 dramatically more useful data will be available = when=20 sensitive and specific diagnostic tests such as = serologic=20 tests for antibody and direct detection systems = for the=20 etiologic agent become available that allow = clinicians to=20 differentiate those who are infected by the etiologic=20 agent (presumably the SARS-associated = coronavirus10-13).=20

Much of the attention and concern that SARS has=20 appropriately elicited is because current = knowledge=20 regarding the transmission of this disease is = rapidly=20 evolving and clinicians must provide patient care = while=20 dealing with a degree of uncertainty. The Centers = for=20 Disease Control and Prevention have published and=20 regularly update logical recommendations for = preventing=20 the spread of the causative agent. The causative = organism=20 appears to spread predominantly by contact and by = droplets and may spread by airborne routes as=20 well.14-15=20 The use of N-95 masks, hand hygiene, gowns, = double=20 gloves, and eye protection seem well advised and = appear=20 to have substantially curtailed spread within=20 hospitals.

Accounts circulating from health care workers who have = seen=20 colleagues stricken and who have themselves developed = this=20 syndrome are reasons for concern. There is also = concern=20 that these workers represent a risk to their = families in=20 terms of spreading this nosocomial pathogen. = Whether=20 these health care workers were infected while = taking=20 proper precautions or whether they were = inadvertently=20 infected when the risk of exposure was not apparent = or=20 when the pressure of events precluded meticulous = precautions=20 remains to be determined.

The best strategy to limit in-hospital transmission is to = focus on clear indications for outpatient and = inpatient=20 care. If patients are not sick enough to warrant=20 admission, the community may be best served by = sending=20 such patients home, provided patients can = restrict their=20 activities in a responsible manner until they are = asymptomatic and less likely to be infectious. For = those=20 who must be hospitalized, current recommended = procedures=20 provide a high degree of safety. However, health care=20 professionals are already recognizing that = certain=20 high-risk procedures, such as intubation, = bronchoscopy,=20 and positive pressure mechanical ventilation, = should be=20 performed only by a highly experienced staff = using the=20 most stringent precautions that are feasible in = the=20 institution. The role for N-99 masks, personal = air-powered=20 respirators, and special high-efficiency particulate=20 air=96filtered travel tents remains to be = determined.=20

In the article by Booth et al,8=20 the authors acknowledge the work and dedication = of health=20 care professionals who risked their lives and the = lives=20 of their families to care for these patients with = SARS.=20 More than 15 years ago, the medical profession = was=20 debating physicians' obligations to treat patients with = HIV/AIDS. Legitimate concern for one's personal = health,=20 exacerbated by uncertainty, fueled the debate = then and=20 have led to similar debates now.16-17=20

The clear and widely recognized resolution from that time = is=20 that physicians and nurses have an obligation to treat = sick and potentially infectious patients because = they are=20 members of a profession whose primary goal is an = ethical=20 calling: caring for the sick. This obligation to = serve=20 the sick is constitutive of medicine as a = profession and=20 is what uniquely distinguishes physicians, = nurses, and=20 other clinicians from other professionals. This = duty is=20 not optional, but comes with being a health care=20 professional. This profession, like that of police, = fire,=20 rescue, and military personnel, is voluntarily=20 chosen.

The duty to treat is strong, and health care = professionals=20 are expected to take some personal risk to do = their duty.=20 This has been quite clear when physicians care = for=20 patients with tuberculosis or influenza or = certain viral=20 hemorrhagic fevers or when surgeons operate on = patients=20 with hepatitis B or HIV. The duty to treat is = not,=20 however, absolute. Countervailing considerations, = including=20 a high potential for serious injury or even death, = need to=20 be evaluated. If the danger of serious injury or = death is=20 too high, such risk could and should limit that = primary=20 duty.

Assessment of the degree of risk should be measured = against=20 the risks health care professionals assume in other=20 aspects of caring, such as the risks of morbidity = and=20 mortality from other infectious agents, such as=20 influenza, meningococcus, drug-resistant = bacteria, and=20 Ebola virus, entities that are not always amenable = to=20 therapy and that can cause death. Health care = professionals=20 are recognizing more and more clearly that their = patient=20 care facilities harbor a host of dangerous = infectious=20 agents, some of which are difficult or impossible = to=20 treat. Patients and health care professionals = have come=20 to accept that such facilities do pose risks for=20 acquiring potentially dangerous pathogens, but = through=20 vigilant infection control practices, such risk = can be=20 reduced to acceptable levels but not to zero. While = there=20 is no explicit level at which risks become excessive,=20 physicians and other health care professionals = must=20 recognize that their roles and responsibilities = cannot=20 always be successfully carried out in a risk-free = environment.

Health care leaders, like the frontline caregivers, must=20 also recognize their responsibilities. They must = provide=20 equipment and environmental controls that = maximize the=20 safety of their health care staff. While much can = be done=20 with appropriate equipment in existing = facilities, the=20 issue of whether the United States needs better=20 containment facilities for patients with SARS and = those=20 with other contagious pathogens must be carefully = reexamined.=20

Global efforts have described this new syndrome with=20 dramatic speed and identified and sequenced the = apparent=20 etiologic agents. With expedited efforts to = develop a=20 specific diagnostic test for SARS-associated = coronavirus,=20 effective infection-control techniques, and = concentrated=20 efforts to develop effective therapies and = vaccines,=20 there is much reason for optimism. Only time will = tell=20 whether the disease will reappear when seasons again = change=20 or when the virus is reintroduced by some unexpected=20 vector. To be prepared for that challenge, health = care=20 professionals must not forsake their patients, = the=20 research community must help provide answers to = the=20 unanswered questions, and health care leadership = must=20 take the knowledge from that research to rapidly=20 implement whatever strategies might be necessary to=20 better combat this newly emerging infectious = disease.=20


AUTHOR INFORMATION=20

Corresponding Author and Reprints:=20 Henry Masur, MD, Critical Care Medicine = Department,=20 National Institutes of Health, 10 Center Dr, Bldg = 10,=20 Room 7D43, Bethesda, MD 20892-1662 (e-mail: hmasur@cc.nih.gov).

Editorials represent the opinions of the authors and THE=20 JOURNAL and not those of the American Medical=20 Association.

Author Affiliations: Critical Care Medicine = Department=20 and Department of Bioethics, Clinical Center, and Office of = the=20 Clinical Director, National Institute of Allergy and = Infectious=20 Diseases, National Institutes of Health, Bethesda, Md. =


REFERENCES=20

1.=20 World Health Organization. WHO issues a global alert about = cases of=20 atypical pneumonia. Available at: http://www.who= .int/csr/sarsarchive/2003_03_12/en/.=20 Accessed April 29, 2003.
2.=20 World Health Organization. Cumulative number of reported = probable=20 cases of severe acute respiratory syndrome (SARS). Available = at: http://www.who.= int/csr/sarscountry/2003_04_28/en.=20 Accessed April 29, 2003.
3.=20 Centers for Disease Control and Prevention. Update: outbreak = of=20 severe acute respiratory syndrome=97worldwide, 2003. = Available at: http://www= .cdc.gov/mmwr/preview/mmwrhtml/mm5212a1.htm.=20 Accessed April 29, 2003.
4.=20 Ksiazek TG, Erdman D, Goldsmith CS, et al. A novel = coronavirus=20 associated with severe acute respiratory syndrome. N Engl = J=20 Med. Available at: http://co= ntent.nejm.org/cgi/reprint/NEJMoa030781v4.pdf.=20 Accessed May 1, 2003.
5.=20 Poutanen SM, Low DE, Henry B, et al. Identification of = severe acute=20 respiratory syndrome in Canada. N Engl J Med. = Available at:=20 http://co= ntent.nejm.org/cgi/reprint/NEJMoa030634v3.pdf.=20 Accessed May 1, 2003.
6.=20 Tsang KW, Ho PL, Ooi GC, et al. A cluster of cases of severe = acute=20 respiratory syndrome in Hong Kong. N Engl J Med. = Available=20 at: http://co= ntent.nejm.org/cgi/reprint/NEJMoa030666v3.pdf.=20 Accessed May 1, 2003.
7.=20 Lee N, Hui D, Wu A, et al. A major outbreak of severe acute=20 respiratory syndrome in Hong Kong. N Engl J Med. = Available=20 at: http://co= ntent.nejm.org/cgi/reprint/NEJMoa030685v2.pdf.=20 Accessed May 1, 2003.
8.=20 Booth CM, Matukas LM, Tomlinson GA, et al. Clinical features = and=20 short-term outcomes of 144 patients with SARS in the greater = Toronto=20 area. JAMA. 2003;289:1-9.
9.=20 Peiris JS, Lai ST, Poon LL, et al. Coronavirus as a possible = cause=20 of severe acute respiratory syndrome. Lancet.=20 2003;361:1319-1325.=20 MEDLINE
10.=20 Drosten C, Gunther S, Preiser W, et al. Identification of a = novel=20 virus in patients with severe acute respiratory syndrome. = N Engl=20 J Med. Available at: http://co= ntent.nejm.org/cgi/reprint/NEJMoa030747v2.pdf.=20 Accessed May 1, 2003.
11.=20 British Columbia Genome Sciences Centre. SARS associated=20 coronavirus. Available at: http://www.bcgsc.ca/bioinfo/SA= RS/.=20 Accessed April 29, 2003.
12.=20 Centers for Disease Control and Prevention. SARS coronavirus = sequencing. Available at: http://www.cdc.gov/n= cidod/sars/sequence.htm.=20 Accessed April 29, 2003.
13.=20 Centers for Disease Control and Prevention. Severe acute = respiratory=20 syndrome and coronavirus testing=97United States, 2003. = Available at:=20 http://www= .cdc.gov/mmwr/preview/mmwrhtml/mm5214a1.htm.=20 Accessed April 29, 2003.
14.=20 Centers for Disease Control and Prevention. Interim guidance = on=20 infection control precautions for patients with suspected = severe=20 acute respiratory syndrome (SARS) and close contacts in = households.=20 Available at http://www.cdc.gov/= travel/other/sars_can.htm.
15.=20 Centers for Disease Control and Prevention. Updated interim = domestic=20 guidelines for triage and disposition of patients who may = have=20 severe acute respiratory syndrome (SARS). Available at: http:= //www.cdc.gov/ncidod/sars/triage_interim_guidance.htm.=20 Accessed May 1, 2003.
16.=20 Emanuel EJ. Do physicians have an obligation to treat = patients with=20 AIDS? N Engl J Med. 1988;318:1686-1690.=20 MEDLINE
17.=20 Freedman B. Health professions, codes, and the right to = refuse to=20 treat HIV-infectious patients. Hastings Cent Rep.=20 1988;18:suppl 20-5.=20 MEDLINE

RELATED ARTICLES IN=20 JAMA=20

Clinical Features and Short-term Outcomes = of 144=20 Patients With SARS in the Greater Toronto=20 Area
Christopher M. Booth, Larissa M. Matukas, = George A.=20 Tomlinson, Anita R. Rachlis, David B. Rose, Hy A. Dwosh, = Sharon L.=20 Walmsley, Tony Mazzulli, Monica Avendano, Peter Derkach, = Issa E.=20 Ephtimios, Ian Kitai, Barbara D. Mederski, Steven B. = Shadowitz,=20 Wayne L. Gold, Laura A. Hawryluck, Elizabeth Rea, Jordan S. = Chenkin,=20 David W. Cescon, Susan M. Poutanen, and Allan S. Detsky=20
JAMA. 2003;0:289213088-9.
= ABSTRACT=20 | FULL= =20 TEXT  =20



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