America's emergency care system and severe acute respiratory syndrome: are we ready?

To date, severe acute respiratory syndrome (SARS) has sickened at least 8,400 individuals and killed more than 820 worldwide. Before public health officials in China recognized the significance of the initial outbreak of this new disease, infected travelers had sparked secondary outbreaks in several Asian nations and in Toronto, Ontario, Canada. The severity of the ensuing illness and its ready transmissibility severely challenged the medical care systems of affected countries.1-4 Although much has been learned about SARS since the disease was first identified, many questions are unanswered. It is not yet known, for example, if the disease is seasonal, how it may be transmitted, and why certain individuals are “superspreaders” of infection.5,6 SARS is characterized by a high degree of infectivity among close personal contacts, including treating health care workers.7,8 To date, SARS infection has not produced a random pattern of contagious spread.1-3,9,10 The virus can contaminate buildings, fixtures, and patient care areas, but details of how contamination takes place and the persistence of infectious material are unknown.4 As yet, no antimicrobial agent (alone or in combination with other drugs such as corticosteroids) has been established as effective. Worse yet, the disease is highly virulent. Despite widespread provision of intensive care, including endotracheal intubation and mechanical ventilation, the disease produced a case-fatality rate among hospitalized patients of 10% to 15%.11-13 Aggressive respiratory care increased the risk of disease transmission to treating health care workers.7,8,14,15 The combination of ready transmissibility and virulence makes SARS a particularly dangerous disease, one that resembles the Class A bioterrorism agents (Table). Because the first outbreaks of SARS and deaths occurred outside the United States, public concern in this country was intense, but short-lived. When the worldwide incidence of SARS declined this past spring, officials quickly declared victory. The June 18, 2003 edition of USA Today announced, “Experts: SARS Is Stopped.”5 This statement may be regretfully premature. It is extremely difficult to predict the course of a new epidemic disease, particularly one that is still being characterized. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, offered a cautionary note. “We still have the same conditions in China that led to the emergence of this epidemic, so there’s no reason to believe it’s not going to happen again,” he observed. “We’re just one case from the disease reappearing.”5 There are also historical reasons to worry. The influenza pandemic of 1918 to 1919 was a global disaster. First identified in Spain in February 1918, the disease was named “Spanish flu” or “La Grippe.” The initial outbreak in the United States occurred at a Kansas army camp in March 1918. Like many viral respiratory diseases, Spanish flu subsided with the onset of summer. Only isolated cases were identified over the next few months. The disease reemerged with explosive force in the autumn of 1918. The first major outbreaks in the United States occurred in Boston, MA, and Philadelphia, PA. By the time the Spanish flu ran its course, more than 25% of the US population had fallen ill, and 675,000 Americans had died. Worldwide, Spanish flu I N F E C T I O U S D I S E A S E / E D I T O R I A L