Officials Expect Outbreak of SARS
U.S. Seeks Plan For D.C. Region

(Jerome M. Hauer says people infected with SARS but not seriously ill could be assembled at the Washington Convention Center.

By Avram Goldstein
Washington Post Staff Writer
Sunday, July 6, 2003; Page C01

Health officials say a SARS outbreak of some type is highly likely this year, and they are conferring with doctors and hospitals across the Washington region on how to contain the infection and provide services to people who quarantine themselves at home.

There is urgency in the work, they say, even though the spread of the disease appears to have been checked around the world for now. The reason for the urgency is that experts expect a resurgence of the disease, known as severe acute respiratory syndrome, when temperatures drop in the Northern Hemisphere in several months. And infectious disease specialists agree that an outbreak could be more widespread than earlier this year, when Virginia reported three probable SARS infections and seven suspected cases. None was reported in the District or Maryland.

Jerome M. Hauer, the U.S. Department of Health and Human Services assistant secretary for public health emergency preparedness, is leading a series of meetings with Washington area health officials and the Department of Homeland Security to devise a plan for an area with so many adjacent and overlapping federal, state and local jurisdictions.

"Because the federal government is in fact a target, what happens to us spills over to the city and states," Hauer said. "We have a unique relationship here, and unique responsibilities."

Maryland, Virginia and the District have various plans, but Hauer has offered them the use of the HHS emergency command center to communicate rapidly across the region.

"We will try to have good command and coordination, but obviously the governors and the mayor are basically the commanders," Hauer said. The two meetings so far have been open forums for health care officials, and Hauer has appointed committees to study narrower issues.

A multi-jurisdiction plan, officials say, is necessary to protect medical workers and patients from needless exposure to the SARS virus while enabling hospitals to stay open to treat routine illnesses. "It's a national security issue for the capital of the United States to keep its hospitals open," said Robert Malson, president of the D.C. Hospital Association.

Any regional protocol would require significant coordination and cooperation from dozens of hospitals and tens of thousands of health care workers. Hospitals would have to avoid transferring patients to other facilities, and workers, many of whom work in several hospitals, would be stopped from working at more than one.

A plan for expanding the Washington region's "surge capacity" has to be worked out in the event of a large-scale outbreak, although many scenarios are, at this point, takeoff points for discussion. Hauer said he thinks it might be necessary to set up a centralized facility to care for infected people who are not severely ill, though many local officials doubt the wisdom doing so.

"If we had a big SARS outbreak, the [new] convention center would be an ideal place to locate people," Hauer said. "It is large and has significant infrastructure for kitchens and rest room facilities. That way, you save hospital space for only the most critically ill."

A Washington Convention Center official acknowledged that D.C. Mayor Anthony A. Williams (D) could simply order the facility to be used as a SARS care center if he were convinced it was necessary.

But Daniel R. Lucey, an infectious disease specialist at Washington Hospital Center, said he thinks the major problem will be with those who are at home in voluntary quarantine after being exposed to the virus. Lucey advises the D.C. Health Department and co-chairs a D.C. Hospital Association committee on bioterrorism and emerging diseases, and he said he doesn't think the solution is massive hospital wards.

"The major lesson learned from the outbreak of SARS in the world is the need to isolate patients and voluntarily quarantine people who may be infected" until the 10-day incubation period has passed, he said.

"If you're going to isolate patients and voluntarily quarantine people, you need to know where you're going to do that," Lucey said. "If it's in people's homes, there may be a lot of issues arising about daily living, such as getting food and water and caring for their families. Preparing for a surge of SARS cases not only involves the care of patients who are ill and symptomatic but the contacts of people who are not ill or slightly ill. It involves a lot more than hospital beds."

The trigger for a full-scale regional alert probably would be a lone SARS patient entering a hospital, Lucey said. That, he said, is when an agreed-upon plan would be invaluable. Transfers of patients between hospitals would cease, and workers would be reminded of necessary precautions to take around suspected SARS patients, Lucey said. In hospitals with suspected cases, employees would be fit-tested for masks and outsiders would be barred except to visit a dying patient. Men with beards would be asked to shave so their masks would fit.

Lucey is volunteering at a Toronto hospital for two weeks to learn the medical and social aspects of an epidemic that has caused 8,439 probable infections and 812 deaths worldwide, including 73 probable SARS cases and no deaths in the United States. He said the experience gives him a window on how a SARS epidemic would affect the Washington area.

Canada has reported 251 probable infections and 38 deaths, and thousands of people have been ordered into 10-day quarantine after possible exposure to the virus. All people who seek to enter any Toronto hospital now must submit to having their temperature taken and answer a questionnaire on how they feel and where they have been, Lucey said.

A key challenge would be motivating a health care system that relies on doctors, nurses and others who work at multiple hospitals to abruptly restrict their movements as a public health measure.

Lucey said each doctor would be asked to work at only one hospital. That would be difficult for hospitals and physicians, but it could limit the spread of SARS from hospital to hospital.

Temporary nursing agencies would be asked to ensure that their temps comply with requests from public health officials to stay in a single workplace. They aren't as easily tracked as salaried hospital workers, who can be placed on paid administrative leave if exposed to the virus.

"Telling agency nurses they can't work and won't be paid is a big blow," one hospital official said. "How do we contain a nurse unless the information [that she has been exposed to the virus] gets back to the agency? That's a huge piece of it. It's also true for respiratory therapists. There's hardly a respiratory therapist in this city who doesn't work at three hospitals."

The risks of health care worker transmission of SARS were demonstrated in an unpublicized incident last year in which critical care units at 13 Washington area hospitals were visited by temporary staffers who were exposed to active tuberculosis, according to several hospital officials. All 13 hospitals had to provide precautionary care to everyone in those units.

Dan Hanfling, director of emergency management and disaster medicine for Inova Health System, said the federal government's involvement is an opportunity.

"Jerry Hauer and his office helping to look at these issues from the 50,000-foot level is a great addition to what we're working on at the local level," Hanfling said. "Maybe we can get the additional resources that would be required for this."

Lucey said his Toronto experience has shown him that there is little room for trial and error in managing an epidemic.

"The consequences of not being prepared are so severe," he said.