County health experts say Marin is prepared to cope with the super-pneumonia called SARS should an outbreak strike here.
To date, the World Health Organization has reported 229 deaths from severe acute respiratory syndrome, which first appeared in China and has spread to Singapore, Hanoi and, more recently, Toronto.
In the United States, the Centers for Disease Control and Prevention lists 39 cases of probable SARS.
Two suspected cases of SARS have been reported in Marin, the first on March 25, the second on April 19. Both patients had recently traveled to one of the areas of concern.
Marin's public health officer Dr. Fred Schwartz said the county health department launched its response to SARS on the same day WHO issued a global health advisory on the disease - March 15. Since that time, he said his office has been working closely with the staff of Marin's three hospitals and with a "wide group of physicians," both meeting in person and sending out almost daily e-mails with updated CDC guidelines and information.
"No one really knows where this is going to go," Schwartz said. "So the emphasis is now on making sure that information is current, that it's available and that travelers returning from the areas designated by the CDC as areas of concern maintain a high awareness about the symptoms that they need to watch for, namely fever or respiratory symptoms. If they have those symptoms within 10 days of returning from one of those areas, they should take precautions, notify public health agencies and get checks."
The county has set up triage guidelines at local clinics so that staff can quickly identify any patients that might be at risk for SARS and take action to protect other patients and themselves from potential exposure.
"The important point here is that we are trying to recognize any individuals who meet the case definition early, using infection control precautions whether in the physician's office or at home, and follow up with those patients and their contacts," Schwartz said.
He could not say exactly how much money the county has spent preparing its SARS response, but acknowledged there are "a lot of staff hours" dedicated to it. He said the county's response to SARS is similar to its efforts to prepare for other "emerging pathogens, like West Nile virus or bioterrorism."
Keeping up with daily CDC updates and passing them on to local health care providers is a big part of Schwartz's job.
Quarantine inspectors are distributing health alert cards to air passengers returning in airplanes either directly or indirectly to the United States from China, Singapore and Vietnam. The notices inform travelers about SARS and its symptoms and ask them to monitor their health for 10 days and to see a doctor if they get a fever with a cough or have difficulty breathing.
Karen Anderson, clinical laboratory scientist and infection control coordinator at Marin General and Novato Community hospitals, said both Sutter Health facilities are following CDC and county protocols, offering training to emergency room staff, including clerks and triage nurses who first see patients when they arrive.
A sign in English and Spanish outside the two hospitals' emergency rooms asks anyone with upper respiratory problems and a history of travel to one of the known SARS areas to don a surgical mask before entering.
Hospital staff treating patients whose symptoms fit the SARS profile must wear the "N95" mask, first developed for treating tuberculosis patients, according to Anderson. Possible SARS or TB patients are examined in special "negative pressure" rooms where the air is filtered and changed at least 12 times an hour and not recirculated.
"The staff in the very beginning was, as everyone was, a bit nervous about SARS when we first started hearing about it," Anderson said. "As we get more information, they feel more confident that we can handle this too. As we get more information, they know the questions to ask."
But California Nurses Association labor representative Bill Urman questions just how ready for SARS the two Marin Sutter Health hospitals really are, citing an April 2 memo Anderson sent to MGH/NCH department managers and nursing and clinical supervisors on the use of TB masks.
"Due to SARS and the anxiety that it has caused, the TB mask that we use is on back order until the end of April," Anderson wrote the managers. "We currently have a limited supply."
Anderson's memo advised managers to ask staff "to restrict their use of the TB masks to (working with) those patients that really require its use" and use instead the "common surgical mask (which) provides very good protection, when needed, for close care of patients with common pneumonia."
Anderson said last week "there was never a shortage of masks," but simply some concern because the vendor had not initially sent the hospitals their full order. She also said some staff members were using the TB masks when they weren't needed.
"People grab a mask and use it for something other than an airborne infectious disease because it's easy to get to," she said.
A TB mask costs "maybe 75 cents," Anderson said, while a surgical mask might run about 33 cents.
"Nurses are obviously upset that such a basic and important supply is being 'rationed,'" Urman said. "Some nurses took offense at the memo, which implied that the shortage was created by health care workers who have overreacted to the SARS scare."
At the University of California at San Francisco, Dr. Ellen Weber, clinical professor of medicine and clinical director of the emergency department, said her department doesn't ask respiratory patients who have traveled to SARS areas to put on surgical masks before they enter.
"We haven't seen enough evidence here to make everybody that anxious, and we'd be putting an awful lot of masks on people who don't need them," she said. "We're not being blas, but also we don't want to stigmatize everybody who walks into the department."
Still, Weber said, because the UCSF emergency room is crowded and so little is known about how the disease is spread, admitting staff there screen respiratory patients as soon as they enter the Emergency Department and give them masks if there's any possibility they have an infectious respiratory disease.
The same procedure is followed at Kaiser Permanente Medical Center in San Rafael.
Dr. David Witt, Kaiser Permanente's chair of infectious disease for Northern California, said all Kaiser hospitals are following the CDC's guidelines for treating and preventing the spread of SARS and updating staff of new information as it breaks.
Kaiser staff members are concerned about their safety, Witt said.
"Clearly we're more likely to be exposed than the general public," Witt said. "It's not abject panic, but people are definitely concerned. They're calling me. A lot of people in the hallway grab you as you walk through and ask what you think about it ... Most of us are willing to take our fair risk, but we don't want to have to have unnecessary exposure."
The uncertainty surrounding SARS makes it difficult for health care providers to reassure the public, Witt said.
"We don't know what to tell people," he said. "What people really want to know is - is this a pandemic? Is this nothing? Is this going to be like ebola, that comes every five years and goes away? I think we really don't know. I think what makes public health people nervous is that uncertainty."
UCSF's Weber is as uncertain as anyone. But she is heartened by SARS' relatively slow rate of infection in the United States.
"We've seen a milder form, I think, or for some reason people getting hit here are not getting as ill," Weber said. "I think sort of the better news right now is it doesn't seem to have spread like wildfire here the way it did in the Far East."
A telecast Tuesday from CDC director Dr. Julie Gerberding echoed Weber's optimism but urged caution.
"I think the good news is that we do see effective containment in some areas and some measures do seem to be very successful," Gerberding said. "I think we're also very sobered by the ongoing transmission in parts of the world, including Hong Kong, where very, very appropriate public health steps have been taken, and yet the epidemic is continuing to evolve there. So it's too soon to predict where it's going to go."
But Gerberding insisted on preparedness.
"We must remain vigilant here. The last thing that we can do at this point in time is relax and say, well, thank goodness we don't have very many probable cases in the United States, and therefore, maybe we're not ever going to have any subsequent spread so that we don't need to be doing the things that we're doing now. This is exactly the time where we need to continue to do what we're doing and learn our lessons from what we are observing in the other countries who are working on this problem."
From the Marin IJ |  | | Infectious disease specialist Dr. Catherine Treseler stands in the doorway of one of two negative-pressure rooms at the emergency department at Kaiser Permanente Medical Center in San Rafael. |
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Saturday, February 4, 2012