SARS vs. flu: Can you tell serious disease from common malady?
If it comes back this fall, we’ve got problems; it’s going to be tough’
Like half the patients you’ve seen today, this one is coughing, fatigued, and has a moderately high fever. You’re busy and don’t have much time for what seems like just another case of the flu, so you start to rattle off the standard regimen for flu care.
Then the patient mentions that he just got off a plane from China — or maybe Toronto.
Does that get your attention? It should, says Brian F. Keaton, MD, FACEP, attending physician in the department of emergency medicine at Summa Health System, in Akron, OH, and a member of the board of the American College of Emergency Physicians in Washington, DC. The travel link may be the only solid reason you have to suspect a case of severe acute respiratory syndrome (SARS) instead of the common flu, Keaton says.
Without knowing much more, simply traveling to certain areas may sound like a flimsy way to label a patient as a "potential SARS case," especially since that action will create a fuss with media inquiries, special isolation needs, and public health reporting. But you should consider yourself lucky if the patient you’re wondering about actually has traveled to areas of SARS outbreaks. Otherwise, you might be at a real disadvantage when trying to make a diagnosis, Keaton says.
SARS could be more difficult to diagnose this year because the Centers for Disease Control and Prevention (CDC) in Atlanta removed most of the travel warnings that served as red flags last year. Keaton says that doesn’t leave you with much to go on.
"SARS in year one was fairly easy to differentiate based on CDC definitions because you had travel as a warning sign," he says. "But if you take away travel in year two — and this coronavirus is going to be more ubiquitous — all of a sudden, you’re left with a temperature of greater than 100.4 and respiratory complaints. Without travel, you’re left with everyone who has a common cold or the flu, or a variety of other maladies that show up with coughing, shortness of breath, and low-grade fever."
There may be less emphasis on travel as an official warning sign this year, but Keaton says it, nevertheless, should be considered this fall when trying to differentiate potential SARS from the flu. Although it may be less useful as a diagnostic factor than it was last year, it still might be reason for you to raise your level of suspicion, he adds.
The General Accounting Office (GAO) recently reported that SARS could reappear this fall and that a major outbreak during flu season could lead to severe overcrowding in the ED. Few hospitals have adequate staff, medical resources, or equipment to respond to a SARS outbreak, the report says. Of 2,000 hospitals surveyed by the GAO, half had fewer than four isolation beds for every 100 hospital beds, for instance.
The report warns that a large influx of SARS patients could cause hospitals to seal off entire units, along with the staff, to isolate the virus.
If it comes back, we’ve got problems’
The experts who specialize in flu and SARS are getting nervous about what will happen this fall. Arnold S. Monto, MD, professor of epidemiology at the University of Michigan School of Public Health in Ann Arbor, specializes in researching the flu and common cold, and now SARS.
He tells ED Management that "if it comes back this fall, we’ve got problems. . . . Without a rapid diagnostic test, it’s going to be tough."
Much of the burden will fall on emergency staff because they are the first health professionals with an opportunity to spot the disease, Monto says. He doesn’t envy the challenges they will face.
"We are ruling SARS out by ruling other things in because we do not have a test that can rapidly identify SARS in the early stage," he says.
The case definition is being revised, but it basically states that SARS is atypical pneumonia in an individual from a SARS-infected area, or an individual in contact with a SARS case, Monto says.
"But if people come in with atypical pneumonia, which happens all the time, and they come from a place that had SARS in the past, what do you do?" he asks.
All advice for emergency staff is based on speculation that SARS will recur in the areas previously hit by the disease and that the coronavirus will be imported into the country again. Whether that will happen is still uncertain, but Monto says that is what he expects.
"A lot of us in this field are terribly concerned because we’re not used to having something go away completely after infecting a fair number of people," he emphasizes.
Monto points out that emergency staff may have to be cautious when faced with a questionable case, playing it safe by applying the "potential SARS diagnosis" label until they have more information.
Stay abreast of public health reports
Still, it is entirely possible that if you do have patients with SARS in your ED, the first ones will pass through without your realizing that they don’t have the flu, Keaton says. Your real work may begin when you get word of the first diagnosis in your own community. Then you will have to ratchet up your index of suspicion even higher.
It comes down to awareness: knowing what’s going on in your community and working with your public health colleagues, Keaton says.
"But in terms of the individual patient who shows up at my doorway with a temp of 100.4 and a cough, I don’t think there’s a great way to sort out who’s early in SARS, who’s early in influenza, and who’s got a common cold," he continues. "So much of your reaction depends on knowing what is going on in your community."
Plan for isolation of potential SARS cases
Much of what you can do to prepare for SARS involves planning for respiratory isolation, Keaton says. Do you have enough isolation rooms available? What is your alternate plan when those rooms are full?
"You need to anticipate that and sit down with infection control, epidemiology, nursing managers, and others and play a disaster game," he says. "What will we do when we get hit with SARS cases? What other areas become available to us if we really need them?"
It could be a good idea to draw up a SARS response plan that includes dividing your waiting area into two rooms: one for those with respiratory ailments and one for everyone else. The plan also could call for more use of masks and more hand washing.
The good news, Keaton and Monto say, is that the coronavirus is not a hardy bug. The virus is fragile, so it can be controlled with good hand washing and other universal precautions.
"That can be very effective, so that’s probably where we need to focus. We know that works," Keaton says.
Monto says the medical community will learn a great deal more about SARS this fall, and that ED staff will be responsible for spotting cases before the disease gets out of control.
That is not an easy task, he acknowledges, but he urges emergency staff to consider the ramifications if they do not take the threat seriously.
"Emergency department physicians need to be alert and remember that they may have to identify many cases as possible SARS that really aren’t, simply to be sure that the real cases aren’t missed," he says. (For more information on SARS, see "7 Steps to Submit Suspicious Samples for SARS Testing." Also see articles covering isolation and other steps, ED Management, May 2003, pp. 49-53, plus a triage screening insert.)
Sources and Resources
For more information on severe acute respiratory syndrome (SARS), contact:
- Brian F. Keaton, MD, Board of Directors, American College of Emergency Physicians, 2121 K St., Suite 325, Washington, DC 20037. Telephone: (800) 320-0610.
- Arnold S. Monto, MD, Professor of Epidemiology, University of Michigan School of Public Health, 109 Observatory St., Ann Arbor, MI 48109-2029. Telephone: (734) 764-5425.
• The Frontlines of Medicine Project has extensive advice about how emergency physicians can address SARS, including an ED surveillance form that can help with diagnoses. See the web site at www.frontlinesmed.org. Click on the link to the SARS surveillance information, then the link to the surveillance form.
• See the Centers for Disease Control and Prevention (CDC) web site for the latest news, case definitions, and other useful information about SARS. The CDC SARS web page for clinicians is www.cdc.gov/ncidod/sars/clinicians.htm.
• The American College of Emergency Physicians offers SARS resources at its web site, www.acep.org. The specific address is www.acep.org/1,32620,0.html.
Like half the patients youve seen today, this one is coughing, fatigued, and has a moderately high fever. Youre busy and dont have much time for what seems like just another case of the flu, so you start to rattle off the standard regimen for flu care.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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