SARS: preparing for next time

The deans of medicine at U of T and Queen's weigh in

By Janet Baine

At last, an Rx for SARS By Katherine Addleman During the dark days of the SARS outbreak in the spring of 2003, different treatments were tried including antibiotics, ribavirin, corticosteroids, immunoglobulins, protease inhibitors and fusion inhibitors, among others. None of these seemed to help much, and ribavirin was sometimes quite toxic. So a group of frontline physicians at the North York General Hospital in Toronto decided to add interferon -- a known antiviral -- to the stew, combining it with corticosteroids in suspected SARS patients. The encouraging results of their study have been published in the December 24 Journal of the American Medical Association. The team treated 13 SARS patients with corticosteroids, specifically oral prednisone or intravenous (IV) methylprednisolone. If symptoms got worse, the patients were given pulsed high-dose IV methylprednisolone for three days, tapering to oral prednisone over 20 days. Nine other patients got the corticosteroids, but also received 10 days of subcutaneous interferon alfacon-1 treatment (the first Health Canada-approved interferon use for SARS). In the corticosteroid group about 23% of patients needed intubation and mechanical ventilation, and one patient died. But in the steroid plus interferon combo, only 11% of patients were intubated and there were no deaths. What's more, patients who received interferon also had faster lung improvement on X ray, better oxygen saturation, got off the supplemental oxygen, resolved their lactate dehydrogenase spikes more quickly, and had lower creatine kinase levels. Side effects were minimal. Only one patient was taken off the interferon, and that was because of a fever -- maybe caused by the drug, maybe not. Interferon alfas have proven themselves in treating hepatitis B and C, and in fighting other respiratory coronavirus infections.

With one confirmed case of SARS in China this month and more suspected cases in Guangdong province (where the disease originated), is Ontario ready for a reappearance of this or another infectious disease?

The SARS outbreak, deemed the biggest Canadian news story of 2003, took 44 lives. The last person to die of the disease was a doctor, while two nurses also lost their lives to SARS.

Seventy-five recommendations for changes to the health system were contained in the federal government's National Advisory Committee on SARS and Public Health headed by Dr David Naylor issued in mid-December. He called Canada's handling of the outbreak an "international embarrassment" and "a learning opportunity."

An Ontario interim report based on the findings of an expert panel led by Dr.David Walker, Dean of Medicine at Queen's university, also released last month, and contained more than 50 recommendations. "SARS offered us a lesson that we cannot ignore," said Dr Walker. He also endorsed the Dr Naylor's report.

In preparation for another outbreak, the province now has a two-month stockpile of personal protective equipment such as alcohol hand wash, N95 masks, gowns and gloves. Yet another, task force will soon provide recommendations on use of masks in non-outbreak situations.

"We are starting up a pilot project at Toronto area Public Health Units, which will be using the Integrated Public Health Information System (IPHIS)," says John Letherby an Ontario health ministry spokesperson.

Dr Walker recommends

• Establish an agency responsible for public health.
• Develop regional infection control guidelines and standards.
• Establish an Office of Health Emergency Preparedness.
• Establish a health sector communications infrastructure.
• Develop a comprehensive infectious disease surveillance plan.
• Develop a public health human resource strategy.
• Increasing full-time or regular part-time nursing positions.