As SARS threat dwindles, lessons linger for medical community

Ophthalmologists reflect on their experiences with the potentially deadly virus. While the threat has subsided for now, surgeons say this is no time for complacency.

The global threat of severe acute respiratory syndrome, or SARS, appears to have largely abated as even the most fear-ridden areas of the world are quietly regaining a sense of normality.

Yet the global health community is not likely to quickly forget the harsh lessons of SARS, according to surgeons around the world who have, directly or indirectly, been forced to confront the epidemic.

“People’s sense of confidence is coming back, but it is definitely not fully recovered,” Dennis S.C. Lam, MD, FRCS, FRCOphth, who practices in Hong Kong, told Ocular Surgery News.

Dr. Lam said the situation in Hong Kong, which registered nearly 1,800 cases of SARS since its first appearance in November 2002, has improved dramatically since the World Health Organization (WHO) declared the country free of local transmission in late June.

The outbreak in Hong Kong, with its dense population and close proximity to mainland China, was one of the hardest to control, according to WHO.

During the height of the outbreak in March, patient confidence took a nosedive, causing an estimated 30% to 40% drop in patient volume in eye clinics, Dr. Lam said.

The numbers are going back up now, he said, but most clinics are still enforcing the same preventive measures — protective garb and frequent hand-washing — they did during the peak. “For the moment, we feel we have won this battle. But we want to be fully prepared in case it comes back,” Dr. Lam said.

Keeping vigilant

Public health officials acknowledge the possibility that SARS could make a comeback, especially if just one new case is missed. This message does not appear to be lost on ophthalmologists from the SARS “hot spots,” who remain on guard.

“Whether SARS will have an impact on ophthalmology in the future depends on whether SARS will reappear this winter,” said Fung-Rong Hu, MD, a professor of ophthalmology at National Taiwan University Hospital in Taipei.

Dr. Hu said bolstering patient confidence with stringent precautionary measures is critical to ensuring that patient volume does not drop significantly again, as it did during the peak of the SARS crisis. Her hospital saw a decline in patients of more than 50% during the peak, although patient volume has now returned to roughly 80% of normal, she said.

“If the patients still regard the hospital as a dangerous area to get infection, the number of (those seeking) elective surgery will decrease,” Dr. Hu said.

Taiwan, the second hardest hit region after mainland China, registered 674 cumulative cases of SARS between November 1, 2002, and July 4, 2003, according to WHO. On July 5, it became the last area to be removed from WHO’s list of areas with recent local transmission of SARS.

Ray Jui-Fang Tsai, MD, a professor and chairman of ophthalmology at Chang Gung Memorial Hospital in Taiwan, said his clinic reduced its clinical load in response to the growing number of SARS cases and closed its doors for about 2 weeks during the height of the scare. As in other affected areas, protective equipment and attention to hygiene became a central focus when the clinic reopened.

Dr. Hu said precautionary measures also played a critical role in calming fears at National Taiwan University Hospital. She said masks, head caps, disposable gowns, shoe covers and face shields became the required uniform while caring for SARS patients, and those who were suspected to have had unprotected contact with a SARS-infected patient were subject to mandatory quarantine for 14 days.

“I have confidence in the infection control committee of my hospital, so I am not afraid to work at my hospital,” Dr. Hu said.

According to Steve A. Arshinoff, MD, FRCSC, of Toronto, hospitals were a primary location for infection.

“In Canada, where we had fewer cases than China, Taiwan or Hong Kong, the greatest risk of the disease was not to the public; it was to the doctors and nurses who were caring for the initial few patients who had contracted the disease in Hong Kong and imported it to Toronto,” Dr. Arshinoff said. He recounted the case of a Canadian nurse who contracted the disease and spread it to her husband. She and her husband ultimately died from the infection, he said. A second nurse also died.

Dr. Arshinoff noted that it was not uncommon for multiple deaths to occur in the same family when one member became infected.

“The concern with this disease is not high prevalence; the concern was that it was highly lethal,” he said. “It’s not as contagious as most cold viruses, but the death rate was extremely high.”

More than 250 people in Toronto had been confirmed or suspected of having SARS by the time WHO removed Canada from the list of countries with recent transmissions on July 2. Forty-one people in Canada had died from the disease as of July 20. In Canada, SARS was restricted to the Toronto area, where it was first imported from Hong Kong.

Value of information

Dr. Lam, of Hong Kong, said he feels that information has become the medical community’s best weapon against SARS there.

“In the beginning, this was new to us and we did not know what was the best treatment. Now we feel much more confident — we know it’s preventable — and psychologically this is very important,” he said.

Dr. Lam said that while SARS is not associated with severe ocular effects, he and his staff noticed that some SARS patients experienced an increase in intraocular pressure, likely resulting from the high doses of steroids administered to control their respiratory symptoms.

In Singapore, another risk area, surgeons implemented “a full suite of precautionary measures aimed to assure safety and protection,” including full protective equipment and infection control training for the entire staff, according to Chong-Lye Ang, MD, medical director of the Singapore National Eye Centre (SNEC).

“All these stringent measures have paid off, and we were glad that the SNEC fortress has not been breached at all and has remained SARS- free throughout the outbreak,” Dr. Ang said.

He added that his staff also exercised a “high index of suspicion” with immunocompromised patients, such as corneal graft patients, those with uveitis, or diabetics on renal dialysis, because their febrile symptoms can be masked.

Dr. Ang said that at the height of the crisis, SNEC assigned more than 50 staff members to teams that were not allowed to intermingle to prevent spreading the disease. These staff members were required to practice in separate designated clinics, and all common facilities were closed temporarily.

“We have had to scale down our workload to allow the full implementation of these measures and strategies, but we are pleased that no services had to be disrupted,” Dr. Ang said. “Elective work was intentionally scaled down, but we were able to attend to and treat any eye patients who needed care throughout the SARS outbreak.”

In Toronto, closed hospitals created longer preoperative waiting periods in a city that already has a significant backlog for elective ocular surgery. Hospitals were closed twice for 4 to 6 weeks for all elective procedures during separate outbreaks in late February and in late April.

Many patients in Canada already wait between 1 and 3 years for cataract surgery, according to Raymond Stein, MD, FRCSC, president of the Canadian Society for Cataract and Refractive Surgery. The SARS outbreaks only exacerbated that situation, he said.

“The only surgery that could be done was emergency surgery, such as a retinal detachment. But all elective surgery was canceled,” Dr. Stein said. “It’s very difficult for us to catch up. Those times are lost.”

Dr. Arshinoff said, “In every hospital, they would station three or four nurses and up to 10 other staff at the front door, with all other doors being locked, and they had to wear full gowns and masks and shields, and everyone who came to the door was interrogated about whether they were exposed to SARS.

“No visitors, company reps or anybody except essential personnel were allowed in. All staff, once in the hospital, wore special masks and gowns and had their mobility restricted within the hospital,” he said. “You can imagine, all of a sudden, people are ordering millions of (respirator) masks — it’s kind of hard to find them. Every company that makes them was sold out for a while, and we were just scrambling to get them.”

All patients had to complete and sign a standard government- and medical association-approved questionnaire documenting any possible exposure to SARS. Dr. Arshinoff said his practice and many others took the extra step of calling patients the night before their appointments to ask about symptoms of SARS and exposure history. The practices requested anyone who showed symptoms of SARS to reschedule in order to avoid possible exposure of other patients.

Thousands of people in Toronto were quarantined, usually at home, when exposure was suspected, said Dr. Arshinoff. All radio and television stations in Toronto repeatedly broadcast daily updates and instructions to people throughout the crisis.

“It was a scary experience, and a clear warning to any of us who may think that man has conquered infectious disease,” he said.

While Japan has not been affected by SARS, surgeons there also remained on guard against the infection.

Shunji Kusaka, MD, of Osaka, said his hospital took precautionary measures. Yet, in general, the medical community there was not over-fearful.

“We were told to wear a mask with a plastic face guard and plastic gloves when we think that a patient might have a possible SARS infection. However, since there have been no SARS patients in Japan, we are optimistic about (avoiding) this crisis,” Dr. Kusaka said.

Despite the general sense of guardedness felt in his clinic, Dr. Kusaka said SARS had virtually no effect on his practice.

“One reason is that I assumed that possible SARS patients would first go to the general clinic or the (emergency room). So I did not expect that they would be coming to our clinic first,” he said.

The role of the media

Dr. Tsai said that while the SARS crisis has caused increased vigilance in his practice, he feels the media hype surrounding the crisis has been “over-blown.”

“We worked with pressure but not with fear,” Dr. Tsai said. “Fear comes from poor understanding.”

Dr. Kusaka, on the other hand, is not among those who believe the media exaggerated the gravity of the threat.

“I personally think that since the risk management of the Japanese government and also the Japanese people is generally very poor, what the media did (for) the Japanese people was quite appropriate,” he said.

Amar Agarwal, MD, whose main clinic is in Chennai, India, agreed that the media played an important role in educating government officials and the public on the facts.

“It is better to err on the cautious side,” Dr. Agarwal said. “We might say today that India is SARS-free so there is no problem. But (during the height of the crisis) we were not sure. Here, the problem was something totally new and unheard of.”

Dr. Agarwal said his clinic, one of the largest eye surgery centers in the Asian region, was indirectly affected by the health crisis because of the large influx of international patients typically received there. Tight travel restrictions throughout the region somewhat hampered surgical volume because of the “small dip in the patients flowing in,” he said.

Dr. Agarwal said he made wearing masks compulsory for his surgeons and staff during a 1-month period. There are approximately 25 surgeons working at a time in the outpatient department of Dr. Agarwal’s Eye Hospital to treat some 250 to 300 outpatients per day, he said.

“All doctors were wearing masks during the 1-month peak time. Anyone could have been infected by patients traveling through, and we might not have known,” he said.

However, Dr. Agarwal said neither he nor his surgeons would have turned away patients who came from affected areas.

“We would have taken anyone. I work on a lot of HIV-positive patients, too. We must be cautious as doctors, but we would never stop a patient from getting treatment,” he said.

Global problem, response

While many countries were not directly affected by SARS, the global health care community was quick to recognize that any modern epidemic can quickly and easily be transmitted from country to country.

Several European surgeons contacted by Ocular Surgery News expressed relief that the infection did not become more of a problem in Europe, considering the ease of international travel.

“International travel is so frequent nowadays that we need to know whenever and wherever any contagious disease is present,” said Juan Murube, MD, of Madrid, Spain.

“In old times, pandemics were not very frequent because of the difficult relations among the cities. But when an epidemic affected a city, it spread easily because of the low standards of hygiene,” he said. “Nowadays, it is just the opposite, in that epidemics can easily extend internationally, but they can be circumscribed in each city because of high preventative and curative measures.”

Dr. Murube said that his practice and travel plans remained basically unaffected by SARS. The handful of cases that were suspected in Spain did not provoke alarm, he said.

In France, SARS did not specifically affect ophthalmology, but practitioners were given specific instructions on how to handle a suspected case.

“As the head of two different departments, I received at least 500 pages (containing) various instructions in case I received any patient suspected of (having) SARS,” said Christophe Baudouin, MD, PhD, of the Quinze Vingts Hopital in Paris.

Dr. Baudouin said he feels the French media “excessively focused on the risk of contracting SARS,” even though nobody died there from the disease and there were only a handful of contaminated subjects.

He conceded that he probably would have been apprehensive about traveling to southeast Asia during the outbreak.

Dominique Bremond-Gignac, MD, PhD, also of Paris, agreed that the most significant impact SARS may have had on ophthalmology and health care in France had to do with travel.

“I work in a hospital, and no special codes had been changed except for those people who were coming from endemic areas,” Dr. Bremond said. “It was also (strongly) recommended to stay in France and to avoid missions (to) endemic areas.”

The situation was similar in Germany, according to Michael C. Knorz, MD, of Mannheim. Germany reported just 10 cases and no deaths, according to WHO. Dr. Knorz said fear of SARS was not rampant there, except as it pertained to travel plans.

“It affected me personally only in the sense that I canceled a planned trip to Hong Kong,” Dr. Knorz said.

Closer to China, Australian surgeons echoed stories of canceled trips and changed itineraries. But overall, they said, practice was affected only indirectly by SARS.

Noel A. Alpins, FRACO, FRCOphth, FACS, of Cheltenham, Australia, said his hospital screened out some patients traveling from high-risk countries in southeast Asia, so his regional patient load from that area declined slightly.

Dr. Alpins said he traveled to San Francisco in April, as planned, for the American Society of Cataract and Refractive Surgery meeting. Yet his outlook on travel was altered, he said.

“When traveling, I did carry masks and wore them once when a plane was delayed for 45 minutes on the tarmac with the air conditioning turned off. For a while, while traveling I moved away when close to someone who was coughing or sneezing,” he said.

Ivan Goldberg, MBBS, FRANZCO, FRACS, of Sydney, reported that two meetings he planned to attend — one in Beijing and one in Hong Kong — were canceled because of SARS. He also opted to cancel his plans to travel to a weekend meeting in Italy that would have required a 24-hour trip each way via Singapore.

Dr. Goldberg said his mentality regarding patients shifted slightly during the peak of the outbreak.

“In common with many colleagues, I don’t think we would have welcomed elective consultations with visitors just arrived from SARS sites,” he said.

Asked whether he thinks the media hype has been overblown, Dr. Goldberg offered a resounding “No.”

“This is an aggressive virus with no immunization, poor identification in the early stages and no treatment,” he said.

Changes in plans

Surgeons throughout Asia were the hardest hit in terms of travel restrictions and disrupted plans. Travel anecdotes from this area are abundant.

Dr. Agarwal, of India, said he changed his ASCRS travel plans so he would fly to San Francisco through Germany instead of through Singapore, costing him a good deal of money and time.

Dr. Lam, of Hong Kong, said he canceled at least five trips during the peak of the outbreak.

Dr. Hu, of Taiwain, said her country was subject to stringent international scrutiny, and that some countries “refused to issue visas to visitors from Taiwan” after the SARS outbreak there. She said Taiwanese authorities required all health care workers to postpone traveling abroad unless they did not have contact with SARS-infected patients for at least 10 days before the flight and were proven to be in good health.

International ophthalmology meetings have also felt the effects of SARS.

The 16th International Meeting on Cataract, Implant, Microsurgery and Refractive Keratoplasty of the Asian-Pacific Association of Cataract and Refractive Surgeons (APACRS) was originally planned for August this year in Singapore.

Because of SARS, APACRS decided instead to hold a mini-meeting in conjunction with the Australian Society of Cataract and Refractive Surgeons in July.

“Due to the SARS outbreak, the preventative measures required, including the segregation and non-mingling of medical staff, made it difficult to hold any meetings needed to organize the meeting,” said Dr. Ang, of APACRS.

However, some organizers feel that proceeding with planned meetings in recovering areas is the best way to fully bounce back from the crisis.

For example, Dr. Lam said that the Meeting of the Asian-Pacific Glaucoma Society will be held in October this year in Hong Kong as planned, despite some early thoughts of canceling the conference.

All conferences scheduled for Toronto between March and June were canceled, Dr. Arshinoff said. Doctors were instructed not to attend to patients in more than one hospital, and departmental and other medical meetings involving doctors from more than one hospital were canceled. All of these restrictions have now been lifted, he said.

As of July 11, 32 nations and/or administrative regions had seen cases of SARS. Hardest hit have been China and Hong Kong, followed by Canada. The case total as of July 11, including deaths, stood at 8,398. (Source: Centers for Disease Control and Prevention.)

Hard-earned lessons

Overall, the sense seems to be that the health care community has pulled through a crisis and is stronger for it.

“For a while, most of us have had to become general ophthalmologists, tackling any and every eye condition. The experience has been both enlightening and humbling at times,” Dr. Ang said.

Locally and globally, the experience, while harrowing, has spawned significant lessons.

“If (SARS) is coming back, then our mode of practice has to change in ophthalmology,” Dr. Lam said. He said ophthalmology students in parts of Asia may have to learn new ways of diagnosing and treating that do not entail close contact with patients. For now, he said, eye hospitals in areas that could see a resurgence of SARS should be treated as potentially risky.

Dr. Stein said that SARS might change the way the Canadian government views elective surgery and prompt greater funding for surgical centers such as the Bochner Eye Institute, where he is medical director. The institute currently provides elective surgery only 1 day a week, he said.

“They now recognize that hospitals should be for sick patients, and that healthy patients undergoing routine elective surgery should be done outside of a hospital environment, at a freestanding ambulatory surgical center,” Dr. Stein said. “Healthy patients are concerned about going into a hospital now for elective surgery.”

While it is still unclear whether human tears, aqueous and vitreous are capable of transmitting SARS, other bodily fluids, such as respiratory secretions, saliva and urine, do carry the virus, according to Dr. Lam. Furthermore, procedures such as intubation and operations that require general anesthesia could be potential spreading grounds for SARS, he said.

Dr. Ang noted that good infection control measures should become standard practice in light of their efficacy in containing this outbreak of SARS.

“I would like to see that the recent emphasis on good hygiene and infection control practices become a way of life for health care workers,” he said. “The SARS outbreak has also shown certain gaps in the way our clinics are configured and the way work processes are managed. Until now, they have tended to be designed to achieve volume and cost efficiency sometimes at the expense of (necessary) safety.”

Surgeons resoundingly agreed that the SARS epidemic should serve as a wake-up call for global health authorities regarding the efficiency of current methods for identifying and attacking infectious diseases in their initial stages.

“Because people are traveling so freely, and disease is likely to spread quickly, we need an excellent international surveillance system,” Dr. Lam said.

Editor’s Note: Beth Herskovits contributed to this article.

For Your Information:

• Dennis S.C. Lam, MD, FRCS, FRCOphth, is a professor and chairman of the Department of Ophthalmology and Visual Sciences at the Chinese University of Hong Kong. He can be reached at 3F Hong Kong Eye Hospital, 147K Argyle St., Kowloon, Hong Kong SAR, China; +(85) 2-2762-3157; fax: +(85) 2-2715-9490; e-mail: dennislam@cuhk.edu.hk.
• Fung-Rong Hu, MD, is a professor at National Taiwan University Hospital. She can be reached at Department of Ophthalmology, 7 Chung-Shan S. Road, Taipei, Taiwan; +(88) 62-23123456; fax: +(88) 62-23412875; e-mail: fungrong@ha.mc.ntu.edu.tw.
• Ray Jui-Fang Tsai, MD, is a professor and chairman, Department of Ophthalmology, Chang Gung Memorial Hospital, Chang Gung University. He can be reached at 5 Fu -Shin St., Kuei-Shan Shiang, Taoyuan, Taiwan; +(88) 63-32-81-200, ext. 8671; fax: +(88) 63-32-87-798; e-mail: raytsai@adm.cgmh.org.tw.
• Steve A. Arshinoff, MD, FRCSC, can be reached at 2115 Finch Ave. West, Suite 316, Toronto, ONT M3N2VG Canada; +(1) 416-745-6969; fax: +(1) 416-745-6724; e-mail: saaeyes@idirect.com.
• Chong-Lye Ang, FRCS(G), FRCOphth, is medical director and senior consultant/head, Vitreo-Retinal Service, Singapore National Eye Centre. He can be reached at 11 Third Hospital Ave., Singapore 168751; +(65) 632-28-335; fax: +(65) 622-77-291; e-mail: ang_chong_lai@snec.com.sg.
• Raymond Stein, MD, FRCSC, can be reached at the Bochner Eye Institute, 40 Prince Arthur Ave., Toronto, ONT M5R1A9 Canada; +(1) 416-972-1100; fax: +(1) 416-966-8917; e-mail: rstein@bochner.com.
• Shunji Kusaka, MD, directs the Division of Ophthalmology, Osaka Prefectural General Hospital, 3-1-56 Bandai-Higashi, Sumiyoshi, Osaka City, Osaka, 558-0056, Japan; +(81) 6-6692-1201; fax: +(81) 6-6606-7102; e-mail: kusaka-ns@umin.ac.jp.
• Amar Agarwal, MS, FRCS, FRCOphth, can be reached at Dr. Agarwal’s Eye Hospital & Eye Research Centre, 19 Cathedral Road, Chennai-600 086, Tamil Nadu, India; +(91) 44-2811-6233/2811-3704; fax: +(91) 44-2811-5871; e-mail: dragarwal@vsnl.com.
• Juan Murube, MD, can be reached at Clinica Murube, San Modesto 44, E-28034, Madrid, Spain; +(34) 917-350-760; fax: +(34) 917-340-956; e-mail: murubejuan@terra.es.
• Christophe Baudouin, MD, PhD, can be reached at Quinze Vingts hospital, 28 Rue de Charenton, Paris 75012 France; +(33) 1-49-09-55-08; fax: +(33) 1-49-09-59-11; e-mail: arepo@worldnet.fr.
• Dominique Brémond-Gignac, MD, PhD, can be reached at Ophthalmology Hôpital Robert Debre, 48, Bd. Serurier 75019 Paris, France; +(33) 1-40-03-57-63; fax: +(33) 1-40-03-24-32; e-mail: dominique.bremond@rdb.ap-hop-paris.fr.
• Michael C. Knorz, MD, can be reached at University Eye Hospital, Klinikum Mannheim, Theodor Kutzer Ufer 1-3, 68167 Mannheim, Germany; +(49) 621-383-3410; fax: +(49) 621-383-1984; e-mail: knorz@eyes.de.
• Noel A. Alpins, FRACO, FRCOphth, FACS, can be reached at 7 Chesterville Road, Cheltenham, VIC 3192, Australia; +(61) 3-9584-6122; fax: +(61) 3-9585-0995; e-mail: alpins@newvisionclinics.com.au.
• Ivan Goldberg, MBBS, FRANZCO, FRACS, can be reached at 187 Macquarie St. Park House, Floor 4, Suite 2, Sydney, NSW 2000 Australia; +(61) 2-9247-9972; fax: +(61) 2-9232-3086; e-mail: rauaroha@medeserv.com.au.