Miami Herald - April 7, 2003
Elinor J. Brecher and Gail Epstein Nieves, ebrecher@herald.com

National anxiety about the Asian viral infection, which may have affected 115 Americans, has prompted the Florida Department of Health to issue news releases long on the state's ability to monitor an outbreak but short on specific information about the afflicted.

The state Health Department's website -- which provides detailed information on everything from body piercing to tuberculosis -- has the barest mention of SARS.

"If you warn too early on the basis of insufficient evidence, you risk panic," said Kenneth Goodman, who heads the University of Miami's bioethics department. "Disclose too late and you allow people to come to grief because of that lateness."

It's never an easy call, said Goodman, who suggests that the Department of Homeland Security's oft-ridiculed color-coded threat alerts can be considered an example of "more fine-grained levels of disclosure."

It's especially difficult when so little is known about SARS, he added.

"A lot of people have symptoms that look like it, [so] disclosing that this malady is in a particular hospital is premature."

As long as public health agencies "are taking certain steps, we need to cut them some slack," Goodman said.

Added. Mary Jo Trepka, director of epidemiology for the Miami-Dade Health Department: "You have to balance a police state with the public safety."

The steps being taken in Florida appear to be much like those other states are taking.

Florida doctors have been asked to report suspicious cases to county health departments, which in turn report them to the state. They're using a broad definition of the virus, and the state Health Department has been careful to say each of the five cases is suspect, not definitively SARS.

Centers for Disease Control and Prevention spokesman Von Roebeck said, "We can't say if we agree or disagree" with the way local health departments are handling individual cases.

Though the CDC doesn't compel states to report suspected SARS cases, the states have made reports, enabling the CDC to keep a running tally.

South Florida hospitals, doctors and health departments say they are following CDC procedures and guidelines, which are all available on the CDC website, where a state-by-state tally of cases stood at 115 on Sunday.

CHANGE BY THE HOUR

Roebeck said the numbers change by the hour and reflect both new suspected cases and "people dropping off the list as not a fit for SARS. Florida may have [five] today, but could be down to three or up to six tomorrow."

None of Miami-Dade County's three suspected SARS patients is hospitalized. Health officials are monitoring them at home, Trepka said.

"We're in contact with them every day. We believe this is appropriate under CDC guidelines. We will follow them until 10 days after their symptoms stop."

That's how other localities are handling it.

Joy Alexiou, public information officer for the Santa Clara County Public Health Department in California, said there are nine suspected cases there, none currently hospitalized, though four were at some point.

She said that eight are on home isolation and one "is well after 10 days of home isolation."

Home isolation means "we want them to wear masks. You do not go outside the house. The yard is OK. You don't go to the store or work."

Alexiou said that public health nurses call or visit each patient daily.

"They have all cooperated" and have been home for the calls and visits, she said, adding that patients are considered cleared after 10 days without symptoms.

All of the patients had traveled to one of the affected areas, Alexiou said.

Someone who hasn't traveled would be at risk only if he had close contact with a suspected SARS victim. For example, if someone infected got off a plane from Hong Kong and took a cab, the cab driver would be at risk only if the passenger coughed or sneezed in the car.

Dr. Andrew Quartin, intensive care specialist with UM's medical school, says that the definition of the virus "is essentially anybody with any respiratory symptom, a fever and a contact history. . . . Right now it's a really lousy disease definition, but this is how you start when you have a syndrome.

"You're looking for an underlying virus or bacterium that causes it, and right now they don't know that. They come up with an over-liberal case definition that allows them to collect a lot of people with similar-looking problems and sort through the microbiology. They start narrowing it down."

When that's done, Quartin said, "It may be that we have no one with the disease here. That wouldn't be terribly improbable. That's why probably a restrained response to it is not inappropriate. The other thing to realize is one of the best ways to spread the disease is by putting people in the hospital."

MEDICAL CHALLENGE

With such a broad definition, identifying potential SARS cases is proving a challenge to doctors.

Miami Beach pulmonologists Dr. Robert Galbut and Dr. Lawrence Ciment thought they might have had a case Friday but weren't sure.

Their patient, a jeweler, had a 102-degree fever, a dry cough and worked in a shop visited by some 10 Hong Kong jewelry salesman in recent weeks. But the patient's lung X-rays came up clear.

"We're going to call the Health Department and take the precaution of putting him in quarantine at home until his fever goes away," Galbut said. "We'll give him a mask. If he has it, it shouldn't spread, but we don't think he has it."

As U.S. Secretary of Health and Human Services in the Clinton administration, Donna Shalala -- now University of Miami president -- was involved in matters of public health and patient privacy.

She thinks that the state Health Department has it right.

Individuals shouldn't be identified and potentially stigmatized, she said -- a lesson learned from the early days of the AIDS crisis.

"Just because someone lives next door doesn't mean you're going to be exposed," she said. "We learned that creating a stigma can slow us down in dealing with the health issue. What it really did [with AIDS] was mean we were years behind in dealing with the health crisis."

Dr. Jonathan Fielding, Los Angeles County director of public health, said it's crucial for public health officials to provide perspective.

Los Angeles County has had seven patients, all of whom have been discharged from hospitals.

With SARS in the United States, "there have been no deaths, while in the same period, there have been a couple thousand from influenza. We have new HIV patients. People die from violence. I remind people they're more likely to be killed by a drunk driver than to ever have to worry about SARS.

"Those sound bites are important because when something is new, people think it's omnipresent."

KEEPING ABREAST

Experience has taught that "it's very important to get ahead of things and as soon as we can, report something" when it's clear what health officials are dealing with.

In this situation, he said, patients' travel histories were revealed, and whether they were adults or children but not ages or specific cities, to avoid invasions of privacy.

"We do not want people calling hospitals trying to figure out if a 32-year-old woman has been admitted."

Herald writer Fred Tasker contributed to this story.

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