Anatomy
of a SARS scare
Coordinated
response to a possible epidemic draws upon a host of University
strengths
June
9 was not the typical Monday morning for Pete Reinhardt.
From the time he walked into the office until the time he left,
his phone kept ringing.
As director of Environment, Health and Safety, it was Reinhardt's
job to keep the callers safe. And at that point, many of them
were feeling anything but.
Most of the employees were either angry or scared when they called,
or both. Worse, they wanted, expected, demanded answers to questions
nobody had any answers to.
So what could he tell people to reassure them that everything
would be all right?
Precious little. At least not yet.
Five days before, the Orange County Health Department had issued
an advisory about "an Orange County man" who was suspected of
having Severe Acute Respiratory Syndrome, or SARS. That was June
5. That "Orange County man" also happened to be a University contract
employee who works in the Giles Horney Building.
On June 9, the same day Reinhardt's phone heated up, the state
released laboratory results that confirmed the employee had SARS,
making him the eighth confirmed case in the United States -- and
the first in North Carolina.
After the worker was diagnosed with SARS, health officials began
monitoring two co-workers of his after they developed pneumonia,
a key condition associated with the illness.
Reinhardt kept going through the various scenarios in his mind:
Under the worst-case scenario, one or both of the so-called "secondary"
cases could prove positive and that could trigger a panic among
employees, neighbors and friends who had been in contact with
them.
And if the situation was allowed to spin out of control, people
who might have been infected could end up infecting others as
they crammed into hospitals and doctor's offices seeking testing
and treatment. And if that happened, Reinhardt knew, the University
could end up becoming the epicenter of a national epidemic.
In retrospect, that may sound alarmist, but as Reinhardt well
knows, it's his job to be paranoid.
"I
do what I call reasonable worst-case thinking," Reinhardt said.
"If there had been a secondary infection, it would have been the
first in the United States -- and that's the beginning of an epidemic.
We were really worried about that. Our employees were obviously
worried about that."
Those worried found further expression the following day, June
10, when Reinhardt and medical experts met with employees of the
Giles Horney Building to listen to their concerns and answer what
questions they could.
Mary Crabtree, workplace safety manager for Environment, Health
and Safety, remembers how emotions ran high and sometimes got
hot. Some employees were angry. Others were scared. All of them
wanted answers, and there were few definitive answers health experts
could give them. All the most knowledgeable people could do was
to be honest and tell employees that there was precious little
that anyone yet knew about SARS for certain.
Meanwhile, family members of the man with SARS, along with 12
health-care workers from Wake County who treated the man on May
27 and May 30, remained under quarantine, as did three UNC Healthcare
workers. None of the people in quarantine developed symptoms.
The hour-to-hour, day-by-day drama would end up taking another
two weeks to unfold from that Monday morning when Reinhardt's
phone kept ringing.
Both the man with SARS and one of the co-workers under surveillance
recovered. But the other co-worker turned gravely ill and died
June 13, on the same day preliminary tests from the Centers for
Disease Control and Prevention (CDC) indicated he did not have
SARS, and the cause of his death had been heart failure and pneumonia.
Tests proved negative for the other man under surveillance as
well. Still, the test results were only preliminary, which meant
it was far too early for the University to sound the all clear.
It would not be until June 23 that the CDC announced officially
the results of final tests that proved the deceased man did not
have SARS.
What happened between June 5 and June 23 -- and how the University
responded -- is more than just a dramatic story worth telling.
The quick, coordinated action, both within the University and
among the University and county and state health agencies, could
become a national model for other universities that could be faced
with similar public-health risks, including the ever-present threat
of bioterrorism.
Center
of the storm
Every day,
it seemed, was a different stage of the crisis, with its own set
of issues to resolve.
One of the most critical issues came to a head on Wednesday, June
11. The meeting involved both University administrators and doctors
as well as outside public health officials. It would stretch from
4 to 8 p.m.
University officials wanted to establish a screening clinic to
respond to the concerns that employees had about their vulnerability
to the disease.
At the June 10 information sessions with employees, some workers
had demanded that they be tested for SARS. But the CDC was already
swamped with a backlog of high-risk cases. Employees at Giles
Horney were not considered high-risk because they had been exposed
to the man with SARS more than two weeks before and had not developed
symptoms. However, 39 percent of the 184 Giles Horney employees
who responded to a health questionnaire reported symptoms of fever
or respiratory illness during that time period.
University officials knew that there were more than medical questions
to consider. As an employer, the University had to address other
needs and concerns connected to the SARS scare that were no less
real.
Given employees' level of concern, and given the University's
level of expertise, University administrators told outside officials
that the University wanted to set up a screening clinic for employees
to be tested for SARS.
Outside health officials, though, feared that establishing the
screening clinic would fan the flames of fear rather than dampen
them.
The idea encountered resistance until University officials could
explain how they would handle the clinic, said Brian Goldstein,
chief of staff for UNC Hospitals.
"The
concern of outsiders, I think, was that we could potentially be
seen as overreacting or even panicking to the situation," Goldstein
said.
Goldstein said he had three priorities at that time. The first
was to provide a service to the University and community in a
time of need. The second was to protect the University's employees
and physicians. The third was to protect the clinic itself, which
had to be done to achieve the other two priorities.
People who went to the hospital for testing and treatment in Toronto,
for example, triggered the outbreak there.
That scenario was averted here, in large part, as a result of
the effectiveness of UNC Healthlink, a phone service that allowed
employees to talk to nurses to describe their symptoms and find
out where to go if their symptoms warranted further testing or
treatment. On June 10, staffing for the line was increased so
that people could call in during daytime business hours.
But employees who believed they might have SARS needed a place
to go to be screened -- and the place that was finally picked
was the park-and-ride lot on Airport Road. It was closed for the
summer, and better yet, close enough to be convenient for employees
working in the Giles Horney Building but far enough from the work
site to avoid fueling undue concerns.
Even as these high-level meetings about the clinic were taking
place, faculty and staff within the hospitals' Occupational Health
Clinic had been busy testing and training employees on how to
use N-95 respirators that were on stock to deal with such infectious
respiratory diseases as tuberculosis. The respirators, if it came
to it, could be used to protect doctors and nurses who would be
called upon to care for SARS patients.
Three tents were set up: the first -- Tent A -- where everybody
was sent; the second tent, where further screening was conducted;
and the third tent, where diagnostic equipment was in place for
people to be examined.
The clinic operated from 7 a.m. to 5:30 p.m. on June 13 and from
about 9 a.m. to noon June
14.
In the end, the University found the clinic to have fulfilled
its intended purpose of recognizing employees' concerns and responding
to them in a prompt but measured way.
David Weber, a professor of epidemiology in the School of Public
Health and of pediatrics and medicine in the School of Medicine,
said the screening site struck a balance between responding to
the legitimate fears of employees without going so far so fast
as to create hysteria.
More than 40 people were seen over the two days the clinic operated,
Weber said. None of them were found to have SARS, but two people
with unrelated medical problems were sent to the emergency room
for needed treatment.
Goldstein said University officials struck a delicate balance
between being responsive to employees' concerns, but at the same
time evaluating decisions based on sound science. That balance
was illustrated both by the decision to set up the temporary clinic,
he said, and the decision not to fumigate the Giles Horney Building,
as some employees had demanded.
As Goldstein put it, "You have to listen and hear what people's
concerns are, and you can do that and address concerns without
indulging them to the point of doing more harm than good.
"It
was appropriate not to fumigate the building, even as it was appropriate
to screen individuals one at a time in the temporary facility."
Drawing
upon varied assets
As difficult
as the situation proved to be, University administrators knew
even in the midst of it that they had several factors riding in
their favor.
The first thing was that the University had not been caught unprepared.
Even before the health alert, Reinhardt and his unit, along with
other representatives from the University and Orange County Health
Department, had been developing contingency plans for how the
campus should respond if a SARS case was reported here. Already,
his department had thought through the possibility of a faculty
member returning from abroad who might have become infected, or
international students -- or their family members -- arriving
to campus for the first time in the fall.
The second thing was the expertise of the faculty and the close
contacts many of them had with both state health agencies and
the CDC.
There was Bill Roper, the dean of the School of Public Health,
who had directed the CDC in Atlanta and kept close ties with it.
There was Ralph S. Baric, a professor of epidemiology in the School
of Public Health and microbiology and immunology in the School
of Medicine, who is an expert on coronaviruses -- the newest of
which is SARS.
There was Weber, who had helped lead preparedness efforts at UNC
Hospitals, where he is a clinician and also associate director
of the Statewide Program in Infection Control and Epidemiology.
There was Peter H. Gilligan, director of the Clinical Microbiology
and Immunology Laboratories and professor of microbiology and
immunology and pathology and laboratory medicine at the School
of Medicine, who is an expert in the diagnosis of infectious diseases,
including emerging infectious diseases.
There was Myron S. Cohen, J. Herbert Bate professor of medicine,
microbiology and immunology within the School of Medicine, chief
of the Division of Infectious Diseases and director of the Center
for Infectious Diseases. Cohen's research focuses on the transmission
and prevention of transmission of pathogens, and he teaches courses
relating to immunology, microbial pathogenesis, HIV and clinical
infectious diseases.
And there was Pia MacDonald, project director for the N.C. Center
for Public Health Preparedness and a research assistant professor
in the School of Public Health's Department of Epidemiology, whose
expertise includes applying epidemiology to the state and local
health departments and outbreak investigation and surveillance.
The third thing was the cooperation that took place both within
the University and between the University and outside public health
agencies.
"There
was tremendous internal cooperation between the University and
the UNC Healthcare System, at a couple of different levels," Goldstein
said. "We were cooperating at one level as members of a family
and that was because the index case of SARS happened to be a contract
employee of the University."
At another level, the University as a whole was part of a bigger
community that included Chapel Hill and Carrboro and Orange County
and the surrounding region. And as part of this bigger community,
the University cooperated with such agencies as the Orange County
Health Department and the state communicable disease organization.
"I
thought the cooperation was excellent at both levels," Goldstein
said. "I hate to sound like a Pollyanna, but everybody -- from
the medical staff to the administrators of the Healthcare System,
from Environment, Health and Safety to University administrators
-- just excelled."
Crabtree agreed. "I think the biggest thing that helped us was
the collaboration between the University and the hospital," Crabtree
said. "We were able to pull together quickly in response to a
situation that could have been an epidemic. The experience proved
to be a great learning tool for all of us."
The fourth thing was the caliber of the University community itself,
which would end up expressing itself in so many ways as the crisis
played out.
Goldstein gives credit to the work crews from Facilities Services
who set up the screening clinic in a matter of hours.
"I
was extremely impressed," Goldstein said. "They deserve an incredible
amount of credit and accolades for getting that going in the short
time frame, and that includes folks from both the University side
and the healthcare system side."
Worldwide, incidents of SARS have dropped over the past month.
That's the good news, Reinhardt said, along with the lessons learned
here in response to the possibility of an outbreak.
The bad news is that SARS could end up being a seasonal illness
that could reappear next year. And that is why those lessons learned
could prove to be valuable -- and why those lessons already are
being shared.
Reinhardt and Crabtree have been asked to review the University's
handling of the situation at the 2003 College Safety Health Environmental
Management Association Conference.
Laurie Charest, associate vice chancellor for Human Resources,
will review the episode from a human resources perspective at
a conference in Minneapolis.
And Raymond Hackney, the industrial hygiene manager for Environment,
Health and Safety, will give a presentation in Philadelphia at
the conference of the American Biological Safety Association.
Reinhardt knows that these discussions about the SARS scare here
may be theoretical. Then again, he is a worse-case thinker, and
knows there is a chance SARS may re-emerge about the time most
people have begun to forget about it.
"My
point is that, with the many thousands of students who travel
between Asia and the United States, there is at least a chance
that some universities in the United States could be dealing with
this problem next year," Reinhardt said. "And I'm hopeful that
the lessons we've learned here could help other people."
In fact, the University will continue to learn, too, as a new
SARS task force led by Roper will make sure the campus is ready
for any new developments in the illness.
