The chaotic handling of a suspected SARS case in Dublin this week should sound alarm bells, argues Dr Muiris Houston, Medical Correspondent
In the early hours of last Wednesday morning outside the GPO in Dublin's O'Connell Street, a very different scene to the famous Easter week events of 1916 took place. A car, which had been slowly cruising the streets of the capital for a number of hours, screeched to a halt. Three masked women jumped out and pursued two Chinese women, who moved away anxiously. After a few minutes, the visibly frightened Chinese women agreed to put on face masks and accompany the Irish women back to their car. All five drove off in the direction of Cherry Orchard Hospital.
The three women cruising the streets of Dublin were senior public health doctors from the National Disease Surveillance Centre (NDSC) and the Eastern Regional Health Authority (ERHA). Although on strike for 10 days, they had decided to try to find a Chinese woman who had gone missing from SARS quarantine late on Tuesday night. They eventually found the Chinese national and her sister in front of the GPO.
Welcome to communicable disease management, Irish-style. Such Keystone Cops-type antics won't be found in the World Health Organisation (WHO) manual of best practice for dealing with emergencies. However, the management of this woman with suspected SARS during a five-day period over Easter is likely to find its way into future training notes as an extreme example of how not to manage a potential infectious disease epidemic.
The extraordinary sequence of events, which has raised questions about the Government's ability to control a growing threat to health, began on Good Friday. The Chinese woman, an immigrant worker from Guangdong province, arrived at the accident and emergency department of St Vincent's University Hospital. She had been feeling unwell for four to five days, since returning from Guangdong to the hostel in Dún Laoghaire where she lived. Her temperature was above 38° C and she had multiple aches and a cough. A chest X-ray performed in the A&E department was inconclusive, with some disagreement among doctors as to whether it showed the type of "pulmonary infiltration" indicative of SARS.
After some discussion and a contribution from a specialist outside the hospital it was decided to discharge the woman back to the hostel with instructions to wear a respiratory mask. However, no translator was available and, although she was now a probable SARS case (according to WHO guidelines), striking public health doctors were not contacted. As a result, there was no formal attempt to quarantine her over the Easter weekend and no arrangements made for tracing people who had been in close contact with her.
However, late on Monday, a senior official in the Department of Health was made aware of the case. Realising the potential gravity of the situation, he recommended that the striking public health doctors be asked to review the case first thing on Tuesday morning. Five specialists agreed to come off the picket lines and went to the Dún Laoghaire hostel to assess the situation. They immediately advised that the woman and her sister - who also resides at the hostel - should be quarantined. The Irish Times understands that a delay then ensued while suitable quarantine facilities were located by the ERHA. Ironically, the long-standing infectious disease isolation unit at Cherry Orchard Hospital had been decommissioned on January 1st this year. Despite the six-week-old SARS crisis, it appeared there was no alternative location available.
Not surprisingly, the now thoroughly confused Chinese national was extremely anxious. She and her sister left the hostel, unknown to doctors who were waiting in another part of the building for an official decision on her quarantine location. After some four hours missing, both women were found by the public health doctors (not by the Garda, as has been reported) in the small hours of Wednesday.
As if this demonstration of our bungling health service was not enough, yesterday we had the Department of Health's Chief Medical Officer being contradicted by the ERHA. Subsequently, the Chief Medical Officer stated that the Chinese woman was a suspect SARS case and not a probable one. He confirmed to The Irish Times that the confusion arose from a difficulty in interpreting her chest X-ray. However, a formal report from the ERHA has now stated that there is no evidence of a pulmonary infiltrate on the Chinese woman's X-ray. Therefore, according to WHO guidelines, she does not fit the criteria for probable SARS.
Even without a public health doctors' dispute, this case is another example of the organisational mess that is the Republic's health service. It has clearly demonstrated the lack of co-ordination between the various sectors of the health service. A fundamental inability to manage and to organise has been illustrated time and time again over the past number of years.
The potentially catastrophic scenario presented by SARS highlights such deficiencies. However, to seasoned observers, such problems occur on a regular, if less dramatic, basis.
There has never been a formal out-of-hours system in place whereby a hospital doctor concerned about a patient who represents a potential risk to the public can contact a colleague with expertise in the area of public health. Neither GPs nor hospital consultants are trained to consider broader public health issues; not unreasonably, their focus and expertise is directed at the patient in front of them. It is a situation akin to expecting your plumber to turn his hand to the electrical problems in your home - something you simply would not ask or expect him to do.
It is also worth noting that it is public health doctors themselves who have asked for a change in their working conditions that will allow them to be formally rostered for weekends and holiday periods. It has taken nine years, several reviews and an alleged breach of promise before they initiated strike action.
There are specific questions raised by the events of the past week. Why was no translator available in St Vincent's Hospital to ensure an accurate and, from the woman's point of view, stress-free encounter with our health service? Why was there confusion as to the best place to quarantine the patient? Was it appropriate to use public transport to return this woman to her hostel? And having decided to "quarantine" her in the community, who was appointed to monitor her condition?
The handling of this immigrant patient last weekend reflects the necessity of publishing the Brennan and Prospectus Management Consultants reports on the future structure and management of our health system. In a perverse way, it is a vindication of the priorities outlined by the Minister for Health, Micheál Martin, since the publication of the health strategy document, Quality and Fairness - A Health System for You. Our health service is crying out for improvement.