Best defence is not exclusion, say guidelines

The decision by the Minister for Health to request athletes from SARS endemic areas not to travel to the Special Olympics here…

The decision by the Minister for Health to request athletes from SARS endemic areas not to travel to the Special Olympics here in June has come as a shock to many people, but it could yet be reversed, writes Dr Muiris Houston, Medical Correspondent.

Mr Martin has clearly stated that he acted on the direct advice of an expert group set up to consider the issue. Its members include consultant microbiologists, infectious disease specialists and scientific experts; however, public health experts from health boards and the National Disease Surveillance Centre (NDSC) did not participate in the process because of the ongoing public health doctors' dispute.

Such an expert group will have considered a number of issues before arriving at a decision. First and foremost is the scientific and medical evidence available to it.

A search of the medical literature yesterday did not come up with any reference that would indicate the decision was based exclusively on scientific grounds. Although the death rate from SARS is rising towards 10 per cent, the available evidence points to the disease being particularly dangerous to those over 70 rather than to younger people.

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There is, as yet, no published medical research which has examined the particular vulnerability of young people with intellectual disability to the virus.

There is some scientific work which suggests that the disabled may be at greater risk of respiratory infection in general.

However, what was available to the group was advice from both the Centre for Disease Control (CDC) and the World Health Organisation (WHO) - which is itself the product of scientific and medical opinion - that the kind of restriction announced on Thursday was unnecessary.

The Centre for Disease Control in Atlanta issued advice on May 14th. Referring to the thousands of people arriving in the United States from SARS areas it says: "At this time, CDC does not recommend cancelling or postponing classes, meetings or other gatherings that will include persons travelling to the United States from areas with SARS."

The World Health Organisation published a guideline - "Guidance for mass gatherings: hosting persons arriving from an area of recent local transmission of SARS" on May 15th.

Concluding that "the best defence is not exclusion but good management of the situation in the unlikely event that someone attending a meeting were to become sick with SARS", the guideline outlined the principles to be followed.

However, part of the WHO advisory may give some insight into why the committee reached the conclusion it did.

It says: "A person who develops symptoms within 10 days of arrival in the host country (including sudden fever above 38 degrees Celsius, dry cough, shortness of breath and/or difficulty in breathing) should do the following:

Not leave his/her room.

Call the medical service of the hosting organisation to ensure that proper isolation can be carried out according to the standardised procedures of the hosting country."

This advice leads into the issue of resources which The Irish Times understands the expert group also considered in detail.

In other words, how many of the athletes were likely to develop symptoms which would have placed them in the category of "a suspect SARS" case?

It would seem the experts felt this number could be significant, with a potential knock-on- effect that could have stretched the medical resources available in the Republic.

Risk assessment and risk management are not an exact science.

People of a cautious disposition will reach separate and equally valid conclusions from those of a less cautious nature. However, public health specialists and other doctors who take risk management decisions on a daily basis have told The Irish Times that, in their opinion, the decision of the expert committee is flawed.

They are in no doubt that the athletes from the five nations could have been safely accommodated by the State.

They argue that a group of athletes who have been carefully monitored for months and who could be medically checked on a daily basis by virtue of travelling in tightly knit groups represents a less risky influx than tourists or returning students.

In the words of one: "The decision is far too radical for a disease that is fairly but not seriously infectious. It is more appropriate to the risk of smallpox than SARS."

The Minister's decision could yet be reversed up to 10 days prior to the games' commencement on June 16th.