foreign tourist arrived in New York City early this month with a guidebook in hand and Knicks tickets in his pocket. But he did not use them because he also arrived with a suspected case of SARS and spent virtually his entire vacation involuntarily detained in a hospital.
The tourist entered the hospital voluntarily because of a fever and flulike symptoms that met the definition of a case of severe acute respiratory syndrome. But he stayed against his will because he refused to comply with the New York City Department of Health and Mental Hygiene's policy that suspected SARS patients voluntarily isolate themselves for at least 10 days, depending on the course of their illness, to avoid the possibility of spreading SARS to other people.
Because the tourist had nowhere to stay in isolation for 10 days, the Health Department exercised its power to involuntary isolate him. Only once before in the last 25 years has the Health Department invoked this power for a disease other than tuberculosis, said Wilfredo Lopez, the department's general counsel. The last time was in 1994, when a traveler arrived in New York with suspected pneumonic plague during an outbreak of the disease in India, Mr. Lopez said.
The Health Department declined to release the man's name, his nationality or the name of the hospital where he was detained because of patient confidentiality. Upon discharge from isolation, the tourist went directly to the airport feeling physically well, but not happy about his experience. Only after findings from tests on his blood and respiratory secretions will doctors know if he truly had SARS, and they may not know even then.
Such detention orders are given only when ``there is a public interest in a patient being cured, because your right to cough and sneeze on someone else ends when you have a dangerous communicable disease and you cannot be isolated otherwise,'' Dr. Thomas R. Frieden, the city's health commissioner, said in an interview.
Over the last 25 years, the Health Department has involuntary isolated several hundred patients who were infected with strains of the tuberculosis bacterium resistant to the drugs that can usually cure it. The peak was from 1993 to 1996. Dr. Frieden said such detention is used only after all other treatment attempts have failed, and that its use has greatly helped reduce the spread of drug-resistant tuberculosis cases.
About six tuberculosis patients are now involuntarily isolated, Dr. Frieden said.
The Health Department says it will quarantine healthy people who are exposed to SARS patients only if necessary.
Quarantine differs from isolation. Although definitions vary, and health officials apply them differently, quarantine usually applies only to healthy people who have been exposed to a highly communicable disease during the period when the agent can be transmitted.
Isolation refers to control measures like requiring a patient with an infectious disease to stay in a room with negative pressure, which is designed to prevent the escape of germs in the air. In the case of SARS, the measures also call for health workers to wear masks, gloves, gowns and goggles when caring for a patient.
The tourist went to a hospital because he had a fever, a cough and felt slightly short of breath. He said he had stopped in a SARS-affected area, Hong Kong, en route to New York. Because the man met the definition of a suspected SARS case according to the Centers for Disease Control and Prevention, the doctors applied the recommended isolation control procedures and reported the case to the Health Department.
The day after he was admitted to the hospital, his fever subsided. He said he felt much better and insisted on leaving to sightsee and go to the Knicks game.
However, there was no way for doctors to know with certainty whether the man had SARS or some other type of respiratory illness because there is no test for SARS.
All that doctors can rely on is the definition of a SARS case. The C.D.C. in Atlanta has created two definitions. The one for a suspected SARS case does not include pneumonia. But the C.D.C. defines a probable SARS case as including pneumonia to comply with the World Health Organization's definition. The federal agency developed the broader classification because it does not want to miss any possible SARS case in this country.
The tourist was classified as suspect because he did not have evidence of pneumonia, Dr. Frieden said.
To help resolve the tourist's case, his doctors at the hospital called a Health Department official who asked the patient to stay in isolation somewhere for the advised 10-day period after his temperature returned to normal. But the tourist declined to cooperate, Dr. Frieden said.
If the man had been a New York City resident, he probably would have been allowed to stay at home in isolation from other people. The Health Department would have called every day to monitor his condition. But the man had no residence in New York City and his hosts for the first two days he spent in the city before he went to the hospital could not provide space where he could be isolated.
In New York City, there have been 23 possible cases of SARS; three of them, including the tourist, have been taken off the list because they have been discharged from isolation or were found to have other causes of illness.
As of yesterday, the current list includes 18 suspected cases and 2 probable cases. One patient remains in a hospital. None of the 23 have had serious, life-threatening illness, Dr. Frieden said. Also, he said, scientists at the C.D.C. have not found evidence of the coronavirus that is believed to be the cause of SARS in any of the suspect or probable patients in New York City. The experimental tests available at this point of the epidemic, however, are not precise enough. So doctors must consider suspected and probable cases as true SARS cases. All but the tourist have have complied with requests to remain isolated in a hospital or at home.
As of Saturday, the C.D.C. said that 38 states had reported 270 cases, of which 220 were suspect and 50 probable. None were fatal. The 50 meet the W.H.O.'s definition, which requires evidence of pneumonia.
California and New York have reported the largest number of suspected cases (35 and 25, respectively) as well as probable cases (20 and 5, respectively).
Connecticut has reported six cases (four suspected and two probable). New Jersey has reported four cases (three suspected and one probable). Pennsylvania has reported 10 cases (nine suspected and one probable).
As of Saturday, the W.H.O. said that 27 countries and Hong Kong have reported 4,836 cases, including 293 deaths, for a death rate of 6.1 percent.
In New York City, the Health Department decided against allowing the man with suspected SARS to move to a hotel because of a number of concerns. One was that he might check out without permission at any time. Another was that even if he cooperated fully and stayed in his room the entire time, the ventilation system might not be designed to prevent the air he exhaled from circulating to other areas of the building to potentially expose many others to the SARS virus. In trying to find a hospitable solution, Dr. Frieden said his department fleetingly considered using Gracie Mansion, which is empty because Mayor Michael R. Bloomberg lives in his own town house.
With no less restrictive alternative available, Dr. Frieden ordered the man to stay in isolation in the hospital even though no one could be sure he had SARS.
``It was certainly a judgment call, but our judgment was to err on the side of safety, in case he did have SARS he would not infect others in New York City,'' Dr. Frieden said.
The Health Department discussed the man's case with diplomats in his country's consulate here; they communicated with the man and supported the Health Department's decision, Dr. Frieden said. He also said that his department advised the man of his right to legal counsel or a hearing, but he did not exercise it.
Health officials monitored all the people with whom the man came in contact in New York before he entered the hospital. None of them have become ill, Dr. Frieden said.
Now the episode has become an issue of finances: who pays for the tourist's extended hospital stay? If the man's health insurance will not pay, as is probable, the department has asked the federal government to reimburse the hospital. And if the federal government does not pay? ``We'll figure out some way,'' Dr. Frieden said.