Severe acute respiratory syndrome (SARS) is an infectious disease caused by SARS corona virus (SARS-CoV). It is a dangerous, not well understood, and easy to transmit disease. Its most dangerous features are that SARS outbreaks occur within the hospital setting, it can be deadly, and has no definitive set of symptoms. There is a distinct probability of another global outbreak of SARS.
On February 28, 2003, Carlo Urbani, a medical doctor working for the World Health Organization in Vietnam, examined an American patient in a French hospital in Hanoi. The patient presented with atypical pneumonia, a respiratory disease with an unusual panel of symptoms. Two weeks later, there was an outbreak of the disease at the hospital. Twenty-two healthcare workers were infected. Dr Urbani identified this as a new disease, and named it sudden acute respiratory syndrome (SARS) (Xing, 2010).
On March 29, 2003, Carlo Urbani died of SARS (Xing, 2010).
On March 11, 2003, a similar outbreak of atypical pneumonia was reported among healthcare workers in Hong Kong. The outbreak was later traced to a medical doctor visiting from Guangdong Province (Xing, 2010).
Outbreaks of SARS generally occur within the hospital setting, thus SARS has been categorized as a health-care associated infection (HCAI) disease. A single patient can infect dozens of people, mainly adults, and mostly females. Children are seldom affected (Hui and Chan, 2010).
SARS is caused by SARS corona virus, which has a mean incubation period of 5 days with a range of 2-10 days. The disease is not well understood, and no one can predict an outbreak. It is possible that SARS-CoV could lay dormant for years in some animal or plant and resurface when conditions converge to allow it to infect a human host. The only things known for sure about SARS is that it when it strikes, it strikes a hard blow; 11% of the people that were infected in 2003 died (Hui and Chan, 2010).
Second Week of Illness
The patient develops a dry cough, dyspnoea and diarrhoea. In severe cases, a patient may experience respiratory distress and oxygen desaturation. The risk of transmission is highest during the second week of illness (World Health Organization).
Laboratory Corroboration of SARS
A patient may be diagnosed with SARS if the patient has symptoms that are clinically suggestive of SARS, AND laboratory analysis of clinical specimens for SARS-CoV come back positive (World Health Organization).
Epidemiological Data on the Outbreak
The global SARS outbreak of 2003 began in Southern China, infected over 8,000 people and killed more than 900 people around the world (Xing, 2010). An epidemiologic analysis of the outbreak of SARS in Hong Kong, Beijing and Taiwan showed a large discrepancy in the relative prevalence of symptoms and the number of deaths among the three regions; although within the three regions, fever, a dry cough, and rapid progression of the disease were amongst the most prominent features of SARS (Wong and Yuen, 2008).
Route of Transmission
During the 2003 SARS outbreak in Toronto, healthcare workers and patients became infected with SARS-CoV even when strict control procedures were followed. Experts could not determine the best methods to prevent SARS-CoV from spreading, although they did establish that the virus could spread though direct contact with surfaces and respiratory droplets. The transmission route could also shift from droplet to airborne (Xing, 2010).
There is no specific and trusted treatment for SARS, and the epidemiology of SARS coronavirus infection is not well understood; an outbreak could occur anywhere and at any time. The best recourse for the healthcare community is to remain vigilant, and know, and adhere to international protocols for the diagnosis and containment of SARS (Wong and Yuen, 2008).
The first step in the containment of SARS is to file a SARS Alert with the proper authorities when (1) three or more persons within the same health care unit develop an HCAI with clinical symptoms suggestive of SARS, and (2) they all become ill during the same 10-day period (Wong and Yuen, 2008).
International Pattern of Movement
SARS originated in Southern China in November 2002, and arrived in Hong Kong in February 2003. From Hong Kong, it spread around the world but mostly to Asian countries. Toronto, with a large Chinese population, was the largest city affected among western countries (Wong and Yuen, 2008).
Potential Effect of SARS Outbreak in My Community
SARS can move like brushfire through a community; an outbreak in a hospital in Hong Kong traced 280 out of 465 infections to 5 five patients, out of 20 patients infected. When a SARS outbreak occurs in a community, and a SARS Alert is raised, measures to prevent transmission may have to be instituted far beyond the hospital setting. Every person who comes into contact with a suspected or confirmed case of SARS must be identified and placed under quarantine for a period of 10 days.
The person will be informed of the clinical manifestations of SARS and its danger to the community, and urged not to come into contact with any other individual, and to report anyone they may already have had come into contact with. If quarantined at home, the person has to be monitored daily for signs of fever, or any other symptoms associated with SARS. Having to undergo quarantine for a potentially fatal disease can be quite stressful, and the fear factor is high. People who survived the 2003 SARS outbreak were shown to develop post-traumatic stress syndrome (PTSD) (World Health Organization).
The quarantine of members of the community on its own can have a severe impact on the community; since those who are placed under quarantine would need to stay away from the workplace, and thus many community services could be disturbed. Entire schools may have to be placed under quarantine, or closed until the outbreak is over. There is also the extra healthcare burden of having to monitor every individual who must undergo surveillance under quarantine, and later, to treat those who may develop PTSD. But perhaps the biggest loss to the community is the loss of healthcare workers who choose to opt out of working in healthcare ever again (Connolly, 2005).
A suspected or confirmed SARS outbreak should be officially and immediately reported to the proper authorities, including officials from the Center for Disease control and the World Health Organization. A report must include a detailed account of the clinical data of each suspected case of SARS, AND must be accompanied with positive lab results. Asymptomatic persons with positive laboratory tests or symptomatic persons without laboratory confirmation are not to be reported (Connolly, 2005).
When a hospital goes under SARS Alert, routine healthcare will demand higher levels of quality and intensity, which may prove difficult to sustain. Preventive measures too would have to be intensified (Connolly, 2005). For example, in addition to taking steps to isolate the infected patients to prevent transmission of the disease, I would strongly recommended that the most vulnerable patients be also isolated, to further lower their risk of infection. In this case, patients with respiratory diseases should be isolated from the general population of patients and monitored aggressively for any signs of fever or any other symptoms suggestive of SARS. If the situation were to warrant it, I would consider recommending that patients with respiratory diseases be discharged to homecare.
Healthcare workers who have come in contact with a SARS case should be monitored for signs and symptoms of SARS, and perhaps cohorted to care for the suspected or confirmed patients with SARS. Exposed staff should not be allowed to come into any contact whatsoever with any patient having a respiratory disease. If possible, exposed staff should be quarantined (Connolly, 2005).
Modification of Care of Patients with Respiratory Disorders in Response to Increased Risk due to Poor Air Quality
Patients with respiratory disorders, who may be at increased health risk due to detrimental changes in environmental air quality, may benefit from a combination of non-pharmacological and pharmacological strategies. In essence, these strategies include an increase in the level of therapies already in their treatment protocols. The following are adapted from the World Health Organization guidelines for the management of respiratory diseases (WHO, 2002).
Non- pharmacological Strategies
Patients with respiratory problems are already having trouble breathing, so poor air quality would impact the patients’ ability to breathe even more. Supplemental oxygen would deliver better quality air and may be advisable during the full duration of the poor quality air alert.
Mucus control is critical in patients with respiratory problems, and during poor quality air alerts intervention for its control should be more rigorous. Non-pharmacological strategies include giving patients more fluids to drink to help loosen any accumulation of mucus and soothe irritated throats. The patient’s head should also be elevated to keep mucus from blocking the airways during sleep.
Keep Nasal Passages Moist
Keeping the nostrils moist with nasal sprays or water-soluble gel can help unblock the nasal passages and help patients breathing. More frequent moistening of the nostrils may be advisable during a poor air quality alert.
Nurses should work in close cooperation with inhalation, or pulmonary, therapists. Breathing exercises can help patients increase their respiratory function. During a poor air quality alert, hospitalized patients who are not already on respiratory therapy should begin their exercises.
A nurse should be even more vigilant during poor air alerts for symptoms of respiratory distress, such as shortness of breath or nasal congestion, and provide medication to alleviate these symptoms. Some of these medications may include bronchodilators to improve airflow in the bronchi and bronchioles in patients with asthma, COPD, or sarcoidosis.
Anti-anxiety medication should be strongly considered for all patients with respiratory diseases especially under these circumstances of a SARS alert, combined with poor air quality alert. Anxiety is known to exacerbate the symptoms of these diseases.
Connolly MA. Communicable disease control in emergencies – a field manual. Geneva: World Health Organization. 2005. Available: http://www.who.int/infectious-disease-news/IDdocs/whocds200527/ISBN_9241546166.pdf. Accessed 3 May 2012.
Hui, D.S., & Chan, P.K. (2010). Severe acute respiratory syndrome and coronavirus. Infect Dis Clin North Am, 24(3):619-38.
Wong S.S., & Yuen K.Y. (2008). The management of coronavirus infections with particular reference to SARS. J Antimicrob Chemother, 62 (3): 437-41.
World Health Organization. (2003) Consensus document on the epidemiology of severe acute respiratory syndrome (SARS) Geneva: Department of Communicable Disease Surveillance and Response, World Health Organization; 2003.