The 2003 SARS outbreak and its impact on infection control practices

Karen Shaw, Karen Shaw

Abstract

Severe Acute Respiratory Syndrome (SARS) emerged recently as a new infectious disease that was transmitted efficiently in the healthcare setting and particularly affected healthcare workers (HCWs), patients and visitors. The efficiency of transmission within healthcare facilities was recognised following significant hospital outbreaks of SARS in Canada, China, Hong Kong, Singapore, Taiwan and Vietnam. The causative agent of SARS was identified as a novel coronavirus, the SARS coronavirus. This was largely spread by direct or indirect contact with large respiratory droplets, although airborne transmission has also been reported. High infection rates among HCWs led initially to the theory that SARS was highly contagious and the concept of 'super-spreading events'. Such events illustrated that lack of infection control (IC) measures or failure to comply with IC precautions could lead to large-scale hospital outbreaks. SARS was eventually contained by the stringent application of IC measures that limited exposure of HCWs to potentially infectious individuals. As the 'global village' becomes smaller and other microbial threats to health emerge, or re-emerge, there is an urgent need to develop a global strategy for infection control in hospitals. This paper provides an overview of the main IC practices employed during the 2003 SARS outbreak, including management measures, dedicated SARS hospitals, personal protective equipment, isolation, handwashing, environmental decontamination, education and training. The psychological and psychosocial impact on HCWs during the outbreak are also discussed. Requirements for IC programmes in the post-SARS period are proposed based on the major lessons learnt from the SARS outbreak.

References

    1. World Health Organization. Summary of probable SARS cases with onset of illness from; 1 November 2002 to 31 July 2003. Available from: .
    1. Varia M., Wilson S., Sarwal S., McGeer A., Gournis E., Galanis E. Hospital outbreak investigation team. Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada. Can Med Assoc J. 2003;169:285–292.
    1. Zhao Z., Zhang F., Xu M., Huang K., Zhong W., Cai W. Description and clinical treatment of an early outbreak of severe acute respiratory syndrome (SARS) in Guangzhou, PR China. J Med Microbiol. 2003;52:715–720.
    1. Ho A.S., Sung J.J., Chan-Yeung M. An outbreak of severe acute respiratory syndrome among hospital workers in a community hospital in Hong Kong. Ann Intern Med. 2003;139:564–567.
    1. Gopalakrishna G., Choo P., Leo Y.S., Tay B.K., Lim Y.T., Khan A.S. SARS transmission and hospital containment. Emerg Infect Dis. 2004;10:395–400.
    1. Twu S.J., Chen T.J., Chen C.J., Olsen S.J., Lee L.T., Fisk T. Control measures for severe acute respiratory syndrome (SARS) in Taiwan. Emerg Infect Dis. 2003;9:718–720.
    1. Le D.H., Bloom S.A., Nguyen Q.H., Maloney S.A., Le Q.M., Leitmeyer K.C. Lack of SARS transmission among public hospital workers, Vietnam. Emerg Infect Dis. 2004;10:265–268.
    1. Drosten C., Gunther S., Preiser W., van der Werf S., Brodt H.R., Becker S. Identification of a novel coronavirus in patients with severe acute respiratory syndrome. N Engl J Med. 2003;348:1967–1976. [Epub 2003 Apr 10]
    1. Peiris J.S., Lai S.T., Poon L.L., Guan Y., Yam L.Y., Lim W. Coronavirus as a possible cause of severe acute respiratory syndrome. Lancet. 2003;361:1319–1325.
    1. Yu I.T., Li Y., Wong T.W., Tam W., Chan A.T., Lee J.H. Evidence of airborne transmission of the severe acute respiratory syndrome virus. N Engl J Med. 2004;350:1731–1739.
    1. World Health Organization. Consensus document on the epidemiology of severe acute respiratory syndrome (SARS). Available from: .
    1. Tsang K.W., Ho P.L., Ooi G.C., Yee W.K., Wang T., Chan-Yeung M. A cluster of cases of severe acute respiratory syndrome in Hong Kong. N Engl J Med. 2003;348:1977–1985. [Epub 2003 Mar 31]
    1. Shen Z., Ning F., Zhou W., He X., Lin C., Chin D.P. Superspreading SARS events, Beijing, 2003. Emerg Infect Dis. 2004;10:256–260.
    1. Centers for Disease Control and Prevention (CDC). Severe acute respiratory syndrome—Taiwan, 2003. MMWR Morb Mortal Wkly Rep 2003;52:461–36.
    1. Chow K.Y., Lee C.E., Ling M.L., Heng D.M., Yap S.G. Outbreak of severe acute respiratory syndrome in a tertiary hospital in Singapore, linked to an index patient with atypical presentation: epidemiological study. Br Med J. 2004;328:195. [Epub 2004 Jan 15]
    1. Ofner M., Lem M., Sarwal S., Vearncombe M., Simor A. Cluster of severe acute respiratory syndrome cases among protected health care workers—Toronto, April 2003. Can Commun Dis Rep. 2003;29:93–97.
    1. Riley S., Fraser C., Donnelly C.A., Ghani A.C., Abu-Raddad L.J., Hedley A.J. Transmission dynamics of the etiological agent of SARS in Hong Kong: impact of public health interventions. Science. 2003;300:1961–1966. [Epub 2003 May 23]
    1. Lipsitch M., Cohen T., Cooper B., Robins J.M., Ma S., James L. Transmission dynamics and control of severe acute respiratory syndrome. Science. 2003;300:1966–1970. [Epub 2003 May 23]
    1. Mackenzie J.S., Drury P., Ellis A., Grein T., Leitmeyer K.C., Mardel S. The WHO response to SARS and preparations for the future. In: Knobler S., Mahmoud A., Lemon S., Mack A., Sivitz L., Oberholtzer K., editors. Learning from SARS: preparing for the next disease outbreak—workshop summary. Institute of Medicine, The National Academies Press; Washington, DC: 2004. Available from:
    1. Li T.S., Buckley T.A., Yap F.H., Sung J.J., Joynt G.M. Severe acute respiratory syndrome (SARS): infection control. Lancet. 2003;361:1386.
    1. Tsai M.C., Arnold J.L., Chuang C.C., Chi C.H., Liu C.C., Yang Y.J. Impact of an outbreak of severe acute respiratory syndrome on a hospital in Taiwan, ROC. Emerg Med J. 2004;21:311–316.
    1. Ho P.L., Tang X.P., Seto W.H. SARS: hospital infection control and admission strategies. Respirology. 2003;8(supplement):S41–S45.
    1. Lee N., Sung J.J. Nosocomial transmission of SARS. Curr Infect Dis Rep. 2003;5:473–476.
    1. Lee N.E., Siriarayapon P., Tappero J., Chen K.T., Shuey D., Limpakarnjanarat K. SARS mobile response team investigators. Infection control practices for SARS in lao people's democratic republic, Taiwan, and Thailand: experience from mobile SARS containment teams, 2003. Am J Infect Control. 2004;32:377–383.
    1. Svoboda T., Henry B., Shulman L., Kennedy E., Rea E., Ng W. Public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in Toronto. N Engl J Med. 2004;350:2352–2361.
    1. Maunder R., Hunter J., Vincent L., Bennett J., Peladeau N., Leszcz M. The immediate psychological and occupational impact of the SARS outbreak in a teaching hospital. Can Med Assoc J. 2003;168:1245–1251.
    1. Centers for Disease Control and Prevention (CDC). Severe acute respiratory syndrome—Singapore, 2003. MMWR Morb Mortal Wkly Rep 2003;52:405–11.
    1. Lau J.T., Fung K.S., Wong T.W., Kim J.H., Wong E., Chung S. SARS transmission among hospital workers in Hong Kong. Emerg Infect Dis. 2004;10:280–286.
    1. Loeb M., McGeer A., Henry B., Ofner M., Rose D., Hlywka T. SARS among critical care nurses, Toronto. Emerg Infect Dis. 2004;10:251–255.
    1. Seto W.H., Tsang D., Yung R.W., Ching T.Y., Ng T.K., Ho M. Advisors of Expert SARS group of Hospital Authority. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS) Lancet. 2003;361:1519–1520.
    1. Mukhopadhyay A., Tambyah P.A., Singh K.S., Lim T.K., Lee K.H. SARS in a hospital visitor and her intensivist. J Hosp Infect. 2004;56:249–250.
    1. Park B.J., Peck A.J., Kuehnert M.J., Newbern C., Smelser C., Comer J.A. Lack of SARS transmission among healthcare workers, United States. Emerg Infect Dis. 2004;10:244–248.
    1. Tambyah P.A. Severe acute respiratory syndrome from the trenches, at a Singapore university hospital. Lancet Infect Dis. 2004;4:690–696.
    1. Cetron M., Maloney S., Koppaka R., Simone P. Isolation and quarantine: containment strategies for SARS 2003. In: Knobler S., Mahmoud A., Lemon S., Mack A., Sivitz L., Oberholtzer K., editors. Learning from SARS: preparing for the next disease outbreak—workshop Summary. Institute of Medicine of The National Academies, The National Academies Press; Washington, DC: 2004. Available from: .
    1. World Health Organization. Hospital infection control guidance for severe acute respiratory syndrome (SARS). Available from: .
    1. Seow E. SARS: experience from the emergency department, Tan Tock Seng Hospital, Singapore. Emerg Med J. 2003;20:501–504.
    1. McDonald L.C., Simor A.E., Su I.J., Maloney S., Ofner M., Chen K.T. SARS in healthcare facilities, Toronto and Taiwan. Emerg Infect Dis. 2004;10:777–781.
    1. Esswein E.J., Kiefer M., Wallingford K., Burr G., Lee L.J., Wang J.D. Environmental and occupational health response to SARS, Taiwan, 2003. Emerg Infect Dis. 2004;10:1187–1194.
    1. Wong T.W., Lee C.K., Tam W., Lau J.T., Yu T.S., Lui S.F. Cluster of SARS among medical students exposed to single patient, Hong Kong. Emerg Infect Dis. 2004;10:269–276.
    1. Gamage B., Moore D., Copes R., Yassi A., Bryce E., The BC interdisciplinary respiratory protection study group Protecting health care workers from SARS and other respiratory pathogens: a review of the infection control literature. Am J Infect Control. 2005;33:114–121.
    1. Jarvis W.R. Handwashing—the Semmelweis lesson forgotten? Lancet. 1994;344:1311–1312.
    1. Pittet D., Mourouga P., Perneger T.V. Compliance with handwashing in a teaching hospital. Infection control program. Ann Intern Med. 1999;130:126–130.
    1. Tiwari A., Chan S., Wong A., Tai J., Cheng K., Chan J. Nursing task force on anti-SARS of queen mary hospital. Severe acute respiratory syndrome (SARS) in Hong Kong: patients' experiences. Nurs Outlook. 2003;51:212–219.
    1. Loutfy M.R., Wallington T., Rutledge T., Mederski B., Rose K., Kwolek S. Hospital preparedness and SARS. Emerg Infect Dis. 2004;10:771–776.
    1. Straus S.E., Wilson K., Rambaldini G., Rath D., Lin Y., Gold W.L. Severe acute respiratory syndrome and its impact on professionalism: qualitative study of physicians' behaviour during an emerging healthcare crisis. Br Med J. 2004;329:83. [Epub 2004 Jun 2]
    1. Nickell L.A., Crighton E.J., Tracy C.S., Al-Enazy H., Bolaji Y., Hanjrah S. Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution. Can Med Assoc J. 2004;170:793–798.
    1. Maunder R. The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers in Toronto: lessons learned. Philos Trans R Soc Lond B Biol Sci. 2004;359:1117–1125.
    1. Gershon R.R., Karkashian C.D., Grosch J.W., Murphy L.R., Escamilla-Cejudo A., Flanagan P.A. Hospital safety climate and its relationship with safe work practices and workplace exposure incidents. Am J Infect Control. 2000;28:211–221.
    1. Pittet D., Allegranzi B., Sax H., Bertinato L., Concia E., Cookson B. Considerations for a WHO European strategy on health-care-associated infection, surveillance, and control. Lancet Infect Dis. 2005;5:242–250.
    1. Sehulster L., Chinn R.Y. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the healthcare infection control practices advisory committee (HICPAC) MMWR Recomm Rep. 2003;52(RR-10):1–42.
    1. Pittet D., Hugonnet S., Harbarth S., Mourouga P., Sauvan V., Touveneau S. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection control programme. Lancet. 2000;356:1307–1312.
    1. Cheng S.M., Streifel A.J. Infection control considerations during construction activities: land excavation and demolition. Am J Infect Control. 2001;29:321–328.
    1. Jeffe D.B., Mutha S., L'Ecuyer P.B., Kim L.E., Singal R.B., Evanoff B.A. Healthcare workers' attitudes and compliance with universal precautions: gender, occupation, and specialty differences. Infect Control Hosp Epidemiol. 1997;18:710–712.

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