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6/6/2003

Lessons Learned From SARS Outbreak

Donna Young

Scarborough Hospital, Grace Division, in Toronto, Canada, on March 7 admitted 43-year-old Chi Kwai Tse who had a fever and a persistent cough. Six days later, he was dead.

Tse’s mother, who had recently traveled to Hong Kong, had died at home on March 5 of what a local coroner assumed was a heart attack, according to an April 19 article in the Toronto Star.

Unknown to health care workers at the hospital, Tse and his mother had severe acute respiratory syndrome (SARS).

Because there was a lack of awareness of SARS in Canada—the World Health Organization (WHO) had not yet issued its March 12 global alert—Scarborough health care workers had not taken intensive respiratory precautions when caring for Tse, and the mysterious illness spread to other patients and health care workers in the hospital, according to a report released early in the online Journal of the American Medical Association.1

Other Toronto hospitals were affected when SARS patients were transferred between institutions, further spreading the infection to their patients, health care workers, and hospital visitors, researchers reported.

Of 144 patients with suspected or probable cases of SARS admitted to 10 Toronto-area hospitals between March 7 and April 10, 77% were exposed to SARS while in those facilities, researchers found.

Use protection. Unprotected exposure, due to poor hand hygiene and failure to use protective equipment, including gloves, gowns, respirator masks, and eye shields, led to the transmission of SARS from patients to health care workers, according to the Centers for Disease Control and Prevention (CDC).

Most documented transmissions have been to either health care workers or  people in close contact with SARS patients, such as family members, the agency stated.

Hsiu Ling Hau, pharmacy manager for Scarborough Hospital, General Division, sister hospital to Grace Division, said her health system was not unlike any other health system before WHO’s alert about SARS “in that we were not fully prepared for this outbreak.”

Even though Scarborough had been preparing since September 11, 2001, for bioterrorism attacks, such as an outbreak of smallpox, Hau said the SARS outbreak aided her health system in identifying its vulnerabilities in dealing with an unknown illness.

After WHO’s alert, she said, her health system quickly implemented policies requiring its staff to wear protective gloves, gowns, and masks when caring for patients with suspected SARS infection.

Health care workers infected. WHO reported on March 21 that more than 90% of some 135 SARS cases in Hong Kong and Vietnam were health care workers. Carlo Urbani, a physician and the WHO officer who had first identified the outbreak, died of the disease on March 29 in Hanoi, Vietnam, after treating an American businessman who had SARS.

A Hong Kong nurse died of SARS on April 26, and a physician from the territory who had been treating SARS patients died on May 13.

The Hong Kong Hospital Authority’s chief executive was admitted to a local hospital on March 23 with SARS. He later recovered.

In its April 18 Morbidity and Mortality Weekly Report, CDC reported the first probable case of SARS in a health care worker in the United States who had provided care to a patient with the illness.

CDC Issues Guidance

Persons returning from an area affected by severe acute respiratory syndrome (SARS) should monitor their health for 10 days, the Centers for Disease Control and Prevention (CDC) advised in a May interim guidance document. If symptoms occur during that period, the person should consult a health care provider and inform the provider of his or her recent travel, the agency stated.

But, CDC suggested, a person with symptoms of SARS should contact a health care provider by phone before visiting an office or emergency room so that the provider can make arrangements to prevent transmission to others in the health care setting.

If fever or respiratory symptoms develop in a health care worker within 10 days after exposure to a patient with SARS, the worker should not report for duty and should report symptoms to the health system’s occupational health or infection control office, CDC advised.

The health system’s appropriate point of contact should regularly communicate over a 10-day period with a health care worker exposed to SARS.

If the worker’s symptoms improve or resolve within 72 hours after onset, CDC counseled, the person may, after consultation with the infection control office, return to duty. If the fever or respiratory symptoms persist beyond 72 hours, infection control and isolation should be continued for an additional 72 hours.

Health care facilities that care for SARS patients should implement surveillance of health care workers who have any contact with SARS patients or their environment of care, CDC stated.

Surveillance should include maintaining a list of all personnel who enter the room of a SARS patient or who are involved in the patient’s care.

Health systems should monitor employee absenteeism and notify local and state health authorities of unusual increases in respiratory illness in the work force, CDC counseled.

Health care workers who have unprotected high-risk exposures—presence in the same room as a probable SARS patient during a high-risk aerosol-generating procedure or event and when recommended infection control precautions are absent or breached—should be excluded from duty for 10 days after the exposure and monitored closely by the health system’s infection control office, CDC recommended.

Persons who meet the case definition of SARS should not return to work until 10 days after the resolution of symptoms.

The definition of SARS exposure, according to CDC, includes travel from areas with documented or suspected community transmission.

A pharmacist’s experience. One health-system pharmacist working in a supervisory role at an East Coast hospital traveled to Hong Kong in late March to attend a family member’s funeral. Within days after her return to the United States, she had cold symptoms, including sinus congestion and a sore throat.

She stayed home for three days and returned to work on a Monday.

The pharmacist, who asked not to be identified, notified her hospital’s employee health coordinator and infection control office about her cold symptoms and recent travel to a SARS-affected area and inquired if she needed to take any specific precautions before returning to work.

The health coordinator told the pharmacist that, as long as she did not have a fever and did not work in the hospital’s patient care units, she could work but should wear a protective mask when near patient areas until she no longer had cold symptoms.

“But they called me in a panic the next day,” she said. “They said they heard I was getting worse, so they wanted me to go to a doctor and get clearance before I could come back to work. Obviously I would do whatever I needed to do not to pass whatever I had around the hospital,” she said.

Because of the nature of her work as a supervisor, the pharmacist was able to work from home during her week of isolation.

By the next Monday, she was over her cold symptoms and returned to work.

“I never did go to the doctor to get the documentation” that she did not have SARS, the pharmacist said, adding that the employee health coordinator did not examine her or ask for the documentation on the pharmacist’s return to work.

The experience, the pharmacist said, taught her that her hospital was unprepared to respond to an unknown infectious disease epidemic or an act of bioterrorism, and the facility lacked consistent policies and procedures regarding employees who had been possibly exposed to SARS.

“If we don’t learn from this live example, the next time something like this comes around, if we repeat the same thing . . . we are just being stupid,” she said.

Immediate action. Betty J. Dong, a professor of clinical pharmacy for the University of California, San Francisco (UCSF), said her medical center’s infection control department created a SARS Web site within days after WHO issued its global alert.

UCSF issued its first set of SARS guidelines on April 3 for its health care workers, she added.

Dong’s health system was fortunate, she said, because many public health personnel work in UCSF’s system and were able to share up-to-date information.

UCSF held a SARS informational presentation for its health care staff on May 7, Dong said. The event was simulcast to the system’s various facilities and videotaped for workers who could not attend the session, she added.

B. Joseph Guglielmo, vice chair of UCSF’s clinical pharmacy department, said his facility had one probable case of SARS as of mid-May.

The patient, who resided in the San Francisco Bay area, had recently visited Hong Kong, he said.

Because the patient had cancer and heart disease, Guglielmo noted, it was difficult to determine a diagnosis at first. But, he added, because of the patient’s travel history, respiratory symptoms, and fever, the hospital took immediate precautions and isolated the patient.

The patient was treated with doxycycline and ceftriaxone, Guglielmo said, noting that UCSF was awaiting the results of tests that would confirm whether this was a SARS case.

Scarborough’s Hau said her pharmacy has initiated a policy to discard unused drug products that have been delivered to a care unit with SARS patients.

If an expensive injectable drug was delivered to the nursing unit but did not come in close contact with a SARS patient or the patient’s room, the pharmacy would consider sterilizing the drug, she said.

“But with the cheaper drugs, whether they got near the patient or not, we just throw them out because it is not worth the risk” of contamination, she said.

Another precaution her pharmacy has taken, when possible, is to counsel SARS patients by phone about their medications rather than in person to avoid possible exposure.

“But we want to make sure we are providing the same quality of care to our SARS patients as any other patient. We don’t want them to feel even more isolated,” she said. “So if a patient requests that a pharmacist speak to them in person, then we will do that. But we take very strict precautions.”