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Transmission of SARS-CoV in healthcare facilities was a major factor
in the spread of SARS during the 2003 global epidemic. In areas with
extensive outbreaks, the virus spread most readily among hospital workers
caring for SARS patients, other patients, and visitors. In Toronto,
77% of the patients in the first phase of the outbreak were infected
in the hospital setting, and half of all SARS cases in Toronto were in
healthcare workers (Booth 2003). Even in Hong Kong, where there was
significant community transmission, 21% of all SARS cases occurred in
healthcare workers (Ho 2003). Factors that likely contribute to the disproportionate
rate of transmission in healthcare settings include: 1) a higher virus
titer in respiratory secretions during the second week of illness when
patients are likely to be hospitalized (Peiris 2003), 2) use of ventilators,
nebulizers, endotracheal intubation, and other droplet- and aerosol-generating
devices and procedures, and 3) frequent exposures of workers to patients,
their secretions, and potentially contaminated environments (Varia 2003).
The large number of hospital personnel who contracted SARS-CoV disease
demonstrates the importance of early detection, infection control, and
contact tracing in limiting the spread of disease. In every region in
which major outbreaks were reported, a substantial proportion of cases
resulted from delays in clinical recognition and isolation of patients.
SARS-CoV was also transmitted by infected visitors and by hospitalized
patients with other medical conditions that masked the symptoms of SARS
(Varia 2003). Case recognition and implementation of appropriate precautions
greatly reduced the risks of SARS-CoV transmission. However, even with
appropriate precautions, there were isolated reports of transmission
to healthcare workers in the settings of aerosol-producing procedures
and lapses in infection control technique (CDC 2003).
SARS-CoV transmission in a healthcare facility presents occupational
and psychological challenges that, in the 2003 outbreaks, required heroic
efforts to overcome. Experience also indicates, however, that early detection
and isolation of cases, strict adherence to infection control precautions,
and aggressive contact tracing and monitoring can minimize the impact
of a SARS outbreak (Seto 2003). The success of these measures depends
on exhaustive planning, clear communication, collaboration among disciplines,
authoritative leadership, and provision of relevant support.
This Supplement provides recommendations for how to prepare for and
respond to an introduction of SARS-CoV in a healthcare facility. It outlines
basic response measures as well as the enhanced activities that may be
needed to address larger outbreaks. As preparedness and response
activities for SARS are in many ways analogous to those required for
other types of emergency and mass-casualty events, planning for SARS
may only require integration of SARS-specific activities into existing
preparedness plans and protocols.
The goals of a preparedness and response plan in a healthcare facility
are:
- Rapidly
identify and isolate all potential SARS patients.
- Implement
infection control practices and contract tracing to interrupt SARS-CoV
transmission.
- Ensure
rapid communication within healthcare facilities and between healthcare
facilities and health departments.
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