SARS (Severe Acute Respiratory Syndrome) is a respiratory illness caused by a coronavirus, originally reported in Asia in February 2003 and spread to over two dozen countries before being contained (Centers for Disease Control and Prevention [CDC], 2005). Once infected, individuals with SARS initially develop a high fever and other flu-like symptoms including headache, body aches and “overall feeling of discomfort” before, in most cases, progressing to pneumonia (CDC, 2005).
The disease was first diagnosed in a middle-aged man who had flown from China to Hong Kong. A few days after the announcement of the disease, rumors and panic began to spread, causing people to buy out food and supplies, as the Chinese government insisted the disease was under control and insisted on calm (“Timeline,” 2003). As the disease killed the man and the physician diagnosing the disease, it continued to spread through multiple countries, infecting thousands of people and killing hundreds (“SARS,” 2011).
By the end of the month, Hong Kong and Vietnam were reporting cases of severe and “atypical” pneumonia (“Timeline,” 2003). In March 2003, the WHO issued a global health alert and an emergency travel advisory, and United States officials encouraged all citizens to suspend non-essential travel to the affected countries and Singapore, Ontario and Hong Kong initiated home quarantine (“Timeline,” 2003). Schools in Southeast Asia closed and there were significant economic effects as well as air travel stalled and business worldwide was affected.
In April, countries threatened to quarantine entire planeloads of people if anyone on board showed symptoms, and others threatened jail time for those who obstruct the attempts to control the disease (“Timeline,” 2003). On April 3, 2003, SARS became a communicable disease for which a healthy person suspected of being infected in the United States could be quarantined against their will (“Executive Order,” 2003). By June 2003, the number of new cases had slowed down enough to end the daily WHO updates and travel advisories were slowly being lifted (“SARS,” 2011).
On July 5, the WHO declared SARS had been contained (“WHO,” 2003). As of 2005, no new cases of person-to-person transmission have been reported (“Surveillance,” 2005). Indicators and Data The main epidemiological indicators for SARS identified by leading healthcare organizations such as the WHO and EpiNorth are the incubation period, infectious period, and case-fatality ratios (World Health Organization: Department of Communicable Disease Surveillance and Response [WHO/DCDSR], 2003; Kutsar, 2004).
According to the WHO, the median incubation period reported was 4-5 days, with a minimum reported incubation period of 1 day in 4 cases and a maximum of 14 days reported in China. After further analysis of 1425 cases it was determined that 95% of patients would begin to experience symptoms within 14. 22 days on infection (WHO/DCDSR, 2003). The infectious period, or the period of communicability, was determined to be within the second week of illness, when patients are more severely ill and experiencing rapid deterioration (Kutsar, 2004).
During the SARS outbreak of 2003, 8,093 people were infected and 774 of these people died as a result of their infection, with a case-fatality rate of 9. 6% (CDC, 2005; “Revised U. S. Surveillance,” 2003). The cases were reported from 29 countries on 4 continents, with 29 cases from the United States (“Revised U. S. Surveillance,” 2003). Other epidemiologic factors affecting the spread of SARS were found, as well. Twenty-one percent of all cases were healthcare workers involved in procedures that generated aerosols, with 3% of the United States cases and 43% of the Canadian cases being people in this group (Kutsar, 2004).
Other risk factors found included “household contact with a probable case of SARS, increasing age, male sex and the presence of co-morbidities” and, in China the slaughter of wildlife for human consumption (WHO/DCDSR, 2003, p. 14). Routes of Transmission In the laboratory setting, the virus was found in respiratory droplets, feces, saliva, tears and urine (WHO/DCDSR, 2003). SARS is primarily spread through close, personal contact, such as kissing, hugging, eating or drinking, as well as being within 3 feet of a person who coughs or sneezes while infected and shedding the virus.
These activities allow the respiratory droplets shed during these activities to come in contact with mucous membranes found in the eyes, nose and mouth (Kutsar, 2004). Other modes of transmission include aerosolizing procedures in hospital settings and contamination of surfaces in “healthcare facilities, households and other closed environments” (Kutsar, 2004, para. 12). There has been no confirmation of fecal-oral transmission or of transmission via water or food; however, over one-third of the earliest cases in China were among food handlers (Kutsar, 2004).
Finally, there is a possibility of animal vector transmission, as discussed in regards to the Hong Kong’s Amoy Gardens (WHO/DCDSR, 2003). Effect of Outbreak on Community The SARS outbreak caused major effects on the communities affected. Based on the 2003 outbreak, one can assume similar issues would develop should the disease recur. The biggest impact to communities affected would be the strain on the healthcare system. Since SARS is a largely respiratory disease, it can cause very serious problems in the patients infected, requiring hospitalization in many cases.
In the 2003 outbreak, population most likely to develop SARS was healthcare workers. As such, an increase in hospitalizations within a community with a decreased amount of healthcare workers worsens the strain on the community’s healthcare system. Further effects on the community in the event of a SARS outbreak would be seen in the closing of public buildings, such as schools. If the schools closed, as they did in Southeast Asia during the 2003 outbreak, families with two working parents would have to find alternatives for their children.
With employment rates in the United States being low at this time, many people may be hesitant to ask for time off work, fearing that someone else would easily replace them in their position. These concerns could also increase the possibility of mass transmission, as many people may try to continue working while sick, not realizing they were carrying the deadly disease. Additionally, many people may procrastinate seeking medical advice on their symptoms, fearing they would be instructed to stay home from work, hospitalized or even quarantined.
As evidenced in laboratory studies of the virus, virus secretion increases as the disease lingers (Kutsar, 2004). Simply, the longer a person is infected, the more easily they transmit the infection to others. As more and more of the community becomes infected, and possibly quarantined, other services in the community will suffer. Grocery store shelves may remain empty longer, as healthy staff struggle to keep up with the demand.
Mail delivery may lengthen due to more postal carriers becoming ill and staying home. Businesses in general may be forced to shorten their hours due to an inability to schedule staff, resulting in problems with banking, supplies, and even medication disbursement. Further, the community health system would be greatly stressed, as the number of people needing care would grow, potentially covering a larger area than normally served and straining the resources of the public health system.
This strain would impact all of the programs served out of the local offices, impacting even more people. Protocol In the State of Illinois, SARS is listed with the Class I(a) conditions that have been declared to be “contagious, infectious, or communicable and may be dangerous to the public health,” and, needs to be reported to the local health department within three hours of initial clinical suspicion (Control of Communicable Diseases Code, 2008).
This can be done electronically through mail, phone, fax or the web-based system, I-NEDSS (Illinois National Electronic Disease Surveillance System) and will include case name and contact information as well that of the physician. After the local public health office has been notified, they will contact the Illinois Department of Public Health, also within three hours using the same techniques. This report shall include race, gender, and ethnicity as well (Control of Communicable Diseases Code, 2008).
These reports are sent via the National Notifiable Disease Surveillance System (NNDSS), which is operated by the Centers for Disease Control (CDC) in collaboration with the Council of State and Territorial Epidemiologists (CSTE) and allows the CDC to monitor new cases and disease trends as well as evaluate the efficiency of prevention and control activities, program planning and evaluation, and policy development (Centers for Disease Control and Prevention [CDC], 2011). Modification of Care As a community health nurse, one must be constantly aware of changes in the environment served.
If a report of poor air quality is issued while the community health nurse is caring for patients suffering from asthma and other respiratory disorders, immediate action must be taken as the poor air quality can cause exacerbations. First, the nurse will need to prioritize the patient load—which patient is the most susceptible to this change in air quality and should be seen first? Then, the nurse will begin calling or, if time allows, visiting the patients to check in and provide further direction.
Some of the interventions the nurse may suggest are to stay indoors closing all windows and doors to prevent the poor air from entering the home and interfering with the patient’s breathing. Additional suggestions would be to limit activity which would increase the oxygen demand in the patient’s body, resulting in faster, less efficient respirations. Patients should be reminded to keep their rescue inhalers with them at all times, as well as to be sure and take all their preventative medications as prescribed.
If the nurse is making home visits, s/he will be checking the medication bottles to see if the patient has been compliant. While in the home, she will auscultate the patient’s lungs to assess for worsened wheezing from baseline and recommend a visit to the patient’s physician if necessary. As the air quality reports improve in the next few days, the nurse will continue to monitor those patients most susceptible to ensure they have no residual effects from the previous days.
Courtney from Study Moose
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