2002–2004 SARS outbreak among healthcare workers
The rapid spread of severe acute respiratory syndrome in healthcare workers —most notably in Toronto hospitals—during the global outbreak of SARS in 2002–2003 contributed to dozens of identified cases, some of them fatal. Researchers have found several key reasons for this development, such as the high-risk performances of medical operations on patients with SARS, inadequate use of protective equipment, psychological effects on the workers in response to the stress of dealing with the outbreak, and lack of information and training on treating SARS. Lessons learned from this outbreak among healthcare workers have contributed to newly developed treatment and prevention efforts and new recommendations from groups such as the Centers for Disease Control and Prevention.
Background
spread around the world from the Guangdong Province of China, to multiple locations, like Hong Kong and then Toronto, Canada from 2002–2003. The spread of SARS originated from a doctor residing in a hotel in Hong Kong to other tourists staying in the same hotel, who then travelled back home to locations like Toronto. The growing number of cases in Toronto gave HCWs a significant challenge, as they were tasked with stopping the spread of the disease in their city. Unfortunately, this unprepared-for challenge led several hospitals in the city and in the surrounding Ontario region to see dozens of cases of SARS arise not only in typical patients but also in HCWs themselves.Noticing this development, on March 28, 2003, the POC in Ontario established a set of SARS-specific recommendations and suggestions for all hospitals in Toronto in order to guide them on how to best avoid the transmission of SARS among HCWs. They hoped that these initiatives would protect HCWs from the disease, allowing them to continue treating other SARS-infected patients without putting themselves at risk.
A study published in 2006, however, suggests that these directives were not fully practiced and/or enforced, causing many HCWs to still get the disease. The study followed 17 HCWs in Toronto hospitals who had developed the disease and interviewed 15 of them about their habits and practices during the time of the outbreak. Specifically, the study involved asking the HCWs questions regarding the amount of training they had received on dealing with SARS cases in a cautionary way, how often they used protective equipment, etc. In the end, results showed that the practices of these HCWs did not fully meet the recommendations set forth by the POC, providing greater evidence that these poor practices led to the development of the disease in HCWs more than anything else.
Causes of transmission
High-risk performance
Many HCWs became more susceptible to contracting the disease due to their operations and high-risk interactions with SARS patients. Many of these interactions, such as caring for a patient directly or communicating with the patient, create high-risk scenarios in which the HCWs have many ways of becoming infected. There are three main categories of High-Risk Performance: direct contact by patient, indirect contact by patient, and high-risk events.Direct contact by patient
Direct contact and resulting transmission of the disease "occurs when there is physical contact between an infected person and a susceptible person". This direct contact can be various types of contact involving blood or bodily fluids, but some SARS-specific examples include when a patient receives supplemental oxygen or mechanical ventilation with the aid of HCWs. These require the direct contact of a patient with a HCW, making it a viable method of SARS transmission. As direct contact is the most common form of high-risk performance, all seventeen HCWs participating in the study encountered some sort of direct contact with a patient in the 10 days before getting the disease.High-risk procedures
High-risk procedures include intentional actions that are taken by the HCW in order to help a patient. They are considered high-risk because the chances of a disease being transmitted during these procedures are far greater than typical direct or indirect contact with a patient. While there are myriad high-risk procedures, those that are SARS-specific include intubation, manual ventilation, nebulizer therapy, and several others. As was highlighted in the study, fourteen of the seventeen HCWs taking part in the study were involved in some high-risk procedure in the 10 days before getting the disease.Indirect contact by patient
While direct contact involves the physical contact of two people, indirect contact does not. Instead, indirect contact "occurs when there is no direct human-to-human contact," and it can involve contact of a human with a contaminated surface, which are known as fomites. The most plausible cases of transmission through indirect contact are when an HCW or healthy person touches a surface contaminated with droplets from an infected patient's sneeze or cough or inhales those droplets themselves. At the same time, if the droplets come in contact with the healthy person's mouth, eye, or nose, the healthy person also risks becoming ill. Other types of high-risk events include diarrhea and vomiting, which can very easily contaminate a HCW with bacteria or fluid that contains the SARS disease through indirect contact. Regarding coming into contact with contaminated surfaces or fomites, many HCWs had habits of wearing jewelry, eating lunch on site or in designated cafeterias, wearing glasses, using makeup, etc., which are all potential new fomites that could foster the transmission of disease. Just like with direct contact, all seventeen HCWs participating in the study encountered some type of high-risk event in the 10 days before getting the disease.Equipment inadequacy
One large guideline for HCWs in Toronto hospitals was the use of sufficient and protective equipment to avoid transmission of the disease. The most widely suggested and used pieces of equipment were masks, gowns, gloves, and eye protection. While these pieces of equipment were used by most HCWs, they were not always used—if at all—by everyone, allowing SARS transmission to take place more easily.Masks
s were suggested to be used by both HCWs and patients. This is because the specifically recommended type of masks do a good job of preventing one's own bacteria and fluid from escaping into the air—keeping both a patient and a HCW's bacteria and fluid to themselves. Less intentionally but also important, these masks discourage patients and HCWs from putting their fingers or hands in contact with the nose and mouth, which could usually allow bacteria to spread from the hand to these areas. Contrary to popular belief, some types of masks do little to prevent fluid and bacteria from coming in contact with the wearer of the mask, but they can still help prevent airborne infection. Therefore, it is important that both the patient and the HCW wear the mask. However, the aforementioned study's results indicate that HCWs wore them much more often than the patients themselves; in fact, fourteen of the HCWS always wore their mask, while only 1 of the patients always wore his/her mask.Gowns
s are another piece of equipment used by HCWs during the outbreak. Used mostly for those who are having trouble changing/moving their lower body, gowns are easy for patients to put on when they are bedridden. They are also helpful for HCWs to attempt to avoid contamination, as the gowns can be removed and disposed of easily after an operation or interaction with a patient. While seemingly less critical than masks, gowns were worn nearly the same amount by HCWs as masks.Gloves
s, like masks and gowns, also serve the purpose of preventing contamination of disease by blocking contact between the hands and the various bacteria, fluid, and fomites that carry the disease. HCWs can again, like gowns, easily dispose of and change gloves in order to help improve and maintain good sanitary conditions. Compared to all of the other pieces of equipment, gloves were worn the most often by HCWs who contracted the disease.Eye protection
HCWs used and continue to use a variety of eye protection, like personal and safety glasses, goggles, and face shields, but most relied on face shields and goggles when dealing with SARS patients. In general, eye protection is most helpful in blocking any harmful particles from entering the eye of a HCW. One distinction between eye protection and the other types of equipment, however, is that eye protection is often reusable. This characteristic of eye protection therefore makes understanding the methods used to clean the eye protection equipment a factor when assessing the success of using eye protection to prevent disease transmission. These include how often the equipment is cleaned, what is used to clean the equipment, and the location of where the equipment is being cleaned. While nearly all HCWs that contracted the disease reported that they wore some form of eye protection, many of them inadequately washed their eye equipment and did so in a SARS unit.Psychological effects
During outbreaks like the SARS outbreak in 2002–2003, HCWs are put under significantly greater amounts of stress and pressure to help cure patients and relieve them of disease. Because there was no known cure for SARS, the pressure and stress was especially prominent among HCWs. With this challenge came many psychological effects—most notably stress.Stress was a psychological effect experienced by many HCWs during the outbreak. This stress resulted from the fatigue and pressure of having to work longer hours and shifts in attempt to improve the treatment and the containment of the disease. Meanwhile, many HCWs refrained from returning home in between shifts to avoid the possibility of transmitting the disease to family members or others in the community, which only exacerbated the emotional and physical stress and fatigue that the HCWs experienced. Even more, the occupational stress of the HCWs only grew by dealing with sick and often dying patients. This stress has the capability to ease the transmission of the disease, which is a large reason for it being a cause of the disease in HCWs. This is because, as HCWs become more stressed and tired, they compromise the strength of their immune system. As a result, HCWs are more prone to actually getting the disease when they encounter certain causes of transmission, like the high-risk performance causes above.