Market2002–2004 SARS outbreak among healthcare workers
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2002–2004 SARS outbreak among healthcare workers

The rapid spread of severe acute respiratory syndrome (SARS) in healthcare workers (HCW)—most notably in Toronto, Ontario hospitals—during the global outbreak of SARS in 2002–2003 contributed to dozens of identified cases, some of them fatal.

Background
SARS spread around the world from the Guangdong Province of China, to multiple locations, like Hong Kong and then Toronto, Canada from 2002 to 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 (without knowing that they had the disease). 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 (Provincial Operating Centre) 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. 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 (described below) led to the development of the disease in HCWs more than anything else. ==Retrospect==
Retrospect
In retrospect, according to infectious disease specialist Allison McGeer of the Sinai Health System, Ontario officials "clearly did enough right to control the outbreak". Emergency measures included: • premier Ernie Eves declared SARS a provincial emergency • overnight, all hospitals required to create units to care for SARS patients • Ontario activated its multi-ministry provincial operations centre for emergency response • all hospitals in the Greater Toronto Area and Simcoe County instructed to activate "Code Orange" emergency plans, which entailed suspending all non-essential services • visitor limitations imposed • isolation unit created for possible SARS patients • protective clothing mandates implemented for exposed staff • four days later, officials extended access restrictions to all hospitals in Ontario As further determined in retrospect, some measures taken at the time were more extreme than necessary: • imposition of quarantine on the presymptomatic exposed was excessive because "SARS is among the unusual infections that was not infectious before people got sick", although this was not certain knowledge at the time • extent of hospital closures and disruption to general care greater than necessary because of poor data collection on likely patterns of spread among hospitals Broadly, the right measures were taken within the system, but insufficient training of HCWs lead to an implementation shortfall. == Causes of transmission ==
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. 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". 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. 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. 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. 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. 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. 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. These factors collectively allowed the disease to spread much quicker at first, infecting HCWs who knew little about the method of transmission of the disease. They were therefore unable to adequately protect themselves from the disease, and communication surrounding disease treatment and prevention was inhibited by their lack of knowledge. Inadequate training for HCWs In addition to the POC's release of its set of SARS-specific directives in 2003, there was also training that was to be completed by HCWs planning to deal with and care for SARS patients. This training included video sessions and other lessons equipping HCWs for safe interactions with SARS patients. Unfortunately, not all of this training was done—if at all—before HCWs began to interact with SARS patients. Over a third of HCWs never received any type of formal training, and half of those receiving any formal training received it after they had begun to interact with and care for SARS patients. At the same time, many of the HCWs receiving training received it from another HCW, allowing for the possibility of some error in the training. Aside from this type of training, many HCWs complained that most efforts—which included only posting informational posters in the wards—were inadequate. == Prevention and treatment in the future ==
Prevention and treatment in the future
After the large outbreak of SARS in 2002–2003, many doctors and organizations, such as the CDC, published a new set of recommendations and guidelines on preventing and dealing with possible outbreaks or cases of SARS in the future. They “revised the draft based on comments received from public health partners, healthcare providers, and others” in November 2003 in order to improve prevention and treatment success throughout the world. The document is divided into several sections, which include guidelines targeted specifically towards HCWs (e.g. “Preparedness and Response in Healthcare Facilities”) and other proactive measures directed towards whole communities (e.g. “Communication and Education” and “Managing International Travel-Related Transmission Risk”). Fortunately, various governments, health-focused non-profits, and research groups have been working with the CDC and other organizations to try and successfully find a cure for the disease. Prevention Because there is no effective cure for SARS yet, types of prevention, including sanitary and cautionary methods (e.g. hand-washing and wearing a surgical mask) remain some of the best ways to prevent the spread of the disease. Even more, lessons learned from the 2002-2003 outbreak point out that greater knowledge about the disease and its methods of transmission, better and more effective training for HCWs, and potential stress-reducers for HCWs dealing with SARS patients, will all help prevent the disease from being transmitted to HCWs and others in the future. == Further reading and external links ==
Further reading and external links
Severe acute respiratory syndrome: Wikipedia's article on SARS for further information on the symptoms, diagnosis, treatments, history, etc. of SARS in general. • SARS: CDC's main webpage on SARS, including information about the disease, guidelines for treatment and prevention, groups with risk for the disease, etc. • SARS: LESSONS FROM TORONTO Information on the chronology of the SARS outbreak in Toronto regarding average citizens and HCWs. • Cluster of Cases of Severe Acute Respiratory Syndrome Among Toronto Healthcare Workers After Implementation of Infection Control Precautions: A Case Series Full Study referenced in article regarding causes of SARS in Toronto HCWs. • Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) CDC's set of recommendations and guidelines on preventing and dealing with SARS in future that is referenced earlier in the article. • Transmission (medicine): Wikipedia article that provides more extensive detail on the methods of disease transmission in general; includes but is not limited to information applying to SARS transmission. • SARS News and Alerts Archive: provides relevant news articles and updates published from 2003 to 2004 regarding SARS cases that popped up in that time. == References ==
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