The 2003 SARS outbreak and its impact on infection control practices
Identifieur interne : 001449 ( Pmc/Corpus ); précédent : 001448; suivant : 001450The 2003 SARS outbreak and its impact on infection control practices
Auteurs : Karen ShawSource :
- Public Health [ 0033-3506 ] ; 2005.
Abstract
Severe Acute Respiratory Syndrome (SARS) emerged recently as a new infectious disease that was transmitted efficiently in the healthcare setting and particularly affected healthcare workers (HCWs), patients and visitors. The efficiency of transmission within healthcare facilities was recognised following significant hospital outbreaks of SARS in Canada, China, Hong Kong, Singapore, Taiwan and Vietnam.
The causative agent of SARS was identified as a novel coronavirus, the SARS coronavirus. This was largely spread by direct or indirect contact with large respiratory droplets, although airborne transmission has also been reported. High infection rates among HCWs led initially to the theory that SARS was highly contagious and the concept of ‘super-spreading events’. Such events illustrated that lack of infection control (IC) measures or failure to comply with IC precautions could lead to large-scale hospital outbreaks. SARS was eventually contained by the stringent application of IC measures that limited exposure of HCWs to potentially infectious individuals. As the ‘global village’ becomes smaller and other microbial threats to health emerge, or re-emerge, there is an urgent need to develop a global strategy for infection control in hospitals.
This paper provides an overview of the main IC practices employed during the 2003 SARS outbreak, including management measures, dedicated SARS hospitals, personal protective equipment, isolation, handwashing, environmental decontamination, education and training. The psychological and psychosocial impact on HCWs during the outbreak are also discussed. Requirements for IC programmes in the post-SARS period are proposed based on the major lessons learnt from the SARS outbreak.
Url:
DOI: 10.1016/j.puhe.2005.10.002
PubMed: 16297415
PubMed Central: 7118748
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PMC:7118748Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">The 2003 SARS outbreak and its impact on infection control practices</title><author><name sortKey="Shaw, Karen" sort="Shaw, Karen" uniqKey="Shaw K" first="Karen" last="Shaw">Karen Shaw</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">16297415</idno><idno type="pmc">7118748</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7118748</idno><idno type="RBID">PMC:7118748</idno><idno type="doi">10.1016/j.puhe.2005.10.002</idno><date when="2005">2005</date><idno type="wicri:Area/Pmc/Corpus">001449</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001449</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">The 2003 SARS outbreak and its impact on infection control practices</title><author><name sortKey="Shaw, Karen" sort="Shaw, Karen" uniqKey="Shaw K" first="Karen" last="Shaw">Karen Shaw</name></author></analytic><series><title level="j">Public Health</title><idno type="ISSN">0033-3506</idno><idno type="eISSN">1476-5616</idno><imprint><date when="2005">2005</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>Summary</title><p>Severe Acute Respiratory Syndrome (SARS) emerged recently as a new infectious disease that was transmitted efficiently in the healthcare setting and particularly affected healthcare workers (HCWs), patients and visitors. The efficiency of transmission within healthcare facilities was recognised following significant hospital outbreaks of SARS in Canada, China, Hong Kong, Singapore, Taiwan and Vietnam.</p><p>The causative agent of SARS was identified as a novel coronavirus, the SARS coronavirus. This was largely spread by direct or indirect contact with large respiratory droplets, although airborne transmission has also been reported. High infection rates among HCWs led initially to the theory that SARS was highly contagious and the concept of ‘super-spreading events’. Such events illustrated that lack of infection control (IC) measures or failure to comply with IC precautions could lead to large-scale hospital outbreaks. SARS was eventually contained by the stringent application of IC measures that limited exposure of HCWs to potentially infectious individuals. As the ‘global village’ becomes smaller and other microbial threats to health emerge, or re-emerge, there is an urgent need to develop a global strategy for infection control in hospitals.</p><p>This paper provides an overview of the main IC practices employed during the 2003 SARS outbreak, including management measures, dedicated SARS hospitals, personal protective equipment, isolation, handwashing, environmental decontamination, education and training. The psychological and psychosocial impact on HCWs during the outbreak are also discussed. Requirements for IC programmes in the post-SARS period are proposed based on the major lessons learnt from the SARS outbreak.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Varia, M" uniqKey="Varia M">M. Varia</name></author><author><name sortKey="Wilson, S" uniqKey="Wilson S">S. Wilson</name></author><author><name sortKey="Sarwal, S" uniqKey="Sarwal S">S. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Public Health</journal-id><journal-id journal-id-type="iso-abbrev">Public Health</journal-id><journal-title-group><journal-title>Public Health</journal-title></journal-title-group><issn pub-type="ppub">0033-3506</issn><issn pub-type="epub">1476-5616</issn><publisher><publisher-name>The Royal Institute of Public Health. Published by Elsevier Ltd.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">16297415</article-id><article-id pub-id-type="pmc">7118748</article-id><article-id pub-id-type="publisher-id">S0033-3506(05)00236-2</article-id><article-id pub-id-type="doi">10.1016/j.puhe.2005.10.002</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>The 2003 SARS outbreak and its impact on infection control practices</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Shaw</surname><given-names>Karen</given-names></name><email>karen.shaw@hpa.org.uk</email><xref rid="cor1" ref-type="corresp">⁎</xref></contrib></contrib-group><aff>Health Protection Agency, South East Regional Office, 6th Floor New Court, 48 Carey Street, London WC2A 2JE, UK</aff><author-notes><corresp id="cor1"><label>⁎</label>Corresponding author. Tel.: +44 20 74920431; fax: +44 20 74920481. <email>karen.shaw@hpa.org.uk</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>16</day><month>11</month><year>2005</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="ppub"><month>1</month><year>2006</year></pub-date><pub-date pub-type="epub"><day>16</day><month>11</month><year>2005</year></pub-date><volume>120</volume><issue>1</issue><fpage>8</fpage><lpage>14</lpage><permissions><copyright-statement>Copyright © 2005 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.</copyright-statement><copyright-year>2005</copyright-year><copyright-holder>The Royal Institute of Public Health</copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract><title>Summary</title><p>Severe Acute Respiratory Syndrome (SARS) emerged recently as a new infectious disease that was transmitted efficiently in the healthcare setting and particularly affected healthcare workers (HCWs), patients and visitors. The efficiency of transmission within healthcare facilities was recognised following significant hospital outbreaks of SARS in Canada, China, Hong Kong, Singapore, Taiwan and Vietnam.</p><p>The causative agent of SARS was identified as a novel coronavirus, the SARS coronavirus. This was largely spread by direct or indirect contact with large respiratory droplets, although airborne transmission has also been reported. High infection rates among HCWs led initially to the theory that SARS was highly contagious and the concept of ‘super-spreading events’. Such events illustrated that lack of infection control (IC) measures or failure to comply with IC precautions could lead to large-scale hospital outbreaks. SARS was eventually contained by the stringent application of IC measures that limited exposure of HCWs to potentially infectious individuals. As the ‘global village’ becomes smaller and other microbial threats to health emerge, or re-emerge, there is an urgent need to develop a global strategy for infection control in hospitals.</p><p>This paper provides an overview of the main IC practices employed during the 2003 SARS outbreak, including management measures, dedicated SARS hospitals, personal protective equipment, isolation, handwashing, environmental decontamination, education and training. The psychological and psychosocial impact on HCWs during the outbreak are also discussed. Requirements for IC programmes in the post-SARS period are proposed based on the major lessons learnt from the SARS outbreak.</p></abstract><kwd-group><title>Keywords</title><kwd>Severe Acute Respiratory</kwd><kwd>Syndrome</kwd><kwd>Healthcare workers</kwd><kwd>Infection control</kwd></kwd-group></article-meta></front><body><sec><title>Introduction</title><p>Severe acute respiratory syndrome (SARS) has emerged recently as a new acute respiratory illness that spread rapidly across the world resulting in 8096 cases and 774 deaths.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> During the 2003 outbreak SARS was transmitted efficiently among healthcare workers (HCWs), patients and hospital visitors. Documented hospital outbreaks of SARS occurred in Canada, China, Hong Kong, Singapore, Taiwan and Vietnam and highlighted the weak infection control (IC) infrastructure present in healthcare facilities in resource rich and resource poor areas.<xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib6" ref-type="bibr">6</xref>, <xref rid="bib7" ref-type="bibr">7</xref> The morbidity and mortality seen in HCWs as a result of SARS focused attention on IC practices, including the use of personal protective equipment (PPE), and the role of education and training in the prevention of SARS. Indeed, one of the major lessons learnt from the SARS outbreak was that IC practices and programmes need strengthening globally.</p><p>This paper summarises the main IC practices employed during the 2003 SARS outbreak and suggests requirements for IC programmes in the post-SARS period. The content of this paper is based upon personal observation and experience before, during and after the SARS epidemic, a review of the scientific literature, attending conferences and meetings and discussions with colleagues directly involved in efforts to contain SARS.</p><p>IC practices within the laboratory environment are also an important issue particularly as a number of laboratory-related incidents occurred following containment of the initial outbreak. However, they are not discussed in this paper.</p></sec><sec><title>Transmission</title><p>Before discussing the role of IC as a component of the public health response to the containment of SARS, it is necessary to have an understanding of how SARS is transmitted.</p><p>The causative agent of SARS was identified as a novel coronavirus, the SARS coronavirus (SARS-CoV).<xref rid="bib8" ref-type="bibr">8</xref>, <xref rid="bib9" ref-type="bibr">9</xref> Epidemiological data indicate that the virus is largely spread by direct or indirect contact with respiratory droplets, airborne transmission has also been reported.<xref rid="bib10" ref-type="bibr">10</xref>, <xref rid="bib11" ref-type="bibr">11</xref> Initially, as a result of early reports of high infection rates among HCWs, SARS was thought to be highly contagious. This was reinforced with the reporting of ‘super-spreading events’.<xref rid="bib1" ref-type="bibr">1</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib12" ref-type="bibr">12</xref>, <xref rid="bib13" ref-type="bibr">13</xref>, <xref rid="bib14" ref-type="bibr">14</xref>, <xref rid="bib15" ref-type="bibr">15</xref> The concept of super-spreading events has been proposed to explain incidents where a SARS patient infects many more persons than would be expected. Such events contributed to large-scale nosocomial outbreaks and have been attributed to the lack of stringent IC measures in hospitals. However, this does not fully explain these events and further research is required to understand the underlying risk factors. Aerosol-generating procedures have been associated with increased risk of transmission through the aerosolisation of virus-containing particles.<xref rid="bib16" ref-type="bibr"><sup>16</sup></xref> In addition patients with unrecognised SARS, particularly those with atypical presentations were the source of a number of nosocomial outbreaks.<xref rid="bib13" ref-type="bibr">13</xref>, <xref rid="bib15" ref-type="bibr">15</xref></p><p>As the outbreak evolved SARS was shown to be only moderately transmissible with an estimated basic reproductive number of approximately three.<xref rid="bib17" ref-type="bibr">17</xref>, <xref rid="bib18" ref-type="bibr">18</xref> The basic reproductive number refers to the average number of secondary cases generated by one primary case in a susceptible population. For SARS this is much lower than for influenza, and unlike influenza and other viral respiratory diseases, SARS-CoV has a long incubation period (up to 14 days), with the viral load peaking during the second week of illness and appearing to be highest in patients with more severe disease.<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> This may explain why transmission has not been identified in asymptomatic patients or after symptoms have resolved, and why transmission mainly occurs in hospitals.</p></sec><sec><title>Infection control practices during the SARS outbreak</title><p>The World Health Organization (WHO) coordinated the global response to SARS and together with a number of technical partners including the Global Outbreak Alert and Response Network (GOARN) provided support, including field teams, to health authorities to combat SARS.<xref rid="bib19" ref-type="bibr"><sup>19</sup></xref> WHO also established a number of virtual networks which linked clinicians, epidemiologists, microbiologists, virologists, public health experts, IC practitioners and others enabling the rapid exchange of data and information.<xref rid="bib19" ref-type="bibr"><sup>19</sup></xref> These discussion groups, particularly those of the clinical network, helped fashion the IC guidance provided by WHO on its website. Many countries and regions employed WHO or other IC guidelines directly, or modified them to suit local circumstances.<xref rid="bib20" ref-type="bibr"><sup>20</sup></xref></p><p>Early in the course of the epidemic hospital outbreaks of SARS occurred in Canada, China, Hong Kong, Singapore, Taiwan, and Vietnam.<xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib6" ref-type="bibr">6</xref>, <xref rid="bib7" ref-type="bibr">7</xref> A total of 1706 cases of SARS occurred among HCWs and their distribution varied by country.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> Major IC measures implemented in hospitals to control the outbreak included the following.</p><sec><title>Management measures</title><p>These were implemented to prevent further transmission of infection on the wards as well as in the outpatient setting and, to provide reassurance to healthcare workers and the wider community. Management measures included: closure of hospitals; written policies for SARS IC practices; triage screening; restriction of hospital visitors; limiting non-essential contact between HCWs and patients; closure of emergency departments (ED); and the use of masks by HCWs, patients and hospital visitors.<xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib21" ref-type="bibr">21</xref>, <xref rid="bib22" ref-type="bibr">22</xref>, <xref rid="bib23" ref-type="bibr">23</xref>, <xref rid="bib24" ref-type="bibr">24</xref>, <xref rid="bib25" ref-type="bibr">25</xref> However, despite IC policies being made available during the SARS outbreak, direct observation indicated that they were not applied consistently.<xref rid="bib22" ref-type="bibr">22</xref>, <xref rid="bib26" ref-type="bibr">26</xref></p></sec><sec><title>Dedicated SARS hospitals</title><p>In a number of areas that had major outbreaks of SARS, one or more hospitals were designated to manage SARS patients exclusively.<xref rid="bib22" ref-type="bibr">22</xref>, <xref rid="bib27" ref-type="bibr">27</xref> Early on in the outbreak this led to the inadvertent spread of SARS as patients discharged to provide beds for incoming suspect and probable SARS cases were themselves incubating SARS and acted as ‘Trojan horses’ carrying SARS-CoV with them and starting nosocomial outbreaks elsewhere. It is unclear whether the designation of a SARS hospital is an effective method of controlling the spread of the SARS-CoV. However, among the lessons learnt from this was that patients should be isolated rather than transferred to other hospitals.</p></sec><sec><title>Personal protective equipment</title><p>During the SARS outbreak experts were divided on the adequacy of IC measures, types of PPE that should be used and the need for protective eyewear. There were reports that masks, fit testing and fit checking practices varied and did not always take place.<xref rid="bib28" ref-type="bibr"><sup>28</sup></xref> However, subsequent evidence has shown that the use of a mask, either surgical or an N95 respirator (or equivalent), was protective compared to no mask.<xref rid="bib28" ref-type="bibr"><sup>28</sup></xref> It was also reported from Toronto that SARS was less likely to develop if a mask was used consistently with each patient contact.<xref rid="bib29" ref-type="bibr"><sup>29</sup></xref> This is supported by evidence from Hong Kong which suggests that HCWs who used complete precautionary measures were less likely to become infected than those who omitted even one precautionary measure.<xref rid="bib30" ref-type="bibr"><sup>30</sup></xref> However, there is evidence that some HCWs were infected with SARS following exposure to aerosol- and droplet-generating procedures despite wearing full PPE (that is N95 mask (or equivalent), gown, eye protection and gloves).<xref rid="bib6" ref-type="bibr">6</xref>, <xref rid="bib16" ref-type="bibr">16</xref>, <xref rid="bib19" ref-type="bibr">19</xref>, <xref rid="bib31" ref-type="bibr">31</xref> A number of reasons were proposed for this including incomplete compliance with infection control guidance such as removing PPE unsafely, reuse of single use PPE, not having masks correctly fitted prior to use and not using eye protection. In contrast, a retrospective study reported that 70% (72/102) of HCWs in the United States who cared for SARS patients did not use eye protection.<xref rid="bib32" ref-type="bibr"><sup>32</sup></xref> Furthermore, no documented transmission of SARS-CoV was reported, even among those who had been within 3 feet of a confirmed case.</p><p>Although it is generally agreed that the widespread use of PPE was effective in controlling the spread of SARS in the hospital environment, the costs were prohibitive. In Singapore where routine use of PPE was instituted early in the epidemic, it is estimated that in the first 6 weeks of the epidemic US$700 000 was spent on PPE alone.<xref rid="bib33" ref-type="bibr"><sup>33</sup></xref> Furthermore, inappropriate use of PPE and respirators resulted in shortages and guidelines had to be developed to prioritise those who should use respirators and where they should be worn.<xref rid="bib22" ref-type="bibr">22</xref>, <xref rid="bib23" ref-type="bibr">23</xref> This demonstrates the importance of planning and preparedness, particularly with regard to supplies of essential equipment.</p></sec><sec><title>Isolation</title><p>Isolation refers to the separation and restricted movement of ill persons who have a contagious disease in order to prevent its transmission to others.<xref rid="bib34" ref-type="bibr"><sup>34</sup></xref> Isolation measures typically occur in a hospital setting and may be applied to individuals or larger groups to interrupt disease transmission. During the SARS outbreak rapid identification and isolation of SARS patients together with rapid identification and management of contacts proved to be highly effective in interrupting transmission. However, isolation practices varied both between and within countries. This was most likely due to important variations in resources and IC practices.</p><p>WHO recommended that probable SARS patients be placed in a negative pressure room, isolated in a single room or cohorted in areas with independent air circulation.<xref rid="bib35" ref-type="bibr"><sup>35</sup></xref> In response to this a number of countries and areas designated certain hospitals or wards for SARS patients only. Others constructed new isolation wards and rooms or carried out extensive engineering modifications to existing structures.<xref rid="bib22" ref-type="bibr">22</xref>, <xref rid="bib36" ref-type="bibr">36</xref>, <xref rid="bib37" ref-type="bibr">37</xref>, <xref rid="bib38" ref-type="bibr">38</xref> Those lacking such facilities and resources responded with innovative solutions. Three examples were: hospital staff attempting to create negative-pressure relative to hallways by using fans and windows opening to the exterior; the development of guidelines to enable the re-use of respirators; and the erection of glass walls in hallways to create anterooms to patients' rooms.<xref rid="bib7" ref-type="bibr">7</xref>, <xref rid="bib22" ref-type="bibr">22</xref></p></sec><sec><title>Physical space separation</title><p>There is evidence indicating that the risk of developing SARS was related to proximity to a case.<xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib39" ref-type="bibr">39</xref>, <xref rid="bib40" ref-type="bibr">40</xref> In one study a ‘Hierarchy of Risk’ was developed which showed that the risk of infection increased with proximity of contact, and that in the absence of aerosol-generating procedures, exposures <1 m from a case of SARS (with or without contact) were those that posed the highest risk.<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> These results suggest that physical separation of SARS patients from HCWs, hospital visitors and other patients should reduce the transmission of SARS. Indeed, in many of the areas with a large number of SARS cases several different measures were implemented in order to do this. These included the rapid identification and isolation of possible SARS patients waiting in Emergency Departments; isolating potential SARS patients either individually or in cohorts; designating lifts for use by potential SARS cases only; and, using anterooms for the donning and removal of PPE.<xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib7" ref-type="bibr">7</xref>, <xref rid="bib22" ref-type="bibr">22</xref>, <xref rid="bib23" ref-type="bibr">23</xref></p></sec><sec><title>Handwashing</title><p>Despite a number of studies demonstrating that handwashing is effective in reducing the transmission of pathogens, it is recognised that compliance among HCWs is poor.<xref rid="bib41" ref-type="bibr">41</xref>, <xref rid="bib42" ref-type="bibr">42</xref> Although there have not been any formal evaluations of the impact of handwashing on SARS-CoV transmission, recent evidence indicates that HCWs who washed their hands while caring for SARS patients were less likely to develop SARS compared to those that did not.<xref rid="bib30" ref-type="bibr"><sup>30</sup></xref></p></sec><sec><title>Environmental decontamination</title><p>SARS-CoV is present in all body fluids making precautions with waste disposal essential. There is also evidence of probable survival on inanimate hospital surfaces for up to 72 h.<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> The cleaning and disinfection of environmental surfaces in hospitals employing commonly used disinfectants is believed to be effective against SARS-CoV.<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> There is little research evidence, however, regarding the effectiveness of this practice in reducing hospital transmission of SARS.</p></sec><sec><title>Education and training</title><p>The SARS outbreak has highlighted the importance of educating and training all HCWs in complying with all IC recommendations. Not understanding IC training was associated with an increased risk of SARS infection.<xref rid="bib28" ref-type="bibr"><sup>28</sup></xref> Lack of ‘surge capacity’ in hospitals, particularly those with large numbers of infected HCWs, led to some of the following measures: cross-training of staff in IC and the recognition of potential SARS cases; reduction in nurse-patient and doctor-patient ratios; and, the implementation of shorter shifts and shorter working weeks.<xref rid="bib43" ref-type="bibr">43</xref>, <xref rid="bib44" ref-type="bibr">44</xref> One of the positive effects of this education and training was that it resulted in positive behavioural changes regarding IC practices. The challenge is ensuring that these behavioural changes are maintained.</p></sec><sec><title>Psychological and psychosocial impact</title><p>As a result of concern about transmission and the uncertainties associated with SARS, HCWs experienced anxiety, stress and poor morale. Other negative effects of the SARS outbreak among HCWs included: fear of infection; financial loss; stigmatisation; changes to personal and family lifestyle; caring for colleagues as patients; staff refusing to care for or assist with the triaging of SARS cases; concern for family and personal safety; and, masks interfering with work, family and social relationships.<xref rid="bib25" ref-type="bibr">25</xref>, <xref rid="bib45" ref-type="bibr">45</xref>, <xref rid="bib46" ref-type="bibr">46</xref>Taken together these factors would have contributed to increased stress levels, a heightened sense of social isolation and a reduction in effectiveness of healthcare provision, at a time when meticulous attention to detail was most needed.<xref rid="bib47" ref-type="bibr">47</xref>, <xref rid="bib48" ref-type="bibr">48</xref></p><p>Despite the reported negative effects of SARS on HCWs, a number of positive aspects were also identified. These included: an increased awareness of IC; identifying the SARS outbreak as a positive learning experience; an increased sense of togetherness and cooperation; and a greater appreciation of life and work.<xref rid="bib45" ref-type="bibr">45</xref>, <xref rid="bib46" ref-type="bibr">46</xref></p></sec></sec><sec><title>Infection control in the post-SARS period</title><p>Although it is widely acknowledged that hospital IC and prevention is an important issue, it is usually given a low priority and focuses mainly on physicians and nurses rather than all HCWs. Many basic IC measures are not universally applied and there are inequalities in the distribution of staff and resources, both between and within countries. However, common components have been identified which should be considered for inclusion in IC strategies in the post-SARS period.</p><p>At the national level there should be an IC programme, which would provide healthcare facilities with appropriate direction, guidance and support in preventing the spread of infection in healthcare facilities. This will ensure consistency of approach.<xref rid="bib49" ref-type="bibr"><sup>49</sup></xref> In those areas without existing legislation to make IC and prevention interventions mandatory, public health officials should promote meetings with policy makers to lobby for legislation to mandate that each hospital should have an IC committee (ICC) with a specified core membership and an appropriate IC infrastructure, including resources. Functions of the hospital ICC should include outbreak investigation, surveillance, reviewing local epidemiological data, educating staff, patients and visitors, developing and promoting local guidelines and estimating resource needs. The ICC should be multidisciplinary and include nursing, medical, laboratory, public health, pharmacy, occupational health, hospital management and engineering representatives.</p><p>IC guidelines should be developed, revised and updated regularly and compliance monitored and reinforced as part of an IC strategy.<xref rid="bib50" ref-type="bibr"><sup>50</sup></xref> Most will require HCWs to comply with hand hygiene which is the single most effective IC measure, they should also emphasise the safe donning, removal and disposal of PPE.<xref rid="bib51" ref-type="bibr"><sup>51</sup></xref> It is recognised that HCWs work within a wide range of financial, technological and human resource constraints and that policies should be adapted for local use employing locally available infrastructure. The design of health care facilities is therefore important and should support HCWs in their implementation of IC procedures. IC practitioners should be consulted when designing new hospitals and when other hospital buildings are being redesigned or renovated.<xref rid="bib52" ref-type="bibr"><sup>52</sup></xref></p><p>Prompt diagnosis is critical for any effective IC programme. This requires reliable and effective methods of surveillance with early detection of outbreaks and contact tracing in both the healthcare setting as well as in the community. As clinical diagnosis may not always be sufficiently reliable, rapid isolation and strict IC practices will need to be applied. Also, given that the clustering of fever and respiratory tract illness in HCWs was a feature of SARS, clusters of infection among staff members should be recognised and investigated.</p><p>Training of all HCWs in proper IC practices should begin during the initial years of their professional training and be regularly updated.<xref rid="bib53" ref-type="bibr"><sup>53</sup></xref> All staff in a health care facility should receive routine training and reinforcement regarding IC practices as well as targeted training when required for instance in outbreak situations or after the introduction of a new policy or intervention. This will provide ‘surge capacity,’ as well as increased preparedness to deal with unexpected outbreaks.</p><p>Attendance at regional and international training courses and meetings should be promoted in order to gain knowledge and establish links. Efforts should be made to collaborate with existing networks as well as establish and link national, regional and global networks in order to conduct research, coordinate activities, standardise practices, support educational activities and identify innovative IC measures.</p><p>Advances in technology mean that most countries have access to computer technology and the Internet. These can greatly assist in IC programmes in a variety of ways including surveillance, communication, and distance learning. Appropriate internal and external communication channels are essential. ICCs will therefore need to assess communication needs and capacity, and establish protocols to communicate data and information that will need to be reported during an outbreak or similar major hospital-based incident.</p><p>Quality improvement strategies, including the use of evaluation, audit and research, should be built-in to IC programmes. In addition, major outbreak plans should be developed, tested and regularly updated.</p></sec><sec><title>A window of opportunity</title><p>For many years IC has been considered a low priority and as a result was addressed in a limited and fragmented manner. Recent events such as the SARS, Ebola and avian influenza outbreaks and the continuing rise of healthcare associated infections, such as methicillin-resistant <italic>Staphylococcus aureus</italic> (MRSA), have challenged the international public health community to apply the lessons learnt from IC practices during the 2003 SARS outbreak on a global basis. Indeed, international experts and policy makers have gathered at regional consultations supported by WHO and recommended that a global strategy be developed for IC practices in order to establish international minimum standards.<xref rid="bib49" ref-type="bibr"><sup>49</sup></xref></p><p>In the wake of SARS, IC has been provided with a window of opportunity to revolutionise the way it is viewed and ensure that in future it is considered as a high priority. SARS has clearly demonstrated that IC is not only about implementing and following guidelines or knowing how to don and remove PPE. It is also about surveillance, surge capacity, information provision, consistent application of IC measures and an appropriate and adequate public health infrastructure. Many of the IC measures implemented during SARS are yet to be formally evaluated. 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In particular I would like to thank colleagues in the Western Pacific Regional Office, the China office, Headquarters, Geneva and South East Asia Regional Office. I would like to thank Professor Barry Cookson for his comments on the manuscript.</p></ack></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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