SARS lesson: Err on side of infection control precautions to protect HCWs

Safety can't wait for science

Hospitals must act swiftly to protect health care workers from infectious diseases, even when the scientific evidence is unclear about transmission. Failing to do so put health care workers at greater risk during the emergence of severe acute respiratory syndrome (SARS) in 2005.

That is the conclusion of a stinging report from the SARS Commission in Ontario, Canada, with direct implications for preparedness for pandemic influenza. Safety should have superceded the debates over the use of N95 respirators vs. surgical masks, aerosol vs. droplet spread, and the need for fit-testing, concluded Ontario Superior Court Justice Archie Campbell, who served as commissioner of the Commission to Investigate the Introduction and Spread of Severe Acute Respiratory Syndrome (SARS).

Two nurses and a doctor died in the 2003 Ontario outbreak and 45% of the 375 probable cases were among health care workers.

"The point is not who is right and who is wrong about airborne transmission," wrote Campbell. "The point is not science, but safety. Scientific knowledge changes constantly. Yesterday's scientific dogma is today's discarded fable. When it comes to worker safety in hospitals, we should not be driven by the scientific dogma of yesterday or even the scientific dogma of today.

"We should be driven by the precautionary principle that reasonable steps to reduce risk should not await scientific certainty. Until this precautionary principle is fully recognized, mandated and enforced in Ontario's hospitals, workers will continue to be at risk."

Campbell also endorsed stronger worker safety regulation in hospitals, including more inspections.

Linda Haslam-Stroud, RN, president of the Ontario Nurses Association (ONA), lauded the report as a "wake-up call for the government and the employers in Ontario." It also has received attention in the United States as hospitals gear up their pandemic influenza plans.

"It's an excellent description of the state of health care worker health and safety, not just in Canada but in the U.S.," says Bill Borwegen, MPH, occupational safety and health director for the Service Employees International Union (SEIU). "There are perennial issues that have not been adequately addressed."

Nurses need to trust in protections

Clearly, pandemic influenza differs from SARS in important ways. Surveillance is likely to detect the first human-to-human transmission of a novel flu strain before it reaches North America. And while the SARS outbreaks occurred in hospitals, influenza spreads widely across communities.

But the lessons of SARS still apply. Nurses continued to work during the SARS epidemic, despite their fears of becoming ill or infecting their family members. Yet when a second wave of cases occurred after public health authorities claimed the outbreak was over — despite concerns raised by frontline nurses — nurses lost the sense of trust that they were receiving adequate protection, says Haslam-Stroud. The ONA has sued the government of Ontario for failing to enforce health and safety standards at hospitals.

"The nurses in Ontario have very clearly said, 'You provide us the protection we need or we are not going to put our lives and our families' lives at risk [during pandemic influenza],'" she says. "We have learned the hard way with SARS that the government and employers unfortunately didn't take our protection as seriously as they should have."

U.S. nurses also are concerned about their protection from infectious diseases. Less than half (48%) of employees would be willing to report to work during a SARS outbreak, according to a survey of 6,428 workers from 47 health care facilities in the greater New York City area by researchers at the Mailman School of Public Health of Columbia University in New York.

Yet health care workers did continue to work in Toronto, even as their colleagues succumbed to the illness. "I was amazed by the response of health care workers, mostly nurses, to step up to the plate and care for patients in the face of danger," says Donald Low, MD, FRCP, chief of microbiology at Mount Sinai Hospital, who was involved in the SARS outbreak containment. "It was not only in the early days of SARS, but also after there was thought to be transmission through precautions."

Still, the SARS experience may make health care workers wary if they felt they weren't adequately protected, Low says. Frontline workers need to be involved in the development of policies and procedures that would be used during future outbreaks of an emerging infectious disease, he says.

Employee health and infection control professionals will need to address this legacy of SARS as they plan for pandemic influenza, employee health experts say. "If [health care workers] don't feel that they're protected at work, if they think for a minute they'll take this home [to their families], they won't come to work," says
Gabor Lantos, MD, PEng, MBA, president of Occupational Health Management Services in Toronto.

Some hospitals failed to fit-test

Low acknowledges that mistakes were made in Toronto hospitals, particularly the failure to realize the importance of fit-testing the N95 respirators. But he insists that "the protection of all health care workers was taken seriously right from the beginning."

In fact, Toronto hospitals had consumed the available supply of N95s, he says. "If the outbreak had gone on any longer, there wouldn't have been any more to buy," he says. "We literally bought the last shipment."

When health officials realized that illness was spreading from a novel virus, the hospital immediately began using personal protective equipment and isolating patients in a negative pressure room.

But there was a delay in detecting the first cases and understanding their significance. The first Toronto victim of SARS flew home on Feb. 23, after staying in the Hong Kong Metropole Hotel, later identified as the site of global spread. A physician from Guangdong Province in China who had treated patients in an outbreak of atypical pneumonia was a fellow hotel guest — and he was ill.

"Mrs. K" developed a high fever and dry cough, and when she died at home in Toronto on March 5, her cause of death was listed as heart attack. Her son soon became ill, and he was brought to Scarborough Grace Hospital on March 7 by ambulance. (Two patients in the emergency department subsequently developed SARS.)

However, no one yet connected this illness to the "atypical pneumonia" that China had reported or the outbreak in Hong Kong. "Mr. T" was not isolated until 21 hours after he arrived in the emergency department. In fact, even the following days, the hospital was slow in implementing the highest level of infection control measures, says Low.

"When it was recognized on March 13 or March 14 that we had a problem because of what happened in Hong Kong and what was going on in Hanoi (where SARS spread), that's when the alert should have been sounded," he says. "It was difficult convincing people that we had a big problem on our hands here."

On March 25, Scarborough Grace Hospital was shut down because of the SARS outbreak and on March 26, Toronto hospitals went into a Code Orange, suspending nonessential procedures, restricting visitors, sending home administrative staff, and putting nurses on a work-home quarantine. Everyone still working in the hospitals wore gowns, gloves and N95s.

Meanwhile, infection control had received little attention and few resources prior to the SARS outbreak, and provincial laws on fit-testing were ignored, the SARS commission reported. Even during the SARS epidemic, some infection control practitioners continued to argue that the disease was spread by droplets and N95s were not necessary except during aerosol-producing procedures, the commission reported.

The SARS commission report questions the distinction between airborne and droplet spread, but says that scientific debate shouldn't dictate safety precautions. "The real problem is not the N95 respirator but the deep structural contradictions in hospital worker safety. These problems include a profound lack of awareness within the health system of worker safety best practices and principles," it says.

Today, Mount Sinai Hospital fit-tests employees annually, as do other Toronto hospitals. Throughout the province, new investments have been made in infection control and public health. "There is no question that there have been lessons learned and people are taking that to heart," Low says. "It's refreshing to see that kind of interest in public health and infection control again."

Outbreak averted in B.C.

One other lesson of SARS comes from Vancouver, where a prevailing culture of safety prevented a potential outbreak, the SARS commission concluded.

"Mr. C" had stayed in the Metropole Hotel, then visited Indonesia before returning to Vancouver on March 7. He was sick on the plane and went directly from the airport to the emergency department at Vancouver General.

He was immediately isolated in a curtained cubicle where beds are at least 2.5 meters from other patient beds. Within 15 minutes, he was placed on full respiratory precautions. Within 2½ hours, he was placed in a negative pressure room.

Vancouver had the advantage of more information about the spread of an atypical pneumonia in Asia. The hospital had a policy of using the highest level of precautions with an undiagnosed respiratory illness until there is further information, the report said.

British Columbia also had developed a pandemic influenza plan, which played a key role in preventing the spread of SARS, the commission report stated. The Workers Compensation Board issued guidelines on how to protect health care workers and conducted inspections of hospitals to make sure they were being carried out.

Only one nurse contracted SARS in Vancouver, and there was no nosocomial spread to patients or visitors.

"SARS taught us that we must be ready for the unseen," Justice Campbell concluded in his report. "That is one of the most important lessons of SARS. Although no one did foresee and perhaps no one could foresee the unique convergence of factors that made SARS a perfect storm, we know now that new microbial threats like SARS have happened and can happen again.

"However, there is no longer any excuse for governments and hospitals to be caught off-guard and no longer any excuse for health workers not to have available the maximum level of protection through appropriate equipment and training," he continued.

(Editor's note: The SARS Commission report is available at