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Running head: SEVERE ACUTE RESPIRATORY SYNDROME Severe Acute Respiratory Syndrome an Emerging Infectious Disease Emily Gullena Ferris State University 1 SEVERE ACUTE RESPIRATORY SYNDROME 2 Abstract The transmission of SARS is examined. The isolation of the SARS-CoV virus and findings are discussed. The clinical presentation, diagnosis, and treatments for patients with SARS are identified. There is a brief category describing the biological, environmental, and situational factors regarding emerging infectious diseases. Also, considerations and applications for nurses and health care workers are explored. Keywords: SARS, infectious disease, transmission, isolation, clinical presentation, diagnosis SEVERE ACUTE RESPIRATORY SYNDROME 3 Severe Acute Respiratory Syndrome Severe Acute Respiratory Syndrome or SARS is a newly emerging infection that was first seen in China in late 2002 (Rhinehart, Jackson, & Chiarello, 2007). The viral respiratory illness quickly spread to more than two dozen countries including North America, South America, Europe, and throughout Asia before being contained (Veenema, 2007, p. 443). The mortality rate is less than 10% (Veenema, 2007, p. 444). Initially, 8,098 people became sick and 774 died from SARS complications (Veenema, 2007, p. 443). The virus was most fatal to the young, elderly, and people with chronic health issues (Veenema, 2007, p. 443). The SARS pandemic received a great deal of media exposure and caused fear in people who may have been exposed. Since the emergence of the SARS infection epidemiologists and health care workers have been able to state a mode of transmission of the virus, have isolated of the virus, identified signs and symptoms and a clinical presentation of the disease, found criteria for diagnosing SARS, initiated therapy for treatment, explored some of the environmental and situational factors that precipitate the disease, and have used evidenced based research to find the best practices for nursing care of SARS patients in the hospital setting. Transmission The SARS virus was first seen in people who traveled to China, Hong Kong, and Taiwan or those had close contact with someone that was in one of those countries (Veenema, 2007, p. 448). It was quickly identified as being spread by close contact and by droplet routes (Rhinehart et al., 2007). It is suggested that airborne transmission is possible with in a room (Rhinehart et al., 2007). It initially was been spread by large droplets on airplanes and from people who were at the Amoy Gardens where the virus originated in Hong Kong (Veenema, 2007, p. 443). SEVERE ACUTE RESPIRATORY SYNDROME 4 SARS is also found to be spread by small airborne droplets in hospitals (Veenema, 2007, p. 443). SARS transmission has been associated with exposure when performing procedures such as endotracheal intubation, when using noninvasive positive pressure ventilation, and during cardiopulmonary resuscitation (Rhinehart et al., 2007). Also, it is important to note that laboratories where SARS-CoV was being studied were the source of most cases reported after the initial outbreaks in the winter and spring of 2003 (Rhinehart et al., 2007). Preventing transmission in the public sector requires the use of a simple mask to protect people in close contact from large droplet transmission (Veenema, 2007, p. 443). In the hospital setting, it is recommended to wear N-95 masks, use hepa filters, and place the patient in a negative pressure room (Veenema, 2007, p. 443). Isolation SARS is caused by SARS CoV, a new member of the coronavirus family (Rhinehart et al., 2007). It was hard to diagnose initially because it presents similarly to many other respiratory illnesses. The incubation period of the SARS CoV virus is generally 2 to 7 days (Rhinehart et al., 2007). Some uncommon cases reported an incubation period of greater than 10 days (Rhinehart et al., 2007). The SARS-CoV virus can be grown in cell culture (Jiang, He, & Liu, 2005). It can live in urine and feces for up to 2 days (Jiang et al., 2005). Because the virus is fatal it is considered a Category C priority pathogen by the National Institute of Allergy and Infectious Diseases Biodefense agency (Jiang et al., 2005). Scientists are currently working on 3 types of vaccine development which includes using the inactivated SARS-CoV virus, a full-length S protein, and a vaccine based on fragments with neutralizing isotopes (Jiang et al., 2005). SEVERE ACUTE RESPIRATORY SYNDROME 5 Clinical Presentation The prodromal or early symptoms of SARS include a fever greater than 38 degrees Celsius, myalgia, headache, and diarrhea (Veenema, 2007, p. 444). Other early noted findings are chills, rigors, a sore throat, and rhinorrhea. Severe presentation, in addition to the early symptoms, would include a positive chest x-ray for pneumonia, Acute Respiratory Distress Syndrome (ARDS), and an autopsy that shows findings of SARS (Veenema, 2007, p. 445). Of course clinicians need to be aware of the patient’s recent activity or travel to areas with SARS outbreaks Diagnosis There is no rapid and reliable test at this time to diagnose SARS. Instead, a diagnosis of SARS is done by performing a chest radiograph, pulse oximetry, a complete blood count (CBC), blood cultures, sputum cultures, testing for influenza A and B, testing for legionella and pneumonia urinary antigens, and an RT-PCR test. Also, SARS can be identified by a serum antibody to SARS-CoV, isolation in cells of SARS-CoV, or detection of SARS-CoV in Ribonucleic acid (RNA) (Veenema, 2007, p. 444). Therapy At this time there is no known treatment for SARS outside of the supportive treatments that are available (Veenema, 2007, p. 444). A few patients that have the mildest symptoms recover without any treatment or intervention (So, Lau, & Yam, 2006). SARS patients present with symptoms similar to community acquired pneumonia and the initial course of treatment is antibiotics (So et al., 2006). After the discovery of the virus SARS-CoV antiviral treatment was used even though there is little evidence to determine its effectiveness (So et al., 2006). Antiviral treatments include Ribavirin, Tamiflu, Kaletra, and human interferons and immunoglobulins (So SEVERE ACUTE RESPIRATORY SYNDROME et al., 2006). The Chinese have also used a component of the liquorice root that has been used to effectively treat HIV and Hepatitis C in the past (So et al., 2006). With most infections proinflammatory cytokines are releases and a corticosteroid is used for immunomodulatory therapy (So et al., 2006). This can help to effectively reduce fever and improve oxygenation (So et al., 2006). Approximately 20 to 30% of SARS patients will end up in an Intensive Care Unit and 10 to 20% of patients require mechanical ventilation and intubation (So et al., 2006). Other options to help with oxygenation are face masks, nasal masks, and continuous positive airway pressure (CPAP). Treatment protocols have been developed have shown positive outcomes in Hong Kong (So et al., 2006). Biological, Environmental, Behavioral, and Situational Factors Host susceptibility plays a major role in the emergence of new diseases (Veenema, 2007, p. 438). Those that are most susceptible to a virus include people with Human immunodeficiency virus (HIV), patients who have received an organ transplant, cancer patients, people who have overused antibiotics and have less good bacteria, and people who are malnourished (Veenema, 2007, p. 438). Climate can be a factor in disease transmission. For example, places that have prolonged warm weather. Also, changes in the environment can affect the prevalence and emergence of a disease. Studies show that 75% of emerging diseases are zoonotic or transmitted from an animal Some scientists believe that the SARS-CoV virus originated in animals. It was identified in palm civets and other animals in the live animal markets of Guangdong, China (Jiang et al., 2005). The virus that was found in animals does not cause the disease. It is thought that the animals are not a host transmitting the virus to humans (). The virus is instead thought to have 6 SEVERE ACUTE RESPIRATORY SYNDROME evolved into the human form of SARS-CoV (Jiang et al., 2005). International travel is another factor that contributes to the spread of the disease (Veenema, 2007, p. 438). Application to Nursing Practice Nurses are able to help evaluate the patient for alternative diagnosis. They can monitor labs, vital signs including pulse oximetry, obtain blood cultures and sputum cultures, and perform tests for influenza A and B (Veenema, 2007, p. 448). Nurses should have an awareness and knowledge of recent health department findings and clusters of patients that have similar presentation (Veenema, 2007, p. 448). SARS has had a significant impact on health care workers. A large number of health care personnel were infected with SARS due to infected patients being undiagnosed (Rhinehart et al., 2007). Initially when a patient arrives with a suspected respiratory illness the nurse must implement protective infection control and initiate droplet precautions to prevent the spread to other patients and to health care workers. A study done in a Toronto hospital found that “consistent use of an N95 respirator was slightly more protective than a mask” (Rhinehart et al., 2007). The Centers for Disease Control and Prevention offer many recommendations for health care workers preparedness and response to the SARS infection. They recommend that the facility has a written plan in place, a SARS coordinator for communication needs, and identifies the appropriate state and local health department contacts (Center for Disease Control and Prevention, 2004). The CDC recommends testing the facilities response with exercises. Also, they advise in educating clinicians in early detection, signs and symptoms, how to report incidences, modes of transmission, and isolation procedures and guidelines (CDC, 2004). They suggest maintaining the air-handling capacity of designated rooms and planning for supplies 7 SEVERE ACUTE RESPIRATORY SYNDROME 8 (CDC, 2004). The CDC suggests identifying what personnel what care for SARS patients and any additional staffing needs during an outbreak (CDC, 2004). And lastly, they recommend the organization creating a policy regarding controlled access to the hospital and when to close the facility (CDC, 2004). Conclusion It is noted that in dealing with emerging diseases “Nurses, the largest sector of the health care profession, are poised to take the lead in the fight against these invisible enemies” (Veenema, 2007, p. 453). Training and continued education regarding emerging infectious diseases allows nurses to help in identifying and minimizing the negative impact of such illnesses. The information that health care providers have learned from the outbreaks of SARS can be of great value when responding to future pandemics or bioterrorism. SEVERE ACUTE RESPIRATORY SYNDROME 9 References Center for Disease Control and Prevention (2004). Severe acute respiratory syndrome: Preparedness and response in health care facilities. Retrieved from http://www.cdc.gov/ncidod/sars/guidance/C/pdf/app2.pdf Jiang, S., He, Y., & Liu, S. (2005). SARS Vaccine Development: Origin and Evolution of SARS-CoV. Medscape News. Retrieved from http://www.medscape.com/viewarticle/507912_2 Siegel, J., Rhinehart, E., Jackson, M., & Chiarello, L. (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Centers for disease control and prevention. Retrieved from http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf Veenema, T. (2007). Disaster Nursing and Emergency Preparedness. New York: Springer Publishing Company. So, L., Lau, A., & Yam, L. (2006). SARS Treatment. SARS reference. Retrieved from http://www.sarsreference.com/sarsref/treat.htm