Severe Acute Respiratory Syndrome (SARS): Public Health Response

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The responsible virus about SARS is called Coronavirus-SARS.1 This virus started in Asia in 2003 and spread in only a few months to more than 12 countries. According to the World Health Organization (WHO), 8439 people have been infected with SARS and 9.6% have died because of this infection.2 Additionally, 20% of those cases were healthcare providers.2 According to the MMWR evaluation guidelines for surveillance systems, engaging stakeholders in the surveillance system evaluation process.3 As a Ph.D. nursing student, I will evaluate the surveillance system and engage the following stakeholders: the CDC, local health departments (LHD), healthcare providers, and Oregon Public Health Division (OPHD), patients and their close contacts, legal communities, and laboratories.

 The Public Health Importance of SARS

SARS is a viral infection, which is caused by Coronavirus-SARS1 and can spread by close human’s contact through respiratory droplet in males and females.1 In 2003 in the USA, out of 161 suspected cases, eight cases were confirmed to be infected with SARS. According to WHO, the mortality rate of SARS is 50% in older adults (>65 years old), 15% in middle age adults (45-65 years old), 6% in young adults (25-44 years old), and 6% in younger than 24 years old.4 The highest fatality ration was 15-19% in Canada, 13-15% in Singapore, 11-17% in Hong Kong, and 5-13% in China.4 Karlberg and Lai found that females had a lower mortality rate than men, women 13% and men 21%.5

SARS infection is associated with considerable mortality and morbidity rates in the acute phase.6 For instance, some people who in the early rehabilitation phase showed muscle weakness and others developed pulmonary fibrosis.6 Unfortunately, SARS did not only alter the physical functions of those patients, but some had developed psychological behavior changes. For example, few people developed a mild psychiatric problem, such as suicidal ideas and anxiety; others had hallucination.6 Additionally, SARS caused a noticeable global economic decline during the outbreak. Hong Kong lost about the US $3.7 Billion GBD in the first and second quarter of 2003.7 Hens, the associated morbidity, mortality and cost with SARS infection, indicates that eradicating or preventing SARS infection is essential.

The Purpose and Operation of SARS Surveillance System

After the SARS outbreak in 2003, the CDC in the USA initiated an emergency public health response and established national surveillance for SARS. The system used sensitive case analysis and incorporated clinics, laboratories, and epidemiologic response.8 The CDC had used the World Health Organization initial surveillance response classification or definition of SARS (table 1).9 The inclusion criteria: US-resident during the time SARS outbreak, Non-US residents who became sick and diagnosed with SARS while they were in the US. On the other hand, US-citizens who were not in the US at the time of the SARS outbreak was excluded from the surveillance.

The definition had two criteria: 1) clinical criteria, was when a patient had an unexplained respiratory illness. 2) had a link or exposure with SARS infection within ten days. Initially, any unexplained respiratory illness was reported to the CDC and evaluated for SARS. The responsibly of reporting those cases was from clinicians. The reporting and communication between clinicians and state or local health departments used teleconference, fax, or phone. Then, the local health departments’ personal reported the suspected cases with CDC. Patients who met those criteria were labeled as “line list.” Additionally, clinicians had consented the patients to collect the samples in case they were suspected cases of SARS. Patients who were hospitalized were monitored on a daily basis. Data transporting between local healthcare services and CDC used paper-based, then that information was recorded at the CDC database. After April 2003, the SARS-Corona virus was identified, and the CDC had incorporated a laboratory confirmation to the surveillance process (Table 2).9 Local health departments used convalescent serum, stool samples, naso-oropharyngeal swab from the identified cases. CDC classified the case-patients as confirmed, negative or undetermined for SARS-covirus (Table2).9 

 

Sensitivity and Representativeness

 

Despite the great effort of states, local health departments and CDC to confine SARS infection during the outbreak, the surveillance had few limitations that require improvements. First, the initial screening process included high-risk patients, who were identified by the system. However, there was a lack of knowledge about illegal immigrants who usually live as big groups. Those immigrants could be at higher risk of acquiring SARS infection or a host of the cor-virus. The surveillance system did not specify what were the used measures to protect those patients’ information? Therefore, there could be unknown infected cases among this minority group, who may not receive the proper treatment.

 

Usefulness

 

The usefulness of the surveillance system could be identified by measuring the screening and detecting process, treatment, and the ability to confine the infection. Based on our evaluation, the infection rate in the United States was much lesser than Europe, Asia, and Australia. However, the detected or reported cases were about either citizens or immigrants who are living in the USA legally. There was a lack of information about infected cases if they were undocumented or lived in the USA illegally.

 

Data quality, Flexibility, and Simplicity

 

CDC4 received the highest number of cases at the beginning of the SARS outbreak, but those cases had been identified clinically but no laboratory confirmation. Therefore, evaluating the sensitivity of the SARS surveillance system is limited. On the other hand, evaluating the system is possible if surveillance included only laboratory confirmed cases. Even though the surveillance system was not very sensitive, it was fixable to incorporate new detect cases globally. For instance, the system updated the information within hours when China was added to SARS-affected areas.9

 

Timeliness and Stability

The median time to report the affected cases to CDC in the first 12 weeks took 3-8 days and then was increased by 40% after 12 weeks.9 The increased reporting time could be due to lack of sufficient healthcare providers, including laboratory personnel. Another reason could be growing of surveillance work-load. Adding a laboratory confirmation was added later to the surveillance, and the system relayed heavily on clinicians’ reports. In the US, suspected cases with SARS were recognized if they had Pneumonia, but patients usually do not exhibit signs of Pneumonia until 4-7 days. Between the time of exposure and developing symptoms of pneumonia, patients could be carriers of SARS infection and may have spread the disease. The delay in reporting to the surveillance system also could be because SARS infection had similar signs and symptoms like other respiratory infections. Patients were tested for multiple types or respiratory illness, such as influenza B.

Acceptability

SARS surveillance system had an initial start and assisted in detecting the disease. However, the system lacks information on illegal minority groups or invisible section of the population.

Justify and State Conclusions and Make Recommendations

Despite the success of SARS surveillance system in managing the infection, the system has few areas that require improvements. The system relayed heavily on clinical detection, lab confirmation and personnel reporting to CDC. 

Recommendations: Hospital healthcare providers and patients with pneumonia should be screened and tested for SARS-COV. Add all new kinds of mutated SARS-CoV to hospitals and screening, such as Coronavirus in the Middle East.

  

  1. Centers for Disease Control and Prevention (2017). Sever Acute Respiratory Syndrome (SARS). Retrieved from https://www.cdc.gov/sars/about/fs-sars.html#outbreak
  2. World Health Organization (2003). SARS outbreak contained worldwide. Retrieved from https://www.who.int/mediacentre/news/releases/2003/pr56/en/
  3. German, R.R (2001). Updated Guidelines for Evaluating Public Health Surveillance Systems. Centers for Disease Control and Prevention, 50(RR13);1-35
  4. World Health Organization (2003). Emergencies preparedness, response. Retrieved from https://www.who.int/csr/sars/archive/2003_05_07a/en/
  5. J. Karlberg, D. S. Y. Chong, W. Y. Y. Lai, Do Men Have a Higher Case Fatality Rate of Severe Acute Respiratory Syndrome than Women Do?, American Journal of Epidemiology, Volume 159, Issue 3, 1 February 2004, Pages 229–231, https://doi.org/10.1093/aje/kwh056
  6. Chan, K., Zheng, J., Mok, Y., Li, Y., Liu, Y., Chu, C., & Ip, M. (2003). SARS: Prognosis, outcome and sequelae. Respirology., 8 Suppl, S36-S40.
  7. Keogh-Brown, M. R., & Smith, R. D. (2008).The economic impact of SARS: How does the reality match the predictions? Health Policy,88 (1) 110-120.
  8. Schrag, S. J., Brooks, J. T., Van Beneden, C., Parashar, U. D., Griffin, P. M., Anderson, L. J….Chamberland, M. E. (2004). SARS Surveillance during Emergency Public Health Response, United States, March–July 2003. Emerging Infectious Diseases10(2), 185-194. https://dx.doi.org/10.3201/eid1002.030752.
  9. Schrag, et al. (2004). SARS Surveillance during emergency public health Response, United States, March–July 2003. Retrieved from https://wwwnc.cdc.gov/eid/article/10/2/pdfs/03-0752-combined.pdf
  10. Psychiatric complications in patients with severe Psychiatric complications in patients with severe acute respiratory syndrome (SARS) during the acute respiratory syndrome (SARS) during the acute treatment phase: a series of 10 cases S. K. W. CHENG, J. S. K. TSANG, K. H. KU, C. W. WONG and Y. K. NG S. K. W. CHENG, J. S. K. TSANG, K. H. KU, C. W. WONG and Y. K. NG
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