Facing up to severe acute respirator syndrome: New Zealand will not escape the epidemic of severe acute respiratory syndrome. Nurses need to be informed and to understand their professional responsibilities.

SEVERE ACUTE respiratory syndrome (SARS), has been identified by the World Health Organisation (WHO) as a global health threat. It has been declared a notifiable disease in New Zealand. In this article I have summarized some key points on SARS, including why it became the focus of a global alert, and what is now known about SARS and its transmission. I have also identified concerns raised by health care workers about caring for patients with SARS and looked at what the professional responsibilities for nurses in New Zealand are.

On March 12 this year, the WHO issued a global alert relating to an atypical pneumonia. (1) The event that initiated the alert was a report from the Department of Health in Hong Kong to WHO of an outbreak of pneumonia in a public hospital. The report occurred at a similar time the WHO received reports of a severe respiratory syndrome from other countries, including China, Singapore, Vietnam, Thailand, Indonesia, Taiwan, Philippines, Canada, Germany and the United States. (2) This became the first global alert by the WHO for more than a decade (3) and worldwide surveillance was instituted. (4)

Some of the features associated with the syndrome were:

* The spread of the illness to close contacts, including Family and health care workers of affected individuals.

* Normal laboratory testing for known pathogens did not provide comprehensive diagnostic answers.

* The route of transmission of infection and pathogenesis was not known.

* The failure of patients to respond to the typical antimicrobial/clinical treatment regimes for atypical pneumonias. (5,6,7) This syndrome has crone to be known as SARS.

The WHO recommended strict adherence to isolation measures for patients with SARS, using precautions for airborne, contact and droplet transmission. These included the use of masks (particulate filter masks were recommended), gowns, gloves, eye protection and where possible, patients with SARS were to be nursed in negative pressure rooms with the doors closed. Where negative pressure isolation rooms and/or particulate filter masks were unavailable, guidance was provided on alternatives. (5) Criteria were also provided to assist identifying patients who may be at risk of having SARS, with suspect and probable SARS categories identified.

As a result of the WHO global alert, the New Zealand Ministry of Health (MoH) issued a national alert on March 17. Since this time the MoH, regional public health authorities and district health boards (DHBs) have been preparing for the inevitable--that individuals infected with SARS would be identified in New Zealand.

Since the global alert, the information known about SARS has changed significantly and such change is likely to continue. It is now thought the virus originated in the Guandong Province in China late 2002. (5) Scientists from 13 laboratories in ten countries have been working collaboratively to identify the causal organism. On April 16 the WHO announced that "a new pathogen, a member of the coronavirus never before seen in humans or animals, is the cause of SARS". (7) Those in the laboratory, network were commended as having "put aside profit and prestige to work to gether to find the cause of the new disease and to find new ways of fighting it". The pathogen responsible for the common cold is also a coronavirus. (8)

The incubation period for SARS appears to be typically two to 11 days. (4) The clinical symptoms of SARS patients are being quickly reported. The illness generally commences with a fever characterised by a temperature higher than 38 degrees Celsius. It is reported as sometimes being associated with chills and rigours, dry cough, dyspnoea, malaise and headache. (9,10) Less common symptoms may include sputum production, sore throat, nausea and vomiting and diarrhoea. (10) Transmission is considered to be via droplet spread. Research is ongoing to try and establish how long the SARS virus can survive outside the body and in what body fluids it may be found and in what concentrations. (11)

At the time of writing, the number of individuals reported to WHO as having probable SARS for the period November 1, 2002 to April 30, 2003 is a total of 5663 probable SARS cases, reported from 26 different countries, with 372 deaths reported. According to various WHO press releases, the reported mortality rates vary between four to six percent, and a significant number of those dying of SARS have underlying health problems.

The WHO keeps a cumulative total of the number of cases of SARS, the number of deaths and the countries where SARS cases have been identified. Details can be obtained from the WHO web site www.who.org. The New Zealand Ministry reported the first probable case of SARS to WHO on April 29.

There are some successes to report. Vietnam, which was one of four early countries where community spread of SARS was originally noted, has been reported to have successfully contained its SARS outbreak with a combination of infection control and public health measures. No new cases have been reported over a consecutive 20-day period. (12)

History contains many examples of the discovery of previously unknown infectioncausing pathogens or those that cross from animals to humans, including those that have the potential to cause severe illness. Examples of such pathogens are the Nipah Virus, (8) and H5N1 influenza. The emergence of SARS, although very recent, will almost certainly not be the last such discovery. Health care organisations and workers need to be aware of this in decision-making processes to ensure unreasonable or unrealistic precedents are not set.

Some staff are requesting they should get the opportunity to volunteer to care for patients with suspected SARS, rather than be required to provide care. Others have identified they may not provide care, while others have said they will not provide care. For some nurses there is no issue with caring for SARS patients. Anecdotal reports indicate these concerns are evident nationally. The fear appears to be related to the number of health care workers who developed SARS prior to the syndrome being "recognised" and prior to the implementation of strict isolation precautions. This appears a normal occurance when the pathogen and etiology of the disease are unknown. Similar concerns were identified in the early 1980s when the human immunodeficiency virus (HIV) was identified.

NZNO has received enquires from some members regarding their right to refuse to care for patients suspected of being infected with SARS and NZNO has stated there is "no express right to refuse to care for an infected patient. Nurses who refuse to care for patients need to be aware of the risks in taking such a decision.". (NZNO website statement: www.nzno.org.nz).

Part II of the Human Rights Act 1993 identifies that it is unlawful to discriminate against those with a disability. The term disability is further defined and includes "the presence in the body of organisms capable of causing illness". (13) This legislation means we cannot discriminate against patients with SARS.

The Health and Safety in Employment Act 1993 identifies that employers must take all reasonable steps to ensure the safety of employees. The provision of appropriate personal protective equipment (PPE) and education are components of this. Employees must take responsibility for using the required PPE appropriately.

In addition, nurses have obligations under the International Council of Nurses Code of Ethics. Under the code, nurses have four fundamental responsibilities: "To promote health, to prevent illness, to restore health and to alleviate suffering." Nurses' primary professional responsibility is to those requiring nursing care. "In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected." (14)

Yes, we are nurses, but we are also individuals, and, as such, we have personal thoughts and emotions that need to be expressed. Consideration needs to be given to the appropriate forum for this to occur. We are also professionals who have a professional responsibility to provide nursing care to those who need it. Our challenge is to learn lessons from the past, be proactive and flexible in adapting to the new information discovered in the present, and to be aware that in the future we may well have similar but new challenges.

The Ministry of Health's SARS information website is: www.moh.govt.nz/sars.

REFERENCES

1) World Health Organisation (WHO) press release. www.who.int/csr/don/2003 03 12/en/.

2) Chan-Yeung, W. (2003) Outbreak of severe acute respiratory syndrome in Hong Kong Special Administrative Region: Case report. BMJ: 326, 850 852

3) Zambon. M. (2003) Severe Acute Respiratory Syndrome revisited. BMJ; 326, 831 2.

4) Tsang, K.W. et al. (2003) A cluster of cases of severe acute respiratory syndrome in Hong Kong, The New England Journal of Medicine. www.nejm.org. March 31, 2003.

5) Ksiazek. T.D. (et al) A novel coronavirus associated with severe acute respiratory syndrome. The New England Journal of Medicine; 348:19.

6) WHO press release.www.who.int/csr/surveillance/infectioncontrol/en/.

7) WHO press release, April 16, 2003. www.who.int/mediacentre/releases/2003/pr31/en/.

8) Chin. J. (2000) Control of Communicable Disease Manual. Washington: American Public Health Association.

9) Preliminary clinical description of severe acute respiratory syndrome. MMWR Weekly, 52: 12, 255-256.

10) Lee, N. et al. (2003) A major outbreak of severe acute respiratory syndrome in Hong Kong, The New England Journal of Medicine. 348:19.

11) Parry, J. (2003) SARS virus identified but the disease is still spreading. BMJ; 326: 897.

12) WHO press release, April 28, 2003.

13) Human Rights Act 1993. II Unlawful Discrimination.

14) The International Code of Ethics for Nurses. (2000) International Council of Nurses. Geneva. www.ien.ch/icncode.pdf.

Public health nurses' role in SARS

PUBLIC HEALTH nurses (PHNs) would expect to be involved in any outbreak of severe acute respiratory syndrome (SARS), according to the chair of NZNO's public health nurses (PHN) national section, Julia Anderson.

"I would consider this work fundamental to why we have a PHN workforce in New Zealand. It is also the traditional work of PHNs. Unfortunately, it is unlikely the current PHN workforce in most areas could respond, given our decreased numbers and the complex activities and functions PHNs are currently involved in daily," she said.

This, however should not exclude PHN being involved in developing protective measures nationally. "I would also expect PHN services to have guidelines and protective equipment for all PHNs to respond to any potential SARS threat."

Anderson said she was aware the role of the PHN workforce was under discussion at Ministry of Health level. "We would expect to be included in the loop for any emergency or control measures."

The role of PHNs in any SARS threat is on the agenda for the section's national committee meeting in Wellington next month.

Karen Davis, RCpN, BHSc, CIC, is a nurse clinician, injection control nursing for Lakes District Health Board, based in Rotorua. She is chair of the NZNO's Division of Infection Control Nurses.