STZ1 Task 3
Washington Western Governor’s University

A1. Description SARS is a viral disease caused by a coronavirus, a viral subgroup that causes of many instances of the common cold. Although SARS’ precise origin isn’t definitively known, all current data points to small mammals know as civets as the most plausible source of human transmission. The outbreak of SARs started in November of 2002 in the Mainland Chinese Province known as Guangdong, where the civets were viewed as a delicacy. In a misguided attempt prevent panic, the Chinese government failed to inform the World Health Organization of the initial outbreak for nearly four months. Subsequently the virus was contracted by 8098 people between November 2002 and June 2003. 774 of these cases proved fatal worldwide. (Trivedi, 2013)
The 3 primary factors that enabled SARS to spread so far and so fast were a lack of early reporting by Chinese officials, lack its high virulence, and international flight paths. Early awareness of SARS was severely by attempts at secrecy within the Chinese government in an attempt to prevent panic. This secrecy delayed awareness reaching both the WHO and healthcare staff, who were unaware of SARS virulence and potency. As mentioned, the SARS outbreak originated in the Guangdong Province in China. SARS was easily spread to healthcare staff who in-turn infected their friends, family, colleagues, and other patients. Also, family members would sick patients, and then transport the virus back out into the community. This scenario played out repeatedly whenever a SARS carrier reached a new population, and was especially destructive in Hong Kong, which had at least two different people import the virus directly from Guangdong. (Tsang & Ho, 2003)
One of the chief catalysts for the 2003 outbreak was a doctor from Guangdong Province, who contracted SARS in the healthcare setting. In February of 2003, this doctor traveled to Hong Kong and checked into the Metropole Hotel and lodging on the ninth floor. The subsequent SARS infections in Canada, Vietnam, and Singapore where all directly traced to people who stayed on the ninth floor during the same period of time as the doctor from Guangdong. From Vietnam, another doctor carried SARS to Thailand. From Singapore, yet another doctor traveled to both the United States and Germany before being detained by health officials. Beijing China was afflicted by personal both arriving directly from Guangdong Province, as well as from Hong Kong. Taiwan was the last region to report a person-to-person transmission and it was declared clear by the WHO in July of 2003. (WHO, 2003),
Several SARS cases have been reported since June of 2003, the result of direct laboratory contact or in nature, presumably from civet contact. From that time on, the virus has apparently been contained. There have been no reports of SARS since June of 2004. By the epidemic’s conclusion, over 25 countries had reported cases with only Antarctica and South America being without instances.
A2&3 Epidemiological Indicators & Analysis
SARS patients present with myalgia, fever, malaise, and subsequent respiratory symptoms such as shortness of breath and cough. Diarrhea occurs is some instances. The 2002 epidemic was first classified as an unusually intense pneumonia with no known origin. Amongst health care works, the transmission rate was high. (Trivedi, 2013)
“Some of these patients were positive for SARS-CoV in the nasopharyngeal aspirates(NPA), whereas 87% patients had positive antibodies to SARS-CoV in their convalescent sera. Genetic analysis showed that the SARS-CoV isolates from Guangzhou had the same origin as those in other countries, with a phylogenetic pathway that matched the spread of SARS to other parts of the world.” (Trivedi, 2013)
The SARS outbreak primarily afflicted China, Singapore, Taiwan, and Hong Kong. Canada experienced an outbreak in and around Toronto, Ontario. 8 United States citizens contracted SARS in the laboratory setting. As previously stated, 8089 cases of SARS and 774 deaths where documented as a result of the original outbreak. 1706, or 21%, of contracted cases were health care workers. SARS posted a fatality rate of 9.6%. (November 2002 through July of 2003) The geographic breakdown of SARS cases and deaths is as follows:
COUNTRY CASES DEATHS
China (mainland) 5327 349
Hong Kong 1755 299
Taiwan 346 37
Canada 251 43
Singapore 238 33
Vietnam 63 5
Philippines 14 2
Thailand 9 2
Malaysia 5 2
France 7 1
South Africa 1 1
(Trivedi, 2013)

A4. Transmission.
Although studies are ongoing on how humans transmit SARS between each other the current consensus is that water droplets, which are generated by the cough or sneeze of an infected person, are the most prevalent route of transmission. This suggests that transmission is likely to occur when physically close to an infected person or by contacting a surface contaminated by droplets. This indicates that SARS actually isn’t airborne, conversely, water droplets that are sneezed or coughed up fall rapidly to the floor, not remaining suspended in the air. A6. Effect on Prosser, Washington
In South Eastern Washington, a major concern is air quality. The Columbia Basin is a dry, arid environment that sits in a depression causing frequent dust storms. This is compounded by the fact that the area is booming and there a dozens of residential construction sites that add to the issue of blowing dust. The dust is significant because it exacerbates existing respiratory conditions such as COPD and asthma. These conditions coupled with an outbreak of SARS, which presents as severe pneumonia, would further impair gas exchange in afflicted persons. Another local issue is that a large segment of the population does not speak English and tends to avoid the health care system. It would require a multi-faceted approach to promote awareness. The Benton-Franklin Health District would need to coordinate with local schools, hospitals, and media platforms. An effort would also need to be made to enlist additional interpreters to inform the Spanish speaking population, many of which are lower class migrant working, living in conditions that could facilitate the transmission of SARS.
Agriculture, specifically the production of fresh produce, is huge component of the local economy. Until the virus was confirmed contained, all distributions of local would need to put on hold, a painful but necessary blow to the region. Also, events that put large numbers of people in cross proximity such as movies, sporting events, and religious gatherings, would need to be curtailed until the region was cleared of SARS. Hospitals would need to focus on staff and awareness as provide a list of all personnel who had the potential to be exposed to SARS patients. These personnel would need to be contacted immediately to prevent them from traveling and to be tested for SARS.
In the school setting, staff nurses would need in services on signs and symptoms of SARS. School nurses would need to assist in the drafting of letters appraising parents of the situation, and urging them not to send students with any respiratory systems to school. If SARS did manifest in the population of a school, that school would need to be closed immediately. School nurses should also arrange to address the school and provide awareness education to students on signs and symptoms to observe for. Obviously, the Benton-Franklin Health District would need to work closely with the Washington State Department of Health, the Center for Disease Control, and the World Health Organization.

B. CDC protocols stipulate that confirmed cases of severe, acute, respiratory syndrome or SARS be reported immediately. As a community health nurse in prosser, I would be required to alert the Benton Franklin Health District of this occurrence. Prior to the report, the nurse should ensure that the three primary criterion for a SARS case have been fulfilled:
• All persons requiring hospitalization for radiographically confirmed pneumonia who report at least one of the three risk factors for exposure to SARS-CoV
• Any clusters (two or more persons) of unexplained pneumonia, especially among healthcare workers
• Any positive SARS-CoV test result (CDC, 2003)

From this point, The Benton Franklin Health District is required to immediately alert the Washington State Department of Health. Lastly, the Department of Health will contact the Center for Disease Control in Atlanta, Georgia. The most import aspect of SAR reporting is that needs to be done immediately and through the correct channels. During this process, nursing care will focus on containment, such as implementation of droplet precautions.
C. Poor air quality exacerbates COPD and asthma symptoms, causing coughing, wheezing, dyspnea, and ultimately impaired gas exchange. In severe cases of respiratory distress, patients will need to be hospitalized. There are several things the nurse can do to limit patients exposure to poor air and prevent or alleviate symptoms.
1. Limit Exposure. Every effort should be made to keep the patient from venturing outside and exposing themselves to dirty, contaminated air. If that patient must be outside, the nurse should try to schedule activities in the early morning or evening when air quality is best. The nurse can also close all windows and doors. The nurse should continue to monitor the air quality forecast when planning activities in the coming days.
2. Medication Readiness The nurse should ensure that respiratory medications such as Flovent and Advair are readily available. If the patient requires oxygen, the nurse should insure that orders are in place to allow for titration. Increased frequency of SPo2 monitoring is indicated as well as frequent reassessment.
3. Nasal Breathing. Patient teaching on nasal breathing is indicated. The nose is designed to warm and filter the air. On days with reduced air quality, it is imperative that the patient utilize this natural filtration system.
4. Promote Hydration. The lungs, function at an optimal level when they have the correct amount of fluid. Dehydration can cause decreased secretions which inhibit the ability to keep particles out, and to expel contaminants via productive coughing. (Payne, 2010)

REFERENCES
Center for Disease Control and Prevention. 2003. Severe Acute Respiratory Syndrome. Available at http://www.cdc.gov/ncidod/sars/. Accessed June 17, 2014.
Payne, W. (2010, June 11). Air Pollution and Asthma: 4 Ways to Stay Safe on 'Ozone-Alert' Days. . Retrieved June 19, 2014, from http://health.usnews.com/health-news/family-health/respiratory-disorders/articles/2010/06/11/air-pollution-and-asthma-4-ways-to-stay-safe-on-ozone-alert-days
Trivedi, M. N. (2013, September 30). Severe Acute Respiratory Syndrome (SARS). . Retrieved June 20, 2014, from http://emedicine.medscape.com/article/237755-overview#a0156
Tsang KW, Ho PL, Ooi GC, Yee WK, Wang T, Chan-Yeung M, et al. A cluster of cases of severe acute respiratory syndrome in Hong Kong. N Engl J Med. May 15 2003;348(20):1977-85. [Medline].
WHO. Update 95—SARS: chronology of a serial killer. 2003. Retrieved June 20, 2014 from http://www.who.int/csr/don/2003_07_04/en/