An Outbreak of Severe Acute Respiratory Syndrome in a Nursing Home

To the Editor: Over a period of 4 months, the severe acute respiratory distress syndrome (SARS) infected 1,755 persons, resulting in 298 deaths in Hong Kong. ¹ Nursing homes are particularly vulnerable to cross‐infection as a result of the crowded living environment, inadequate ventilation, substandard hygiene, and lack of qualified nursing staff. Recognition of clinical features at an earlier stage of the infection and stringent isolation procedures could prevent outbreaks in institutions, but the presentation of SARS may be less florid in older people. ² Nursing home residents, because of their frailty and comorbidities, are frequent users of hospital services, including emergency rooms (ERs) and acute wards, thus increasing their risk of exposure to infectious agents in hospitals. Demented or extremely frail patients may pose particular risk to other persons, because they may not be able to communicate and are only recognized after those who have come into contact with them fall ill. Also, cognitively impaired older patients may have difficulty keeping their facemasks on and sometimes exhibit high‐risk behavior such as spitting. We report a cluster of seven cases (Table 1) illustrating the spread of SARS from a hospital to the community and, in particular, a nursing home. All the cases were diagnosed clinically ³ and had positive viral isolates or serological tests to coronavirus.

Table 1.

  A Cluster of Cases with Confirmed Severe Acute Respiratory Syndrome at a Nursing Home (NH) in April 2003

	Case Number	Sex/Age	Status in Nursing Home		Date of Onset of Illness	Probable Mode of Transmission	Outcome
Resident			Employee	Visitor
1	Female/87	√			April 12	Likely to have been infected by a nurse during a recent admission (April 4 to 8), when there was an outbreak on the ward.	Recovered
2	Female/81	√			April 13	Exposed to Case 1 in NH between April 8 and 12.	Died on Day 13
3	Female/65		√		April 15	Exposed to Case 1 in NH between April 8 and 12.	Died on Day 37
4	Male/28			√	April 15	Case 1's grandson. Exposed to Case 1 while visiting her at NH between April 8 and 12.	Recovered
5	Male/27			√	April 18	Another grandson of Case 1, and Case 4's younger brother. Exposed to Case 4 and possibly Case 6 via household contact.	Recovered
6	Male/88			√	April 19	Case 1's husband. Exposed to Case 1 while visiting her at NH between April 8 and 12. Also lived with Cases 4 and 5.	Recovered
7	Female/93	√			April 25	Admitted to a “fever” ward with fever and clinical features of heart failure on April 16. Initially improved with diuretics and antibiotics. Developed fever again on Day 9, subsequently confirmed to have SARS, probably acquired on “fever” ward.	Died on Day 20

The nursing home involved was typical of many privately run institutions of its type. Located in an old building, it was crowded, with an average living space of 6 m² per resident. Individual beds were separated with wooden boards approximately 1.2 m high. The small communal toilet and shower area was near the living and dining area. Frailer residents usually used bedside urinals or commodes for toileting. No single room was available for isolation purposes. The staff‐to‐resident ratio was around 1:15, and the majority of carers had no formal training in health care.

This report illustrates how a single nursing home resident infected with SARS during hospitalization gave rise to several secondary cases, some resulting in death. During the SARS epidemic, nursing homes residents admitted to some acute hospitals with fever, but clinically not suspected to be suffering from SARS, would be transferred from a “fever” ward to a “cohorting” ward for about 10 days before returning to their nursing homes. Although such measures may have reduced the spread of the infection to nursing homes, they have, nevertheless, increased the workload of acute hospitals tremendously, and in some unfortunate instances, led to further in‐hospital outbreaks. Community‐based outreach teams including geriatricians and nurses were mobilized to closely monitor nursing home residents discharged from hospitals. They worked closely with the department of health and hospital wards to keep up‐to‐date information on nursing home residents afflicted with SARS. Advice was given to nursing home staff on the use of protective gear and provision of isolation facilities for residents with febrile illness and those recently discharged from hospitals to prevent cross‐infection. Perhaps the way to manage this in the future is to keep nursing home residents on‐site wherever possible, avoiding the need to come into contact with high‐risk areas such as the ER and hospital wards