People & Opinions

On learning thepractical clinical lessons of SARS

with Dr. Wava Truscott

HPN: What did you think about first when you started to hear about SARS?

Truscott: Given the world’s circumstances, I know a lot of people immediately jumped to the possibility of a bioterrorism event. But my thoughts were more, ‘Here comes yet another variety of flu.’ But I also realized that it was an odd season for the onset of flu. I wondered about the quality of infection control precautions that were in place, or even if the newness would reveal a lack of concern and thus lax precautions. Infection control precautions are always your first and best line of defense, and properly practiced they help buy valuable time against a disease while you’re getting to diagnosis, vaccination and cure. It was clear early on, however, that SARS was something that would have to be reckoned with.

HPN: What are some precautions that infection control practitioners and nurses should be aware of regarding possible SARS patients?

Truscott: In an unknown situation, basic infection control protocols are always important for dealing with any patient:

-Wash hands after patient contact or surfaces that may have been contaminated by the patient; alcohol-based hand sanitizers may be used if hands are not visibly soiled. Be certain to let hands dry by evaporation before donning gloves or adding lotion or wiping with a towel. The evaporation phase is part of the “kill” process.

-Use of gloves, gowns, masks and eye protection are prescribed for fluid and this level of:
— Standard precautions plus
— Airborne precautions plus
— Contact precautions

These more stringent requirements are necessary for protection when caring for suspected SARS patients at least until more is known about the transmission mode.

-Use gowns: Cover/isolation gowns are recommended. If these are not available, the healthcare professional may use an impervious cover gown. If the impervious cover gown is uncomfortable in the working environment, a spunbond gown may be used; however, spunbond is typically recommended for only dry particulate barrier protection.

-Use gloves: Gloves should provide durable in-use barrier protection to prevent the risk of exposure to the SARS infectious agent. Kimberly-Clark does not recommend the use of vinyl gloves when activities require the risk of exposure to infectious agents including SARS. Gloves should be powder-free, regardless of the base material (latex, Nitrile, etc.) as microorganisms can adhere to, and be transported by, powder.

-Use N-95 filtering disposable respirator masks. Where possible, a fit test should be conducted. Fit test instructions are online on the CDC website at www.cdc.gov/niosh/pdfs/99-142.pdf
- The CDC specifies “If N-95 respirators are not available for healthcare personnel, then surgical masks should be worn. It is critical that the surgical mask chosen fit well, that there are no gaps open to the environment and that the nose piece is pinched or bent to fit securely over the nasal ridge. The ties must be positioned to hold the mask snugly.

In addition be aware that SARS patients may become hypoxic and require respiratory ventilation. Aerosol generating procedures such as airway suctioning must be conducted with extreme care. Individuals performing suction activities must utilize full standard, airborne and contact precautions. Closed endotracheal suction systems may minimize aerosol production and reduce the risk of further depleting the oxygen reserves of hypoxic SARS patients. 

HPN: Do protocols exist for dealing with SARS and diseases like it? If not, where should hospitals turn for guidance and advice?

Truscott: The Centers for Disease Control and Prevention is the standard-bearer for emerging infectious diseases in the United States. Other resources include the Food and Drug Administration and the World Health Organization.

Most hospitals have in place a protocol for dealing with unknown infectious diseases. Staff should be educated and periodically reminded of the protocol and its importance.

HPN: What are some products that may be useful when treating SARS patients?

Truscott: I mentioned the precautions for standard, airborne and contact and the categories of products that should be used. But let’s talk a minute more about surgical masks.

Filtration of surgical masks varies widely. Using the standard ASTM F2101 (BFE) test, efficiencies can range from 60 percent or lower to greater than 99 percent depending on the materials utilized, surface treatments and manufacturing technologies applied. The tests most routinely and credibly performed in the industry are:

Test  Size of Challenge
Particle Filtration Efficiency (PFE) 0.1 micron
NIOSH Sodium Chloride test 0.3 micron
Bacterial Filtration Efficiency (BFE) 3.0 micron

-Request performance data reflecting the same test (or all three tests) from the manufacturer of each mask under consideration to facilitate appropriate product-to-product comparisons.

-Use a surgical mask for suspected SARS patients when they are being transported in the healthcare setting or when cared for at home. If the homebound patient is unable to wear a mask, the caregivers and household contacts should wear a mask.

HPN: How can suppliers help providers in combating the spread of SARS?

Truscott: Education, education, education. Kimberly-Clark, for example, offers courses on the implementation of Standard and Transmission Precautions as well as mask fit. 

HPN: What can be learned from how China has dealt with the SARS issue?

Truscott: The situation in China was a proof point showing just how vital it is to contain a disease as it starts to spread. This is so critical every time a disease crosses species lines or an old disease evolves and adapts to behaviors we do not expect. The threat posed by antibiotic-resistant mutation of a known disease is as severe as the threat by the appearance of a heretofore unknown pathogen. 

Allowing the global infection control network to do its job is another good lesson. The World Health Organization, the CDC, and the global interconnection of numerous state local, regional and national health authorities around the globe need good, continuous information as soon as a suspected event is in progress. ‘Soon’ saves lives.

We also learned how important it is to be properly supplied as new diseases occur in the future. And they will.

HPN: Aside from SARS, how prepared are hospitals for bioterrorist attacks that could result in similar events?

Truscott: The FDA is very concerned that we are not prepared. Even given the incredible cost constraints of today’s healthcare environment, hospitals need to identify the basic items they need for general outbreaks, and make sure that at some level these supplies are on hand. This includes masks, eye protection, gowns and gloves. National stockpiles need to be constantly assessed and evaluated.

HPN: Where is the U.S. hospital system lacking in planning for disasters and epidemics?

Truscott: The fundamental need is the thought process of complete compliance to the appropriate precautions guidelines, knowing when and where and what to do. And it will take everyone in the continuum of care to do his and her part. HPN

Dr. Wava Truscott is director, scientific affairs and clinical education for Kimberly-Clark Health Care, Roswell, GA, where she is directly responsible for the creation of educational and technical services information, presentations, research studies and technical support. Dr. Truscott has an extensive background in the glove manufacturing industry, specifically with regards to barrier integrity, biocompatibility, and sensitization as it relates to reactions and claims substantiation issues. 

Dr. Truscott is known internationally for having authored several papers relating to areas including: macrophage activity during fowl cholera infections; viral penetration studies of glove barrier materials; dermal, respiratory and systemic reactions to gloves; and general biocompatibility issues. She co-authored the Microbiological section of the Association for the Advancement of Medical Instrumentation Sterilization and Recommended Practices, co-chaired the Health Industry Manufacturers Association Latex Sensitivity Task Force and was the U.S. delegate to the International Standards Organization on Biocompatibility Testing of Medical Devices regarding systemic toxicity.

HPN

June