Why did outbreaks of severe acute respiratory syndrome occur in some hospital wards but not in others?
BACKGROUND
Most documented "superspreading events" of severe acute respiratory syndrome (SARS) occurred in hospitals, but the underlying causes remain unclear. We systematically analyzed the risk factors for nosocomial outbreaks of SARS among hospital wards in Guangzhou and Hong Kong, China.


METHODS
A case-control study was conducted. Case wards were hospital wards in which superspreading events of SARS occurred, and control wards were wards in which patients with SARS were admitted, but no subsequent nosocomial outbreaks occurred. Information on environmental and administrative factors was obtained through visits to the wards and interviews with ward managers or nursing officers. Relevant information about host factors was abstracted from the medical records. Logistic regression analyses were used to identify the major risk factors for superspreading events.


RESULTS
Eighty-six wards in 21 hospitals in Guangzhou and 38 wards in 5 hospitals in Hong Kong were included in the study. Six risk factors were significant in the final multiple-logistic regression model: minimum distance between beds of < or = 1 m (odds ratio [OR], 6.94; 95% confidence interval [CI], 1.68-28.75), availability of washing or changing facilities for staff (OR, 0.12; 95% CI, 0.02-0.97), whether resuscitation was ever performed in the ward (OR, 3.81; 95% CI, 1.04-13.87), whether staff members worked while experiencing symptoms (OR, 10.55; 95% CI, 2.28-48.87), whether any host patients (index patient or the first patient with SARS admitted to a ward) required oxygen therapy (OR, 4.30; 95% CI, 1.00-18.43), and whether any host patients required bi-level positive airway pressure ventilation (OR, 11.82; 95% CI, 1.97-70.80).


CONCLUSIONS
Our results revealed that factors that were associated with the ward environment and administration were important in nosocomial outbreaks of SARS. The lessons learned from this study remain very important and highly relevant to the daily operation of hospital wards if we are to prevent nosocomial outbreaks of other respiratory infections in the future.
Yu
Ignatius T
IT
Centre for Emerging Infectious Disease, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China.
Xie
Zhan Hong
ZH
Tsoi
Kelvin K
KK
Chiu
Yuk Lan
YL
Lok
Siu Wai
SW
Tang
Xiao Ping
XP
Hui
David S
DS
Lee
Nelson
N
Li
Yi Min
YM
Huang
Zhi Tong
ZT
Liu
Tao
T
Wong
Tze Wai
TW
Zhong
Nan Shan
NS
Sung
Joseph J
JJ
D016022:Case-Control Studies; D002681:China / Q000453:epidemiology; D003428:Cross Infection / Q000453:epidemiology*; D004196:Disease Outbreaks; D006757:Hospital Units; D006801:Humans; D017053:Infection Control; D010356:Patient Isolation; D012307:Risk Factors; D045169:Severe Acute Respiratory Syndrome / Q000453:epidemiology*; D014691:Ventilation