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. 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. 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 and had positive viral isolates or serological tests to coronavirus. The nursing home involved was typical of many privately run institutions of its type. Located in an old