Psychosocial Impact for Health Care Workers

1
Psychosocial Impact for Health Care Workers
Learning from SARS The

• David S. Goldbloom, MD, FRCPC
• Centre for Addiction and Mental Health
• University of Toronto
• April 19, 2004
• Disaster Response Conference

2
Learning Objectives

• To understand the trajectory of SARS as it spread
  through hospitals and around the world
• To describe the psychosocial impact of SARS on
  health care workers
• To discuss interventions to minimize the impact
  of such outbreaks on health care workers

3
Health Care Professionals Who Died of SARS in
Toronto
Tecla Lin, nurse
Nestor Yanga, physician
Nelia Laroza, nurse
4
Government Inquiry

• Learning from SARS Renewal of Public Health in
  Canada A Report of the National Advisory
  Committee on SARS and Public Health, October 2003
• Committee chaired by Dean David Naylor, Faculty
  of Medicine, University of Toronto
• Full report available on-line at
  www.hc-sc.gc.ca/english/pdf/sars/sars-e.pdf

5
SARS Overview

• Caused by a novel coronavirus
• Emerged in China (Guangdong) in November 2002
• 8500 people worldwide diagnosed with probable
  SARS 21 of them HCWs (43 in Canada)
• gt900 SARS deaths worldwide
• Diagnosis in acute illness is clinical
• Treatment is primarily supportive
• Transmission by respiratory droplet contact with
  eyes, nose mouth (NOT airborne, says WHO)
• Risk of transmission greatest at day 10

6
Virus is stable in feces and urine at room temp
for 1-2 days
Virus is stable in diarrheal stool
for up to 4 days because of its higher pH
Virus loses infectivity after
exposure to common disinfectants
7
Emerging Infectious Diseases

• Since 1973, gt30 infectious diseases of bacterial
  and viral origin have emerged that are new or
  increased in incidence and geography
• Ebola (1977) Legionnaires (1977) E.
  Coli-linked hemolytic uremic syndrome (1982) HIV
  (1983) Hepatitis C (1989) variant
  Creutzfeld-Jacob (1996) avian flu (1997) West
  Nile (1999)
• SARS The first novel 21st century disease

8
Globalization

• According to World Tourism Organization data,
  715 million international tourist arrivals were
  registered at borders in 2002
• The volume, speed and reach of human travel has
  accelerated the spread of infectious diseases it
  took smallpox centuries to cross the Atlantic. It
  took weeks for SARS to travel to 30 countries on
  5 continents
• Globalization includes the food and feed trades
• This is compounded by the threat of intentional
  or accidental release of biological agents as
  acts of terrorism

9
Globalization

• 40 verified flights on which one or more people
  with SARS traveled while symptomatic
• Five international flights have been associated
  with transmission of SARS from symptomatic
  probable cases to passengers or crew
• No evidence of confirmed transmission after March
  27 travel advisory and implementation of
  screening measures
• WHO Consensus Document on the Epidemiology of
  SARS, October 2003 (www.who.int/csr/sars/en/WHOcon
  sensus.pdf)

10
The Pace of Discovery

• It took almost 10 years to determine the complete
  genetic sequence of HIV
• It took 11 weeks from the identification of the
  corona virus as the likely cause of SARS to the
  determination of its complete genetic sequence

11
Anatomy of the Outbreak

• Have you heard of an epidemic in Guangzhou? An
  acquaintance of mine from a teachers Internet
  chat room lives there and reports that the
  hospitals there have been closed and people are
  dying
• Dr. Stephen Cunnion, February 10, 2003
• WHO weekly newsletter February 14, 2003 describes
  unusual respiratory illness affecting 300 people,
  more than 100 of them HCWs, in Guangdong
  province, with 5 fatalities

12
Anatomy of the Outbreak

• Guangdong outbreak publicized by Health Canada on
  its Fluwatch bulletin summarizing activity Feb
  9-15, 2003 and the next week Fluwatch reported
  that Chinese authorities declared the outbreak
  over

13
Anatomy of the Outbreak

• February 19 Hong Kong officials report case of
  avian influenza and, in conference call with
  Health Canadas Pandemic Influenza Committee,
  recommend that all provinces be vigilant for
  influenza-like illnesses in returning travellers,
  particularly from Hong Kong China
• February 20 Health Canada issues alerts re avian
  flu to all Public Health and hospital infection
  control officers

14
Anatomy of the Outbreak Hong Kong

• Dr. Liu Jianlun, a 65 year old MD who treated
  atypical pneumonia patients in Guangdong travels
  to Hong Kong for nephews wedding
• Feels unwell as he checks into room 911 of the
  Metropole Hotel
• Infects at least 12 other guests and visitors on
  9th floor from several countries, including a 78
  year old woman from Canada

15
Anatomy of an Outbreak- Patient Zero in Canada

• February 23 Mrs. K returns to Canada
• February 25 she develops high fever
• February 28 she visits her FP, also complaining
  of muscle aches, dry cough
• March 5 she dies at home
• No autopsy
• Heart attack listed as cause of death

16
Anatomy of the Outbreak Son of Patient Zero

• March 7 her 44 year old son arrives at
  Scarborough Grace ER with cough, fever, and
  dyspnea and is kept in an open ER for 18-20 hours
  awaiting admission he is near other patients and
  has many visitors
• March 8- he deteriorates needs intubation in
  ICU clinical concern was that he might have TB.
  He had not been outside Canada in 8 years
• March 13 he dies of SARS and his TB test was
  negative

17
Anatomy of the Outbreak The Hospital Spread

• March 16 patient who had been in adjacent ER
  bed returns to hospital with SARS symptoms he
  dies of SARS on March 21
• His wife and 3 other family members were
  infected, including his 6-month old son
• His wife infected 7 visitors to ER, 6 hospital
  staff, 2 patients, 2 paramedics, a firefighter
  and a housekeeper
• The MD who intubated him in ICU wore mask, eye
  protection, gown and gloves but developed SARS,
  as did 3 nurses present at intubation

18
Anatomy of the Outbreak The Inter-Hospital
Spread

• March 13 -A second patient who had been in the ER
  on March 7 was brought back to ER with an MI. He
  had mild respiratory symptoms and was treated
  with standard infection control procedures and
  was transferred to York Central Hospital
• He became the source of a 2nd cluster that
  affected gt50 people and closed the hospital

19
Anatomy of the Outbreak The Government
Response

• March 13 Health Canada notified of the Toronto
  cluster and initiates daily federal/provincial
  public health teleconferences
• March 14 Ontario Ministry of Health and
  Longterm Care (MOHLTC) holds press conference
  with Toronto Public Health and hospital officials
  re atypical pneumonia cluster

20
Anatomy of the Outbreak

• SARS continues to spread among staff, patients
  and visitors to Scarborough Grace
• March 23 ICU and ER at Grace closed and
  hospital closed to admissions/transfers
  outpatient clinics closed and employees barred
  from working at other hospitals. Anyone who had
  entered the hospital after March 16 asked to go
  on voluntary 10-day home quarantine. Stringent
  infection control implemented (N95 masks, etc
  isolation/negative pressure rooms for SARS pts)

21
Anatomy of the Outbreak

• March 23 West Park Hospital, a rehab facility,
  is re-commissioned to create 25-bed SARS unit.
  Staff can be found for only 14 patients
• March 25 Ontario government designates SARS as
  reportable, communicable, and virulent disease
  under the Health Protection and Promotion Act,
  giving Public Health officials tracking authority
  as well as authority to prevent activities that
  might transmit the disease

22
Anatomy of the Outbreak

• March 25 Health Canada reports 19 cases of SARS
  in Canada but 48 presumptive cases were
  hospitalized by the end of that day
• March 25-27 highest peak in epidemiol curve
• March 26 West Park unit and all negative
  pressure rooms in Toronto are full 10 ill staff
  from Scarborough Grace are in ER awaiting
  admission and more are at home
• March 26 - Provincial emergency declared and all
  hospitals required to create SARS units
• Within 48 hours, Sunnybrook Womens puts 40
  negative pressure rooms into operation

23
Anatomy of the Outbreak

• March 26 multi-ministry Provincial Operations
  Centre for emergency response activated
• Code Orange implemented for all Toronto and
  Simcoe County hospitals
• Non-essential services suspended
• Visitors limited
• Protective clothing for staff
• Isolation units for SARS patients
• March 30 access restrictions extended to all
  Ontario hospitals

24
Anatomy of the Outbreak

• Meanwhile, elsewhere in Canada
• March 13 man who had stayed at Metropole hotel
  arrived at Vancouver General Hospital with
  flu-like illness he lived with wife, had not
  been in contact with family/friends, and went to
  hospital directly when he became symptomatic
• He was masked and isolated
• No known secondary transmissions from this case

25
Anatomy of the Outbreak

• Meanwhile, elsewhere in the world
• February 26 -American man who had been at
  Metropole hotel flew to Hanoi and went to
  hospital there several nurses fell ill.
• Dr. Carlo Urbani of WHO sent to Vietnam to
  investigate
• March 11 -Dr. Urbani develops symptoms
• March 29 -Dr. Urbani dies of SARS
• March 11 23 HCWs admitted to isolation ward in
  Hong Kong with SARS symptoms
• March 12 WHO issues global alert

26
Information Sharing and Data Technology

• April 1 SARS surveillance system efforts
  initiated provincial infectious disease tracking
  and outbreak management software described as an
  archaic DOS platform used in the late 80s
• Public Health developed new software, but
  individual cases and contacts were maintained on
  paper charts with colour-coded Post-It notes
• Hospitals in daily teleconferences

27
Scientific Advisory Committee

• Volunteers (MDs, infection control practitioners,
  administrators) who worked 24/7 to develop
  guidelines and directives which were then passed
  on to the Hospitals branch of MOHLTC for
  translation into Hospitalese and
  implementation
• Nuances sometimes lost and meanings sometimes
  blurred as directives passed through multiple
  channels some directives controversial and
  difficult to implement (e.g., N95 mask use and
  fit testing)

28
Leadership

• We never knew who was in charge
• Provincial Operations Centre jointly led by Dr.
  Colin DCunha, Chief Medical Officer and
  Commissioner of Public Health, and Dr. Jim Young,
  Commissioner of Public Safety and Security
• Both subsequently agreed a single leader SARS
  czar would have been preferable

29
SARS One

• February 23-April 23
• Largely a hospital-based disease spread
• Concerns re community spread
• April 3 attendees at funeral home fell ill
• Employee of I.T. company defied quarantine,
  infected 1 co-worker, 200 on home isolation
• School closed when 1 student, son of a nurse,
  fell ill
• Screening of fellow passengers of a nurse on a
  commuter train who fell ill
• 31 cases in close-knit religious community
• 10,000 people placed on home quarantine

30
SARS One

• Public Health investigated gt1900 reports in
  addition to 220 cases
• Guidelines for family MDs not issued until April
  3
• Lack of system to distribute protective gear to
  family MDs until April 21
• April 13 difficult intubation of infected MD
  led to infection of 11 HCWs at Sunnybrook and
  Womens
• April 20 Sunnybrook Womens closed its ICU
  and SARS unit Canadas largest trauma centre
  stopped taking trauma patients

31
SARS One

• CDC investigators help determine transmission and
  reveal risks of inadvertent spread even with
  protective gear
• Extremely difficult to recruit staff from other
  hospitals to assist SW which had largest volume
  of SARS patients
• April 19 a hospital ward in British Columbia
  closed following secondary transmission of SARS
  to a nurse first such case in B.C the other
  three B.C. cases were travel-acquired

32
SARS One

• Easter/Passover approaches and church-based
  practices change
• April 23 despite the accumulation of SARS
  cases, only 1 new case in previous 2 weeks
• April 23 WHO issues travel advisory, as they
  had already done for Guangdong and Hong Kong
• April 30 WHO travel advisory withdrawn
• May 14 WHO removes Toronto from list of sites
  with recent local transmission
• May 17 Provincial emergency lifted, Provincial
  Operations Centre dismantled, Code Orange over

33
The Respite

• April 24 May 22
• All levels of government state SARS over
• 140 probable and 178 suspect cases, and 24 deaths
• Hospitals ease rules re protective equipment,
  of visitors, rules re distance sitting apart at
  meals
• BUTNorth York General and St. Johns
  Rehabilitation Hospitals.

34
North York General Hospital

• April 20-May 7 3 former inpatients on psychiatry
  unit present with pneumonia but no
  epidemiological links. Ruled out as new cluster
• Meanwhile, several elderly patients on orthopedic
  unit presented with what appeared to be post-op
  lung infections
• April 29 ICU nurse from NYGH admitted with
  respiratory symptoms which ultimately were SARs
• Mid-May family members of orthopedic patient
  present to ER with SARS symptoms

35
St. Johns Rehabilitation Hospital

• Steady flow of patients from acute care
  hospitals, including NYGH
• 3rd week in May 3 patients with SARS-like
  symptoms
• May 22 Public Health visits hospital. No
  epidemiological link found

36
SARS Two

• May 23-June 30
• May 23 5 new people under investigation anyone
  who had been in St. Johns Rehab or NYGH in
  preceding 2 weeks ordered into quarantine
• NYGH open only to SARS admissions
• Exact chain of events leading to SARS Two remains
  a mystery

37
SARS Two

• All hospitals resume infection control rules
• 4 hospitals declared SARS facilities
• Problem of multiple leaders recurred
• May 30 48 probable, 25 suspect cases
• Mainly hospitalized patients, HCWs and their
  families
• Medical student became ill 2 days after
  completing quarantine and during obstetrics
  rotation, leading to quarantine of mothers,
  newborns and staff

38
HCW Casualties

• June 30 Nelia Laroza, nurse, first Canadian HCW
  to die of SARS
• July 19 Tecla Lin, nurse, dies of SARS
• August 13 Nestor Yanga, physician, dies of SARS
• HCWs account for 40 of SARS cases in Toronto
  outbreak, second only to Vietnam where HCWs
  accounted for 57 of cases

39
Communication

• SARS updates on websites of Health Canada,
  MOHLTC, Toronto Public Health
• Daily SARS televised press conferences
• Dr. Donald Low, chief microbiologist at Mount
  Sinai, became unofficial leader of SARS battle
• Too many talking heads with different views
• No coherent communications strategy evident

40
Research

• March 15 WHO establishes network of labs to
  identify SARS agent and succeeds within a month
• March 31 first scientific papers describing
  SARS from Hong Kong and Canada appear on New
  England Journal of Medicine website, and
  subsequently in Science (genetic sequence of
  Toronto SARS virus), BMJ, Lancet, JAMA (clinical
  features)
• July 26 Lancet paper supporting coronavirus as
  cause of SARS had patient data from 6 countries

41
Clinical Challenges

• Non-specific symptoms
• No unequivocally effective treatment
• No previous clinical experience with it
• Single SARS facility versus universal capacity
• Learning on the fly ribavirin. Both clinical
  experience and in vitro evidence showed lack of
  benefit and clinical harm
• The race by early April, there were already
  91 probable and 135 suspect cases and 10 deaths

42
SARS in Canada

• Outside Asia, Canada hardest hit in world
• In Canada, Toronto hardest hit
• By August 2003, 438 probable and suspect cases of
  SARS, mainly in greater Toronto area
• 44 deaths (all in Toronto)
• gt100 healthcare workers (HCWs) developed SARS and
  3 died of SARS (2 nurses and 1 physician)

43
SARS and Death

• Case fatality ratios
• Canada 16.7 of probable SARS cases and 9.3 of
  suspect and probable cases
• Median age 75 years 83 gt 60 years
• China 349 deaths among 5,327 suspect and
  probable cases
• Global case fatality ratio 11

44
SARS and Ethical Issues

• Public Health versus Civil Liberties quarantine
• Privacy of Information versus the Publics Right
  to Know name of index patient released but not
  name of nurse on GO train
• Duty of Care of Health Professionals and Duty of
  Support and Protection for them by Institutions
• Collateral Damage the consequences for non-SARS
  illnesses

University of Toronto Joint Centre for Bioethics
BMJ 2003 327 1342-1344
45
Ongoing Challenges

• Diagnosis
• Treatment
• Implications of mass outbreak
• Longterm sequelae of SARS and its treatment
  (early reports of avascular necrosis in 10 of
  400 SARS patients in Hong Kong)

46
Impact on Healthcare Workers Doing the SARS hop
47
From the Front Lines

• Nobody ever thought this was the kind of job
  they could potentially die from ICU nurse
• You cannot appreciate, I dont believe, what the
  feeling of isolation was. Physical isolationyou
  see nothing but peoples eyes for days on end
  I.D. physician
• How terrible it is if you have to look after
  your own colleagueswhen word came down that
  several children of sick HCWs had come down with
  the disease it broke peoples hearts - MD
• Emerg would just kind of fall apart because oh
  no, its a staff member - nurse

48
Impact of SARS on HCWs

• Initial unstructured study by Maunder et al
• Concerns re personal safety, familial
  transmission and stigmatization
• Responses included fear, anxiety, anger and
  frustration
• Stressors included caring for colleagues as
  patients, redeployment to unfamiliar tasks,
  workload changes
• Maunder R et al. CMAJ 2003 168 1245-1251

49
Impact of SARS on HCWs

• Subsequent cross-sectional, anonymous,
  self-report survey of HCWs at Mount Sinai
  Hospital, St. Michaels Hospital CAMH
• Data collection
• MSH May 12-June 8
• CAMH May 22-June 20
• SMH May 13-May 28

50
Goal

• To identify constructs that may mediate the
  traumatic responses to the stress of SARS and are
  open to intervention in similar future outbreaks
• To determine the magnitude of the association of
  these constructs to outcome

51
Impact of SARS on HCWs

• Measures
• Impact of Event Scale a measure of traumatic
  stress (Horowitz et al, 1979)
• Study of HCWs Perception of Risk and Preventive
  Measures for SARS (Fones and Koh, 2003)
  developed for use in Toronto and Singapore)
• Demographics, attitudes, and contact with SARS
  patients

52
Impact of Event Scale

• 15 items probing frequency of attitudes over past
  week related to a particular stressor (SARS
  outbreak)
• Items probe intrusive emotions and thoughts as
  well as avoidance
• Psychometric properties established
• Score gt19 considered high and of clinical
  significance

53
Results

• 1,601 respondents
• SMH response rate 24
• MSH/CAMH response rate 10
• 571 HCWs had IES scores gt19, above the cutoff for
  a stress response syndrome
• This represents 36 of all respondents, and 5 of
  all HCWs at these facilities

54
Responders

• Female 75
• Doctors 8
• Nurses 28
• Other allied health professionals 64
• Mean age 40 (SD 11)
• Mean years of hospital experience 14.3 (SD 10.6)
• Sample is representative of staff discipline
  distribution at hospitals studied

55
IES Scores

• No significant difference in mean scores (95
  confidence intervals) between groups of HCWs
  caring for
• Cases under investigation (n72 IES 16-24)
• Suspect or probable SARS (n137 IES 18-23)
• Both (n187 IES 19-23)
• These groups were thus collapsed into one
• IES for HCWs who did not care for cases under
  investigation, suspect or probable significantly
  lower (n1207 IES 15-16)

56
IES Scores and Personal Characteristics

• Higher IES scores predicted by
• Exposure to SARS patients
• Having children
• Having 5 or more years of HCW experience

• Higher IES scores NOT predicted by
• Age
• Gender
• Marital status

Univariate ANOVA with Bonferroni correction
57
IES Scores and Professional Role

• Nurse (n437 IES 19-21)
• MD (n116 IES 9-13)
• Other HCW professional (SW, OT, RT, etc)
  (n175 IES 14-18)
• HCW non-professionals with patient contact
  (clerical, housekeeping, etc) (n192 IES 16-21)
• Administration (n118 IES 13-18)

58
IES Scores and Ethnoracial Status

• Asian community in Toronto significantly
  stigmatized during SARS
• Asian HCWs in survey (n238) reported
  significantly higher IES scores than caucasian
  HCWs but did not report higher stigma related to
  professional role stigma based on ethnoracial
  status not probed

59
(No Transcript)
60
(No Transcript)
61
(No Transcript)
62
(No Transcript)
63
(No Transcript)
64

• Risk Factors
• Care of SARS patients
• Being a nurse
• 3.Having children
• 4.Job stress
• 5.Perceived social rejection
• 6.Avoidance of crowds and colleagues
• 7.Relationship insecurity

65
(No Transcript)
66
Mediating Factors

• For HCWs having contact with SARS patients and
  experiencing emotional distress, the mediating
  factors were
• Fear for own health/health of others
• Social isolation
• Increased job stress

67
Psychosocial effects of SARS on hospital staff
(2004)

• 71 patients with SARS (23 of them HCWs) were
  admitted to Sunnybrook and Womens College Health
  Sciences Centre (SWC) and gt1,000 patients seen at
  their outpatient SARS assessment clinic
• Self-administered questionnaire distributed to
  employees April 10-22, 2003
• Demographics, occupation, work history
• SARS concerns and SARS precautions
• General Health Questionnaire 12-item version
  (score gt3 emotional distress/break from normal
  function)

Nickell LA et al, 2004
68
Responders

• 2001 (27) of the 7474 staff of SWC responded and
  25 of responses included the GHQ
• 79 female
• 9 physicians
• 26 nurses
• 33 allied health professionals
• 32 non-clinical staff
• This is representative of the hospital staff
  population as a whole

69
Concerns about health risks

• Concerns re own health during SARS 65
• Concerns re family health during SARS 63
• Nurses most frequently concerned 76
• Doctors least frequently concerned 60
• 94 of those who reported concerns felt they had
  friends, family, or others to talk to about those
  concerns

70
Increased level of concern for personal/family
health

• Logistic regression analysis identified 4 factors
  significantly associated with increased level of
  concern
• Perception of greater risk of death from SARS
• Living with children
• Personal/family lifestyle affected by SARS
• Being treated differently by other people because
  of working in a hospital

71
Decreased level of concern for personal/family
health

• Logistic regression analysis identified 3 factors
  significantly associated with decreased level of
  concern
• Working in a management or supervisory position
• Believing precautions were sufficient
• Being 50 years old or older

72
Implications of level of concern data

• Being stigmatized has been associated with
  increased level of concern in other outbreak
  studies
• Being in a management/supervisory position may
  provide some real or perceived level of control
  over a situation that reduces psychosocial effects

73
Emotional Distress

• Of the 510 GHQ respondents, 29 had scores gt3
  (more than double the rate in the general adult
  Canadian population), with highly significant
  differences between professional groups
• 45 of nurses
• 33 of allied health professionals
• 17 of physicians
• 19 of non-clinical staff
• Study of nurses in 3 Singapore hospitals working
  under normal circumstances, 15 scored gt3

74
Factors associated with Emotional Distress

• Regression analysis identified 4 factors as
  significantly associated with emotional distress
• Being a nurse
• Being a part-time employee
• Lifestyle affected by SARS outbreak
• Ability to do ones job affected by precautionary
  measures

75
Reactions to SARS Precautions

• Workplace precautions were
• Sufficient (74)
• Insufficient (8)
• Dont know (18)
• Precautions affect ability to do job
• Yes (42)
• No (58)

76
Reactions to SARS Precautions

• Most bothersome precaution
• Mask (70)
• Access restriction to own hospital (14)
• All others endorsed by 5 or fewer
• More on masks
• Particularly bothersome (85)
• Physical discomfort (93)
• Difficulty communicating (47)
• Difficulty recognizing people (24)
• Sense of isolation (13)

77
Other Work/Life Implications

• Changes to regular job duties (52)
• Working overtime (23)
• Being treated differently because of working in a
  hospital (28)
• Personal/family lifestyle impact (38)

78
Positive Aspects of SARS

• 58 felt there were positive outcomes
• Increased awareness of disease control (41)
• Learning experience (26)
• Increased cohesion/cooperation (24)
• Less busy than usual (4)
• Greater appreciation of life and work (2)
• Other (3 includes cancellation of student exams
  and good business for mask and glove companies!)

79
Psychological Impact of SARS In Asia

• In Singapore, where 238 cases of SARS diagnosed,
  psychiatric morbidity was present among 21 of
  HCWs
• In Taiwan, up to 75 of HCWs experienced
  psychiatric morbidity
• Drs. Kang Sim and Hong Choon Chua, Institute of
  Mental Health, Woodbridge Hospital, Singapore,
  2004

80
What would reduce the psychological impact of an
outbreak?

• Increased interpersonal contact
• Attention to the interpersonal costs of infection
  control protocols
• Extensive 2-way communication by e-mail and other
  means
• Clear communication of risk and non-risk to
  community media to reduce stigma

81
(No Transcript)
82
What would reduce the psychological impact of an
outbreak?

• Reduced job stress
• Increased mastery
• Increased attention to training and support when
  redeployment is required
• Dedicated SARS wards
• Attention to workload issues
• Including self-imposed!

83
What would reduce the psychological impact of an
outbreak?

• Reduced job stress
• Financial security
• Employees in quarantine or ill
• Families of employees in quarantine or ill
• Part-time employees denied access to 2nd hospital

84
What would reduce the psychological impact of an
outbreak?

• Responsive, protective authority
• Clear communication
• Response to concerns questions
• Advocacy in community and media

85
(No Transcript)
86
Agenda for Future Research

• Systematic evaluation of psychological impact
  more broadly on population
• Prospective research to evaluate longitudinal
  impact
• Rigorous evaluation of outcome of psychosocial
  interventions

87
The Future

• Why SARS Will Not Return A Polemic
• Dr. Donald Low, leading Toronto microbiologist
  during SARS, CMAJ 2004 170
• SARS Make No Mistake There Will Be A Next Time
• Dr. Alan Bernstein, President, Canadian
  Institutes for Health Research, Hospital
  Quarterly 2003 6 21-22

88
(No Transcript)