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Psychosocial Impact for Health Care Workers David S. Goldbloom, MD, FRCPC Centre for Addiction and Mental Health University of Toronto April 19, 2004 Disaster.

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Presentation on theme: "Psychosocial Impact for Health Care Workers David S. Goldbloom, MD, FRCPC Centre for Addiction and Mental Health University of Toronto April 19, 2004 Disaster."— Presentation transcript:

1 Psychosocial Impact for Health Care Workers David S. Goldbloom, MD, FRCPC Centre for Addiction and Mental Health University of Toronto April 19, 2004 Disaster Response Conference Learning from SARS: The

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 CanadaLearning 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: 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) >900 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, >30 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 21 st 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 (

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 all provinces be vigilant for influenza-like illnesses in returning travellers, particularly from Hong Kong & ChinaFebruary 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 9 th 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 2 nd cluster that affected >50 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 >1900 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 S&W 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 BUT…North 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 3 rd 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) >100 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% > 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 isolation…you see nothing but peoples eyes for days on end – I.D. physician How terrible it is if you have to look after your own colleagues…[when 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 >19 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 >19, 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 (n=72; IES 16-24) –Suspect or probable SARS (n=137; IES 18-23) –Both (n=187; 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 (n=1207; 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 (n=437; IES 19-21) MD (n=116; IES 9-13) Other HCW professional (SW, OT, RT, etc) (n=175; IES 14-18) HCW non-professionals with patient contact (clerical, housekeeping, etc) (n=192; IES 16-21) Administration (n=118; IES 13-18)

58 IES Scores and Ethnoracial Status Asian community in Toronto significantly stigmatized during SARS professionalAsian HCWs in survey (n=238) 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






64 Risk Factors: 1.Care of SARS patients 2.Being a nurse 3.Having children 4.Job stress 5.Perceived social rejection 6.Avoidance of crowds and colleagues 7.Relationship insecurity Interpersonal Isolation


66 Mediating Factors For HCWs having contact with SARS patients and experiencing emotional distress, the mediating factors were: 1.Fear for own health/health of others 2.Social isolation 3.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 >1,000 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 >3 = 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: 1.Perception of greater risk of death from SARS 2.Living with children 3.Personal/family lifestyle affected by SARS 4.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: 1.Working in a management or supervisory position 2.Believing precautions were sufficient 3.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 >3 (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 normalStudy of nurses in 3 Singapore hospitals working under normal circumstances, 15% scored >3

74 Factors associated with Emotional Distress Regression analysis identified 4 factors as significantly associated with emotional distress: 1.Being a nurse 2.Being a part-time employee 3.Lifestyle affected by SARS outbreak 4.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 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 What would reduce the psychological impact of an outbreak?


82 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! What would reduce the psychological impact of an outbreak?

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


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


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