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Psychosocial Impact for Health Care Workers

Learning from SARS: The. 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 Objectives.

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Psychosocial Impact for Health Care Workers

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  1. Learning from SARS: The 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

  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) • >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); Legionnaire’s (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/WHOconsensus.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 Canada’s 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 nephew’s 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 >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 & Women’s puts 40 negative pressure rooms into operation

  23. Anatomy of the Outbreak • March 26 – multi-ministry Provincial Operations Centre for emergency response activated • CodeOrange 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 D’Cunha, 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 Women’s • April 20 – Sunnybrook & Women’s closed its ICU and SARS unit; Canada’s 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. John’s 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. John’s 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. John’s 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 Public’s 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 don’t believe, what the feeling of isolation was. Physical isolation…you see nothing but people’s 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 people’s hearts” - MD • “Emerg would just kind of fall apart because ‘oh no, it’s 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. Michael’s 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

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