SARS Unmasked: Risk Communication of Pandemics and Influenza in Canada 9780773576858

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SARS UNMASKED

m c gill-queen’s/associated medical services studies in the history of medicine, health, and society series editors: s.o. freedman and j.t.h. connor Volumes in this series have financial support from Associated Medical Services, Inc. (ams). Associated Medical Services Inc. was established in 1936 by Dr Jason Hannah as a pioneer prepaid not-for-profit health-care organization in Ontario. With the advent of medicare, ams became a charitable organization supporting innovations in academic medicine and health services, specifically the history of medicine and health care, as well as innovations in health professional education and bioethics. 1 Home Medicine The Newfoundland Experience John K. Crellin 2 A Long Way from Home The Tuberculosis Epidemic among the Inuit Pat Sandiford Grygier 3 Labrador Odyssey The Journal and Photographs of Eliot Curwen on the Second Voyage of Wilfred Grenfell, 1893 Ronald Rompkey 4 Architecture in the Family Way Doctors, Houses, and Women, 1870–1900 Annmarie Adams 5 Local Hospitals in Ancien Régime France Rationalization, Resistance, Renewal, 1530–1789 Daniel Hickey 6 Foisted upon the Government? State Responsibilities, Family Obligations, and the Care of the Dependant Aged in Nineteenth-Century Ontario Edgar-André Montigny

7 A Young Man’s Benefit The Independent Order of Odd Fellows and Sickness Insurance in the United States and Canada, 1860–1929 George Emery and J.C. Herbert Emery 8 The Weariness, the Fever, and the Fret The Campaign against Tuberculosis in Canada, 1900–1950 Katherine McCuaig 9 The War Diary of Clare Gass, 1915–1918 Edited by Susan Mann 10 Committed to the State Asylum Insanity and Society in Nineteenth-Century Quebec and Ontario James E. Moran 11 Jessi Luther at the Grenfell Mission Edited by Ronald Rompkey 12 Negotiating Disease Power and Cancer Care, 1900–1950 Barbara Clow

13 For Patients of Moderate Means A Social History of the Voluntary Public General Hospital in Canada, 1890–1950 David Gagan and Rosemary Gagan 14 Into the House of Old A History of Residential Care in British Columbia Megan J. Davies 15 St Mary’s The History of a London Teaching Hospital E.A. Heaman 16 Women, Health, and Nation Canada and the United States since 1945 Edited by Georgina Feldberg, Molly Ladd-Taylor, Alison Li, and Kathryn McPherson 17 The Labrador Memoir of Dr Henry Paddon, 1912–1938 Edited by Ronald Rompkey 18 J.B. Collip and the Development of Medical Research in Canada Extracts and Enterprise Alison Li 19 The Ontario Cancer Institute Successes and Reverses at Sherbourne Street E.A. McCulloch 20 Island Doctor John Mackieson and Medicine in Nineteenth-Century Prince Edward Island David A.E. Shephard

21 The Struggle to Serve A History of the Moncton Hospital, 1895 to 1953 W.G. Godfrey 22 An Element of Hope Radium and the Response to Cancer in Canada, 1900–1940 Charles Hayter 23 Labour in the Laboratory Medical Laboratory Workers in the Maritimes, 1900–1950 Peter L. Twohig 24 Rockefeller Foundation Funding and Medical Education in Toronto, Montreal, and Halifax Marianne P. Fedunkiw 25 Push! The Struggle for Midwifery in Ontario Ivy Lynn Bourgeault 26 Mental Health and Canadian Society Historical Perspectives James Moran/ David Wright 27 sars in Context Memory, History, and Policy Edited by Jacalyn Duffin and Arthur Sweetman 28 Lyndhurst Canada’s First Rehabilitation Centre for People with Spinal Cord Injuries, 1945–1998 Geoffrey Reaume 29 J. Wendell Macleod Saskatchewan’s “Red Dean” Louis Horlicky

30 Who Killed the Queen? What Works and What to Fix in Canadian Health Care Holly Dressel

33 A Sadly Troubled History The Meanings of Suicide in the Modern Age John C. Weaver

31 Healing the World’s Children Interdisciplinary Perspectives on Health in the Twentieth Century Edited by Cynthia Comacchio, Janet Golden, and George Weisz

34 sars Unmasked Risk Communication of Pandemics and Influenza in Canada Michael G. Tyshenko with assistance from Cathy Paterson

32 A Canadian Surgeon in the Army of the Potomac Francis M. Wafer Edited by Cheryl A. Wells

SARS Unmasked Risk Communication of Pandemics and Influenza in Canada MICHAEL G. TYSHENKO WITH ASSISTANCE FROM CATHY PATERSON

McGill-Queen’s University Press Montreal & Kingston London Ithaca G

G

© McGill-Queen’s University Press 2010 isbn 978-0-7735-3617-3 (cloth) isbn 978-0-7735-3618-0 (paper) Legal deposit first quarter 2010 Bibliothèque nationale du Québec Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free This book has been published with the help of a grant from the Canadian Federation for the Humanities and Social Sciences, through the Aid to Scholarly Publications Programme, using funds provided by the Social Sciences and Humanities Research Council of Canada. McGill-Queen’s University Press acknowledges the support of the Canada Council for the Arts for our publishing program. We also acknowledge the financial support of the Government of Canada through the Book Publishing Industry Development Program (bpidp) for our publishing activities. Library and Archives Canada Cataloguing in Publication Tyshenko, Michael G. (Michael George), 1964– sars unmasked : risk communication of pandemics and influenza in Canada / Michael G. Tyshenko ; with assistance from Cathy Paterson. (McGill-Queen’s/Associated Medical Services studies in the history of medicine, health, and society, 1198–4503 ; 34) Includes bibliographical references and index. isbn 978-0-7735-3617-3 (bound). – isbn 978-0-7735-3618-0 (pbk.) 1. Health risk communication – Canada. 2. Communicable diseases – Risk factors – Canada. 3. sars (Disease) – Ontario – Toronto. 4. sars (Disease) – Risk factors – Canada. I. Paterson, Cathy II. Title. III. Series: McGill-Queen’s/Associated Medical Services studies in the history of medicine, health, and society 34 ra644.s17t97 2010

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Typeset by Jay Tee Graphics Ltd. in 10.5/13 Sabon

Contents

Acknowledgments Preface xi

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Part One: sars in Canada 1 sars Timeline: What Happened When in Canada 3 2 Emergency Room Culture and Dealing with sars 41 3 Properties of Coronaviruses and Factors Contributing to sars Transmission 71 4 The sars Experience 86 5 The Social Amplification of Risk and sars as a Risk Issue 121 6 The Stigma of sars and Its Effect on People and Places 147 7 The Need for Sex- and Gender-Sensitive Supports for Healthcare Workers During Infectious Disease Outbreaks 172 8 sars Hospitals and Infectious Disease Response 188 9 Public sars Reports – Recommendations from Expert Panels 210 Part Two: Risk Communication and Pandemic Disease 10 11 12 13

Risk Communication of sars in Canada 244 sars and Risk Communication in Other Affected Countries 277 Avian Influenza 310 Emergency Preparedness for Future Pandemics: Lessons from sars 336 Appendix: sars Timelines Notes 387 Bibliography 401 Index 441

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For my Aunt Audrey and Uncle Otto Knibutat whose generosity and love those many years ago has never been forgotten. It made all of my successes, including this book, possible. michael g. tyshenko

For all the nurses who, when confronted with sars, sacrificed a part of themselves to keep the rest of us safe. cathy paterson

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Preface

In late September 2004 I met Cathy Paterson, a good friend I hadn’t seen in several years, by chance in a small Kingston, Ontario restaurant. It was an auspicious event that led to this book about risk communication of pandemic disease, and a detailed treatment of risk communication during the Severe Acute Respiratory Syndrome (sars) outbreak in Canada. At the time of the sars outbreak in Toronto, Cathy worked in one of the hardest hit hospitals as a nurse clinician. After reading numerous newspaper accounts and seeing many rather alarmist televised reports of the sars outbreak, I was excited to get the chance to talk to someone who was on the front lines, someone who had experienced sars firsthand. During the meeting I monopolized her time and asked her many questions pertaining to the sars outbreak: What was it like physically to get sars? What was it like to be a nurse working on a sars-designated ward? How did it personally impact her and other nurses? How had infectious disease control changed in hospitals after sars? Were “we” in Canada now prepared for the return of sars or the next pandemic? As someone who works in the areas of molecular biology, risk communication, and science policy I was fascinated by her answers, which led in turn to more questions. My inquiry spanned aspects of biology, medicine, health administration, public policy, hospital practices, public perception, news media treatment, and risk communication. After a few hours of discussion about various aspects of sars it became clear that the ordeal had placed an enormous amount of stress on the healthcare system and its workers. There had been very little acknowledgement from anyone of just how

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hard nurses worked as a group to contain sars, preventing what likely would have been a larger Canada-wide epidemic. The nurses had made many sacrifices with self-induced isolation and work quarantines that, for some of them, lasted up to five months. By the end of the evening, Cathy had captured the human aspect of dealing with sars, saying that every nurse and doctor who worked with sars patients had been affected both physically and emotionally to some degree. That first meeting led to over sixty more hours of intense, often emotional interviews. She is the lead author of an insightful chapter recounting her experience working on a sars ward during the spring 2003 outbreak. She also assisted with another chapter that describes the clinical effects of sars. Information from her interviews was used to develop the themes within this book. The rest of the chapters are my responsibility and Cathy should not be held accountable for my opinions, interpretation of events, ideas of risk communication related to sars, or the examination of infectious disease in Canada. I am also the author of chapter seven and grateful for assistance from the Women’s Health Research Unit at the University of Ottawa. The sars outbreak was a time of incredible uncertainty and stress for healthcare workers. Nurses who watched friends and coworkers become seriously ill from sars despite their best efforts to protect themselves became fearful; for some the ordeal was too stressful to endure. Cathy, like all the nurses involved, had a story to tell about her experiences of living through a turbulent time, full of stigma, fear, anxiety, stress, and uncertainty. This book is an attempt to recount, in context, what happened to nurses and other healthcare professionals in Canada who worked so incredibly hard during the sars outbreak. It is a reminder that we are indebted to our Canadian healthcare providers. It also serves as a memorial to those who died. The message is undeniable: healthcare workers as first responders must be fully prepared and adequately protected during pandemics. If we do not take care of them, who will take care of us?

SARS UNMASKED

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1

SARS Timeline: What Happened When in Canada It was all-consuming. Everything stopped. My whole life was put on hold, it was completely focused on sars. Some nights lying in bed after I’d finally got home I’d think ‘Is this ever going to end?’ Donald Low, Chief Microbiologist at Mount Sinai Hospital and Professor of Microbiology and Medicine at the University of Toronto (Cormier, 2003)

It began as a mystery illness, with an onset that mimicked several other minor diseases with innocuous symptoms, making its initial diagnosis difficult. Infected individuals unknowingly spread Severe Acute Respiratory Syndrome (sars) to others, including hospital staff, before strict isolation, screening, and quarantine measures were established. More frighteningly, the disease was transmitted between healthcare workers even after strict protective measures were put in place. The disease may have started off with symptoms similar to a mild flu but for some who were infected, there was nothing normal about the illness. Its forceful onset resulted in pneumonia, putting up to 20 per cent of its victims onto assisted-breathing ventilation machines in a matter of days. The atypical pneumonia-like disease originated in China and was transmitted to several other countries through international travellers who were unknowingly infected and spread the disease. Two infected individuals returning to Toronto, Ontario, and Vancouver, British Columbia, in early 2003 brought the contagion to Canada. The disease in Toronto was able to take hold in the population where it seeded several infections of atypical pneumonia that were eventually contained within local area hospitals. During the early

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spread of the disease there was no reliable laboratory diagnostic test, no established medical diagnostic methods, no optimal treatment, and no effective drug regime due to a poor understanding of the virus’s immunopathological mechanism (Jiang et al., 2005). Without a confirmatory test doctors used the following criteria to diagnose sars cases: a Suspect case was a person who developed a fever and at least one or more respiratory symptoms within ten days of having had close contact with a Probable case (direct contact) or had returned from travel to known areas in Asia where sars was reported (direct epidemiological link). A Probable case was similar to a Suspect case, with patients experiencing more severe and progressive symptoms such as difficulty breathing, and chest x-ray confirmation of atypical pneumonia. Surveillance of Suspect patients and isolation control measures were used to eventually verify and contain the true Probable cases. Medical assessments used to assign Suspect and Probable status relied heavily on epidemiological contact tracing that established links to known sars cases and confirmed areas throughout the outbreak.1 By late March 2003, when individual cases began appearing outside China, Chinese officials finally admitted to international authorities that an atypical pneumonia outbreak was also occurring in Guangdong Province. The magnitude of the outbreak in China was much larger than previously thought. Officials had already documented almost 800 sars cases, with a total of thirty-four deaths. Initially, criteria to determine who was a Suspect or Probable case were poorly defined, with several countries improperly categorizing and diagnosing cases; however, all cases reported from other countries linked epidemiologically back to China. The crucial delay in reporting the infectious disease to the international community, and slowness in dealing with the situation internally, meant that China faced a far more severe epidemic than other countries. Many other countries instituted containment measures quickly when the first patients were identified; this response prevented the disease from spreading as widely as it did in China. Canada was one of the countries that acquired exported, travelrelated cases of sars, and like other infected areas, its healthcare system had to deal with the spread of an unknown, influenza-like disease with little information. Afraid that sars might be spreading unchecked in Toronto, government officials in the province of

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Ontario eventually declared a provincial “sars emergency” under rarely used legislation. The Ontario Health Protection and Promotion Act allowed legal action to remove personal freedoms of those affected, if necessary, to prevent spread of the disease by compulsory quarantine (cbc News, 2003a). Canadian cases of transmission remained contained within Toronto hospitals due to the determined infection control efforts of healthcare workers and the activity of the Ontario sars Scientific Advisory Committee that managed and recommended infectious disease control measures. Health officials at the provincial level worked tirelessly to establish epidemiology and quarantine lists for all potential sars contacts. The advisory committee was responsible for developing quarantine guidelines, new hospital directives, visitation policy, isolation procedures, healthcare self-screening protocols, and patient transfer guidelines. The directives were passed to the director of the Ontario Ministry of Health and Long-Term Care and also to hospital staff with practical working knowledge, who reworded the directives for practical implementation (phac, 2004a). On the front lines this translated into new procedures, programs, and policies for dealing with Suspect and Probable sars patients. Hospitals converted standard rooms to supply more negative pressure isolation for patients, to reduce the spread of airborne infectious particles; full personal protective equipment (ppe) for workers was implemented; mask-fitting was performed; work quarantines for high risk workers were established and hospitals restricted visits in order to eventually contain and overcome the disease outbreak. The outbreak lasted from 23 February (the first known case in Canada) until 12 June 2003 (the last confirmed infection in Canada). Only when twenty days or two infectious incubation cycles had elapsed since any new infections were reported to the World Health Organization (who) did this group remove Toronto from its list of sars-affected cities on 2 July 2003 (World Health Organization, 2003c). Canadian experts were cautiously optimistic that the chain of human-to-human transmission had been stopped and sars was over. Even in July nearly twenty sars patients still remained ill in isolation or were still being treated but listed as “recovering” in Toronto hospitals (Daily News, 2003). In Canada, the sars outbreak can be divided into five main time periods.

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stage one: before sars arrived in canada (november 2002 to 22 february 2003) Health Canada’s Global Public Health Intelligence Network (gphin) received a Chinese-language news report (one of many such global health news items) of a flu outbreak occurring in mainland China. gphin is an early-warning media monitoring system that continuously scans available Internet news sources for reports of infectious disease outbreaks around the world. The Chinese news report, published on 27 November 2002, was sent to the World Health Organization (who) with an English header but the rest of the report in Mandarin was not translated. The first official report of the new mystery outbreak to who occurred two and a half months later, on 11 February 2003. The who report of those infected cited 305 affected persons, 5 of whom had died. Disturbingly, 30 per cent of all those infected were healthcare workers. Health Canada did publish information about the Guangdong outbreak in its subsequent FluWatch bulletin that told of the new Chinese influenza outbreak between 9 and 15 February 2003. FluWatch reported that Chinese authorities claimed the Guangdong outbreak was over. A second monitoring program, the Program for Monitoring Emerging Diseases (ProMED), is an Internet-based reporting system that, like Health Canada’s gphin, also provides email updates on infectious disease outbreaks occurring globally. Promed alerted subscribers2 that the Chinese government official’s claim that the new illness was not a threat might not be true, that the contagion was still present and causing new infections, and the origin of the outbreak had not been clearly established. At the same time as these reports about sars were circulating, officials in Hong Kong reported a case of highly pathogenic avian influenza in a human. On 19 February 2003, with warnings of avian flu from Hong Kong and reports of similar flu-like illness occurring in China, federal officials in Canada sent out a country-wide warning recommending that all provinces be vigilant for influenza-like illnesses in returning travellers, particularly those returning from Hong Kong or China (phac, 2003a). While we know now that these were two separate types of infectious disease occurring in China, namely the avian flu and the

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mystery influenza later identified as sars, it was unclear at the time whether the outbreaks were the same.3 Conflicting reports from Chinese officials only intensified the concerns of public health officials at Health Canada, who remained watchful. It was clear that at least one new zoonotic disease was emanating from China and beginning to be transmitted person-to-person. Officials at Health Canada took the precaution of writing to a number of other groups (the Pandemic Influenza Committee, the Council of the Chief Medical Officers of Health, the Canadian Public Health Laboratory Network, the FluWatch network, and veterinarians) on 20 and 21 February 2003, warning them to be on the alert for a new influenza strain. The international spread of the disease occurred when a physician from Guangdong Province checked into the Metropole Hotel in Hong Kong on 21 February 2003. He had treated patients in Guangdong with atypical pneumonia before his departure. He appeared asymptomatic on arrival in Hong Kong, but during his stay symptoms of the atypical pneumonia manifested. While passing other guests in the hotel hallways and sharing the small elevator, the Chinese physician infected at least twelve other people on the ninth floor, including a seventy-eightyear-old woman from Toronto, identified in the medical literature as Mrs K. The infection of international travellers visiting Hong Kong seeded outbreaks in a number of countries and resulted in Canada’s first imported sa rs cases in Toronto and British Columbia. At the end of February news reports began surfacing of a severe atypical pneumonia appearing in other Asian countries. The virulent pneumonia had spread to both Hong Kong and Vietnam. The Vietnamese cases were traced back to a middle-aged man admitted to a Hanoi hospital experiencing symptoms of fever, dry cough, muscle soreness, and a sore throat. The infected individual with severe flu transmitted the disease to about twenty hospital staff, who became ill with similar symptoms and pneumonia. It wasn’t until the end of February, with reports of the infection’s wider spread, that the Chinese Ministry of Health reported the occurrence of an “atypical pneumonia,” wrongly diagnosed as being caused by Chlamydia pneumoniae, a bacterium known to produce pneumonia in humans.

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stage two: the initial outbreak, sars1 in 4 canada (23 february to 19 april 2003) Toronto, Ontario sars arrived in Canada on 23 February 2003, when Mrs K. stepped off a twenty-hour flight from Hong Kong to Toronto. Mrs K. and her husband were returning from a ten-day holiday to Hong Kong. A few days after their return, Mrs K. felt terribly feverish and unwell. Thinking she had caught the common yearly flu, her family helped care for the elderly woman at home. On 5 March she died. At first her death was deemed unremarkable by Canadian doctors as many older individuals with weakened immune systems succumb to influenza every year. Her family did not wish to have an autopsy done and the cause of death was officially listed as a heart attack. Two days later, on 7 March 2003, Mrs K.’s son, Mr T., and another family member visited their family doctor complaining of similar influenza-like symptoms, including a fever that had come upon them suddenly. Later that same day, with rapidly worsening symptoms, Mrs K.’s son arrived at the Emergency Department (ed) of Scarborough Grace Hospital in Toronto. He was feeling extremely weak, with a raging fever, and was having increasing difficulty breathing. While waiting to see a doctor Mr T. was moved out of the waiting room and into observation, a larger room in the emergency ward, which he shared with two elderly male patients. Mr T. remained in the open observation ward of the busy Emergency Department with others for eighteen to twenty hours. Only thin curtains separated him from nearby patients as he actively shed virus particles that were dispersed into the air. By the next day, Mr T.’s condition had deteriorated to the point that he was admitted to the Intensive Care Unit (icu), and he eventually required intubation and ventilation, a procedure where doctors insert a plastic tube through the mouth and down the windpipe to aid breathing with the help of a mechanical ventilator. Several patients and staff were exposed to Mr T. before he was finally placed in isolation. Due to hospital overcrowding, Mr T. remained in the Emergency Department’s observation area long after doctors had authorized his hospital admission. While waiting for a bed to become free, Mr T. received oxygen and vaporized medications. It was later determined that both procedures are high

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risk and create dispersed infectious aerosolized droplets. He also had numerous visitors during this time. His stay in the observation area, with treatments and visitors, was standard practice. Two days later, on 9 March 2003, three more family members related to Mrs K. arrived at the hospital, all complaining of fever and pneumonia-like symptoms similar to Mr T.’s. Doctors finally realized a cluster of infections was occurring. Mr T. was moved into isolation and attending staff were asked to treat him as an infectious case. The isolation greatly helped to contain the outbreak by preventing further spread to other patients and healthcare workers. After recognizing that Mr T. and other close family members with related pneumonia-like symptoms represented a cluster, the Scarborough Grace doctors called Toronto Public Health and warned officials that there could be a tuberculosis outbreak in Toronto. However, on 13 March 2003 diagnostic x-rays and skin tests for tuberculosis all came back negative. By that time the atypical pneumonia was aggressively attacking Mr T. and he was moved to the Intensive Care Unit at Sunnybrook Hospital for more specialized care. His condition had continued to worsen, with “heavy” lungs that made it difficult for him to breathe properly. That night, Mr T.’s sister, Mr T.’s wife, and their five-month-old baby were rushed by ambulance to Mount Sinai Hospital. While Mr T. was being tested and treated the who issued a global alert regarding the mystery illness that was occurring primarily among healthcare workers in Hanoi and Hong Kong. Physicians at several hospitals in Toronto involved in the initial outbreak were unaware of the alert information that was available. Believing their trip to Asia was inconsequential to the family’s developing non-tuberculosis-like pneumonia, Mrs K.’s husband never mentioned their recent travel to areas where the atypical pneumonia was known to have surfaced. Mr K., who was also infected with the atypical pneumonia, was still well enough to speak, but despite questioning by medical staff and public health officials, his answers provided no clues as to what was making his family sick. By this time public health officials in Ontario realized that this unusual cluster of pneumonia required more scrutiny and they started holding daily updates for the provincial ministry, Health Canada and local hospitals. Mr T., forty-four years old, died that night in mid-March from atypical pneumonia, and only then did officials realize that the Canadian cluster could be the same as

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the atypical pneumonia that was being reported from Asia. sars had already infected hundreds worldwide, and its appearance in Canada was a possibility, but without an epidemiological link the Canadian cluster remained a mystery. Public health officials in Ontario began mobilizing quickly to contain what they believed was a possible sars cluster. They first tracked down another son of Mr and Mrs K., who told them his parents had been to China and Hong Kong on vacation at the end of February, finally establishing an epidemiological link to known sars-infected areas. Officials searched Mr and Mrs K.’s home for luggage tags and airline tickets so they could determine which flight the couple had returned on. Using airline passenger lists and a minute-by-minute outline of where each of the family members had been after their parents had returned to Canada, health officials attempted to compile a list of everyone the couple might have talked to and with whom they had come into contact. A list of almost 500 names was established of individuals who had face-toface contact with the couple. The next morning everyone on the list was contacted individually, and the twenty public health staff enlisted for telephone duty waited anxiously to answer calls directed to a special hotline (Palmer and Talaga, 2003). A seventy-six-year-old man known in the medical and epidemiological literature as Patient 8 or Mr P.5 went to the emergency department of Scarborough Grace Hospital on 7 March 2003. He was suffering from arrhythmia, an abnormal heart rhythm, a notunexpected condition given his medical history and advanced age. At this point, sars didn’t even have a name, but it was lurking in the Emergency Department at Scarborough Grace Hospital. The man with heart problems spent the night in the observation room with Mr T. With the virus circulating in the air, Mr P. unknowingly contracted sars during his stay. Unknown to public health officials he had become another potential line of unchecked sars infections. The next day, Mr P. was evaluated for his heart arrhythmia and then released from hospital, returning home to recover. On 16 March 2003 Mr P. returned to Scarborough General Hospital’s Emergency Department, not for heart complications this time but complaining of a severe fever and respiratory symptoms that were making breathing increasingly difficult. He was quickly admitted to the icu. At the time of his admission he was hypoxic and fighting for every breath. At this time Health Canada announced eleven Suspect cases of sars in Canada; there were nine in Ontario, one in

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British Columbia, and one in Alberta. sars was still moving undetected in Toronto area hospitals, being transmitted between patients and from patients to healthcare workers (phac, 2004a). On 21 March 2003 Mr P. died of sars, becoming Toronto’s third atypical pneumonia fatality. His wife, Mrs P., and three other close family members had also become ill with the disease. Mr P. had infected several others, including his wife, seven er visitors, two other er patients, one hospital staff member, three er nurses, two er clerks, one housekeeper, two ems workers, one firefighter, three icu nurses, and one medical doctor. Later, Mr P.’s wife also succumbed to sars. Between them, the couple infected twenty-nine other people, most of them healthcare workers. The doctor who intubated Mr P. in the icu at Scarborough General Hospital had worn full protection, including mask, eye protection, gown, and gloves, but later developed sars. Three nurses present during the intubation procedure were also infected. The transmission of the disease through close contact during high-risk procedures magnified the anxiety, uncertainty, and fear about personal safety. The transmission of the contagion while wearing full personal protective equipment (ppe) was a frightening development for nurses and an indication of how difficult it was for healthcare workers to protect themselves while caring for sars-infected patients who were actively shedding virus. At this point in time the cause of the atypical pneumonia still remained unknown. Another patient in contact with Mr T. during his stay in the observation area had also been unknowingly exposed. Identified as Mr H., he became ill and suffered a heart attack. His condition, coupled with low-level fever and “small infiltrate”6 on his chest x-ray lowered the doctor’s suspicion of sars, and only standard precautions were used for infectious disease containment. He was transferred to York Central Hospital, a treatment center that was much better equipped to deal with his heart attack. He was later diagnosed with sars and was the source of another infectious cluster involving nineteen direct contacts. He transmitted sars to his wife, eight hospital staff members, one ems worker, and three other patients (Campbell, 2006b). As a result York Central Hospital closed its doors to general admissions and instituted a Level 3 containment for infectious disease (phac, 2004a). Canadian scientists attempting to identify the cause of sars announced they had isolated the virus responsible for the mystery illness. Human metapneumovirus was detected in six of the eight

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Canadian cases; the virus comes from the same family that gives people mumps or measles. However, this virus proved not to be the true cause of the disease. On 24 March 2003 the true cause of sars was finally identified: the mysterious atypical pneumonia was caused by a novel coronavirus. But it was not until 16 April that the who announced that the coronavirus was, without any doubt, the causative agent of sars (World Health Organization, 2003a). This class of virus is known to attack and infect a wide variety of animals, including humans. The human strains can cause acute respiratory disease and gastroenteritis. Coronavirus strains are the cause of 10–15 per cent of all common colds in humans, but they can also cause pneumonia. During the early stages of the outbreak, researchers worked tirelessly to identify the virus. Identification of the causative agent was extremely important as the knowledge gained from early cases and knowledge of the virus type would help to greatly improve prevention and treatment strategies. The who eventually established three types of diagnostic tests. However, two of the three diagnostic tests detect human antibodies to the virus only after the tenth (ifa)7 and twenty-first days (elisa)8 of infection (antibodies are substances made by the body’s immune system to fight a specific infection). The tests were not timely enough to provide information for containment. The third test, Polymerase Chain Reaction (pcr),9 detects the genetic material of the virus and while it can be performed readily it resulted in a high number of false negative results. Cell tissue culture was also used as a test to detect the presence of live virus, but its utility as a diagnostic tool was limited (iapa, 2003; World Health Organization, 2003b). With cases of sars continuing to increase and hospital staff and visitors alike becoming ill with sars, the threat of containment failure loomed. Both Sunnybrook Hospital and Scarborough Grace Hospital closed their emergency services and intensive care units on 23 March 2003. The hospitals also began refusing new admissions and transfers from other hospitals, their outpatient clinics were closed, and employees were barred from working at other institutions. sars continued to spread at Scarborough Grace Hospital. With the containment of sars still in question on 25 March 2003, the disease was declared a reportable illness by the Ontario government. Emergency measures allowed for patient tracking and forceful containment during quarantine if necessary (cbc News, 2003a).

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All available negative pressure rooms in Toronto were filled to capacity by 26 March 2003. In response to the ever-growing numbers of patients requiring isolation, several Toronto hospitals mobilized and quickly built makeshift, temporary negative pressure isolation rooms to deal with the number of patients. West Park Hospital, a former tuberculosis hospital, was opened to accept sars cases and staff was found to care for fourteen patients. Ontario’s premier, Ernie Eves, activated Code Orange for all Toronto hospitals in response to the growing number of infectious disease cases. Suspect and Probable sars patients were cared for at over twenty different hospitals throughout the Greater Toronto Area. The heightened emergency level resulted in area hospitals suspending all non-essential services, increasing security, and barring visitors. Rules from the Ministry of Health requiring the wearing of personal protective equipment by all hospital staff were implemented and strictly adhered to. In a precautionary move, on 31 March health officials required all other Ontario hospitals to implement Code Orange rules to facilitate containment should sars appear in other cities. From 27 March to 7 April, many hospitals quickly mobilized to put sars surveillance systems and a number of other new activities in place to respond to the new infectious disease. Daily reporting and meetings about sars became standard practice at Greater Toronto Area hospitals. As a result of the invocation of the Public Health Emergency Act, local public health services were overwhelmed by individuals concerned that they might have contracted sars. Despite the fact that the outbreak in Toronto was contained in hospitals, the who requested that airlines begin screening passengers for sars on flights leaving from high risk areas: Canada (Toronto), Hong Kong, Singapore, Vietnam, Chinese Taipei or Taiwan, and China’s Guangdong Province. The federal government convened an invitational sars Summit in Toronto on 30 April and 1 May 2003, working out the details for a national sars containment strategy. The event helped build communication links and strategies in the effort to contain sars. (The meeting was later criticized because several front-line clinical physicians, public health physicians, and administrators who had been fighting sars at ground level in Toronto were not invited or asked for their input.) Health Canada also facilitated the purchase of approximately 1.5 million n95 masks for the National Emergency

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Stockpile System (ness), and sent 10,000 masks to Toronto health officials. (n95 masks filter at least 95 per cent of all particulates that are 0.3 microns or larger and are known to provide the highest level of protection to healthcare workers against inhaling viral particles.) Discussions for sars containment were surprisingly narrow in focus, centered on individuals arriving at hospitals for treatment of sars and strategies for containment, although there were several instances of patients with sars who visited their family physicians first as their health was deteriorating (as Mrs K. did on 28 February 2003). General practitioners, paramedics, and family doctors were largely a forgotten, vulnerable group at risk of contracting sars from individuals returning from overseas visits. The concerns of family physicians were voiced to Ontario Provincial health officials as early as 28 March 2003, and the Ontario Medical Association (oma) issued guidelines for family doctors by fax and email on 3 April 2003. The oma proposed that the fastest way for family doctors to get personal protective equipment was for them to buy their own supplies wherever they could find them and they would be reimbursed later. A growing number of family physicians were concerned by the lack of provincial support and the lack of any plan to distribute protective equipment. It wasn’t until almost four weeks later, after the Province of Ontario declared a health emergency, that the province finally used its vaccine distribution network as a way to distribute needed protective equipment to family doctors and their office staff. Other events that occurred during this time period highlighted different aspects of infectious disease containment. On 4 April 2003 a Toronto family visiting Australia, suspected of having sars, was placed in isolation at a hospital near Melbourne; this was the first instance of Canada exporting sars to another country. The movement of sars between countries by air travel revealed the difficulties of international disease containment. In a second event on 9 April 2003, a single Toronto area worker defied his quarantine order and went to work even after showing sars symptoms. As a result, public health officials placed 197 employees at a HewlettPackard plant in Markham, Ontario, under quarantine. Despite plenty of coverage of sars by the news media detailing what was known about transmission and the dangers of having even a single breach in quarantine, individuals who intentionally broke quaran-

sars timeline

15

tine presented a major problem for public health officials who were attempting to track contacts and contain the outbreak. A third major event was determination of the complete genetic code for the sars coronavirus, the causative agent. The genetic code was completed by Canadian researchers and reported worldwide on 12 April 2003. Two days later the who announced that this novel coronavirus sequenced in Canada was, without a doubt, the causative agent of sars. During mid-March an eighty-two-year-old man who had gone to Scarborough Grace to be treated for a knee injury contracted sars along with two family members. This led to the spread of infection within a Catholic Church group and another cluster outbreak of sars in Toronto. The man later died, on 1 April 2003. The cluster was contained but fourteen members of his family had contracted sars; fourteen members of the church group and three healthcare workers were also infected. On 14 April 2003, Toronto health officials ordered all 500 members of the Toronto Catholic Church group into quarantine as a precaution after their group was linked to cases of sars. The church group members had been exposed to the disease two weeks prior at a funeral. Despite the second outbreak of sars cases Toronto health officials publicly insisted (rightly) that the sars outbreak was not out of control (phac, 2004a). Canada’s largest trauma unit, Sunnybrook Hospital in Toronto, stopped accepting new patients after at least four healthcare workers showed signs of sars on 20 April 2003. The disease was contained within the hospital but its workers were at the greatest risk of exposure, especially during high-risk procedures that aerosolized the virus. Attempting containment, Sunnybrook Hospital closed its critical care, cardiovascular intensive care, and sars units for one infectious cycle (ten days). Ontario’s chief medical officer of Health wanted doctors and nurses to wear full-face shields, double gowns, and double gloves as a precaution. The changes were instituted after fifteen hospital staff contracted sars while clearing the airways of patients with the disease. Throughout April 2003 Sunnybrook Hospital and the Women’s College Health Sciences Centre cared for the largest number of sars patients, but many of its physicians with relevant expertise or experience were either ill with sars or on restricted work quarantine. Other Toronto area institutions were struggling with their own sars workload and had few extra workers to spare. One sister hospital eventually sent one

16

sars unmasked

senior resident to help with general medicine coverage, freeing up on-site staff to concentrate on sars patients. The mobilization of physicians and nurses to respond effectively to infectious disease outbreaks was one of the areas that showed marked shortcomings. Vancouver, British Columbia True Probable cases of sars were reported only in Ontario and British Columbia, while Suspect cases that turned out not to be true sars cases were reported in several other provinces. Vancouver’s hospital encounter with sars was very different than that reported from Toronto. Mr C. and his wife (Patients 0 and 1) returned to Vancouver on 7 March 2003 after a trip to Hong Kong, during which they stayed on the fourteenth floor of the Metropole Hotel from 20–24 February and again 3–6 March 2003. On the return flight Mr C. began feeling unwell, and upon arrival in the late afternoon his symptoms were rapidly worsening. Mr C. went to his family physician, who sent him directly to the Emergency Department at Vancouver General Hospital. Due to his high fever and increasing difficulty breathing, hospital staff moved him from the crowded waiting room and placed him alone in a small room within five minutes. Within fifteen minutes he was isolated and put on full respiratory precautions. None of the healthcare workers who assisted became infected, as they wore n95 protective masks. After less than two more hours Mr C. was moved to a negative pressure isolation room. The nurses and doctors did not know what Mr C. had acquired, but provincial authorities had alerted them to a new viral illness (potential human-to-human spread of avian influenza) originating from Asia (McCaughey, 2007). Vancouver health authorities issued the first alerts to hospitals and doctors on 20 February and 24 February, warning them to be on the lookout for patients meeting certain criteria. This included individuals presenting with influenzalike symptoms and atypical pneumonia who had recently travelled to Hong Kong or China (McIlroy, 2003). The who did not issue a global health alert to watch for cases of atypical pneumonia until 12 March but Vancouver had already taken precautions to avoid secondary transmissions by those presenting with any flu-like illnesses (Macdonald, 2004). Due to the precautions taken, the 148

sars timeline

17

hospital workers who contacted Mr C. during the first ten days after his arrival showed no secondary transmission or seroconversion events.10 Mr C.’s wife (Patient 1) recovered from her infection, a mild illness that required no further follow-up. The couple had no other household contacts. Patient 2 had stayed in Hong Kong for an extended period of time and had contact with two family members in Hong Kong who later died from sars. Asymptomatic but concerned that she had been exposed, she went to her family physician after her return to Vancouver on 26 March 2003. Chest radiographs showed bilateral consolidation, an indicator of sars, and she was sent to a nearby hospital and admitted directly to a negative pressure isolation room. Her condition deteriorated and she was transferred to the Intensive Care Unit of a second hospital for assisted ventilation. Two household contacts remained healthy and had no detectable sars-cov antibody six to seven months after potential exposure to Patient 2 (Skowronski et al., 2006). Patient 3 stayed at the Amoy Gardens apartment complex in Hong Kong from 28–30 March 2003 (Yu et al., 2004). After returning to Vancouver he remained self-isolated at home in his finished basement with no contacts. Other household members were quarantined but remained asymptomatic. With his symptoms worsening and increasing difficulty breathing, Patient 3 went to hospital on 3 April 2003. (His son drove him – both wore masks – and follow-up showed the son had no detectable sars-cov antibody six months after potential exposure.) Computed tomography scans showed widespread, patchy, ground-glass opacification in both lungs, indicative of sars infection.11 Patient 3 was admitted to a second hospital and placed directly in a negative pressure isolation room (Skowronski et al., 2006). Patient 4 was a Vancouver-area nurse who cared for Patient 2 in hospital from 29 to 30 March 2003. Patient 2 was receiving oxygen by mask and nebulization therapy. The nurse helped Patient 2 to use the toilet and viral particles were likely aerosolized when the toilet was flushed in her presence.12 The nurse had diligently followed the personal protection equipment guidelines that were in place but at the time these did not include eye protection. She developed symptoms on 4 April 2003 and went to hospital on 15 April where she was admitted directly to a negative pressure isolation room. A household contact remained asymptomatic for sars.

18

sars unmasked

All five patients with sars in Vancouver recovered fully and no secondary transmission was observed. When tested later none of 442 staff members of the five hospitals that cared for the sars patients had detectable sars-cov antibody (Skowronski et al., 2006).

stage three: between sars1 and sars2 (20 april to 22 may 2003) In Ontario, the time between sars 1 and 2 saw declining numbers of Suspect sars patients. From 20 April to 7 May 2003 three psychiatric patients developed pneumonia with no known epidemiological link. Several elderly patients on an orthopedic ward also showed common symptoms of typical post-operative pneumonia and collectively they infected several staff members who also became ill. On 23 April 2003 the who warned against all unnecessary travel to Toronto, Beijing, and China’s Shanxi Province because of the ongoing uncontained sars outbreak. As the Easter and Passover holidays took place (18–21 April 2003), public health officials braced themselves for a potential spike of cases that never materialized from the previous religious group cluster exposure. Catholic churches in Toronto instituted sars precautionary measures with communion wafers placed in hands rather than mouths, and confessions took place outside the usual booths. The effects of poor infectious disease management were reflected in the actions of the provincial government. At the end of April 2003 Ernie Eves, Ontario’s premier, had introduced Bill 1 – the sars Assistance and Recovery Strategy Act – in the Provincial Legislature, and it was passed quickly in a single sitting. The bill, the first piece of legislation to come before the House in the new session, was an attempt to help improve the capacity of Toronto Hospitals to deal with sars and future, similar infectious disease outbreaks. The bill advanced the government’s comprehensive sars Assistance and Recovery Strategy by protecting the jobs of people affected by sars-related personal illness, quarantine, or isolation. Under the bill, employees are entitled to an unpaid leave of absence if sick or quarantined and reinstatement when they are able to return to work. The new legislation made adjustments to the Emergency Management Act, strengthening enforcement powers to prevent the spread of sars and other infectious diseases. The bill also gave the

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19

Ontario tourism businesses that were hardest hit some relief by exempting all admissions and accommodations across the province from retail sales tax from 1 May to 30 September 2003 based on a reassessment of its provisions during the sars emergency. The emergency management laws were amended in November 2003 and Justice Archie Campbell, convening an expert panel on sars, commented on the amendments swiftly made to the emergency management laws during the height of the outbreak. He believed that the powers in Ontario’s emergency legislation were “awesome” in scope, and the laws “could override any law that promotes the public good or protects individual rights.” Some of the possible powers included forced mass immunizations, fines, and jail for people who refuse to disclose information the province demands (Dwortzan and Saltus, 2003). The amended legislation “gives government officials unrestricted authority to override virtually every other Ontario law that gets in the way of any power they consider necessary to exercise in an emergency,” wrote Campbell in his second interim report on the sars crisis. While he noted the sweeping powers attributed to the law’s amendments, he also acknowledged that Ontario’s legislation follows the format implemented by almost every other province in the country. In his interim report, Campbell raised questions about the vague and broad powers given to Ontario government officials and said that the emergency management laws would likely face a legal challenge if used. The danger, he noted, was that if the bill were challenged in court and if any part of it were struck down as unconstitutional, it could have disastrous effects on emergency response. Campbell stated that a fundamental legal and constitutional overhaul by Ontario’s attorney general of the amendments introduced on November 2003 was needed before the next sars-like infectious disease outbreak to ensure that they comply with the Charter of Rights and Freedoms (Livingston, 2005). During the first week of May 2003 the who announced that the virus that causes sars might be much more resilient than originally thought. New research showed that the virus could survive outside the human body for hours or even days, spreading through sewage and on contaminated objects. On 14 May 2003 the who removed Toronto from the list of areas with recent local transmission of the disease. This elimination of Canada from hotspot areas was widely interpreted as an indication that the outbreak in Toronto had come

20

sars unmasked

to its end – that containment had been achieved. Consistent with the idea that sars was now contained the premier of Ontario lifted the emergency sars sanctions on 17 May 2003. Code Orange status for hospitals was revoked and the Provincial Operations Centre that had been overseeing the outbreak details was rapidly dismantled. All levels of government were acting on the understanding that sars had been contained. Health Canada began to issue weekly rather than daily bulletins concerning the infectious disease. By 19 May 2003, there was a feeling that sars had been declared over in Toronto, at least unofficially. Personal protective equipment and sars containment precautions were relaxed in hospital emergency departments and icu wards. Some staff skeptical of the announcement remained in full ppe. The next day (20 May 2003) hospital officials returned to work to find most nurses back in full ppe and news of a new cluster of individuals with atypical pneumonia. The new cases stemmed from two small family clusters that had epidemiological links to other known sars patients. The Ontario Ministry of Health and Long-Term Care attempted to find all individuals who might have contacted sars-infected patients. Individuals who had been at various local Toronto hospitals were encouraged to self-isolate and contact health officials. Individuals who were at St. Michael’s Hospital’s neurosurgery unit, North York General Hospital, and Scarborough General Hospital and people who entered St. John’s Rehabilitation Hospital in Toronto during the month of May were all asked to quarantine themselves and call the Toronto Public Health Unit’s Telehealth line. The provincial government had established a health telephone infoline and an Internet site with information for people who did not have any symptoms but were concerned about sars. It was a way for “worried but well” individuals in the community to obtain credible information (Ontario Ministry of Health and Long-Term Care, 2003). Later, on 22 May 2003, a new sars outbreak was detected in Toronto. In a matter of days, most cases in the new outbreak were epidemiologically linked to the original cluster, except for the first case in the new cluster. It was not clear how the ninety-six-year-old man, who had since died of sars, became infected after surgery for a fractured pelvis; he had been on a different floor from the sars patients being treated in isolation. A series of weekend news conferences was held to communicate what was happening with the new

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21

cluster of sars patients. Dr Donald Low, chief microbiologist at Mount Sinai Hospital, appeared overworked, announcing a new list of Probable and Suspect cases to the news media. Doctors had overwhelming evidence that indicated that the disease was spread primarily through close contact with droplets from a sars-infected person, something that does not appear to have been possible in this case. The infection likely resulted from environmental contamination through equipment used first on a sars-infected individual and then used on the elderly patient. (cnn News, 2003).

stage four: the second outbreak, sars2 in canada (23 may to 12 june 2003) sa rs 2 resulted in North York General Hospital’s shutdown on Friday, 23 May 2003. Due to the hidden cases and previously relaxed p p e orders, most staff were put on ten day work quarantine. The Emergency Department became a sa rs diagnostic unit for staff and families who might have been exposed to the new cluster of sa rs . Over the next eight days, thirty staff and physicians were admitted with sa rs . Two sa rs units were opened to deal with the new patients; one was a sa rs i c u to deal with severely affected individuals. The second outbreak cluster included 11 Probable and 41 Suspect cases of sars. Contact tracing of those infected resulted in at least 2,200 people being put into self-quarantine. The seriousness of the outbreak that had gone undetected resulted in hospitals in the Toronto area resuming sars screening in their Emergency Departments. During this time four hospitals – St. John’s Rehabilitation Hospital, North York General Hospital, Scarborough Grace Hospital, and St. Michael’s Hospital trauma and neurosurgery units – were shut down to visitors and new admissions (Murray, 2003). It was only at this time that academic researchers and epidemiologists modeling transmission of sars realized what the public health officials had already suspected for some time: the disease was contagious enough to have pandemic potential if left unchecked. Rigorous public health measures of early case detection, quarantine, and prompt medical treatment would, they estimated, be enough to contain sars. For epidemiologists and risk modelers sars presented many unknown factors. The mathematical models

22

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generated to estimate pandemics are complex and it was difficult to predict early in the sars outbreak how such an epidemic might spread, especially when caused by an unknown virus. News reports detailed that nurses at Toronto hospitals where the second sars cluster originated had attempted to warn officials of the problem days before the cases were made public, but their warnings and their concerns that healthcare precautions in the city were being relaxed too soon were ignored. The latest group of patients began showing symptoms of the disease after 15 May 2003, the day hospitals relaxed the policy that required healthcare workers to wear masks at all times. Nurses from North York General Hospital and St. John’s Rehabilitation Hospital reported concerns about possible sars cases on 20 May 2003. Ontario health authorities went public with the suspected new cases on 22 May, requested hospital unit closures, and insisted that they had heard no warnings before that date. The second cluster of sars patients resulted in four Toronto hospitals being designated as sars centers. The move was aimed at trying to limit the spread of the cluster in city hospitals by containing all new sars patients at one of four locations. The new cases were to be treated in four hospitals only: North York General Hospital, Scarborough Grace Hospital, St. Michael’s Hospital, and the Etobicoke site of the William Osler Health Centre. The system was implemented to allow other hospitals to resume normal schedules and, more importantly, to protect desperately needed healthcare workers whose numbers had been depleted by sars and work quarantines. Politicians attempted to deflect criticism over the handling of sars and the new outbreak cluster. Provincial Minister of Health Tony Clement believed that Ontario maintained strict rules to prevent the spread of sars but added he eventually wanted to know how sars flared back up again. Dr Colin D’Cunha, Ontario’s commissioner for Public Health, told news media that there was little point in trying to assign blame for the latest flare-up, “This very simply is a lesson learned – keep up the guard and if need be, increase the level of guard.” This was little consolation to the cluster of nurses and other healthcare workers who became infected due to the second sars outbreak. Donald Low, the expert on infectious disease, stated, “The masks came off on the 15th ... and we started seeing cases immediately ... All this stuff falls into place” (ctv News, 2003a). Toronto public health’s command centre had

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23

scaled back from 400 personnel to only 20. The workforce was re-expanded to 100 with the news of the second outbreak cluster to allow for the necessary contact tracing and quarantine monitoring. Thousands of people telephoned Toronto’s sars hotlines seeking information once news of the new outbreak became public. The who was monitoring developments of the new outbreak in Toronto closely and the U.S. Centers for Disease Control and Prevention reissued a travel alert for Toronto as a result (cbc News, 2003b). sars appeared to be under control in Toronto and globally by late May 2003. The who had lifted its travel advisories for Hong Kong, China’s Guangdong Province, and the Philippines only a week after taking Toronto off the list of “affected areas.” Almost two months had passed since Ontario Premier Ernie Eves imposed the provincial emergency measures through the Health Measures Act first put into effect on 26 March in the effort to combat sars.

stage five: after sars2, containment and recovery (after12 june 2003) In June few sars incidents occurred, as the outbreak was largely contained. Noted incidents included a medical student who had been placed in quarantine after potential sars exposure during an obstetrics rotation at North York General Hospital. In an unusually long incubation period of twelve days (two days after his quarantine time had expired) the student developed symptoms while working in obstetrics at Mount Sinai Hospital. A number of hospital staff along with five women and their newborns were quarantined without further problems. A second incident involved 1,700 students at a high school in Markham who were quarantined after a student at their school fell ill. The last new case of sars in Toronto was reported on 12 June 2003 and by 23 June 2003 the number of sars cases in Toronto hospitals and worldwide continued to fall. Only twenty-four active Probable sars patients remained in Toronto hospitals, down from forty-four individuals a week earlier. Of the remaining sars patients about half (fourteen out of twenty-four) were in critical condition. Initially, officials declared Toronto “sars free” on 14 May 2003, only to be added to the who’s affected areas list again when a second outbreak was discovered on 22 May. By mid-June officials for Ontario’s Ministry of Health were much more cautious and the

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spokesperson for the Ontario Ministry of Health was extremely careful when announcing for the second time that sars was over. Realizing that even a single, undetected domestic or international traveller could ignite a fresh outbreak, the declaration was made in a more cautious, muted but optimistic tone. Health officials were remaining wary: “At this point we’re taking it day by day... we’re happy we haven’t had any new cases since the twelfth, but at the same time cautious. High vigilance” (Chealth, 2003). On 2 July 2003 the who removed Toronto from its list of sars-infected areas for the second time. The early July announcement by the who left Taiwan as the only place with active, uncontained sars cases and subject to the who travel advisory. Hospitals in Toronto finally reduced vigilance for sars and North York General Hospital and other designated healthcare institutions were downgraded to Level 1 status. With remaining, recovering cases dwindling into single digits, most Toronto area hospitals were again fully open by the beginning of September 2003. SARS

Exported to Other Countries from Canada

On 12 March 2003, the w h o ’s headquarters in Geneva issued a “global alert” warning of an outbreak of unexplained cases of atypical pneumonia. A few days later the organization alerted world health authorities, airlines, and travellers to the disease’s symptoms and advised anyone showing these symptoms not to travel. The w h o activated its Global Outbreak Alert and Response Network (g oa r n ), bringing together eleven laboratories in ten countries to search for the cause of the disease (Centers for Disease Control and Prevention, 2003a). It was eventually established that sa rs was caused by a new virus, the sa rs coronavirus or sa rs - c ov, a strain not previously seen in humans or animals. After a period of four months, on 14 July 2003, the w h o stopped publishing daily cumulative numbers of reported Probable sa rs cases. sa rs was detected in several countries but the overwhelming majority of cases globally (95 per cent) occurred in the Western Pacific region (see table 1.1). Gradually, the global daily toll of sars infections came down. Taiwan was the last area to be de-listed from those places with local transmission (on 5 July 2003) but vigilance and monitoring efforts

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Table 1.1 sars incidence in major geographic regions, percentages Region Western Pacific Americas Europe South East Asia Others

Incidence of SARS (%) 95.53 2.59 0.96 0.16 0.02

at the who’s Western Pacific Regional Office continued. In the post-outbreak period, a core team of health professionals and epidemiologists continued to work on sars, preparing for its possible re-emergence. The team focused on strengthening infection control in hospitals and community settings, reviewing laboratory biosafety protocols and updating guidelines. Table 1.2 summarizes the total number of individuals (male and female) that contracted sars, the number of deaths, Case Fatality rates, the number of imported cases, and the number of healthcare workers affected, shown by country. One of the greatest difficulties with implementing an effective quarantine and containment strategy to reduce the spread of disease between countries was having good knowledge of the epidemiology, traced through people’s movements and contacts. Canadian hospitals and the Ontario sars Scientific Advisory Committee did a great deal of detective work, contacting many people who had potentially been exposed to sars-infected individuals. Early during the sars outbreak Health Canada worked to investigate reports of sars cases and individuals diagnosed abroad who they thought had been exposed in Canada. Exported sars cases were reported internationally from Canada to Australia, Germany, the United States, and the Philippines (phac, 2003b). Australia experienced sars as a result of the disease being exported from Canada. A family of five (two adults and three children) residing in the Greater Toronto Area departed Toronto on 28 March 2003 and arrived in Australia on 29 March 2003. Child A had onset of influenza-like illness symptoms on 31 March 2003 and was hospitalized on 3 April 2003 with high fever and respiratory distress. A chest x-ray revealed infiltrate in the lungs, a strong indicator of sars. Child A was diagnosed as a Suspect sars case

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Table 1.2 Summary of Probable sars cases with onset of illness from 1 November 2002 to 31 July 2003 for all reported countries Number of deathsa

Case fatality Number of Number of imported ratio HCW cases (%) affected (%) (%)

Country

Female

Male

Total

Australia Canada China Hong Kong, China Macao, China Taiwan France Germany India Indonesia Italy Kuwait Malaysia Mongolia New Zealand Philippines Republic of Ireland Republic of Korea Romania Russia Singapore South Africa Spain Sweden Switzerland Thailand United Kingdom

4 151 2674 977

2 100 2607 778

6 251 5327b 1755

0 43 349 299

0 17 7 17

6 (100) 5 (2) – –

0 (0) 109 (43) 1002 (19) 386 (22)

0 218 1 4 0 0 1 1 1 8 1 8 0

1 128 6 5 3 2 3 0 4 1 0 6 1

1 346c 7 9 3 2 4 1 5 9 1 14 1

0 37 1 0 0 0 0 0 2 0 0 2 0

0 11 14 0 0 0 0 0 40 0 0 14 0

1 (100) 21 (6) 7 (100) 9 (100) 3 (100) 2 (100) 4 (100) 1 (100) 5 (100) 8 (89) 1 (100) 7 (50) 1 (100)

0 (0) 68 (20) 2 (29)d 1 (11) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 4 (29) 0 (0)

0

3

3

0

0

3 (100)

0 (0)

0 0 161 0 0 3 0 5 2

1 1 77 1 1 2 1 4 2

1 1 238 1 1 5 1 9 4

0 0 33 1 0 0 0 2 0

0 0 14 100 0 0 0 22 0

1 (100) – 8 (3) 1 (100) 1 (100) 5 (100) 1 (100) 9 (100) 4 (100)

0 (0) 0 (0) 97 (41) 0 (0) 0 (0) 0 (0) 0 (0) 1 (11)d 0 (0)

13 39

14 24

27 63 8096

0 5 774

27 (100) 1 (2) 142

0 (0) 36 (57) 1706

United States Vietnam Total

0 8 9.6

a. Includes only cases whose death is attributed to sars. b. Case classification by sex is unknown for forty-six cases. c. Since 11 July 2003, 325 cases have been discarded in Taiwan, China. Laboratory information was insufficient or incomplete for 135 discarded cases, of whom 101 died. d. Includes hcws who acquired the illness in other areas. hcw = Healthcare workers (–) information was not available. Table modified from http://www.who.int/csr/sars/country/table2004_04_21/en/.

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according to the who case definition, which differs from the Canadian sars case definition, including Toronto as an “affected area.” Child B had onset of cough and other symptoms on 25 March 2003. Child C had onset of symptoms on 1 April 2003. Both Child B and Child C were subsequently reported as Probable sars cases according to the who case definition. All three children recovered quickly. Both adults remained well. No clear epidemiological link to any known sars cases in Canada could be established and no secondary transmission was observed. In Canada, none of the children would have met the case definition for a Probable or Suspect case of sars. Child A would have been classified as a person with fever and symptoms consistent with severe atypical pneumonia who has been in an area with local chains of transmission of at least three generations but who does not have an established epidemiological link. Children B and C would have been classified as Persons Under Investigation requiring quarantine, but not as Probable cases. Germany also acquired sars from Canada through a twenty-sixyear-old woman who was temporarily residing in Toronto. On 31 March 2003 she flew from Toronto to Germany. She was asymptomatic until 3 April 2003 when she developed headache, nausea, and vomiting. She subsequently developed fever and cough and was later admitted to hospital on 7 April 2003. Doctors diagnosed her with pneumonia, with a chest x-ray revealing infiltrates, but no clear epidemiological link to any known sars cases in Canada could be established and no secondary transmission was observed. In Canada, this woman would not have met the case definition for either Probable or Suspect sars. Rather, because of her mild fever (below 38°c) and lack of epidemiological link, she would have been classified as a Person Under Investigation. A third case involved a fifty-two-year-old American man residing in Pennsylvania who travelled alone by car to Toronto on 28 March 2003 and returned to Pennsylvania alone on 1 April 2003. On 3 April he became symptomatic with chills, fatigue, myalgia, headache, and diaphoresis (excessive sweating). On 6 April a fever of 38.2°C was documented and on 7 April 2003 he developed respiratory symptoms. He was hospitalized on 14 April 2003 with pneumonia. A chest x-ray showed bilateral patchy infiltrates, serum was positive for coronavirus antibodies, and he was diagnosed with Suspect sars. Given his clinical evidence he would have been diagnosed as a Suspect case in Canada. The man recovered and was

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discharged from hospital on 21 April 2003. The suspected exposure was thought to have occurred at a religious meeting he attended in Toronto on 28–29 March 2003, where a symptomatic individual with sars was also present, establishing a clear epidemiological link. Pennsylvania health authorities reported that a family member had symptoms consistent with the Suspect sars case definition, but the onset of symptoms in the family member occurred before having had contact with the affected individual who visited Toronto. Therefore, they concluded that the second family member could not be considered a true case of transmission. The United States reported 73 Probable cases and 346 Suspect cases, with no deaths. In another case, a forty-six-year-old woman residing in the Greater Toronto Area departed Toronto on 3 April 2003 and arrived in Manila, Philippines, on 4 April 2003, having stopped at Narita Airport in Japan en route. This case recorded the onset of fever on 6 April 2003. On 11 April 2003 she developed diarrhea and cough, and the next day she was admitted to a local hospital, at which time a chest x-ray revealed extensive bilateral infiltrates. She continued to deteriorate in health and on 13 April 2003 family members drove her to a hospital in Manila where she was admitted and diagnosed with Probable sars. She continued to deteriorate and died the following day. The suspected exposure was thought to have occurred in Toronto on 1–2 April, when she spent several short periods of time in the home of a symptomatic Probable sars case. She did not have direct contact with this sars case; it is hypothesized she may have had contact with an object carrying the infection in the home of the case. The Philippines authorities reported secondary transmission to a healthcare worker, who was also diagnosed as a Probable sars case. In addition, the father of the woman, who was ill with cancer, died and was subsequently reported by the Philippine Department of Health as a Probable case of sars. There is insufficient information to judge whether these two cases of transmission would have been classified the same way in Canada, but the woman would have been classified initially as a Probable case of sars in Canada (phac, 2003b). Finally, a previously healthy twenty-four-year-old Finnish man attended a conference in Toronto from 24–28 April 2003. A day after returning to Finland, he developed a high fever and cough and was admitted to Turku University Central Hospital. He was placed in isolation as a Suspect case of sars. Initially his chest x-ray was

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29

normal but three days later it showed infiltrate, confirming Probable sars. His fever lasted for five days without the need for mechanical ventilation; he was discharged from hospital on 13 May 2003. Diagnostic testing ruled out other possible infections (pneumonia, influenza A and B, adenovirus, parainfluenza 1,2,3, respiratory syncytial virus, Chlamydia pneumoniae, and Mycoplasma pneumoniae). sars was confirmed by reverse transcriptase-polymerase chain reaction (rt-pcr),13 a highly specific diagnostic nucleic acid test that detects the presence of the virus’ genetic material, on 8 May 2003 but later confirmatory pcr failed to detect sars-cov. No epidemiologic link could be established to explain the man’s exposure in Toronto. There were no other reports of sars-like illnesses among others who attended the conference. This was the first Probable case of sars reported in Finland. The case met the who definition of sars because of the individual’s visit to Toronto, an area with known, recent local transmission (Nuorti, 2003). The single positive pcr diagnostic result, however, did not meet the who criteria for a laboratory-confirmed sars case. Confirmation required a second positive pcr result or a positive result by another laboratory test specific to sars-cov. One explanation for the lack of positive confirmation on re-testing is that the genetic material in sars-cov samples (rna) may be easily degraded in samples by endogenous ribonucleases if they are not handled and stored properly. The lack of confirmation by a second rt-pcr test should not be viewed as entirely surprising. Exported cases of sars resulted in significant media attention in the countries where they were detected. The appearance of sars created considerable public anxiety and negative perceptions about the country of origin. The impact of the identification of even a few cases from Canada served to highlight and confirm Toronto as a risk area internationally (Nuorti, 2003). A summary of sars timelines from Canada, China, Hong Kong, Singapore, Taiwan, the United States, Vietnam, and the World Health Organization appear in the appendix. Analysis of the SARS Outbreak in Canada The initial multi-country sars outbreak was seeded by a single individual, a doctor (figure 1.1, index case A) who had travelled from China to Hong Kong, where he infected twelve hotel residents

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(figure 1.1 b-m). Many of the initial contacts were international travellers who went on to seed outbreaks in various countries. Infectious patients transmitted the disease to healthcare workers as shown in figure 1.1. The number of healthcare workers eventually infected and the percentage of the total cases that were attributable to healthcare workers are shown in figure 1.1. In Canada the majority of all new sars cases were contracted in Toronto area hospitals by patients, visitors, and healthcare workers. Healthcare workers accounted for 43 per cent of all new infections. Hospitals in Toronto were closed for containment and security during the outbreak, and work quarantine for healthcare workers helped to contain it. Elective clinics and surgeries were cancelled in Toronto for extended periods, also affecting non-sars patients (Booth and Stewart, 2005). The number of sars patients shows a biphasic occurrence over time in Canada, forming two main clusters. However, according to Bonnie Adamson, president and ceo of North York General Hospital, some hospitals, like North York General, never had a reprieve between the two outbreaks. North York General Hospital had 101 sars cases: 47 were healthcare workers; 19 of the patients ended up in the icu, and 6 died. With new Suspect cases, Probable cases, and many recovering cases, sars1 and sars2 merged into one continuous event. More than 100 healthcare workers were infected in Toronto and 3 healthcare workers died. On 30 June 2003, Nelia Laroza, a fiftyone-year-old nurse at North York General Hospital, became the first Canadian healthcare worker to die from sars contracted at work. Hundreds of friends, fellow nurses, other colleagues, the premier of Ontario, and officials from the Ministry of Health and Long-Term Care all gathered at St. Michael’s Cathedral in Toronto to pay tribute to her. A second nurse, Tecla Lin, died from sars on 19 July 2003 and family physician Nestor Santiago Yanga died on 13 August 2003. A study completed just after the containment of sars in June 2003 showed that healthcare workers in Toronto involved in the early critical care treatment of patients were at substantially greater risk of contracting the illness from multiple contacts. Prior to the establishment of the practice of using full protective gear for highrisk procedures, 122 healthcare workers studied were exposed to as many as seven different sars patients (Doheny, 2004). Knowledge

sars timeline

Guandong Province China Total: 5327 hcw: 1002 (19%) Deaths: 349

Hong Kong Total: 1755 hcw: 386 (22%) Deaths: 299 Over 100 initial contacts

Vietnam Total: 63 hcw: 36 (57%) Deaths: 5 21 initial contacts

A

Hotel M, Hong Kong A

31

L M

A

B C

Infected B,C,D,E,F, G,H,I,J, K,L,M

D E,F,G

K

H I J

Canada Total: 251 hcw: 109 (43%) Deaths: 44 11 initial contacts

Ireland Total: 1 hcw: 0 (0%) Deaths: 0

United States Total: 29 hcw: 0 (0%) Deaths: 0

Singapore Total: 238 hcw: 97 (41%) Deaths: 33 37 initial contacts

Figure 1.1 The spread of sars from index case A who stayed at Hotel m in Hong Kong. Individual initial contacts are named with capital letters. The doctor from China, designated as individual a (top, centre box), infected hotel guests (b-m). These individuals went on to seed a number of outbreaks in other countries. The total number, the number and percentage of healthcare workers eventually infected in other countries by individuals (b-m), and the total number of deaths from sars are listed in the boxes. Initial contacts from individuals b-m, if known, are also shown (Centers for Disease Control and Prevention, 2003a; World Health Organization, 2006a).

that sars patients included colleagues and friends was a source of profound stress, emotion, and anxiety for many nurses and doctors. The Toronto sars outbreak followed a biphasic epidemiological pattern, with new cases occurring until 12 June 2003 (figure 1.2). In Ontario there were 257 Probable and Suspect cases in total during sars1, with twenty-seven deaths. sars2 had a total number of 118 cases with seventeen deaths.14 After the end of sars the cumulative totals for Probable and Suspect sars cases in Canada revealed that Ontario was, by far, hard-

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10

sars 1

sars 2

9 7 6 5 4 3 2 1

ly Ju 7

Ju

n

n 24

Ju 11

M

ay

ay 29

M 16

M

ay

pr 3

A

pr A 7

20

ar M

ar

25

M

Fe

b

b 12

27

Fe 14

Fe

b

0

1

Number of Cases

8

Date of Onset (2003)

Figure 1.2 Probable sars cases in Canada from 1 February to 4 July 2003, showing a biphasic distribution pattern Modified from World Health Organization data: http://www.who.int/csr/sars/epicurve/epiindex/en/ index6.html.

est hit by this outbreak (tables 1.3 and 1.4). A total of 375 Probable and Suspect cases were reported in the province of Ontario during the main outbreak period. In Vancouver there were approximately 2,000 passengers who arrived on direct flights from mainland China and Hong Kong each day. In Toronto about 500 people, on average, also arrived from these areas. Both cities acted as entry points for this emerging pathogen from Asia (Skowronski et al., 2006). The same day the first sars patient, Mr C., was admitted to Vancouver General Hospital, Mr T. arrived at Scarborough Grace Hospital in Toronto, presenting with similar symptoms. In both cases sars and its virus were unknown and diagnosis remained difficult to determine. In Toronto no precautions were taken to isolate patients with respiratory illnesses, except when patients showed symptoms of active tuberculosis. The Naylor Report confirmed that for most hospitals in Ontario, infection control was not a high priority. The majority of the people who contracted sars (77 per cent) acquired it in a hospital (Naylor, 2003). Several days after Mr T.’s admission in Toronto, hospital administrators insisted that ordinary surgical masks were sufficient and no added protection was needed until research proved otherwise. In

sars timeline

33

Table 1.3 Probable Cases (Total Number = 251) of Canadian sars as of 3 September 2003 from Ontario and British Columbia (bc) Case Status

Ontario First Cluster*

Ontario Second Cluster**

BC

Totals

136 110

111 94

4 4

251 208

26

17

0

43

Cumulative Total Discharged from hospital, recovered, never hospitalized or other Deaths

Modified from: http://www.phac-aspc.gc.ca/sars-sras/cn-cc/20030903_e.html.

Table 1.4 Suspect Cases (Total Number = 187) of Canadian sars numbers as of 3 September 2003 from various provinces including Ontario, British Columbia (bc), Alberta (ab), New Brunswick (nb), Prince Edward Island (pei), and Saskatchewan (sk) Case Status Cumulative Total Discharged from hospital, recovered, never hospitalized or other Hospitalized Total active

Ontario First Cluster*

Ontario Second Cluster**

BC

AB

NB

PEI

SK

Total

121

7

46

6

2

4

1

187

103

6

10

1

1

4

1

126

18 0

1 0

36 0

5 0

1 0

0 0

0 0

61 0

* The Province of Ontario defines the “first cluster” cases as those identified and reported prior to 22 May 2003. First cluster cases are equivalent to sars 1 cases. ** “Second cluster” cases are those identified on or after 22 May 2003. No Probable or Suspect cases had been reported from other provinces/territories and are not listed. Second cluster cases are equivalent to sars2 cases. Modified from: http://www.phac-aspc.gc.ca/sars-sras/cn-cc/20030903_e.html.

Vancouver, administration took a precautionary approach and ordered its staff to wear N95 masks. In Vancouver, the decision may have been due to concerns over avian influenza; precautions were implemented pending proof that less protection was needed. The actions taken with the index patient in Vancouver General Hospital prevented the disease from spreading to other patients, staff, or visitors. On 18 March, the Ontario Ministry of Health and Long-Term Care recommended gloves, gowns, N95 masks, and eye protection when treating sars patients. Part of the problem in Ontario was one of hospital culture. Dr James Young, the commissioner of Public Safety and Security for Ontario, said, “We did not have doctors

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and nurses … who were used to getting in and out of gloves, and gowns, and masks, who were used to working in these situations, who knew and thought about infection control every day of their lives” (Naylor, 2003). The British Columbia Centre for Disease Control (bccdc), aware of a potential pandemic risk, had been active for several years increasing preparedness and planning capacity. In British Columbia health officials have the authority to control any infectious disease outbreak posing a threat to public health under its Health Act. A medical health officer can obtain a court order to quarantine any individuals who do not comply with quarantine orders. Officials can also require testing and treatment of individuals who may be placing others at risk of infection (bc Center for Disease Control, 2003). In British Columbia both Influenza A h5n1 in Hong Kong and the unexplained atypical pneumonia in China were reported and relayed through an electronic distribution system established to disseminate communicable disease reports to healthcare facilities across the province. bccdc issued its first alert on 20 February 2003, asking hospitals to enhance vigilance for severe influenza-like illness in travellers returning from China and Hong Kong or among their close contacts. Similar alerts were repeated on 24 February, 28 February, and 12 March 2003 (Skowronski et al., 2006). Doctors and nurses at the five Vancouver hospitals followed standard infection control practices, had the patient wear a mask, and quickly isolated him from others. As a result of their actions there were no reports of secondary transmissions from the first index case. In Toronto, treatment of Mrs K. as an index case was the exact opposite: Mrs K. returned home and was surrounded by a large family and sought care only from family members as her condition worsened. Three other Probable sars patients occurred in British Columbia, all individuals who had contracted the disease outside the country. One nurse who was caring for sars patients contracted the disease and forced the closure of a ward at the Royal Columbian Hospital near Vancouver on 19 April 2003. This was the first case of secondary transmission in British Columbia. In the end British Columbia had five sars cases and forty-six cases that did not go on to develop sars (table 1.4). A summary of the sarsconfirmed patients from Vancouver is shown in table 1.5.

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35

conclusions By the end of June 2003, a mere four months after the initial who global alert, an exhaustive public health effort culminated in termination of human-to-human transmission of sars in Canada. The total global numbers show there were 8,437 cases reported from twenty-six countries, and 774 people died as a result of sars (World Health Organization, 2006a). Global numbers of sars infections show a single distribution curve (figure 1.3). The global average Case Fatality rate for sars was 9.6 per cent. (The case fatality rate is defined as the ratio of the number of deaths caused by a specified disease to the total number of diagnosed cases of that disease.) The localities most affected were China (Guangdong, Beijing, and Hong Kong), Taiwan, Singapore, Vietnam (Hanoi), and Canada (Toronto). All of the most affected countries, except Taiwan, had cases prior to who alerts from citizens travelling to and from known hotspots. Approximately two-thirds of the cases (5,327 of 8,437 or 63 per cent) and close to half of the deaths from sars (349 of 774 or 45 per cent) were reported from mainland China (Skowronski et al., 2005). In Canada the final tally of the effects of the outbreak was 438 Probable and Suspect cases and 44 deaths. Canada experienced 251 true (Probable) cases out of the 8,437 cases reported globally (3 per cent) and 44 out of 774 deaths reported globally (5.5 per cent).15 To give a sense of perspective, Statistics Canada reported there were 8,032 deaths among Canadians from pneumonia and influenza during 1997, the most recent year statistics have been reported for these two diseases. The death rate for pneumonia and influenza at 3.7 per cent was much lower (4.7 times) than the rate for sars in Canada, which was 17.5 per cent. In the end the numbers told the story of just how much effort went into containing the Canadian outbreak. In Toronto, public health officials investigated 2,132 potential cases of sars. They identified 23,103 people who came in contact with sars patients who required quarantine. The efforts put into contact tracing, issuing quarantine notices, follow-up, and tracking taxed public health and hospital staffs to capacity. The amount of work involved in investigating potential cases and contacts was staggering, and the majority of the work

Table 1.5 Clinical data and details for the five patients confirmed with sars in Vancouver, British Columbia Patient 0

Sex/Age Male/55

Reported symptoms

Travel-related SARS Yes-Return from Hong Kong, 6 March 2003

G G G G G G G

1

Female/54

Yes-Return from Hong Kong, 6 March 2003

G G G G G

2

Female/54

Yes-Return from Hong Kong, 20 March 2003

G G G G G G G G G G

3

Male/49

Yes-Return from Hong Kong, 30 March 2003

G G G G G

chills cough diarrhea fever headache malaise shortness of breath chills fever headache malaise sore muscles chest discomfort chills cough diarrhea fever headache malaise nausea shortness of breath sore muscles diarrhea fever headache shortness of breath sore muscles

Hospital duration

Time to respiratory precautions after admittance

7 March to 12 June 2003

15 minutes

Not admitted to hospital

Not applicable

28 March to 21 April 2003

Immediately; arrived masked and admitted directly to negative pressure isolation room

3 April to21 April 2003

Immediately; arrived masked and admitted directly to negative pressure isolation room

Table 1.5 continued 4

Female/44

No-Acquired in Vancouver-|area hospital. This nurse cared for patient 2 from 29 to 30 March 2003

G G G G G G G

Modified from Skowronski et al, 2006.

cough diarrhea fever headache malaise shortness of breath sore muscles

15 April to 24 May 2003

11 minutes

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160 140 Number of Cases

120 100 80 60 40 20

–0 7

6 –0

11

5 20

–0 30

–0 5

4 –0

09

3 18

–0 28

–0 3 07

2 03 20 –01 03 24 –1 14 –0 2

–1 13

01 20 –11 02 22 –1 1

0

Date

Figure 1.3 The number of cases of Probable sars by date of onset reported worldwide (total number = 5,910) from 1 November 2002 to 10 July 2003. The graph does not include 2,527 cases of Probable sars in China (2,521 of these reported from Beijing, China), for which no dates of onset are available. World Health Organization data from: http://www.who.int/csr/ sars/epicurve/epiindex/en/index1.html.

was done on the front lines by staff working at the public health unit. It was also difficult to track patients who were suspected of having sars but were sent home on quarantine. Those managing the crisis didn’t know those patients’ outcomes (Doheny, 2004). Non-cumulative numbers in quarantine in Canada from 4 April 15 to July 2003 are shown in table 1.6. Cumulative numbers of individuals in quarantine on any given day for this period are shown in figure 1.4. There is a time lag between the rise and fall of quarantine values and the number of Probable and Suspect sars cases shown in figure 1.2, table 1.3, and table 1.4. The numbers show that once a cluster of cases was identified, contact tracing of individuals and quarantines quickly followed for both sars1 and sars2. Health officials received more than 300,000 calls on a local sars hotline from worried individuals seeking information and reassurance. At the end of July 2003 over two dozen people still remained in hospital recovering from sars, while 194 had officially recovered and been released. All but three travel-related cases were linked to the infected patients returning from Hong Kong. To prevent the

sars timeline

39

Table 1.6 Non-cumulative, average numbers of individuals quarantined in Canada from 4 April to 15 July 2003. Total number of people quarantined was 105,545. Week 4-Apr

10-Apr

16-Apr

22-Apr

28-Apr

Number

Week

0 4,799 5,442.5 6,086 3,635 3,240 3,269 1,262 951 795.5 640 489 690 788

4-May

909 909 866 780 880 755 598 441 438 385 402.5 420 355 97 123 119

10-May

16-May

22-May

28-May

Number 117 83 90 152 125 97 63 34 27 20 20 2 5 5 5 5 4 7 6 33 33 120 2,187 3,442 4,916 7,026 7,415 7,350 5,237 6,379

Week

Number

Week

Number

3-Jun

4,889 987 840 864 737 610 595 582 585 1,016 1,146 1,098 1,050 913

3-Jul

70 69 5 3 1 1 1 1 0 0 0 0 0 105,545

9-Jun

15-Jun

21-Jun

27-Jun

9-Jul

15-Jul Total

933 707 714 330 216.5 159.75 103 87 73 81 95 87 83 79 81 83

Data from The Ontario Ministry of Health and Long-Term Care, 2003.

outbreak from spreading, public health officials conducted intense follow-ups of people who had contact with sars patients, and imposed a ten-day quarantine in most cases. Health officials also stepped up infection-control measures in Toronto area hospitals. Patients hospitalized with respiratory symptoms who were suspect were watched closely to determine if they had contracted sars. The increased surveillance and infection-control measures in hospitals, and the efforts to deal with sars patients, was a strain on both public health and hospital staff. The sheer amount of work required in the investigation of potential cases and contacts to establish

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sars unmasked

8000

Number of Quarantined

7000 6000 5000 4000 3000 2000 1000

4– A 10 pr –A p 16 r –A 22 pr –A 28 pr –A p 4– r M 10 ay –M 16 ay –M 22 ay –M 28 ay –M ay 3– Ju n 9– Ju 15 n –J u 21 n –J u 27 n –J un 3– Ju l 9– Ju 15 l –J ul

0

Time Figure 1.4 Cumulative numbers of individuals quarantined in Canada from 4 April to 15 July 2003 Data from The Ontario Ministry of Health and Long-Term Care, 2003.

precise epidemiology was immense. Bonnie Henry stated that, “For every case that we had, we ended up investigating 100 potential cases, all of which were very time-sensitive.” There was a definite need for increased capacity to deal with the tracking of people who may have been exposed to sars. Those involved in contact tracing and patient follow-ups to establish epidemiology and ensure containment put forth an incredible effort. If even a single case escaped detection it could have resulted in yet another disastrous untraced cluster with the potential to spread throughout Toronto and to other cities in Canada (Doheny, 2004). The lack of occurrence of more clusters of sars indicative of missed cases is a testament to the high vigilance and tremendous amount of work carried out by public health officials and healthcare workers during the 2003 sars outbreak.

ked room culture

2

Emergency Room Culture and Dealing with SARS CATHY PATERSON WITH MICHAEL G. TYSHENKO

If you have never worn full personal protective equipment and a properly fitting n95 mask, it is difficult to imagine how confining and uncomfortable it can be. The masks are not easy to breathe through, and were meant to be worn for short periods of time, not for an entire day. Many of us could never quite get used to the masks and equipment during the sars outbreak – still, we did it, and at the time we would have it no other way as they represented our safety, and our family’s well-being. Cathy Paterson, Nurse Clinician North York General Hospital, October 2004

As an emergency nurse clinician working in one of the busiest hospitals in one of Canada’s biggest cities I can tell you that doctors and nurses see human tragedy all the time. The magnitude can often be overwhelming, even for healthcare professionals, especially if they have not been trained properly to deal with triage situations or in an emergency setting. Nurses in the Emergency Department (ed) have to deal with severe accidents, broken bodies, and diagnosing people with life-threatening conditions, like aggressive cancers, every day. In emergency treatment nurses have to be as efficient as possible to save lives – time is a luxury that healthcare workers don’t have, and for some patients getting treatment quickly is an absolute requirement for survival. With so many critical care patients coming through the ed’s doors every day there is little time for grieving. As healthcare professionals, we try to do the very best for our patients, and it is heart-rending to see otherwise healthy people

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succumb to accidental injuries, but we have to go on because the pace never stops. As professionals doing a job we have many people arriving every day who rely on the healthcare system. They put their absolute trust in us. The worst-case scenario for nurses occurs when treating a very young person who is dying, often tragically, in front of our very eyes while we are doing everything that is in our power to save them. Sometimes we will work for hours to the point of exhaustion because there is still a faint glimmer of hope to save a life. When we get these difficult cases, we tend to do the job at hand, working diligently and swiftly trying to save a life. We tend to put our emotions aside at the time, but they are never gone and we do grieve. We are no more resilient, no more immune to the tragedies we see every day than any other person. Doing such a job filled with human tragedy and suffering that we experience every day is stressful emotionally and an enormous amount of responsibility. As a way of coping we tend to find humor in situations whenever we can, and we love to laugh, so we often find levity in the inane, in everyday, silly observations, and find strength in each other. North York General Hospital in Toronto receives over 200 visits, including forty to fifty ambulances, to the ed each day. This is typical patient volume for a hospital of this size in a large Canadian city. It can be a difficult and trying career at times, especially given the overcrowding and lack of primary care for many Canadians. In the ed, the situation and patients change constantly, and we work in an unpredictable, often chaotic environment. This is the reality of emergency care; it is expected that nurses and doctors will provide the best medical treatment and care regardless of the circumstances. We are able to deal with the day-to-day stresses presented by emergency medicine and our department usually can deal with the day-to-day caseload. However, for the staff that experienced the sars outbreak it was a very different situation; psychologically it was unlike anything most of us had ever dealt with. The outbreak started and it continued for weeks, and at times it seemed as if there was no end in sight. The uncertainty and increasing numbers of patients who contracted the illness chipped away at our confidence, but we continued, finding strength from each other, and the daily doses of camaraderie and humor. It is extremely difficult to explain how much anxiety, fear, and stress healthcare professionals experienced in dealing with the

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43

reality of a new, mysterious, infectious disease. Initial apprehension surrounding the new mystery illness lessened due to the daily routine that required increased infectious disease protocols. Throughout the outbreak the situation seemed to worsen, with the perception that the outbreak was becoming more dismal with each passing day. For most of us, the worst part of the sars experience was the convergence of a number of different factors that seemed to amplify the overall effect. The knowledge that if sars escaped into the general public the situation could get much worse, the chance that we could infect friends and family after every work shift, and not knowing when the outbreak would end all contributed to a synergistic, demoralizing perception of the situation that weighed heavily upon us. The longer the outbreak went on, the more we felt as if it would never end. We saw events happen that as healthcare workers we thought never could happen in Canada, for example the open-ended continuous work quarantines, profound changes and restrictions to hospital access, infectious disease procedures reinvented, extended city-wide hospital ward closures, the need to wear full personal protective equipment (ppe) all the time when working, and the infection and deaths of co-workers as a result of their jobs. During the sars outbreak it seemed that anything was possible and that containment was not a certainty.

protecting ourselves – personal protective clothing and n95 masks Wearing masks and full protective gear meant that we were constantly changing and disposing of protective clothing in a carefully practiced method so as not to contaminate ourselves each and every time we entered and exited a patient’s room. Sometimes, getting dressed in and removing contaminated clothing occurred dozens of times a day as we moved between different isolation rooms treating patients. The continual dressing and disrobing took time to do carefully and added to the already hectic daily pace, increasing the amount of psychological stress. The cluster of sa rs (the majority of sa rs 2) among Canadian healthcare workers occurred despite careful compliance with recommended infection control precautions. There was a gap in time, of about one week, when sa rs was declared over and p p e was relaxed. It was in this week when, despite the fact that many kept the p p e to a

44

sars unmasked

maximum, sars remained present and more healthcare workers became infected. Many healthcare workers initially lacked knowledge of how best to remove gowns and masks properly without contaminating themselves in the process. Although we all learn these procedures during our education, it became confusing because now the necessary “clean areas” were also considered contaminated with the virus. No one knew how to handle a situation in which the entire organization was potentially environmentally contaminated, and there was no safe place to remove our masks. The vital point of protection depended on excellent handwashing practices, and prudent removal of the protective masks. Spreading contaminants near the nasopharynx is very easy to do if hands and masks are contaminated. The simple act of removing a mask improperly can result in a break in technique, thus risking infection. Careful hand hygiene was believed to play an important role in reducing the overall risk of sars transmission (Puro and Nicastri, 2004). Of all of the new containment procedures, wearing the mask was said to be the most bothersome precaution when nurses were surveyed (70.2 per cent), but there were also many other precautions that nurses found disruptive, including: restricted access within one’s own hospital work area (14.0 per cent); restricted meetings (5.5 per cent); restricted access to other hospitals (5.0 per cent); wearing of gloves (3.1 per cent); wearing goggles or visors (3.0 per cent); and constant handwashing procedures (4.9 per cent) (Nickell et al., 2004). Respiratory masks with a n95 efficiency rating were used by hospital workers to prevent sars infections; the rating meant the masks blocked ~95 per cent of virus particles 0.3 µm (microns) in size or larger.1 The masks were designed to filter out most viruses and bacteria. The mesh size of the mask, which is worn tightly around the nose and mouth, makes breathing somewhat laboured initially, and then it becomes tolerable. It was never comfortable wearing a n95 mask all day and it is something that I would never choose to put myself through again, yet I would do it if required of me. After all, it was my layer of defence: it kept me, and more importantly, my family and friends safe from sars. Initially, most Toronto hospitals were ill-equipped to handle a sars-like situation. We had the knowledge, but not enough n95 masks for everyone to wear all day. It was not part of most pre-

emergency room culture

45

existing hospital plans to have enormous stockpiles of masks and disposable protective equipment. Many hospitals have been n95 mask-fit testing workers routinely for some time, and now after sars this is mandatory due to the New Normal,2 which included mandatory mask fitting for all new healthcare professionals at all hospitals. Mask fitting started during sars, when it was not convenient to do mask-fit testing. Yet, it was necessary and so it became mandatory. In early June, some staff members still fearful of sars chose to stay away from work after the masks they were given did not fit properly. In an expedited ruling, the Ontario Ministry of Labour advised that even though the workers were assigned to lowrisk areas of the hospital, “these circumstances were likely to endanger” the workers involved. Inappropriate ppe and inadequate training in its use was a concern to all healthcare workers throughout the crisis. This prompted the Ontario Nurses’ Association to send a letter to the premier of Ontario (Ernie Eves) on 18 June 2003 documenting their concerns for public safety because some of the sars masks for staff were not fitted properly. Earlier during the outbreak, the US Centers for Disease Control was critical when it suggested that many Toronto-area hospitals had not met the basic safety requirements for mask-fit testing and that improperly fitted masks most likely contributed to the spread of sars (cbc News, 2003c). At North York General Hospital during the sars outbreak, I was quite pleased with the organization’s efforts for our safety. They brought staff from the 3m Company to work around the clock to ensure all staff had at least two masks that fit properly. Those who did not have suitable masks had special orders for different masks. Mask-fit testing for our staff quickly became a major issue, with 4,000 staff, volunteers, and physicians to mask-fit in a short time. It was a time-consuming process and we certainly didn’t have a lot of time to spare (Adamson, 2003). When we were trying to do this mask-fit testing in the midst of the sars outbreak it was nothing short of a nightmare logistically. There was difficulty accommodating staff and reaching everyone to have fittings done as soon as possible. There were issues among healthcare workers with allergies, sinusitis, and skin problems emerging from the materials in the masks and by virtue of wearing them all day. Irritated contact dermatitis, painful skin breakouts, and ugly rashes on the face were common; we may have had increased sars protection but we were not an attractive group.

46

sars unmasked

The problems of mask-fit testing were not unique to North York General Hospital. The ppe at all the hospitals were in short supply initially, particularly n95 masks. Affected hospitals went to great lengths to comply with provincial directives with respect to maskfit testing. However, constantly changing directives and the demands of managing the crisis at hand made fit testing a very complicated task. When one of us failed the fit test an alternative mask was not always available.3 In the ed at St. Michael’s Hospital in Toronto, approximately 30 per cent of the registered nurses had failed fit testing at any given time (Lozon, 2003). In one survey of nurses, approximately 85 per cent found that wearing the mask was particularly bothersome for a number of reasons, including physical discomfort (92.9 per cent), difficulty communicating emotively and effectively (47.0 per cent), difficulty recognizing people and gauging their emotional responses to situations (23.9 per cent), and a sense of isolation while wearing the mask (13.0 per cent) (Nickell et al., 2004). The masks provided very good protection against sars when fitted properly, excluding 95 per cent of the viral particles. But they were not foolproof, as witnessed by the number of healthcare workers who, despite their best efforts to wear masks and protective gear, still contracted sars.4 The thought of contracting sars, or, worse perhaps, passing it along to our families, weighed heavily on us. Still, we persevered in the face of daily uncertainty. Some Toronto residents, panicked by the perceived risk of sars, bought all kinds of masks in an attempt to protect themselves in case of exposure. Different kinds of masks were tested independently for their efficacy in filtering out biological agents that were the same size as the sars virus (0.3 microns). Various masks tested included the ones recommended for healthcare workers used during the sars outbreak (the n95 mask), a procedure mask (the kind worn by dentists), a surgical mask (like the ones you see worn by doctors in a hospital), and dust masks (found in hardware stores and used for painting and home repairs). The masks were a sampling of products commonly available in Toronto stores at the time of the sars outbreak, and some people were using them as self-protection against sars. The n95 masks when tested filtered out 97 per cent of all the virus-sized particles, as guaranteed by the manufacturer. The procedure mask filtered only 34 per cent while the surgical mask was able to prevent 62 per cent of the particles from passing through. The worst protection was offered by the dust

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masks, which filtered out only 11 per cent of the particles (cbc Marketplace, 2003). The perception of personal danger to all healthcare workers was made worse by the ongoing uncertainty. Changes in infection control procedures and public health recommendations occurred each day, sometimes two or three updates a day. That only heightened our sense of uncertainty. A good example of this was the initial determination of just how much personal protection equipment would be enough to prevent infection of hospital staff. Initially it was the use of n95 masks. Then n95 masks, one per day, with gowns. Then n95 masks (one every six hours) /face shields, gowns, gloves, hair and shoe covers. After that it was n95/face shields, double gowns, double gloves, hair and shoe covers, change greens (basic uniform). Then it was back down to n95, single gown, gloves, shield as needed. And, finally, using the Stryker t4 System for high-risk procedures. The Stryker outfit is best described as a protective space suit worn over the full ppe. It is a high-efficiency system that filters and removes at least 98 per cent of aerosolized particulate virus. It consists of a helmet that delivers positive pressure filtered air inside the suit with a battery driven fan, a large protective toga, a mask, and a clear visor that covers the helmet and the body. A battery is attached to the waist inside the gown, which powers the fan in the helmet. After getting into the suit, another pair of gloves is put on. Getting in and out of the Stryker equipment was a challenge and not intuitive, so it had to be learned to prevent self-contamination after high-risk procedures, which are defined as those activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions, particularly those procedures that create aerosols. We were pleased to see the evolution of standards as more became known about the etiology and transmission of sars. There were some hospital workers who wondered how protected they were prior to and during the changes in personal protective equipment standards; I never thought about this aspect as the use of n95 masks, the primary barrier to prevent inhalation of the sars virus, remained constant. Eventually, at North York General Hospital we settled on a standard for ppe requirements, and purchased the Stryker t4 system for risky procedures. Dealing with sa rs patients who became so sick they had trouble breathing was itself demanding as it was a new, deadly infection that required our constant attention as caregivers. High-risk

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procedures like intubation, where a tube is threaded down the windpipe of the patient to aid breathing, place the practitioner in a dangerous situation, having to come very close to the patient to perform the procedure. The procedure itself aerosolizes a high number of viral particles, easily infecting the person performing it. Other high-risk procedures for staff that required the use of Stryker suits included: bvm (bivalve mask), bronchoscopy, thoracostomy, cpr (cardiopulmonary resuscitation), bipap (biphasic positive pressure), nebulization therapy, and suctioning. All these procedures require face-to-face contact and are procedures that readily aerosolize viral particles. The number and size of the droplets are directly correlated to the velocity force that aerosolizes the particles. For example, a violent cough or sneeze, or a medical procedure like suctioning, tends to aerosolize more particles, creating droplets both finer in size and greater in number. Particle size also determines the location in the respiratory tract where airborne infectious particles will be deposited due to how fast they settle out. Respiratory droplets greater than 5 micrometers (µm) in diameter that transmit respiratory viruses such as influenza, respiratory syncytial virus, and coronaviruses (like sars) rapidly fall to the ground once they are released by coughing or sneezing. Smaller droplets (less than 5 µm in diameter) are called “droplet nuclei” and may remain suspended in the air for several hours, depending on the ambient air conditions (Peters et al., 1996; Evans, 2000, Yassi et al., 2005), extending the window and range of infection. Tuberculosis (tb) is an example of a disease that is spread by droplet nuclei. Many studies have been conducted on tb transmission and environmental factors such as the use of negative pressure rooms and ppe (including masks). They have shown that both are key protective devices in preventing the spread of tuberculosis in healthcare institutions. In a study of seventeen Canadian hospitals, inadequate ventilation, defined as systems that provide fewer than two air exchanges per hour, was associated with an increased risk of tb infection in healthcare workers. During sars, a number of environmental controls similar to tb controls were applied, for example the use of quarantine, negative pressure rooms, and masks. In the beginning when so little was known about sars transmission, other than that it was a respiratory illness, enhanced environmental controls and decontamination to prevent the spread of sars based on previous tb experiences appeared to

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be a good, rational choice (Menzies et al., 2000). The sars coronavirus was later shown to survive on plastic surfaces for up to two days, and up to four days in feces or other substances. sars was also shown to be transmissible through indirect contact with inanimate surfaces. In Hong Kong, three hospital cleaning staff developed sars by environmental contact without direct patient contact: their only exposure to the virus was with rooms previously occupied by sars patients (Ho et al., 2003; Yassi et al., 2005). In a Toronto case study, 29 of 144 sars patients (20 per cent) were admitted to the intensive care unit (icu) and 20 of these (69 per cent) received mechanical ventilation. Critical care nurses who assisted with suctioning before and during intubation of sars patients were four times more likely to become infected with sars than nurses who did not. In addition, manipulation of a sars patient’s oxygen mask was also found to be a high-risk activity. In the study, eleven nurses who did not enter a sars patient’s room or assist in high-risk procedures did not become infected (Centers for Disease Control and Prevention, 2003b). The findings revealed that there was an increased risk of contracting sars, about 6 per cent per shift worked, for critical care nurses. There was little evidence to show that environmental transmission of sars was a major risk factor. That is to say, healthcare workers did not contract sars very often through contact with contaminated surfaces, used gowns, caps, booties, or exposed protective clothing. It was mainly the high-risk activities that were associated with droplet nuclei formation or limited aerosol spread that were the likely sources of sars transmission to healthcare nurses (Scales et al., 2003). Both surgical masks and n95 masks were protective for healthcare workers in hospitals. A study from Hong Kong showed that there was nearly an 80 per cent reduction in risk for infection to nurses who consistently wore masks (either surgical or n95). When compared, n95 masks reduced the relative risk by half, but because of the small sample size the result was not statistically significant. The study did, however, confirm other studies that tested and compared different masks for efficacy (Seto et al., 2003). In Canada the use of personal protective equipment was highly variable early in the outbreak because healthcare workers were often unaware that the patients were infected and shedding sars virus. Despite differences in the amounts and kinds of personal protective equipment used in sars-affected countries, the outcomes suggest that early

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adoption and use of masks when caring for sars patients was an important factor for overall risk reduction. It was estimated that if the entire cohort of nurses in the Toronto case study group had used masks consistently from the very beginning, the risk of contracting sars would have been reduced from 6 per cent to 1.4 per cent per shift (Loeb et al., 2004). Everybody at our hospital (North York General) was worried about exposure and preventing possible sars patients from infecting not only other patients but also healthcare workers. The perception of personal danger was also heightened by the intense media coverage of the outbreak and its effects. Reading headlines such as “Hospital Masks Are in Short Supply” (Toronto Star, 29 March 2003)5 only increased personal anxiety among us.

protecting ourselves – work quarantine Quarantine is the term used when well people are asked to isolate themselves from others after a possible exposure to an infectious agent like sars. Individuals entered quarantine for ten days if they either had been exposed to a sars patient or were in a hospital setting where sars was known to have been transmitted. Quarantine was one of the best preventive measures to ensure containment of the disease if the quarantined individual did eventually become ill. “Work quarantine” allowed any hospital staff member to continue to work at hospitals where they were exposed as long as they remained healthy (nurses on work quarantine had to follow strict at-home isolation measures). It was necessary to ensure that healthcare services continued to be provided. Usually non-healthcare workers who had potentially been exposed experienced a one-time, ten-day quarantine. For some of the nurses, work quarantine meant repeated ten-day quarantines resulting in an extended period of quarantine that lasted for more than four months. There were rules to follow and strict limitations involved to insure work quarantine compliance. One might wonder if the average person could endure these restrictions as a result of their work, particularly after enjoying the freedoms and rights we take for granted. Yet, all of us working during the sars outbreak had to conform to severe restrictions every hour of every day. The risks were too high to break the rules. For healthcare workers, following work quarantine restrictions meant that:

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1 The healthcare worker had to wear an n95 mask at all times while at work and practice diligent hand hygiene. Nurses had to stay at least two meters away from others while eating. Food was to be individually wrapped and not shared. 2 Individuals on work quarantine had to commute to work alone in a private vehicle if at all possible. If they had to be in a private vehicle with someone else, the quarantined individual had to wear an n95 mask and sit at the opposite end of the car. 3 The healthcare worker could not enter another hospital site except as authorized by the Medical Director/Administrator of the second site. 4 Quarantined healthcare workers with offices in the community were allowed to see essential patients in their offices. Routine checkups and other non-essential visits had to be deferred. The quarantined worker and all other office staff were required to wear n95 masks at all times, and practice diligent hand hygiene. 5 The quarantined healthcare worker had to monitor body temperature twice a day. They had to immediately stop work and notify their local health unit if they developed a fever or any other symptoms such as a headache, sore muscles, chills, cough, or shortness of breath. When individuals in work quarantine were not at work, they were to follow the rules of home quarantine as outlined below: 1 Remain at home, do not leave your house and do not have anyone visit you at home. Family or household members do not have to be isolated or quarantined at home, unless a member of the household is diagnosed with sars. Stops on the way home are not allowed (to purchase gas from a pump, for example). Dental, medical, and personal appointments are not permitted, and healthcare must be sought at your hospital of employment. 2 Wear a mask when you are in the same room with another member of your household, but attempt to remain alone in a room. 3 Change your mask as directed. Family or household members do not have to wear masks. 4 Do not share personal items, such as towels, drinking cups, or cutlery. Do not kiss or hug anyone, including family members. 5 Wash your hands frequently. 6 Sleep in separate rooms.

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7 Measure your temperature with your own thermometer twice a day over the ten-day period. The strict rules meant that all staff were isolated at work and isolated at home. Many found long-term work quarantine psychologically stressful, as every workday there was the possibility of contracting sars and infecting family members despite continued isolation.

gaps in canadian healthcare exposed by sars During the sars outbreak, thousands of people possibly exposed to the disease were asked to go into home quarantine. For many, the short ten-day quarantine experience was stressful, inconvenient, and isolating; for some it involved lost wages. Many healthcare workers were also off due to home quarantine early in the sars outbreak, so affected hospitals were short-staffed. At North York General we did have replacement agency nurses to assist with the workload. Agency staff often works at the same hospital repeatedly, so they have some familiarity with the institution. However, they do not participate in ongoing education and updates at individual hospitals. Each hospital has its own culture, organization, and ways of doing things, so agency staff members must orient themselves to the hospital. However, during sars, we could no longer rely on this since they also needed to be fitted for masks, learn the sars containment protocols handed down from the Ministry of Health (that changed daily), and learn our emergency procedures.6 The result was that regular staff had to teach agency staff, take on additional work that only they were trained to do, and all for less pay than agency staff.7 I worked along with others during these trying days; long hours and sleeping on my office floor became routine. All of us on the management team worked relentlessly to meet the demands of those particularly busy days; there just weren’t enough nurses to do all the work with so many away on full quarantine. The first round of sars presented problems for the hospital because the system was quickly overwhelmed by the need for extra isolation rooms. Work quarantine was instituted to deal with the issue of everyone potentially having been exposed to sars, regardless of

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whether they were healthy and well. If we had all had to stay home in full quarantine, no one would have been available to work. If there is another sars-like outbreak or a biological weapons threat, I think the healthcare system should be better prepared. Provisions must be put in place to deal with an emerging disease as a “special case” that requires extra staffing procedures regardless of bureaucracy and existing policy. The consequences of not having a strong plan in place to ensure an adequate number of healthcare workers would be devastating if the healthcare system and containment failed. While it sounds like an easy thing to do – simply add extra staff during an emerging disease outbreak – it doesn’t work that way in reality, for a number of reasons. Healthcare workers were already so overtaxed with daily demands that extra staffing was needed for sars patients who required intensive care, but it was very difficult to get any extra personnel from outside institutions. Even though staff may have been available from non-sars hospitals, they were forbidden by the rules imposed by the Health Emergency Act to work anywhere else. While the intention of the Health Act rule was to prevent infected workers from transmitting disease between hospitals, its result was a shortage of workers. In the current system many healthcare professionals, including physicians, work at more than one place. Knowing which staff members work elsewhere requires staff consent and the need for a sophisticated tracking system. The work quarantines and Health Emergency Act rules made it difficult to recruit staff with appropriate ed and infectious disease training to work at the hospitals where they would be of greatest help. The hospitals with active sars patients each had established their own particular version of a sars unit but had to recruit from their limited staff rosters. Human resource approaches need to be developed to address the reality that healthcare staff and physicians work in many settings and in many different roles. The healthcare system will never be able to sustain or finance a one-staff, one-site model. It is important to coordinate resources across the system, and this is essential during sars-like outbreaks. During the first round of sars,8 all of the floors or units at North York General Hospital were open and every resource was stretched beyond capacity. Working on the sars units was voluntary. Several healthcare professionals did volunteer and worked with sars

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patients but there was a high degree of uncertainty among many workers about their personal safety. I was pleased to do whatever needed to be done during the sars outbreak. There were many things happening simultaneously as the outbreak evolved over time, all requiring attention and all equally important. I spent a portion of my time informing and educating others about the current literature, finding the latest medical news and interpreting the clinical finding of sars. I felt it was important to give staff on the front lines the most current information possible. People were overwhelmed, and needed the correct evidence-based information quickly. Many healthcare workers had a lot of questions about the mystery illness, and wanted rumors dispelled or verified with information from credible sources. I was approached occasionally by people who trusted me and knew the extent of my knowledge of sars. I learned from others, and often shared insights into recently published articles that I had read. I was fascinated by this atypical pneumonia and read absolutely everything I found on sars in the literature. I would stay up all night reading everything that was new on the Internet and any peer-reviewed literature on sars, summarizing what was known and adding any important information that had just come out. My curiosity about sars translated at work into daily informal educational sessions and water cooler-type chats as a way to disseminate knowledge to others. We gathered to exchange information and would communicate the latest sars news to one another. This happened frequently, and became a source of comfort that things were progressing, that we were indeed learning more about the mystery infection as time went on. Most of us had many roles that were new and changing during the outbreak. I experienced different responsibilities and new tasks. One of these tasks, somewhat self-imposed, was gathering information in a just-in-time fashion. I felt a need to do this, to take the confusing and contradictory information and disseminate it in a way that made sense in the context of what we already knew. The library staff worked hard to keep current information available and easy to access. It was not always possible to impart the latest information to everyone quickly, because not everyone had the time or inclination to keep checking. In an ideal world, there would be people who could take the large amount of information that was being generated, sort through what was valuable and what was misinformation, and ensure that it made sense to all who needed it.

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Nurses are used to working long hours and, in the short term, can work extra shifts if needed. But being short-staffed while facing uncertainty about the disease, not knowing how long sars would last, added to our psychological stress. Nurses’ workloads were increased by the extra requirements imposed by sars caregiving. Getting into the personal protective equipment and working in that gear for twelve hours, knowing there was a constant risk of being exposed to sars, was stressful. Even experts at the cdc recommend working in such gear for only a few hours at any one time. Working in n95 masks and ppe suits for twelve or more hours at a time is just not normally done. The nurses tried to take breaks if they could find the time, but it was a hassle getting outside the hospital doors to have a breather. Eating and drinking require removing a mask and rules for infectious disease control meant that this mask removal was done alone. Face-to-face communication with masks on most of the time, with breaks taken alone, only heightened the sense of isolation. Healthcare workers were also discouraged from interacting with colleagues outside the hospital after hours, and staff meetings were discouraged or restricted. The overall effect of social segregation was counterproductive, occurring at a time when people were most likely to seek each other out for psychological support, shared experiences, and solace. The news media was insatiable for any sars images or news, and they would be waiting to take pictures of the nurses the second they stepped outside to get away from the stress inside the hospital. Being on display for the media was unsettling and made most of the nurses feel vulnerable, giving them the feeling of working in a fishbowl. It was a strange combination of personal isolation and lack of privacy, and it seemed as if there was no place to go to relax. Luckily sars was contained, but one lesson learned was the importance of having good lines of communication and the latest information. Not having details about the epidemiology and transmission of sars early on could have been disastrous. Emergency staff were well-informed and performed exceptionally at a time of extreme uncertainty. I am very proud of how they worked from day to day under such high stress. The nurses captured every sars case in triage and were on top of the situation to contain it. They were really superb, and everyone who worked in the ed gave their best effort. Some nurses and doctors felt that the outbreak was too risky and, although highly trained in dealing with infectious diseases, they did

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not contribute to battling sars in any capacity. The refusal to work on sars wards was a personal choice each healthcare worker had to make given their own situation. I couldn’t imagine letting my colleagues down or letting the public down and I made it a personal mission to ensure that the fewest number of people, including co-workers, would succumb to sars on my watch. For the most part, the physicians who worked in the sars unit did a remarkable job. A few of the physicians who were working at other hospitals weren’t allowed back into our unit since officials didn’t want physicians moving back and forth potentially transmitting the disease between hospitals. This was a source of great frustration for physicians who wanted to help but couldn’t. Everyone who worked during the outbreak has a story of how sars affected them. For example, some individuals had deaths in their families during the outbreak but couldn’t go to the funerals. Others missed weddings, babies’ first words or steps, anniversaries and birthdays, because healthcare workers were isolated by restricted quarantines. In life you make choices, but I have few regrets from my experience with sars, and these are minor. I worked overtime for months and I did a lot of extra work helping to make sure sars was contained. I went through a lot of stress, and I will never get back the extra time I gave to the hospital and the “greater good” in the effort to contain and triumph over sars. A lot of nurses did not get time off to recover from sars or to make up for all of the additional time they worked during the outbreak. In context, I consider myself one of the lucky ones; I didn’t get sars or the more serious stressrelated disorders experienced by some of my friends and colleagues. As a nurse clinician my job encompasses many different areas. I write documents and protocols, assess medical directives, keep current on the latest research to help inform health policy decisions, teach procedures to nursing staff, and work some shifts in the ed. When sars occurred, due to my multidisciplinary job I took on a number of tasks to deal with it. Many were things I wasn’t really responsible for, but there was no one else to fill in. Other hospitals in the Toronto area had similar individuals who stepped up and assumed roles well beyond their usual responsibilities. A prominent example was Donald Low, Chief Microbiologist at Mount Sinai Hospital and Professor of Microbiology and Medicine at the University of Toronto, who, speaking in retrospect about his sars expe-

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rience, said “None of what I did for this city was in my job description.” He dealt with sars patients on the front lines, reviewed treatment and containment procedures, helped develop containment and emergency policies with the city, reviewed numerous Suspect and Probable sars cases, and became a spokesperson for the city’s healthcare system, appearing on the evening news almost daily to deliver important information to the public. Dr Low pushed himself so much that his weight dropped precipitously from 170 lbs to 145 lbs during the outbreak as a result of stress and overwork. For all involved with sars, the months of crisis were a time of overwork, very little food, and very little sleep. Other doctors and nurses fighting to contain sars also dropped weight during the crisis. They jokingly called it “the sarsdale diet” at North York General hospital. “There was no time to eat,” said Dr Low, whose weight loss was so apparent that perfect strangers who regularly saw him on television emailed him to express concern about his obviously and quickly deteriorating physical appearance. He was even put into quarantine after coming into contact with a colleague who had developed sars, but while in quarantine Dr Low found himself just as busy at home with long teleconferences, and demands for his expert opinion and advice from other experts and the news media by phone and fax all day long, every day (Cormier, 2003). The government commissioned expert reports that were completed after the outbreak (The Campbell Commission, the Walker Report and the Naylor Report9). These reports highlighted and confirmed what we had experienced: that during sars it was the action and hard work of nurses, doctors, and other people who filled the gaps in a system that did not have any influenza emergency preparedness plans or the capacity to deal with a virulent pandemic. The reports were one of the few acknowledgements the nurses received after the end of sars. During the sars outbreak I was responsible for myriad tasks, including a number of administrative responsibilities. I assumed a leadership role. Many highly skilled people had been laid off over the years as a result of budget cuts. This ongoing decrease in healthcare funding did not go unnoticed by some who had warned that it was weakening the entire system.10 I shudder to think what might have happened with the containment and eventual outcome of sars if some key knowledgeable, experienced people hadn’t been in place to provide leadership and continuity due to funding

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cutbacks. The outcome for sars containment and the overall mortality numbers could have been quite different. The expert reports that reviewed the sars outbreak (The Campbell Commission Report, Naylor Report and Walker Report) highlighted the lack of capacity in the healthcare system and a lack of qualified people as a result of widespread federal and provincial funding cuts that had occurred throughout the 1990s.

the effects of sars on healthcare workers At first I didn’t think that my sars experience had affected me very much, but in the months following the outbreak I could still feel myself under a lot of stress as a direct result. I was exceptionally disillusioned with the healthcare system on the whole. However, the people who work so incredibly hard within, and sometimes despite, the system to save lives, including the other nurses, doctors, and management, counterbalanced this negative feeling. sars exposed glaring weaknesses in our healthcare system but brought out the best in the people who worked on the front lines and in administration. I can’t say what were the exact numbers of nurses who experienced some negative psychological effects from dealing with sars, but the effect seemed to be pervasive. Quantifying the impact and long-term psychological effects of an event like sars is difficult since different people coped with the situation differently. Some nurses were affected strongly and a lot of people who worked in the hospital during the sars outbreak, in the ed and elsewhere, were stressed to the point where they simply could not cope anymore. Some had to take a six-month leave afterwards. As a nurse clinician I could see a lot of the negative effects that manifested as variations of anxiety, acute stress indicators, longer-term depression, and posttraumatic stress disorder (ptsd) indicators. ptsd is a psychiatric disorder that can occur following life-threatening events (whether experienced or observed) such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. After a traumatic event, people can experience a wide range of normal reactions, including anxiety, hyper-arousal, fatigue, irritability, hyper-vigilance, increased emotionality, problems sleeping, exaggerated startle response, changes in appetite, feeling overwhelmed, increased impatience, and withdrawal from family

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and friends. When the effects are experienced in the short term but individuals recover, the condition is called Acute Stress Disorder (asd). According to the dsm-iv,11 a person may be diagnosed with asd in response to a traumatic event if he or she experiences a specified number of symptoms in four categories: hyper-arousal (difficulty sleeping, anxiety, fear, irritability or anger), intrusions (nightmares, flashbacks, and reliving the traumatic events), avoidance (being unable to go back to work and avoiding the traumatic subject), and psychic numbing (a sense of unreality, spacing out and dissociative amnesia). These changes occur within a month of the incident, and last for at least two days but not more than four weeks. The symptoms must have a significant negative impact on important areas of functioning such as social or occupational function, or the ability to obtain and use support. If the symptoms begin or persist beyond a month after the traumatic event, the person is diagnosed as having ptsd (American Psychiatric Association, 1994).12 A small percentage of individuals who experience ptsd can go on to manifest other related clinical disorders or suffer chronic long-term effects. The continual week-after-week stress and isolation of work and home quarantine affected personalities, changed behaviours, and affected healthcare workers’ interpersonal relationships. Quarantine only amplified their sense of isolation and frustration: they felt that others (non-healthcare workers) couldn’t possibly understand their situation and empathize with what they were experiencing. There were some people who took a very long time to return to work at the hospital because they couldn’t deal with their intense anxiety and stress. Other people were too sick to come back to work as the sars virus had ravaged them physically. Still others who had experienced equal levels of stress came back immediately; they were able to deal with it. So the effect sars had on healthcare workers really varied. Within a year most were back to work, but there are lingering after-effects. Many nurses still feel continual personal insecurity as a result of sars; this fear, for themselves and their families, of virulent contagions that they may be exposed to while on the job, still persists. The ptsd indicators definitely varied from nurse to nurse. The effects of the stress appear in the longterm, after the fact, and it looks as though little is being done to deal with it. There are few provisions or structures in place within the healthcare system to recognize and help individuals experiencing

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these persistent after-effects. Although few have been diagnosed, I think there was a lot of undiagnosed asd and ptsd in healthcare workers as a result of the sars experience. After-effects of the sars outbreak were eerily similar to Gulf War Syndrome, where soldiers returned from a very stressful situation and then, many months later, had a mass psychogenic experience, believing they had been poisoned by unknown nerve agents or chemicals in the field. Some of the soldiers came down with all kinds of perceived symptoms while others in the same squads were perfectly fine. A clear division between individuals who coped with the situation and others who were psychologically overwhelmed was apparent. A lot of the perceived medical effects were determined to be of a psychological nature: the long periods of stress they endured eventually resulted in post-traumatic stress disorder. For many healthcare workers, the sars experience was similar to a game of Russian roulette. It is not normal to work in the ed day after day, week after week, with no certainty that the containment of the virus and your personal safety are assured. There was no guarantee to any of the healthcare workers or to the larger community that the end of the outbreak would ever arrive. Mentally, this uncertainty was extremely difficult for the nurses to deal with. Realistically, working in the ed you have to assume some level of risk of being exposed to pathogens; it comes with the job. Also, there have been times when healthcare workers’ lives have been in danger from far less exotic causes than an infectious disease like sars. In the past we have experienced threats from people walking into the ed with guns, gang members with knives, and other violent people in highly unpredictable emotional states. In one incident at St. Michael’s Hospital a physician was taken hostage. Violent behaviour and gang-related incidents are not a common occurrence in Canadian hospitals, but violent acts that threaten healthcare workers do happen. As a nurse I have also been at personal risk from the many different types of infectious agents I have been exposed to. Over time, in my career as an emergency nurse, I have contracted Staphylococcus, Streptococcus (S. pneumoniae is a leading cause of pneumonia in all ages particularly the young and old), several other viral pathogens of the upper respiratory tract, middle ear infections (otitis media), and meningococcemia (a sudden-onset infection of the bloodstream and subsequent inflammation of the blood vessels by the bacteria Neisseria meningitides that frequently

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lives in the upper respiratory tract) on the job. Family members of healthcare workers who have been exposed to an infectious disease are also at increased risk, as many of these bacteria and viruses can be transmitted from person to person. Meningococcal blood poisoning, agents that cause encephalitis (infection and swelling of the brain), and viruses are routinely transferred from nurses to family members. The bottom line is that work exposures to infectious agents are usually episodic, and occur to workers sporadically over a long period of time. sars presented a much more dangerous and constant threat that was psychologically difficult to deal with.

the difficulties presented by quarantine Nurses were very stressed out by sars since in the beginning no one knew what it was or how to treat it. This pneumonia-like disease that sometimes placed patients on ventilators within hours of being admitted presented a frightening mental image of what could happen to the nurses regardless of the extreme measures of wearing full personal protective equipment. Under self-imposed work quarantine nurses could still do everyday things like going outside, driving their cars, or walking around outside on the street when not at work, but they had to remain twenty feet or more from other people. Work quarantine attempted to minimize nurses’ exposure to each other and to other people. If, as a result of carrying out your nursing duties, you became infected with sars, this would minimize the spread of the disease to the general public. If you were symptomatic or suspected then you were put into isolation until confirmed. From the early days of sars it was clear that infected people could quickly infect others if they were not properly isolated. Work quarantine is just a low-level form of isolation motivated by practical concerns; you can’t quarantine all the healthcare workers or the entire hospital. Everyone on the designated sars teams who had self-imposed quarantines were really good about their situation; they all used reasonable judgment as healthcare workers to minimize the spread while not at work. Hospital employees entered a voluntary ten-day quarantine if they contacted an individual with sars. Healthcare workers who were quarantined were apprehensive for their own health, feared transmitting sars to family members, worried about being stigmatized, and were uneasy with the interpersonal isolation. Staff

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members who continued to work were concerned about understaffing and overwork. Hospital employees who were not directly involved in patient care (about 40–50 per cent of staff) were deemed non-essential and were asked to stay at home indefinitely. Being designated as non-essential left some workers feeling unimportant and useless, unable to contribute in a meaningful way to the unfolding crisis. Some were called back to work and given other responsibilities and found it was more satisfying to work and make a contribution than to stay home. During the first week of sars1 I created a master document to keep track of all healthcare workers, a complete staff list so we could call people to ask about their quarantine status, health, and exposures. It gave us a way to screen or call back staff to keep track of those workers who had been exposed. I first found out about the work quarantine during sars1 when someone from the hospital called me; I had recently left work after a long shift. I remember answering my cell phone in the middle of a very large, busy retail store, doing some after-work shopping, and getting the news that I needed to put myself into quarantine immediately. The work quarantine meant that I was to continue working but minimize my contact with all others. The news hit me pretty hard and I left my full shopping cart in the middle of the aisle and exited the store as quickly as possible. After the work quarantine began, many of the other nurses voluntarily restricted themselves from going into any public places. It was extremely confining constantly having to avoid people unless we were wearing masks. Even at work while wearing masks there were some quarantine restrictions. At the hospital we couldn’t go to the cafeteria, but they provided food for those of us on the sars unit. At the beginning of sars no one knew how long the outbreak was going to last. Initially we received meal tickets as part of the work quarantine. That seemed to be a good idea, but it went by the wayside once it was realized how long sars might last. After some time the cafeteria staff just started sending us food. They sent us a few boxes every day. The cafeteria supplying meals was an enormous help to us; we were so busy. They constantly sent us sandwiches, pasta, vegetable platters, and other meals. They sent soft drinks, bottled water, and always enough food. It was very much appreciated by all the nurses who couldn’t go elsewhere to eat without breaking quarantine. The meals had to be individually wrapped, a quarantine precaution to

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prevent an infected worker from spreading sars to others through communal food dishes. Just after we received news that quarantine meant we were barred from the cafeteria, and feeling a growing sense of isolation, we came up with a joke email chain letter as a way to make fun of our predicament. It discussed our new “sars diet,” which consisted only of food items that the cafeteria staff would be able to slide under our doors. Menu items on our sars diet required a high degree of creativity to achieve variety and to get our personal favourite foods. The joke menu consisted of very thincrust pizza, flounder, flat tortilla shells, and any other flat foods that we could think of. Even ice cream made our list of foods, but of course we had to wait for the ice cream to melt and have it poured under the door. At the time it was silly and funny and we used this kind of humor to deal with the reality of being excluded from the cafeteria. The self-imposed quarantine made life difficult. Little things that you don’t normally think about became problematic. For healthcare workers who drove their cars to work, filling up with gasoline was impossible without potentially exposing others. Workers without cars would have to rely on mass transit (buses, subways) or cabs to get to work, again making containment a problem. Other daily tasks like shopping for food, eating out, picking up children from daycare or school, going to a video rental store, going to a movie theater – none were allowed during the quarantine period as people attempted to isolate themselves from others. The hospital did try to help those who were on work quarantines. When workers needed gasoline for their cars the hospital set up a mini gas station so we could fill up with minimum exposure of others. It was little things like helping to provide food and gas availability that really made a big difference in coping with the sars situation. That sort of capacity to help workers during exceptional circumstances is an important part of a quarantine strategy. Work quarantine minimized our face-to-face interactions and we relied more than usual on the use of electronic mail. We sent information and jokes to one another to maintain a sense of community and our morale. Work quarantine, however, was not a foolproof way of ensuring the containment of sars, and it is likely one of the biggest weaknesses in the system, potentially allowing contagious pathogens to escape into the general public. Individuals who do not adhere strictly to the rules of work quarantine jeopardize contain-

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ment efforts. One example of this was a nurse who became infected with sars and took the go (commuter) train on two occasions. Both times she was in a four-passenger car with three other people. The woman had symptoms of sars when she first took the train on 14 April, leaving Toronto’s Union Station at 4:30 p.m. The next morning, the woman took the train again at 7:32 a.m., a peak time for commuters, to go to work as a nurse at Mount Sinai Hospital. She had a fever and was feeling unwell but was not coughing. The next day she was admitted to Mount Sinai for treatment of sars. This incident occurred well into the sars outbreak and the six exposed passengers that travelled with her could have become infected, unknowingly seeding a wave of uncontained sars in the greater Toronto area and potentially other cities (cbc News, 2003d). Realistically, you can’t quarantine everyone; people need to work. They can’t stay in buildings that are quarantined all the time. As an individual on self-imposed quarantine you can do everyday tasks but there are restrictions; you have to use reasonable judgment and minimize contact with all others as much as possible. Clearly the nurse on work quarantine broke the rules of containment by getting onto a busy train. Patients were equally challenged by the ordeal of quarantine during the sars crisis. In future, if we maintain the work quarantine system, we should provide special help to ensure containment during travel to and from work. It was well known that many patients were frightened and isolated because visitor restrictions prevented them from seeing families and friends at a stressful time. Both nurses and physicians made an extra effort to fill this void while recognizing that patient safety was always of primary importance. However, nurses and doctors also found the work quarantine isolating when, as was the case with sars, it extended over many months.

living and working with sars In the early stages of the disease, when symptoms hadn’t yet surfaced, it was difficult to tell when an infected person was contagious and shedding viral particles. Diagnosing sars, especially when there was no clear epidemiological link to existing cases, was often incredibly difficult. Getting the diagnosis wrong, whether misjudging a patient with sars or announcing that the disease itself

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had been beaten prematurely (as evidenced by the second outbreak at North York General Hospital), could and did have disastrous consequences for disease containment. The sars virus, we found out later, can be detected in almost every body fluid: in sweat, aerosolized cough droplets, and diarrhea. We suspected this was the case from the beginning and the patients were put into a room alone when isolated. We saw a few different, commercial devices for isolation and containment of patients, and some of the methods looked interesting but they didn’t work very well. The success rates for some isolation chambers were terrible and some of the units weren’t practical. One set-up isolated the patient in a mini-tent that completely covered the bed. It worked but made it difficult to deliver medical care or observe their airways. Overall it just minimized their space and you can’t do that to a patient already in full isolation. You can achieve the same effect by having them in the isolation room. It does the same thing. Initially, under the threat of sars and its unknown level of virulence, we were wearing full protective gear all the time. We doubled up on gloves and gowns with booties. It didn’t make any sense, as there was no scientific data to confirm that what we were doing was effective to reduce infection, but the directives came from officials so we followed them without question. I helped to devise the strategy to get in and out of the layers of protective clothing but the ministry (provincial) told us to put on another layer. I think they were being cautious. These directives came all the time, sometimes two or three times a day. We had to make signs and post them so people knew how to get in and out of rooms. We had to make a sign for each room: one outside to tell people how to dress to get into the room, a second in the room telling them the correct procedure for leaving the room. As many rooms as we had, we had to make different signs for getting in and getting out. I will try to explain how the process of entering and exiting a patient’s room worked during sars, as it is a good example of the difficulties involved in containment when treating multiple patients who were Probable and Suspect cases. First we had signs posted on the doors of the patients’ rooms with procedures on how to enter and how to exit the room. The signs and the directions changed all the time and I was the person responsible for printing out all of the signs. Even though the signs kept changing with different nuances of protocol, the staff wasn’t particularly stressed out by it. They were just happy

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something was in place for containment. It was comforting that there was a clear protocol in place that would help protect them when entering and exiting high-risk areas. It evolved over time and everyone understood that the information changed – sometimes by the hour – as more became known about the mystery illness. Exiting the room was more complicated than entering and required a detailed method. When a nurse left a sars-infected patient’s room she had to take the outer gown layer off first, carefully folding it in upon itself, leaving it in a hamper right by the door inside the patient’s room. Then the nurse would step out of the room. Next the extra gloves came off and the second set of ppe came off once outside the room, and these were placed in another hamper. Dressing up to enter the room was less problematic as everything was sterile and sars-free. The procedure for containment exiting the sars patients’ rooms generated quite a bit of waste. Initially we were running out of yellow gowns. Some are disposable but some were washable. Hand sanitizer was used every time we left an isolation room; it was proven to kill the virus. The use of double gloves with hand sanitizer was likely unnecessary but it was better to take precautions. Initially, patients would walk into our Emergency Room and be greeted by a triage nurse and assessed with our screening tool (a series of questions to gauge their symptoms and to establish if there was an epidemiological link to sars patients or places). If the patient failed the screening, they were put into isolation. During the crisis we quickly ran out of rooms, with the ever-increasing numbers of Probable sars cases, so we improvised and set up a number of makeshift rooms for containment, each lined with clear plastic. Eventually, once we realized that sars containment and increased public panic were both occurring, we set up a tent just outside the ed that acted as the sars Walk-In Assessment Clinic. The tent itself was furnished with as little equipment as possible. The assessment clinic consisted of several rooms, all separated, all negative pressure, and each room had its own air circulation to minimize the risk of contamination. The assessment clinic worked much like the earlier assessment procedure we did inside the ed, but it provided better containment. Patients would arrive and park their cars in the parking lot. Then they would be greeted by a triage nurse (in full ppe) and escorted to the assessment area. Patients were given surgical masks before entering the assessment clinic and then screened,

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using a series of questions that the nurses asked to establish whether a patient had fever and other symptoms, and if they had an epidemiological link to known sars patients or regions where sars was active. If patients passed the screening test they were escorted out of the assessment tent. We carefully controlled the flow and movement of patients, and saw them only one at a time. If they failed the screening they were immediately moved to one of the assessment rooms for further testing, and put into isolation as sars Suspect. We were so cautious that we wouldn’t even let the patients touch the plastic so we had a hospital staff member there to open the hanging plastic that led into the assessment room, to maintain containment integrity. Individuals who came in for assessment who were positive for sars knew that they were in trouble. Their increasing difficulty breathing, shortness of breath, and rapidly deteriorating symptoms clearly signaled that they had no ordinary flu. The sars Assessment Clinic was set up in the hospital’s ambulance bay in under a week, and required new equipment and construction. The area was brightly lit, with a freshly painted grey floor, but somehow still looked like a set from a low-budget science fiction-horror film than a bona fide hospital infectious disease containment area. Thin cloth curtains lined with thick plastic on both sides hung down to the floor from a fixed aluminum railing about two meters high. These curtains divided the area into two large rectangles separated by a three-meter-long hallway. The left and right sides were further subdivided into five or six smaller assessment rooms. Each small room had a doorway but no door. Instead, a double sheet of plastic-covered curtain was used. Periodic seams in the plastic were sealed by long pieces of grey duct tape. Overhead a long, shiny, silver-coloured air duct, about one meter in diameter, was suspended from the ceiling and travelled the length of the hallway like a giant spine. Connected to this backbone were rib-like extensions that sent smaller silver air pipes down to the top of each of the assessment rooms. The silver pipes that led to each of the small rooms were used for ventilation, as a way to create negativepressure airflow that helped to remove any aerosolized sars viral particles. As you walked along the short hallway, the thin plasticcovered curtains that made up the walls revealed opaque shadows of people moving about on the other side. They were almost visible, but not quite. Someone standing close to the plastic wall cast a ghostly image of a distorted mask-covered face. The assessment

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rooms were intentionally barren. Each plastic-lined room contained a single vinyl chair, and beside the chair was a small tray on which sat a minimal set of diagnostic tools, a stethoscope, some hand cleaner and a portable hepa filter. Nurses working in the sars Assessment Clinic moved quietly and efficiently, and looked identical to one another, much like worker bees in a hive; all wore identical-coloured masks, gloves, visors, blue booties, blue surgical caps, and hospital-green clothes that were covered by a yellow gown tied at the back. Standard-issue full protective equipment also included masks and visors, which were strictly required in such a high-risk area. It was not easy to judge nurses’ emotions as you passed them in the hallways since they all wore protective masks that covered most of their faces. Eyes, framed by a mask and hair cover, peered from behind a clear visor. People knew of or had heard of sars, and after the Emergency Health Act was declared, many people came in to the assessment clinic wanting to know if they had sars or if they had an epidemiological link. The assessment clinic had 221 visits, with 16 admissions. Most patients who were positive for sars were very worried, but took the news as best as could be expected. They knew their symptoms were continuously deteriorating and that they required medical attention. Some people, however, didn’t take the news well at all. One woman diagnosed with sars was very angry she had gotten it from work and that she might have unknowingly exposed all of her family to the disease. Others were not upset for their own safety but expressed an overwhelming sense of guilt and fear for their families that they had endangered. The thought of accidentally infecting their children caused people a lot of anger, guilt, and worry. For nurses the situation was the same as a lot of the nurses who had children at home felt constantly worried about infecting them. Some people were so affected by their diagnosis that they shut down and couldn’t talk about feeling depressed about it. In my experience, the people who withdrew were the fragile ones, while people who were usually strong reacted by becoming angry. But surprisingly, strong personality types were mostly angry with themselves and the situation they found themselves in, and, to a lesser extent, the healthcare system and the randomness of world events that culminated in their infection. Nurses were not paid very well

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considering the personal risks they took. Contracting sars themselves as a result was devastating for some. There is a high burnout factor for doctors and nurses who work in the ed even without sars. The hospital has exceptional social workers who deal with these emotional problems all the time as available counseling staff. Hospital staff members who got sars had a variety of reactions just like non-healthcare workers. Everyone’s response was different, with some people who were angry, while some people were too sick to comprehend the seriousness of their situations. Others were very frightened; at the opposite end of the spectrum some people accepted the situation immediately and quickly tried to make plans in case they succumbed to the illness. Of all people to walk into the sars Assessment Clinic or who were quarantined, we captured every sars patient, and no active sars cases went undetected by us. During sars anybody with any kind of upper respiratory system problem or any respiratory system illness with fever, or any combination of a fever with other symptoms, was isolated as a precaution. Even people who had pneumonia that was not atypical were isolated in a single room. Usually it’s hard to get pneumonia from someone, as you have to be exposed for prolonged periods of time. So community-acquired pneumonia is something we don’t usually worry about too much.

changes in healthcare workers’ attitudes after sars Much time has passed since the sars outbreak ended, and many people have asked me what I learned from this experience. This is a complicated question to answer. It doesn’t seem to matter how many times I am asked; I still have to stop and think about it carefully. Remembering the events as they happened results in a blur and rush of mixed emotional memories – days that merged together during the outbreak – the lack of sleep – increasing levels of anxiety – watching as friends and colleagues contracted sars, and then watching them recover – critically ill patients on ventilators – constant wearing of masks and ppe – the isolation of work quarantine – the stigma of being a sars nurse – the end of sars declared twice – the relief of knowing the sars outbreak was truly over, and recovering, personally and institutionally. My first response is the most obvious one: our infection-control procedures and our

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hospital capacity to deal with sars (or another sars-like disease) has increased tremendously. Nurses and doctors are now much more aware of infectious disease control procedures, and we will wear a n95 mask any time, anywhere without a second thought. Second, many nurses, including myself, realized that being a sars nurse was a thankless job. The public seemed to have very little understanding or appreciation of just how hard we worked to protect them. This under-appreciation and lack of awareness was perhaps the greatest disappointment felt by many nurses even to this day. Finally, sars really increased a sense of camaraderie among nurses and bonded us together. At the beginning of sars we only had two bona fide containment rooms for infectious disease control. Since then, hospital renovations and infectious disease control protocols have greatly improved matters. There is much more capacity at our hospital (North York General) now for the next infectious disease outbreak. We have eighteen isolation rooms and a bunch of single rooms that can easily be converted into extra isolation rooms if needed. The isolation rooms are state-of-the-art, with led-polarized glass that goes opaque within seconds when needed, controlling visual access to the rooms. This allows young doctors in training the opportunity to observe high-risk aerosol and infection control procedures through the glass without taking the time to dress and without risk of exposure if their ppe is compromised. The room can be used for other purposes and switched to a negative pressure room when needed. It was very expensive to put this in place for future isolation. North York General Hospital is one of only a few hospitals that have this many and this quality of isolation rooms. Many of the problems we encountered during sars have been addressed, including movement of infected patients for x-rays, developing better procedures for containment, mask-fitting, protective equipment, training in several aspects of infection control, and emergency preparedness plans. Through the tragedy of sars we have, personally and institutionally, learned a lot. We are much stronger and better able to deal with future influenza pandemics than ever before.

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Properties of Coronaviruses and Factors Contributing to SARS Transmission As their lungs filled … the patients became short of breath and increasingly cyanotic. After gasping for several hours they became delirious and incontinent, and many died struggling to clear their airways of a blood-tinged froth that sometimes gushed from their nose and mouth. It was a dreadful business. Isaac Starr, third-year medical student, University of Pennsylvania, 1918 (Crane, 2002)

While many wrongly believe that sars and coronavirus are the same, they are in fact two separate and distinct things. Severe Acute Respiratory Syndrome is the name given to the clinical manifestation of symptoms resulting from the viral infection of coronavirus, which is the causative agent. Coronavirus belongs to a different viral group than common yearly influenza1 and is a member of the hemagglutinin h5 group (influenza strains are in the h1, h2, and h3 groups). Coronaviruses are one of several types of virus that cause mild upper-respiratory infections and common colds in humans, but they can also lead to more severe outcomes like pneumonia or acute respiratory distress syndrome (ards).2 There are three main groups of coronaviruses. Groups i and ii predominantly infect mammalian hosts (humans, cattle, pigs, dogs, cats, rabbits, and rats) and cause respiratory and enteric diseases in humans and other animals. Group ii also includes turkey coronavirus, while group iii consists of avian coronaviruses (chicken and turkey). Within each group the coronaviruses are classified by host range, antigenic relationships,3 and genome organization. The virus responsible for sars was a much more virulent strain of coronavirus, leading scientists to believe that it had its origins in

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an animal reservoir, where the virus can have more severe effects. Like most cold viruses, the coronavirus that causes sars can be spread from person to person by coughing and sneezing or through close personal contact. The virus is transmitted on tiny droplets of saliva or mucus into the air. It is then inhaled directly or contaminates objects in the environment, leading to indirect transmission between individuals. Coronavirus, like other types of singlestranded ribonucleic acid (rna) viruses, tends to mutate during its reproductive cycle. These mutations give rise to new strains as they pass through populations over time. One of the great difficulties in developing a vaccine for viruses is precisely due to the fact that they are constantly changing over time. The sars coronavirus is abbreviated “sars-cov” in research and medical literature. The name coronavirus is derived from the halo or corona around the viral particles when viewed under a microscope, which is a result of the protruding spike proteins that coat the surface of the virus. The enveloped viral particle is 60–130 nanometers in diameter and contains a single-stranded positive rna genome. It is the small physical size of the virus that allows it to evade the human immune system, but as a result it cannot contain very much genetic material. There are eleven open reading frames (orfs) in sars-cov (the areas that encode the genes), and genome organization of the major structural proteins in sars-cov is typical of other coronaviruses. The entire sars-cov genome is just 29,272 nucleotides in length, with 41 per cent of the bases being guanine or cytosine g/c residues (for comparison, the recently sequenced human genome consists of three billion nucleotide base pairs, with 30,000 identified genes each on an average of 3,000 nucleotide bases). In other words, even considering only the important gene-coding regions of our human genome (a mere 3 per cent) the coronavirus contains 3,000 times less genetic material. Coronavirus has a relatively large genome size as far as rna viruses are concerned, and this is a characteristic feature. Sequence analysis of a limited region of the replicase (rep) gene supports the idea that sars-cov is distinct from all other coronaviruses (Drosten et al., 2003; Ksiazek et al., 2003). sars-cov infectivity of humans is a new variant, and this coronavirus has been assigned to a separate group (group iv). Prior to sars-cov, two other coronavirus strains, hcov–229e (group i) and hcov–oc43 (group ii) were known to infect humans

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(Holmes, 2001; Lai and Holmes, 2001; Holmes, 2003). Human coronaviruses are responsible for approximately 30 per cent of mild upper–respiratory tract illnesses (Rota et al., 2003) but have also been linked to the occurrence of gastroenteritis (Sharma and Khuller, 2001). Typically coronaviruses have narrow host ranges for infectivity; it appears that sars-cov (the strain infecting humans) has a greater ability to infect a wider variety of cells. Research has shown sars-cov can infect different kinds of cell cultures used in the laboratory, including African green monkey (Ceropithecus aethiops) kidney cells (Vero cells), fetal rhesus kidney cells (frhk–4), and human colorectal adenocarcinoma cells (Caco–2). Other coronaviruses do not have the ability to infect such a range of cells. Coronaviruses have also been associated with hospital-acquired infections related to the environmental spread of the virus (Holmes, 2001; Sizun et al., 1995; Sizan et al., 2000). After the 2003 sars outbreak another group I coronavirus that infects humans, hcov-nl63, was also reported in the Netherlands in 2004. It caused an upper-respiratory illness similar to the common cold and likely would have gone undetected if not for increased diagnostic testing for sars coronaviruses (Naqi et al., 2003). The detection of new coronaviruses through increased surveillance suggests that we may find several other, as-yet-unidentified coronavirus strains present in human populations (van der Hoek et al., 2004; Fouchier et al., 2004). Prior to the sars outbreak the coronaviruses that infect humans had been poorly studied since they did not usually cause morbidity and were not perceived to be a great risk to human health (Skowronski et al., 2005). During the worldwide outbreak in 2003, two distinct sars-cov genotypes were identified. One genotype originated from Hotel M in Hong Kong, while the other originated from cases in Guangdong, Hong Kong, and Beijing. Due to the mutation-prone process of viral replication in sars-cov, there is still the possibility that different strains will emerge, causing future outbreaks. Estimates of the incubation period for sars range from approximately two to ten days (Poutanen et al., 2003; Tsang et al., 2003). The symptomatic period for sars determined from data shows a range between eight and twenty-four days with a mean of sixteen days (Poutanen et al., 2003; Tsang et al., 2003). Data from Hong Kong provided similar numbers with a slightly longer average incubation time from infection to onset of 6.37 days (range 5.29 to 7.75

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days) and 95 per cent of patients showing symptoms within 14.22 days after infection (Donnelly et al., 2003). At the start of the global sars outbreak, the World Health Organization (who) guessed that the vast majority of those infected had an incubation period of less than ten days. This information was questioned due to the nature of other known coronaviruses (Berger et al., 2004). Other human coronaviruses have the ability to remain in incubation for much longer periods of time, which could mean that some of those infected could carry the disease for longer than periods identified in the current projections on which the who bases quarantine times (Enserink, 2003a). The lengthy, asymptomatic incubation period for sars is what allowed the disease to spread between countries as travellers returned home on international flights.

the spread of sars – contributing factors There were several reasons identified for the differences observed in the aggressiveness of the sars-cov outbreaks experienced by different countries: m u tat i o n o r c h a n g e o f v i ru s r e s u lt e d i n a mo r e v i ru l e n t s t r a i n l o c a l to to ro n to It was believed that the sars-cov strain in Toronto was a more virulent mutated strain (Poutanen and Low, 2004). Doctors in Taiwan determined that at least two strains existed in the population but the strain that took hold in that country was the more virulent form (Shih et al., 2005; Skowronski et al., 2005). Older individuals and those with comorbid4 (simultaneously occurring but unrelated) illnesses were at higher risk for more serious complications from sars. Finally, hospital capacity, behavioral factors (individuals breaking quarantine), and the environmental context (extent of environmental contamination) all contributed to the magnitude and spread of the coronavirus outbreak (Skowronski et al., 2005). t h e l e v e l o f c o n tag i o n va r i e d b e f o r e S A R S s p e c i f i c d i s e as e - c o n t ro l m e as u r e s w e r e i n s t i t u t e d , a n d t h e r e w e r e “ s u p e r- s p r e a d i n g ” e v e n t s Individuals with sars shed viral particles by coughing and sneezing, and were highly infective for a period of time at the onset of the

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disease. If during this window of infection the individuals were quarantined and did not come into contact with others, the chain of infection was broken. In Toronto, infected individuals who visited hospitals actively shed virus particles in crowded hospital hallways and communal areas prior to more rigorous infectious disease control measures (patient isolation and sars assessment clinics). Epidemiological evidence of the spread between patients early during the outbreak supports this idea. Not all cities or countries that received sars-infected patients, even during the early stage of the outbreak, when little was known, experienced sustained transmission or outbreaks. For example, in Canada, the Greater Toronto Area in the province of Ontario and the city of Vancouver, British Columbia both received symptomatic sars patients. While Toronto hospitals experienced an extensive nosocomial outbreak (contracted in the hospital context), Vancouver did not experience a secondary spread of sars (Poutanen et al., 2003). Likewise there was no continued transmission of sars in the United States despite multiple introductions of the virus. The standard practices in hospitals in different jurisdictions either helped or hindered sars transmission and was a contributing factor in transmitting the disease to new hosts. In the United States, patients presenting with infectious symptoms (tuberculosis or pneumonia) are immediately isolated and examined by doctors with protective masks as standard procedures (Skowronski et al., 2005). In some countries, like China, individuals who were not contained through quarantine acted as propagators (Wu et al., 2004). sars c o ro n av i ru s c a n a f f e c t i n d i v i dual s d i f f e r e n t ly The most critical risk factor for a fatal outcome for anyone who contracted sars was the person’s age. Children younger than twelve years experienced excellent recovery outcomes, while patients older than sixty-five years experienced case fatalities that exceeded 50 per cent (Peiris et al., 2003; Tsui et al., 2003; Choi et al., 2003). Other existing health conditions also greatly impacted outcomes of sars patients. For example, sars patients with diabetes mellitus, hepatitis b virus infection, and heart disease as pre- existing conditions were shown to have higher mortality. These were consistent independent predictors of sars-increased mortality outcomes (Christian et al., 2004; Fowler et al., 2003; Lew et al., 2003; Peiris et

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al., 2003). The general overall health of the individual was also a predictor of outcomes; individuals who had a high neutrophil (infection-fighting white blood cell) count, high initial lactate dehydrogenase (indicating existing tissue damage),5 and low cd4 and cd8 lymphocyte counts at admission (indicating that individuals were already under severe physical stress) were associated with poor recovery outcomes; these individuals were greatly affected by the coronavirus infection (Skowronski et al., 2005; Peiris et al., 2003; Tsui et al., 2003). h o s p i ta l c o n ta i n m e n t p r ac t i c e s t h at g av e t h e v i ru s o p p o rt u n i t i e s to s p r e a d Healthcare providers could have been infected as a result of the lack of masks and personal protective equipment (and, later, improperly fitting masks), incorrectly removing personal protective equipment, incorrectly disposing of equipment when disrobing, and partaking in high-risk procedures. Moreover, the practice of moving infected patients through hallways from quarantined isolation rooms to x-ray departments and back again may also have contributed. sars was markedly a hospital-acquired infection. Healthcare workers comprised 22 per cent of all reported cases in Hong Kong and Guangdong, China, and more than 40 per cent of all reported cases in Canada and Singapore (World Health Organization, 2004; Skowronski et al., 2005). It is the symptomatic patient who most efficiently transmits sars; this happens on average within ten days after symptoms first appear. Maximal virus excretion occurs at about ten days in the respiratory tract and at about thirteen days in stool. sars-cov can survive up to two days at room temperature and up to four days in stool. On surfaces it can be fairly easily killed with heat or many common disinfectants (Berger et al., 2004). During the outbreak there were no commercial disinfectants registered by the United States Environmental Protection Agency (us epa) or by Health Canada specifically listed as having the ability to kill the new sars coronavirus, for use on environmental surfaces. However, related viruses that have similar physical and biochemical properties can be killed with dilute bleach, ammonia, or alcohol solutions, or store-purchased cleaning agents containing any of these disinfectants. During the sars outbreak, hospitals used hand cleaner containing an alcohol disinfectant and viricide (virus-killing chemical) extensively as a way to ensure decontami-

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nation. Cleaning agents are highly effective against viral environmental surface contamination and should be used according to the manufacturer’s instructions.

where did sars come from? The current belief among scientists is that viruses are escaped fragments of nucleic acid that have assumed an independent existence. They are collections of genes that have escaped from prokaryotic (single-celled) or eukaryotic (multi-celled) organisms but remain dependent on those cells for their metabolism and reproduction. The viruses are subject to natural selection pressures and undergo evolution, as do all genomes. Each virus in existence today arose independently and, consequently, viruses are not evolutionarily related to each other in the same way as other organisms. As a result, while we can analyze relatedness within viral strains as they change over time, there is no true evolutionary phylogeny for viruses as there is for other animals. For example, we know, based on genome similarity, that chimpanzees are close relatives of humans, but different viruses do not have such an evolutionary lineage. Viruses are most closely related to the cells from which they escaped. Therefore, a human flu virus’ genetic material is most closely related to humans’. The evolution becomes complicated with viruses that have moved between hosts over time (Fox, 1998). Coronaviruses are extremely variable. They have shown that as they evolve they are capable of jumping species, easily adapting to different cell types and displaying altered pathology. The first theory about the emergence of sars is that the virus jumped from one of many animal coronavirus reservoirs into humans (van der Hoek et al., 2004). There are several animal coronaviruses that are quite similar to sars-cov. The closest versions are strains that infect the Himalayan palm civet, hog badger, and raccoon dog, all animals routinely found in Chinese live-animal markets. Coronavirus isolates from these animals are 99.8 per cent identical to human sars-cov and have a characteristic omission of only twenty-nine nucleotide base pairs in their genomes (McGoldrick et al., 1999). Although species-jumping is a rare event, considering that such animal reservoirs are in constant proximity with humans, this theory, supported by the high degree of viral sequence homology, is extremely plausible (Chan et al., 2004).

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A second theory for the emergence of sars-cov suggests that the virus was already established in the human population, causing mild asymptomatic disease, and subsequently converted into a more virulent form. The epidemiological origin of sars pointed to China as the site for the initial spread of the virus, but the actual animal host reservoir and source remained poorly understood until several months after the global outbreak had ended (Zhong et al., 2003). Research has pinpointed the location and likely zoonotic origin of the virus that jumped from animals to humans. A microbiology team from the University of Hong Kong investigated the origins of the coronavirus in China by testing eight different species of wild and domestic animals obtained from a live-animal market in Guangdong, China, in May 2003. A total of twenty-five animals were tested, and sars-like coronavirus was detected in four civet cats and one raccoon dog. Antibodies were also found in three palm civets, a raccoon dog, and a Chinese ferret badger. The genetic sequence of the human sars coronavirus and the virus detected in the civet cats and other animals were very closely related. While there were plenty of similarities between the genetic sequences, there were also many differences. It is unknown how the virus, which appears to be common in animals reared for food in the Guangdong area, managed to cross the species barrier and become a dangerous virus for humans. The most plausible explanation is the live-animal markets, with large numbers of humans working in close proximity to wild animals, allowing for viral mixing and repeated viral passage between animals and humans. The conditions provided the virus the opportunity to “amplify and transmit to new hosts” (bbc News, 2003). To test the hypothesis, researchers took blood samples from 1,500 market workers. The test results revealed a subset of 55 market workers who were seropositive for the coronavirus: that is to say that antibodies to the sars-cov virus were detected in their blood samples, meaning these individuals had already been exposed to the virus. Of these, eight were wild animal traders, three workers routinely slaughtered wild animals, and one was a vegetable seller who handled live animals. None of the workers who tested positive for the presence of coronavirus’ cross-reacting antibodies had reported being sick or having any sars-like symptoms in the previous six months. It is unknown why the workers didn’t show any symptoms, but researchers suspect that the positive anti-

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body test indicated that these individuals had been exposed to the coronavirus up to several years previously (Parry, 2003; Guan et al., 2003). A second serologic study from Hong Kong confirms that sarslike viruses may have circulated in human populations in the past. Using standard assays, antibodies to human sars-cov and animal sars-cov-like virus were detected in 17 (1.8 per cent) out of 938 adults. This study, carried out in 2001, showed that a small proportion of healthy individuals in Hong Kong had been exposed to a sars-related viruses at least two years before the recent sars outbreak that was recorded in Guandong Province, China (Zheng et al., 2004). sars may be the result of rapid evolution of a related coronavirus that had previously jumped to humans and then experienced mutations. More than one third of early cases of sars in Guangdong occurred in live-animal or food handlers. When tested, about 10 per cent of asymptomatic animal handlers at the markets in Guangdong Province in China had antibodies against sars-cov, compared with 1 per cent – 3 per cent of the general population, showing that the animal handlers had already come into contact with coronaviruses and had immune responses from being previously infected by sars (Skowronski et al., 2005). The study uncovered some important facts. First, the coronavirus was found in several animal reservoirs. Second, the testing of animals showed the existence of incubating reservoirs that are in close association with humans, providing a zoonotic link between the two groups. Third, even before the first recorded sars outbreak in southern China in November 2002, different market workers and animals were already carrying coronavirus; the virus had likely been passed back and forth between humans and animals on several discrete occasions (Parry, 2003; Guan et al., 2003). Thus, the initial cases of an atypical pneumonia that emerged in Guangdong Province of China in mid-November 2002 were not the first occurrence of animal-to-human zoonotic transmissions for this coronavirus. The severity of the November 2002 cases indicate that the coronavirus had undergone some genetic change, perhaps an antigenic shift6 or antigenic drift,7 as it was passed between animals and humans. The repeated passing changed its virulence and its ability to infect human hosts. Later, other independent clusters of sars cases occurred in several Chinese provincial municipalities through December to mid-January 2003.

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In the past, coronaviruses have been known to convert from enteric (intestinal) infections to respiratory, neurotropic (affecting the nervous system), or hepatotropic (affecting the liver) forms, which lends support to this idea of several previous versions cycling between animals and humans. Furthermore, the feline coronavirus fipv has been shown to regain fatal virulence after circulating in a host population as a relatively harmless strain (de Aribba et al., 2002). These two theories for the emergence of sars emphasize the genetic variability of the virus. Coronavirus rna polymerase is highly error-prone, making many mistakes (estimated at one change per 10,000 bases copied, on average), resulting in frequent mutations. Moreover, coronavirus polymerase is known to switch between rna templates within host cells, causing radical genomic deletions and even recombination between two coronavirus species in a host infected with both. The implication is that antigenic shifts can occur at a higher frequency with the creation of new hybrid viruses that have the opportunity to jump between species if the conditions permit it (Bi et al., 2003; Marra et al., 2003). For example, the feline coronavirus fcov type II is apparently the result of a homologous recombination event that occurred between the cat and dog coronavirus types (feline fcov type I coronavirus and the canine ccv coronavirus) (Ho et al., 2004; Chan et al., 2004). When humans are in close contact with animals, coronaviruses have been known to recombine to become pathogenic to people. Although there is no conclusive evidence about where the sars-cov originated from, determining potential animal hosts is an imperative step in developing disease-control options. If the virus that causes human infection can exist in multiple domestic and wild animals, it will be difficult to eradicate future sars-like zoonotic jumps by culling host reservoirs. sars was devastating for humans who had no immunity from the novel virus. The most obvious parallel example of this is avian influenza. The flu virus usually lives in the stomachs of birds (ducks or geese), and the virus and birds are co-adapted, which is to say that the birds do not get sick from carrying the virus. The prevailing theory among virologists, however, is that domestication of ducks in southern China about 2,000–3,000 years ago created the conditions needed for the virus to mutate and jump between species. Southern China still provides a suitable mixing vessel, with high

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human population densities in close proximity to large populations of ducks, chickens, and pigs. The flu was transferred from ducks to all other species in these high-density regions and, since establishing itself as a transmissible disease, it has jumped back and forth between its different hosts, mutating and recombining with destructive effects. The virus survives and thrives by constantly mutating by either drifts or shifts. High population densities of animals and people living closely together provide ideal conditions for the creation of entirely new strains with genetic fragments taken from viruses found from different species. Blood tests on birds, animals, and people in various areas including Hong Kong, Taiwan, and in Jiangsu province and the Pearl River Delta in China, have shown that farmers are positive for a variety of flu antibodies, suggesting exposure to most types of flu that exist in other species. Sensitive laboratory testing using reverse transcriptase-polymerase chain reaction (rt-pcr) or serology has shown that other animals including snakes, fruit bats, and wild pigs are also positive for sars-like coronaviruses. The virus-jumping between species increases the probability that one of these viral types may recombine, adapting to defenseless human populations with epidemic-like devastation (Davies, 2003). In Britain, scientists put forward their theory that sars originally came from outer space. The speculative paper was published in The Lancet, a prestigious medical journal. The idea isn’t that farfetched; it relies on the concept of panspermia, an idea that life on Earth originated from, and continues to be seeded by, bacteria and viruses brought into the Earth’s atmosphere by comets (Wickramasinghe et al., 2003). According to this theory, “a small amount of the culprit virus introduced into the stratosphere could make a first tentative fall out east of the great mountain range of the Himalayas, where the stratosphere is thinnest, followed by sporadic deposits in neighbouring areas.” Astronomical data is consistent with the widespread distribution of complex organic molecules and dust particles that may harbour freeze-dried bacteria and viruses. A minute (0.000000000000000000001 per cent) survival rate of freezedried bacteria in space is all that is needed to ensure the continual recycling of cosmic microbial life in the galaxy. The theory holds that comets would then have seeded Earth, Mars, and indeed all other habitable planetary bodies in the inner regions of the solar system (Wickramasinghe, 2004). Scientists have detected what they

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consider to be large quantities of viable micro-organisms in samples of stratospheric air, and estimated that a metric ton of bacterial material falls to Earth from space every day, which translates into about 1,019 bacteria, or 20,000 bacteria/m2 introduced to the Earth’s surface (Murray, 2003). Dr Donald Low, the head of microbiology at Mount Sinai Hospital in Toronto and the expert spokesperson on sars and infectious diseases during the outbreak in 2003, found the concept of panspermia entirely academic, with little relevance to solving the sars outbreak and issues of viral reservoirs, disease containment, disease treatment, and epidemiology. Given what was known about the coronavirus emergence from Guangzhou province in China, Dr Low stated, “You don’t have to go to Mars to get a coronavirus ... a viral particle – where it’s rna or dna – being able to survive entry into our atmosphere and then fall to Earth in an infectious form is just a little bit beyond me” (cbs News, 2003e). In addition to expert, science-based theories, there were some nonexpert opinions that appeared on Internet web pages speculating about the origins of sars. With little supporting evidence or validity, they will only be mentioned here in passing, to record their existence for historical posterity and to highlight the importance of improved risk communication and risk-issue management of contagious diseases within a global context. Due to a heightened awareness and fear of biological terrorism after anthrax-laden letters were distributed in the United States postal system in the fall of 2001, several American Internet Web sites posted conspiracy theories that sars was, in fact, a biological weapon that had accidentally escaped laboratory containment from a military research facility in China. At the same time, several Asian Web sites posted similar anti-US conspiracy theories suggesting that sars was an American-made, intentionally distributed biological weapon that targeted those of Asian descent as a way to weaken China’s rapidly growing economy and increasing dominance, and to maintain and further American hegemony. Americans and Asians blamed each other for the occurrence of sars, linking the incidence of a naturally occurring infectious disease to clandestine offensive bio-weapons programs and international political issues. The conspiracy theory of sars as a bioweapon, however, holds very little merit, given that the coronavirus was completely sequenced independently by two laboratories. The

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complete genetic sequence was carefully scrutinized but did not reveal any unusual remnants of human intervention by molecular tinkering (for example the occurrence of tell-tale plasmid vector sequences or new enzyme restriction enzyme sites from vector multiple cloning site regions, antibiotic selection genes, new promoter or enhancer elements from other species, new additional genes from other species, or other elements to indicate that the genome had been in any way engineered). There is no genetic evidence to support the idea of sars as an engineered bio-weapon; that fear can best be described as stemming from the uncertainty of the epidemic situation.

was anyone to blame for the inadequate sars response? News media reports laid blame for the poor handling of the sars outbreak in Canada on the provincial and federal governments. Those outside the Toronto region stigmatized the residents of the city and area hospitals, leading others to blame the poor management of sars on healthcare workers and nurses. Dr Michael Gardam, who usually sees tuberculosis patients, was outspoken in pointing out where fault lay, stating that guidelines have been in place for dealing with infectious diseases like pneumonia and tuberculosis all along. Guidelines from Health Canada clearly tell healthcare workers how they are supposed to protect themselves when seeing certain types of infectious patients. The outbreak of sars would not have occurred if hospitals had followed previously established guidelines for dealing with infectious patients. While Dr Gardam noted procedural failings at hospitals in the earliest stages of the outbreak, Dr Low,8 who acted as an unofficial expert spokesperson, also pointed a finger at a lack of funding for infection control that contributed to the difficulty of containment. Many have asked why sars was so difficult to contain in local Toronto hospitals. Several other countries and even another province in Canada (British Columbia) had their own index case like Toronto but these other jurisdictions were able to quickly contain sars, and did not see high numbers of infections or secondary transmissions to healthcare workers. There is a need to examine existing Canadian hospital practices and policies for infectious diseases to determine how containment can be improved.

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Several countries were able to contain sars, but its effect on the public in some of the hardest-hit countries was enormous, psychologically and financially.9 Economies in countries that had higher numbers of sars cases were greatly affected, with businesses losing millions of dollars in revenue (The Conference Board of Canada, 2003; cbc, 2003j). sars had effects on healthcare services as well, with nurses and doctors in several countries who refused to work due to fear of exposure, and with many quitting their jobs. Nurses brought legal suits against administrators, claiming they were not adequately protected during the outbreak, and healthcare workers have experienced a number of devastating long-term psychological problems from the emotional stress they experienced. All of these effects stemmed from the sars outbreak. Many in Canada felt it could have been handled better, from the coordination between the main players to capacity levels and risk communication. Was there blame to be laid for the handling of sars? If so, who was to blame – hospitals, hospital workers, the federal government, the provincial government, a combination of groups, or everyone involved? Nurses, doctors, and hospitals were stretched to the limit in their heroic efforts to contain sars, and during the outbreak Toronto hospitals were the main locus of the outbreak in Canada. A few of the commissioned reports (The Campbell Commission, The Walker Report, and The Naylor Report) concerning the handling of sars had great praise for the front line workers who had to deal with limited resources, placing the blame on a system close to the breaking point from years of underfunding, which led to systemic lack of capacity and resulted in hospital practices that left everyone vulnerable to infectious disease. When sars arrived the lack of planning for infectious disease only made the situation worse, with hospital managers and health officials scrambling to cobble together workable solutions in an under-resourced system.

was sars a pandemic? When sars first arrived in March 2003, it seemed unstoppable, with a lack of information confounding containment efforts. Experts from the World Health Organization warned that the mysterious disease had the potential to become a pandemic, then as quickly as it arrived in many countries it had been contained. So did sars potentially have the ability to become a pandemic? The

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answer is a qualified yes, as international travel was instrumental in distributing the contagion quickly and efficiently to many countries. In Canada the disease put 20 per cent of all its victims onto respiratory support; without such intervention the mortality rate would have been much higher. Only through a massive healthcare effort, use of precautionary intervention efforts, contact tracing, quarantine of suspected cases, wearing of protective equipment, and isolation of confirmed patients singly or on small wards, was the disease brought under control. The sars outbreak was an uncomfortable reminder that new contagions are continually evolving and emerging, with devastating social and economic effects. Multi-country infectious disease outbreaks can cripple economies through fear and stigma even if they do not kill large numbers of people (Enserink, 2003b).

ked perience

4

The SARS Experience WITH CATHY PATERSON

These people are like my angels. God bless them! The first words spoken by a Canadian sars patient after eighty days of mechanical ventilation, referring to her caregivers (Adamson, 2003).

Many of us have had very bad colds and flus that left us feeling miserable, but how do these experiences compare to sars, as an illness that many of us will never experience? Just what was it like to live through and recover from sars? Almost all sars patients had fever and many had associated symptoms like headaches, chills, muscle aches, and general malaise. Although sars was universally thought of as a respiratory condition this is not strictly true. In a study of over 1,600 cases of sars in Hong Kong it was found that only 61 per cent showed respiratory symptoms. Most of the others (32 per cent) had vomiting and diarrhea as primary symptoms of the illness. It is recognized that animal coronaviruses commonly affect either the gastrointestinal tract or the respiratory system. It is not exactly clear why the symptoms of sars varied in different people who were exposed to the same coronavirus, with some showing respiratory problems while others did not (McKeown, 2003a). Generally speaking, people who arrived at the hospital who were assessed with Probable sars described feeling unwell overall and were usually feverish. Even though some early clinical reports described the onset of sars symptoms similar to a cold, very few reported that their early symptoms were only like bad cold symptoms. Infected individuals often described feeling knocked out and simply had no energy. The lack of energy experienced by most

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patients became increasingly evident, to the point of being profound as symptoms progressed. Battling the disease seemed to sap the energy of those afflicted. Patients described that just getting up from the bed and walking to the door or walking across the room to use the bathroom became a monumental, effortful task. They would become very winded and short of breath from normal activity. It seemed it was hard to get their breath back after doing the simplest of tasks, like walking a short distance; there was a feeling of “air hunger” that most patients found highly distressing. Dyspnea is the clinical name for this shortness of breath, and it usually indicates a much more severe underlying problem with the respiratory tract. One of the common experiences shared by sars patients was that they just couldn’t catch their breath. Another frequent ailment was extreme muscle soreness, known as myalgia. The feeling of pain and discomfort from this soreness was unbelievable, to the point that many patients had difficulty finding a comfortable position on soft mattresses because their muscles hurt so much. The muscle pain wasn’t localized in specific parts of the body such as leg or arm muscles; pain radiated throughout the muscles of the body. Many patients described the muscle pain as a feeling of “all-over intense bruising and tenderness.” The list of various symptoms for Toronto patients with sars is categorized in table 4.1. Probable sars patients with more serious symptoms described a difficulty in catching their breath, a sign of deteriorating lung function. One research study looked at the post-mortem lung sections from eight patients who died from sars during the Singapore outbreak in spring 2003 to determine exactly what kind of damage was occurring to the lung tissue. The predominant pattern of lung injury in all cases was diffuse alveolar damage. Histology (examination of thin tissue sections under a microscope) of lung tissues showed damage to the lung’s alveoli or air sacs, a common biopsy finding most frequently associated with infection. Study of the lung tissue showed differences in damage that varied according to the duration of the illness. Cases of ten days’ duration or less showed acutephase diffuse alveolar damage, fluid in the lung air spaces and an elastic, white fibrous protein formed in the coagulation of blood (bronchiolar fibrin). Cases of longer than ten days’ duration exhibited more diffuse alveolar damage along with several other detectable abnormalities, including: type II pneumocyte hyperplasia, squamous metaplasia,

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Table 4.1 Clinical profile at admission to hospital for sars from 144 patients in Toronto. Average age of patients was forty-five years (range thirty-four to fifty-seven). Frequency of reported symptoms is shown (adapted from Christian et al., 2004). Reported symptoms Fever Non-productive cough Muscle soreness (Myalgia) Air hunger (Dyspnea) Headache Malaise (general weakness) Chills and rigors Diarrhea Nausea Vomiting Sore throat Joint Pain (Arthalgia) Chest pain Productive cough Dizziness Abdominal pain Runny nose (Rhinorrhea) Head cold (Coryza)

Frequency in Toronto (%) 99.3 69.4 49.3 41.7 35.4 31.2 27.8 23.6 19.4 19.4 12.5 10.4 10.4 4.9 4.2 3.5 2.1 2.1

multinucleated giant cells, and acute bronchopneumonia, all indicating major cellular problems and extensive damage to the lung tissue. sars-cov rna in the samples was identified by reverse transcriptase-polymerase chain reaction (rt-pcr), an extremely sensitive method that amplifies minute quantities of genetic material to confirm the presence of the virus. The virus was found in fresh autopsy tissue in seven of the eight cases and in all formalin-fixed, paraffin-embedded lung tissues sampled (Franks et al., 2004). Some research studies have shown that people who smoke cigarettes have an increase in influenza infections compared to nonsmokers and that there is a higher mortality rate for smokers than non-smokers from the common flu (Arcavi and Benowitz, 2004). In addition, nicotine has been shown to suppress leukocyte (white blood cell) migration during infection; this contributes to delayed wound healing and increased incidence of repeated respiratory infections among smokers. These factors tend to increase the severity of influenza for smokers (Razani-Boroujerdi et al., 2004). While it might seem that being a smoker would increase the severity of coronavirus infections similar to influenza, anecdotally, there appeared to be little difference in symptoms, time to onset, and severity of sars between smokers and non-smokers. This is sur-

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prising since it is a disease that affects the respiratory system. Most of the patients who contracted sars were non-smokers, so the sample size is too small to allow any strong conclusions to be drawn. Those who were smokers didn’t seem to have worse symptoms and didn’t seem to be more severely affected by the disease. Some people just fared better than others and there are likely a number of reasons for this. The main factors affecting the severity of sars infections and patient recovery included the general overall health of the person, their age, and the strength of their immune system. Most individuals with sars initially had a fever similar to that experienced with the flu, but these people also had respiratory symptoms that worsened over time. Medical doctor Ong Pei Yuin, twenty-six, was convinced she had been misdiagnosed with sars when she was put into quarantine. She was bored and frustrated by the isolation at the hospital but once her fever climbed dangerously high, very rapidly, she realized that she had no ordinary flu. “It was then I realized that something was not quite right,” she said. As a doctor she knew what the appearance of extensive cloudy infiltrate on her chest x-rays meant about the increasing severity of her clinical condition. “My eyes almost popped out when I saw my own chest x-ray.” There was no doubt she had contracted sars, and her condition rapidly deteriorated (cbs News, 2003a). Most patients said they felt little distress in the beginning, but with worsening symptoms there was a feeling that their lungs were becoming tight, as if they were constricted by a weight or rope around the chest. Anyone who has asthma will have a good sense of what it was like during this phase of sars. There is a feeling that the lungs have lost their elasticity, making normal breathing nearly impossible. This condition is known as dyspnea or “air hunger.” It is the feeling that you just can’t get enough air into your lungs no matter what you do or how hard you try. It is horrible, inducing a sense of extreme panic at being fully conscious and literally unable to breathe in air, analogous to suffocating alive. For sars patients experiencing air hunger it was a traumatic physical sign that indicated a severe downturn and an increased level of seriousness of the disease. The result of air hunger is hypoxia, or a reduced amount of oxygen in the blood and brain, which in turn has other effects. Most notably, hypoxic patients display a condition known as cyanosis, a bluish discoloration of the skin and mucous membranes due to lack

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of oxygen in the blood. The condition also results in patients having impaired levels of consciousness and reduced clarity of thought due to the lack of oxygen in the brain; they are usually unaware of just how irrational they have become. The ability to think rationally is greatly affected; patients would make irrational statements and appear confused. As the hypoxia worsens, the breathing rate skyrockets as the body tries to compensate physiologically for low oxygen levels in the brain. Patients experienced respiratory distress and described a feeling of being suffocated alive; the situation was confusing and it was difficult for them to think clearly. One sars patient described the frightening descent of symptoms before succumbing to hypoxia: “I became breathless. I saw my hands, my nail beds, and my toes turning blue. I was panting always and felt as though I was drowning in water. It was really frightening” (cbs News, 2003a). At the point when a sars patient had symptoms of air hunger, they were very sick, and they deteriorated quickly within a matter of hours. Many of these critical patients didn’t know that they had lost consciousness from hypoxia and worsening respiratory distress. A lot of people within this group of critical patients do not remember getting so sick so quickly and ending up in critical care after only a few hours of being hypoxic. The lack of oxygen to the brain left sars patients believing they were lucid and rational when in fact their judgments and thought processes were highly impaired. If patients remember being in the intensive care unit (icu) initially they do not remember that they had been there for several days or weeks battling sars. Patients in the icu were usually intubated (had a tube placed down their windpipe to assist breathing) and were placed on a ventilator machine (a machine that forces air into the lungs). Those who had recovered and were well enough to be removed from the ventilator after several days or weeks awoke and were confused by their surroundings, and usually had no idea of how long they had been unconscious. However, this phenomenon of disorientation is common for icu patients; it is not a condition specific to recovering sars patients. Most critically ill patients experience a lapse in time as most don’t have a sense of how long they were on ventilation. Critically ill sars patients were usually unconscious when they were intubated, placed on a ventilator, and sedated. (This is a standard practice with someone who is on a ventilator. The pressure of

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the air being forced unnaturally into the lungs, and the tubing from the ventilator, can cause panic in those not used to it.) Greg Bruce, a Toronto paramedic who spent three weeks in hospital being treated for complications from sars in early April 2003, recounted his experience. “I’m missing five or six days of my life when I was really sick. I remember only small things – a nurse telling me she was determined to make me better no matter what it took. Staff bringing me my favorite foods (Häagen-Dazs ice cream and pad thai noodles) to get me to eat. Kind voices that kept my spirits up when I was feeling frightened, isolated, and depressed” (Goel, 2004a). Patients who were ventilated for long periods of time and used to the experience did communicate by writing short messages. People with mild symptoms of sars and therefore not on ventilators could talk but were very weak, and tired easily; they could sit up and watch television for short periods of time. Some patients would read newspapers or books but the effort required was great and they could only concentrate for short periods of time. Patients with sars also tended to lose a lot of weight. There were a number of reasons for this. Many of the patients simply didn’t have the energy to eat; it became hard work to physically chew and swallow. Weight loss also occurred in some patients who had diarrhea. In people with sars who experienced myalgia, many lost their appetites from the extreme pain. Usually if anybody is that ill they have no appetite for food – it isn’t a sars-specific symptom. Dr Alan Tallmeister, an anaesthetist at Scarborough Grace Hospital, contracted sars in mid-March 2003 while treating one of Toronto’s first infected patients. Tallmeister lost over twenty pounds at the peak of his illness. sars made him so sick that he could not bring himself to eat. The effect of sars itself, the medical treatment of the disease with antiviral drugs, or a combination of both distorted his senses of taste and smell. Taste became limited, with food tasting extremely salty or extremely sweet. The flavour of coffee became intolerable and food aromas also “smelled funny.” Tallmeister described his meal experience during sars. “They’d bring us from the cafeteria these food plates. And you’d lift the steam hood and it smelled like you were opening up a hot, damp gym bag.” For many sars patients, eating became a very effortful, difficult, and unpleasant experience. The fatality outcomes from sars based on age mortality data studied from a total of 269 fatal cases in Hong Kong, including five

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Table 4.2 Age group breakdown of 269 sars fatalities in Hong Kong, percentages Pre-existing Illness? Age Group 0 – 14 years old 15 – 64 years old 65 years old or above Total

Yes

No

Total

0 15 55 70

0 22 8 30

0 37 63 100

Data from the Hong Kong Economic and Trade Office, sars update – New Cases in Decline. 28 May 2003, Washington DC, http://www.hongkong.org/miscellaneous/sarsreport052803.html.

healthcare workers, reveal that most of the patients who succumbed to sars had pre-existing medical illnesses (70 per cent), such as hypertension, heart diseases, diabetes mellitus, and stroke. The majority of sars victims (63 per cent) were aged sixty-five or older. All children under the age of fourteen who contracted sars recovered fully. A breakdown by age groups is shown in table 4.2.

the clinical description of sars and its treatment The majority of patients with sars presented with a fever greater than 38°c lasting longer than twenty-four hours, accompanied by chills. More than half of the patients complained of non-productive cough, difficulty breathing, malaise, and headache. Very few patients described upper respiratory tract symptoms such as rhinorrhea (runny nose), nasal obstruction, sneezing, sore throat, or hoarseness usually encountered with the common cold. There was usually a window of three to seven days from the onset of fever to the appearance of more severe symptoms like dyspnea (air hunger). When first presenting to hospitals in emergency rooms or sars Assessment Clinics, if the person answered “yes” to questions about the presence of initial sars symptoms (fever, malaise, dyspnea, or non-productive cough) they were considered Suspect and isolated for further testing. Everyday staff entering the hospital to work were asked to answer the same set of questions and required to record their temperatures as a method of screening for sars. The questions, provided by the Ontario Ministry of Health and Long-Term Care, were:

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1 Have you had unprotected contact with a person with sars in the last ten days? 2 In the last ten days, have you been in a hospital closed due to sars? 3 Have you been to China, Hong Kong, Vietnam, Singapore, or Taiwan in the last ten days? 4 Are you experiencing any of the following symptoms: myalgia (muscle aches) or malaise (severe fatigue or feeling unwell) or severe headache (worse than usual) or cough (onset within seven days) or shortness of breath (worse than is normal for you)? 5 Have you worked at another hospital, long-term care facility, home care agency, nursing agency, or for any other healthcare employer in the last ten days? 6 Have you been a patient or visitor in another healthcare facility in the last ten days? sars patients were divided into two groups when assessed: Suspect or Probable. Suspect cases presented with a fever (over 38°c), cough, or breathing difficulties and had one or more epidemiological link exposures ten days prior to the onset of symptoms. Exposure categories included close contact with a person who was a Suspect or Probable sars case (contact with infected individuals), recent travel to an area with recent local transmission of sars outside Canada (contact with sars-affected regions), recent visit to an identified setting in Canada where exposure to sars may have occurred (e.g. in a hospital, household, workplace, or school). Individuals were also considered Suspect if they had the above conditions and had an unexplained acute respiratory illness resulting in death after 1 November 2002, but no autopsy was performed on them. Probable sars cases were Suspect individuals who presented with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (rds) on chest x-ray, or a Suspect case with autopsy findings consistent with the pathology of respiratory distress syndrome (rds) without an identifiable cause. Both Suspect and Probable sars cases could be excluded if an alternate diagnosis was available that fully explained their illness (Ontario Ministry of Health and Long-Term Care Ontario, 2005a). Conditions for categorizing sars patients are shown in table 4.3.

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Table 4.3 Summary listing for diagnosis of Probable and Suspect sars Probable case of SARS G

G G

G

A suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (rds) on chest x-ray (cxr) A suspect case positive for sars coronavirus by one or more assays A suspect case with autopsy findings consistent with the pathology of rds without an identifiable cause A case should be excluded if an alternative diagnosis can fully explain the illness

Suspect case of SARS G

G

A person who had an unexplained acute respiratory illness resulting in death after 1 November 2002 (but on whom no autopsy has been performed) A person presenting after 1 November 2002 with history of high fever (>38°c) and cough or breathing difficulty and one or more of the following exposures during the ten days prior to onset of symptoms: i. close contact with a person who is a Suspect or Probable case of sars ii. history of travel to an area with recent local transmission of sars iii. residence in an area with recent local transmission of sars From: Skowronski et al., 2005.

Most patients identified with sars were healthy adults aged twenty-five to seventy years. A few cases of sars were reported among children (fourteen years or younger). Some cases had mild respiratory symptoms at the beginning of the illness. Usually rash and neurological or gastrointestinal symptoms were absent, although a few patients reported diarrhea during the fever stage of the illness. Three to seven days after symptom onset, a lower respiratory phase usually began, characterized by a dry, non-productive cough or dyspnea that for some patients was accompanied by or progressed to hypoxemia. In one or two cases out of every ten, sars symptoms were severe enough to require intubation and mechanical ventilation. Some patients’ chest radiographs appeared normal during the early fever stage and throughout the early course of illness. However, in many of the patients, the respiratory phase was characterized by early infiltrates progressing to more generalized, patchy, interstitial infiltrates on chest x-rays. Chest radiographs from patients in the late stages of sars usually showed areas of consolidation. This is a condition in which the lung tissue becomes firm and solid rather than elastic, and air-filled because it has accumulated fluids and tissue debris. The condition of consolidation was used in many cases to help confirm a sars diagnosis. Physical examination of the chests

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of infected individuals eventually revealed crackles and dullness on percussion, due to inflammation and protein and water buildup in the lungs. Overall white cell counts were generally normal or somewhat decreased. At the peak of the respiratory illness, up to half of patients had leukopenia (low white cell counts) and thrombocytopenia or low-normal platelet counts (50,000 – 150,000 /µl). Leukocytosis, a condition characterized by an elevated number of white cells in the blood due to infection, leukopenia, and thrombocytopenia were not observed at the beginning of a sars infection. However, low white cell counts (lymphopenia and leukopenia, with < 1,500 cells/mm3) were almost always seen at the time of disease onset (appearance of symptoms). Patients with severe infections displayed what is called a left shift of the cell counts. This is the normal reaction of bone marrow to infection or inflammation, an increase in the number of white blood cells, predominantly polymorphonuclear leukocytes and less mature cell forms. In the case of sars the left shift indicated that an extreme response to the infection had occurred – all of the white blood cells were used up fighting it. Some patients developed critical symptoms quickly over a number of hours as a result of their immune systems failing to overcome the viral infection. These patients were monitored very closely in the icu. (Abramson and Melton, 2000; Skowronski et al., 2005). Early in the respiratory phase, elevated creatinine phosphokinase levels (up to 3000 iu/l) had been noted, but this enzyme remained normal in the majority of patients. The serum creatinine phosphokinase enzyme (cpk) enters the blood rapidly following damage to muscle cells and has been used as a marker for acute myocardial infarction (heart damage) or skeletal muscle damage. Unfortunately, cpk levels rise and fall rapidly and coincide with a variety of other circumstances including surgical procedures, vigorous exercise, or a deep intramuscular injection. Nevertheless, the measurement of cpk levels provides valuable, differentiating, diagnostic information, and in the case of sars it was used to indicate the presence of damage to lung tissue. Other enzymes such as transaminases1 (including aspartate aminotransferase-ast or alanine aminotransferase-alt) were slightly elevated in 40–60 per cent of patients. Transaminases are used as a benchmark to determine normal liver functioning in a patient.

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People who are sick with viral infections or other diseases will show disturbed enzyme levels. Elevated liver transaminase enzymes indicated that a lot of tissue damage was occurring in sars patients. The transaminases have different forms and doctors can tell from the pattern of liver enzymes which tissue is being affected. Hepatic transaminases were elevated two to six times higher than the upper limits of normal, but these values tended to normalize with both clinical recovery, or reduction of symptoms, and radiologic recovery, or the return to a normal appearance of lung tissue (both methods were used to monitor recovering sars patients). Treatment regimens included a variety of antibiotics to treat known bacterial agents of atypical pneumonia. In several locations, therapy also included antiviral agents such as oseltamivir2 or ribavirin.3 Steroids were given orally or intravenously to patients in combination with ribavirin and other antimicrobials (World Health Organization 2003e; Tsang et al., 2003; Poutanen et al., 2003; Lee et al., 2003). Daily radiographic assessments were essential to monitor rapidly progressive pneumonic illness. The primary radiographic appearance of sars is air-space shadowing, and this is readily demonstrated using high-resolution computed tomography (ct) scans. The consolidation appears to be subpleural (between the lining and the wall of the lung) with “ground glass opacities.” Ground-glass opacity refers to the hazy appearance on ct scans that suggests alveolar wall inflammation or thickening, with partial air-space filling, or some combination of the two. These changes predominantly affect the lower lobes of the lungs indicating increasing fluid and protein accumulation. Initial radiographs might be normal, but progression of ground glass opacity can occur rapidly even over the span of a few hours, despite potent antibiotic therapy. The appearance of ground glass opacities is probably the most helpful diagnostic clue. Air-space opacification often progresses within a few days in size and severity. Radiographically, sars closely mimics other infections like bacterial bronchopneumonia and other viral pneumonias. The appearance of the high-resolution ct scan of sars could imitate that of other interstitial lung diseases that result in subpleural air-space shadowing, such as bronchiolitis organizing pneumonia and acute interstitial pneumonia (Tsang et al., 2003; Lee et al., 2003). However, contrary to bronchiolitis organizing pneumonia, there is no abnormal enlargement of the lymph nodes, usually associated with disease or infection, or pleural effusion4 (fluid in the

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lungs) in sars (Tsang et al., 2003; Wong et al., 2003). In the later stages, particularly with diffuse involvement of the lungs, the radiographic appearance of sars is similar to that of acute respiratory distress syndrome (ards) (Tsang and Lam, 2003). Early in the onset of sars, patients would show only a few symptoms, the most prominent being fever, cough, muscle soreness, and fatigue, all of which are generalized symptoms. It was difficult to tell what disease patients had contracted, as the symptoms were indicative of several different diseases. If someone had a fever or a cough we categorized them as sars Suspect. If their symptoms progressed to having infiltrate on a chest x-ray or if their cpk levels became elevated along with their other transaminase levels, we knew there was a progression of symptoms, and these individuals were reclassified as “sars Probable.” For treatment, patients were usually given antiviral agents, often in combination with corticosteroids. Antiviral agents (ribavirin) and protease inhibitors (lopinavir/ritonavir) are known to show activity against a number of rna and dna viruses, including some animal coronaviruses (Koren et al., 2003). Doses of ribavirin varied between 1.5 and 4 grams daily. A typical course was a 2 gram intravenous loading dose, followed by 1 gram intravenously every six hours for three days, followed by a lower dose (e.g. 500 milligrams every eight hours) for four more days. Ribavirin often caused uncomfortable side effects in already-sick sars patients, most frequently nausea. Insomnia was a common result of treatment with corticosteroids, usually in combination with anxiety, physical discomfort, and hospital routines (Maunder et al., 2003; Skowronski et al., 2005). With little information to go on prior to its identification, and even after the agent had been identified as a new coronavirus, doctors prescribed antiviral drugs to treat sars. Initial reports noted improvement in patients for symptoms such as fever and blood oxygenation and the appearance of lung tissue on x-rays (Poutanen et al., 2003). Other reports that followed, however, did not show very much improvement of sars patients’ symptoms when treated with antiviral drugs (Booth et al., 2003; Hsu et al., 2003). Antiviral drugs appeared to have a number of adverse effects in patients treated with high doses, including the severe breakdown of red blood cells (hemolysis) (Booth et al., 2003; Knowles et al., 2003) hemolytic anemia (61 per cent), hypocalcemia (58 per cent) (low

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calcium levels) and hypomagnesemia (46 per cent) (low magnesium levels). Finally, laboratory in vitro tests of sars-cov indicated that ribavirin is not active against this virus at clinically achievable concentrations (Skowronski et al., 2005). Postmortem findings confirmed this suspicion, as high viral loads persisted in most patients despite treatment with antiviral drugs. This made their use to treat sars questionable (Mazzulli et al., 2004). Interferons also inhibited sars-cov in experimental tissue culture studies (Ng et al., 2003). One clinical study compared patients who received interferon to another group that received a lower dose of corticosteroid. Faster improvement in radiographic appearance and oxygenation to lung tissue occurred in the group receiving interferon (Loufty et al., 2003). A second clinical study looked at treatments with combinations of ribavirin, interferon, and differing doses of corticosteroids. Lung infections improved (as judged by radiographic appearance on chest x-rays) only in the patients that received interferon in combination with a high dose of corticosteroids (Skowronski et al., 2005). Interferon was already known to be useful in treating hepatitis B, hepatitis C, and other respiratory coronavirus infections (Addleman, 2004). Research also focused on developing vaccines to combat sars, but a vaccine may provide little benefit to someone already infected. Passive immune therapy is a new approach being developed that offers a fast method to fight emerging diseases in the early stages of infection, and this type of treatment can be adapted for use against any new infection. In this therapy, B cells that make antibodies are taken from a recovered sars patient and a short stretch of synthetic dna is attached that mimics a unique segment of the dna found in the invading virus. The reactivated memory b cells recognize the short synthetic dna as foreign, and generate a mixture of specific antibodies against them. The researchers examined these new antibodies and determined which ones worked best against the sars coronavirus; when tested in mice the new antibodies prevented the coronavirus from multiplying in the respiratory system. Such a treatment may hold much promise as an eventual treatment therapy (Traggiai et al., 2004; Reuters, 2004).

the problems of diagnosing sars Individuals who arrived at the hospital and were believed to be infected needed to be placed in isolation. This can present a chal-

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lenge for a healthcare system designed to handle isolation of only a limited number of people. If there are many cases it becomes a problem of what to do with them and how to keep track of them all. During the Toronto outbreak, public health officials investigated 2,132 potential cases of sars. They identified 23,103 people who came in contact with sars patients who required quarantine. The officials also received more than 300,000 calls on a local sars telephone hotline from individuals seeking credible information and reassurance. Of all of these potential infectious disease contacts, 225 people were diagnosed with true sars. All but 3 travelrelated cases were linked to the original infected patient in Hong Kong. To prevent the outbreak from spreading, public health officials conducted follow-ups with people who had contact with sars patients, and imposed a ten-day quarantine in many cases. Patients hospitalized with respiratory symptoms but with no other epidemiological links were also watched closely to determine if they had contracted sars. At North York General Hospital, by the time sars2 arrived, everyone who was Suspect including all patients that had a fever, were admitted. Initially we started tracking people because we didn’t know if it was a virus; when people started coming in with fever during sars1, the early chest x-rays showed most individuals had very little infiltrate, one of the diagnostic features of lung tissue inflammation. People who were suspect for sars due to fever didn’t have infiltrate on the chest x-rays initially. Only about 20 per cent of sars patients (one in five) went on to develop infiltrate, so doctors were having trouble distinguishing sars Suspect from sars Probable individuals. Infiltrate indicates infection of the lungs; on a chest x-ray the lung tissue looks as if it is milky-white and cloudy instead of being clear. The x-ray presents like an atypical pneumonia, appearing patchy and full of large grey and white areas indicative of consolidation, which means there is a pneumonia-like infection. Another method we used for determining sars was ct scanning, a computerized x-ray procedure that produces cross-sectional images of the body. The images are far more detailed than x-ray films, and can reveal disease or abnormalities in soft tissues (like the lung) and bone. The procedure is usually noninvasive and relatively quick to perform; the person lies on a bed in a large tube and we scan around their entire chest. Rarely would we find a lot of infiltrate in patients early in the sars infection; we figured out through experience that by day five, people with true sars

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infection would typically begin to show infiltrate with consolidation. People showed up initially with fever, we sent them home on self-quarantine, and then they showed up again at the hospital five days or a week later with more serious symptoms. We assumed from the beginning that the virus was transmitted by air, body fluids, and in diarrhea. Sometimes these infected people had no respiratory symptoms, but we had a 100 per cent capture rate of sars patients at triage – we didn’t mistakenly place infected patients somewhere where they shouldn’t have been; they were isolated quickly. The emergency nurses did an amazing job. In that five-day window between fever and infiltrate appearing on x-rays, the people who were infectious were shedding coronavirus but still very mobile, able to walk around freely, infecting others. The ability to quarantine and have Suspect sars individuals adhere strictly to self-imposed quarantine (avoiding other people, maintaining a safe distance) was important for containing this outbreak. As symptoms of sars progressed, Suspect patients who had been in quarantine at home would usually return to our Emergency Department and have a fever and symptoms that were worsening; they easily became short of breath, and physically looked terrible, and after x-ray or ct scan confirmation they would be categorized as sars Probable.

diagnostic tests for sars There were various tests used to detect the presence of the sars virus in individuals. Two very different types of screening tests were used with different purposes. The first type was mass screening with thermal scanners. This was a method of screening for the presence of sars in the general population, used in communal areas. The use of mass screening was a way to detect sars-infected individuals who were travelling in and out of the country. The second type of diagnostic test was laboratory-based and used samples from individuals. The laboratory techniques helped doctors to confirm the presence of the disease. Mass Population Screening Infrared thermal scanning cameras that were in use to detect sars and sars-like viruses in incoming and outgoing international pas-

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sengers were removed at two of Canada’s busiest airports just prior to the first post-sars flu season in December 2004. The infrared cameras were used for an eighteen-month period at Pearson International Airport in Toronto and in Vancouver airport in Vancouver, British Columbia. The scanners were part of a pilot project launched during the height of the sars crisis in May 2003 as a method to test how well the machines could detect sars-infected travellers. Health Canada selected thermal imaging scanners from four different suppliers, for a total of twelve machines (flir Thermacam® e2 Infrared Cameras; cti Thermo Image Processor System; MiKronScan 7302 Thermo Imaging System, and Cantronic FeverScan m3000). As a pilot project, all suppliers who met the technical specifications were selected to participate in the project, in order to enable Health Canada to assess a broad range of machines. The focus of the pilot study was to determine whether the machines provided a reliable means of measuring temperature (the ability to detect active sars in individuals), and to see which thermal scanning machines were best, should Health Canada decide to use thermal imaging scanners on a long-term basis. Data collected during the pilot study included: the number of persons screened; numbers of individuals detected with elevated temperature (fever); numbers referred for further medical assessment to a quarantine officer as a suspected sars case; and the number of persons hospitalized. The different machines screened different numbers of people depending on their location (either in Toronto or Vancouver). The flir machines screened the most passengers (275,047), the cti screened 224,988 passengers, the MiKron screened 56,509 passengers, and the single Cantronic FeverScan M3000 unit experienced a technical malfunction early in the project and was not replaced. Of the passengers screened using the flir machines, 171 were sent for medical assessment as a result of elevated temperature detection. The cti machines flagged 47 passengers, and 2 passengers were singled out by the MiKron machines. All suspect passengers were sent for medical assessment as a result of their elevated temperatures. There were no passengers referred by a quarantine officer as suspected sars cases, and there were no passengers hospitalized. An assessment of the technical specifications of the three machines yielded no conclusive data with respect to differences among them. From a sars-prevention point of view, assessment of the thermal scanner study is difficult as no sars cases were detected among

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screened passengers. For the pilot study the machines performed as expected but all produced a number of false positives (phac, 2003d). Canada did export a small number of sars cases to other countries, and imported a small number of cases (five individuals) (World Health Organization, 2003f). The Standards, Productivity and Innovation Board of Singapore (spring) had previously convened a national conference on thermal imagers for fever screening at airports. Singapore was the first country to use and test thermal scanners for health screening, and is at the forefront of assessing the effectiveness of such thermal imaging scanners. The spring results show industrial infrared thermometers for body temperature measurements did not work well in airport settings, and machines with a higher degree of sensitivity should be tested to see if screening can be improved upon (phac, 2003c). In hindsight, Health Canada, which studied the efficacy of the thermal scanners, found that as a predictive detection device they were a useful but a crude screening method during the sars crisis. The thermal scanners are in permanent use at airports in other countries including Singapore, Hong Kong, China, and Malaysia (Godfrey, 2004). Clinical Screening and Detection of SARS Coronavirus Genetic Material Several laboratory tests can be used to detect the sars-associated coronavirus (sars-cov). A reverse transcriptase-polymerase chain reaction (rt-pcr) test can detect sars-cov in clinical specimens, including blood, stool, and nasal secretions. Polymerase chain reaction (pcr) is a laboratory method for detecting the genetic material (dna or rna) of an infectious disease agent in specimens from patients. It works by amplifying selected sections of the genetic material. pcr uses the same molecules that nature uses for copying our own genetic material when our cells divide. The amplification of otherwise undetectable genetic material occurs by using two “primers” that flag the beginning and end of the dna stretch to be copied; an enzyme called polymerase is added that walks along the segment of viral dna, reading and copying it as it moves along. By repeating the cycle that replicates the genetic material, the newly made segments amplify geometrically, making literally millions of copies after relatively few cycles (usually twenty-five to thirty-five cycles). The technique, done in test tubes, is very efficient so that

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millions of copies can be made in a few hours and easily detected. The technique has become an essential tool in biotechnology, forensics, medicine, and genetic research. Serologic testing also can be performed to detect sars-cov antibodies produced after infection. A serologic test is a laboratory method for detecting the presence and level of antibodies to an infectious agent in a person’s serum. Finally, viral culture has been used to detect sars-cov. For a viral culture, a small sample of tissue or fluid that may be infected is placed in a container along with cells that favour the growth of the virus. If the virus grows in the culture, it will cause changes in the cells that can be seen under a microscope. During sars, the available diagnostic tests (pcr, serological, and viral culture) were neither accurate enough nor timely enough to reliably detect the sars coronavirus in the first few days of illness, a limitation that made the disease harder to control, as infected individuals may be very mobile and shedding the disease through aerosolized droplets. It takes twenty days of infection for the Enzyme Linked ImmunoSorbent Assay (elisa) test to detect antibodies accurately. The immunofluorescence assay (ifa), detects antibodies reliably as of day ten of infection, but is a comparatively slow test that requires the growth of virus in cell culture. The pcr test for virus genetic material could detect infection very early, in theory, but is highly inaccurate for sars. Even though shedding of the virus is relatively low in the first few days and doesn’t peak until about ten days after the onset of illness, patients are capable of infecting others during the initial phase and therefore need to be reliably detected and quickly isolated. Serologic testing on the detection of specific igg5 antibodies against sars-cov in patients is very specific, but it takes thirty days before just over 90 per cent of infected patients will show a significant rise in antibody titres (the concentration level indicating a significant presence of antibodies to a particular disease). The who also reported that tests to detect sars antibodies do not work reliably until about the tenth day of illness. The pathologic findings of sars, readily recognizable on autopsy and open-lung biopsies as diffuse alveolar damage, are still regarded as nonspecific, easily confused with pneumonia or other lung infections, and, more importantly, do not provide any early diagnostic value. In lieu of accurate laboratory diagnostic tests, the who continued to recommend use of its case definitions, based on clinical presentation, distinct chest x-rays, and a history of possible contact

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with sars patients as the best way to detect Suspect and Probable cases. The early diagnosis of sars therefore remains a clinical decision that can be made only by an experienced physician on the basis of the clinical features, radiologic findings, and hematologic and biochemical profiles of a patient. More importantly, the diagnosis should be made only after considerable efforts are made to exclude background pneumonia, especially that caused by atypical organisms (e.g., Mycoplasma pneumoniae, Chylamdia pneumoniae, and Legionella pneumophilia) and other mimicking diseases (especially bronchiolitis organizing pneumonia). Diagnosis of sars depends on key evidence including the presence of radiologic evidence of consolidation on x-rays, failure to demonstrate a clinical or radiologic response to potent antibiotic therapy (this excludes bacterial infections), history of contact with suspected or confirmed patients with sars, recent travel to risk areas (establishing an epidemiological exposure link), and otherwise unexplained and persistently abnormal lymphopenia (low levels of lymphocytes, a kind of white blood cell) and raised ast and alt (elevated levels of liver enzymes). There are several reverse transcriptase polymerase chain reaction (rt-pcr) techniques, but these remain to be validated. They have the disadvantages of relatively low sensitivity and specificity, but the advantage of high volume for diagnostic testing. The United States Centers for Disease Control and Prevention (cdc) made the test it developed for the sars virus, which uses polymerase chain reaction (pcr), available to about 100 specialized testing laboratories around the country in early June 2003. The experimental test can detect the coronavirus in a couple of hours, versus the alternate method that requires several days to grow the virus in tissue cell culture (cidrap News, 2003). In an attempt to better use chest x-rays as a diagnostic, researchers in one study analyzed 4,369 chest radiographs from 313 sars patients from the time of their admission to hospital until death or discharge. Chest radiographs from the 313 patients with sars (48 of whom died) were scored on the basis of the percentage area and location of lung opacification. Lung opacification is the appearance of white shadows in the lungs on the radiographs where black areas denoting air should be. The appearance of opacification indicates severe damage to the lung tissue and the presence of fluid in the airspaces.

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Statistics were used to determine if the amount, type, and rate of lung opacification was correlated to age, sex, or eventual mortality. The results showed that older men had an increased risk of mortality, but no significant difference was seen in the percentage area of opacification in the lung between men and women with fatal outcomes or the group of patients who were discharged. Also, no differences existed between age groups (those under sixty-five years old compared to those older than sixty-five), except for the data that showed that of those who died, older patients had less opacification than younger patients. More than half of the patients who died from the disease had greater than 20 per cent lung opacification on the seventh day, while 86 per cent of those who survived had less than 10 per cent lung opacification on the seventh day. Thus, the analysis could predict with a reasonable degree of accuracy whether the case of sars in the patient was a potentially fatal or not by analysis of chest x-rays by day seven. The x-rays were predictive of the proportion of patients with fatal outcomes and showed high agreement with the actual percentage of patients who died. The analysis of chest radiographs, by scoring the amount of opacification (by the percentage of lung or by the number of zones opacified) by day seven, could be used as a fatal prognostic indicator. This early determination could allow a physician to better tailor treatment. These findings could help in determining when more aggressive or different treatment, such as introducing new drugs or transferring the patient to a specialized intensive care unit, might be required. The predictive ability of the x-rays may also help as a way to measure new evidence-based treatments that could reduce the mortality rate of the disease (Antonio et al., 2005; Xinhuanet, 2005). The analysis of chest radiographs can help to establish a positive diagnosis for sars and be predictive of mortality, but there are still some caveats when using radiographs for diagnosis. Although the clinical features of sars symptoms such as fever, difficulty breathing, and rapid progression to pneumonia have been well described, this disease, like other viral illnesses, can present with only mild symptoms in some individuals. One study looked at 372 healthcare workers at a large teaching hospital where twenty-one patients with sars were treated. A questionnaire was used to determine which

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workers had direct contact with sars patients, who had no direct contact but were exposed, and who were not exposed. Subjects provided blood serum samples at the time of possible sars exposure and again thirty-one days later. The samples were then screened for sars antibodies using two sensitive antibody tests (either elisa or a dot-blot immunoassay). The investigators reported that of the 260 hospital workers classified as not exposed all were seronegative for the virus (uninfected). Of 112 who classified as exposed, 8 were seropositive using two different standard antibody tests. Half of the seropositive (4 of 8) had direct contact with sars-infected patients; the other half had been in wards where sars patients had been accommodated before being transferred to a different facility. The tests were very sensitive. All 8 had had fever, but only 6 had radiographic evidence of pneumonia and met clinical criteria for sars. Symptoms in the 2 mildly infected subjects included chills, myalgia, and cough, all of which resolved within three days of symptomatic therapy. The study from Singapore demonstrated that the infection in a small number of healthcare workers showed normal chest x-rays. No secondary transmission involving the two subjects with mild disease was observed, and this may reflect lowered transmission of sars between individuals due to low viral loads. The implication of the study is that early detection of sars-associated coronavirus outbreaks will require closer attention to all Probable sars cases. Those with mild symptoms that resolve quickly could be misdiagnosed as being sars free, and even though they recover quickly they still present a small window in time when they could act as unknowing carriers spreading sars to others in crowded urban areas. Some mildly symptomatic sars cases could remain undetected if diagnosed by symptoms and chest x-ray alone. All probable sars patients should be actively tested with more sensitive antibody assays during diagnosis (Ho et al., 2004).

recovering from sars A common complaint expressed by sars patients was that it took a long time to fully recover from their ordeals. A lot of people recovering from sars found that for many weeks and months afterwards they still easily became short of breath doing routine tasks, and were rapidly winded by exertion, although much less than what

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they experienced during the infection. Recovered sars patients remained very tired physically afterwards and tended to sleep more than usual. Simple physical movements that we all take for granted (getting out of bed, sitting down, walking up stairs, carrying objects) remained effortful for some recovered sars patients, even many months later. People reported a huge range of post-sars symptoms, but commonly they involved problems with physical mobility, limitations of mobility, reduced lung capacity, and overall reduced energy levels. Patients who had recovered from sars also continued to show physical deterioration for many months afterwards. While most people recovered and regained body weight, a few people still appeared wasted, remaining thin and gaunt. Individuals who had poor recovery also displayed comorbid effects (coexisting problems) – they had trouble concentrating for any length of time, they were easily confused and had trouble performing simple tasks. The loss of mental acuity may be a long-term effect of experiencing long-term hypoxia. It is very difficult to know for sure, as there is limited literature of the long-term effects of sars. Anybody who had been intubated was at increased risk of scar tissue in their lungs due to the severity of infection, and especially if they had been intubated for long periods of time. Also, having the pressure of the ventilator forcing air into lungs that were literally seized and less elastic for extended periods of time resulted in scar tissue. Having any foreign object in the body like that can increase the risk of tissue scarring, causing problems afterwards. The increased lung tissue damage tended to reduce the overall oxygen and carbon dioxide transfer in the patient afterwards. The scarred lung tissue may have affected brain function and slowed recovery time indirectly through subclinical hypercapnia (asymptomatic excess of carbon dioxide in the blood) and hypoxia. sars often does extensive lung damage: it’s comparable to asthma, causing a decrease in the elasticity of the lungs. Hoewever, even afterwards the scarring of the lung tissue results in reduced flexibility. The lungs are not able to bend and contract. This is measurable in sars patients by observing the decreased volume of oxygen that they can have their lungs at one time. In females, the overall capacity for air volume might be 500–600 milliliters (mLs) and for a fit male 800 mLs, but after sars these values are noticeably reduced. After having this kind of respiratory illness for a length of time it is unknown

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just how extensive the damage can be. The scar tissue also decreases the surface area of the lungs where diffusion takes place, and complications like alveolar collapse can occur. Another problem was fluid in the alveoli or the small air sacs of the lung. Most people who had worsening symptoms of sars said that they reached a point where they were just not able to cough to clear their lungs. Usually if someone has a mild cold or flu and they wake up after lying horizontally for a long period of time with a crackling or watery chest, they cough to remove that little bit of accumulated fluid. sars patients physically could not cough with enough force to remove this extra fluid; it would then accumulate, further complicating their symptoms and causing alveolar collapse. As a result there were fewer alveoli that were available for oxygen uptake and transport into the bloodstream. In sars patients the fluid just sits there and continues to pool in the lungs and the end results are pneumonia and other related respiratory illnesses. Although everyone thinks of sars as a new disease, it develops clinical symptoms consistent with pneumonia, and patients literally drown in excess fluid. When you look at the extra infiltrate or white areas on the ct scans, sars is identical to what pneumonia would look like. The lung fluid is part of the body’s inflammation response to the replication of the virus. There were some complications with recovery from sars that have been recorded in medical literature. Patients recovering from sars show an increased incidence of thrombotic complications (blood clots). Research from Singapore following 206 patients who contracted sars found five developed large artery cerebral infarctions, a type of stroke caused by brain hemorrhage. Four were critically ill and three died. An increased incidence of deep venous thrombosis and pulmonary embolism (blood clot blocking the artery of the lungs) was also observed among critically ill sars patients (Umapathi et al., 2004). A follow up study of fourteen healthcare workers who were treated and discharged from the sars unit at the West Park Healthcare Centre revealed that by the second month after discharge, the results of chest radiography were normal for all patients. However, ct scans of the chest showed abnormalities in some patients for up to six months after discharge. Most of the recovered patients returned to work, the average time before

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returning being two months after the onset of acute illness. The most common persisting symptoms were fatigue, dyspnea on exertion, and insomnia. Complications in recovery have also been observed, not from the virus itself but likely from the drugs used during treatment to combat inflammation of lung tissue. After the sars outbreak ended, a young, previously healthy female healthcare worker who had recovered from sars presented with severe hip and knee joint pain that had developed during her hospital stay, and persisted since hospital discharge. Magnetic resonance imaging (mri) of the hips and knees revealed avascular necrosis of the leg bones (femoral heads, femoral condyles, and tibial condyles). Avascular necrosis is a disease resulting from the temporary or permanent loss of the blood supply to the bones. Without blood, the bone tissue dies and causes the bone to collapse. If the process involves the bones near a joint, it often leads to collapse of the joint surface. This disease also is known as osteonecrosis or bone degeneration (Griffith et al., 2005). Empirically, more than 50 per cent of patients experienced large joint pain following recovery from sars. The vast majority of these joints show no abnormality on mri examination. However, joint pain following viral infections is not uncommon and there are arthritogenic viruses (that cause inflammation of joints), including hepatitis c, rubella, and human t-cell lymphotrophic virus type 1 (htlv i) (Masuko-Hongo et al., 2003). When the issue was studied, researchers found that avascular necrosis was present in approximately 5 per cent of patients with sars who underwent treatment. At first it was unknown whether this bone necrosis was a complication of the infection itself or a result of the treatment (particularly corticosteroids) or both (Griffith et al., 2005). Research indicates that corticosteroids were likely a factor, since corticosteroids were almost uniformly used to treat sars patients. It is known that corticosteroids can induce osteonecrosis by decreasing regional blood flow (Beltran et al., 1990). High-dose steroids administered over a short period to patients who were not predisposed to the condition did not seem to increase the risk of osteonecrosis. High-dose steroids, administered over a longer period to predisposed patients (patients with systemic lupus erythematosus, rheumatoid arthritis, malignancy, or after organ transplantation), has shown a dose-related risk of bone degenera-

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tion between 4 and 52 per cent. Statistical analysis determined that the cumulative dose of corticosteroid used for treating sars was the most important risk factor in predicting degeneration. Empirical evidence suggests that osteonecrosis was not observed in patients who received less than 3 grams of corticosteroid (prednisolone) but if patients received more than 3 grams of corticosteroid, about 12.5 per cent went on to develop osteonecrosis (Cook et al., 2001; Zizic et al., 1985). Unlike many of the other side effects of long-term corticosteroid therapy, such as immunosuppression, weakening or wasting of muscles (myopathy), and reduced bone density, once osteonecrosis has occurred, affected bone tissue will not recover on discontinuation of steroid therapy. It is important that joint pain following sars should not be dismissed as unrelated, and similarly, it cannot be used as a reliable clinical indicator to determine osteonecrosis following steroid treatment for sars. Due to extended steroid therapy, suppression of normal adrenal steroid production has occurred in sars patients, an expected outcome. Many recovered sars patients were still on steroid replacement therapy months after hospital discharge. Patients continued to fail steroid challenge tests and were thus not weaned off exogeneous corticosteroids (Ahuja and Ooi, 2004). Another disturbing finding, although it was not recorded in any Canadian sars cases, were news reports from Hong Kong where doctors reported that, for reasons that were not entirely understood, twelve patients who had recovered from sars had relapsed weeks after they had been discharged. The ramifications of such information suggests that people may be infectious long after they’ve left isolation, which could re-ignite new outbreaks in areas where sars has been brought under control. While it is increasingly being recognized that the mode of transmission of sars is predominantly aerosolized viral droplets, it is now suspected that it can also be transmitted by fomites contaminating sewage systems (substance in sewage is capable of absorbing, retaining, and transporting contagious or infectious germs and viruses); it is believed that the sars virus can survive in fecal matter for up to two days (Seto et al., 2003). The possibility of patient relapse becomes more ominous if those who have diarrhea but are relatively asymptomatic for severe respiratory complications are released; they could spread the disease again (Walsh, 2003).

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psychological effects of sars on patients In addition to the physical effects of sars, most patients experienced a number of psychological effects (Avendano et al., 2003). Individuals on quarantine, family members of sars victims, and healthcare workers suffered different kinds of problems from the stress and uncertainty of the sars outbreak. Generally, patients with mild-to-moderate symptoms required some psychosocial support; these patients were in the majority. Shortly after admission, healthcare workers identified patients’ recent contacts with people who would then be required to quarantine themselves; this resulted in patients suffering feelings of guilt, anger, and fear for the welfare of friends and family. Patients worried that they would be resented, that their contacts would be stigmatized, and would lose income due to quarantine. Patients also often had to spend several hours alone between brief visits from hospital staff. Outside communication was only available by telephone and, in some cases, by email. As a result, patients with mild symptoms complained of boredom and loneliness. In the absence of specific laboratory tests, the most prominent symptom to indicate disease progression was body temperature. This was monitored carefully by staff and patients who, if well enough, self-monitored. Several patients who experienced anxiety throughout their stay in hospital reported that peaks of anxiety coincided with feeling feverish or learning of an elevated temperature. One patient with a pre-existing panic disorder experienced episodes of panic during spikes of fever. Other patients reported feeling discouraged and frightened by the return of fever after an afebrile period. Most expressed sadness about missing their loved ones. Patients who were healthcare workers expressed concern about risk of infection to staff caring for them. Fear of the potential lethality of the illness, and anger because their risk of exposure had not been recognized earlier, were voiced less often than other concerns. Hospital inpatients without sars were concerned about becoming infected. Restrictions on transfer to other institutions, cancelled procedures, the need for quarantine upon discharge, or delayed discharge were common frustrations. Patients deprived of family visits experienced insomnia, anxiety, and interpersonal friction with staff. Limited access to external resources resulted in difficulty obtaining items

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that would usually provide comfort, such as books, music, and toiletries. Asian patients reported stigmatization and racist reactions in the community, because the outbreak was known to have originated in China. Patients with sars received an initial visit from the psychiatric clinician nurse specialist, the consultation–liaison psychiatrist and/ or a social worker familiar with the intensive care setting. In these screening assessment interviews, it was emphasized that a wide range of emotional responses was expected in the face of such an extraordinary situation. Patients were assured that the concerns and feelings they expressed were predicted, normal responses. Immediate concerns were reviewed, especially patients’ family situations, relationships with people on their “contact lists,” expectations and fears about their own medical conditions, and current symptoms. When indicated and desired, subsequent supportive psychotherapy aimed to balance a permissive approach to expression of feelings with pragmatic attention to the particulars of the patients’ external reality. For the patients who were both parents and healthcare providers, particular attention was given to issues of powerlessness and the conflicting responsibilities of these two roles. In some cases, the simple presence of a person with the time and willingness to visit was identified as most valuable, especially for patients with sars who were doing well and thus receiving relatively less nursing contact. Some useful interventions were straightforwardly pragmatic, such as arranging for pizza to be delivered to a patient’s family at home. Individuals recovering from sars endured a long and slow process. They didn’t just “bounce back,” said Dr Andrew Simor, an infectious disease expert at Sunnybrook Hospital in Toronto. In this way sars differs greatly from other viruses; unlike the influenza or Norwalk viruses that develop quickly and resolve symptoms almost as fast, sars takes up to a week to develop into a full-blown illness and healing is slow. Patients recovering from sars were left with overall body weakness, fatigue, shortness of breath, and persistent cough. Depending on age and other underlying medical issues, such as heart problems or diabetes, recovery time can be even slower. Most of the damage caused by sars was from lung tissue inflammation, and once it resolves it leaves people with almost normal (pre-sars) lung function. sars patients who have recovered and do not have irreversible damage to their lungs do not subsequently

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appear to have increased susceptibility to viral infections. A more difficult impact to measure is the mental condition of sars survivors after the very stressful experience of illness. For some people it was extremely difficult to return to the place that made them so sick in the first place. Not only did healthcare workers see colleagues getting sick, but they then became ill and became patients in the hospital themselves (Medical News Today, 2003a). Many patients were still recovering from the trauma of the infection and, for some, their near-death experiences, six months after the event. Patients who developed psychiatric symptoms after their sars infection underwent mri of the brain after their hospital discharge. None of the mris demonstrated any physical abnormalities. While there appears to be no physical damage, patients who have recovered from sars do show symptoms of psychological trauma. When surveyed during the early weeks of sars recovery, 26 per cent of patients showed moderate to severe degrees of anxiety, and 16 per cent showed moderate to severe depression. The same study reported data from another group of patients who were evaluated one to two months after hospital discharge. Only 5 per cent of these patients were reported to have moderate to severe anxiety and depressive symptoms in this later stage. The incidence of anxiety and depression decreased as patients continued to recover over time (Chan et al., 2003).

psychological effects of sars on healthcare workers Healthcare workers, particularly nurses, were greatly affected by the sars outbreak. Public health guidelines indicated that staff did not need to take special precautions such as using masks while on quarantine at home, although many did self-quarantine while at home. Many healthcare workers worried about transmitting the illness to loved ones or friends. Instructions to minimize contact with other hospital staff, reducing the numbers of individuals at meetings, and preventing movement of hospital workers between institutions left healthcare workers uncertain as to just how contained sars was, as they were considered the biggest potential vectors of disease while on work quarantine. At North York General Hospital, where 3,000 staff and 850 doctors were quarantined, 70 staff fell ill. Several months after

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sars ended, about 40 individuals were still suffering effects of their sars battles. At the time, hospital ceo Bonnie Adamson described the situation, saying, “I’m not sure they’ll ever return. They’re certainly in no position to care for anyone else.” The situation hadn’t improved much a year after the end of sars, with the Ontario Nurses’ Association estimating that at least two dozen nurses across the city of Toronto were still on sick leave. The long-term psychological effects have been devastating for some. “About three dozen nurses were sick with sars, and most of them are not back to their former state of health,” said association president Barb Wahl. Nurses comprise the single largest occupational group in most hospitals and are directly involved in patient care. Understanding the psychological impact of an infectious outbreak on nurses is extremely important, especially in planning for future outbreaks of emerging infectious diseases, so healthcare workers do not become psychological victims. At the time of the sars outbreak, there were only a few published, peer-reviewed studies of the psychological impacts to nurses from a disease outbreak situation comparable to sars. One study dealt with the psychological effect on nurses of the emergence and spread of an outbreak of Vancomycin-resistant enterococci (vre). As the front-line caregivers, the nurses were responsible for vre patient care and halting the further spread of this antibiotic-resistant pathogen. The majority of nurses found dealing with the outbreak situation extremely stressful because of the need to act as gatekeepers, monitoring visitors and staff practices. Nurses felt higher levels of stress as a result of those responsibilities, and felt they were inadequately supported. Some nurses felt they were being blamed for the outbreak, and that their workloads increased as they took on duties of other staff (Mitchell et al., 2002). Reports of the acute psychological impact of the sars outbreak on hospital workers indicate similar but greater levels of stress. Nurses working on sars wards commonly experienced high levels of distress. In a survey of one Toronto hospital during the outbreak, 29 per cent of healthcare workers scored above the threshold for emotional distress on a General Health Questionnaire (Nickell et al., 2004). A survey that was completed by 1,557 healthcare workers just after the sars outbreak had ended, in June 2003, asked healthcare workers at three Toronto hospitals to answer questions designed to

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test their psychological stress levels. Seventy-six different items probed their attitudes to sars and its effects. The study revealed that nurses and healthcare workers having contact with sars patients scored much higher on tests for emotional distress. The main drivers for the higher scores were health fears, social isolation due to extended work quarantine and reduced contact with colleagues, and increased job stress (Maunder et al., 2004). This result for emotional distress found in Canadian nurses was similar to levels found in other countries when tested. In Singapore, 27 per cent of healthcare respondents at a general hospital affected by sars scored above the threshold on a similar version of the General Health Questionnaire. The psychological outcomes from prolonged acute stress encountered during patient care, reflected by the high emotional stress scores from sars, are unknown. Some may question whether these results are artifacts of nursing as a stressful profession. However, another study established that nurses in sarsaffected hospitals experienced more distress than other hospital workers and nurses on other wards (Chan and Huak, 2004). A second eighteen-question survey given to Hong Kong nurses asked them to rank their overall degrees of mental distress on a ten-point scale. The mean overall distress levels for doctors, nurses, and healthcare assistants were 5.91, 6.52, and 5.44 respectively. The overall distress level for nurses was significantly higher than that of doctors, and correlated with six sources of distress: vulnerability/ loss of control; health of self; uncertainty with the spread of virus; health of family and others; changes in work; and isolation. When dealing with sars, doctors were significantly more likely to use planning as a coping strategy, while nurses were significantly more likely to use behavioural disengagement and self-distractions. Nurses who felt they coped well adopted strategies of acceptance, active coping, and positive framing. The three most important variables that accounted for the distress level were loss of control/vulnerability, fear for self-health and spread of the virus (Wong et al., 2005). The duration and uncertainty of sars caused a set of shared psychological outcomes among all hospital staff members, regardless of country, including: fear, anxiety, anger, and frustration. Supervisors and those at the forefront of the outbreak found it difficult to remain at home or leave the hospital where they worked, because they felt a responsibility to be present with their staff to manage the crisis. Hospital staff felt an extreme contrast between the seemingly

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normal external environment and a highly stressful work environment. Those working at the hospitals with sars found there was a wide discrepancy in the workload between those working on sars wards and those who weren’t (entire ward closures accentuated this separation). On medical wards that treated patients with sars, some nurses reported anxiety and resentment about being chosen for the task (Maunder et al., 2003). On the sars isolation units, anxiety occurred in association with several events: when isolation precaution procedures changed, when infectious disease staff entered quarantine or treatment, when healthcare workers were admitted with an unclear source of infection, when one of the sars-unit nurses developed a fever (not due to sars), and when a previously discharged sars patient was readmitted with fever. Physically, nurses reported fatigue, insomnia, irritability, and decreased appetites that impacted their mental capacity to cope with sars. Nurses had the extremely difficult and emotional task of caring for patients who were themselves healthcare workers who had contracted sars. The line between patients and staff became blurred as nurses experienced strong emotional identification with their healthcare worker patients. This resulted in increased anxiety. Nurses made efforts to deal with the uncertainty and fear of sars by disseminating clear information, repeating succinct messages, team-building at staff meetings, and the use of protective equipment and supplies. Psychiatric staff was available on all sars units to support healthcare workers. Advising nurses, for example, to get enough rejuvenating sleep was one of the simple and effective ways to improve their ability to cope. Nurses who were reluctant to talk about personal concerns with psychiatrists with whom they had working relationships could consult another psychiatrist. A confidential telephone support line staffed by inpatient psychiatric nurses was also set up for all hospital staff; this was used by those in quarantine. Staff members on home isolation who had email access were able to receive all communications from the hospital (Maunder et al., 2003). There were also differences between those who worked in hospitals versus those who didn’t, in both physical and psychological experiences. Nurses who did not work in sars units were also affected by the outbreak experience, but to a much lesser extent. Nurses working at the entrance doors of the Mount Sinai Hospital

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had only a moment to rapidly assess the condition of each person that came through the doors, explain the current restrictions (which changed routinely during the outbreak), and deal with the consequences. It was not uncommon to have to turn away entire families hoping to visit a newborn baby, bearing flowers and well wishes, or explain the “one visitor” policy to family members who arrived to visit their seriously ill or dying loved ones. These situations were emotionally difficult for the nurses who had never had to act as police and turn away visitors. The nurses empathized greatly with the families. In Toronto during the outbreak, the loved ones of sars patients would deliver small packages of food, music, books, cards, and flowers in the evening, and plead with hospital door staff to ensure that the cards and letters, their only connection, were successfully delivered (Goel, 2004a). Near the end of the Toronto sars outbreak (2 June 2003), healthcare workers (nurses, x-ray technicians, custodial staff, and maintenance workers) marched outside in the rain to protest Ontario’s lifting of strict sars infection-protection procedures, and to push for a public inquiry probing the province’s response to the deadly respiratory illness. Workers at Scarborough General, North York General, St. Michael’s, and the Etobicoke site of the William Osler Health Centre were upset at the formation of the four-hospital partnership created to handle the bulk of sars cases. They worried that sars patients would be transferred between these hospitals and increased the risk of spreading sars amongst healthcare workers (Habib, 2003a). The death of a Toronto nurse from sars had a profound psychological effect on many front line nurses. Nelia Laroza, a nurse at North York General Hospital, became the first Canadian healthcare worker to die of sars, raising the Canadian death toll from the flu-like illness in Toronto to thirty-nine at that point in time. Several other healthcare workers were in critical condition on ventilators, some with poor prognosis for recovery. Even before sars was declared contained, experts were predicting that the battle against the disease, already waged for months, would likely result in many professionals leaving the healthcare field, and deter others from entering or returning. The impacts of sars and watching colleagues get sick and die were, according to Allison McGeer, the head of infection control at Mount Sinai Hospital in Toronto, “just too much” for many nurses to endure (National Union, 2003).

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Some post-sars-infected healthcare workers have found it difficult to return to the hospital workplace they associate with the source of their infection. This is one of the indicators for post-traumatic stress disorder, and recovery may require long-term rehabilitation (Ahuja and Ooi, 2004). Hospitals across Toronto began offering counseling to staff members in early July 2003 to help treat those suffering from such symptoms6 (National Union, 2003).

conclusions Toronto experienced a large number of nosocomial (contained in the hospital) transmissions of sars during the outbreak, with a total of 128 sars cases (72 Probable, 56 Suspect) identified, including those who became infected in the hospital as well as the next generation of illness arising among the people they contacted. At the end of the sars outbreak (10 July 2003), 17 of the 128 people who contracted sars had died, for an overall case-fatality rate of 13.3 per cent. Most of the people who died were older, aged sixty years or more, or had other complicating medical conditions. The case fatality rates among sars patients under sixty years of age was 2.9 per cent, while among those sixty years or older it was much higher, at 53.8 per cent. The age-related disparity in mortality for sars in Toronto was comparable to that reported in Hong Kong at 6.8 per cent and 55 per cent respectively (Donnelly et al., 2003). In spite of the higher case fatality rate among the older cohorts it was found that the rate was much higher among cases that were already hospital inpatients before their sars exposure than among staff, visitors, and close contacts. The overall case fatality rate was higher in Toronto at 13.3 per cent (Booth et al., 2003) than reported by other countries (2 per cent – 6.5 per cent) (Lee et al., 2003; Peiris et al., 2003). The highest rate among the nursing staff for contracting sars occurred in the Critical Care Unit (ccu) (60 per cent). This is likely due to the close and extended contact with patients and exposure to high- risk procedures by nurses in the ccu, compared with shorter contact with patients in the emergency department (Varia et al., 2003). Hospital staff effectively communicated directives even when they were changing over time. Distribution of sars treatment information at informal work meetings and a high degree of collaboration between disciplines within each hospital allowed for the

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exchange of information during a rapidly evolving situation. Leadership both internally and from the provincial Ministry of Health and Long-Term Care (through the sars Advisory Committee) was very important in maintaining a sense of team cohesion during the sars outbreak. Maunder and his co-authors suggest that sarsunit nurses may have experienced less distress than other nurses on other medical wards caring for patients with sars due to a greater sense of mastery and less uncertainty as multiple support measures were quickly put into place for sars unit workers. Caring for healthcare workers as patients was emotionally difficult for many nurses during sars. The uncertainty of the situation, isolation, and stigma impacted both staff and patients. The most prominent emotional effects upon patients with sars were feelings of fear, loneliness, boredom, and anger. Patients with sars were worried about the effects of quarantine and passing sars to their loved ones. They also experienced the psychological effects of physical symptoms, especially anxiety about fever, dysphoria (mental unease) due to nausea, and the effects of insomnia on mood and ability to cope. The presence of psychiatrists and counselors for hospital staff helped to foster communication. Maunder et al. suggest that simply knowing that psychosocial support was available at any time may have been enough for many resilient staff members. During sars, the lack of sleep or loss of restful sleep was one of the earliest symptoms of stress experienced by staff, due to ongoing anxiety. Education of staff and patients about the impairment that results from sleep deprivation and ways to treat insomnia should be one of the interventions during infectious disease outbreaks. Tired people make more mistakes and are less resilient. Most people, including healthcare workers, can cope well and benefit from relatively small amounts of shared concern, good information, and availability of support. It was important and telling that individuals made efforts to overcome the isolating effects of work quarantine and the wearing of protective equipment by making jokes, sharing experiences on the nursing station, increased use of emails and conference calls. Finally, near the end of the outbreak, a poll commissioned by the Canadian Federation of Nurses asked 1,001 Canadians their views about the role of nurses in the healthcare system. Of those surveyed by Ipsos-Reid, 62 per cent said they think the healthcare system is

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unprepared to deal with future threats to human health based on recent handling of sars, West Nile virus and Mad Cow Disease outbreaks. The majority of those polled (83 per cent) said a shortage of nurses makes the healthcare system more vulnerable to future threats to human health, while 64 per cent stated that they are more aware of the importance of nurses now than before the outbreaks (Habib, 2003a). The public clearly understood the importance of nurses to public safety, ranking them highly, but have less confidence in the capacity of the healthcare system itself to deal with another sars or sars-like pandemic outbreak. The level of psychosocial impact on healthcare workers remains poorly quantified, but it is clear that many observable negative outcomes, comorbid outcomes, and varying degrees of post-traumatic stress disorder and associated indicators were experienced by nurses as a result of sars.

ked amplification of risk

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The Social Amplification of Risk and SARS as a Risk Issue Providing the public with the necessary information to defend itself from a disease is an essential public service that the media provides. There is little doubt that a public health emergency needs to be reported by the media. But what purpose did it serve to interview people from their balcony apartments or on the phone while they were in quarantine? It could be argued that images such as those served to show the human side of the disease. But I would argue that it was unnecessary and sensationalism at work. When news is made, it should be reported. But when there is no news, it should not be created. John Kung, Ottawa (Robertson, 2003)

Numerous studies have shown that most adults in North America get their news about science, health, medicine, and the environment from the mass media. Daily newspapers are one of the biggest influences on public perceptions of risk. Mass media play an important role by alerting people about environmental health risks but can also distort perceptions through a mechanism that has been called the social amplification of risk. The Social Amplification of Risk Framework (sarf) was developed in the late 1980s as a way to describe the various processes by which some hazards and events become the focus of intense social and political concern and activity (amplification). This occurs even though experts and risk assessment can establish that the risk under scrutiny is a relatively low statistical probability, while other potentially more serious events receive comparatively little public attention (attenuation). The theory of social amplification of risk also describes how social and individual factors act to magnify, diminish, or alter our perceptions of risk. The alteration of risk by social

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amplification creates secondary effects such as stigmatization of people, places, objects, technologies, and ideas. Economic losses and regulatory impacts can also occur due to mass distortion of public risk perception (Kasperson et al., 1988). Several variables were identified that affect the social risk amplification process, including physical consequences, the amount of news media coverage, pre-existing individual perceptions, public responses to the risk issue, activities of different stakeholders, socioeconomic impacts, and political context. The social amplification of risk has occurred in several recent risk issues, including food safety (genetically modified foods and Mad Cow Disease), chemical accidents, nuclear power (waste and accidents), and contaminated water (Frewer et al., 2002; Setbon et al., 2005; de Souza Porto and de Freitas, 1995; Slovic et al., 1991). The amplification of risk begins with a signal event, either a physical event such as an accident or natural disaster or the recognition of an adverse effect such as global warming trends. Regardless of the risk issue involved, individuals will select specific characteristics of the signal event and interpret them according to their own perceptions and pre-existing ideas of the risk. Interpretations of expert scientific data or other information are then communicated to others as new messages. Those who receive the messages (other individuals or social groups) also process the information and may respond in a number of ways. Some individuals or groups may change their previously held beliefs about the communicated risk, some may gain additional knowledge, some may be motivated to alter behaviour (take action in response), and other individuals may continue the amplification process by relaying or composing a new message that they will send to other interested parties or back to the original source (Renn, 1991). Individuals, groups, or institutions that collect and respond to information about risks act as amplification stations through their communication and behavioral responses (Lee, 1986). It is in this way that we can explain why some events with relatively minor physical consequences can result in strong public concern and extraordinarily severe social impacts (Frewer et al., 2002). The social amplification of risk framework is useful to describe the perceptions associated with a risk issue, and can help to integrate risk communication strategies that will mitigate distortions of perceptions of risk.

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Socially amplified risks have the potential to generate stigma or transmit values that affect places, consumer products, technologies, people, groups, or objects. Stigma then creates an adverse effect and magnifies the initial consequences. For stigma to be assigned to an individual, place, or object, certain criteria need to be met: an attribute is selected as negative, it is perceived as negative by others, and there is a widespread devaluation of the one who is stigmatized, frequently including labeling and communication of the labels to others. The process of stigma stemming from socially amplified risk issues involves three stages. First, the social amplification of a risk issue receives high visibility through communication processes and leads to establishing a perception of high risk, usually through imagery. Second, marks are placed upon the thing that is stigmatized to identify it as an undesirable risk. Third, the social amplification of risk and stigmata marking change the identity of the person, object, place, technology, or idea, which subsequently results in behavioural changes by those who later contact them. Stigma as a process is usually grounded in a narrative that can have secondary or ripple effects beyond those linked to the underlying risk. Added impacts can arise from social responses such as product boycotts, economic losses, regulation, loss of trust, and reduced public confidence (Kasperson et al., 2001).

the sars outbreak and social amplification of risk Kasperson et al. (2001) proposed that risk amplification occurs with the release of information (reports from government, non-governmental groups, news media, or others) that provides new information about a risk. The presentation of the information to the general public, rather than personal experience, creates awareness of the risk. For sars the signal event occurred with early newspaper reports of a mystery illness, and the signal was validated by the who report of a new infectious disease from southern China. The signal was further reinforced by who travel alerts and subsequent news conferences that provided little useful information for mitigation or to dispel uncertainty of the situation, but substantially raised awareness of the issue. The news media had a unique role in the dissemination of the new knowledge by framing and forming

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the risk through the use of language, including metaphors, symbols, and comparisons. References characterized the new risk of sars as highly uncertain, and little linkage was made to other known experiences and events. sars as a risk issue was greatly affected by the social amplification of risk due to the initial uncertainty surrounding the disease, the unknown nature of the infectious agent, news coverage, and the potential socioeconomic and political results of a failure to contain the contagion. Perception of a new risk issue like sars is shaped by contextual factors that influence individual risk estimations and evaluations (Slovic, 1987; Renn, 1990). Factors such as the choice to assume a risk, personal ability to influence risks, familiarity with the hazard, and the catastrophic potential of the risk all provide information that individuals use when constructing their interpretation of risk. Psychological studies into risk perception fail to explain why individuals select certain characteristics and ignore others, sometimes focusing only on some pieces of information while excluding others. Among the perceived risky attributes of sars were the possibility of becoming ill or being identified as a part of a high risk group that had been exposed to sars (for example those on quarantine or nurses who worked on sars wards), with death and long-term debilitating recovery as outcomes. Thus, public attitudes around sars were predominately negative. These stigma-generating criteria were communicated widely through the popular press and in television reports that singled out nurses, an easily identified group due to their uniforms and n95 masks. The social science aspect of risk management is often neglected by the technical community (research scientists and risk assessors) and by risk managers who rely only on the scientific aspect of risk assessments when making policy decisions (Murdock et al., 2003). In many instances, the social amplification of risk leads to exaggerated secondary social and economic responses that lead to far more serious impacts than the initial threat (Murdock et al., 2003). Other deleterious outcomes are regulatory constraints, litigation, community conflicts, and investor flight (Kasperson et al., 1988). Frewer et al. (2002), looking at the perception of genetically modified food as a risk to human health, found evidence that sudden changes in the volume and content of risk reporting by news sources about a particular hazard potentially produce changes in

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attitudes and perception of risk consistent with that predicted by the social amplification of risk framework. The analysis showed that perceptions of risk and other negative potential consequences associated with a risk issue (in this case genetically modified food) increased during the highest levels of reporting but were subsequently reduced as reporting levels diminished. This was initially accompanied by decreased perceptions of benefit associated with genetically modified food. Unlike perceptions of risk, perceptions of benefit remained depressed a year after the volume of reporting had declined. For sars as a contagion, there appear to be no benefits. It is assumed that people’s reactions to a risk hazard will depend on their level of trust in the institution or bodies that regulate and manage the risks in order to protect the public. The sars example demonstrates how some mechanisms associated with managing the hazard led to deeply rooted responses of concern that resulted in social and economic impacts far greater than would have been predicted on the basis of estimated physical harm. Workers were stigmatized, travellers avoided certain areas, and those areas therefore suffered economic losses (Gregory et al., 2002). In national surveys of health risk perception in Canada, which addressed a wide spectrum of topics, respondents cited the news media as their most common source of information on health risks, and expressed most trust and confidence in risk information provided by the medical profession (Krewski et al., 1995). It is already well-known through research that people tend to overestimate the risks of dramatic or sensational causes of death such as nuclear power plant accidents, and underestimate the risks of unremarkable, familiar causes such as asthma or diabetes, which only take one life at a time and are commonly thought of in non-fatal forms. This disparity in risk judgment stems from the experience of past events. Any factor that makes a hazard unusually memorable, like a recent catastrophic disaster, intense media coverage, or vivid imagery, can seriously distorts receptions of risk. sars was covered in the media as a disaster. There was intense media coverage and pictures of nurses and people wearing masks provided vivid imagery, fulfilling the criteria for distorted risk judgment. Risks that are not memorable, obvious, or tangible tend to be underestimated. People often respond emotionally to information about threats to their health, safety, or the environment. Strong feelings of fear, hostility, outrage, panic, and helplessness are often triggered by

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dreaded or newly discovered risks; these feelings tend to be most intense when people perceive the risk as being imposed on them without their consent, and usually with little benefit. The most extreme emotional reactions are generated when the risk is particularly dreaded, and when worst-case scenarios are presented (Fischhoff, 1985; Covello, 1992). The news articles provide a natural window into this social amplification of risk. Content analysis can help us better understand the perception and the conceptualization of risk surrounding sars. Risk communication analysis has previously demonstrated dysfunctions in risk-issue management, risk models, and a gap between ideas of acceptable risk held by the public and those held by regulatory bodies or industry (Leiss, 2001). From the beginning of the news coverage the words used to describe sars and its symptoms were pejorative and created negative individual perceptions. There were updated reports on a daily basis. The ever-increasing numbers of cases were presented as cumulative values, amplifying this negative interpretation. Due to the language used and the way in which the data was presented to the reader, it seemed as if the numbers of infected, dead, and quarantined people were increasing at an alarming rate – much more rapidly than would be expected for a risk of minimal concern, or a risk that was under control. As a news story, sars set off a number of media triggers, receiving coverage due to its high potential for catastrophe. The human health effects portended further future ills, with the contagion’s ability to escape and infect others again highlighting the uncertainty of the risk issue. Other media triggers include the portrayal of the public as potential victims and the involuntary nature of the risk in the many people who could be exposed to the risk without knowing. Newsrooms, editors, and reporters were acutely aware of the explosive nature of the story and state that they tried to be diligent about striking a balance between presenting the public with the information it had to have about the disease, yet not stepping over the line into what would be considered alarmist hype. In the early stages of reporting, the news media had to deal with the unfolding reality that the medical community itself was under great pressure from an unknown, new contagious disease. When one of the country’s top microbiologists (Donald Low), who was acting as unofficial spokesperson about the infectious disease situation in Canada, was quarantined for ten days because he was suspected of having

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acquired sars through patient contact, the news media intensified its focused on sars, knowing the disease had enormous potential to cause great damage. News reporters justified their volume of reporting by stating that the public had to know all the details and be made aware of the serious consequences of not taking precautions when visiting hospitals and paying attention to rudimentary aspects of cleanliness. The travel warning from the who about sars reframed the story as an international risk. The reasons for the travel advisory and the controversy surrounding the travel ban became fodder for the news media, intensifying coverage of other political and economic aspects of the story (Robertson, 2003). Still other events, such as people breaking quarantine, the activity and comments of politicians, the loss of tourism, stigmatization of Asian businesses and of nurses, and local economic losses, were all tangents to the sars outbreak that provided story lines considered newsworthy. Newsmakers themselves have suggested that they fulfilled an educational need, informing citizens of the risks of the contagious disease. However, was the purpose of the intense and voluminous news media coverage truly to educate the public? First, individuals’ mental models are highly resistant to change. Once an initial impression (either good or bad) has been formed, it influences and distorts the interpretation and integration of subsequent new evidence. Second, individuals use broad categories when making decisions about risk, and ultimately use a binary decision-making process to accept or reject risks. Individuals tend to oversimplify risk estimates as a way to find easy solutions to complex problems; the simplification reduces confusion due to cognitive strain and emotional anxiety. Third, rational individuals may have inaccurate perceptions of the risks to which they are exposed and are influenced by emotions. Hazards that are associated with vivid imagery or produce severe outcomes (multiple deaths, disease, suffering) tend to evoke high levels of dread. Risks from dreaded consequences are overestimated while common, less dramatic, and less vivid events that involve single individuals are underestimated. Research shows that, on its own, increasing the amount of information given to the public does not produce changes in the way people perceive or accept risks (Slovic et al., 1977). Little is known about the processes involved in changing established mental models and perceptions, but it is known that broad-

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based, non-focused appeals for behavioural change are the least effective approach. The massive amount of news coverage about multiple aspects of sars falls into this category of broad-based and non-focused information. Green and Brown (1980) found that where reliable and precise objective estimates are available, an individual’s beliefs are very accurate. This lends support to the idea that public understanding of risks is greatly influenced by the information they receive, and that it can be improved by specific, targeted educational campaigns. The over-reporting of sars that occurred during the outbreak was neither specific nor targeted educational material, and did not improve individual risk choices. Extra, inconsequential news articles only served to confuse the public and distorted their perception of the true risks of sars. The social amplification of risk for sars is clearly demonstrated by comparing it to another hospital outbreak that was occurring at almost the same time in Canada, and that exhibited social attenuation of risk. The Clostridium difficile bacterial outbreak in Montreal, Quebec resulted in more than twice the number of deaths as sars, and yet this risk issue was not amplified by excessive news coverage and went largely unnoticed in Canada outside the outbreak area.

local messages about sars and risk amplification The media play an important role in conveying information about the risks of various hazards to the public, and the news treatment of sars was no exception. The media have been criticized for a number of limitations and deficiencies concerning the way in which the sars outbreak was handled. In the past they have been disparaged for biased reporting that has a tendency to highlight drama, conflict, disagreements between experts, and uncertainties. They are especially selective toward stories that contain vivid or sensationalistic material, while paying much less attention to mundane daily occurrences that kill or injure many more people each year but take only one life at a time. For example, car accidents kill 40,000 people in Canada per year, but little news media coverage reports the ongoing, increasing, cumulative number on a daily basis. There is no stigmatization of people in regions with higher fatalities or economic losses from a steady stream of deaths from car accidents. During sars, however, the media kept a running tally of deaths

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throughout the outbreak. When reporting about new health risks like sars, journalists focused on the concerns of the public and elements of the story that would catch their attention. Potentially catastrophic health effects, a lack of full scientific assessment, a poor understanding of the nature of the risk, a lack of personal choice in risk exposure, risks to individuals, their families, and future generations, unclear benefits, and an unequal distribution of risks, all highlighted the uncertainty of the sars outbreak situation. The media have been belittled for oversimplifications, distortions, and inaccuracies in reporting information about health and environmental risks (Zuckerman, 2003; Motl et al., 2005). This is nothing new. Studies of the reporting of health and environmental risks have documented a great deal of misinformation (Pribble et al., 2006). Media coverage is deficient not only in what is contained in the story but also in what is left out; many of these problems in news reporting stem from the characteristics and constraints under which reporters work. With few exceptions, reporters do not have enough time or space to deal adequately with complexities and uncertainties surrounding most multifaceted health and technical scientific issues. Journalists do attempt to achieve objectivity in a story by balancing opposing views, but are source-dependent; with tight deadlines, they tend to rely heavily on sources that are easily accessible and willing to speak out, which may cause a skewing of reported ideas. New sources that are difficult to contact, hard to draw out, or who elect to provide uninteresting and nonqualified statements, are often left out. Finally, there are very few science reporters who have the appropriate level of scientific background and expertise needed to understand and write about complex scientific data, or to appropriately present data, scientific risk assessment, disagreements about health, and the environmental risks that surround them. The sa rs situation was full of uncertainties and unknowns, but just what messages were Toronto-area residents and other Canadians receiving from news articles that appeared during the outbreak of 2003? The Canadian Newsstand Major Dailies database contains all news articles from national and leading regional papers such as the National Post, Calgary Herald, Edmonton Journal, Montreal Gazette, Ottawa Citizen, Regina Leader Post, Vancouver Sun, and the Victoria Times-Colonist, from 1985 until the present.

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This database was searched for the keywords “sars,” “Canada,” and “Toronto Star” and returned 354 newsprint articles published between 1 January 2003 and 1 December 2004. (The Toronto Star is a local newspaper serving the Greater Toronto Area.) Of the 354 documents, 6 were articles from other newspapers that mentioned the Toronto newspaper by name; these were not included in the analysis. In the Toronto Star in 2003, there were 302 news articles about sars. There were only 46 articles that appeared in 2004 (figure 5.1). The majority of articles appearing in 2004 focused on the economic impact of sars on the local Toronto economy and the ongoing effects to specific business sectors like tourism and air travel. The very first local news article that appeared in the Toronto Star that contained information about sars appeared on 16 March 2003; it ran with the headline “Global Alarm at Mystery Illness; U.N. Warns of Worldwide Threat from Killer Ailment, Seventh Torontonian Falls Sick from Contagious Disease.” At this time, sars was still a nameless mystery illness. The news article title alone communicated the idea that the risk was uncharacterized, uncontained, of global concern, highly transmissible, and deadly. For newsmakers, sars bore all the hallmarks of an emerging, virulent, global pandemic. The first two sentences of the first sars news article juxtaposed two very different risk communication messages: “Officials stress no risk to general public. A Toronto woman has become the city’s seventh person to fall sick with symptoms of a deadly illness that has already killed two members of a Scarborough family, and put four other members of the same family into hospital quarantine.” In the first sentence it was reported that officials claimed there is no risk to the general public (a zero risk message) while the second sentence detailed mortality and physical relocation of local community members into institutionalized quarantine. The fact that people had already died, were sick, and actively being quarantined in the community invalidated the “zero risk” statements uttered by officials in attempts to dispel fear. The uncertainty and uncharacterized state of the disease, coupled with its unknown but assumed high virulence, quickly induced a sense of dread. The story of the mystery disease was quickly picked up by several other regional newspapers and appeared the next day in several other provincial-regional newspapers in Nova Scotia, Newfoundland, Saskatchewan, and Alberta: “Mystery Outbreak

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Figure 5.1 The total number of sars news articles appearing within the Greater Toronto Area each month in the Toronto Star from 1 January 2003 to December 2004. Monthly values shown for sars news articles are not cumulative. (Tyshenko, 2007)

Spreads as Experts Scramble for Cause;” “Heavy Drug Doses Beat Mystery Pneumonia: 10 Canadians Now With Deadly Disease;” “Mystery Illness Prompts Global Scramble: ‘Atypical Pneumonia’ Strikes 10 in Canada;” and “Mystery Illness Cases Increase.” The number of local news articles pertaining to sars quickly outpaced the mortality numbers of the contained outbreak (figure 5.2).

national risk communication messages about sars A larger, published study of news media content examined 1,600 articles found in a number of newspapers including the Toronto Star, the Globe and Mail, the National Post, the New York Times, and USA Today. The coverage in Canadian newspapers (Globe and Mail, Toronto Star, and National Post) was similar in subject matter, content, and analysis. The Star was far more critical of the Ontario government’s management of and lack of preparedness for an emerging epidemic in local Toronto hospitals; the Post and the

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Time Figure 5.2 Cumulative numbers of sars deaths (L) and cumulative numbers of local news articles (I) appearing within the Greater Toronto Area each month in the Toronto Star between 17 March 2003 and 28 July 2003 (Tyshenko, 2007)

Globe focused on the system’s inadequacies in dealing with sars, placing the emphasis on the role of the federal government for its handling of infectious disease control. Even though healthcare is predominantly a provincial matter, the Post tended to criticize the federal government for mishandling the outbreak, while the Star focused on the provincial government’s responsibility. The Globe blamed mismanagement of the crisis equally on both levels of government. Seth Feldman, director of the Robarts Centre for Canadian Studies at York University, said confusing, constantly changing, and conflicting messages from politicians were one of the reasons the sars story remained entrenched in the daily headlines (Palmer, 2003). Upon analysis of the content of 1,600 articles out of a total of 2,600 articles sampled, researchers found that overall, coverage was fair and balanced, but the large number of articles gave the impression that the disease was rampant. D. Drache, a professor of

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political science, believed that, “This media saturation may have reinforced the worldwide impression that sars was out of control in Toronto, even if that’s not the reality” (Drache et al., 2003; Palmer, 2003; Rezza et al., 2004). Local residents were inundated with news coverage concerning the sars outbreak. The Toronto Star carried an average of 6.1 sars-related articles per day between the initial outbreak on 25 March and the end of the second outbreak on 30 May 2003. The national newspapers (National Post and Globe and Mail) averaged four sars news articles per day during this period. The high saturation of coverage in the local newspaper may have reinforced the idea both locally and worldwide that the sars outbreak was out of control in Toronto. Stories from the New York Times reflected this feeling and influenced perception with headlines such as, “The sars Epidemic: Canada Health Officials Seek Help from U.S. to Control Virus,” suggesting that the sars situation was not under control. During the sars crisis, the Toronto Star had 556 news articles about sars, while the New York Times had fewer than half that number (273). The American news coverage was similar to the Canadian, with a focus on the health aspects, and later more coverage of the economic impacts. The reduced level of coverage of sars in the US was due to their coverage of the war in Iraq. US media coverage, while less saturated, may have contributed to the perception of increased sars risk in Toronto. In stories on the subject, Canada was often included with Asian countries affected by sars where the disease was active in the general population. The continual linking of Canada to Asian countries during the sars outbreak was an important factor creating the impression that the risk of sars was greater in Toronto than it actually was. USA Today news articles linked Canada to China in 41 per cent of all stories, largely neglecting the fact that in Canada the outbreak was contained in hospitals, the difference made by Canada’s hospital infrastructure, the capacity of the Canadian healthcare system and its institutional ability to contain the outbreak. News coverage between 25 March and 30 May had four main peaks, concentrating the stories in clusters. The four news peaks tracked the initial outbreak (sars1); the World Health Organization (who) Travel advisory from 20 April to 30 April; the end of the initial outbreak with news coverage between 14 May to 18 May; and finally, the glut of articles concerning the second out-

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break (sars2) between 23 May and 30 May 2003. During the peak news periods the number of articles per day increased dramatically, with 200-300 per cent more coverage, and a high of twenty-five news articles per day, per paper, detailing the effects of sars. After 30 May the health impact and fear of contagiousness of sa rs diminished, and more news articles concerning the economic impacts appeared. During the initial outbreak, approximately 90 per cent of all news stories concentrated on the health aspects of sa rs . By the end of the second outbreak, health-related stories accounted for less than 50 per cent of all related stories, with the balance of articles dealing with either the political and economic aspects. The number of sars newspaper articles published was nothing less than extraordinary. In a span of about four and a half months from 17 March to 28 July 2003 the major Canadian newspaper dailies collectively printed 11,814 stories about sars (figure 5.3). Risk communication of sars occurred locally, regionally, nationally, and internationally. The same message about containing the virus was interpreted differently by different groups, and stakeholders quickly found themselves working at cross-purposes. Doctors and healthcare workers urged a strict precautionary approach, while local businesses (the tourism, hotel, and air travel industries) wanted the travel advisory lifted quickly. Politicians were caught in the middle attempting to safeguard the public, interpret the science, and find a workable way to minimize economic losses. Andrew Laing, president of Cormex Research, who contributed to the media content analysis, suggested that the intense media saturation was also due to intense competition among the three Canadian papers, each of which was striving to become the authoritative media voice on the subject. News coverage, while excessive, gave public health officials and the health sector a strong voice throughout the crisis. The who travel advisory caused a shift in coverage, giving politicians and businesses more opportunity to communicate their concerns about how the sars outbreak was affecting the local economy. Healthcare workers received further attention during the second outbreak, as many of them became sick, and the others were at higher risk for contracting sars. Although the sars coverage changed from a purely medical story initially into one with economic and political implications, each of the five major newspapers continued to

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Time Figure 5.3 Cumulative numbers of deaths and cumulative numbers of Canadian newspaper articles on sars appearing between 17 March 2003 and 28 July 2003. The cumulative number of Canadian deaths is shown above the dates. (Tyshenko, 2007)

provide important health information throughout the fourteenweek outbreak (Palmer, 2003). While content analysis of the five major newspapers has uncovered a saturation effect, the effect was magnified by other media including tabloids, newspapers with lower circulation rates, radio, the Internet, and, most important, television coverage, from which the majority of North Americans receive their news. Television coverage relied on distressing images related to sars and seemed to be fixated on showing people in masks. This made Toronto appear unsafe, with people wearing masks for protection throughout the region. While the media seek to serve the public interest by covering important events, the saturation coverage of sars became part of the crisis itself (Zerbisias, 2003).

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The overwhelming amount of information concerning sars from officials, acting as experts, had the effect of lessening public confidence. During a crisis or an escalating risk issue, individuals look for a credible, trusted, and consistent source of information. Due to the saturating news coverage of the sars crisis in Toronto, there were times when several different public health officials from different levels of government were being quoted, interviewed, and photographed with information updates. The numerous experts appeared to be acting as purveyors of information only, and not as official government voices. Health Canada, Toronto Public Health, and the Ontario Ministry of Health and Long-Term Care all issued regular sars updates on their Web sites. Daily national, televised sars press conferences were held, featuring a number of officials including Dr James Young (Ontario’s commissioner of Public Safety and Security), Dr Colin D’Cunha (Ontario’s chief medical officer of Health), Dr Sheela Basrur (Toronto’s medical officer of Health), Dr Donald Low (chief microbiologist at Mount Sinai Hospital), and other leaders or infectious disease experts. Many unscripted interviews were given. In a situation where so many officials sounded off with sometimes differing opinions about sars, it left the impression that no one with any authority was truly in control of the situation, let alone certain of the latest information. The saturating effect of sars coverage also occurred within the scientific community. In the year and a half since sars first emerged in several countries there were approximately 3,000 sars-related publications that appeared in peer-reviewed journals. This is an astounding number of research articles, with an average of about 160 peer-reviewed articles each month. The research represents an impressive collection of clinical, epidemiological, and scientific knowledge, the purpose of which was to deconstruct a novel respiratory-borne pathogen as quickly as possible (Skowronski et al., 2005; Dixon, 2003).

the

C. DIFFICILE

story – social attenuation of risk

By comparison, another disease outbreak occurring at the same time as sars garnered almost no media attention. During 2003 and 2004, at least twelve hospitals in Montreal had been battling an outbreak of Clostridium difficile, a bacterial organism that is natu-

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rally resistant to most broad-spectrum antibiotics used on hospital wards. At six Montreal hospitals, more than 1,400 patients had tested positive for the infection in 2003, according to a doctor’s chart review. Hospitals in Calgary, Alberta, were also were faced with a similar, smaller bacterial outbreak in that city. Officials were alarmed by the latest outbreak and recorded, on average, ten new cases of C. difficile per month at each of the city’s three main hospitals. The usual rate is between three and five new cases per month. Clostridium difficile is a common type of bacteria found in the gastrointestinal tract of humans. It was given its species name “difficile,” for difficult, because when it was first discovered it was extremely tough to grow in research laboratories, which made it hard to study. In humans, C. difficile grows in the large bowel: the bacteria thrive in the stool compressed inside the colon. The bacterial infection occurs in some patients after they’ve taken antibiotics. It is thought that antibiotics reduce the normal bacterial population of the small intestine, allowing C. difficile to colonize areas of the gut tract it usually can’t do well in. Some strains of the bacteria can produce toxins (e.g. cytotoxin B) that cause diarrhea and damage the cells lining the bowel.1 Toxin-producing strains of C. difficile can cause critical illness and death in elderly, immune-compromised, or very sick patients. Patients suffer mild or severe diarrhea, which can be accompanied by hemorrhage, and those with intractable cases may require a colectomy2 to treat the problem. C. difficile is, more often than not, a hospital-transmitted and hospital-contained infection. By June 2004, the bacterial infections had been blamed for at least 89 deaths in hospitals in Montreal and Calgary in the previous year. Four months later, a published study showed the bacterial outbreak in Quebec could be categorized as an epidemic. It had killed 109 people in ten hospitals in Montreal and Sherbrooke, Quebec over a six-month period in 2004 (Loo et al., 2004). According to a medical review, there were 7,000 C. difficile infections by the middle of the previous year (the time of the sars outbreak), much higher than earlier reports. Problems with bacterial infections can result in other serious comorbid outcomes: for example, after C. difficile infections, thirty-three patients underwent major intestinal surgery to control their affliction (cbc News, 2004a). Earlier studies had established estimates for the incidence of C. difficile in Canada in the mid-1990s in Canada, with a national

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average C. difficile-associated diarrhea (cad) incidence of 36.18 / 100,000 patient days or 3.06 / 1,000 admissions in hospitals with more than 200 beds (Alfa et al., 1998). This rate of infection was similar to other reported rates from the United States and Europe (Olson et al., 1994; Karlstrom et al., 1998). Rates of nosocomial C. difficile infections increased to nearly thirty persons per 1,000 admissions in 2003 (a mean of 28.2 per 1,000 admissions with a range from 12.8–45.0 per 1,000 admissions) (Loo et al., 2004). The increase is about nine times the rate previously reported as the national average in 1997. Since this time, infections have fallen to eleven cases per 1,000 admissions (Valiquette et al., 2004). In addition to the alarming rise in the number of cases, there was an increase in mortality rates directly linked to the bacterial infections. The precise number of deaths that occurred after patients contracted C. difficile during the Montreal outbreak was difficult to ascertain, because most of the hospitals would not release their individual statistics. By October 2004, local attention was focused on C. difficile and, due to mounting public pressure, the Quebec Health Department decided that it would make the rate of acquired-in-hospital infections involving C. difficile public by using the Internet, reversing its earlier decision to withhold these statistics. Data was to be released to the public only after six months or more had passed. At this point in time nearly 180 people had died in local hospitals, but only certain Montreal and Sherbrooke hospitals chose to make their data public. The lack of transparency on the part of hospital administrators made it hard to determine which hospitals had the best or worst rates of infection control, what progress was being made against the bacteria, and if interventions such as different cleaning methods were effective. The reason for such a position by the hospitals was believed to be due to issues of liability. Moreover, hospital-acquired infection rates may stigmatize hospitals and cause panic among the public (The Montreal Gazette, 2004). As of November 2004, hospitals were required by law to report all new cases to the province as soon as they were discovered. The change in reporting was a result of the published study by Dr Loo showing markedly more deaths from C. difficile infections. Previously, it was not a reportable disease because nosocomial infections were viewed as being confined to hospitals and were not seen as a risk to the public. There have been recorded cases of C. difficile

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being contracted by at least one doctor, a volunteer, and some healthcare workers who were otherwise healthy at St. Mary’s Hospital in Montreal. In any event, the logic for not releasing the data to the public is flawed. Patients who contracted the bacteria were usually admitted for other illnesses and while a few victims were young, most were elderly, with comorbid medical conditions or immunocompromised. Healthcare officials should have acted in a precautionary manner to protect this group of vulnerable individuals who were at increased risk for this exposure. In two reported cases, otherwise healthy patients in hospital for joint surgery contracted C. difficile and died (Eggerston and Sibald, 2004). Elderly patients in hospital for other treatments routinely became infected with C. difficile, developed serious diarrhea, and died. Many infected patients deteriorated very quickly and within hours some became extremely ill, with low blood pressure, requiring intensive care to keep them alive. The difficulty of eliminating the bacteria is due to its robustness. When conditions for its survival are unfavourable it can make spores, which spread easily and are difficult to get rid of. Spores can be transported on the hands of healthcare personnel who have direct contact with infected patients and can be found on almost any surface, including toilet seats, doorknobs, and hand railings. Patients with C. difficile infection and diarrhea can spread the bacteria or its spores by touching an object if their hands have not been washed well. The spores produced by C. difficile are remarkably resistant, and can withstand the effects of drying and direct sunlight, surviving for up to seventy days on surfaces, waiting to infect another person. When someone comes in contact with the spores and then touches a hand to their face, while eating for instance, the spores can get into the gastrointestinal tract and grow there. Even though the bacteria are sometimes triggered when a patient takes antibiotics, the most effective treatments are the use of other specific antibiotics. Short courses – three to five days – of antibiotics such as Flagyl and Vancomycin are most common. In some cases, doctors also inject patients with immunoglobulins to boost their immune systems. Several reasons were suggested for the increased number of C. difficile infections in Canadian hospitals. An aging population and changes in how healthcare is delivered resulted in an older, less resilient average inpatient. Both age and comorbidity are risk factors for

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contracting hospital-acquired infections, and, due to demographics, these increased rates are not wholly avoidable. Changes in antibiotic treatment and the increasing use of proton pump inhibitors for other medical conditions have benefits, but these therapies may increase the risk of C. difficile infections. A series of organizational factors may also have contributed to higher rates of bacterial infection, including aging hospital infrastructure, increased numbers of patients per room, and progressively fewer resources assigned to housekeeping and cleaning. However, all of these risk factors are present in many hospitals across Canada. The much higher C. difficile rates experienced by Montreal hospitals suggested that a new, more virulent or highly transmissible strain of the bacteria had appeared (Valiquette et al., 2004). In several ways, the C. difficile news story is the antithesis of the sars story. The hospital-acquired bacterium was well-known, with a disease etiology and spread that was already well-characterized. Paradoxically, the C. difficile story had more possible media triggers than sars. For C. difficile there were controversial triggers of victims, an alleged cover-up or lack of transparency by officials in reporting of the number of deaths that occurred, a high level of dread for those at risk entering known C. difficile hospitals, the inability to reduce infections over time within hospitals (demonstrating a lack of local containment), more than one city involved in the outbreaks (showing transmissibility between regions), an increased virulence of the pathogen, the involuntary nature of the risk (in that people must go to the hospitals for medical procedures), inequitable distribution of the risks to vulnerable and older individuals, and a higher overall morbidity from the strain causing disease when compared to other hospitals. All of these factors surrounding C. difficile did not result in a social amplification of risk effect of the magnitude observed with sars. In Toronto, the Toronto Star ran 348 sars stories over a two-year period surrounding the outbreak. By comparison, the Montreal Gazette, during the two-year period from 1 May 2003 to 1 May 2005, only ran 89 news articles about the bacterial outbreaks that were ongoing in that city. In other cities that also had emerging C. difficile outbreaks the news media attention was also relatively meagre. The Edmonton Journal had only 12 stories and the Calgary Herald ran 16 stories about C. difficile during the same two-year period. Overall, Canadian newspapers collectively ran 349 stories on C. difficile

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Figure 5.4 Cumulative number of news articles about C. difficile appearing in all major Canadian news dailies over a ten-month period from June 2004 until April 2005 (Tyshenko, 2007)

during that two-year span (figure 5.4). Both sars and C. difficile presented similar media triggers and a similar level of dread, uncertainty, and catastrophic potential as a nosocomial outbreak. More people died from C. difficile than sars, and yet the two stories were reported differently, and the associated messages about uncertainty were received very differently by the public.

the internet as a new tool for social amplification of risk To answer the question of why C. difficile remained socially attenuated while sars, as a news story, became amplified, we can look at the types of information sources as the main driver of the events. sars was the first infectious disease outbreak to occur in the era of an Internet-connected public locally, across Canada, and globally.

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While much of this chapter has focused on local and national print media, other methods of information transmission leading to social amplification were also responsible for distortion of risk perception. As sars was a new infectious disease with a high degree of uncertainty, many individuals actively sought out information. Individuals with Internet access were able to read Canadian news on the subject from peer-reviewed and non-peer-reviewed sites, but were also able to obtain sars information, stories, and pictures from other affected countries. Access to global information about infectious disease, images of individuals wearing masks for protection, and peer-reviewed medical data provided additional information contributing to perception distortion during sars. C. difficile lacked this dimension of international transmission and, as a story, appeared on many fewer Canadian or international Web pages. Rodrigue (2001) presented two case studies that showed the power of the Internet as a new medium to inflate concern over minor hazards and dull concern over serious ones, complicating assessment and communication of emerging risk issues. The low cost of Internet communication enables the circumvention of established media priorities, story agendas, filters in story coverage, and professional peer-review mechanisms. Risk-issue management is normally informed by scientific risk assessment, but the Internet can lead to distortions of public perception and rapid mobilization of activism leading to legal challenges that can overemphasize less serious risks or attenuate serious risks (Rodrigue, 2001). Risk assessment scientists, risk management policy makers, and non-governmental organizations have frequently voiced their frustration over getting their messages to the general public through traditional news media. Of growing importance for social amplification of risk is the use of the Internet as a medium to generate awareness, transfer knowledge, and also distort public perception. The Internet can be a far more interactive medium and allows for real-time movement of information. Messages can be distributed to relatively large audiences through email, Usenet, listservs, real-time Internet messaging, and Web pages.3 The cost of using the Internet as an information dissemination tool is relatively low. The Internet al.so enables the exponential expansion of communication through chain-mail dynamics and forwarding of electronic mail. For the first time, ordinary citizens and risk assessment scientists have the means to communicate their messages to large audiences and have

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access to global pools of information. The Internet makes it possible for a small number of individuals to mobilize a politically potent movement concerning hazards deemed trivial in probability and minor in consequence by conventional risk assessment. During sars, individuals relied on large, well-funded news sources for information, but many Web sites appeared containing information and images about sars. Health Canada’s Web site drew more than 760,000 Canadian visitors in April 2003, an increase of more than two thirds over previous months – mostly individuals searching for information about sars. The activity was also evident on medical Web sites, with traffic to Webmd (an internet health information site) increasing by over 100 per cent during the initial sars outbreak from mid-February through May 2003. According to one estimate, over half a million new Web pages were generated on the topic of sars in the first few months of the outbreak. Two years after the declared end of sars globally, close to six million individual Web pages were available with information on the topic (McAdams, 2003).

conclusions Sensationalized news coverage about sars in Canada and other countries tended to amplify public concern about a minimal risk, with outbreaks largely hospital-contained in a relatively short time. Negative information from news sources tends to be weighed more heavily than positive information by individuals who are seeking information when making assessments of “just how risky” a situation is in the face of uncertainty. Our predisposition to prevent selfharm and reduce harm to others altruistically is adaptive, because it allows us to avoid the threat of hazardous events, but it also tends to lead us to overestimate unknown or low-probability risks. From the beginning, news stories about sars focused on several factors of uncertainty about the new contagion: its cause stemmed from an unidentified biological agent, the methods of transmission were unknown, and the amount of personal protection required was unquantified. The social amplification of risk of a new, unknown biological contagion was driven by the news media within the context of other events at that time. The recent terrorist attacks on the World Trade Center on 11 September 2001, and subsequent anthrax letters of October 2001, had heightened the public’s awareness of

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possible terrorist activity that could use contagions as biological weapons to induce social disruption and fear. The amount of news coverage greatly hampered efforts by government officials to respond to the outbreak; the number of articles and reports tended to dilute effective risk communication messages from trusted, credible sources. Domestic sars stories competed with international stories and tracked the events in other jurisdictions. Other countries with uncontained sars outbreaks, higher mortality, and similar or higher Probable case numbers (China had 5,327 cases, Hong Kong had 1,755 cases, Taiwan reported 346 cases, and in Singapore there were 238 cases) provided a glimpse into the possible future of sars in Canada if the contagious disease ever escaped hospital containment and epidemiological tracking. Doctors and university professors are experts whose opinions are trusted by the public, but the overwhelming number of media interviews from doctors at hospitals and universities made it difficult for individuals to separate relevant expert opinion from unnecessary information. The result was a higher level of confusion and uncertainty surrounding the voluminous amount of information concerning the risks of sars. The uncertainty and risk of sars, as a news story, fed upon itself as people were looking for critical pieces of information that would allow them to make informed risk-issue choices. This increased newspaper sales, which in turn increased the focus on producing more sars stories. Amplification of risk due to media coverage of the sars story was a result of a number of factors. The novelty, unknown risk, sudden ferocity, political fallout, lack of coordination among various health and government players, and the sheer lack of knowledge about the disease all contributed to the generation of news articles ultimately causing a media overkill (Zerbisias, 2003). By comparison, the media don’t pay much attention to the cumulative mortality and morbidity numbers of the common, yearly influenza. Canadian news reporting gave prominence to the story of sars as a risk to human health over economic and political stories. While sars was also a major story in the United States, the media there reported nearly twice as often about research on the disease (27 per cent versus 14 per cent for Canadian news articles). American stories ignored the impact of the disease on the health system in Canada. When stories of the effects of sars were reported in Canada, the Canadian news media usually placed them in the context of

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problems with the healthcare system. Although economic losses gained substantial news coverage following the who travel advisory, the health story remained the main focus for news articles. Just after sars, another infectious disease outbreak, C. difficile, was occurring in Canadian hospitals, but for several reasons it garnered little public interest. This other virulent infection had broken out in hospitals in two different provinces, and yet neither public health nor hospital officials attempted to warn the public about this growing problem until a peer-reviewed journal article detailed the ongoing bacterial outbreak occurring in Canadian hospitals (Eggerston and Sibbald, 2004). The difference in media treatment, public awareness, and risk communication resulting in the attenuation of risk was pointed out by researchers who said in a peerreviewed Canadian medical journal, “More people have died after contracting a virulent infection that has broken out in hospitals in Montreal and Calgary than were killed by sars – yet neither public health nor hospital officials warned the public until cmaj broke the news” (Eggertson and Sibbald, 2004). The C. difficile outbreak had been ongoing and yet media attention remained low. The focus on sars was overwhelming by comparison. By social amplification of risk criteria, the C. difficile outbreak should have been a risk issue that was amplified as it displayed more media triggers for uncertainty and controversy than sars. The bacterial outbreak was a relatively new and possibly catastrophic risk that had emerged and was increasing over time. Hospital managers tried to conceal the risk of hospital-acquired bacterial infections by actively attempting to reduce the level of transparency. They showed that they could not be trusted to convey risk information. They seemed unable to reduce C. difficile-related deaths and were not in control of the hazard or exposure. Re-analysis of hospital charts revealed that higher numbers of deaths had occurred than were at first reported. Despite all of these media triggers, C. difficile remained in the shadows as a risk issue. Differential social amplification was clearly demonstrated by the way the news media and Internet sites treated the C. difficile and sars outbreaks. Both were nosocomial outbreaks and were largely hospital-acquired and -contained diseases. There were twice as many deaths from C. difficile in Canada as from sars, and the bacteria was recorded in outbreaks in several Canadian hospitals, showing a wider distribution. Moreover, the C. difficile outbreak was a repetitive event.

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There are reasons the C. difficile outbreak showed social attenuation of risk. As a hospital-borne disease, the risk did not resonate with members of the public, who were, for the most part, unaffected by the outbreak. Secondly, news reporting on the hazard was limited and not sustained. C. difficile lacked an international aspect, making it a minor regional Quebec or Alberta outbreak. Low levels of C. difficile infections and deaths have been occurring in hospitals for many years and have not been a major news story. Perhaps the main reason C. difficile was not amplified as a news story was that the cause of the outbreaks that was already wellknown. Quebec doctors blamed poor hospital sanitation, a result of budget cuts to cleaning staff and hygiene, as the main culprit that allowed the bacteria to spread unchecked. In Montreal hospitals, the number of patients contracting C. difficile is at least four times higher than it was seven years ago, attributable to reduced housekeeping staff and eroded cleaning standards. The C. difficile story, by all news accounts, was largely unremarkable, as healthy personto-person transmission is rare. Social amplification effects of sars were observed in the number of news articles that appeared in print media. In four months, over 11,800 news articles appeared in Canadian newspapers (as determined by searching the Canadian Newsstand Database), thirty-four times more news articles than the 350 news articles on C. difficile over a ten-month time period. The number of sars news articles was well out of proportion to the actual risks. The difference, then, must be due to the nature of the risk. C. difficile is not contagious, and for healthy people, hospital visitors, the general public, and healthcare workers, the risk of transmission of the resistant bacteria was extremely low. However, sars presented a potentially risky contagion that could spread from person to person if uncontained, and had the potential to quickly overwhelm current healthcare system capacity. News sources picked up and amplified the uncertainty of the contagion and the possibility of an uncontained outbreak. The focus on the potential catastrophic outcome altered public perception, resulting in widespread fear and uncertainty. The result of social amplification in the case of sars was an intense and prolonged stigma of persons, including those recovering from sars and nurses associated with known sars hospitals. The amplification also resulted in a stigmatization of place focused on hospitals and the Toronto region.

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The Stigma of SARS and Its Effect on People and Places A young boy sat at the kitchen table all alone, incredibly sad and dejected. The colourful balloons and party streamers had been hung all around the house and the invitations had been sent to friends weeks before but no one had dared to attend his fifth birthday party. His mother, a nurse at North York General Hospital, stood in the background, feeling as upset as her son looked. “Mommy,” the boy quietly said, “…do people hate us?” The concerned mother replied, “People don’t hate us, they are afraid of getting sick… afraid of catching sars.” The boy looked up very confused, “But you are a nurse, you help people get better, you don’t make people sick, that is just crazy.” The mother tousled her son’s hair and kissed the top of his forehead to console him, trying to hide the tears welling up in her eyes, and replied, “It sure is crazy… it sure is.” Cathy Paterson, nurse clinician, North York General Hospital

Sometimes objects, people, or ideas acquire positive or negative associations. Early anthropologists described these associations as “magical thinking,” which was governed by either of two laws: contagion and similarity (Frazer, 1922). The essence of the law of contagion is summarized by the phrase, “Once in contact, always in contact.” An object considered impure transmits this characteristic to the person it has contacted, and the recipient cannot get rid of the effects of the contagion without recourse to a purification ritual. The law of similarity is summed up as, “Image equals object.” When demonstrators hang and burn an effigy, or burn pictures of a despised public figure, they use the person’s image as a focal point for their emotion, evoking the law of similarity. Another wellknown example of similarity is the practice of voodoo by some

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cultures. Needles are used to “torture” a representative image of one’s enemy, which is supposed to induce similar suffering in the person’s actual physical body. The two principal laws of magical thinking have occurred many times in various societies throughout history, linking and transferring qualities between objects (Rozin et al., 1986). The idea of magical thinking, with its first law of contagion, may seem like an odd way to introduce the concept of stigma as it relates to the events of sars, but I will explain how it is a very appropriate way to view the events of the outbreak. Medical doctors use the primary dictionary definition of contagion – the communication or transmission of disease by contact. Anthropologists and social scientists define contagion slightly differently, as the spread of an idea or emotion. Public perception and news media coverage of sars operated by the law of contagion. Thus, the contagion of sars was literally an infective virus as in the biological definition of the word, but it also, through magical thinking, stigmatized associated objects and concepts. When describing the properties shared by people or objects, the anthropological meaning of contagion focuses on the idea that once contact is made between them, properties (whether good or bad) from one are passed permanently to the other.

actual risk and perceived risk Risk is defined as the probability that a substance or situation will produce harm under specified conditions. Risk is a combination of two factors: the probability that an adverse event will occur, and the consequences of the adverse event. In order to be accepted by individuals and society, risks must be quantified in some way and, as a result, risk as a concept embodies other dimensions. Modern cognitive psychology suggests that there are two fundamental ways that individuals comprehend and assess risks for acceptability: the experiential system (Zajonc, 1980) and the rational or analytic system (Epstein, 1994). The experiential system is intuitive, quick, and largely inaccessible to conscious awareness, relying on images and associations linked by experience, emotion, and affect (in cognitive science “affect” is used to mean the conscious subjective aspect of feeling or emotion). This “risk as a feeling” is a way to determine whether a given risk is acceptable and allows, ultimately, for a simplified binary decision to either accept or reject it (Lowenstein et al.,

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2001). Thus, individual assessments of risk are usually comparative, with at least implicit reference to benchmarks (using experiential anchors of risky activities such as skydiving) that people can relate to (Brenner et al., 1996). The analytic system uses algorithms, calculation of probability, normative rules, and formal risk assessment, making it a comparatively slower process requiring directed conscious control. While both systems require a level of rationality to derive a decision, the “risk as analysis” or “logical analysis of risk” system is used as a tool to enhance the rationality of the experiential system. While both systems of risk analysis are continually active and interacting at the individual level (Finucane et al., 2003), most risk analysis by the public is handled by the experiential mode of thinking (Slovic et al., 2004). The public depends heavily on analytic risk assessments by experts who convey their knowledge of the risk. Analytical methods use equations to account for complex, multifactorial hazards or assign variables for unknown hazards, to analyze and accurately derive measures of risk. The ability of individuals to accept or reject risks originates from psychological quantities that are estimates or approximations of reality based on previously acquired experience and knowledge (Nelson, 2001; Griffin and Tversky, 1992; Fischhoff, 1982; Tversky and Kahneman, 1982). Individuals often use rule-of-thumb processes called heuristics to produce usable mental values (shortcuts in thinking), although they are subject to certain biases. As a result of past experiences, most people gain the ability to mark or identify people or things that are risky; this is an important way to avoid and minimize risks (Hammond, 2000). One of the influences on people’s behaviour when there is a risk issue that is high in uncertainty is public risk perception. Experts, industry, and authorities evaluate risks using various probabilistic tools based on mortality and morbidity (death and injury) rates associated with a given risk issue. Individuals, however, evaluate risk differently, using past experiences and feelings. Experts often describe this non-analytical analysis as irrational. For example, an individual’s perception of risk may involve other factors including ethics, morality, or a social equity component. This is particularly true when it comes to possible dangers associated with health issues affecting us personally or our families. Consequently, risk embodies values beyond scientific and clinical data involving social and

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cultural factors. Not all groups and cultures are equally fearful or worried about risks, and not all cultures worry about the same risks. Communicating the risks and benefits of an emerging issue like sars to the public is more complicated than simply providing accurate scientific and medical data. New information must be distributed by means that will be understandable, consequential, and practical. In the case of sars there was a knowledge gap between the scientific-medical experts (with specialized language and understanding of the risks) and the public. Experts who attempted to communicate highly scientific information did poorly, often failing to communicate the important facts to journalists, who lacked science training and therefore did not know what questions to ask. Similarly, the public lacked an initial frame of reference for the emerging viral infection and epidemic. Individuals have certain mental models or previously acquired beliefs concerning any given risk issue that is informed by their personal histories and their definitions of risk. These mental models filter all newly provided information using this pre-existing lens that may be inaccurate and misleading. If new information cannot fit into a person’s mental model concerning a new or unknown risk then it will likely be ignored. Scientific information about risk issues must be presented in an understandable form that connects with an individual’s preexisting thoughts and beliefs about known risks (Longstaff, 2003). Early in the sars outbreak, there were no risk anchors (examples of known, familiar similar kinds of risks) offered to the general public to help them understand just how dangerous sars was. The Health Canada Web site stated that, “For most Canadians, the risk of getting Severe Acute Respiratory Syndrome (sars) is extremely low” (Health Canada, 2004). On 23 March 2003, Dr Colin D’Cunha, Ontario’s Public Health Commissioner, stated, “For members of the general public, the risk appears to be … slim and near zero” (cbc News, 2003e). Most people are familiar with some risk-measurement tools. Scientists use risk ladders and verbal risk scales to help individuals incorporate new and low-probability risks into their decision-making. Logarithmic scales used commonly include the Richter scale for measuring earthquake magnitude, the ph scale for hydrogen ion concentration to determine the acidity of solutions, and the decibel scale for measuring the intensity of sound. A number of loga-

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rithm-based scales are also available to measure risk. Integer logarithmic scales are often used to present risk magnitude information in a more manageable format, allowing individuals to compare new risks like sars to other well-known risks. Chief Medical Officer Sir Kenneth Calman from the United Kingdom suggested that individuals are greatly affected by perceived risk as well as real risks. As a result, new risks are meaningless to individuals unless they are related to already familiar, well-known risks and to similar risks encountered in everyday life. The Calman chart divides risk into six main categories ranked on a logarithmic scale from high (less than one in 100) to negligible (less than one in a million) (Calman, 1996). The probability of catching sars in Toronto for the general public was estimated at one in 196,000 (MacDonald, 2003), which is the equivalent of Health Canada’s rank of “extremely low.” This value given for sars, when using the Calman logarithmic risk scale, categorizes it as a minimal risk, with the same probability as dying from a railway accident or homicide. Minimal risk is ten times lower than the likelihood of dying due to an accident at home or at work, or one hundred times less likely than dying from domestic violence, poisoning, auto accidents, or the common flu, or one thousand times less than the probability of dying from smoking ten cigarettes a day or from all other natural causes before the fortieth birthday. Unfortunately, no one took the time to communicate just what “extremely low” or “near zero” meant, to allow the public to quantify the level of risk of sars in an understandable context. In this vacuum, without information about what “extremely low” meant, the public was left with amorphous fear and a large amount of uncertainty surrounding sars. During the sars outbreak the news media was one of the public’s primary sources of information, and early news stories were full of uncertainty. This uncertainty prompted many people to see the outbreak in an unnecessarily negative light. The first few local news articles characterized sars as a “deadly illness,” “mysterious outbreak,” “highly contagious disease,” “mystery illness,” and said it had “sickened hundreds worldwide.” Experts and scientists were characterized in the same early news articles as “scrambling to identify the pathogen,” “experts (who) can’t agree,” and “unable to identify a cause for the disease.”1 Individuals also paid attention to international hot zones and the news of how other countries were dealing with sars. China’s initial

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denial of sars and underreporting of cases was a story well-covered in the media, and it only fuelled paranoia that government officials elsewhere might be covering up or ignorant of the true spread of sars. The lack of response by other countries increased the level of uncertainty; it meant more international travellers with sars could arrive in Canada each day. The early news articles framed the story as one of dread; that was difficult to overcome in subsequent communications about the risks. Later attempts by experts to communicate the risks were sincere efforts to appear transparent and to transmit credible knowledge about sars as a way to reduce fear and anxiety. However, the early heuristic, or gut feeling, established by the news media was only reinforced by well-meaning experts, who communicated the increasing numbers of Suspect and Probable sars cases.

the stigma of sars Stigma is the Latin form of the ancient Greek word that means a mark or tattoo, especially as a mark that signifies disgrace or shame. The physical appearance of stigma is an external marking that enables members of a community to instantly differentiate those who possess it from those who are normal and socially desirable. In addition to the immediate recognition of the mark as an external manifestation, there can also be a negative inner state of being associated with stigma such as criminality, social deviance, or, in the case of disease, identification as a carrier. The stigma has a strongly negative connotation, the opposite of cachet, which is a mark of approval or prestige in society (Leiss, 2001). Stigma can be assigned to people, products, places, objects, or technologies marked as undesirable. They are shunned, often at a high economic, social, and personal cost. The stigmatization of products was observed with public rejection of genetically modified foods in Britain over the perceived negative health and environmental impacts. It resulted in large financial losses to farmers and producers, and occurred in the absence of any carefully scientifically documented evidence of statistical risk. Stigmatization has also occurred in an environmental context, most often associated with increasing societal concerns about the ecological and human health risks of technologies, including nuclear power, hazardous waste storage, genetic engineering, and cellular phones (electromagnetic

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fields). In terms of risk, technological stigma is slightly different, referring to a technology or process that is avoided not only because it is perceived to be dangerous, but also because it reverses a previously normative condition. What once was thought to be a normative societal good and acceptable, is thereafter marked as tainted and to be avoided. Nuclear power in North America was initially a welcome technology that over time has become tainted through stigma. In other countries, like France, that rely heavily on nuclear power for abundant, cheap energy, the technology is not widely stigmatized. Stigmatization has also been shown to apply to human populations, in particular to residents of resource communities (mining towns) and to those living in or near sites associated with technological hazards. The change in social perception leading to stigmatization of a person is a result of factors such as dread, loss of control, uncertainty of anticipated outcomes, lack of perceived benefits, distrust, and risk aversion behaviours (Gregory and Satterfield, 2002). Stigmatization of a person due to biological disease is a result of the law of contagion, due to individual risk perception stemming both from pre-existing attitudes and recently acquired information. Individuals attempt to make choices and perform behaviours that minimize risk, and usually arrive at these choices through rational decision-making. There are other factors besides probability and consequences that influence choices surrounding risk acceptability. Heuristic responses can be influenced by personal experience, knowledge levels, and media coverage of the risk issue. The effect of new information, emotional reactions to images, and the level of uncertainty surrounding new information also play an important role in people’s decision processes (Loewenstein et al., 2001). These factors are important when individuals face decisions that involve difficult trade-offs between competing attributes, or where there is ambiguity concerning what constitutes a right answer. In these cases, people often appear to resolve their dilemmas by focusing on those cues that send the strongest affective signals (Kunreuther, 2002). For sars the media served to reinforce heuristics of avoidance behaviour that manifested as stigma against healthcare workers and against the city of Toronto. The news media sent strong affective signals with images of nurses in n95 masks that left the public wondering how bad the mystery illness was when all nurses in the region’s hospitals were required to wear protective equipment and

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masks. Further, despite the extremely low probability of catching sars in the community, media images focused on the few people wearing masks when using mass transit (subway, bus, and go train); this sent very strong affective signals that tended to heighten levels of anxiety and uncertainty among the general public. So during sars perceived risks were high and individuals stigmatized those they associated with the hazard (nurses, doctors, other healthcare workers, paramedics, and individuals of Asian ethnicity) and changed their behaviours (avoided places and areas with potential sars contacts) – all results of irrational fears derived through a rational thought process. The sars outbreak had social stigmatizing effects well beyond what was expected, fuelled largely by the overwhelming amount of media coverage that heightened the perceptions of uncertainty, fear, and loss of control. During the outbreak, the public and the experts learned about new information almost simultaneously through the media and Internet sources. The message sent by health officials was that the sars outbreak was contained in Toronto and there was little to worry about. Clear epidemiological links had been established for those contracting sars in Toronto hospitals. However, media images of other Canadian hospitals far removed from the Toronto area with staff wearing masks seemed to contradict this message. It suggested the possibility that sars could appear in hospitals hundreds of kilometres away. Many people living in other cities in Ontario saw pictures of familiar, local hospital staff now wearing protective masks, and became fearful of sars transmission in their communities. Regardless of what officials were saying, the out-of-the-ordinary images of masked healthcare workers at hospital entrances brought into play cognitive and physiological mechanisms of fear and dread. Some individuals afraid of catching sars when using mass transit (trains, subways, or airplanes) wore protective masks to reduce their personal risk, and these pictures also appeared several times in newspapers and on television news broadcasts, once again influencing public perception of the situation and reflecting the mounting paranoia. Some people did not fully believe the messages being given by Canadian health officials that the disease was certainly contained within local hospitals. Comparatively, sars itself was not as deadly or as risky, quantitatively speaking, as the common yearly influenza. The common flu

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and the complications it triggers, such as pneumonia, kill hundreds of Canadians each year. Health Canada reports that, on average, 500 to 1,500 people die annually from the flu. In the United States flu kills 22,000, and worldwide it kills 400,000 people every year. Statistical modeling similar to that used by the Centers for Disease Control (cdc) in the United States estimated that the Canadian numbers might be even higher, with between 700 to 2,500 deaths attributable to influenza each year (Sibbald, 2003a). Elderly people and individuals with chronic ailments are at the highest risk from the flu. The flu, which kills more Canadians each year than did sars, does not cause the same profound levels of anxiety or garner huge media coverage and resulting negative economic consequences (Branswell, 2003). Why was the reaction to sars so markedly different from the reaction to similar diseases, like influenza? The answer has to do with two key ideas, the form of risk and the specific configuration of the risk that influenced the public’s perception of the risk of sars.

the form of the risk Several factors pertaining to the form of risk have been identified that produce a sense of dread and outrage. For sars, these factors were evident and greatly influenced how individuals reacted. First, a nearby, physical risk that can be observed, represented by images, or imagined generates more fear than a distant, abstract risk. Influenza is a familiar yearly risk that is widespread and uncontained; the virus sweeps across continents, cycling around the world, causing little dread or outrage. sars, however, was a new disease emerging from only a few epicentres and was seen as a new form of risk. Second, sars was centred in Canada’s largest urban center, and media images of familiar places that became quarantined facilitated a strong “close to home” factor. Third, sars also presented an involuntary risk. Individuals voluntarily take on some risks, like skydiving or rock climbing, and see the risk as less problematic than an imposed risk over which there is no personal control. Fourth, risk taken without the individual’s knowledge induces a powerful outrage factor. sars could only be acquired by close contact with places and other people who were infected. In a densely populated urban centre with people moving freely into and out of hospitals, there was no way to tell for sure, at the beginning of the sars out-

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break, who had been exposed to an epidemiological link. sars, unlike other forms of risky behaviour, offers no perceived benefit (e.g. the adrenaline rush in skydiving). There was no method to differentiate sars-uninfected people (suffering from cold or common flu) from sars-infected individuals who, in the early stages, would appear to have similar cold or flu-like symptoms. The only voluntary control for self-protection was to avoid perceived risks. The inability to identify and control sars risks was a source of dread and anxiety. The possible danger of contracting sars through casual contact in apartment buildings, shopping areas, work areas, and mass transit made it impossible for individuals to protect themselves from the risk. Risk perception is affected by whether the causes of the risk are human or natural. Risks considered to be natural are thought to produce less outrage than those that result from human action. sars, while a natural pathogen in origin, only infected Canadians in Toronto through a series of human actions. The farmers in the southern Chinese province of Guangdong live in close contact with animals, allowing the virus to jump to humans. Close human contact then spread the infection to several other people, and modern air travel spread the disease to other countries. Finally, risks associated with familiar technologies (driving an automobile) cause less outrage than those associated with new, poorly understood technologies, such as genetic engineering or stem cell research. From the beginning, the media presented an image of sars as a poorly understood, unquantified risk.

configuration of the risk Risk assessment uses probabilities, and experts analysing any risk issue rely on analysis of statistical data to derive probabilities on which to base workable public health policy options. Individuals, however, perceive risk in an experiential way. The problems associated with risk acceptability and perceptions are compounded by the difficulty individuals have in interpreting low-probability risks and complex medical and scientific risks when making decisions (Kunreuther et al., 2001). In fact, there is evidence to show that people may not even want data on the likelihood of a low-probability event occurring. When individuals were required to search out their own information on a hypothetical risk, they rarely asked to be provided with any data on probabilities (Huber et al., 1997).

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The experiential system, made up of these biases in judgment, is intuitive, quick, and largely inaccessible to conscious awareness, relying on images and associations linked by experience. “Risk as a feeling,” allows for a simplified, binary decision to either accept or reject a risk construct (Lowenstein et al., 2001). When presented with new, unknown risk, individuals have an intense need to understand how much personal risk is involved. In the case of sars, there were two experiential, subjective reactions to such risks: either “I will catch sars” (with a negative outcome) or “I won’t catch sars” (with a positive or neutral outcome). The binary answer yes or no depends on the level of information the person has, as well as its form, and the characteristics of the risk. Finally, the personal factor comes into play, the not-easily-accepted contrast between individual experience and statistical data. While the actual probability of catching sars was a extremely low for the public, the news media presented a consistent daily raft of statistics on the increasing numbers of individuals contracting sars locally and worldwide; gave statistics on the number of individuals being quarantined or people suspected of having sars through contact with infected patients; and kept a running tally of the increasing number of sars deaths in Toronto. The ongoing uncertainty resulted in distorted perceptions of the risk, and this led to a high degree of stigmatization of people and of places.

stigmatized individuals In the countries with the largest outbreaks of sars, stigmatization of healthcare workers, especially nurses, was rampant. This was certainly the case in Canada. One nurse was given a nickname at her local gym so others would know to avoid her: they called her “sars.” She started going to the gym at night to avoid the verbal abuse, and eventually ended up switching gyms altogether. One nurse who contracted sa rs in North York General Hospital on the orthopaedic ward in May 2003 was in isolation for two weeks, recovered, and was quarantined at home for another two weeks. As a result of her illness and the stigma she experienced, she did not work for several months. Many nurses who experienced stigma and quarantine found the situation mentally difficult to deal with at a time when support from friends and family was essential.

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The general public did not understand sars, its clinical pathology or biology, so nurses who contracted sars and recovered still found themselves outcasts; even though individuals had recovered from sars, their friends often still avoided them out of fear (Nursing Standard, 2004). John Neto, who lives in Toronto, saw the stigma as divided between those who lived in Toronto and those who lived outside of Toronto. People in Toronto were largely unaffected, and by appearances carried on as usual. There was little panic, and although a few people wore masks in the streets, the majority of people did not. He felt that the fear of sars existed outside the city due to news reports that consistently showed masked people in hospital settings. The images gave the impression that the city was rampant with contagion, and that the sars outbreak was spiralling out of control. People who lived in Toronto, while not panicked over the situation, were definitely fearful, distressed, and anxious about sars. One individual who commuted to work in Toronto on a daily basis noticed that during the sars outbreak, when another commuter coughed repeatedly, all the other passengers got up and rushed for another compartment, afraid for their safety and sure that the person had sars. The effect was immediate and unmistakable –stigma and shunning due to fear of contagion. Some international travellers felt they were receiving mixed messages from news sources in Canada and internationally, and were not sure exactly what to do to minimize risk or even if there was a significant level of risk. Kathy Fardell, from England, travelled with her children through the Toronto airport three times in two weeks during the sars outbreak, and despite all the media coverage she was surprised to find there was no overt screening process and little detectable fear among Canadian airport and airline staff. She and her family still took personal measures; they wore masks and cancelled plans to stay in downtown Toronto. The lack of clearly stated, consistent guidelines about travelling, screening, and subsequent isolation left a knowledge vacuum. She believed that informing people about sars at international airports and providing guidelines and screening methods would have helped to reduce the levels of confusion and panic surrounding the real and perceived risks of sars when travelling (bbc News, 2003). Canadians abroad also experienced stigma simply due to the fact that they were identified as individuals from a country known to

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have a high number of sars-infected individuals. Eight Fanshawe College students from London, Ontario were living at the epicentre of sars, in the southern Chinese city of Guangzhou in Guangdong Province, there on a four-month work placement to complete the requirements for their early childhood education diplomas. The students arrived in China on 27 February 2003, days before the first news reports about a mysterious illness in Asia started appearing. In mid-March the World Health Organization (who) had issued an alert about the mysterious illness with symptoms of an atypical pneumonia. The illness had already claimed two people in Ontario and several others were infected. However, London teacher Sandy Reeves and her several students, ages nineteen to twentyseven, were unaware of an infectious disease circulating freely between countries. Sandy Reeves said that they were more worried about the news stories concerning the United States’ war in Iraq, and had heard nothing about sars until they began receiving worried emails from their families. It wasn’t until the middle of March that sars’ visibility as a problem increased, with more people in Guangzhou wearing masks, and reports appearing in the newspapers. When not teaching, the Fanshawe students toured the area and attended classes about Chinese history, culture, and food. Planned tours to other parts of the country were then cancelled due to sars, and the students weren’t allowed to travel outside the province. People in other major cities around the world who became aware of sars reacted no differently than they did in Toronto, the epicentre of the Canadian outbreak. The reaction to the Canadians in China was one of ethnic stigma. Reeves thought the entire situation was ironic. “Because we’re the foreigners, people will cross the street to avoid us, or put their mask on if they’re sitting near us on a bus.” She noted that, “Here, if you’re a foreigner, they think you must have it.” Parents of the Canadian students were worried for their children who were in China, as they didn’t know what was going on and how the students were faring. Reeves stated that, “People here don’t believe what the government is saying.” According to her, the Chinese believed that their government didn’t bother to tell them what was happening during the sars outbreak in that country, and few believed officials once the outbreak was over (Belanger, 2003). Workers in other countries who contracted and recovered from sars also experienced stigma. On 28 March 2003, a forty-two-

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year-old office cleaner and mother of three was discharged from a Hanoi hospital after recovering from sars. Her family was heavily stigmatized by the event. Chu Thi Phuong said stigma hurt her family immensely. “Sometimes I go out and the local kids see me and hold their noses.” Her nine-year-old son had trouble finding afterschool playmates, while her four-year-old son was sent to play alone in an outdoor courtyard by a fearful daycare worker. Even close friends avoided her after her release, fearing that they might contract sars. Ms Phuong contracted sars through a work acquaintance, Johnny Chen, an American merchandise manager from Gilwood Company Ltd., a New York garment company. He had visited Gilwood’s Shanghai office on Sunday, 23 February 2003, after a short stay at the Metropole Hotel in Hong Kong, where he had become infected. Three days later Ms Phuong heard that Mr Chen was ill, so she went out and got him some hot rice porridge and extra blankets. The next day Mr Chen was found in bed with a raging fever. Ms Phuong helped take Mr Chen to the Hanoi French Hospital, exposing herself in the process. Ms Phuong visited Mr Chen’s bedside each day. “He was a stranger here,” she said, so she tried as best she could to reduce his discomfort during his illness. Five days later she began feeling ill herself, and was diagnosed with sars. During her recovery she learned that Chen had died from sars in Hong Kong. For Ms Phuong, the stigma also resulted in the loss of her job as the garment firm quickly decided to relocate its Hanoi office elsewhere in Vietnam to avoid the stigma created by its workers contracting sars: they felt it could potentially hurt their sales internationally (Boosman, 2003). One nurse who was admitted after contracting sars died. Like the other nurses, forty-six-year-old nurse Nguyen Thi Luong, had direct contact with Johnny Chen. He was the first sars patient in Hanoi. Within a week, many in the hospital were falling ill with sars, including nurses and patients. Many of the French hospital nurses who contracted sars experienced high levels of stigma as a result, after recovering. Dang Thi Tuyet Van said that due to sars, many friends refused to see her, and she felt very isolated. She remembers Chen saying “Why? Why am I so tired? Why is my fever so high? Why am I coughing so much?” However, doctors and nurses had few answers for their first patient whose disease was still a mystery at that point in time. Chen had exposed many people in

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the hospital, and on 6 March 2003 Tuyet Van and five other nurses checked into the hospital with sars symptoms at the same time. Tuyet Van found stigma was rampant afterwards, although she tried in vain to explain that she was not contagious after her recovery. But people who knew that she had experienced sars did not seem to understand. “Even though Vietnam doesn’t have any more sars cases,” said Tuyet Van, “I don’t think my life will return to normal.” Disenfranchisement and distrust are hallmarks of stigmatized groups. Kim Van, another of the six nurses from the Hanoi French Hospital, also helped to care for the sickest sars patients before falling ill herself. In March, more than half the hospital staff was sick with sars; even the accountants were serving as nurses. She worked long hours, doing everything she could to care for the sick. “I didn’t think I should stay home,” said Van, who lives near the hospital. Van first heard the name sars while watching a televised report about the disease from her hospital bed on 16 March 2003, a day after she was admitted with the mystery illness. After spending nineteen days gasping for air in a hospital bed, she recovered fully, and after being declared free of sars she returned home to find two of her housemates, who greeted her by covering their faces, turning their backs, and avoiding her altogether; a few days later, they moved out due to fears of contracting sars. “I came back, and I was all alone,” she said. Some of her closest friends shunned her. “I felt shocked and very sad and a little bit angry,” said Van. She is especially dumbfounded by the actions of one of her ex-roommates who was a medical student. Another nurse, forty-five-year-old Bui Thi Thanh Xuan, who had treated Chen for several days, shared a room with Van in the hospital. For several days Van remembers her colleague coughing terribly, crying a lot, and being so feverishly weak that she could not even hold the telephone to talk to friends and family. Xuan, like the other infected nurses, had cared for many sars-infected colleagues before falling ill herself. When she was discharged on 3 April 2003, her husband and twenty-year-old son greeted her, but her sisterin-law, whose apartment is next door, with a shared bathroom and a patio, had closed all her doors and windows despite the heat in Hanoi. She did not come outside and even removed her hanging laundry when she saw Xuan’s laundry hanging on the patio, afraid that the clothes might be contaminated with sars. Her

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sister-in-law explained that she was terribly afraid for her children, and thought Xuan might still be infected. Xuan’s and other nurses’ experiences of stigma are unsettling. Her message to the world was, “Don’t treat sars patients like lepers,” (Stocking, 2003). Nurses in Singapore who were at the forefront of treating sars patients were heavily stigmatized in a similar manner. The nurses were shunned in trains, some were asked by their landlords to move from their rental units, taxi drivers sped past them and refused to pick them up, and nurses in apartment buildings were instructed by their neighbours to avoid taking the buildings’ elevators to avoid the risk of contaminating them. News of the health workers being avoided in public due to their recognizable gowns prompted a call by the Singapore Nurses Association (sna) for their members to be allowed to shower and change out of their white uniforms before boarding public transport. Health Minister Lim Hng Kiang disagreed, saying this would bring further humiliation to the 18,000 nurses working in the affluent city state. “I am proud of our nurses and I urge Singaporeans to treat them without bias,” he said, but due to uncertainty about the sars virus, people remained wary of nurses despite his assurances. Nurses in Singapore were stigmatized simply for the job they did. A thirty-nine-year-old nurse was told by her landlord to vacate her rented room even though she works at a hospital in Singapore that does not treat sars patients. “I understand their worries, but I feel hurt,” she said. Another nurse tells of how she and her colleagues were shunned at the elevator in their high-rise apartment building. An anonymous letter arrived in their mailbox asking them to avoid using the elevator, and to change clothes before returning home after work. The nurse who received the note did not even work at Tan Tock Seng Hospital, where the sars patients were; she felt the stigma was “humiliating.” Nurses working at Tan Tock Seng Hospital have many stories of sars-related stigma; buses and taxis refused to stop for them and many friends distanced themselves, afraid of the risk of catching sars. One nurse who works at Tan Tock Seng Hospital was angry and stated, “I feel betrayed. We are doing a job that other people do not want to do and yet we are treated like this.” At the time, non-nurses expressed much fear and anxiety; this usually stemmed from the lack of knowledge about sars. Early in the outbreak there was little information on how it was transmitted, except for mounting evidence that direct close

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contact was involved – for example, being next to a sars-infected person who sneezes or coughs. This knowledge translated into stigma and avoidance behaviours by those fearful of sars (Agence France Presse, 2003). Stigma spilled over from individuals in hospitals to those individuals who lived nearby. Chantal Louw noted that in Taipai, Taiwan, people who lived near hospitals that had sars patients were shunned. Rationally, just living near such a hospital does not mean that people were automatically exposed to sars. Even in countries with minimal sars cases, fear of the virus stigmatized those who were identified as Asian. One Taiwanese university contract worker temporarily living in the United Kingdom said sars fear and stigma had affected him. Returning home one night from work two teenagers shouted “sars” at him, and made him start to worry about possible racist attacks on Asians (bbc News, 2003).

stigmatized place When an epidemic occurs, the fear and stigma associated with the disease can alter the behaviour of entire communities and even larger populations towards both individuals and places. One of the more dramatic examples that shows stigma of individuals, place, and a transference of extended stigma from place to the individual, are outbreaks of Ebola, a highly contagious disease. This is an acute viral disease in which 90 per cent of the victims die. It is one of the most feared infectious diseases in Africa. In small Ugandan towns during an Ebola outbreak people refuse to shake hands, will not handle money touched by others, and wear latex gloves. The stigma extends to people from the affected towns regardless of contagion contact. The intensity of the stigma stems from a fear so great that epidemiologists have referred to it as a “second epidemic.” Stigma was observed for both people and place with Toronto’s sars outbreak. It affected nurses, doctors, those of Asian descent, local hospitals, local Asian businesses, and the city of Toronto. To a lesser extent than seen with the Ebola example, a second wave of stigma occurred during the sars outbreak, with people avoiding individuals and the city not because they were in fact contagious, but because of the association of an unacceptable level of risk. Reducing social stigma of this type is extremely difficult, but can be helped by credible, clear explanation of the disease to those who are

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affected. Effective risk communication needs to be a priority to control the secondary social impacts of epidemics like sars. For sars in Toronto, the effect of the law of contagion and the stigma were vanquished by a coming together of individuals from both within and outside of the Greater Toronto Area in a purification ritual that reset the heuristics of both the place and the persons. The interplay of the characteristics of stigma is similar regardless of whether it refers to a place, a technology, a product, a person, or an object. Places can become stigmatized when a number of conditions are fulfilled. Primarily, when a number of people feel compelled to avoid a place or object, and this feeling or heuristic dominates, reflecting the sense that there is something wrong with the place. The quality of wrongness is represented by some sort of mark that may manifest itself in a number of ways. Stigma of place can stem from perceptions that it is dangerous, contaminated, physically unpleasant, immoral, risky, or inferior. Regardless of the circumstances causing stigma of place, they tend to share a number of common characteristics. First, stigmatized places conjure up negative imagery that in turn triggers strong emotional reactions from many people who live elsewhere. Avoidance of place as a way to minimize risk is a natural behavioural response. News media typically support and amplify the impression of qualities deemed unacceptable in stigmatized places with stories that repeat what is wrong with the place. The law of contagion transfers the stigma of place to local residents. People living within stigmatized places feel victimized, at the mercy of forces beyond their control. That leads to an overwhelming sense of helplessness (Flynn et al., 2001). Stigma of place can be a strong emotional force. For example, the Metropole Hotel gained much notoriety after the Chinese doctor who stayed in room 911 spread the disease to a dozen other international guests. The role played by the doctor from Guangzhou and room 911 in the global sars outbreak cannot be overemphasized. It was the subject of an investigation by the who that established that most of the initial cases, excluding those in China, could be traced back to the Metropole Hotel. One year after the outbreak, the hotel room in which the infected doctor stayed was renumbered out of existence. Hotel management, which once considered turning the room into a museum dedicated to the sars outbreak, removed the brass plaque with the infamous number and replaced it with the

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number 913. Every subsequent odd-numbered room on the ninth floor also had its number changed too (Taipei Times, 2004). Stigma associated with places results in economic losses to the affected communities as people exhibit avoidance behaviours to mitigate their personal risk. The who issued an unprecedented advisory, warning those travelling to defer non-essential trips to Hong Kong and China’s Guangdong Province, where the world’s first cases of sars surfaced. Toronto was not initially included on list of places to avoid due to sars. The travel ban was suggested for sars-affected areas including Hanoi, the rest of Vietnam, Hong Kong, Guangdong Province in southern China, and Singapore. At the same time Chinese officials admitted there had been three deaths in Beijing, about 2,000 kilometres north of Guangdong Province, as a result of the disease. In early April 2003 Australian Foreign Minister Alexander Downer, visiting the United Nations in New York to discuss the war in Iraq, publicly advised citizens not to travel to Toronto: “We love Canada, we have a lot to do with them,” he said. “Toronto is a wonderful city [but] I must tell the people what the problems are in Toronto … We must provide appropriate protection to the Australian people.” Several other countries, including Ireland and Spain, recommended that visitors not make unnecessary trips to Toronto and other sars “hotspots.” The us State Department issued an alert to warn its citizens that Ontario had declared a provincial health emergency due to sars. A British travel advisory also listed Canada and Toronto as places to be avoided. A major conference of 12,000 cancer experts was scheduled to occur in Toronto; its cancellation resulted in a loss of revenues estimated in the millions of dollars. Federal Health Minister Anne McLellan attempted in vain to overcome the now monumental worldwide negative public perception of Toronto and stigma around sars. She was reported as saying the travel alerts were an “overreaction,” and that if an individual takes “sensible and reasonable precautions, there’s absolutely no reason why you shouldn’t go to Toronto.” Her message, however, appeared out of place when other health officials were communicating the growing numbers of suspected and confirmed sars patients, still on the rise on a daily basis. It seemed strange that a federal public health official appeared more concerned about the resulting potential for economic fallout from lost tourism dollars rather than erring on the side of caution. McLellan suggested that

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the federal government adopt a public relations role to take steps to minimize the damage (Powell, 2003ab). The who issued a travel warning on 23 April 2003, after the second outbreak that affected mostly healthcare workers, recommending that “all but essential travel” to Toronto should be cancelled due to the outbreak of sars. Toronto’s tourism sector was hit hard by the World Health Organization warning against “unnecessary” travel. At the end of April 2003, then-Premier Ernie Eves announced the province would spend $118 million to counter the effect of the sars outbreak. The effect he spoke of was the stigma attached to Toronto (cbc News, 2003f). Toronto, Beijing, Hong Kong, and Shanxi Province and Guangdong Province in China were on the who’s list of destinations to avoid because of the sars risk. The recommended travel warning was issued for a three-week period; this attached the stigma of place to the Greater Toronto Area, marking it as a place to be avoided. Municipal officials were outraged by the travel ban but seemed more concerned about the economics and negative impacts on business than effects on the public or healthcare workers. Health officials believed that categorizing Toronto with Beijing or other areas of China as not having achieved safe levels of sars containment was a gross misrepresentation of the situation. Despite these complaints, Toronto was correctly added to the who travel advisory after sars was spread to another country from Canada, causing five new cases in health workers. This fulfilled one of the criteria for a travel ban: exporting new cases of sars and showing failure of containment. During the initial outbreak, Health Canada urged Canadians to delay or cancel trips to the most affected parts of Southeast Asia. It is surprising that Canadian officials so strongly opposed the who travel advisory once Toronto was included, given the fact that they issued similar statements only a few weeks previously, and had no complaints about the previous who travel bans that stigmatized Asian cities. People requiring medical care stayed away from hospital emergency departments in Ontario during the 2003 sars crisis and continued to avoid emergency rooms in Toronto for months after the outbreak was contained, due to stigma of place. The stigma of sars had a profound effect on emergency room (er) use in Ontario hospitals, according to the results of a study by the Canadian Institute for Health Information (cihi). There are more than five mil-

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lion patient visits to emergency rooms in Ontario each year, and there are 188 ers in the province. Due to stigma of place the number of people visiting emergency departments at the eight hospitals where the sars virus was detected fell sharply, by about 45 per cent at the peak of the outbreak in April 2003. The rate of visits for minor pain, sore throats, and similar conditions was down by 60 per cent in known sars-infected facilities at this time, and by 40 per cent across all other hospitals in the Toronto area. Other hospitals in the province of Ontario showed a 30 per cent drop in visits for less urgent cases. The drop in emergency department visits was sustained well beyond the sars outbreak. The data shows that people continued to stay away from Ontario emergency rooms for up to ten months after sars had been declared officially over in June 2003. Hospitals in uninfected areas well away from Toronto saw substantial reductions in emergency visits as well, about 16 per cent overall and 30 per cent fewer visits for non-urgent cases during the same time period. Patient numbers for serious conditions like major trauma or cardiac arrest did not drop throughout the sars outbreak. Reduction in hospital visits was due to a drop in visits for treatment of minor injuries and illnesses. Dr Tom Chan, medical director and chief of Emergency and Urgent Care at Toronto’s Scarborough Hospital, said the reduced numbers reflected the experience of the outbreak. “We saw a big drop in er use, particularly among loweracuity patients.” Surprisingly, Ontario hospitals outside of the Toronto area saw the same patterns to a lesser degree, demonstrating an extension of the stigma of place regardless of the true risk of sars (Picard, 2005).

overcoming stigma – toronto’s sars purification ritual In magical thinking, the law of contagion results in people and places that cannot get rid of the effects of stigma without first going through some sort of purification ritual. Such a ritual demonstrates to the individuals involved and to the broader community that coming into contact with the stigmatized places and people is no longer something to be afraid of. The process of undergoing a purification ritual signifies to the community that safety has been restored and the associated risks have been abolished. With sars in Toronto

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declared officially over on 12 June 2003, the city set about enacting its purification ritual in the form of a goodwill rock concert by The Rolling Stones. Unofficially nicknamed “sars-stock” or “sarsapalooza,” it was initially conceived as a way to tell the world that Toronto was now a safe place and free of sars (cbc News, 2003h). Local politicians saw the idea of a concert as a way to boost tourism and improve the city’s economy. The primary goal of the concert, then, was to help Toronto’s entertainment and tourism industries, which had been devastated, with losses estimated at over $300 million dollars (cbc News, 2003g). The twelve-hour outdoor benefit concert consisted of fifteen different musical acts that performed throughout the day at an operational airfield that had the capacity to hold more than 500,000 people. The concert was planned for and arranged in less than eight weeks in the late spring of 2003, allowing for only about six weeks of event planning by emergency medical services (ems). The same site had previously been used for a gathering of 600,000 people during the papal visit the year before. The experience of the previous event was very helpful in the planning of the sars benefit concert on such short notice. The main stakeholders involved in the concert included the concert promoter (a major beer company), Toronto’s Emergency Medical Services, the Toronto Police Service, Toronto Fire Services, Toronto Public Health, public transit, private security, food vendors, water vendors, and the current users of the airfield (an aircraft manufacturer). The concert was held on a 260-hectare (644 acre) active airfield that was in close proximity to local highway and transit links. Public facilities installed on the site for the day of the concert included 3,500 portable toilets, water, food and beer sales concessions, and accessible seating for disabled spectators. The concert area consisted of a large stage at the northeast corner of the airfield and an elaborate system of fences and video screens. More than 450,000 people attended the concert, according to ticket receipts, and weather conditions were partly sunny skies with a high temperature of 83.3°f (28.5°c) and a relative humidity of 41 per cent. Several musical acts preceded the headline band, The Rolling Stones, with one lesser-known American rock and roll band causing a stir in the crowd when some of the dancers appeared wearing sars masks. The lead singer said the masks were going to be removed symbolically during their performance as an allegory to show the defeat of sars by the nurses. The clever musical perfor-

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mance art was lost on many in the audience, with some near the stage yelling, swearing, and throwing garbage onto the stage to show their displeasure at seeing mask-wearing individuals in public – a visual presentation of contagion uncertainty. Singers made several references to sars throughout the daylong concert, reminding everyone of the purpose of the event. The concert also attracted a number of notable politicians who had been involved with decisions concerning sars and public health. The politicians attending the concert hoping to be associated with the good will it generated included Prime Minister Paul Martin, Agriculture Minister Lyle Vanclief, and Health Minister Anne McLellan; Premiers Ernie Eves of Ontario, Ralph Klein of Alberta, Lorne Calvert of Saskatchewan, and Gary Doer of Manitoba (cbc News, 2003g). The large number of people from outside the Greater Toronto region who participated in the daylong event, exposing themselves both to stigmatized people and place without ill effect, made the purification ritual complete. Attending the rock concert without harm proved to many in the extended community that both place and people were now safe from sars. The news media highlighted the event and wrote positive news articles that discussed sars and the normative benefits of the concert instead of focussing on any remaining uncertainty about containment. Newspapers ran features on the concert under headlines such as: “Toronto Turned Up Rock Decibels in Bid to Drown Out sars Fears,” and the New York Post ran a story with the headline, “The Rolling Stones – and Almost 500,000 People – Kicked Toronto Out of the sars Sickbed for Good.” The news coverage created a positive heuristic that sars was no longer a concern for the Greater Toronto region. While the rock concert was well suited to act as a purification ritual against the stigma of place, individual nurses who felt stigmatized post-sars remained largely unrecognized by the large, impersonal crowd in attendance. William Osler Health Centre, despite only having ten patients and thirty assessments during the two-and-a-half-month outbreak, and having treated far fewer sars patients than other Toronto area hospitals, managed to send the largest group of about 250 employees to the concert, including nurses, respiratory therapists, and physicians. This group, like all of the invited healthcare workers, was given free concert tickets and a special section close to the stage. The special status was meant to single out the healthcare employees, as a token of gratitude for their months of stress and overwork during sars. However, due to poor

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planning, they were dropped off by bus at the least-convenient gate and then had to push their way through the ever-growing crowd, taking them hours before they reached the special area reserved for healthcare workers, close to the concert stage (cbc News, 2003i). Other Toronto-area hospitals also sent groups to the concert. North York General Hospital, which had been hit the hardest by the sars outbreak in previous months, and whose overworked staff likely required more recovery time, unfortunately found itself responsible for providing emergency on-site hospital services for the concert. Organizing the seventy-six bed medical area and medical tents for the largest rock concert ever (the event was even bigger than Woodstock2) for half a million people on only four or five weeks’ notice left many of them feeling under- appreciated once again. For the nurses, the rock concert quickly became an added burden, with little personal benefit. One nurse echoed the thoughts of some other healthcare workers who avoided the concert being put on in their honour, saying that they didn’t even like rock music or attending ear-splitting concerts. As a purification ritual, the concert was aimed at countering the stigma of place and improving the economy. The large, impersonal concert did little as a ritual to help the nurses recover, falling far short of providing individual acknowledgement for their sacrifices during sars; it failed to appropriately acknowledge healthcare workers’ physical and mental suffering; it did not appropriately acknowledge healthcare workers who had died from sars; and it failed, miserably, to abolish the stigma of person. In most other careers we would not tolerate going to work everyday for months, placing ourselves at extremely high risk for infectious disease and death, and dismissively justify the risk as part of the job, but for nurses it is expected that they will accept higher occupational health risks. sars, however, went well beyond normal expectations of acceptable risk even for healthcare workers. The nurses were the real heroes of the sars outbreak, but unfortunately were heavily traumatized and stigmatized; afterwards it seemed that no one noticed their collective sacrifice or cared to take the time to thank them appropriately.

conclusions Both Frazer (1959) and Mauss (1972) described a belief system that is widespread in many cultures to explain how things that have

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been in contact may influence each other through transfer of some of their properties by an essence. This idea of “once in contact, always in contact,” occurs even if exposure is brief. Rozin, Millman, and Nemeroff (1986) showed that this cultural belief system, which they refer to as the law of contagion, was common in many cultures and even our present culture. sars, with its high degree of uncertainty, exhibited this law of contagion as people and place were affected due to their physical association. The main outcome of the law of contagion during the sars outbreak was heavy stigmatization of easily identified healthcare workers by a fearful public. Stigma occurred in all countries that reported multiple cases of Suspect sars infections. In Canada, intensive media reporting that highlighted uncertainty, conflicting expert opinion, an increasing number of infections, the increasing cumulative number of deaths, and the healthcare system’s lack of capacity, tended to fuel attitudes of fear and stigma on the part of those outside the Toronto area. Avoidance of place (Toronto) resulted in economic losses in local tourism, meeting cancellations, hotel booking cancellations, and significantly reduced the amount of travel into Toronto. Due to the association of sars and China as the original source of infection, many Asian Canadians and their businesses in Toronto experienced severe economic losses and extreme stigma. After sars containment, a cultural purification ritual in the form of a large public display was held in Toronto to signal to those outside the Toronto area that there was no longer a risk of disease. Interestingly, the news media that helped to promote conditions that fuelled the stigma was also used to promote the purification ritual. The rock concert, as purification ritual, did help signal to those outside of Toronto that sars was over, but it did little to improve the situation of healthcare workers who had been psychologically stressed by the ordeal. The effects of the outbreak, extended work quarantines, and heavy stigma experienced by healthcare workers left them feeling isolated and depressed. Some nurses exhibited numerous indicators for post-traumatic stress disorder (sleeplessness, loss of appetite, anxiety, issue avoidance, and depression). The loud, impersonal, one-evening event, with intense media coverage that focused on the celebrity performers and the event itself, once again left healthcare workers feeling marginalized.

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The Need for Sex- and Gender-Sensitive Supports for Healthcare Workers during Infectious Disease Outbreaks WITH CAROL AMARATUNGA, KAREN P. PHILLIPS, EILEEN O’CONNOR, TRACEY O’SULLIVAN, MADELINE BOSCOE, LOUISE LEMYRE, AND DANIEL KREWSKI

There was a perception that management might listen more to men than to females. Focus group participant (Amaratunga et al., 2006a)

the gendered history of nursing Differential health impacts for men and women are influenced by the interrelations among gender, sex, and power at societal and institutional levels (Wingwood and DiClemente, 2002; World Health Organization, 2002). Nursing is a profession marked by these gendered gaps in power. Historically, the profession has been shaped by deeply rooted, gendered notions of females’ perceived natural abilities to provide caregiving, nurturing, support, and assistance (Dodd and Gorham, 1994; Strong-Boag, 1991). In the eighteenth and early nineteenth centuries, the work of nursing was delegated to female family members, as it was believed that caring for others was a natural extension of women’s perceived maternal and feminine natures, was not necessarily skilled labour, and did not require compensation (McPherson and Stuart, 1994). By the late nineteenth century, hospital care and medical services rapidly expanded, and a system was developed to train middle class women in nursing based

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on a hospital apprenticeship model (Bates et al., 2005). In the early to mid-twentieth century, nursing was professionalized. Nurses lobbied for licensing legislation and established professional organizations, journals, and university training, including science-based courses (McPherson, 1996). The gendered origins of the profession of nursing resonate in current issues around defining and compensating skilled labour, the ambiguous power differential in the triad (doctor, nurse, patient) regarding adequate voice, power, control, and responsibility in their work environments, and the lack of recognition of the double work day some women grapple with to perform as nurses in the public sphere and caregivers in the private sphere. According to the 2005 National Survey of the Work and Health of Nurses, close to 95 per cent of the estimated 316,000 nurses employed in Canada are women (Canadian Institute for Health Information, 2006), so women clearly have a vested interest in health human resource planning. However, recent studies show gender- and sex-specific issues have been largely overlooked in healthcare planning and service delivery (Grant, 2002; LagroJanssen, 2007). This is congruent with the traditional hierarchical system that has shaped the structure of healthcare organizations, impacting how issues around occupational health planning, worker safety, and patient care have been defined and addressed (Ceci, 2004). As studies in the last decade have demonstrated, the impacts of healthcare planning extend far beyond individual healthcare workers to their patients, families, communities, and broader society. As Donner (2003) described, “by highlighting gender differences, planners can identify and give priority to those areas where gender-sensitive interventions will make a difference.” Decisionmakers can improve disaster response capacity by taking these gaps into account to more effectively support healthcare workers and improve capacity. While sex is a biological distinction between men and women, gender is socially constructed and refers to cultural norms, behaviours, and perceptions assigned to men or women, which are unique to a specific culture or society (Lagro-Janssen, 2007). Sex- and gender-based analysis recognizes the different societal and institutional contexts that influence women and men’s lives and, by extension, their health. Gender is recognized as an important determinant of health, and it is a fundamental aspect of a population health perspective (Donner, 2003).

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Given that most healthcare workers are women, workplace health, safety, and emergency preparedness plans should develop and implement sex- and gender-specific supports. Sex- and genderbased issues pertaining to for effective delivery of health services on a daily basis must be considered, as well as issues that that need to be mitigated during infectious disease outbreaks to better support healthcare workers in their roles as first responders. Healthcare workers include a broad range of occupations essential to the delivery of health services and include nurses, doctors, allied health professionals, technicians, technologists, and ancillary care workers. It is important that sex and gender be included among the factors that influence the health, availability, preparedness, and willingness to work of this group of healthcare workers. The gendered context of the healthcare work environment was examined by selected Canadian research studies and reports. Selected studies include the Caring About Healthcare Workers (cahcw) project (Amaratunga et al., 2006a,b) conducted three years after sars, which documented the opinions, thoughts, and reflections of Canadian Emergency Department and Intensive Care Unit nurses who worked during the outbreak. This study included focus groups, a national Web-based survey of emergency and critical care nurses, and an analysis of multi-jurisdictional emergency plans using an interdisciplinary, population health-based approach. Its findings include how sex and gender roles act as determinants influencing nurses’ health and how these determinants should be integrated into preparedness planning. Quotations from this study used in this chapter were taken from one focus group interview question where respondents were asked whether women and men experienced the sars crisis differently. Other studies include the sars Commission Final Report (Campbell, 2006a) and the Annual General Report from the Ontario Nurses’ Association in 2003. Generalizations across sex and gender cannot be made without considering the biological, psychological, and social contexts that impact men and women in different ways (Jackson et al., 2006). Incorporating sex- and gender-based analysis entails asking new questions to produce new knowledge on health issues related to the workers most affected. The ability to incorporate gender issues into infectious disease outbreak management programs improves the continuum of care throughout all phases (prevention, preparedness,

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response, and recovery) by developing a more refined and informed set of planning tools for pandemic preparedness. Gender mainstreaming is a strategy to ensure that the different effects of sex and gender are considered at all levels of policy development and implementation. Incorporating gender mainstreaming in medical curricula allows clinicians to be aware of sex- and genderspecific needs of patients (Lagro-Janssen, 2007). Another important step is its inclusion in assessing health service delivery and quality (Jackson et al., 2006; Wilson and Jackson, 2006). A sex- and gender-based analysis that incorporates gender mainstreaming for responding to infectious disease outbreaks, such as pandemic influenza, serves to highlight gaps in preparedness. While representative quotations from the Campbell Commission report and the cahcw surveys have been included, more qualitative analysis is required to determine overall impacts to healthcare workers. Disaggregation of data by sex is a first step toward sexand gender-based analysis but it is not enough to interpret research findings accurately. Questions about sex- and gender-specific context must be asked at each stage of research design to determine if methods for data collection and analysis are capable of capturing differential impacts adequately (Jackson et al., 2006). Recognition of the value of sex and gender in healthcare research and planning is now reflected in Health Canada’s Women’s Health Strategy, “to ensure that Health Canada’s policies and programs are responsive to sex and gender differences and to women’s health needs” (Health Canada, 2000; 2003).

sars and gender-based supports The 2003 global outbreak of sars showed the vulnerability of Canada and other countries’ public health preparedness plans. Sex and gender are now recognized as important considerations in emergency preparedness, following Canada’s experience with sars (Health Canada, 2003). Two of the three Suspect and Probable cases in Canada that resulted in the deaths of healthcare workers were female nurses (National Advisory Committee on sars and Public Health, 2003). For the duration of the sars outbreak, many healthcare workers were quarantined, placed on continual workquarantine, and worked extended hours. Further, many nurses

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faced ethical issues involving work-family conflicts, grief, stress, anxiety, personal loss, and trauma (Amaratunga et al., 2007). Dealing with added occupational health risks is an inherent part of the healthcare profession, and even more so during infectious disease outbreaks, where transmission of infection to healthcare workers is increased. During outbreak crises, there is an increased incidence of excessive mental or physical strain from occupational conditions and uncertainty. The impacts manifest as chronic stress affecting the long-term health of those on the front lines. There are, in the context of gender mainstreaming and gender-based analysis, factors in the healthcare work environment that increase (or decrease) the risk differentially. Analysis of these factors can help to determine the types of gendered instrumental, informational, and emotional supports that are needed to reduce the risk to healthcare workers. Several sex- and gender-based factors that affect gender-based supports include power, attitudes and values, roles, and relationships. Instrumental, informational, and emotional supports affected by the gender-based factors as described previously by Heaney and Israel (2002) can be reframed with sex and gender in mind. In general, instrumental supports for healthcare workplaces refer to organizational programs, protocols, occupational supports, and interventions that assist healthcare workers in performing their occupational roles (e.g. human resource mobilization and provisions for protective equipment). Informational supports pertain to all forms of information sharing and communication provided to front line healthcare workers, as well as reception of feedback originating from the front lines (e.g. all forms of communication used to impart knowledge, notices, and directives). Emotional supports refer to any intervention intended to relieve the negative emotional impacts of the work environment on healthcare workers (e.g. provision of space to allow employees to grieve after the death of a patient and on staff counselors). In each category of support, sex and gender play significant roles in the type of support designed and used, and its efficacy. Power Throughout the course of the sars outbreak in Canada, front line nurses voiced concern over the confusion pertaining to personal

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protective equipment (ppe) and a lack of clear communication regarding best practices for personal safety.1 The lack of power and voice of the nurses revealed the incongruence between gender and power. The Campbell Commission report (2006a) details this power differential. When nurses were asked about wearing protective equipment, one nurse responded, “Many nurses raised concerns about ppe,” and another stated, “in the beginning and after first outbreak we were told to remove our ppe – even masks. Nurses were very confused. Those who kept our masks on were told by our medical director to take them off, they were no longer needed even though we had many patients in er at the time with respiratory problems”2 (Campbell, 2006a). Frustration at this lack of power resulted in hundreds of nurses staging a demonstration outside the Scarborough General Hospital in Toronto to make their voices heard. The Annual General Report from the Ontario Nurses’ Association in 2003 highlighted the 4 June gathering. “sars was a major focus of ona activity from March through June. A rally at the Scarborough General Hospital, site of the first outbreak, was one of the ways ona called attention to the plight of front line nurses affected by the outbreak” (Ontario Nurses’ Association, 2003). The nurses wanted better protection for healthcare workers treating sars patients (instrumental support), increased pay for full-time nurses to match that of agency nurses (instrumental support), and a public inquiry into the handling of the outbreak (instrumental, informational, and emotional supports) (Habib, 2003b). When these concerns of front line sars nurses were dismissed, a growing sense of distrust developed. Toronto nurses expressed the sense that they were losing control of their work environment, in particular because their opinions, concerns, and suggestions were not considered by senior managers or physicians, thus highlighting the lack of informational supports (Amaratunga et al., 2006a,b). Canadian nurses who participated in focus groups conducted as part of the cahcw project expressed resentment at their lack of professional authority to directly challenge physicians who were not following infection control protocols during sars. Instrumental supports to assist with this type of situation could include cultural changes that address hierarchical boundaries between professions, and mechanisms for reporting concerns (Amaratunga et al., 2006a,b).

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The lack of informational and instrumental supports related to power was reported by O’Sullivan et al. (2007, 2008). A national survey of Canadian emergency room and intensive care unit nurses indicated that many healthcare workers were not aware of their institutional emergency plans. In healthcare organizations, timely and adequate information flow is important in an emergency. Information about different aspects of an outbreak, for example the newest updates on policy, changes to infection control, and patient care are an essential support for front line staff. Healthcare workers at all levels need to know the protocols, risks, and current status of the outbreak so they can inform their families and the public, and take suitable actions themselves. These examples depict the extent and impact of power differentials that have been perpetuated by a long-standing institutional hierarchy and occupational culture. Physicians, a profession comprising mostly men (67.5 per cent), have more power, prestige, and are regarded as having more credibility than nurses, 95 per cent of whom are women (Canadian Institute for Health Information, 2005; Canadian Institute for Health Information, 2006). Nursing is a good example of sexual divisions of labour and power that have been maintained for decades. The result has been undervaluing of nursing activities and the profession as a whole, which is regarded as women’s work (Evans and Frank, 2003). Women are not alone as a marginalized group in nursing. Male nurses report feeling the power differential, and experience a lack of respect due to their association with a feminine profession. As described by Evans and Frank (2003), “men nurses often emphasize the type of nursing specialty work they do as a means of minimizing the feminine and stigmatized image of nursing … introducing oneself as an emergency room nurse focuses attention on the higher status of the emergency work, not on the lower status of nursing itself.” Power is also linked to allocation of resources. The provision of ppe is an important instrumental support for healthcare workers, for occupational health and safety and also to prevent widespread transmission of disease. Nurses from the focus groups were concerned about the lack of fiscal resources in the healthcare system for adequate supplies. Healthcare workers also expressed concern about the power of financial managers to limit spending on protective equipment and supplies for infection control (Amaratunga et al., 2006a).

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Difficulties surrounding ppe were shared by both men and women during the sars outbreak. One cahcw focus group respondent highlighted the problems with masks. “One of the things that men had to deal with was that they had to shave their beards … some people have personal identity [issues] with their beards, and other[s] … for religious reasons have beards, so that is an issue.” Other problems related to lack of gender-based instrumental support were revealed by focus group participants who indicated poor planning for gender-specific personal equipment. “We realized the masks were so large as they were designed for men. Most of the ppe equipment was designed for males.” Another respondent indicated that the sizing of latex gloves ordered to fit the majority of workers, who are women, was sometimes a problem for men because they were not large enough. The issue of equipment and fitting is directly linked to the ability of healthcare workers to protect themselves. It was a real issue that contributed to the stress and anxiety of many nurses (Amaratunga et al., 2006a; Campbell, 2006a). Adequate access is an important informational support for front line healthcare workers, who are putting their health and in some cases their lives on the line as responders during infectious disease outbreaks. Withholding or limiting access to information is an act of power and reinforces the notion of power differentials within a labour force. A strong literature base highlights the importance of recognizing the interrelationship between gender and power (Wingwood and DiClemente, 2002). Differential health impacts for men and women are influenced by the interrelations between gender and power at societal and institutional levels. This gendered context is based on long-standing beliefs and assumptions, which form the foundations of social structures characterizing the climate and culture of healthcare, and impact nurses and other professionals in their everyday work. Specifically, the major social structures that create gendered gaps in power include: 1) sexual division of labour; 2) sexual division of power; 3) social norms and affective attachments; and 4) anatomical and biomedical properties (Wingwood and DiClemente, 2002). As with all social inequities, the impact is magnified during disaster situations (Enarson and Morrow, 1998), emphasizing the need to ensure that appropriate supports are in place before the next large-scale outbreak or other disaster. Partic-

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ular consideration must be given to gendered ethics of care, the gendered history of nursing, and gender-sensitive supports for emergency planning of healthcare. With regard to occupational supports, the structural arrangement of healthcare organizations, including professional hierarchies, distinctly gendered occupations, and high effort demands make power a central theme in the healthcare work environment (Ceci, 2004; Evans and Frank, 2003). The structure also extends to the role of healthcare workers during disaster management (Amaratunga and O’Sullivan, 2006). Power differentials result from imbalances in control of resources, work assignments, scope of practice, access to information, and attributed authority (Bolman and Deal, 1991). All of these influence the provision and impacts of instrumental, informational, and emotional supports. Attitudes and Values One of the main findings of the Ontario Nurses’ Survey was that more than half of the nurses felt their sars work was not adequately respected (54.5 per cent); 42 per cent did not feel their work was respected, while 12.5 per cent were unsure. The nurses’ perceptions of disrespect were summed up by a respondent who stated, “We were treated so poorly considering what we had to go through. We were not treated with respect.” A second participant stated that nurses were “poorly protected. It was like we were disposable” (Campbell, 2006a). Lack of respect is a common theme in the literature and is often expressed by nurses on the front lines of healthcare (Ontario Nurses’ Association, 2004). In healthcare settings, authority and recognition are attributed to masculine characteristics, such as exerting control, “rational” thinking and speaking, and direct communication styles. In interviews with thirty-six head nurses in Sweden, Nilsson and Satterlund Larsson (2005) found that female head nurses reported feeling an expectation and need to demonstrate masculine-style leadership. In the same study, one male head nurse admitted to experiencing a “naturally” attributed authority in this type of organizational culture, based on his sex. As Nilsson and Satterlund Larsson explained, being male automatically confers greater authority. This finding supports the trends in nursing which show women do not progress vertically into leadership positions as

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quickly as men (Nilsson and Satterlund Larsson, 2005; Brown and Jones, 2004). Evans and Frank (2003), in their qualitative study with male nurses, reported that men in this profession feel pushed toward leadership and administration, and away from bedside care; the same finding was discussed by Nilsson and Satterlund Larsson (2005). Brown and Jones (2004) cited flexible work schedules as an important family-centred organizational support that assists women in coping with dual-role conflict; however, it jeopardizes career paths for women because frequent breaks and part-time status do not facilitate progression through the ranks. An additional element of organizational climate and culture within healthcare institutions is attitudes that project positive appreciation of the roles of healthcare workers on the front lines, compared with negative perceptions which depreciate the contributions of healthcare workers. In Canada, government fiscal policies throughout the 1990s resulted in less money being directed toward Ontario healthcare, forcing the system to reorganize. Much of the reorganization occurred in the acute-care sector of the healthcare system. Nurses, as the largest occupational group within the healthcare system, were disproportionately affected by these efforts (Spence Laschinger et al., 2001). Burke and Greenglass (2000) examined the effects of hospital restructuring and downsizing on full-time and part-time nursing staff. Data collected from nursing staff included measures for personal and situational characteristics, hospital restructuring and downsizing variables, work outcomes, psychological well-being indicators, and work-family experiences. Full- and part-time workers described hospital restructuring and downsizing as having similar impacts on them. Nurses reported greater emotional exhaustion and poorer health, and indicated greater absenteeism. Due to budget constraints, many healthcare institutions adopted a “just-in-time” staffing policy. Hospitals employed a smaller number of full-time workers, increased the number of part-time workers to take over regular shifts, hired more casual staff, and became increasingly dependent on agency nurses and overtime to cover shifts. The change in policies resulted in reduced surge capacity. Baumann et al. (2006) concluded that the consequence of fewer staff was increased overtime that placed the health of nurses in jeopardy. Casualization resulted in some nurses working for multiple employers.

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During the sars outbreak in Toronto, Code Orange, which prevented nurses from working in more than one hospital, stretched nursing resources to their limits. Nurses confirmed that the lack of capacity in the healthcare system increased the vulnerability of the entire system (Baumann et al., 2006). Moreover, casualization has undermined nurses’ level of power, roles and responsibilities, and entrenched historically-held gender values and attitudes. The lack of recognition, the view of nurses as a fiscal liability in the healthcare system, and casualization of nursing labour (Burke and Greenglass, 2000) do not demonstrate appreciation of the contribution of the employee to the overall response effort. Instead, it is a perspective that views the healthcare worker as an economic liability, where work conditions must be controlled to reduce the fiscal impact on the organization due to labour restrictions imposed by union agreements. Again, in terms of divisions of labour and power, nurses are vulnerable to job instability given the piecemeal positions offered to many nurses across the system. Many nurses do not work full time and must work two or three jobs to make up fulltime nursing hours. For nurses who bear the role of lone parent in their household, or sole breadwinner, this pressure creates added stress, which is exacerbated during disaster conditions, particularly biological events that pose personal occupational health risks (Burke and Greenglass, 2000; Baumann et al., 2006). Organizational, instrumental, and emotional supports that dismantle negative or ambiguous attitudes toward front line healthcare workers are needed to ensure that work policies and conditions reflect the genuine value of employee contributions to the provision of essential and quality healthcare services. Instrumental supports include investment in proactive health human resource mobilization, and retention strategies. Emotional supports include strategic actions to mitigate negative hierarchical attitudes toward front line staff, most of whom are women. When examining the work climate and culture for front line nurses, it is important to acknowledge the projected values of healthcare institutions. The health of the healthcare workforce is of paramount concern, but there are continual critical health human resource shortages, high fatigue, employee burnout, and significant levels of work stress, particularly among nurses (Canadian Institute for Health Information, 2006). By prioritizing the health of healthcare workers, institutions will enhance perceptions of organi-

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zational support among staff, enhance commitment, and protect overall response capacity for disasters by investing in the most important assets of their organizations. As described by Rhoades and Eisenberger (2002), workers who perceive high support from their organizations, “generally find their job(s) more pleasurable, are in a better mood at work, and suffer fewer strain symptoms such as fatigue, burnout, anxiety, and headaches.” Roles A role is defined as “a set of activities or behaviours that others expect an individual to perform” (Bellavia and Frone, 2005). During sars, many healthcare workers faced intense conflict between their need to care for the health and welfare of their families and the increased requirements of their commitment at work. Child and eldercare difficulties were rampant, as many staff and family members at daycare programs were afraid of contracting sars, and assumed all healthcare workers who worked in hospitals were contagious. Nurses in the focus groups for the cahcw study explained that the provision of child and eldercare services and resources are essential instrumental and emotional supports, ensuring that staff can come to work during biological outbreaks and pandemics (Amaratunga et al., 2007). Nurses who participated in the focus groups for the cahcw study revealed a second perceived difference in the way male nurses were given recognition compared with female nurses. Many believed that managers and physicians more readily listened to male nurses. In these same focus groups, it was believed that male nurses were allocated certain tasks based on the fact they were male. For example, they would be asked to do more heavy lifting. Men also faced dual-role conflicts, being trained as caregivers but expected to perform other roles based on their gender (Amaratunga et al., 2006a). Nilsson and Satterlund Larsson (2005) found that male nurses were directed toward specific tasks. In their study, the male nurses reported being asked to do technical tasks, such as fixing malfunctioning equipment, whereas female nurses were assumed to be better at relational activities with patients, based on gendered assumptions of care and emotionally-oriented communication. The vertical division of labour and gender-based assignment of tasks within front line nursing presents differential risks for women

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during outbreaks if they have closer contact with patients. Nurses who worked on sars teams or at the front line in emergency departments were at greater risk, and recognition of this fact should be incorporated to improve gender-based supports. When multiple roles become overwhelming, negative stress can result and have detrimental effects on the health of both men and women nurses. In the case of nurses on the front lines during a biological outbreak, role conflict is exacerbated by perceptions of risk and difficult circumstances related to working extended hours, problems finding child care, the need to provide care for ill family members, or activity restrictions resulting from quarantine. In a predominantly female profession, the need to consider caregiving roles (social and emotional supports) and their potential conflict with professional obligations is essential (Amaratunga et al., 2007). Relationships Within any organization, vertical and horizontal relationships are critical determinants of organizational climate and culture (Bolman and Deal, 1991). Supervisor management has a tremendous impact on employees’ feelings of work satisfaction and organizational commitment, as well as overall stress levels (Rhoades and Eisenberger, 2002). Within the gendered hierarchy of healthcare organizations, inter-professional relations tend to vary according to demographic composition. In a study by Zelek and Phillips (2003), power differentials in relationships were due to professional hierarchies, gender, and nurses’ behaviour toward physicians that was dependent on the sex/gender of the physician: “female nurses appear more comfortable approaching and communicating with female doctors, but are also more hostile toward female physicians’ use of medical authority.” Zelek and Phillips (2003) suggest that the gender hierarchy, which predisposes male physicians to have more power over nurses, is diminishing as a result of the feminization of medicine. The increase in the number of female physicians is influencing the organizational culture of healthcare professions.

conclusions A critical analysis of the gendered nature of the healthcare work environment can reveal significant gaps in the ability to achieve improved preparedness planning, response, and recovery. The

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historical conceptualization of the nursing profession is based on the gendered assumption of caring, caregiving, nurturing, and assisting someone else more qualified. Due to the gendered character of their profession, some nurses felt ill prepared and under-supported during their front line response to sars (Campbell, 2006a). Widespread mistrust, structural hierarchies, pre-existing cultural attitudes, poor communication, lack of disaster training, scarce resources, and significant dual-role conflicts plagued the front line sars nurses. These negative characteristics are important symptoms of a troubled healthcare system based on long-standing gendered divisions of labour and power, and professional stereotypes and hierarchies. Gaps in the instrumental, informational, and emotional supports for healthcare workers were evident during the sars outbreak in Canada. These supports would have helped nurses to ameliorate the family and work-life balance issues pertaining to family caregiving. These are important considerations for emergency planning and policy planners within the healthcare system. Long-standing cultural assumptions within the healthcare system contribute to perpetuating gendered hierarchies with respect to communications, access to training, and the provision of social supports. The present gaps not only influence the daily healthcare work environment, but also have implications for institutional and community response capacity. Gender-sensitive and family-friendly organizational supports are required if Canada’s capacity to respond to pandemics and biological disaster events is to be improved. The challenge facing policy- and decision-makers is how best to redress these shortcomings and help front line healthcare workers do their jobs. A thorough sex- and gender-based analysis of conditions and prerequisites on the front line will contribute to a culture of confident preparation. The adoption of gender-sensitive planning will go a long way toward advancing emergency preparedness in Canada. Decision-makers and policy-makers would be well advised to listen to the voices from the front lines and incorporate their risk perceptions into their planning processes to reduce power, attitudinal, value, role, and relationship differentials. Doing so will provide a diverse suite of essential supports for healthcare workers and increase the system’s capacity to respond in case of a pandemic. Based on a gender-sensitive analysis that shows the lack of supports for various factors, policy changes can improve healthcare worker supports during biological outbreaks. Recommendations

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for gender-sensitive instrumental supports to enhance response capacity include providing adequate, paid disaster training. This will give nurses the knowledge and help develop skills needed during outbreak events. Such training should be provided at regular intervals for all front line healthcare professionals, including parttime and casual staff. One of the main problems pointed out by Justice Campbell in his report was the difficulty encountered in mobilizing human resources during the sars outbreak. There needs to be adequate human resource mobilization and surge capacity planning to protect baseline health of front line staff who are vulnerable to chronic fatigue, isolation effects, and burnout, which in turn can lead to illness and withdrawal from the profession. Acknowledgement and recognition of the important role nurses play, and their collective expertise, experience, and courage at the front lines during biological outbreaks, would be a valuable emotional support. This recognition of the value of nurses is important for nurse retention and job satisfaction. New policies should seek to create opportunities for nurse participation and inclusion in decision-making and planning throughout all phases of disaster management, including prevention, preparedness, event, and recovery. Policy should incorporate the awareness of occupational stress and emotional and psychosocial impacts that healthcare workers face from conflicting roles between work and home responsibilities. Finally, provision of adequate support services during pandemic events is needed to help healthcare providers balance work and family responsibilities. Supports could include childcare, elder care, pet care, transportation to and from work during work quarantines, and adequate laundry services within healthcare centres (to enable nurses and personal care workers to leave work in clean clothing and footwear, reducing risks to family or friends) (Armstrong et al., 2006; Amaratunga et al., 2006a,b; Amaratunga et al., 2007). In conclusion, it is evident that several consistent structural weaknesses exist at the front lines of the Canadian healthcare system. During infectious disease outbreaks and quarantine conditions, these weaknesses have the potential to undermine the confidence and performance of healthcare workers. Furthermore, the deficiency of instrumental, informational, and emotional supports contributed directly to healthcare worker burnout, increased stress, and high levels of fatigue during the 2003 sars outbreak. New pol-

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icies can be implemented to minimize the lack of supports. During the next pandemic it is imperative to have a ready, willing, and prepared healthcare workforce with adequate surge capacity, based on the appropriate gender-based supports.

ac k n ow l e d g m e n t s The cahcw study discussed here was funded by the Canadian cbrn Research Technology Initiative (crti), Defence Research and Development Canada. Thanks to the healthcare workers and nurses who participated in and contributed to the various focus groups discussed in this chapter. affiliations of co-authors Carol Amaratunga: Faculty of Health Sciences, University of Ottawa; Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa Karen P. Phillips, Eileen O’Connor, and Tracey O’Sullivan: Faculty of Health Sciences, University of Ottawa; Women’s Health Research Unit, Institute of Population Health, University of Ottawa Madeline Boscoe: Canadian Women’s Health Network, coordinator, Policy Advice and Advocacy Program, Women’s Health Clinic, Winnipeg Louise Lemyre: Gap Santé, Institute of Population Health, University of Ottawa; Faculty of Social Sciences, University of Ottawa Daniel Krewski: McLaughlin Centre for Population Health Risk Assessment, Institute of Population Health; Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa

ked disease response

8 SARS

Hospitals and Infectious Disease Response

I assisted with the intubation of a patient with sars and assisted with an intubation of another patient suspected to have sars. It took phone calls to occupational health, infection control, our director, and human resources, and many more days of waiting before they would change their minds, recognize the reality of the situation and allow us to order the good masks. Keith Olimb, president of the College of Respiratory Therapists of Ontario

A national survey conducted just three years before the outbreak of sars in Toronto found that as many as 80 per cent of hospitals in Canada, when analyzed, fell seriously short in preventing patients from getting hospital-acquired infections. The survey, entitled Resources for Infection Control in Hospitals, was conducted by a group of medical specialists who direct infection control programs in approximately thirty hospitals across the country. It involved 238 hospitals in 150 hospital systems and evaluated human and physical resources, as well as the programs that were in place to use these resources to prevent hospital-acquired infections. All Canadian hospitals with more than eighty acute-care beds were invited to participate, and a majority (73 per cent) participated, showing how seriously hospital administrators regard the problem and actively want to improve the situation with cost-effective solutions. The study revealed there were deficits in the identified components of effective infection control programs. The main recommendation was greater investment in resources to meet recommended standards of infection control that would in turn reduce morbidity, mortality, and expenses associated with nosocomial infections (Zoutman et al., 2003).

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After the sars outbreak, hospital infection control became one of the top issues. The outbreak showed how vulnerable the healthcare system was, how poorly hospitals were equipped to deal with infectious disease, and how they attempted to prevent the spread of infectious disease. Dr Zoutman, an epidemiologist and director of Infection Control Services at Kingston General Hospital in Kingston, Ontario, stated that the study’s findings, just prior to the sars outbreak, were disturbing. It revealed that in Ontario, “Our hospitals are not safe enough.” Even though the threat of sars is over, the study should still send a strong message to all hospitals in Canada that other hospital-acquired infections (equally devastating to staff and patients) will continue to occur and cause added mortality unless improved infection control measures are put into place. Statistics gathered by the Community and Hospital Infection Control Association of Canada indicated that about 250,000 patients a year experience infected surgical wounds, blood infections, and antibiotic-resistant organisms while in hospital. Worryingly, approximately 8,000 of these patients die per year as a result of hospitalacquired infections. The survey contended that hospitals require a higher level of infection control investment and management. Despite this fact, almost half of Canadian hospitals fell short of the minimum recommendations for adequate numbers of infection control staff. This suggested that human resource capacity is relatively weak in most Canadian hospitals. If sars had occurred in other hospitals in Canada, given the same amount of forewarning, many would have experienced similar effects of fatigue and increased stress to healthcare workers. All of the expert panels convened to study the Canadian sars outbreak pointed out the fact that human resource capacity was a critical component for infectious disease outbreak control (Medical News Today, 2003b). Other contributing factors prior to the spread of sars in Toronto included drastic budget reductions to public health units, increasing emergency room overcrowding, the elimination of full-time nursing positions, the casualization of nursing jobs (this increased movement of healthcare workers between institutions), shuttling of patients between institutions for specialized care, inadequate infection control planning, lack of infection control training, and the lack of protective equipment. A factor that compounded the responsewas the poor development of communication systems. Toronto doctors were slow to identify the first sars victims, appar-

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ently because they were not alerted quickly enough to the possibility of a new disease with pneumonia-like symptoms. For example, when Toronto public health officials first discovered that there was a cluster of cases of infectious disease late one night in March 2003, they did not have the emergency phone numbers for Health Canada, the World Health Organization or Toronto-area doctors, to send out information and warnings. The problem was a lack of preparedness and foresight, compounded by the fact that Ontario’s health system had already been stretched to the breaking point by years of chronic underfunding and staff shortages. In Ontario, there was a lack of coordination and communication between various levels of government in the crucial first weeks of the outbreak that added to the confusion. The common practice of shuttling patients from one hospital to another was an important factor in the spread of the disease between hospitals, but so was the movement of healthcare workers between hospitals, as many nurses and doctors routinely work parttime at two or more hospitals. Toronto’s hospitals have particular specialties and thousands of patients are transferred between them each day in order to receive the best treatment from doctors and nurses with the most experience and specialized equipment. As a result of specialized patient care, sars-infected patients and medical staff spread the infectious disease from one hospital to another. It was estimated that more than 70 per cent of the early sars transmissions were solely attributable to Toronto hospital practices. While the number of individuals infected with sars during the outbreak was relatively small (only a few hundred) it led to significant loss of public trust in Canada’s public health system. The news media covered the controversial aspects of the situation, focusing on the “unreliability” of hospitals and the difficulty they had controlling the outbreak (Leahy, 2003). Since containment of sars, Toronto area hospitals have actively pursued ways to improve capacity and implement new practices to deal with infectious diseases (phac, 2003e). The main hospitals involved in responding to the sars outbreak included: St. Michael’s, Scarborough Grace, North York General, York Central, and the William Osler Health Centre. Each hospital’s experience was different with respect to sars, which required slightly different operational responses from each institution. This chapter outlines the activities of the hospitals that were most involved. Their experi-

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ence during the outbreak, their response to the disease, and how they dealt with the situation is reviewed. The sars outbreak resulted in valuable lessons learned, providing improvements for infectious disease control.

st. michael’s hospital and sars St. Michael’s Hospital is a prominent hospital in Toronto with approximately 5,000 staff members and 590 hospital beds (506 acute care, 64 intensive care, 20 nursery). During the sars outbreak, St. Michael’s Hospital had no patient-to-patient, patient-tostaff, or staff-to-staff transmission of the disease. This hospital’s responses to sars1 and sars2 were not the same. During sars1, between 9 March and 25 April, St. Michael’s had four Suspect sars patients and two Probable cases. An additional 199 patients were placed on contact and respiratory precautions. The high-risk group included patients transferred to St. Michael’s from other category 2 and category 3 hospitals for tertiary care. Throughout sars1, St. Michael’s remained a category 1 hospital that supported the acute care needs of the local community, and it continued to provide for additional urgent and emergency cases, including cardiovascular surgery, critical care, and trauma, essential regional and provincial services. During the first outbreak St. Michael’s acted as a system resource for critically ill, non-sars patients, and only treated a small number of patients with sars. During sars2, between 23 May and 30 June, St. Michael’s Hospital cared for 13 patients under investigation, 4 Suspect, and 3 Probable cases of sars. An additional 178 patients were treated under respiratory and contact precautions. During sars2, St. Michael’s was upgraded to a category 2-status hospital. Between 23 May and 4 June, 191 staff and physicians were on a ten-day home or work quarantine as a result of exposure to sars patients transferred from other facilities. During sars2 the hospital dealt with more sars patients and kept a watchful eye on many potential contacts, with reduced hospital activity due to closed wards. sars had a significant effect at St. Michael’s Hospital, resulting in the cancellation of most elective surgeries for three months; in addition, planned education events were either cancelled or postponed. To deal with sars St. Michael’s, like other hospitals, implemented a Code Orange and instituted a twenty-four-hour command

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center that used a centralized decision-making structure. The team for decision-making included hospital management, nurses, and doctors, who met two to three times a day as a way to transfer knowledge, receive updates, and review changing provincial directives. One of the first key decisions was the realization that processes for admitting urgent medical and surgical patients needed to be managed centrally by a dedicated team of doctors and nurses. The hospital chief executive officer (ceo) participated in daily conference calls with the Ministry of Health and Long-Term Care (mohltc) and other sars hospital ceos. A multidisciplinary decision-making structure included an oversight steering committee, a designated sars management team, and a designated sars clinical team, all of which were supported by the use of databases to monitor sars patients, staff exposures, and mask-fit testing. St. Michael’s was also responsible for working with the Ministry to coordinate the ordering and distribution of protective face masks on behalf of the East Greater-Toronto-Area hospital group. With patient safety as a priority, St. Michael’s consistently applied an evidence-based approach to decision-making (Lozon, 2003). The sars healthcare team at St. Michael’s comprised eighty-six registered nurses trained in critical care, forty-nine registered nurses trained in medical or surgical care and obstetrics, and forty-five other healthcare professionals. Some of these individuals were assigned, while others volunteered for the sars team. Not everyone was happy to be recruited to the sars clinical team. One veteran nurse who worked in the Toronto hospital’s dialysis unit refused when she was “drafted” onto the St. Michael’s special sars team. She claimed the right not to work in close proximity with sars patients since she believed that adequate measures were not being taken to protect worker health, and by extension, her children and immuno-compromised mother, who was convalescing at home under her care following a kidney transplant operation. Given the later experience of Nelia Laroza, a healthcare worker who succumbed to sars, this nurse’s fears and reasoning were justified.1 The offer to increase pay to double time for some of the nurses working with sars patients in designated areas was widely seen as danger pay, begging the question that if sars was routine by hospital standards and within the scope of regular nursing practice (the reasoning used to recruit members onto sars-specific team units), then why was there an offer of increased pay? Of course, the hospital could not

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guarantee the safety of those recruited for sars duty, given that so little was known about the transmission and the virus at the time. Despite the danger that sars represented, almost 100 hospital staff volunteered to be part of the hospital’s sars team, but another 65 were needed. Individuals were selected based on emergency room experience. Those recruited involuntarily were put under pressure to join, with the implicit understanding that refusal to join the team might lead to dismissal. Although only one nurse refused, there are nevertheless major implications for the healthcare system when dealing with highly infectious diseases such as sars. Section 43 of Ontario’s Occupational Health and Safety Act states that workers have the right to refuse to work when the “physical condition of the workplace … is likely to endanger.” Several physical conditions that occurred during the sars outbreak fulfilled the criteria of risk in the workplace such as ill-fitting masks, lack of adequate personal protective equipment (ppe) stockpiles, and the necessity of performing a number of high-risk procedures for patient care. Obviously, there is a threshold beyond which we cannot expect healthcare workers to put themselves at risk, and we should respect the decisions of those who do not wish to accept extra life-threatening risks. We don’t require firefighters to jump into a life-threatening burning pit every day, or have police officers throw themselves in front of a bullet several times during each shift, and yet many believed that nurses had an ethical duty, based on their occupation, to accept the higher risk of treating sars patients, placing them and their families at greater risk with every shift worked. Defining what constitutes too great a risk for healthcare workers is difficult; it depends on a variable level of risk acceptability (Sibbald, 2003b). Other countries, like Taiwan, faced much larger numbers of doctors and nurses who refused to put themselves in harm’s way during the escalating sars outbreak. During the third week of May 2003, when the new director general of the Taiwanese Health Ministry announced that nearly 94 per cent of all the known sars infections were transmitted inside hospitals, approximately 160 doctors and nurses quit various hospitals. They were seriously afraid of catching the disease, and believed hospital infection control measures were inadequate (McNeil, 2003).2 The sars unit at St. Michael’s was a closed system, making management decisions and containment easier. There were twenty-one

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dedicated negative pressure beds, of which five were intensive care beds and the remaining sixteen were acute medical and surgical beds. Negative pressure beds, such as those designated for tuberculosis patients and used in the mental health unit, were deemed unsuitable for sars patients as they impeded treatment and monitoring. A designated healthcare team cared for all sars at-risk patients, regardless of their locations in the hospital (Lozon, 2003). Patient care, including all patient transfers to and from St. Michael’s Hospital’s sars unit, was overseen by the medical director as part of a centralized decision-making process. This meant daily updates were required from each medical, surgical, and intensive care unit to keep track of patient movement. The medical director engaged in frequent conference calls and discussions with the other alliance hospitals. The sars medical director and sars nurse manager took central roles supporting the sars healthcare team by developing policies and processes for infection control, developing sars-specific patient care procedures, and participating in infection control training sessions. For example, due to the extensive protective clothing required when caring for sars patients, every staff member on the sars team was fit-tested for n95 masks. Education and training were also a priority for the sars team. Staff on the St. Michael’s team was tested for competence in infection control techniques as well, and they received training in the form of one full-day session to ensure they were competent in gowning and removing protective clothing to avoid self-contamination. ppe at St. Michael’s Hospital conformed to directives and included masks, goggles, foot covers, caps, gowns, gloves, and additional protection for high-risk procedures using the Stryker t4 suit. In addition, gowning and de-gowning required monitoring by another staff member to prevent breaks in infection control practice. An enhanced staffing model was also put in place to manage stress and fatigue. Under normal circumstances at St. Michael’s, there is an intensive care staffing model of one registered nurse per patient. During sars2 this was increased to two registered nurses per patient. With acute care medical and surgical beds, the staffing ratio was normally one registered nurse for four or five patients. During sars2 the ratio was one to two registered nurses per patient. This model was used so that registered nurses did not work with a patient for more than one hour at a time. Nurse fatigue, which could have led to potential breaks in infection control, was felt to be the greatest risk for sars transmission (Lozon, 2003).

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During the sars crisis, affected hospitals also had to treat nonsars patients, many of whom were frightened and isolated because visitor restrictions prevented them from seeing family and friends. The time was stressful for patients, and nurses and doctors made an extra effort to fill this void, while realizing that patient safety was always of paramount importance. St. Michael’s is an inner city hospital, and treats patients from diverse socio-economic backgrounds. Fifty-one of the patients under surveillance during sars1 and 2 were homeless or from a shelter. When these patients came to St. Michael’s with either respiratory illness or fever, they were admitted and kept until discharge, and, when appropriate, given quarantine, as many local community shelters did not have adequate resources for isolation and quarantine. There was no quarantine plan in place to deal with sars in the community hostel system (Lozon, 2003). Since sars, St. Michael’s now has fifty-one negative pressure isolation rooms for patients with infectious diseases (Time – Canadian Edition, 2005).

north york general hospital and sars North York General Hospital has 434 beds with 1,769 full time and 1,268 part time employees and a medical staff of 829 healthcare workers serving the north central Toronto and southern York Regions, a population of 400,000 people. In 2004 the hospital saw 87,698 emergency department visits, performed 5,938 inpatient surgeries, and delivered 5,336 babies.3 North York General Hospital has been described as the focal point of sars2. Bonnie Adamson, the president and ceo of the hospital, stated that for this hospital and its workers, there was no clear division between sars1 and sars2. The nurses who worked at North York General experienced it as a single, unrelenting sars outbreak that lasted almost five months. During sars1, North York General Hospital treated thirty sars patients, and more than ninety during sars2; half of the patients in the second wave were North York General staff. Even as the first wave of sars cases was in decline, the nurses remained at high alert, since the hospital still had a number of recovering sars patients (Adamson, 2003). Testifying at the Campbell inquiry, Adamson commented on the decisions made to remove personal protective equipment on 20 May 2003, after sars1. Some journalists suggested that nurses’

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concerns about sars at North York General Hospital were ignored. However, Adamson asserts that “the concerns were heeded” and that “the idea that anyone, let alone medical professionals, would willfully ignore sars just doesn’t make any sense.” While the intent of the medical professionals is not in question, the decision to relax ppe (with which some nurses refused to comply) was indeed a bad judgment call based on a desire to return to normal and the belief that the outbreak was contained, and even waning. The risks of sars to healthcare workers due to relaxed ppe standards were severely underestimated; the possibility of undetected cases of sars in the community was largely ignored when the decision was made. The actions of Dr Sheela Basrur, Toronto’s senior health official, compounded the misjudgment. Thinking that sars was beaten, and exhausted from the outbreak ordeal, she left for Jamaica. A week later, reading a Canadian newspaper on her return flight, Basrur realized that sars had not been eliminated. In a later interview she told reporters, “We had called it over when it clearly wasn’t over” (Crowe, 2003). The second cluster that occurred during sars2 created new challenges for North York General Hospital. As was the case at other hospitals, a specific infectious disease containment unit was formed. The sars team was described by a number of staff as resembling a mash unit,4 a group of people working together in difficult circumstances trying to make the best of the situation. Given the ad hoc nature of the group, they worked exceptionally well together, a testament to the level of skill and expertise of the nurses and doctors. During the outbreak, patients at North York General struggled enormously with feelings of isolation, and hospital staff went above and beyond to lend emotional support. To help sars patients pass the time in isolation, child and youth workers applied their training to provide distractions including games, newspapers, videos, clock radios (to listen to the news and music), and magazines. Some patients who could barely move due to the debilitating effects of sars were helped by hospital staff, who spent time turning the radio dial until the patient nodded or blinked to indicate a song or station they liked (Adamson, 2003). In the effort to contain the spread of sars at North York General, approximately 7,000 people were put in quarantine. Of this group, more than 4,000 who worked at North York General

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endured home or work quarantines. Stigmatization of healthcare workers was an issue for many staff who worked there, with many unexpectedly ostracized. There were reports of neighbours crossing the street to avoid the houses of individuals who worked at North York General Hospital; one person was given an eviction notice by roommates fearful of catching sars. To confront this stigma, the North York General Hospital human resources department and the hospital foundation set up a compassionate care fund with donations from physicians, staff, and outside supporters. The fund was designated to help those patients and staff who were affected by sars to better deal with the financial and personal hardships that resulted from contracting and recovering from sars. Simple, routine procedures for sars patients required new methods so as not to infect others. For example, sars patients needed chest x-rays at least once a day, but couldn’t go to the diagnostic imaging department, so the technologists brought the portable equipment to the sars units. The technologists had to wear full personal protective equipment, move equipment to the sars unit, and take the x-rays while working around iv’s, tubes and wires, and then had to decontaminate the machines after every single use. A colossal effort was required in order to contain sars while treating patients. Other operational challenges included dealing with Ontario Ministry of Health and Long-Term Care directives that changed from day to day and sometimes from hour to hour. The frequent changes to hospital rules and procedures required time to figure out how to implement. North York General was also faced with the operational problem of how to expand patient bed capacity quickly; the scope of the outbreak rapidly outstripped available resources. North York General was able to adapt within days, creating a large makeshift intensive care unit with more than seventy negative pressure rooms. This was more than any other hospital in Toronto (Adamson, 2003). Communication about the ongoing sars outbreak was continuous both inside and outside the hospital. North York General used teleconferences on a daily basis as a way to keep everyone involved apprised of the ever-changing situation. sars became a major news story, and communicating to the media also became a constant challenge. News reporters added extra pressure as they

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constantly were looking for updates about sars. Television crews and reporters were not allowed to film inside the hospital, which was off limits to just about everyone except hospital staff. As the sars outbreak continued and containment of the virus became a greater issue, other departments within the hospital were shut down. At North York General the first department to close its doors was obstetrics, but other departments soon followed. Administrators at North York General learned valuable lessons from the sars outbreak, primarily that there needed to be more investment in emergency preparedness for infectious disease management. Human resources capacity and stockpiled equipment were both found lacking during the sars outbreak. There was a clear need for an improved communications systems, within hospitals and within the healthcare system. Such systems need to be closely linked to deal effectively with infectious diseases. Information sharing, surveillance for disease, and tracking patient movement between institutions also need to be improved (Adamson, 2003). Significant changes were implemented after the outbreak at North York General based on the knowledge gained from sars. The hospital put in place a sophisticated patient screening and triage system in the emergency department. Emergency plans, an all-hazard plan, and improved infectious disease protocols for protection for patients, staff, volunteers, and visitors entering the hospital are now in place. The number of isolation rooms with improved ventilation was increased, and the size of the infection- control team was tripled. The hospital now has the capacity to quickly establish an infectious disease assessment clinic when needed. Communication with staff and information flow within and between hospitals was also improved as a result of the information dissemination problems experienced during sars. Capacity has also improved with 75,000 square feet of post-sars renovations, and the opening on 16 October 2003 of the new Southeast Tower, a 230,000 square foot expansion of the hospital’s Leslie Street site (North York General Hospital, 2003).

scarborough grace hospital and sars The Scarborough Grace Hospital in Toronto is Canada’s largest urban community hospital, with approximately 3,700 staff members, more than 700 physicians, and 1,100 volunteers. The hospital

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has a 650-bed capacity and provides a diverse range of services across eleven patient care areas. Scarborough Grace Hospital was the first hospital in Ontario to encounter sars, and during the outbreak more than 100 staff became ill with sars. In addition, over 300 patients were assessed in the sars clinic, and the hospital treated a significant percentage of Ontario’s sars patients. Like the North York General Hospital, Scarborough Grace was considered the epicentre for sars by some and suffered a great deal of stigma as a result. One of the first people in Ontario to contract sars arrived at the Scarborough Grace Hospital Emergency Department on 7 March 2003 with respiratory symptoms (the son of Mrs K.). The initial diagnosis was “atypical pneumonia” and the patient was treated according to the Canadian guidelines for community-acquired pneumonia. This included antibiotics and fluids, but the guidelines do not require isolation precautions. At that time, there was no information about sars, knowledge of the specific causative agent (coronavirus), or test that could have provided a sars-positive diagnosis. The next day the sars patient was admitted to a medical unit and entered the intensive care unit at Scarborough Grace as his respiratory symptoms became more severe. Three hours later, isolation protocols were finally started due to speculation that the patient had tuberculosis. This was an important step that helped to prevent further spread of sars to other patients and staff. Even though pneumonia had been an early diagnosis and later tuberculosis was suspected, the rapid progression of symptoms in this patient was not characteristic of either. Diagnostic tests for tuberculosis and for the avian influenza virus h5n1 (reported in some Asian countries) were both negative. After caring for the first sars patient, long before the nature of the disease was known, one of the critical care nurses contracted the virus, and within a very short time, she became so weak she could not walk across the hallway. She experienced typical symptoms of sars with fever, aching muscles, and difficulty breathing. As the outbreak continued the hospital responded quickly. Within a week (on 13 March 2003) the hospital began detailed tracking to identify patients and staff who had had contact with the first patient, and then notified Public Health of these contacts. The retroactive tracking required an extensive review of patient registration lists and staff schedules, and detailed chart reviews of all contacts. The outbreak team focused

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on the initial patient and identified contacts from his arrival in emergency on 7 March until the time the isolation procedures were initiated in the icu, on 8 March. Unfortunately, the sars virus had already been passed to others in the emergency department at Scarborough Grace. As other patients and staff began to experience symptoms of sars the hospital asked for additional help from a team of hospital staff, infectious disease specialists, public health authorities, and occupational health staff to discover the pattern of transmission. They all worked tirelessly to complete a comprehensive contact tracing. What emerged between 14 March and 22 March was a very complex transmission pattern with an increasing spread of infection. The numbers of potential contacts were greater than what had been assumed at first, making the task of containment more difficult. Glenna Raymond, ceo of Scarborough Grace Hospital, stated that the human resources and information systems were not sufficient to update or refine previously produced tracking lists in real time as patients were discharged and readmitted, or as patients moved from one hospital to another. For example, one patient who likely contracted the virus on 7 or 8 March had visited the emergency department twice, was discharged, and several days later was readmitted and then transferred to York Central Hospital, his home community hospital. The patient’s movements (and possible contacts) were determined only after the fact; there was a lack of capacity for effectively tracking and monitoring the spread of infectious disease. As a result of this gap an internal crisis response plan was initiated with Public Health and Scarborough Hospital command centers established. Communications were provided to staff, patients, visitors, volunteers, and the community through special telephone hotlines, through the use of the hospital Web site, and through newspaper advertisements. At the height of the outbreak, updates were held hourly through internal management and staff meetings. Conference calls were held with external specialists, three levels of government, and other healthcare partners to ensure constant information exchange. Isolation precautions were instituted throughout the hospital, with education teams deployed to instruct staff; these measures would later become provincial directives for all Ontario hospitals. Visiting and patient services were restricted. All of these measures were put into place within two weeks of the first patient entering the hospital.

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Daily meetings helped to communicate the situation to staff As a result of the lessons learned from sars, there has been a marked increase in isolation room capacity and the number of infection control specialists. Glenna Raymond stated that they quickly had to learn and implement ways to increase the flexibility of the organization. The hospital closed down emergency and intensive care unit services and eventually suspended all other services. The ceo believed afterwards that the hospital didn’t have to close these facilities but acted prudently. The hospital is now much better prepared, and will likely not need to impose such drastic measures if another sars-like outbreak occurs in the future. During the latter part of the sars outbreak, the hospital had already adapted to the new conditions, and with greater information about the infection, enhanced screening, extreme vigilance, and strict isolation precautions in place they demonstrated that they could safely treat sars patients while, at the same time, still providing care for others. The disruption of patient services due to sars was an outcome that most hospitals and patients had not anticipated prior to the sars outbreak. During sars there were worker shortages at Scarborough Grace Hospital. As staff became sick or quarantined, the issue of human resources management became important. It was suggested that ideally there should be an external and centralized system for locating specialty expertise like additional healthcare workers and human resources during outbreaks. At Scarborough Grace, as at many other hospitals, control and coordination of information, the development of new and improved care protocols for infectious disease, and overall management of infectious diseases have all been improved (Raymond, 2003).

york central hospital and sars York Central Hospital is a community hospital located in Richmond Hill, in the Toronto area. It is a 419-bed facility with 219 acute care beds, 52 chronic care beds, 32 rehabilitation beds, and 116 long-term care beds. The hospital has one of the busiest emergency rooms in the city, with over 62,000 visits the year prior to sars. The hospital has approximately 1,800 staff, 300 physicians, and 800 volunteers. It experienced great difficulty during the early portion of the sars outbreak (Dwosh et al., 2003).

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On 16 March 2003, a seventy-seven-year-old man who required urgent hemodialysis was transferred from Scarborough Grace Hospital to the icu at York Central Hospital. At the time of transfer, it was not known that the patient had been exposed to the sars virus at the referring institution, so no specific respiratory isolation precautions were used. After he had spent thirteen days in intensive care he succumbed to sars, and the cause of death was identified. On 21 March the wife of the first patient was also admitted to York Central Hospital. She also had been exposed to the sars virus while visiting her husband at the referring hospital and while visiting her husband in intensive care during the period of unprotected exposure at York Central Hospital. On 26 March she was transferred to a nursing home for respite care, and three days later she was readmitted to York Central Hospital with persistent respiratory symptoms. Due to the patient’s history of direct contact with a probable sars case (her husband), she was immediately placed in respiratory isolation and transferred to the fifteen-bed sars Assessment and Treatment Unit (satu) upon her arrival (Dwosh et al., 2003). Dr Schabas maintained that sars was introduced to York Central hospital due to existing patient shuttling practices, and that sars as an infectious disease was not actually that highly infectious. The way the healthcare system dealt with operational conditions by transferring patients from hospital to hospital was the main problem, from the perspective of York Central. Even the simple precaution of putting a stop to all patient transfers from Scarborough Grace to other hospitals on 14 March 2003 would have saved York Central Hospital from being drawn into the sars outbreak, as it was when an infected patient was transferred without any warning of the possibility of sars on 16 March. Scarborough Grace Hospital was not closed until 25 March, a window of nine days after the outbreak had apparently been identified5 (Shabas, 2003; Cherney and Heinzl, 2003). Once sars was discovered there, York Central quickly implemented visitor restrictions. Its workers constructed a special fifteenbed sars unit almost overnight, installed a command centre, and set up a screening area in tents outside the hospital. The sars assessment tents were used to screen everyone coming in. Workers disinfected their hands often and were issued masks and gowns. Within a few days the hard-to-disinfect carpeting in the emergency

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department was torn up and replaced by vinyl tile to prevent environmental contact with sars virus particles. The hospital remained closed for twenty-one days (Papp, 2003). In addition to the index case, fifteen individuals (ten hospital staff, three patients, and two visitors) were identified as meeting the case definition for Probable or Suspected sars at York Central Hospital. During the period of unprotected exposure, all but one individual had direct contact with the sars-infected individual. After infection control precautions had been implemented for eight days there were no additional cases identified, and there were also no cases of secondary transmission after twenty-one days (two infectious cycles). The outbreak at York Central Hospital resulted in mass voluntary quarantine of over 5,000 people. Quarantine extended to over 1,800 hospital staff, 225 physicians, 170 neighbouring high school students who use the hospital cafeteria, and hundreds of volunteers, patients, and visitors. A dedicated team of physicians, nurses, and other healthcare workers was recruited from the intensive care unit and the medical respiratory ward to care for sars patients. There was tremendous disruption to the community’s ability to access acute medical care services (Dwosh et al., 2003).

william osler health centre and sars William Osler Health Centre’s campus in Etobicoke was designated as one of four Interim Healthcare Alliance Facilities during the sars outbreak. William Osler’s healthcare team consists of 670 physicians, 3,700 healthcare professionals, and 1,000 dedicated volunteers. The hospital has the largest obstetrical program in the province, with approximately 7,000 births per year, and has 600 beds. There are more than 140,000 emergency visits per year and about 41,000 day surgery procedures performed each year (William Osler Health Centre, 2006). The role of the William Osler Health Centre was to be the primary facility to assess and treat air travellers coming to Toronto who posed a risk for sars due to its proximity to Lester B. Pearson Airport, and to support other hospitals in the west gta. Being designated as a “sars hospital” in the alliance created a great deal of anxiety among staff members who were anxious about their personal safety and that of their families. The hospital didn’t have any sars cases in its

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facility when it was named to the alliance and this provided a small window of time that allowed for preparation (prior to 27 May the hospital had no sars patients). The Health Centre decided to operate a self-contained parallel facility to assess and treat patients with sars, adopting a hospital-within-a-hospital model. To do this meant building controlled isolation zones within the hospital for assessing, treating, and transporting sars patients, and working out strict safety protocols. Training sessions on the use of personal protective equipment and procedures were held ahead of time. The hospital increased communication of information to staff, and offered on-site psychological counseling. Staff working directly with sars patients used a buddy system for extra psychological support, and provided a check for breaks in infection control procedures. The result was the creation of tightly controlled isolation zones for assessing, treating, and transporting patients with Probable or Suspect sars. This included a dedicated inpatient unit, a dedicated er isolation unit, and a free-standing sars Assessment Clinic. The structure allowed the hospital to maintain a fully functioning parallel hospital to ensure comprehensive services to the community with surgery, obstetrics, medicine, pediatrics, diagnostic services, and other emergency care. Willliam Osler was able to continue providing healthcare services, unlike Scarborough Grace, North York General, and York Central, which all suspended many services. To improve capacity as a sars hospital William Osler established a twelve-bed inpatient unit by relocating rehabilitation patients to their Georgetown Campus, and renovating a thirty-two-bed unit into a twelve-bed dedicated sars Isolation Unit that met all the known standards of infection control. Dedicated equipment was purchased to address the assessment and management of the sars patients cared for in the newly built unit. The area located next to the emergency department was renovated to create a dedicated Emergency Isolation Unit specifically staffed and equipped to meet standards for infection control. The number of assessed and confirmed sars patients at William Osler was relatively low compared to other hospitals, and aggressive containment prevented any transmission of sars between patients or to staff. Over a period of two and a half months, ten patients were treated for sars, thirty patients were assessed in the

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clinic, and 230 patients were seen in the Emergency Isolation Unit. There was no secondary transmission of sars to staff, patients, or visitors (Goel, 2004b).

common hospital responses to sars All hospitals learned that infectious disease management could be improved upon in certain areas. The first improvement was in the area of resources, budgeting for supplies, and maintaining surge capacity for infectious disease outbreaks. Each hospital also had to improve communication during an outbreak. Prior to sars all the hospitals had poor communication strategies in place, but these were developed quickly in response to the outbreak. Communication needed to be improved at all levels within and between hospital departments, between hospitals and public health officials, and between all players and the public. Surveillance techniques and reporting for infectious disease needed to be enhanced. Information technology and the use of real time data sharing were highly effective during the sars outbreak, providing individuals with access to medical information. Connections to global infectious disease tracking through the Internet al.lowed people to see a bigger picture of the outbreak that was developing globally. Information was communicated to the public at daily conferences that were held to reassure and educate. Daily media interviews attempted to break through media clutter and to limit speculation and rumours about sars, demonstrate that public health officials were doing what needed to be done, and insure that the media had access to the latest expert information. However, public anxiety was driven more by news headlines and story positioning than content. Many of the deficiencies revealed by sars have already been addressed by hospitals throughout Ontario. Hospitals and public health officials have done an excellent job implementing improvements and strengthening capacity, communications, surveillance, reporting, and staff training. Hospital practices adopted during sars are shown in table 8.1. Hospital practices for infectious disease control were also improved, relying heavily on provincial directives. A list of directives and requirements of workers to reduce sars transmission are listed in table 8.2.

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Table 8.1 The new normal – various hospital practices and policies that were implemented during the sars outbreak to achieve infectious disease containment Hospital practice during SARS

Policy

Visitors Outpatients

All visitors banned (except on compassionate grounds) 1 Phone screening prior to appointment 2 Temperature check on arrival 3 Completion of form indicating symptoms, travel 4 Outpatients wait more than three feet apart to minimize aerosolized viral particle spread 1 Enhanced infection control measures throughout the hospitals 2 Creation of contained sars wards 3 New directives for patient transfers and visitors 4 Work quarantine for selected healthcare staff 5 Limiting the number of healthcare settings in which staff can work 6 Reducing other health services 1 Precautions against airborne contagion included use of n95 respirator or equivalent 2 Negative pressure isolation rooms where available to isolate sars patients 3 Frequent handwashing 4 During high-risk procedures the number of people in the room was kept to a minimum 1 Droplet and Contact Precautions relied on the use of personal protective equipment including gloves, gowns, goggles, face shield, and frequent handwashing 2 Mask-fit testing occurred during the outbreak as many had not been previously fitted 3 Training required for ppe 1 Communications integrated into point of care (poc) 2 Integrated, multi-level communications 3 Teleconference communications 4 Internet communications: public and passwordprotected stakeholder sites for knowledge transfer 5 Public Telephone Information Services 6 Designated communications spokespersons

Infection control practices in hospitals

Isolation capacity

Equipment capacity and training

Communications

conclusions A multidisciplinary approach was used to manage the sars outbreak in Toronto. Hospitals that had to deal with sars quickly adapted to the situation and demonstrated a high degree of flexibility in implementing a number of changing directives. Each hospital created isolation rooms and assessment areas to be used uniquely for the diagnosis of Suspect and Probable sars patients. Each of

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Contact with patients in sars units Screeners at all entrances

X

Departments and staff (Emergency, icu) High risk procedures (intubation, bronchoscopy) Emergency patients and visitors

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Comments

Shoe Cover

Hair Cover

Face Shield

Goggles

Gowns

Alcohol

Gloves

N95 Mask

Table 8.2 Summary of personal protective equipment directives from the Ontario Ministry of Health and Long-Term Care used at hospitals during sars

X

X

X

Proper ppe de-gowning, buddy system Use alcohol wash every thirty minutes Proper ppe de-gowning

X

X

X

Stryker suits, minimize number of people in room Screening tool administered to visitors

icu = Intensive Care Unit ppe = Personal Protective Equipment

the hospitals designated a team, either by very structured recruitment to deal specifically with sars, or on a voluntary basis. sars teams comprised individuals who had extensive emergency room experience; these experienced nurses were usually older. It was logical for administrators to pick the most experienced people for their teams. However, analysis of the epidemiology shows that older individuals were at the greatest risk with sars. Statistics show that mortality increased with age. While experienced nurses may have been intuitively chosen for sars teams, this decision put these workers (who were older, overworked, sleep-compromised, and stressed) at higher risk than younger nurses. A different work model could have been used, with smaller groups of younger nurses (under forty years old) working on sars wards. These younger groups of nurses could have been supervised by and report to an older, more experienced nurse throughout their shifts. Each hospital designated a small group of individuals to manage the unfolding outbreak situation and the sars response team they had created. The management team usually consisted of hospital administrators, experts, and public health officials who reviewed

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the latest evidence and breaking information. The hospitals held teleconferences and media interviews to communicate what was known and unknown about the unfolding situation. Infectious disease control protocols and procedures evolved quickly, and staff was trained in personal protective equipment use and infectious disease practices, and dealt with work quarantine. The approach was successful despite the lack of capacity and human resources problems inherent in the system. Epidemiological evidence about sars provides evidence of its low transmission rate; its route of transmission is by respiratory droplets, and it is known that infections like tuberculosis that are spread by respiratory droplets are not considered highly infectious. The spread of respiratory droplet diseases requires prolonged close contact with an infected person. For sars, the window of infectivity is limited to close contact; typically it is transmitted by people who are already symptomatic. Unfortunately it is exactly this circumstance that occurs in hospitals. Hospital emergency departments are where sick people go, and that’s where they are kept in close proximity with their caregivers and others in overcrowded waiting rooms, emergency rooms, and icus. In Toronto hospitals it was precisely these conditions that allowed the disease to spread during sars1. The same circumstances of close contact are duplicated in household settings, which is why epidemiologists observed some household cluster cases, and why doctors believed early clusters were tuberculosis. A third factor that predisposed hospital spread was that high-risk interventions were used, particularly forms of non-invasive ventilation. Medical procedures that promoted aerosolizing of the virus and the spread of ultra-fine respiratory droplets increased the infectivity of sars. Dr Richard Schabas of York Central Hospital believed that if analysed closely, particularly in sars1 cases, those who were called “super-spreaders” were in fact no more infectious than other sars patients. The so-called super-spreaders were patients put in treatment circumstances that caused an aerosolization of the virus and a super-dispersion of viral particles (Shabas, 2003). The key message missed by many experts and leaders who were communicating with the news media during the outbreak was that for sars there was little evidence of sustained transmission in the community setting. Even in outbreaks elsewhere in the world, specifically in Hong Kong and in Beijing where community clusters

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developed, little secondary transmission occurred compared to the number of contacts that likely took place. In fact, sars was contained in other hotspot areas quickly, and didn’t continue spreading. It was on 26 March that the provincial health emergency was announced, and on 28 March that the drastic closure of the hospital system throughout the Greater Toronto Area region occurred. The containment of sars was the result of the exceptionally hard work and dedication of nurses, doctors, and technicians who were able to quickly mobilize existing resources for containment, and to facilitate sars patient care. Many of the workers and technicians were confronted with an enormous increase in workload in order to treat sars patients and maintain containment. Issues of lack of human resources and communications capacity were systemic, and encountered by all hospitals during the sars outbreak. Existing hospital practices exacerbated the struggle to contain the virus. Each of the hospitals learned many important organizational lessons, and has used the experience of sars to greatly improve infectious disease control capacity and practices. Many hospitals in the Greater Toronto Area are now much better prepared for the next pandemic influenza or infectious disease as a result of the hardships they confronted during the sars outbreak.

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SARS Public Reports – Recommendations from Expert Panels This report is dedicated to those who died from sars, those who suffered from it, those who fought the disease, and all those affected by it. The Honourable Mr Justice Archie Campbell, commissioner. Dedication from the sars Commission Final Report (Campbell, 2006b)

Severe Acute Respiratory Syndrome is a serious form of pneumonia, resulting in acute respiratory distress and sometimes death. This contagious respiratory infection was first described, as a new disease, on 26 February 2003 by World Health Organization (who) physician Dr Carlo Urbani. He diagnosed it in a forty-eightyear-old businessman who had travelled from Guangdong Province, China, to Hong Kong and Vietnam. The businessman died from the mystery illness; Dr Urbani also died from the illness he named Severe Acute Respiratory Syndrome, or sars, on 29 March 2003 at the age of forty-six. Within six weeks of its discovery, it had infected thousands of people around the world and spread quickly to thirtyone countries. The who identified sars as a global health threat and issued an unprecedented travel advisory. Individual countries tracked the spread of sars, and daily updates by the who kept careful watch on affected areas. At the time there was uncertainty and fear over whether sars would become a global pandemic. Canada had two index cases of sars that appeared in two different cities, Vancouver and Toronto. The infectious disease was contained in Vancouver, while in Toronto the outbreak spread through a small number of hospitals, infecting patients, nurses, doctors, and paramedics. In Canada sars was overcome by a combination of increased front line vigilance, contact tracing with voluntary quar-

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antines, negative pressure isolation rooms, and enhanced containment procedures. The sars outbreak required enormous infectious disease containment efforts by officials and healthcare workers, resulting in a literal – if partial – shutdown of Toronto’s healthcare system. Uncertainty concerning the biological agent, its transmission and infectivity, led to the invocation of the Emergency Health Act in the province of Ontario. Public health officials and hospitals mobilized, convening ad hoc sars medical teams to deal with the situation, established epidemiological links to known cases, and quarantined those who had been at hospitals where sars was active. Due to the potential for transmission to other patients, many scheduled and routine medical procedures were delayed or cancelled, disrupting healthcare with further downstream effects on public health. As a precaution, patients in hospital at the time were unable to have visits from family and friends. Individuals who were facing difficult surgeries or other medical procedures did so in isolation with little social support; this too had a significant impact on terminal patients (Goel, 2004a). The global public health response and continued focus by the who helped to stem the spread of the virus. The epidemic had been contained worldwide to the degree that on 7 June 2003 the who stopped issuing its daily sars update reports. As the number of new cases dwindled, travel advisories were rescinded and economies returned to normal, but there was the lurking threat that even a single new case of sars had the potential to reignite another outbreak if rapid diagnosis and containment was not initiated. Officials and healthcare workers in Toronto, who experienced sars1 and then the reemergence of the disease with sars2 due to an undetected line of hospital-acquired infections, learned the lesson of just how dangerous and difficult sars was to contain. The last reported case of sars in Canada became ill on 12 June 2003; by 5 September 2003, there remained only one active case of sars in Canada.1 After more than two and a half months with no new cases and steadily declining numbers of active cases worldwide, Health Canada stopped reporting Canadian sars numbers in October 2003. The failure of the healthcare system and public dread over sars due to healthcare worker deaths did not go unnoticed by federal and provincial government officials. The magnitude of the sars outbreak in terms of mortality, stigma, economic loss, and the exposure of vulnerability to possible future biological

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terrorist agents were contributors that led to the establishment of several commissions and inquiries that were responsible for critically evaluating what went wrong. The expert reports concerning sars examined why this outbreak had such an impact, particularly in Toronto, and all of the commissioned reports provided recommendations on how to improve management of future outbreaks. The main goals of the expert panels were to determine how hospitals dealt with the outbreaks, what lessons were learned, and what would be needed to improve the capacity of Canadian hospitals to deal with infectious disease. While expert panels made recommendations, it was up to government officials and hospital administrators to use the knowledge to improve hospital infectious disease capacity and procedures.

about expert panel reports Expert panels are formed in response to requests from governments and other organizations for guidance on public policy issues where specialized knowledge is required (Royal Society of Canada, 2006). When specific issues occur, governments can convene expert panels as a way to obtain guidance. This is a regular part of the risk management process at Health Canada, in the Province of Ontario, and at other regulatory agencies around the world. For example, expert panels convened by Health Canada’s Health Products and Food Branch (hpfb) review relevant information on a particular issue2 and then, based on evidence and the context of the questions posed, they offer advice to the department for consideration in regulatory decision-making. The first step in convening an expert panel is to identify a chairperson. The leader is usually a well-rounded individual who is recognized as an expert in their own field, with previous experience in chairing meetings and writing reports. Once a chairperson is appointed, the next step is to find panel participants, based on the type of expertise needed. Selection of expert panel members is guided by three principles: members must have extensive, high quality expertise related to the issue being discussed; possesses the ability to participate in the discussion with an open mind and to objectively review the provided information and evidence; and have no conflict of interest that would disqualify them from participating in the panel (Health Canada, 2006).

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Panel members are appointed as individuals on the basis of their expertise, and do not represent the interests of their employer or affiliated organization. Panel members may be paid for their participation by the sponsoring department or serve as volunteers, in which case they are compensated only for their travel and accommodation expenses according to federal government policy. Before the expert panel meeting, members receive information, including literature on the subject, data, evidence, transcripts of interviews, or other relevant evidence. Included in the information the panel members see before the meeting is a list of questions outlining the scope of the discussion. This is done to ensure that the ensuing recommendations cover the areas in question. After the expert panel meeting (or meetings), the chairperson prepares a report outlining the issues or concerns raised by panel members and summarizes, without acknowledgment, the main points of the deliberations and the panel’s expert responses to the questions posed. The panel’s advice and recommendations are then taken into consideration by the sponsoring government department, which is not bound by it and may choose to implement any or all recommendations. The department has the regulatory responsibility for making any final decisions about the issue and the recommendations provided from the expert panel (Health Canada, 2006).

the sars reports The Ontario provincial government and the government of Canada commissioned six different independent reports to investigate the management of the sars outbreak and health emergency response from various perspectives. Of the six reports, one was federal and five were provincial. Three of these are considered major, in-depth reports on sars in Canada: the federally commissioned National Advisory Committee on sars and Public Health Report (The Naylor Report); the Expert Panel on sars and Infectious Disease Control Report (The Walker Report); and the judicial Commission to Investigate the Introduction and Spread of Severe Acute Respiratory Syndrome Report (The Campbell Commission Report). All of the major reports were triggered by the events of sars and focus on many healthcare issues brought to light concerning infectious disease management. The major sars reports all deal with improving public health management in Ontario and in Canada, all look to

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the future of the Canadian public health system, and have identified the need for an increase in the infrastructure of public health through additional investment. The reports were completed independently but have generated many similar expert recommendations as a result of data analysis, expert witness testimony, interviews, invited submissions, and presentations by various groups. The analysis of complementary information from multiple sources has led to many of the same conclusions, the foremost being that the sars outbreak uncovered fundamental flaws in the Canadian healthcare system. All of the major reports point to a lack of capacity, a result of the continued erosion of funding for Canadian public healthcare. The reduced emphasis on public health resources for infectious diseases was a result of the perception by officials that infectious diseases had been beaten, and the demand for acute care services specifically for infectious disease was a lower priority. Ironically, this lack of concern with new infectious diseases has the greatest impact on the aging cohort of baby boomers who are much more susceptible to influenza and other virulent contagious diseases than other age cohorts. The main sars reports identified several fundamental deficiencies within the public health system, including those of coordination, trained personnel, nationally accepted standards and protocols, emergency preparedness, communication protocols, and coordinated information systems. However, according to Justice Campbell, there was no lack of jurisdictional bickering over public health, whether it was between provinces/territories and the federal government, between local health departments and the provinces, between different branches of government at the same level, or between healthcare institutions and healthcare providers. The lack of coordination and absence of clear lines of communication were exposed by the sars crisis at a time when good, efficient communication was needed most. Several people in different jurisdictions became instant public health and infectious disease experts and each tried to direct and manage the outbreak independently (Campbell, 2006b). The reports focused on the idea of creating new provincial, regional, and/or national public health agencies to provide better management and coordination of public health activities. Both Walker and Naylor, in their respective tabled reports, called for independent chief public health officers who would have the

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responsibility for managing these agencies and accountability for the public’s health concerning infectious disease. The public health officer would have the autonomy to act in the public’s interest without political interference. All the major sars expert panel reports recognized the need for investment of new resources, not just realignment of existing funds, to provide needed capacity to improve public healthcare to adequately address the challenges of epidemic and infectious disease management. Only the Walker panel report commissioned by the Ontario provincial government sat as a true expert panel whose final recommendations (whether highly critical of government action or not) were provided at arm’s length, independent of government influence. All of the other panels were funded directly by government agencies, but despite direct funding they were given a high degree of sovereignty and operated largely in an independent fashion, much like an expert panel. The expert working groups and the process by which they generated their recommendations were highly transparent. Officials who funded the reports placed few restrictions on the investigations and did not attempt to alter, change, or filter the information contained in the final reports tabled by the panels. The process and panel reports provided unbiased, credible information and a true critique of the current healthcare system in Ontario. The six different investigations into the sars outbreak that have been carried out in Canada are reviewed and the details of the reports are summarized in table 9.1.3 m ajo r re p o rt s 1) The Naylor Report. A federally commissioned report of the National Advisory Committee on sars and Public Health, chaired by Dr David Naylor, dean of Medicine at the University of Toronto. The mandate was to provide expert opinion and insight surrounding the public health response to sars. The final report was a book entitled Learning from SARS : Renewal of Public Health in Canada. 2) The Campbell Commission. The provincially commissioned report on sars was chaired by the Honourable Mr Justice Archie Campbell. The commission produced two interim reports, “sars Commission Interim Report – sars and Public Health in Ontario” and “sars and Public Health Legislation,” as well as a

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final two-volume report, “Spring of Fear.” The Campbell Commission focused on interviews, submissions from key witnesses, and expert testimony to determine the problems that existed in current healthcare practices and within the healthcare system at large (Campbell, 2006b). 3) The Walker Report. The provincially commissioned report of the Expert Panel on sars and Infectious Disease Control was chaired by Dr David Walker, dean, Faculty of Health Sciences and director, School of Medicine, Queen’s University. The final report was the document entitled “For the Public’s Health: A Plan of Action – Final Report of the Ontario Expert Panel on sars and Infectious Disease Control.” Much like the Naylor and Campbell reports, the Walker panel report assessed the outbreak and made recommendations to improve healthcare in Ontario by identifying deficient areas. m i n o r r e p o rt s 4) The McKeown Report. The provincially commissioned report of the Infection Control and Surveillance Standards Task Force, chaired by Dr David McKeown, medical officer of Health, Peel Region. The final report was entitled “Final Report of the Infection Control and Surveillance Standards Task Force: Community Health Providers Preventing Respiratory Illnesses in Community Settings, Recommendations for Infection Control and Surveillance for Febrile Respiratory Illness (fri) in Community Settings in Non-Outbreak Conditions.” 5) The Henry Report. The provincially commissioned report of the Infection Control Standards Task Force was chaired by Dr Bonnie Henry, associate medical officer of Health, Toronto Public Health. The final report was entitled “Final Report of the Infection Control Standards Task Force: Non-Acute Institutional Settings Preventing Respiratory Illnesses Protecting Residents and Staff In Non-Acute Care Institutions, Recommended Infection Control and Surveillance Standards for Febrile Respiratory Illness in Non-Outbreak Conditions.” 6) The Williams and MacLean Report. The provincially commissioned report of the Infection Control Standards Task Force and

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co-chaired by Robin Williams, medical officer of Health for Regional Niagara Public Health Department, clinical professor, Department of Paediatrics, McMaster University, and James R. MacLean, president and chief executive officer, Markham Stouffville Hospital. The final report was entitled “Preventing Respiratory Illnesses – Protecting Patients and Staff: Recommended Infection Control and Surveillance Standards for Febrile Respiratory Illness in Non-Outbreak Conditions.”

a closer look at the main sars reports ) The Naylor Report: Synopsis and Main Recommendations The National Advisory Committee on sars and Public Health was established in early May 2003 by the minister of Health of the Government of Canada to look at the state of affairs surrounding healthcare and the sars outbreak. The committee’s mandate was to provide a third party assessment of current public health efforts, and determine what lessons had been learned with regard to ongoing and future infectious disease control efforts. Committee members were chosen to represent various disciplines and points of view from across Canada. A number of the participants were directly involved in reacting to sars in different capacities. The committee was chaired by Dr David Naylor, dean of Medicine at the University of Toronto (phac, 2004b; Goel, 2004a). The details of the sars outbreak in Canada, its epidemiology, and several key issues surrounding it were highlighted in the 234-page report released on 7 October 2003. The expert panel suggested seventy-five recommendations gathered from analysis of the outbreak, to be used by policy makers, regulators, and politicians to prepare for and minimize the human health costs of future pandemics. Dr Naylor was very critical of how the sars outbreak was handled prior to his heading the committee. In his report he cited a lack of leadership and poor collaboration and sharing of information between provincial and federal health organizations. He cited public healthcare infrastructure that was hampered by ongoing long-term funding shortages and workforce shortages as the major problem that magnified the effects of sars, pushing the healthcare system to the brink of collapse.

Table 9.1 Summary of all expert investigative panels created to evaluate the Canadian sars outbreak Panel

Naylor

Walker

Campbell

McKeown

Henry

Williams & MacLean

Jurisdiction

Federal

Provincial

Provincial

Provincial

Provincial

Provincial

Chair

Dr David Naylor

Dr David Walker

Mr Justice Archie Campbell

Dr David McKeown

Dr Bonnie Henry

Purpose of report

Provide a third-party assessment of current public health and infectious disease control with reform recommendations

Provide recommendations for public health renewal in Ontario

Provide an overview of healthcare system gaps and recommendations for public health reforms

Recommendations for infection control practices in non-outbreak conditions to prevent disease outbreaks

Number of recommendations

75

103 (initial 50 Dec. 2003; 53 added 21 April 2004)

34

Type of evidence gathered

Documented evidence; 46 interviews; 31 submissions

265 written submissions; 12 focus groups; 150 interviews

First interim report: 53 (with 21 principles for reform) Second interim report: 113 400 confidential interviews; Public hearings (>100); Document examination; Expert consultation

Proposed recommendations for Febrile Respiratory Illness (fri) control in non-outbreak conditions for non-acute care institutions 42

Robin Williams and James R. MacLean Proposed recommendations for infection control and surveillance for Febrile Respiratory Illness (fri) for use in Ontario by adult acute care hospitals

Expert consultation with Infection Control Standards Task Force (25 members)

Expert consultation with Infection Control Standards Task Force for Non-Acute Institutions (31 members)

30

Expert consultation with Infection Control Standards Task Force (43 members)

Table 9.1 continued Jurisdiction

Federal

Provincial

Provincial

Provincial

Provincial

Provincial

Time convened

May 2003– Oct. 2003

May 2003–April 2004

Expert consultation and report written Sept.–Dec. 2003

Expert consultation and report written Sept.–Dec. 2003

Expert consultation and report written Sept.–Dec. 2003

Report date

October 2003

April 2004

10 June 2003–April 2004 with public hearings (6 days: 29–31 Sept. and 17–19 Nov. 2003) April 2004 and April 2005

March 2004

March 2004

December 2003

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Naylor was adamant that Canada should learn from the sars outbreak and fix the problems in its public health system. The Naylor Report declared that the responses of various levels of government to sars were badly coordinated. Not only was coordination between government officials dysfunctional, there was no defined protocol for data and information sharing between the various levels of government; moreover, there were uncertainties about data ownership that delayed dissemination of information. The inadequacies were systemic and uncovered a lack of emergency preparedness and competent infectious disease outbreak management at all levels. The weaknesses in disease management affected the links between public health and personal health services including primary care, institutions, and home care as well. Another major problem cited by the Naylor Report was the inadequacy of institutional outbreak management protocols, infection control, and infectious disease surveillance. This lack of structure was reflected by the lack of capacity for epidemiological investigation of the outbreak and difficulties with timely access to laboratory testing and results. The Naylor Report looked to other countries for international models of public health that were effective and well managed. One of the most important recommendations was for an arm’s-length national agency to oversee the public health agenda to ensure that its priorities are scientific, rather than political. Such an agency would report directly to the health minister, following an octopus model with links to existing and new regional public health centers, instead of being located in one area. Winnipeg, home to Canada’s National Microbiology Laboratory, and Ottawa, home to the Centre for Infectious Disease Prevention and Control, lobbied heavily to become the home of the new agency. The report identified a need to create a national organization to monitor public health. Similar to the Atlanta-based Centers for Disease Control, the Canadian Agency for Public Health, or “cdc North,” would act as an umbrella organization for health agencies across the country to help share and promote information. The national organization would appoint a chief public health officer similar to the surgeon general in the United States. This person would lead the Canadian Agency for Public Health and report directly to the federal minister of health. The goal of the new

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agency would be to form knowledge-sharing partnerships with government and academic research institutions. Naylor was critical of Health Canada, calling the federal department “largely invisible” on the front lines of the outbreak. However, given that healthcare is currently a provincial jurisdiction, it is unclear just what “greater” role the federal government could have played during the sars outbreak without being seen as encroaching upon provincial health matters (phac, 2004b). The Naylor Report also noted that the lack of government cooperation was noticeable and confounded containment and epidemiological linkages during the outbreak. For example, the Ontario Health Ministry didn’t share data with infectious disease experts from the National Microbiology Laboratory in Winnipeg, saying the information could breach patient confidentiality. While this concern was valid, it served to create tension between offices. In addition, Dr Colin D’Cunha, Ontario’s commissioner of public health, and Dr James Young, the province’s commissioner of public safety, were at odds as to who was in charge during the outbreak. “In separate interviews, both Drs Young and D’Cunha acknowledged that the dual leadership structure was less than ideal and one person should have been in charge” (Krawchuck, 2003; phac, 2003f). Naylor was most disconcerted when discussing government action and again highlighted the lack of capacity as a long-term system problem. In the report, the committee echoed recommendations made in 1993 in another study commissioned by Health Canada. “The National Advisory Committee on sars and Public Health has found that there was much to learn from the outbreak of sars in Canada – in large part because too many earlier lessons were ignored,” said the report. Federal, provincial, and territorial governments should work together to create a strategy to address the shortage of public healthcare workers, including nurses, doctors, microbiologists, and infection control experts. The increase in capacity also needed to be applied to improving surveillance. Naylor suggested that Canada, in conjunction with the World Health Organization, should take a lead role and push for international standards regarding when to issue travel advisories and warnings (phac, 2004b). Naylor identified specific examples of “multiple, serious inadequacies” in the handling of the sars outbreak. He praised the

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frontline healthcare employees who laboured in conditions made worse by underfunding and shortages of skilled workers. The committee’s report agreed that healthcare workers’ efforts were hampered by conflicting responses from all levels of government (Krawchuck, 2003). 2) The Campbell Commission: Synopsis and Main Recommendations i n t e r i m r e p o rt s 1 a n d 2 The first investigation into the handling of the sars outbreak released its report, led by Ontario Justice Archie Campbell, on 15 April 2004. The commission’s First Interim Report was entitled “sars and Public Health in Ontario.” The Minister of Health and Long-Term Care made it public on 20 April 2004.4 The mandate was to investigate how the sars virus came to Ontario, how it spread, and the responses to it. Its objectives included an examination of regulatory provisions and powers governing issues such as quarantine of suspected carriers of communicable diseases. The goal was to use the information gained during the investigation to provide recommendations that would improve provincial legislation and regulations. To this end, the commission entertained all submissions that the Province of Ontario made concerning amendments to federal legislation. The expert panel began its work on 10 June 2003, nearly a year before its first report, with most of the commission’s investigation using confidential interviews that were conducted in the summer and continued into the fall. The information used to generate recommendations came from over 400 people, each of whom provided information pertaining to their first-hand experiences of the sars outbreak. When providing information, their anonymity was assured, with the provision that their names would not be used in the report and that their disclosures to the commission were confidential and not subject to private or public access. The investigation called upon witnesses from a variety of positions, and promised whistle-blower protection to obtain accurate and candid information from them. The witnesses spoke candidly about what they had experienced and did so without fear of reprisals. The commission also held six days of public hearings in Toronto. The first round of public hearings was held on 29–30 September

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and 1 October 2003, and the second round of hearings was held on 17–19 November 2003. Many nurses, doctors, and prominent figures including Dr James Young (Ontario’s public security commissioner) and Dr Colin D’Cunha (Ontario’s Public Health Commissioner) gave their descriptions of events. Several organizations also detailed their experiences, including the Registered Nurses’ Association of Ontario, represented by Doris Grinspun; Barb Wahl, president of the Ontario Nurses’ Association; Dr Yoel Abells, chair of Family Physicians Toronto; Dr Larry Erlick, president of the Ontario Medical Association, along with other key representatives (cbc News, 2003k). All individuals that asked to present to the commission were given an opportunity to be heard at the hearings. Over 100 people spoke to the commission during these six days of public hearings, giving valuable insight into the problems of infectious disease management in Canada. The commission also put out a call for submissions to healthcare associations, non-governmental organizations, and relevant industry stakeholders. The call for submissions offered these groups an opportunity to recount their experiences with sars, the lessons they learned from the outbreak, and their views on how the public health system could be improved. The commission also examined hundreds of documents and written reports (cnw Group, 2005). The first report offered fifty-three recommendations and twentyone principles for reform, including the establishment of a provincial centre for disease control. Campbell observed that Ontario’s health system had been unable to manage the crisis effectively because it was “broken.” The province’s medical infrastructure was pushed to its limits. Occupational health and safety issues raised by healthcare workers were among the top issues identified as problematic. While sometimes critical, the investigation acted in a normative way, not attempting to assign blame to individuals but rather to determine how to strengthen the healthcare system to better protect the health of Canadians and the health of frontline nurses and doctors in the future (cbc News, 2004b). The second interim report, entitled “The sars Commission Second Interim Report, sars and Public Health Information” was released on 5 April 2005.5 The second report was extensive, with 500 pages and a total of 113 recommendations. It dealt with aspects of establishing a legislative framework to support and build capacity for public health.

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The main recommendations were: 1 Public health in Ontario requires a new mandate, new leadership, and new resources. 2 Protection against infectious disease requires provincial accountability, direction, and control. 3 Give local medical officers of health the independence to speak out and manage outbreaks. 4 Emergency planning and preparedness are required to protect against the next outbreak of infectious disease. 5 Streamline procedures to ensure local boards of health comply with provincial requirements for infectious disease protection (cbc News, 2004b). t h e f i n a l r e p o rt Mr Justice Campbell completed his final report, containing his findings and recommendations, in December 2006. It was transmitted to the minister of Health and Long-Term Care on 4 January 2007 and released to the public on 9 January 2007. The final report consisted of five volumes, making it the largest of all expert reports. The first volume is an executive summary followed by two comprehensive volumes that together can be considered the final report. The report consists of volume 2, entitled “Spring of Fear,” pages 1–873 (chapters 1 to 4), and volume 3, pages 874–1204 (chapters 5 to 9). The report covers the commission’s mandate (chapter 1), background information on pandemics (chapter 2), the sars story, phases one and two (chapters 3 and 4), victims of sars (chapter 5), a nurses’ questionnaire (chapter 6), after sars (chapter 7), sars management (chapter 8) and recommendations (chapter 9). The report makes recommendations after recounting the story of how sars occurred in Canada and its effect on victims and nurses, its fallout and management. Many of the recommendations focus on improving worker safety. The final report relied heavily upon the written and oral submissions delivered during the public hearings in 2003 and the two preceding interim reports to put together a comprehensive overview of the outbreak in Canada. The commission reviewed submissions from many stakeholders including government, hospitals, unions, and many sectors of the health community to synthesize its final recommendations.

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The final recommendation chapter repeats and draws heavily from the previous recommendations made in the first and second interim reports (volumes 4 and 5 of the final report). The recommendations fall into four main areas summarized below: i) Improved Legislative Framework. Recommendations included a major overhaul of the Health Protection and Promotion Act to remove ambiguities in infectious disease reporting and to provide authorities with the ability to provide a better response than simply invoking Code Orange; review of the Mandatory Health Programs and Services Guidelines; establishing the Ontario Health Protection and Promotion Agency; renew the Central Public Health Laboratory; and providing sufficient long-term funding for public health. ii) Improved Institutional Design and Planning. Justice Campbell pointed out that when sars occurred, Ontario had no single agency in charge of managing the situation; more damning was the fact that there was no pandemic influenza plan in place, leaving Ontario unprepared to deal with any major flu-like outbreak of infectious disease. If there had been a robust influenza plan in place before sars, Ontario would have been much better prepared to deal with the outbreak. The failure reflected a lack of provincial public health leadership and preparedness. To remedy this problem the Campbell Commission suggested the creation of an Ontario centre for disease control, which he called the “Ontario Agency for Health Protection and Promotion.” This agency would also have a chief medical officer of Health who would operate independently of the Ministry of Health. The decline of public health protection in combination with the sars outbreak exposed a lack of preparedness. The reports suggested that while influenza and sars are quite different respiratory infections, possessing different etiologies, if a pandemic flu plan had been in place Ontario would have been better prepared to use pre-existing capacity to deal with the sars outbreak. Justice Campbell recommended that there be Emergency Plans for Orderly Hospital Closure and plans for efficient management during pandemic outbreaks. In order to respond to sars, systems had to be designed from scratch. Ad hoc groups like the epidemiological unit (Epi Unit) and the Science Committee were cobbled

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together. Procedures and protocols were rushed into place, including the process for deciding whether a particular case should be reported as sars. There were no reliable lab tests for sars, making surveillance difficult; in addition it was a difficult disease to diagnose. The system lacked accountability and transparency. The Campbell commission suggested that to avoid this problem in the future, the roles of the chief medical officer of Health and the local medical officers of Health in deciding whether a particular case should be designated as a reportable disease, should be clarified under a transparent system authorized by law. iii) Improved Preparedness Planning and Hospital Management. The lack of an existing plan resulted in improvised management groups being cobbled together in haste to deal with the outbreak. Procedures and protocols such as case review and adjudication processes for reporting sars cases were also rushed into practice. iv) Improved Communications and Reporting. The Campbell commission found the issue of communications and the handling of information concerning sars an area of difficulty. There were too many official spokespersons and their efforts were uncoordinated, confusing the public with mixed messages. On the other hand, Minister of Health Tony Clement correctly pointed out to the commission that any attempt to manage the news by stifling important sources of information would not only have failed but would have led to a loss of public confidence, creating the perception that officials were hiding information about the situation. What was needed was a pre-planned public health communications strategy that avoided either of these problems. Other problems noted by Justice Campbell included the poor sharing of information between the three levels of government. The lack of federal-provincial cooperation was an obvious and serious problem during sars. Again, the lack of pre-existing protocols and agreements prevented the flow of necessary information and analysis between different levels of government. While lack of information sharing was deemed a problem, the commission found no evidence of political interference with public health decisions during the sars crisis. If there is a public health hazard the chief medical officer of Health must be able to tell the public about it without going through a political filter. Safeguards to ensure the independ-

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ence of the chief medical officer of Health were absent during sars but should be put in place to ensure independence in the future. He noted that decisions around outbreak management and direct communication with the public must be both transparent and credible (Campbell, 2004). Justice Campbell was greatly troubled by the general decline of public health protection in Ontario in the recent past, citing other reports such as Mr Justice Krever’s in the blood inquiry, Mr Justice O’Connor’s in the Walkerton inquiry, and the provincial auditor’s report of the West Nile virus experience as examples. Even though these previous reports signaled an urgent need to improve public health capacity, the overall decline of Ontario’s public health capacity received little notice until sars. The sars outbreak, the Campbell report affirmed, was the final, tragic wake-up call. To disregard the obligation to strengthen and prepare the healthcare system to better handle the next sars-like crisis would endanger the lives and the health of everyone in Ontario. The report was very critical of the Ontario public health system’s inability to effectively deal with emerging disease. “The overall system proved woefully inadequate. sars showed Ontario’s central public health system to be unprepared, fragmented, poorly led, uncoordinated, inadequately resourced, professionally impoverished, and generally incapable of discharging its mandate.” Justice Campbell noted that sars was contained only by the heroic efforts of dedicated front line healthcare and public health workers, and the assistance of extraordinary managers and medical advisors. They did it with little assistance from the central provincial public health system that should have been there to help them. The problems of sars were systemic problems, not people problems. Despite the deep flaws in the system, it was supported by people of extraordinary commitment. The interim and final reports detailed a number of weaknesses that led to the failures of the healthcare system, and offered recommendations for strong legislative, institutional, infrastructure, organizational, communication, and management improvements (Campbell, 2006b). 3) The Walker Report: Synopsis and Main Recommendations The Expert Panel on sars and Infectious Disease Control, chaired by Dr David Walker, dean of Medicine at Queen’s University in Kingston, was established by the Ontario Ministry of Health and

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Long-Term Care (mohltc) in May 2003. On 15 December 2003 the panel released its initial report, which provided a series of fiftythree recommendations requiring urgent action. The panel received more than 265 written submissions and conducted 12 focus groups and around 150 interviews with healthcare providers, administrators, and other experts. On 21 April 2004, the final report, entitled “For the Public’s Health – A Plan of Action,” was released. The final report contained another fifty recommendations to complement and build on the initial recommendations. The report was a synthesis of expert opinion from meetings and discussions with a number of experts, healthcare professionals, patients and their families, as well as by a series of independent research projects (Ontario Ministry of Health and Long-Term Care, 2004a). The expert panel was asked to identify the key lessons to be learned from the sars outbreak. They were to provide practical and forward-looking recommendations for the management and control of infectious diseases, and attempt to assess the capacity of the province of Ontario. They were to consider how to improve capacity for future infectious disease outbreaks, and also how to deal with public health emergencies that will occur in the future. sars was viewed in its context not as an isolated infectious disease incident but as an indicator of how the entire system deals with public health threats. sars quickly showed the system’s weaknesses, including a lack of higher-level emergency planning and a lack of lines of communications between hospitals and between public health authorities and hospitals. Given the abundance of telecommunications and computer-based communications tools that surround us, the failure to share information was a glaring deficiency; epidemiological information was a necessity in order to initiate infectious disease containment. The expert panel focused on recommendations that would improve the situation and outlined what types of capacity and infrastructure are needed. The Walker Report used a number of submissions and interviews with various frontline healthcare providers, administrators, and other experts who worked in healthcare facilities and organizations across the province. The agenda of the expert panel was surprisingly biased; they telegraphed their ideas of what the outcome of the report would be. Evidence reviewed by the panel was framed with an eye to system reform and to ensure consistency with other sars reports.

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The Walker Expert Panel believed that provincial and federal efforts to improve public health and emergency preparedness must be coordinated, and that Ontario public health officials should be the main stakeholders ensuring reform of the healthcare system and, especially, capacity for infectious disease control. The Walker Report covered six main areas: Public Health Models, Infection Control, Emergency Preparedness, Communications, Surveillance, and Health Human Resources (a summary of each of the key areas is given). In the aftermath of the sars outbreak, the need for a comprehensive review of Public Health in Ontario became obvious. The expert panel identified a number of areas that were challenged by the sars outbreak including: A lack of communication infrastructure, a lack of human resources, inadequate and outdated organizational structures, and insufficient ability to respond effectively to major health emergencies. The panel identified the need for a new public health model to address these issues. The main recommendation was the establishment of a new Health Protection and Promotion Agency in Ontario, which would report annually to the legislature and have responsibility for the Ontario Public Health Laboratory, existing provincial public health resources, and a new Division of Infection Control (Ontario Ministry of Health and Long-Term Care, 2004a). The large number of Public Health Units in Ontario requires an overarching communications strategy and a sharing of the expertise that exists within the network. Information technology, epidemiological analysis, authority, and overall management of future outbreaks should be centralized. It was also very clear that there is an acute shortage of infection control practitioners and physicians. This is partly due to a lack of educational programs to properly train and certify infection control practitioners, as well as other specialists in infection control. Students in healthcare programs may not be consistently receiving core training in infection control. The panel recommended that targeted funding be established for infection control programs in Ontario to improve human resource capacity in the healthcare system. sars tested Ontario’s preparedness for a health emergency and it was dismally inadequate. The panel heard that there was no plan for the health system to respond to a communicable disease emergency in a coordinated manner. This resulted in unclear roles and

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responsibilities, including lines of authority, communication, and reporting relationships among different levels of government. The panel also learned that there was no comprehensive emergency preparedness planning for hospitals and non-acute facilities on a regional basis. To facilitate an effective response to any future health emergency, the panel recommended creating an Office of Health Emergency Preparedness (ohep ) within the Ministry. ohep would have formal linkages to the Ministry of Community Safety and Correctional Services, and liaise with Emergency Management Ontario. The panel also recommended an immediate review of existing emergency powers and related legislation, with the goal of establishing a graduated and nationally harmonized response system for health emergencies. Finally, the Ministry should support the creation of additional mechanisms to rapidly deploy healthcare personnel during an emergency, and support the development of a new hospital code for infectious disease outbreaks. During the sars outbreak, both the public and healthcare providers needed credible, clear, and timely information. However, provision of this information was hampered by the fact that sars was a disease about which little was known. That said, it became apparent that this difficult situation was worsened by the absence of a clear public health risk communications strategy, even though there was a provincial crisis communications strategy. There were also significant deficiencies in technical aspects of the province’s communications infrastructure, notably the inability to reach many community-based healthcare providers and to allow for two-way communications. These deficiencies further complicated the interpretation and implementation of directives, and prevented the timely sharing of information. The province needs a public health risk communications strategy, which includes risk communications protocols providing information that is clear, concise, credible, accessible, and easy to implement. The rdis (Reportable Diseases Information System), the information system provincially mandated for use by all health units, was functionally incapable of supporting timely outbreak investigation. The surveillance instrument currently being used by Public Health Units does not provide for real-time collection of information. The Integrated Public Health Information System (iphis) must be implemented across all Public Health Units on an expedited basis, together with the necessary information technology supports to allow effective contact tracing

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and quarantine management by public health officials. Data access and data sharing protocols, as well as relevant privacy legislation, must also be reviewed on an urgent basis and amended as necessary to facilitate these public health goals (Ontario Ministry of Health and Long-Term Care, 2004a).

main recommendations 1 The Ministry should immediately establish a Health Protection and Promotion Agency in Ontario. The new agency would strengthen the public health system with expertise in epidemiology, scientific analysis, risk communications, and research. It would act as an over-arching infectious disease control authority. The new protection agency would have clear independence from other health institutions, with a state-of-the-art public health laboratory for surveillance, research, testing, teaching, and sample monitoring, and sufficient resources for effective infectious disease management. It would be headed by the chief medical officer of health, who would report annually to the legislature. The expert panel suggested that the powers of the chief medical officer of health should be broadened in the legislation to provide the position with legal authority to speak and report on matters of public health during an emergency without notifying the minister. This recommendation was an attempt to reduce and simplify the decision-making process, removing it from the political arena. 2 Regional Infection Control Networks should be established across Ontario, with a designated hospital and the Public Health Unit as leaders. The networks should include Public Health Units, hospital infection control practitioners, Emergency Health Services, long-term care providers, and community-based healthcare providers. The network would be monitored with infection control audits and develop comprehensive provincial infection control standards, ensuring that public health standards are being met. 3 Capacity must be improved. The report indicated sufficient supply and distribution of negative pressure rooms should be provided, with need determined on a regional basis. 4 Five recommendations considered various ways to improve training and orientation for system capacity. The ministry, in

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conjunction with the Ministry of Training, Colleges and Universities, should ensure adequate funding for the expansion of existing courses in infection control to increase accessibility for all health professionals. The goals were to increase the number of qualified healthcare professionals to one infection control practitioner per 250 acute care and long-term care beds, and to work toward achieving a target of one infection control practitioner per 120 acute care and long-term care beds within three years. 5 Nine recommendations dealt with the creation of a new office to deal with emergency preparedness. The Ministry should immediately create an Office of Health Emergency Preparedness (ohep ) with appropriate staffing and authority, and with a formal link to the Ministry of Community Safety and Correctional Services. This new branch would coordinate with Health Canada, Emergency Management Ontario, and other relevant organizations regarding public health emergency preparedness. 6 Communications and, in particular, risk communication, were also highlighted in the Walker Report as key areas that needed to be addressed. The panel recommended the establishment of a standing provincial communicable disease committee to advise the Ministry of Health and to coordinate knowledge transfer with regional infection control networks. Each region across Ontario would then be required to establish its own communicable disease and infection control network. Thus, the scheme would result in a unified network for infectious disease surveillance, information sharing, and a higher level of coordination between different areas in the province. One of the problems during sars was the lack of coordination between hospitals. The Ministry should ensure infrastructure for health sector communications so that during a crisis all key stakeholders are in contact. This infrastructure would use email, fax machines, the Internet, and other available types of technologically advanced communications. It would have to be two-way, multifunctional, and enable the Ministry to reach healthcare practitioners, healthcare organizations and institutions, support staff, educational institutions, emergency medical services, professional associations, licensing bodies, and unions. Formally, the infrastructure would become the Public Health Alert Network (phan) and would provide communications concerning infectious disease outbreaks and public health threats to all healthcare providers.

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7 Surveillance for emerging infectious disease was also an important component in improving provincial infectious disease monitoring and contact tracing. Province-wide surveillance requires a multidisciplinary group including scientific, government, information technology, and healthcare partners with linkages to the provincial government. Tools such as Telehealth and Telemedicine, and communications by Internet, require information technology infrastructure. It was proposed that such a surveillance system, or a modified version named the Integrated Public Health Information System (iphis ), be put in place within a year after the sars outbreak ended in Canada. 8 System capacity and human resources were also focuses for recommendations in the Walker Report. Additional medical microbiologist positions (the equivalent of the position Dr Donald Low took on during the sars outbreak) were suggested. As well as increased support for key health professions, including medicine, nursing, and respiratory therapy, the recommendations suggested enhancing training opportunities in epidemiology, medical microbiology, occupational health and safety, community medicine, critical care, and emergency and public health. Recommendations regarding human resource issues specifically targeting infectious disease management were also covered; issues of occupational health and safety, compensation, and psychological support were areas needing review. There was a clear shortage of nurses and other healthcare workers in the system at the time of the sars outbreak. The expert panel recommended that there should be an increase in the percentage of full-time healthcare workers. The increased number of nurses would provide surge capacity during infectious disease crises, when large numbers of nurses might be quarantined or become incapacitated due to disease, or to avoid worker fatigue from overwork (Ontario Ministry of Health and Long-Term Care, 2004; cbc News, 2004c).

a closer look at the minor sars reports Three minor reports were commissioned as a result of the sars outbreak. They focused providing recommendations for improvement in protocols and procedures for infectious diseases. The reports deal

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with infectious disease and other respiratory illnesses that occur in hospitals and critical care facilities. The McKeown Report identified infection control practices required to prevent disease in nonoutbreak conditions, the Henry Report considered Febrile Respiratory Illness (fri) control in non-outbreak conditions in non-acute care institutions; and the Williams and MacLean Report looked at standards of infection control and surveillance for Febrile Respiratory Illness (fri) in Ontario adult acute care hospitals. 4) The McKeown Report: Synopsis and Highlighted Recommendations The spread of sars in healthcare settings caused the healthcare system to re-examine infection control and surveillance practices in place to prevent droplet-spread respiratory infections, both in outbreak and non-outbreak conditions. During the sars outbreaks, the Ontario Ministry of Health and Long-Term Care (mohltc) issued directives to healthcare facilities and community and primary care providers designed to contain the spread of the disease. In December 2003, the mohltc issued directives for infection control during any future outbreaks. In fall 2003, the mohltc also established the Infection Control Standards Task Force to develop recommendations for infection control practices in non-outbreak conditions, which would help Ontario protect against all severe and emerging respiratory illnesses and prevent disease outbreaks. In December 2003, based on the recommendations of the task force, the mohltc issued infection control and surveillance standards for febrile respiratory illness (fri) in acute care hospitals in non-outbreak conditions. Although these standards represent the best advice for infection control in all healthcare settings, the task force recognized that they would have to be modified for use in community settings. On the recommendation of the task force, the mohltc established a working group of the task force to review the report and make recommendations for infection control and surveillance in community health settings. To achieve this, a series of changes and additions to current community health practices were seen as essential, including: screening, counseling and referral, improved reporting, improved infection control practices, increased education and com-

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munication, and implementation of these changes in existing community health settings. The main recommendation of the McKeown Report was that Ontario should greatly improve its surveillance and infection control program for sars and other respiratory illnesses (McKeown, 2003b). 5) The Henry Report: Synopsis and Highlighted Recommendations A task force was set up to review the standards for infection control in non-acute care institutions, including long-term care facilities, chronic care hospitals, rehabilitation hospitals, mental health facilities, and some treatment centers for children. Non-acute care institutions in Ontario differ from acute care institutions in the types and levels of service residents or patients require due to the nature of their conditions and illnesses. While acute care settings focus on short-term, intensive treatment for acute health problems, nonacute care settings provide care after the acute stage and provide continued care, such as: rehabilitation services, psychiatric services, and ongoing, longer-term care for people with chronic, complex, or long-term health problems. The recommendations were divided into six main areas, including surveillance, ongoing surveillance, reporting mechanisms, infection control practices, education and communication, and implementation. The main recommendations of the Henry Report are intended to maintain and improve infection control standards for respiratory illnesses in sars non-outbreak conditions (Henry, 2004). 6) The Williams and MacLean Report: Synopsis and Highlighted Recommendations The Williams and MacLean panel was also established by the Infection Control Standards Task Force in November 2003. The task force’s goal was to work collaboratively with different levels of government to develop a province-wide surveillance program that would guide infection control practices in non-outbreak conditions. Ontario’s standards are for fri, while Health Canada’s guidelines are for severe respiratory infection (sri). fri and sri are two dif-

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ferent points along the continuum of respiratory illness, with sri being a more severe or advanced fri. The taskforce was very interested in supporting and harmonizing provincial and federal practices. The recommendations were divided into five main areas: surveillance, reporting mechanisms, infection control practices, education and communication, implementation. The Williams and MacLean Report recommended integration of provincial infectious disease surveillance with federal initiatives, and provides recommendations for implementation (Williams and MacLean, 2003).

a comparative analysis of the major sars reports All of these reports examine why sars had such an impact on the healthcare system and its workers, particularly in Toronto, and recommend ways to help reduce the risk of recurrence of such an outbreak. Each of the reports reviewed contained a number of recommendations that would improve healthcare and various aspects of infectious disease control. The three main reports (Naylor, Campbell, and Walker) have a number of overlapping recommendations. The broad aims of the reports are summarized in table 9.2. The three main reports all share a common vision for the renewal of our public health systems through increased resources, better federal-provincial and inter-agency cooperation, and system improvement. The goals for improved coordination as stated by all three major reports require the creation of some new form of oversight. The Naylor Report suggests the creation of a Canadian Agency for Public Health at the federal level, with a chief public health officer at its helm, while the Walker and Campbell Reports recommend a provincial-level lead agency similar in scope, to oversee disease control management independently of the Ministry of Health, supporting the chief medical officer. The Naylor report, Walker report, and Campbell report are unanimous in their recommendations of the development of coherent public communication strategies for public health emergencies. The three reports also have similar recommendations regarding the need to address the deficiencies in the federal and Ontario infectious disease information systems in two ways: by improved surveillance and improved communications. Finally, all three reports point to the lack of system capacity and systemic problems with human resources issues. The lack of nurses,

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inadequate protection for workers, and lack of support systems were also noted as common problems.

conclusions Front line workers were the largest continually exposed group. Containment of sars revealed vulnerabilities in the province of Ontario’s healthcare system that made it difficult to protect its own frontline workers from contagious disease. The nurses were at the forefront of the sars crisis in Canada, dealing with containment of a new disease without proper equipment, information, or system capacity. As a result, in Ontario sars had an enormous impact on healthcare workers and their families. There was a real danger that infected healthcare workers could spread the disease to their spouses and children. The first healthcare worker to die from sars in Canada passed the virus to her son and this in turn resulted in all 1,500 students and staff at the private school he attended being put into quarantine from 28 May until 3 June 2003 (Scally, 2003). The ripple effects of exposure to contagions and subsequent quarantines to prevent the spread of sars made healthcare workers and their families into pariahs. Nurses endured stigma and fear from immediate family, friends, and the public. There were reports of children of nurses being bullied at school, and one partner of a healthcare worker was unjustly discharged from work due to sars fears. Healthcare workers and their unions were frustrated by the failures of hospital administrators and government public health officials, who had to scramble to cobble together directives and safety guidelines for front line personnel. Healthcare worker concerns included inadequate personal protective equipment; patient transfer through the system that exposed others to risk; and a premature return to the government-sanctioned “new normal” after the first outbreak.6 In early April, the Ontario Public Service Employees Union7 (opseu) issued a statement warning against reducing precautions and protective measures too early. Similar calls were made by other unions including the Canadian Union of Public Employees8 (cupe), which challenged the Ontario provincial government’s premature lifting of protective procedures at Scarborough Grace Hospital. The way in which the sars outbreak was handled from its beginning to its containment suggested a healthcare system that lacked

Table 9.2 Main recommendations of the Naylor, Walker, and Campbell reports on sars Recommendation Create a new lead agency for public health management

Build Capacity

Develop strategy and emergency preparedness plans

Improve communications (within and between agencies)

Naylor Create a Canadian Agency for Public Health with a Chief Public Health Officer of Canada reporting directly to the Minister of Health Build capacity in public health at the local/municipal levels. Need for significant increase in Public Health Partnerships Program funds ($300 million per year)

Development of a National Health Strategy by the new lead agency. A collaborative development of specific health targets and benchmarks. Improve coordination and communication through specific agreements with Federal-Provincial public health officials.

Walker

Campbell

Create a lead agency; establish a Health Protection and Promotion Agency in Ontario

Create an Ontario Center for Disease Control, independent of the Ministry of Health, to support the Chief Medical Officer

Improve infection control measures by establishing a Regional Infection Control Network, (hospitals, long term care facilities, community health providers, and Public Health units) Create an Office of Health Emergency Preparedness (ohep) to improve emergency preparedness. Develop strategies and plans for pandemics. Improve communications by establishing infrastructure in a Public Health Alert Network (phan). Its purpose is effective science-based communication, disseminating health messages/information to all stakeholders in an emergency.

Review accountability, authority, and funding. Determine roles of province and municipalities in public health protection

Improve emergency planning and preparedness along with public health through added infrastructure. Increase capacity to protect against the next infectious disease outbreak. Need for improved communication and strong links between hospitals and other health care facilities (including nurses, doctors, and other health care workers, their unions and professional organizations).

Table 9.2 continued Improve human resources issues for infectious disease management (especially worker capacity and safety)

Federal, Provincial, and Territorial governments develop and implement a national strategy to renew and sustain public health human resources.

Review and improve the data-sharing protocols between agencies. Improve surveillance by implementing an integrated Public Health Information System across all Public Health units. Improve health and human resources. Provide training in personal protective gear, and provide psychosocial support programs for health care workers.

Enforcement of Section 67 of the Health Protection and Promotion Act by the local Medical Officer of Health to ensure that personnel and equipment needed for public health protection can be mobilized quickly during outbreaks.

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capacity to properly manage risk issues and whose risk communication strategies were not well-developed. Dr James Young, commissioner of Public Safety for Ontario, stated, “It’s a crisis, and in a crisis it’s disordered. The idea of an emergency, in fact, is to return order to a situation that is not orderly. Crises are not happy times for people who like order in their lives.” The question many people, especially healthcare workers, wanted answered after sars containment was: why was this outbreak that infected relatively few people deemed a crisis situation in the first place? Given the extensive healthcare resources already in place in Canada, it was troubling that Toronto, one of the areas hardest hit by the new infectious viral disease, responded the way it did to the situation. The healthcare system had great difficulty dealing with the sars outbreak from the risk-issue management and risk communication standpoints. Initially, there was a lack of personal protective equipment for infectious disease in the system, and during sars1, with staff sent home on quarantine, a worker shortage quickly developed that only compounded the problems of infectious disease containment and management. The lack of an effectively planned, prepared, and coordinated response to infectious disease was clearly evident; there also was a lack of strategy and coordination between groups, and a surprising lack of usable human resource capacity. Dr Larry Erlick, president of the Ontario Medical Association, remarked on the poor communication and coordination during the sars outbreak. “We were frustrated by our limited involvement in the decision making processes at an operational level during the sars outbreak …We recommend that in future any policy framework developed should involve those individuals or stakeholder groups with specific expertise in developing practical and workable policies and guidelines in their affected areas from the beginning of the process.” Dr Brian Schwartz of the Ontario sars Scientific Advisory Committee explained that during the sars outbreak officials were busy dealing with a disease for which there were no test, no diagnostic criteria, no idea of the clinical course, no knowledge of how it was transmitted, no idea of its duration, no idea of the degree of infectivity, and, at least at the outset, no treatment. The initial medical treatment used for sars was found to be largely ineffective and not derived based on evidence. The question remains: why were information gathering, dissemination, and communication

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lacking when the healthcare system was confronted with a novel infectious disease? As healthcare workers were quarantined or became infected during the sars outbreak, the stress on remaining staff members increased as they tried to contain the outbreak. Doctors, nurses, and healthcare technicians knowledgeable about infectious disease best practices, who were already in short supply, became even scarcer. Daily screening for sars symptoms meant that any worker who had a cough, fever, or difficulty breathing was sent home on quarantine. The intensified workload of remaining hospital staff resulted in increased fatigue, stress, and anxiety. The sars crisis revealed that there were problems with the system’s heavy reliance on part-time healthcare workers. Those who had been exposed to sars patients in one hospital were not allowed to work part-time jobs in other hospitals or agencies, causing staffing problems in other care institutions. Tony Clement, Ontario’s minister of Health and Long-Term Care, seemed unaware of the extent to which nurses and other healthcare workers were employed on a casual basis (Tufts, 2003). Of course, the story of organizational problems in the management of the crisis at the beginning was played out and followed closely by the news media with coverage that contributed to the high degree of anxiety and uncertainty felt by the Canadian public. Due to the numerous problems encountered during the outbreak a number of expert committees were convened to study sars and public health focusing on the lessons learned and how to better prepare for and deal with emerging pandemics. The sars outbreak led to a number of tabled reports with much attention focused on ways to improve public health in Canada. Three main expert panels or commissions were convened to better understand the sars experience and to provide recommendations to deal with the fallout of sars and to better prepare for future recurrences of sars or new sars-like diseases. The major reports all agreed on the need to create an agency capable of dealing with many of the problems exposed by infectious disease. While the main focus was on sars as an event and its risk management, far more was discussed in the reports. Many recommendations related to the entire healthcare system, healthcare providers, and institutions outside of public health agencies. Hospitals in Toronto were ill-equipped to deal with sars at the time due to underfunding for infection control. The use

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of part-time staff, a human resource issue, also had a significant impact on the spread and control of the outbreak. Communications were also very poorly handled at a number of levels. For example, the inability to communicate rapidly with community-based practitioners and to provide them with the resources necessary for infection control (e.g. masks and disinfectant) hindered control of the outbreak; this could have been disastrous if the infectious agent had been more virulent or more easily transmissible. Many of the recommendations in the main reports dealt with improvements to the health system in general. Many of the reports’ recommendations have already been implemented, with investments in coordination, communications, public health, and health research at both the national and provincial levels. Communications, information systems that share data, and other resources are vital for infectious disease surveillance and for outbreak management. The three minor reports were much more specific in their focus, dealing with infectious disease practices in non-outbreak conditions, specifically, Febrile Respiratory Illness (fri) control in nonoutbreak conditions in non-acute care institutions, in adult acute care hospitals, and in long-term care facilities. Older and acute care patients comprise one of the most vulnerable groups during outbreak conditions. These reports were a review of current practices in different types of institutions and offered recommendations to improve infectious disease practices. As a result of the seriousness of the need to contain infectious disease, the federal government responded with amendments to the Quarantine Act and Quarantine Regulations. sars has been added to the Quarantine Act’s Schedule of infectious and contagious diseases.9 Under the Quarantine Act, a quarantine officer is authorized to detain a person suspected of having sars for a period not exceeding the prescribed incubation period. The amendments prescribe an incubation period for sars of twenty days. The who’s recommended quarantine period is confirmed as ten days, but the Canadian amendment doubles that as a precaution. New in the Quarantine Act is the authority to distribute sars health information and questionnaires to all persons on board air flights both before arrival in and departure from Canada. Finally, the list of airports to which an aircraft arriving in Canada must report if they have cases of illness or death on board before landing has been extended to include most major Canadian airports (phac, 2003d).

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sars was a dramatic example that revealed just how quickly modern air travel can link distant places and how easily it can spread an emerging disease. It also uncovered how health systems responded to an emerging threat with weaknesses, strengths, and areas that needed improvement. sars has dramatically changed the way that Canada responds to infectious diseases in the era of widespread international travel. The reports looked critically at the sars outbreak as a typical infectious disease that challenged the healthcare system. Recommendations were made regarding management, infrastructure, capacity, human resources, surveillance, and communication, to improve our capacity to respond to future sars-like diseases and potential pandemics.

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Risk Communication of SARS in Canada The epidemic has shown the need for communication of risk that will inform and warn the public, in a way that will improve personal protection, without inducing raised anxiety and fear, as an essential part of epidemic control. A change in risk perception would potentially lead to an increase in early reporting of symptoms as well as improvements in hygiene and prevention of transmission. Christl A. Donnelly, The Lancet, 24 May 2003

Risk involves both the probability of an adverse event and the severity of that event. In our everyday lives we are confronted with myriad risks that we accept for the convenience or perceived benefits. For example, driving a car, smoking, and poor dietary choices are voluntary risks many of us take. Experts employ scientific risk assessment methods to characterize risks as accurately as possible, determining exact probabilities, while the public perceives risk by experience linked to previous events that gives the risk meaning in an individual context (Ali, 2002). When confronted with new risks, individuals react rationally. They want to know just how much risk the unknown represents, and whether or not it requires added precautions for harm to be avoided or minimized. Individuals (non-experts) need accurate information to assess risk levels, and this must be available in a timely manner from a credible source (usually an expert). To facilitate the ability to make informed decisions, good risk communication is required. The field of risk communication developed when researchers combined knowledge about risk assessment and risk management with ideas and qualitative structures from the field of modern communications theory and practice. In this way, statements about risk by various parties are treated as messages

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intended to persuade others to alter their behaviours. The effectiveness of messages can be evaluated according to well-established criteria such as understanding, attention, and believability, and whether they induce individuals to change their actions. Trust and credibility are also important, and tightly linked to how qualified the expert is to assess the situation in its context. Leiss (2001) stated that systematically neglecting the responsibility to initiate conversations about risk allows an information gap to develop; this may well be the most serious failing of all in the domain of risk communication practices. In such situations, the risk communication process itself often becomes an explicit focus of controversy. The results are disastrous, with recurring outcomes such as perception of media bias or sensationalism, distortion of information, selective use of information by different groups, perception of hidden agendas, the perception of irrational standpoints, and the inability or unwillingness of regulatory agencies to communicate essential information in a language the public can understand. During the sars outbreak, many of these charges were heard at public hearings by public officials and others who gave their personal accounts of the events surrounding sars.1 For example, each person’s risk of being injured or killed by sars was a function of various factors in the context of the disease outbreak. Information that influenced the perceived level of risk included the numbers of imported infections, numbers of reported infections, numbers in quarantine, surveillance capabilities of officials, hospital capacity, individual awareness of the symptoms, severity of outcomes, and degree of uncertainty. As more information became known, public perception of the hazard expanded to include other information: the virulence of the virus, ease of transmission of the virus, and efficacy of medical treatments. The most important factors in regard to transmission and exposure included: the amount of time spent in high-risk areas (hospitals or hot spot countries with uncontained outbreaks), the ease of transmission in close proximity to sars patients, or being involved in high-risk procedures that aerosolized the virus. The product of the two factors (hazards and exposures) added up to the overall risk (Leiss and Powell, 2004). For those outside Toronto-area hospitals, the risk was negligible, while those workers on designated sars wards and patients in sars-affected hospitals faced a considerably higher level of risk.

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the sars risk communication gap materializes In Canada prior to sars, the federal government (Health Canada) had relatively weak powers to manage and impose itself onto healthcare issue decision-making processes. The control of healthcare issues was largely a provincial matter. The expert panel reports carried out after the sars outbreak in Canada highlighted the lack of communication and information sharing as a major problem; the scope of sars required communication of infectious disease information, not only within and between hospitals but also between different provincial public health jurisdictions and different levels of government. Information sharing between the federal, provincial, and municipal governments within Canada was inadequate, and there was also no coordinated voice at an international level between Canada and other countries and agencies, (with the United States Centers for Disease Control and institutions like the World Health Organization, for example) (Campbell, 2006a). There was a lack of leadership and little capacity to facilitate communication between groups, government departments, or to the public about the risks of sars when it was needed most. This was largely a result of the fact that public health officials were spending all their time dealing with the emerging risk itself, in the absence of pre-existing planning. This left them little time to deal with the associated risk communication issues. The result was an information and policy gap that left the Canadian public desperate for accurate risk-issue information. From the beginning, the only continual, abundant source of information was the news media, which quickly dominated public perception of the risk issues pertaining to sars. They stayed focused on the contagion’s potential to develop into a pandemic, and the idea that, throughout the outbreak, containment was uncertain.

risk perception and the failure to overcome social amplification of risk The failure of proper risk-issue management for sars was not unique to Canada. For example, the Philippines, a country in close proximity to southern China, Taiwan, and Malaysia, had large movements of people to and from known sars hot zones. The

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Philippines, with a population of just over 87 million people (nearly three times the population of Canada) had only fourteen cases of sars and two deaths. Despite the low number of deaths, small numbers of people infected, and cases that were quickly contained, the belief that catching sars was a high-risk probability persisted among the public. This perception resulted in widespread anxiety and fear. Health officials thought that by holding daily briefings to disseminate information about what was known that they could help inform the public and reduce fear. This strategy failed completely. After the outbreak started, the few messages from public officials were rapidly overwhelmed by news reports that distorted and obscured them. Dr Consorcia Lim-Quizon, head of the National Epidemiological Center, lamented, “the way the media are twisting and turning … the message gets lost.” She appealed for more responsible media reporting. “We cannot quell public hysteria if the media continue to hype it up.” She felt the media chose to focus on the negative impacts of the outbreak rather than anything positive. Similar to Canadian news reports, the stories were framed by the media to focus on the number of sars deaths and not on the number of people who had recovered. Mortality was presented as the primary statistic of sars, with its 5 per cent death rate rather than the 95 per cent recovery rate. Newspapers showed pictures of people performing daily tasks in sars-ravaged Hong Kong, wearing masks because they were afraid of the contagion. Such visual imagery was difficult to overcome with verbal messages (de Castro, 2003). The Use of Cumulative Numbers and Presentation of Data The news media in Canada and elsewhere used cumulative numbers in reporting on sars. In many countries the numbers of Probable and Suspect sars cases were grouped together when reported, giving the outbreak numbers large daily increases. Cases that later turned out to be something other than sars were calculated as potential cases, but this fact was largely ignored by the news media when reporting the cumulative numbers. An overwhelming majority of Canadians who were surveyed nationally and asked to rank health risks and the perceived risk of various health issues (e.g. smoking, street drugs, or aids) indicated that the news media was their most common source of information for risk issues. While the news media provided an easily accessible

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information resource, Canadians also indicated that the credibility of the experts providing the risk message was also an important factor. During the sars outbreak the public relied heavily upon news reports for information. Dr Colin D’Cunha, Ontario’s Chief Medical Officer of Health, and Dr James Young, Ontario’s commissioner of Public Safety, gave daily media updates during the sars crisis. Dr James Young did an excellent job transparently communicating what the experts and officials knew about the disease. In an early media appearance he was quoted as saying, “We’ve got a new illness with very little understood about it, a lot of trouble diagnosing it and a lot of confusion over who has to do what.” While his messages during the outbreak were not the most reassuring, they were realistic and trustworthy, and showed that officials were taking precautions to the best of their ability, given the situation. At an international congress meeting on sars (30 April 2003), Dr Young was highly critical of the way the news media presented sars information to the public, especially the practice of issuing cumulative case numbers every day. He believed that this probably led to an exaggerated perception of the severity of the Toronto-area sars outbreak by the public, both locally and globally. “In retrospect, it is confusing to take a cumulative number . . . is the number going up? Is the number going down? What is the steepness of the curve. That’s really the key to the epidemic. It’s not the cumulative number.” By combining Suspect and Probable cases, numbers were inflated, making for a more controversial news story and conveying a picture of greater uncertainty (Branswell, 2003). Numbers that were reported cumulatively and reiteratively in news articles showed an ever-increasing line slope over time and gave the impression of a disease outbreak that was not only still on the rise but increasing in magnitude. The effect of cumulative number reporting is shown graphically in figure 10.1; it shows how easy it was to conclude in error that the trend line was continually increasing. The data reported by the news media could have been presented in a way that would have better reflected the nature of infectious disease transmission in Canada, making clear that individuals who became infected in hospitals or had potential infectious contacts were quarantined, preventing secondary cases. Figure 10.1 has been redrawn showing non-cumulative numbers of deaths and noncumulative recovery numbers (split into two separate graphs for

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Figure 10.1 Cumulative numbers of deaths, recoveries, and total reported Suspect cases from 17 March 2003 to 28 July 2003 Data reported to the World Health Organization from Canadian sources

easier viewing of the trend lines). The trend lines for data in figures 10.2 (non-cumulative numbers of deaths and non-cumulative number of recoveries) and 10.3 (non-cumulative numbers of deaths and non-cumulative total number) appear to be quite different from the trend lines shown in figure 10.1. At first glance, the trends presented in figure 10.1 (cumulative data) compared with figures 10.2 and 10.3 (non-cumulative data) appear quite different, but they are showing the same data presented in two different ways. The non-cumulative graphs (figure 10.2 and 10.3) show a low number of deaths over the entire time period (the highest one-day total is five deaths). The number of those recovering shows a biphasic distribution that reveals that many people who contracted the disease during sars1 and sars2 recovered (figure 10.2). The same biphasic result is shown for noncumulative totals in figure 10.3. As expected, the distribution

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Figure 10.2 Non-cumulative numbers of deaths and non-cumulative numbers of recoveries of sars cases from 17 March 2003 to 28 July 2003 Data reported to the World Health Organization from Canadian sources. Values shown for non-cumulative deaths are shown above the trend line.

during sars1 was reduced during the week of 14 April 2003, showing that weekly time points (numbers taken at seven day intervals) were shorter than the incubation time of sars (ten days), so fewer people had recovered at the height of sars1 at this time point. While acknowledging the fact that the news media may have had a saturating effect and the amount of media coverage was impacting public perception, government officials did not react to counter this effectively with their own risk communication. They held news conferences daily as the main way to disseminate information, allowing the news media to pick and choose the sound bites and information. Important messages had to compete against other stories and were quickly lost in the volume of reporting. Television news interviews given by sleep-deprived public health officials looking haggard from the sars ordeal did little to reassure the public.

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Time Figure 10.3 Non-cumulative numbers of deaths and non-cumulative total numbers (deaths and recoveries) of sars cases from 17 March 2003 to 28 July 2003 Data reported to the World Health Organization from Canadian sources. Values shown for deaths (italics) and totals (bold) are above the trend lines.

Lack of Familiar Risk Anchors for Comparison and Understanding of the Level of Risk We know from the available statistics that more people died of influenza during the sars outbreak than from sars itself, and yet no effort was made to compare the familiar risk of the yearly flu to sars, nor were any statistics on the subject offered in newspapers or other media. As a result, the actual risks of sars remained unknown to the public, with little basis of comparison available to help them gauge how dangerous or how risky sars really was. While the comparison is not perfect, comparing sars to the common flu virus would have allowed individuals to place the unknown risk of sars in perspective with a known, similarly infectious viral illness. In the midst of the information overload, a number of factors led to a social amplification of the sars risk. The unfamiliarity of the disease, the lack of coordination among various levels of government, international scrutiny, and the sheer lack of knowledge about

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the disease all contributed to the generation of a glut of news articles (Zerbisias, 2003). News stories about sars fragmented into many subject areas, including health risk concerns, human resources deficiencies, economic risks, pandemic preparedness, comparisons to biological terrorism agents, infectious disease management in hospitals, and international aspects of infectious disease, to name a few. The result was public perception of the outbreak that touched on numerous kinds of risk (health, social, economic, ethical, and environmental), making it difficult to manage by public health officials. A negative feeling was created by the media focus on the lack of knowledge about the disease – at the time, not even the causative agent was known to the experts. All the risk issue management and risk communication attempts that followed failed to dislodge the inaccurate mental model of sars established in the minds of most individuals who were relying upon the news media sources for readily available, ongoing information. Complementary Action That Reinforced the Social Amplification of Risk: High Numbers of Individuals Entered Quarantine at the Same Time Retroactive quarantining of individuals coincided with news reports using cumulative numbers, and this also added to the magnification of the perception of risk. Scarborough Grace was the first hospital in Canada to receive patients with sars. Toronto health officials scrambled to find possibly thousands of people who visited Scarborough Grace Hospital from 16 March to 26 March and might have been exposed. Health officials asked that those who had visited Scarborough Grace Hospital during that time period stay home under voluntary quarantine for ten days from the date of their visit. The result of this action meant that a large cohort of individuals entered quarantine at the same time. Locally, knowledge of a large group in quarantine, with more ongoing quarantine cases being identified, gave the impression of an escalating outbreak. The state of health emergency was authorized under the Emergency Plans Act on 26 March. It allowed the premier to rally financial, human, and equipment resources needed to deal with the emerging disease outbreak. The declared state of health emergency was a cautious approach, as Toronto had experienced more cases of sars than

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anywhere else outside of Asia. It was an attempt to provide access to resources in case the thousands of people who had visited the hospital had become infected. Under the provincial health emergency, the province was allowed to cross-reference patient information to track new cases of the disease regardless of patient privacy concerns. The government also declared sars a reportable, communicable disease under the Health Protection and Promotion Act. This meant that people could be quarantined against their will if they refused to comply with a quarantine order. Declaring a health emergency gives specific powers to the Health Ministry to contain the outbreak. The last time these powers were invoked was on 11 September 2001, following the World Trade Center terrorist attacks in New York City (Talanga and Palmer, 2003). Health officials in York Region (a municipality adjoining Toronto, part of the Greater Toronto Area) took legal action against one person who disobeyed the public health directive to stay home on voluntary quarantine; the ´/person had already being given a quarantine order under the province’s Health Promotion and Protection Act. Anyone found in violation of a quarantine order could be fined up to $5,000 a day. Section 35 also authorizes the use of police assistance to ensure the individual is isolated. Seven Ontarians were identified as not abiding by the provincially mandated quarantine; five of these individuals lived in the York Region of Toronto (Powell, 2003b). Luckily, widespread transmission to those who visited the hospital during the early weeks of March did not occur. Mass Quarantine and Simultaneous “Zero Risk” Messages As a result of the retroactive mass quarantine imposed as a way to contain and isolate those potentially infected during hospital visits, a large number of people and hospital patients were sent into tenday quarantines all at once. In addition, healthcare workers were placed on work quarantines. The quarantine as an event itself became a reported news story, and the action contradicted reports from officials that there was “near zero” risk of sars and therefore nothing to worry about.2 Clearly, any observer would surmise that with so many people placed in quarantine, the prevalence of sars in the general population was not well established, and therefore, the true risk must not be well known. The risk communication messages of “near zero” risk juxtaposed with many people in

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quarantine were confusing. The public felt, although this idea was not well articulated, that government officials were saying one thing about the sars outbreak but their actions were seemingly contradictory, and implied a different story. International news stories of Chinese officials denying the prevalence of sars to avoid economic losses was a related example of the lack of public trust in a different jurisdiction (Thiers, 2003). On the same day that sars was declared a health emergency in Toronto, Dr Sheela Basrur, the medical officer of Health, issued a statement recommending that anyone who had visited Scarborough Grace during the initial outbreak period from 16 to 26 March, including patients, visitors of patients, and people who went to the hospital for doctors’ appointments, contact the public health telephone hotline and to stay at home on a self-imposed quarantine. Members of their families were asked to wear a mask at home when having face-to-face contact with the quarantined person. Family members were told that it was fine to leave the house if they were symptom-free. The message was the best attempt at public containment given the situation. At the time of Dr Basrur’s statement, doctors already suspected sars was a respiratory illness that was passed by aerosolized viral particles from a cough or sneeze from an infected person. Scientists didn’t know what caused sars, how to test for it, how long it persisted on surfaces outside of the body, or how long it took for infected patients to start to show symptoms. Infectious disease specialists wrongly speculated that two viruses might have recombined to create sars (coronavirus – which causes colds – and the paramyxovirus, a common agent that causes measles and mumps) (Talaga and Palmer, 2003). The statement that family members could leave a home where individuals were quarantined was practical, but could have had disastrous results had sars been a more virulent strain. The delayed, imposed quarantine affected a substantial number of people – well over a thousand individuals – mostly concentrated in the York Region of Toronto. Even with public health officials acting quickly there was a ten-day window for potential spread of this emerging disease between 16 and 26 March. Barb Wahl, president of the Ontario Nurses’ Association, said a large number of nurses were possibly exposed to sars during this initial ten-day period and were quarantined by voluntary home stays. There were

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also twenty-two paramedics quarantined at this time, and three paramedics who were in hospital with Suspect sars. The quarantined paramedics were part of an elite twenty-four-member unit that transported the sickest patients from hospital to hospital for specialized treatment. The quarantine of paramedics resulted in a shortage, forcing nurses to be sent with ambulances transporting high-risk patients. The large number of healthcare workers quarantined as a precaution left the healthcare system vulnerable (Talaga and Palmer, 2003). North York General Hospital head nurse Cathy Paterson explained that the imposed work quarantine for nurses made life extremely difficult. “Little things that you don’t think about become major problems. For healthcare workers who drove to work, filling up their car with gas was impossible without potentially exposing others. Healthcare workers without cars would have to rely on mass transit (bus, subways, or taxicabs) to get to work, again making containment a problem. Other daily tasks like shopping for food, eating out, picking up children from daycare or school, going to any retail store, or going to a movie theatre all were not allowed during the quarantine period as people would attempt to isolate themselves from others.” While in theory voluntary quarantine of exposed healthcare workers seems like a good solution, in everyday life it was nearly impossible to carry out effectively. For infectious disease management, quarantine is the best line of defense, but it is likely not to be an effective barrier for contagions that are more easily transmitted than sars. Another problem was that there was some difficulty in tracking patients who were suspect for sars but were sent home on quarantine. By the time sars2 arrived Toronto, hospitals, including North York General, were admitting everybody who was suspect for sars or all patients with fevers. In the end, people who were initially sent home on quarantine who later developed sars did eventually return to the hospital. It was clear to the individuals that what they had contracted was no ordinary flu or cold, and their ever-worsening symptoms required immediate medical attention. Invoking the Health Emergency Act resulted in widespread panic that overwhelmed a healthcare system already weakened by healthcare worker quarantines. Emergency rooms were flooded with worried but well people suspecting they had sars. A twenty-four-

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hour, walk-in clinic at the Sunnybrook Health Sciences Centre and Women’s College Hospital opened its doors in the morning to over 100 people who feared they’d been exposed to sars. That same night almost 10,000 people swamped sars telephone hotlines looking for advice; most were fearful and seeking information. On 28 March 2003, just two days after a health emergency was declared and the Health Emergency Act implemented, severe restrictions were placed on hospitals. The imposed limitations included: restriction of visits to hospitals in the greater Toronto area and Simcoe County to parents of pediatric patients and those visiting critically ill or palliative patients only (this meant that many patients in the hospital for other health problems were deprived of family visits); all hospital staff had to wear protective clothing, including masks; all volunteer programs and patient transfers between hospitals were suspended; isolation units were set up at all hospitals; and all staff who had worked at Scarborough Grace since 16 March were prohibited from working at other hospitals (Talaga and Powell, 2003). Public perception of a high risk from sars and the uncertainty during this time had another unforeseen result that also had the potential to impact disease containment and healthcare. Available supplies of protective respiratory masks quickly dwindled as people and governments rushed to purchase and stockpile the only known protective and preventative measure against sars. Respiratory masks with an n95 efficiency rating were essential to protect hospital workers, and recommended for healthcare workers or anyone who had visited Scarborough Grace Hospital since 16 March. The Ontario government was the largest purchaser of 3m Canada’s available N95 mask inventory, worried that panicked customers would purchase all of the masks leaving hospitals with a shortage. The 3m Corporation declared its own emergency response to the sars outbreak, running its American factories around the clock in order to meet demand from hospitals and hosting on-site mask-fitting training sessions (Sorensen, 2003). A quarter of Toronto residents who were quarantined or had a family member or friend quarantined reported it was a major problem for them (24 per cent), while half said it was a minor problem (51 per cent). The most common problems reported were the psychological and emotional difficulty of being confined and isolated.

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Hospital Transmission of SARS and Increased Uncertainty: Healthcare Workers Can’t Protect Themselves Effectively One month after the beginning of the sars crisis, hospital staff were experiencing renewed anxiety as isolation procedures constantly changed and more hospital employees entered quarantine or were diagnosed with sars, requiring treatment. Common reactions were fear, anxiety, anger, frustration, fatigue, insomnia, irritability, and decreased appetite. Healthcare workers felt conflict between their professional responsibilities and the need to ensure their personal safety and protect their families and friends from exposure to infection. Nurses on the sars units usually did not refuse work assignments, but some professional and non-professional staff on general medical floors refused to care for patients with sars. Refusals stemmed from the fear of catching sars. A hospital survey during the outbreak showed one third of healthcare workers experienced some form of emotional distress due to their personal safety concerns. This was more than double that usually seen in the general population of healthcare workers. Nurses and allied healthcare professionals that dealt directly with sars patients had significantly greater emotional distress than did doctors and staff not working in patient care. Several surveys were performed to determine how nurses and other healthcare workers were affected by the sars outbreak. The results of a survey conducted by Toronto’s Emergency Medical Service suggested that nurses and doctors weren’t getting the psychological support they needed during and after the sars outbreak. Paramedics reported that they were very fearful that they would become infected and spread sars to their family and friends. A second concern was how the outbreak would delay patient care. Of the 800 paramedics working on sars in Toronto, only four contracted the respiratory illness, and all recovered. During the outbreak half the paramedics were on voluntary quarantine, having to wear n95 masks both at home and work for ten days, remain isolated, sleep alone, and eat separately from other family members. Dr Gerry Goldberg, the paramedics’ staff psychologist who conducted the study, said workers complained that the public was avoiding them and that they had been stigmatized as a group as a result of sars.

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In a second study, researchers at Toronto’s Sunnybrook and Women’s College Health Sciences Centre used questionnaires during the peak of the city’s first outbreak to survey the hospital’s employees; nurses reported the most emotional distress. The study suggests that almost two thirds of hospital staff were concerned for their own or their family’s health. Nurses reported more signs of emotional distress, such as having trouble sleeping or fearing for their lives, compared to hospital administrators, supervisors, or doctors. Those who said they felt they were stigmatized because they worked in a hospital also tended to show more concern for their own or their family’s health. All hospital staff had to wear masks at all times from the beginning of the outbreak until 17 April, which was also cited as stressful, a constant reminder of the sars situation they were dealing with. In another study, a total of 2,001 employees from Sunnybrook Health Sciences Centre (shsc), representing nearly a third of the hospital’s staff of 7,474, completed a survey. The response rate was relatively low but the proportions of occupations included (doctors, food service workers, and nurses) were representative of the hospital’s staff. About 500 staff members surveyed were also asked to fill out a standardized test of emotional well-being. Of those, 29 per cent had scores indicating probable emotional distress as a result of sars. Individuals who were afraid they might die from sars, who lived with children, or whose family lives were disrupted from dealing with quarantine showed the highest distress levels. Previous research shows that having some level of control, whether real or perceived, reduces the risk of feeling threatened by the disease. Much more research on the long-term psychosocial impact of threats like sars on healthcare workers is needed (Nickell et al., 2004). A fourth study conducted by Dr Esther Greenglass of York University with colleagues in Singapore and the University of British Columbia involved an Internet survey to assess how anxious the general public was during the sars outbreak. The results showed that in affected areas, such as Toronto, individuals were more worried about contracting sars and had a heightened sense of personal risk. It was also evident from the study that Toronto health workers and members of the Asian community had been stigmatized within the community. Due to fear and stigmatization, many in these target groups were plagued by high anxiety levels. The psychological

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after-effects of sars continued well after the outbreak was officially over. The researchers suggested that every level of government failed to do enough to address the concerns of the public, doctors, nurses, and paramedics. Very quickly, once the sars outbreak was contained, government officials seemed to put economic interests ahead of communicating information about sars and helping those hardest hit to deal with lingering psychological and social impacts (Marjanovic et al., 2006). Psychosocial effects are defined as psychological and social factors that affect individuals’ ability to deal with stressful changes and issues of quality of life. Psychological factors include selfesteem, coping mechanisms, pre-existing disorders, beliefs, personal value systems, adaptive stress responses, and emotional stability. Social factors include social network capacity (personal, family, work, or social relationships), daily environments, availability of social supports (food, water, shelter), and financial stability. The news media reported the increasing numbers of healthcare workers who were infected as the sars outbreak continued over time. The message, although subtle, suggested that sars was an incredibly difficult disease to manage and contain. The fact that trained professionals in full protective gear could still become infected at an alarming rate was a disquieting bit of information that played into perceptions of fear and insecurity. Failed Risk Communication – Disenfranchisement of Frontline Workers at High Risk Nurses were deeply affected by the sars outbreak, as reflected by survey data. Two years after the sars outbreak, fifty-three nurses who had become infected with sars filed a class-action lawsuit against the Ontario government. The nurses claim they were not adequately protected during the 2003 sars outbreak and that this was a failure of proper risk communication. The lawsuit, backed by the Ontario Nurses’ Association, contends that the government did not take appropriate action to protect nurses on the front lines, and that nurses suffered greatly dealing with sars. They cited isolation, lost sleep, and social stigma as common effects experienced during the crisis. Due to lengthy work quarantines, sars team nurses

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missed important family and social events. They were and are unable to carry on the normal activities of daily life, including socializing, exercising, doing housework, and engaging in hobbies. Some healthcare workers did not return to work, finding the stressful period of illness and quarantines too much to tolerate. The nurses alleged that healthcare workers weren’t told how to protect themselves from sars until fifteen days after the same information was provided to doctors. In a statement of claim, the Ontario Nurses’ Association accused the province of negligence in its handling of the 2003 outbreak. The nurses accused the government of not enforcing occupational health and safety standards in hospitals. Nurses on the front lines put themselves at risk for the benefit of their patients. In doing so, they should have been properly protected, and it was the government’s responsibility to do so. The failure resulted in nurses seeking compensation for their suffering. In a public news report, government lawyers countered by saying that doctors were warned and informed about how to best protect themselves as a matter of courtesy, but insisted the government was not obliged to inform nurses, that responsibility belonged to the hospital. “The decision to send the information to physicians was entirely discretionary,” government lawyer Kim Twohig told court. The province argued in Ontario’s Superior Court that the suit has no merit because the government was not obliged to protect the nurses, since the government does not directly employ them. Moreover, the nurses cannot claim their Charter rights to life, liberty, and security of person were violated without also pleading there was willful intent to harm, which there clearly was not (ctv News, 2005). In a separate incident, a Toronto nurse launched a $600-million lawsuit against the Ontario and federal governments for damages caused by the sars outbreak of 2003. The nurse contracted sars in May at Toronto’s North York General Hospital where she worked. She believed the people in charge, the politicians and healthcare officials, did not take the threat of sars seriously enough, and the decisions they made put her life in jeopardy. She was quarantined in hospital for eleven days, then had to spend more time recovering in hospital and at home. She has suffered long-term disabilities from sars including severe fatigue and memory loss. She described her experience with sars as near death. “Physically, I could not breathe, my lungs felt as if they were closing. I could not eat. I lost over thirty pounds.” There was the per-

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ception among nurses that officials were more worried about lost tourism revenue and a return to normal than public health (including the safety of healthcare workers), and perhaps, they believed health officials acted too quickly when they declared the end of sars in late April. Infection of about 100 other people – some fatally – indicates that a reduction in infectious disease vigilance had occurred. Given what was known at the time, it is unlikely that officials could have predicted or expected the undetected infections of sars2. They did not intentionally or recklessly seek to harm healthcare workers by their actions (ctv News, 2004a). The lack of strategic plans for infectious disease and the enormous amount of work needed to coordinate and contain sars left little time for risk communication to other groups. Risk communication failure during the sars outbreak resulted in Canada Customs officers nationwide threatening to walk off the job over concerns that they might contract sars from passengers arriving from Asia. The 11,500-member union petitioned the Customs and Revenue Agency to meet a list of demands regarding sars. The confrontation erupted after 292 Koreans were allowed into Canada at Pearson airport without undergoing Health Canada medical checks. Korea was a low-risk country with very few cases of sars, but Customs Excise Union officials were concerned over the safety of their workers, who were processing a large number of individuals and flights from sars hot zones day after day. Union president Ron Moran said managers did not seem to treat the sars epidemic seriously, even though the World Health Organization had banned travel to Toronto. Moran said front line officers needed complete, up-to-date information on sars and appropriate guidelines on how to treat Suspect cases. Officers said most flights from sars hotspots arrived at airports in Toronto, Montreal, and Vancouver, but smaller airports could also be affected due to in-transit and charter flights. Labour Canada officials ruled that the officers’ workplaces were safe. If a cautionary approach to sars management was used, Customs officers could have been included along with doctors, nurses, and paramedics in daily updates, information, and guidelines. Regardless of the occupational risk level no one took the time to communicate with this group about the evolving situation, although they were interacting with high numbers of travellers from known sars-infected areas. Customs officers should have been provided breaking information like other

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high-risk professionals (Godfrey, 2003). This lack of coordinated communication was also seen for other groups that perceived themselves to be at high risk, including paramedics, air transport workers, taxi drivers, and mass transit workers. Lack of Leadership and Incorrect Risk Communication Messages On 8 May 2003, the Toronto City Health Department announced that the outbreak was over. On 12 May the Ontario commissioner of Public Health, Dr Colin D’Cunha, told the news media, “it was preposterous,” when responding to reports that a Finnish man who had been in Toronto had contracted sars during his visit. His use of the word “preposterous” demonstrated the general feeling among those managing the outbreak that it was indeed over. The provincial state of emergency was lifted on 17 May; in fact it was merely the end of sars1 (Basrur, 2003; Tourism Toronto, 2003; Schabas, 2003).3 Dr Schabas was critical of such statements; with no program of active sars surveillance in place in Toronto, there was no basis for assertions by key experts that the outbreak was over. It turned out that his assessment was correct. In fact, by 22 May, the day that sars2 was declared, there were already almost fifty people who had developed sars. It was not until 16 June that the provincial government finally adopted a comprehensive sars surveillance protocol (Schabas, 2003). Dr Shabas’ ideas about the impact of sars on regular hospital care were similar to those of Scarborough Grace Hospital ceo Glenna Raymond. He felt that the massive hospital shutdown throughout the Toronto area for most of the month of April was not necessary. He was also critical of the widespread use of mass quarantine, as he believed it played little or no role in sars containment, but it came at a great cost. Quarantine sapped the resources of the public healthcare system, with staff running around quarantining instead of doing the much more important jobs of identifying people truly at risk and capturing and analyzing the necessary information. Quarantine had a negative psychological and social effect as it fuelled the general sense of an increased risk. Public communication was also an area that was poorly handled, and this had an impact on hospitals and the perceived management of the outbreak. Hospitals should have had evidence-based information and better infectious disease surveillance for sars. There

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were several operational issues that needed to be improved from a communications standpoint (e.g. dissemination of up-to-date knowledge regarding sars; dissemination of new research about sars between staff and different hospitals; and better lines of communication between government departments and hospitals regarding sars).

overcoming social amplification of risk constructs and stigma Countries with the highest sars transmission rates suffered a number of secondary negative effects including stigmatization of nurses, doctors, quarantined individuals, and recovered individuals. Areas with sars suffered widespread stigma and reported economic losses (reduced tourism, resulting in loss of business by local restaurants, hotels, hospitality services, and bookings of mass gathering events such as conferences, concerts, and air travel). One of the main drivers of uncertainty and fear was excessive news reporting, which created a social amplification of risk effect. It altered public perception of risk well beyond the actual level determined by transmission rates. Could the social amplification of risk effect that occurred during the sars outbreak have been avoided? Leiss (2001) suggests that stigma presents itself in different forms, and understanding this may be useful in analysis and management of risk controversies like sars. Stigma can be either a natural or essential characteristic, or an accidental feature resulting from special circumstances. If the stigmatizing process is an essential characteristic of the public understanding of risk, which is likely to remain unaffected by education or increased public knowledge, then little can be done about the resulting social amplification construct. sars falls into the latter class, with stigma that arises from special medical circumstances. It may be possible to manage this type of stigma, as it arises from behavioral influences. Managing stigma in this context means seeking to counteract only the excess or surplus perceived health risk, and not the underlying continuity of public opinion itself. The distinction means that the public is right to be fearful of new infectious diseases and requires accurate information from credible sources. The continuity is that the public is aware of new infectious diseases like mad cow disease, West Nile virus, monkey pox, avian

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flu and sars, and want accurate information along with appropriate risk management from government officials. Zero-risk messages intended to placate the public are unlikely to be accepted as true. Communicating a low risk of infection allows managers to counteract the perception of excessive risk. The management of stigma is important to reduce the negative social and economic outcomes of surplus negative perceived risks. Better risk communication could be a factor in managing stigma, but only if the risk communications come from social actors who have earned the public’s trust. In risk communication, the possibilities for closing the risk information gap depend upon such factors as: 1 whether the types of risks involved have special characteristics of dread and unfamiliarity; 2 whether the public comes to believe that it has been misled by experts; 3 whether extensive media coverage of sensational events, attributable to a particular risk situation, occurs; 4 how scientific research findings are interpreted by various parties; 5 whether key stakeholders choose certain issues for special attention; 6 whether a competent agency assumes responsibility for implementing good risk communication practice at any time in the sequence of events (Leiss and Powell, 2004). For sars, it seemed that all of the possibilities for closing the risk information gap were either poorly addressed or largely ignored. sars was a risk with special characteristics of dread, unfamiliarity, and uncertainty. The extensive media coverage undermined any credible risk messages brought forward by risk managers, and the news media acted as a stakeholder and focused on issues of uncertainty, death, and conflicting expert opinions in order to spur newspaper sales. The public already had a low level of trust in politicians, and the lack of a clear voice did not change this pre-existing condition. In order to overcome social amplification of risk constructs there must be effective ongoing risk communication. In order to address social amplification of risk during the sars outbreak, we must first determine who were the main actors, second, we must understand what kinds of negative outcomes they experienced, and finally we

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must offer some effective advice for risk issue management and risk communication in future.

a framework for sars risk communication To achieve an understanding of what good risk communication would have been requires placing sars, as an event, within a theoretical framework that will allow for this analysis. Modern disaster planning, research, and response have been analyzed in the past using a natural disaster cycle model (Dara et al., 2005; Hogan and Bernstein, 2002) and a man-made disaster cycle model for accidents at nuclear power plants (Schwartz, 2002). Similarly, intentional disaster from a terrorist event has resulted in a model that borrows from earlier natural disaster research to define the chronological phases (Wilkins and Vultee, 2005). The phases of the natural disaster, man-made accident, and terrorism cycle models are shown in table 10.1. In all three versions the frameworks can loosely be divided into: before the event, the event itself, and recovery after the event has occurred. Various disaster frameworks subdivide some of the phases to address important time periods after the event that require special attention by emergency planners. For example, immediately postimpact there is a rescue phase, where efforts are concentrated on finding any remaining survivors, triage for mass casualties, and managing the disaster site effectively in order to minimize hazards to first responders. sars as an infectious disease follows the natural disaster typology, but can also be used as a model for a biological terrorist disaster event. The negative physical outcome of sars was the infection itself, but long-term psychological outcomes also occurred. The social amplification of risk and stigma intensified the negative societal impacts and economic losses stemming from an increased perception of risk and failed risk communication. The psychological impacts of sars both during and after the outbreak must be seen in context with the other comorbid outcomes that manifested along with stigma, and the seriousness of these outcomes need to be understood. Determining the degree of psychological impact will provide information we need to prescribe effective risk communication and risk issue management advice for future sars-like

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Table 10.1 Time stages involved in natural disaster, terrorist, and nuclear accident planning models

Time

Natural Disaster Typology

Terrorist Event Typology

Nuclear Power Plant Accident Management

Prodrome

Incubation

Alert phase

Impact

Impact

Rescue

Immediate post-impact

Accident phase Post-accident phase

Recovery

Recovery

Quiescence

Reorientation

Stage Criteria Anticipatory phase and possible preparation for the disaster. The disastrous event. The immediate response, including triage and medical care for disaster victims – the phase in which timely and appropriate action may save lives. Longer-term management of the aftermath of the disaster, returning society to its normal state. Resolution of the disaster, including assessment of lasting effects.

outbreaks. The enormous number of newspaper articles, journal articles, and Internet grey literature provided a wealth of information on the various population groups affected by sars. For example, risk managers imposed widespread quarantines; this policy decision resulted in secondary psychological effects of isolation, feelings of loneliness, depression, and other psychological indicators of post-traumatic stress. Normative risk communication and risk issue management strategies for mitigating and reducing the risks, negative societal impacts, and negative psychological outcomes for vulnerable populations are offered as ways to improve future infectious disease outbreak management. Some of these risk communication strategies and improvements were implemented both during and after the sars outbreak. Emergency planners, decision makers, government officials, and policy makers can now use the lessons learned from sars to improve capacity and preparedness in anticipation of future infectious disease outbreaks. Figure 10.4 shows sars as a natural disaster event, with mapping of population groups and the main psychological outcomes they experienced. The outcomes included social amplification of risk, stigma and altered behaviours. The most serious outcome was post-traumatic stress disorder (ptsd). Most people who are exposed

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to a traumatic, stressful event experience some of the symptoms of ptsd in the days and weeks following exposure. Available data suggest that about 8 per cent of men and 20 per cent of women who experience such stresses go on to develop ptsd, and approximately 30 per cent of these individuals develop a chronic form that persists throughout the rest of their lifetimes.

risk communication strategies to overcome social amplification of risk and its psychological effects The Prodrome/Incubation/Alert Stage Prior to a disease outbreak, a number of population groups are identified that will require targeted communications to mitigate the social amplification of risk. These include the local community where the infectious disease outbreak occurs, along with the wider public who will perceive the risk and react to such an event; healthcare workers (primarily nurses) who will be the front line defense for dealing with and containing an outbreak; first responders, including family physicians and paramedics, who, like nurses, may be the first contacts with those infected; and government officials at all levels, who must plan for and have a way to manage the risk issue as it unfolds over time. In cases of epidemics and pandemics, government officials must be capable of dealing with the risk issue and other issues that arise during the crisis, especially managing perceived risks that can lead to widespread social amplification effects. The prodrome or incubation phase is an anticipatory stage that allows for an assessment of community capacity, emergency planning, and preparedness by those engaging in effective risk management and risk communication practices. Population groups that can offer capacity, strategies, knowledge, social networks to draw upon, and effective lines of communication between and within existing organizational structures will respond and cope much better in the face of a new and unknown biological contagion than those who are poorly coordinated or have poor community capacity. Unfortunately, during sars, none of the identified groups showed concern over pandemic infectious diseases prior to March 2003. Healthcare workers and first responders had little capacity (they lacked procedural knowledge and personal protective equip-

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Stage Population

all groups

Outcome

Minimal fear and anxiety

impact event sars, Toronto Fear for self and family Fear of medical treatment Anxiety Stigma Quarantine ptsd

Exposed Persons -travellers -hospital workers -lab workers

Fear for self and family Anxiety mups Stigma of person Stigma of place (economic loss) Quarantine

Local Community

Healthcare Workers -nurses -doctors -other hc workers

Distress Fear for self and family Anxiety Stigma Quarantine ptsd

First Responders -paramedics -firefighters -police

Fear for self and family Stigma Anxiety Quarantine ptsd

Rescue and Recovery

Healthcare Workers -nurses -doctors -other hc workers

Government -Federal -Provincial -Territorial -Municipal

Build credibility

Local Community

Foster self-mastery

Quiescent Reorientation

Reduce fear/anxiety First Responders -paramedics -firefighters -police

Figure 10.4 Stage specific outcomes for specific populations (exposed persons, the public, healthcare workers, and first responders). ptsd = Post traumatic stress disorder mups = Medically Unexplained Physical Symptoms The down arrow (↓) indicates that in the case of infectious disease, healthcare workers take on the responsibility and act as first responders for disease containment and treatment.

ment). Public health officials did not have a coordinated emergency plan in place, and the public had no recent experience with a highly transmissible infectious agent. Characteristics of the prodrome

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Table 10.2 sars psychological outcomes for Prodrome/Incubation/Alert stage Stage

Population

Outcome

Risk Communication

Prodrome/ Incubation/ Alert Phase

Local community, public Healthcare workers First responders Government officials

Minimal fear and concern over pandemic

1 No recent history of biological epidemic in Toronto 2 Basic knowledge of zoonotic disease and epidemics 3 Health care system largely untested for biological mass casualty event (Need for proactive risk communication with the public and coordination of infectious disease strategies between healthcare workers, public health officials, and first responders)

stage, the populations, the main outcome, and the risk communication milieu are shown in table 10.2. The Impact/Accident Stage Infectious diseases as natural disasters or accidents present a difficult, poorly defined timeline, as each individual disease transmission can be considered an event in itself, propagating the disease within the population, extending its impact until it is contained (no new outbreaks noted for one infectious cycle). Even a single uncontained infectious disease host who is not identified can result in an entire wave of new infections. This was seen with undiagnosed sars patients in Toronto hospitals, leading to sars2 and extending the outbreak. Other contagious viral biological agents, such as smallpox, Ebola, and other hemorrhagic fevers, will also require quarantine and possibly vaccination for effective containment if they occur in major North American cities. The management of infectious disease by quarantine, vaccination, and instituting emergency health acts with restrictive measures, presents additional issues that will result in psychosocial effects for victims and first responders, and require consideration by planners. The ability to identify biological agents rapidly and administer drugs for effective treatment well before the onset of symptoms, allowing reduction of mortality, coupled with effective risk communication and preparedness, restores mastery to individuals, groups, and the community.

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Table 10.3 sars psychological outcome for Rescue/Recovery stage for exposed individuals Stage Rescue/ Recovery

Population Exposed persons (travellers, hospital workers, lab workers)

Outcome

Risk Communication

Fear for self or family

1 Communicate to address concerns 2 Communicate what is known 3 Provide protective gloves, masks, training 4 Provide counseling for stress work-related 5 Determine health risks for all medical treatments 6 Explain medical treatments and outcomes fully 7 Workplace education 8 Communicate what is known 9 Media messages to address stigma 10 Media messages to address stigma 11 Provide two-way communication 12 Daily briefings from credible source 13 Provide social support of workers on long-term work quarantine 14 Monitor for worker fatigue 15 Provide long-term psychosocial support

Fear of medical treatment

Anxiety

Stigma Quarantine

ptsd

The Recovery/Post-Accident Stage The recovery rescue phase is defined as the time immediately after the occurrence of the impact event, usually lasting up to seventytwo hours for a natural disaster. Again, the inability to contain an outbreak or prevent transmission between hosts can result in an extended recovery phase. The sars recovery phase affected three main groups: exposed persons, the public (especially the local community), and first responders (including healthcare workers). The outcomes to various groups during the recovery phase of sars are shown in tables 10.3, 10.4, and 10.5. One of the interesting complications presented by infectious diseases like sars as a natural disaster is that healthcare workers who are not traditionally thought of as first responders act like first responders; when nurses and doctors are recruited, essentially to deal with a slowly growing mass casualty event, it places an added burden on them when they must deal with work quarantine, stigma, and increased personal risk.

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Table 10.4 sars psychological outcomes for Rescue/Recovery stage for non-exposed individuals Stage Rescue/ Recovery

Population

Outcome

Risk Communication

Local community, Fear for self or family public (nonexposed Anxiety individuals)

1 Communicate to address concerns 2 Provide information from credible source 3 Provide two-way communication 4 Daily briefings from credible source mups 5 Educate to change panic behaviour 6 Communicate known facts to dispel rumours 7 Provide accurate health information (telehealth) to reduce numbers of worried but well individuals Stigma of person 8 Media messages to address stigma 9 Communicate to dispel myths and and place (ecorumours nomic loss) Quarantine 10 Ensure salary, food, counselling, family support for workers on long-term quarantine

Table 10.5 sars psychological outcomes for Rescue/Recovery stage for healthcare workers and first responders Stage

Population

Rescue/ Recovery

Healthcare workers (nurses, doctors, other hc workers), first responders (firefighters, police, paramedics)

Outcome Fear to self or family Distress/ Fatigue

Anxiety Stigma Quarantine ptsd

Risk Communication 1 Ensure access to proper equipment, use approved containment procedures 2 Address difficulty wearing full protective gear 3 n95 masks, institute worker rotation strategy with shorter working shifts 4 Ongoing internal updates/meetings on infection control 5 Media messages to address stigma 6 Ensure salary, food, counselling, family support 7 Provide long term psychosocial support

The Quiescent/Reorientation Stage Disaster literature refers to this as the quiescent, reorientation phase; this time is usually used as a rebuilding or reevaluation stage. In this phase, a significant proportion of the activity is focused on

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risk communication in several areas. Timelines and activities are analyzed in hindsight to determine if there was timely and correct communication between several key groups. For effective risk communication during an event there must be communication between first responders and public health agencies; between government and institutions; between institutions, and most importantly between the public and government and health experts. All risk communication before, during, and after the event must be an attempt to present credible, transparent information to the public and those who must make decisions that impact the health and safety of the public. Outcomes for the quiescent stage are shown in table 10.6.

conclusions There were a number of deficiencies noted in the risk communication and risk issue management during the Toronto sars outbreak. There was a clear lack of communication between key groups that hindered effective transfer of knowledge about the facts surrounding the disease and about the level of risk it carried; this in turn resulted in poor risk communication to the public as the knowns and unknowns of the situation were not quickly disseminated to the experts. From the very beginning, the news media captured sars as a risk issue and continued to fill the void by attempting to provide a large volume of credible information from as many sources as possible. So many authoritative voices, each with a different perspective and each with their own information, led to a cacophony of similar and sometimes conflicting expert opinion. The lack of clear authority in the midst of an uncertain and developing situation only added to the distortion of sars as a high-risk issue. Given the abundance of computer telecommunications capacity, the lack of infrastructure for real-time information sharing became glaringly obvious during sars, as individual hospitals scrambled to produce independent online resources for internal use by their own staffs as a way to communicate the latest research and information. This information, specifically the risks and the most current knowledge, ought to have been sent to all healthcare workers as soon as it became available, using a formal mechanism. Dedicated, hand-held text messaging devices (e.g. BlackBerry devices4) could have been issued to healthcare workers to keep them up to date with targeted information, teleconference summaries, Ministry media briefings,

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Table 10.6 sars psychological outcome for Quiescence/Reorientation stage for the main identified groups Stage

Population

Quiescence Local commuReorientation nity, public

Desired Outcome Self-mastery Education

Healthcare workers

Reduce anxiety and fear

First responders

Reduce anxiety and fear

Government officials

Build credibility and transparency

Risk Communication 1 Emergency preparedness plans; local ngo training/coordination 2 Provide two-way communication 3 Information updates from credible source 4 Training in ppe, triage 5 Stockpile ppe 6 Sharing lessons learned 7 Review psychosocial support strategies and emergency plans 8 Coordinate with other hospitals and public health officials 9 Training in ppe, triage, mock events 10 Stockpile ppe 11 Sharing lessons learned 12 Review psychosocial support strategies 13 Review emergency preparedness plans; provide transparency and access to plans, show how other jurisdictions’ plans are coordinated 14 Provide adequate funding for Healthcare/First responders, increase system capacity 15 Increase human resources capacity and training 16 Improve inter- and intradepartmental communications 17 Overarching department for infectious disease control and coordination with international linkages 18 Improve disease-monitoring networks (surveillance in Canada and internationally)

changes in policy, and the latest medical information pertaining to sars. The information produced during an outbreak situation must be targeted to different healthcare groups, and this information should be available to the public. Highly technical information full of medical terminology will be of little use to the public. Internet sites, if used, should have a multi-user appeal with medical and highly technical information rephrased for non-medical audiences. During the

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sars outbreak there were exceptionally poor pre-existing lines of communications between key groups. The poor communication was demonstrated by the ad hoc teleconferences that were convened daily by public health officials as a way to disseminate information that would be used for decision-making. Another risk communication and risk issue management problem that was evident during sars was the lack of clearly identified expert spokesperson(s). The media scrambled to find information from any medical or expert source at any level of government or from hospitals and universities, regardless of whether they were credible or not. The result was a huge amount of competing information from many different “expert” sources. During an outbreak, spokespersons must be credible, transparent, and trustworthy. These conditions must pre-exist the crisis. A large component that was missing from the risk communication and risk issue management during sars was education and information disseminated to healthcare workers and the public by means other than the news media. The news media focused on specific information and presented data (cumulative numbers) that were easily misinterpreted by the public. Those consumed with managing the crisis at the highest levels apparently had little time to consider risk issue management. Some thought should have been given to developing an effective education plan and information campaign designed to empower the public with credible and usable information from a source other than the news media. The news media focused on the situational uncertainty and potential of catastrophic disaster so the public was understandably confused, fearful, and anxious, with perceptions of a higher degree of risk than really existed. Government and public health stakeholders should have provided an effective means of educating the public about the necessary details of sars in a credible way, including the latest information (clinical, medical, and epidemiological), types of screening measures, changes to hospital visitor policies (and why this was being done), and temporary restrictions of healthcare services. Many individuals now have access to the Internet as a real time information source, and the lack of a credible Web site meant that individuals using the Internet received information from other countries with different healthcare systems, sars management capacity, and non-expert information sources. The public should have access to a credible public health Web site

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available to them for a trusted, transparent, and credible source of infectious disease information in a Canadian context. Such a Web site should include standardized material and notices to distribute to the public and patients. Multi-layered educational Web sites are emerging that communicate information to experts and non-experts, and they are very successful at communicating the risks of highly technical medical and health issues. Would there have been the same degree of fear in Toronto if Canada had followed some of the risk communication and public education strategies employed in other countries? In Singapore, the government distributed thermometers, and provided those in higher-risk jobs or in areas with large public gatherings (airport workers, mass transit workers, schools) with instructions on how to self-monitor for sars. Signs clearly displayed the workers’ infection-free status at communal mass transit and other public gathering places. This, combined with the altruistic public self-monitoring, greatly reduced the levels of uncertainty. There would have been little fear and panic if the real prevalence of sars had been made transparent (through monitoring) and communicated effectively. Thus, there were a number of distinct factors that combined to result in risk communication failure, and a number of additional factors that perpetuated this failure during and after the outbreak. The ability to manage and communicate about the risks effectively during the outbreak would have required a credible, authoritative, and transparent risk communicator. The healthcare system itself was not set up to facilitate the effective lines of communication and transfer of knowledge required to initiate a workable dissemination of that knowledge to the general public. The risk issue of sars was captured early on by news sources that published more information, more often, updated sources, than any other group involved in the outbreak. The news media for the most part reported the events accurately, but presented cumulative numbers that, coupled with other large knowledge gaps, reinforced a sense of overwhelming uncertainty. Clearly, a better risk management strategy is needed in future cases of new infectious diseases, to combat the effects of social amplification or risk issue capture by other groups. Risk communication and risk issue management were handled very differently in other countries; a few (like Singapore) managed to overcome the

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negative effects of social amplification, empowering individuals to act altruistically and collectively during the sars outbreak in that country. The primary purpose in documenting the risk communication failures that occurred during sars in Canada is not to lay blame for poor risk communication and risk management practices, but rather to learn from the mistakes of the past. Much of the damage experienced in Canada stemmed from the development of a risk information vacuum, a process that allowed the risk issues to develop in unforeseen ways. Mistakes in risk communication are inevitable, given the random nature events, with difficult risk management choices being made at a time of great uncertainty. Attempting to learn from them retrospectively is probably the only way of figuring out how to manage infectious disease risk issues more effectively. After sars, there were many calls for improvement of hospital capacity, an increase in numbers of isolation rooms, new hospital infectious disease plans, and training of healthcare professionals. What has not been discussed and implemented are ways to improve risk communication to the Canadian public about new infectious diseases. With the next pandemic predicted to arrive before long, it seems that public health officials have done little to manage the risk of social amplification and stigma that are likely to recur, resulting in economic losses and, more importantly, an erosion of public trust.

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SARS and Risk Communication in Other Affected Countries Infectious diseases are impossible to cover up, you may be able to cover up figures, but you can never cover up viruses. Gao Qiang, executive vice-minister of Health, China, 30 May 2003

By the end of March 2003, sars had been reported in fifteen different countries, including Canada, China, Hong Kong, Taiwan, France, Germany, Italy, Republic of Ireland, Romania, Singapore, Switzerland, Thailand, United Kingdom, United States, and Vietnam. The movement of people between countries presents a huge, ongoing problem for government officials who attempt to contain an outbreak. Temporarily stopping all air traffic and the movement of people during a biological crisis may be highly effective but such measures are only practical in the short term. Biological infections can last for extended periods of time or occur in successive waves, making extended border closures impractical. Due to the integration of economies resulting from globalization, the attempt to implement containment between countries, not only for people but also for goods (that may act as fomites), is exceptionally difficult. Given this reality, dissemination of knowledge, transparency of information, and ongoing risk communication are paramount for dealing with infectious disease outbreaks. Communication about the risk of infectious disease was treated differently by each of the affected countries. The five hardest hit areas, by total number of sars cases, were: China (5,327), Hong Kong (1,755), Taiwan (346), Singapore (238), and Canada (251) (World Health Organization, 2004a). The reasons for poor risk communication in Canada have been discussed at some length in

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the previous chapter. It is of interest to look at the four other hardest hit outbreak areas to compare and determine what risk communication strategies were used when confronting sars.

sars in china and risk communication The outbreak in China occurred in Guangdong, centered in the provincial capital of Guangzhou and the nearby Pearl River Delta area. The outbreak started in November 2002 with small clusters of atypical pneumonia occurring in Guangdong Province, but this was not considered exceptional. A patient with what was believed to be viral pneumonia was treated at the Second Affiliated Hospital of the Sun Yat-sen College of Medical Science in Guangzhou for two days before being transferred to another hospital. During this time, twenty-eight healthcare workers fell ill with sars, including the ambulance driver who transferred the patient between hospitals. It was one of the doctors who had been treating this cluster of patients with atypical pneumonia who later travelled to Hong Kong and stayed at the Metropole Hotel in Kowloon on 21 February 2003, seeding an international outbreak (cdc China, 2003; Dave, 2004). The fear of economic losses from stigma was revealed by the Chinese Minister of Health, Zhang Wenkang, who downplayed the who’s warnings to avoid travelling to southern China. After five months of sars in China and its movement to several other cities and regions, combined with the who’s 3 April 2003 travel advisory, Wenkang stated, “It is perfectly safe to come to China to work, travel, and hold business meetings.” Unfortunately, people kept getting sick with sars, the number of regions affected continued to grow, and news of the ongoing outbreak continued to surface in foreign news reports. Throughout April 2003, sars cases were reported in other provinces and cities of mainland China, including Beijing, Shanxi, Nei Monggol, Tianjin, and Hebei (Hung, 2003). When sars was detected in major cities the authorities increased the police presence on the streets for two reasons: to reduce concerns over potential unrest caused by public fear, and to prevent the spread of the disease by reducing the movement of people. In Beijing, a number of police patrols were put in place to prevent the spread of sars by reducing the movement of people, and military guards sealed off buildings where infections were suspected. Police also used roadblocks to establish perimeters around

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known infectious areas, and inspected vehicles for feverish passengers. At least 12,000 people were under strict quarantine in a number of residential buildings and hospitals because of their possible contact with others who had confirmed sars. Chinese health officials reduced the movement of people into and out of high-risk areas through extensive police and military support. Tens of thousands of immigrant workers and students from rural areas attempted to leave Beijing on 24 April 2003 when news of sars in the city became widely known. However, police patrols turned most of them back, preventing potentially infected individuals from leaving. The public perceived Beijing as a risky place with uncontained sars, but officials had few options and reduced the movement of people out of the city to protect nearby cities. All inter-city transport services were also temporarily cancelled as another way to reduce potential contacts. Other methods employed to reduce the movement of people was the government’s reduction of the week-long May Day holiday, which is traditionally the peak period for travel within China and abroad. In 2002, more than 87 million people travelled between different cities during this week long holiday. Shortening the holiday to a single day had only a limited effect in reducing the movement of people. Beijing Central Station still had thousands of people taking trains each day. Nurses and doctors in masks worked at the station’s Quarantine Centre, examining passengers who failed a thermal imaging check at the station’s entrance (Watts, 2003; World Health Organization, 2003j). Beijing’s primary and middle schools, with an enrollment of at approximately 1.7 million students, were also shut down on 24 April 2003 for two weeks as a precaution. The government fired its health minister, Zhang Wenkang (who was also the mayor of Beijing), on 20 April 2003 for the inadequate response to the sars outbreak. That same day, the government announced sharply higher numbers for sars cases and promised to be more forthcoming with information in the future. Just five weeks into his new position as executive vice-minister of Health (30 May 2003), Gao Qiang, feeling incredible domestic and international pressure over the Chinese government’s handling of sars, finally denied publicly that Beijing had tried to hide the seriousness of the sars virus and the magnitude of the outbreak in China (Watts, 2003). At the time, Gao’s comments were the highest-level response

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to ongoing international pressure and accusations that officials tried to cover up the extent of the illness. The new Chinese minister of health maintained that the government had warned everyone about sars in early February, but near the beginning efforts to combat sars were slowed by poor information dissemination and uptake. He was referring to the Communist Party newspaper, the People’s Daily, which reported a short story on 12 February 2003 about atypical pneumonia that had killed five people in Guangdong Province and infected 305. Gao suggested that an inadequate Chinese public health network infrastructure was to blame for underreporting of the true scale of China’s outbreak, and that the government did not knowingly conceal the truth. “The first time China publicized information about this, the sars problem had not come to any other country,” Gao stated as he referred to the People’s Daily article. “Such publicity was first a warning for China itself and also a warning for the rest of the world.” The short report, on the newspaper’s second page, assured readers that “people should not panic” if good prevention measures were taken, including frequent disinfection, good ventilation, and avoiding crowded public places. Gao’s defensive positioning, denying that the government failed to accurately report sars numbers and warn other countries quickly, did little to appease international critics (cbs News, 2003b). Chinese government officials continuously denied that their lack of cooperation in reporting sars cases was linked to the extensive spread of the disease to a number of other countries, but finally acknowledged the effects of the outbreak nearly six months after sars surfaced in their country. Li Liming, director of the Chinese Centre for Disease Control, stated on 5 April 2003, “Today, we apologize to everyone.” The reason for such poor handling of the sars outbreak, he offered, was poor coordination between medical departments and mass media. “We weren’t able to muster our forces in helping to provide everyone with scientific publicity and allowing the masses to get hold of this sort of knowledge.” Gao’s initial explanation is most likely valid; China’s government consists of thousands of bureaucrats. Dissemination and flow of information within the system is tortuous and convoluted at best. Officials in China were also hampered by the lack of communication occurring between hospitals and government regulators. Government control of the news media, which had an incomplete picture of the

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situation, did not allow for a discrepancy in the reporting of official numbers regardless of the true numbers observed in local hospitals. This statement of how the Chinese government reacted initially to the outbreak left out some very important details that went well beyond the limited reporting in newspapers. The handling of sars in China, as in other places, was primarily a risk communication failure. For the officials in China, this admission of poor communication was a major step forward for global pandemic control, and World Health Organization inspectors believe that China is more likely to report a new outbreak if it occurs in the future (Evenson, 2003). International pressure that resulted in Chinese official statements made by Li Liming in early April 2003 was in part due to popular news media sources outside the country. Even with Li Liming’s official apology in April, the true number of sars patients in China remained a mystery to those outside of the country. A who medical team met with China’s Vice Premier Wu Yi on 9 April 2003 in an effort to influence government officials to reveal the extent of China’s sars outbreak. Despite assurances from the vice premier, a week later allegations surfaced that in the capital city of Beijing, sars patients were actively being moved between hospitals with ambulances so they wouldn’t be discovered and counted by the who medical team. Whether such rumours were true remained unconfirmed, but investigators were not allowed access to medical records, and medical workers offered alternative accounts of the outbreak to the foreign press. By the middle of April 2003, it was still believed that patient numbers were being greatly underreported. The who medical team, keeping careful count of sars patients in the hospitals they visited in Beijing, identified at least 200 cases of sars, compared with the Chinese government’s official number of thirty-seven sars patients. At the end of April 2003, China still found itself losing credibility internationally due to its inaccurate reporting. The Politburo Standing Committee, the country’s top ruling government body, ordered an end to the confusion, demanding, “accurate, timely, and honest reporting of the sars situation” from all major cities, regions, and provinces throughout the country. The Politburo warned that local and provincial officials would be held accountable for failing to fully report their area’s sars situation (Evenson, 2003). The criteria that medical officials in China were using to diagnose and categorize sars patients were different from other countries.

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Many of the patients reported by Beijing as “Suspect” would be classified as “Probable” or true cases according to the case definition set out by who and used in official notifications of cases to who by other countries. The who was reporting only Probable cases in its daily cumulative totals, and such a change in the accounting would have resulted in a large increase in the number of cases notified to the who. The investigating team recommended that Beijing improve its reporting system, possibly using the procedures in Guangdong Province as a model, where the daily sars reports were considered reliable and transparent. who experts also recommended that Beijing revise its definition of what constitutes a Suspect sars case (World Health Organization, 2003h). Thus the mishandling of the situation by China’s officials that resulted in a risk communication debacle was likely due to ineffective lines of communication between government departments and hospital case definitions that were different from those used by the who. The poor reporting of sars as a health issue exposed the incongruity between the increasing global economic integration of China and the government’s reluctance to allow a free flow of information to its citizens or to international agencies. The who eventually obtained a listing of sars cases from various regions in China. After containment China reported 5,327 Probable cases with 349 deaths and a case fatality rate of 7 per cent. The number of Probable cases and their locations are listed in table 11.1. Despite difficulties, a number of control measures were implemented in an attempt to reduce the spread of sars in Beijing. Measures in Beijing included mandatory masks, handwashing, mandatory home quarantine of persons in contact with Probable sars patients, suspension of schools/universities for two weeks, restrictions on public gatherings, screening the body temperatures of air travellers at airports, hindering mass migration by land routes, air, or train, designation of special hospitals for the treatment of sars patients, education on sars transmission, and increased personal protection for healthcare workers (Zhou and Yan, 2003). Penalties were introduced on 28 May 2003 by the Beijing Joint Working Group for sars Prevention and Treatment that included fines for failure to properly disinfect areas where sars cases had been found. People who attempted to evade checkpoints, entered or left designated quarantine areas without permission, or hindered sars-related investigations could be fined the

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Table 11.1 sars case distribution by cities and provinces in China as of 25 June 2003 Western Pacific– City or Region (China) Beijing Tianjin Hebei Shanxi Inner Mongolia Liaoning Jilin Shanghai Jiangsu Zhejiang Anhui Fujian Jiangxi Shandong Henan Hubei Hunan Guangdong Guangxi Chongqing Sichuan Shaanxi Gansu Ningxia Total

Cumulative numbers of Probable SARS cases 2,521 175 215 448 282 7 35 8 7 4 10 3 1 1 15 7 6 1,512 22 3 20 12 8 5 5,327

equivalent of one week’s pay for the average Beijing resident; companies who broke quarantine rules could also be fined. Police and volunteers in Beijing operated disease checkpoints, watching for people with fevers or other flu-like symptoms. Some volunteers had the job of spraying cars and trucks with disinfectant at checkpoints. Checkpoints were also set up at entrances to many buildings, and people were made to disinfect their shoes before entering. While the disinfection of surfaces (automobile tires or the bottoms of shoes) was deemed to be a control activity for sars, the efficacy of such preventative measures to reduce the environmental spread of the virus is highly speculative. China’s Supreme Court also tried to enforce the rule of law, stating that people who cause death or serious injury by knowingly spreading the virus (usually patients who break quarantine) would face penalties ranging from several years imprisonment to the death sentence (cbs News, 2003d).

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The initial assessments of the sars situation in China by the who were detailed in a report issued in late April 2003, following their team’s visit to Guangdong Province. Investigators expressed serious concerns over the lack of urgency in reporting cases of sars in China, and criticized the government for not immediately treating the outbreak as a public health emergency requiring extraordinary measures for its control. A joint news conference that was the first official briefing between high ranking Chinese officials and who officials concerning the sars outbreak did not occur until 12 June 2003, after many countries had been removed from the who’s affected areas list. China’s executive vice-minister of Health, Gao Qiang, and the who’s executive director for communicable diseases, Dr David Heymann, briefed the press on the situation of sars control in China. Improvements in control measures were cited by who officials, including: improved detection and isolation of cases, better speed and efficiency of epidemiological contact tracing, greater passive and active surveillance (such as fever checks at train and bus stations and airports), a nationwide mass media campaign to inform and educate the public, and a large number of fever clinics (the equivalent of Toronto hospital sars assessment clinics) to assess those who suspected they might have symptoms. A major concern was the large number of cases that had no known source of exposure, making it extremely difficult to trace patterns of transmission. In Beijing, the numbers of cases with no identifiable contact with a known sars patient were about 70 percent. China was regarded as the epicenter of the sars outbreak, and the official joint who-China meeting was a huge step forward in helping to implement effective global containment. The sars outbreak revealed substantial weaknesses in disease surveillance and reporting systems in China. When investment in health infrastructure is neglected, conditions are ripe for the unchecked spread of any epidemic-prone disease, often at tremendous cost to a nation’s economy (World Health Organization, 2003i). From September 2003 to May 2004, a small numbers of sars cases occurred in Asia. Four cases were reported in Guandong in January 2004; it was believed that they had an environmental source. China reported to the who on 22 April a new sars case that involved a twenty-year-old nurse being treated in intensive care. On 23 April 2004, who reported the existence of three other cases who had been exposed by the nurse (a twenty-six-year-old

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female student who was carrying out research activities at the National Institute of Virological Research in Beijing; her mother, who lived in Anhui, and who developed symptoms compatible with sars on 8 April, dying in a hospital there on 19 April 2004; and a thirty-one-year-old male researcher from the National Institute of Virological Research, who developed symptoms on 17 April, was hospitalized and was put into isolation on 22 April). On 28 April, the Chinese authorities reported yet another sars case involving a forty-nine-year-old female doctor who was admitted to the same hospital as the nurse. She began to develop symptoms compatible with sars on 19 April and was transferred to a hospital in Ditan where she was put into isolation. The source of the sars infection several months after global containment was believed to be the laboratory where the women worked at the National Institute of Virology in Beijing. In September and December 2003, two cases were reported in Singapore and Taiwan respectively, where the source of sars infection was also associated with laboratory research. Both cases recovered completely and unlike the laboratory-initiated outbreak in China, there wasn’t any further transmission of sars to non-laboratory individuals. The laboratory outbreak proved just as challenging for sars containment in that strict quarantine and containment was essential for preventing new cases. A total of nine cases resulted from the accidental laboratory contamination and one death was reported. Nearly1,000 close contacts were identified by health officials, and these individuals were immediately quarantined. Of those quarantined for ten days, 70 per cent were in Beijing and 30 per cent were in Anhui. Additional exposures may have taken place, since the patients were treated in several different hospitals in Beijing and in Anhui. Two individuals involved had travelled over a wide area within China, with many contacts, during the time they were infected. The Chinese authorities intensified surveillance and follow-up activities with all contacts to ensure containment (eid Weekly Updates, 2004). The laboratory-induced outbreak revealed that China had learned from its previous mistakes, as they quickly mobilized resources and had good lines of communication to prevent the minor outbreak from becoming a major public health threat. Two years after the sars crisis, the Chinese government was still managing the after-effects of sars. More than 100 former sars patients sent an open letter to Beijing mayor Wang Qishan to

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demand that their medical expenses be paid in full. With 2,500 infected and 193 dead, Beijing was one of the city areas hardest hit by the sars outbreak. Many of the sars survivors in Beijing suffered painful consequences of heavy steroid use, which was the recommended medical treatment for the viral infection. In the letter, the sars patients complained of ongoing ailments, including bone degeneration caused by the treatment they received. Many sars patients had to go through artificial joint implant replacement surgery. The patients believed their ongoing medical costs should be fully subsidized by the government, as it was responsible for the scale of the epidemic in the first place. Its slowness to act and to acknowledge the existence of sars put their lives at risk. Foreign news reported that the Chinese government has largely ignored those suffering long-term sars after-effects (Agence France Presse, 2005).

sars in hong kong and risk communication At the beginning of March 2003, the doctor from Guangzhou who had been treating atypical pneumonia cases in a Guangzhou Hospital visited Hong Kong and stayed at a hotel in the Kowloon District. He was admitted to a local hospital with symptoms of acute respiratory disease and a day later died of it. The doctor was the index case infecting several others who stayed on the same floor of the hotel. One of the people he infected was a local Hong Kong resident. All of the exposed cases developed sars and two people died of the disease. When the first cases of sars were identified, the Department of Health of the Hong Kong Special Administrative Region government passed legislation to include sars as a notifiable infectious disease and thus the provisions in the Ordinance and Regulations were applicable.1 sars patients were isolated in hospitals, and family or close contacts were kept under surveillance, initially at home, but later on in isolation centers, where they were kept for quarantine and observation for ten days. In early April 2003 Hong Kong’s healthcare system was overwhelmed by sars, pushing it to the brink of collapse with over 200 cases of sars reported in one city block alone. By mid-April, Hong Kong’s death toll and the number of new infections continued to rise and Hong Kong scientists believed they had a more virulent

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form of the virus in the densely populated city than the strain circulating in other countries. Also at this time, officials launched a largely ineffectual two-day mass cleanup effort across the territory. The government called on every one of its seven million residents to take part in a mass disinfection effort that involved scrubbing housing blocks, streets, parks, public venues, shops, and restaurants. Despite the massive cleanup, a week later (22 April 2003) Hong Kong reported more deaths, with the city total at 1,434 cases of sars and still slowly climbing. Public health workers undertook investigations to track the sources of infections, traced contacts, and applied control measures.2 Strict health measures were introduced to screen travellers coming in or going out by boat or air. Officials were on alert for individuals with fevers exceeding 38°c, and travellers were asked to complete health declaration forms. All these measures were generally effective as preventative measures, raised the awareness of the public about the issue of sars, and provided information. There were, however, problems in the enforcement of these measures that were not observed in previous epidemics (Lee, 2003). In Hong Kong, some hospitals attempted to deal with sars by creating designated wards for sars patients, dividing them into patient groups that were either “confirmed sars,” “suspected sars,” “triage sars” (all admissions prior to being determined as confirmed or suspected status), and “step down sars” (non-sars, equivalent to patients in Canada who passed the sars screening tool). The wards were set up “Nightingale style,” with open cubicles consisting of four to six beds each separated from the next by a two-metre space. Important for the open arrangement was the air exchange rate, which needed to be greater than twelve cubic volumes per hour, and the temperature, which was maintained at 20°C. The high air exchange rate and lower temperature were conditions used to reduce environmental viral contamination of objects. Patients were required to wear surgical masks at all times except when eating meals, and were not allowed visits from family or friends. All nurses and healthcare staff entering the Nightingale wards were required to adhere to stringent procedures for getting into and out of personal protective equipment, under the supervision of a watchful patrol nurse to ensure no breaks in disease containment. Personal protection equipment included a disposable surgical paper cap, n95 mask, reusable goggles, gloves, clear plastic face shield,

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reusable cotton neck-to-heel surgical gown, and reusable surgical boots. Double gloves and the plastic face shields were worn for close patient care, high-risk procedures, and specimen collection procedures. Handwashing or use of hand-sanitizing gel containing alcohol occurred after each contact with sars patients. Dilute bleach (1/50th dilution of 5.25 per cent sodium hypochlorite solution) was used on all work surfaces and floors every hour or after any potential aerosolizing contamination from high-risk procedures. Nebulizer therapy, believed to be the cause of a major hospital outbreak in Hong Kong, was thereafter forbidden for patients with Suspect or Probable sars. Despite the absence of clinical best practices data, most Suspect or Probable sars cases did not receive nasal ventilation or continuous positive airway pressure because of the belief that respiratory secretions could be easily aerosolized in this manner, and would put all nearby individuals and workers at a greater risk (Tsang and Lam, 2003). In Hong Kong the epidemic was characterized by two large clusters initiated by separate super-spreading events, and by ongoing community transmission (Lee, 2003). One of the super-spreading events occurred after a local infected person was admitted into the Prince of Wales Hospital at Shatin. This single case resulted in over 100 healthcare workers becoming infected. The epidemic in Hong Kong reached its peak by the end of March 2003, with the spread of the disease from hospitals into the community. A second superspreader event occurred at the Amoy Gardens housing estate in Kowloon at this time. A thirty-three-year-old man who was being treated regularly at the Prince of Wales Hospital for chronic renal disease acquired sars and developed symptoms on 14 March 2003. He reported only mild symptoms and diarrhea at that time, and during a visit to his brother’s apartment in block E of Amoy Gardens he used the toilet. A month after the initial index case exposure (data recorded as of 15 April 2003) there were a total of 321 sars cases reported at the Amoy Gardens apartment complex. In addition, his brother, sister-in-law, and two nurses who attended to him at the Prince of Wales Hospital subsequently developed sars. There was a concentration of cases in block E, accounting for 41 per cent of the total infections at the apartment complex. The outbreak was traced to a defect found in the sewage system at Amoy Gardens that allowed the sars virus to spread between apartments (Hong Kong Department of Health, 2003).

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Investigation by the Department of Health revealed that the defect was the result of sanitary fixtures in each bathroom. Drains were fitted with a u-shaped water trap to prevent foul odours and insects in the soil stack from entering the toilets. Each block at Amoy Gardens has eight vertical soil stacks, each collecting effluent from the same unit of all floors. The soil stack is connected with the water closets, bathtubs, and bathroom floor drains. For the u traps to function properly they must be sufficiently filled with water. Most residents clean the bathroom floor by mopping instead of washing the floor with large amounts of water. It was believed that the u traps connected to most floor drains would have been dry and would not have been functioning properly, allowing for significant aerosolizing of viral particles through the pipes. As many as twothirds of the sars patients in the Amoy Gardens outbreak reported diarrhea, and it is known that sars patients excrete coronavirus in their stool, where the virus could survive in fomites for extended time periods. The bathroom floor drains with dry u traps provided a pathway through which residents came into contact with small droplets containing viruses from the contaminated sewage. The aerosolized droplets entered the bathroom floor drains through negative pressure generated by exhaust fans that were automatically turned on with the bathroom light. In addition, water vapour generated during showers acted as carrier water droplets. Exposure to freefloating viral particles was high due to the small size of the Amoy Garden apartment bathrooms (about 3.5 square metres). Aerosolized droplets with viral particles could then have been deposited readily on various surfaces including towels, toiletries, toothbrushes, and other bathroom equipment. Over a short period of time the virus spread throughout the Amoy block E building. Subsequently, infected individuals further spread sars in communal areas (elevators and stairwells) and through person-to-person contact (Donelly et al., 2003; Lee, 2003). Despite the confluence of factors that facilitated the Amoy Garden outbreak and that confounded containment efforts, a number of preventive and control measures were undertaken in Hong Kong to help contain sars, including increased education and publicity, epidemiological tracing of the source of infection, instituting control measures of isolation and quarantine, exchange of epidemiological information between Hong Kong and Mainland China, temperature checks of travellers entering and exiting Hong Kong,

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district-wide viral cleansing campaigns, improved collaboration with the World Health Organization, and research to develop a rapid diagnostic test for sars. On 13 May 2003, Hong Kong recorded its first death of a doctor from sars. Dr Tse Yuen-man died in Tuen Mun Hospital, where she had contracted sars while treating patients. By mid-May the numbers of new sars cases were declining, and 400,000 primary school children returned to classes after a mandatory sevenweek quarantine break. Secondary school students in Hong Kong resumed their studies after schools across the territory were closed for three weeks as part of efforts to contain the spread of sars. Face masks were made mandatory for all pupils, and parents were asked to do daily temperature checks to monitor for signs of fever in their children. The sars outbreak reached epidemic proportions in such a short time that hospitals and health authorities were initially ill-prepared to deal with the situation. There was a severe shortage of both masks and protective clothing for healthcare workers. Epidemiological information to help track the spread of the disease was inadequate and prompted the application of more widespread control measures like student school quarantines. There were no designated hospitals in Hong Kong for the isolation and treatment of sars patients, and the wards of the general hospitals were not designed for rigorous containment of infectious diseases. The inadequacies resulted in infection of healthcare staff in these hospitals, which became a serious problem. In the mid-May 2003 the government announced added measures to address the sars outbreak. Committees were established, led by senior government officials. One committee was responsible for the overall cleansing campaigns and environmental improvements of the housing estates in the city. A second committee was responsible for revitalizing tourism, trade and the economy affected by sars, and the third committee was responsible for promoting community involvement in the fight against sars (Lee, 1994; Lee, 2003). The sars outbreak in Hong Kong resulted in many social and economic problems. Tourism, international travel, trade, social activity, business activity, educational programs in schools, and healthcare at hospitals were all negatively affected. As an emergency measure, holiday and recreation centers outside urban areas were temporarily used as quarantine centers for individuals who

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had contacted sars infected patients. The buildings used for quarantine were not designed for isolation purposes. Another measure enacted at the end of May was the government crackdown on the common risk behaviours of spitting and littering. Monetary fines were instituted, aimed at preventing additional sars cases resulting from environmental fomite spread and aerosolized droplets from spitting in crowded streets. Near the end of May 2003, as sars numbers were receding globally, a total of 379 medical, nursing, and other healthcare workers in Hong Kong hospitals had developed sars. Three of the cases – a doctor, a nurse, and one healthcare attendant – died as a result. With continued reports of new cases but deaths in the single digits, on 18 May 2003 a Hong Kong health official reported that the outbreak was “under control.” Hotels and restaurants reported business was slowly recovering as new numbers of reported sars cases remained in the single digits. Hong Kong’s last official new case was reported on 11 June 2003. The who declared Hong Kong effectively free of sars on 23 June 2003. After nearly four months, the disease had infected 1,755 people and killed 299 people in the city, and stigma had ravaged the economy. The average death rate in the Hong Kong outbreak was calculated at 17.0 per cent. The removal of Hong Kong left Beijing, Toronto, and Taiwan still on the who’s list of areas with active sars (Eleventh Hour TimeLines, 2003). As in Canada, the outbreak in Hong Kong infected many nurses with hospital-acquired sars. More than 200 nurses in Hong Kong were reported to have contracted sars, and at least one nurse died after working with contagious patients. According to local press reports, the nurses working in the sars areas contracted the illness despite infection control precautions, sometimes from patients who did not show obvious symptoms. In an effort to reduce transmission of sars from patients, nurses were required to wear personal protective gear that included double gloves, full-length waterproof gowns over their uniforms, shoe covers, goggles, face shields, and respirator masks. Some nurses took even more extreme measures by shaving their heads to reduce the risk of environmental cross-infection (Fitzroy, 2003). There were many factors during the sars outbreak in Hong Kong that made control measures difficult to implement. First, due to inadequate infectious control rooms in hospitals, healthcare

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workers and nurses were disproportionately affected. Second, for sars Probable individuals there was no recognized standard medical treatment for the disease, and treatments varied between hospitals; third, the exact mode of transmission was not fully established until well into the outbreak, making the decision to apply the correct control measures much more complicated (Peiris et al., 2003). Public health measures against the sars epidemic followed infectious disease control practices used historically in previous disease outbreaks of the nineteenth and twentieth centuries. The principles included early detection, notification, isolation, treatment, investigation, and control. All these measures were covered by the Hong Kong Quarantine and Prevention of Disease Ordinance, Chapter 141, and the Prevention of Spread of Infectious Diseases Regulation (Lee, 1994). Similar to the situation in Canada, officials in Hong Kong realized that there was a need to set up a Centre for Diseases Control and Prevention, to improve quarantine procedures, to improve surveillance, improve communication, and better facilitate the exchange of epidemiological information with other health authorities during biological crises (Lee, 2003).

sars in taiwan and risk communication The first known sars patient in Taiwan was in a fifty-four-year-old businessman who returned from Guangdong Province, China, by way of Hong Kong, to Taipei on 21 February 2003. Four days after returning he visited a hospital with symptoms of fever, myalgia, and a dry cough but was not admitted until 8 March. Several hours after admission, he was intubated and required mechanical ventilation for thirteen days. During the initial hospitalization, he was cared for in a single intensive care unit (icu) room by healthcare workers who used standard nursing precautions. Pneumonia was also diagnosed in the businessman’s wife on the morning of 14 March, and both patients were placed in isolation rooms. By the afternoon they were moved to icu negative pressure rooms with full precautions. Their son also developed a fever, and he was hospitalized in a negative pressure isolation room on 21 March 2003. The wife and son were exposed during the period before full protective measures were in place, and both required mechanical ventilation. The illness was confirmed by laboratory testing (reverse transcriptase-poly-

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merase chain reaction, rt-pcr) that indicated the presence of coronavirus. In addition to the identified index case, twenty-three other travel-related sars carriers were implicated in Taiwan’s outbreak. Of the Probable case patients, nineteen (83 per cent) had travelled to either mainland China or Hong Kong in the ten days prior to the onset of illness. The remaining four acquired sars from known primary cases (Twu et al., 2003). By mid-April, unrecognized cases of sars led to a large hospitalborne cluster of infections. sars was transmitted to other healthcare facilities and into the community. The breach of containment in Taiwan resulted in over 131,132 people being sent into quarantine in just over three months, including 50,319 close contacts of sars patients and 80,813 travellers from known sars-affected areas. At the height of the outbreak, Taiwanese government officials, desperate to gain control over sars transmissibility, announced they were thinking of a ban on all air travel to or from China (Centers for Disease Control and Prevention, 2003c). The government fined two hospitals for allegedly covering up sars cases (cbs News, 2003bc). Like other hot spots, Taiwan decreed the syndrome an infectious disease subject to quarantine laws, and banned visits of its civil servants to other known affected areas, including mainland China, Hong Kong, and Vietnam. Just as the second outbreak was occurring in Canada, a similar situation was occurring in Taiwan. It reported its biggest daily jump of sixty-five cases and eight deaths due to sars on Thursday, 22 May 2003. Su Yi-Jen, chief of Taiwan’s Center for Disease Control, attributed the increase in numbers to improvements in Taiwan’s confirmation process. Officials were working faster to confirm a backlog of 400 Suspect sars cases. When sars began spreading in China and Hong Kong, Taiwan began taking aggressive measures against potential outbreaks. Taiwan’s initial efforts were successful but it lost control of the virus as hospitals failed to accurately diagnose, quarantine, and track patients. Taiwan had reported a rapid rise in hospital-acquired sars infections in May, causing nurses and doctors to resign in high numbers because of fears of contracting the virus and due to hospital infection control measures that they believed to be inadequate. About 120 healthcare workers resigned at Chang Gung Hospital in Kaohsiung, forcing hospital authorities to transfer nurses from other hospitals (Fitzroy, 2003).

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A survey by the United Daily newspaper showed that 73 per cent of Taiwanese residents were extremely fearful of sars. Worries about communal transit and transmission in crowded public areas made mask-wearing mandatory in many public spaces. The government of Taiwan failed in its risk communication efforts, only increasing the level of fear with harsh anti-sars measures and poor communication. The heightened hysteria was counterproductive to efforts to control the disease. Taipei Mayor Ma Ying-jeou proposed an automatic three-day quarantine for anyone with a fever, and the Department of Health banned the sale of anti-fever pills by drugstores as a way to force possible sars sufferers to go to see doctors to receive treatment. Taiwan epidemiologists felt the actions of the government health officials confused the public and failed to give them the basic information they needed to put the risk of sars into perspective. Even though over 90 per cent of Taiwan’s sars cases were hospital infections, and communal infection risk was very low, this information was not communicated to the public by government officials. Some people hoarded surgical masks, causing a shortage for medical workers, while others attempted to hide their possible exposure to sars patients in their medical histories, afraid of being stigmatized. In late May, with rising public anxiety, Lee Ying-yuan, an adviser to the government’s sars committee, told a news conference, “Please live your lives normally ... Since it is not transmitted by air, there is no need to panic.” Ying-yuan meant to say that outside of hospital buildings the transmission of sars by air droplets was a remote risk, but his message made it sound as if he was uninformed about sars viral droplet transmissibility. And despite the message to carry on normally the government had, at the same time, implemented a city-wide order to wear masks in all subways and trains, making passengers wary of public transport and uncertain about their safety. The contrasting messages and lack of information from officials only confused the public (Reuters, 2003). By mid-June 2003 Taiwan was still dealing with sars. Two more sars deaths were reported, breaking a run of sixteen successive days without new fatalities. Taiwan announced that another person had become infected, triggering an investigation into whether the island had a hidden cluster. Authorities began examining a large discrepancy between sars numbers compiled by the Health Department and those from local governments. The Health Depart-

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ment reported that sars had killed eighty-three people on the island, while local governments reported cremating 363 sars cases (Nullis, 2003). Finally, on 7 July 2003, the who removed Taiwan from its list of areas with local transmission of sars. After containment Taiwan reported 346 Probable cases and 37 deaths with a case fatality rate of 11 per cent. Quarantine was used in Taiwan as a strategy to contain sars. Anyone who had been in close contact with a sars patient was quarantined for fourteen days. Persons under quarantine were required to stay where they were quarantined, take their temperature two to three times a day, and seek medical attention promptly if they had symptoms of a fever (>38ºC), cough, shortness of breath, or other respiratory symptoms. Those quarantined were instructed to cover their noses and mouths with tissue paper when coughing or sneezing, and wear surgical masks when around other persons. Individuals on quarantine were not allowed to use public transportation, visit hospitalized patients, or visit crowded public places. Persons could leave the quarantine site for activities deemed necessary by local health authorities, but required approval. If needed, meals were delivered. Failure to comply with quarantine regulations, submitting incomplete sars survey forms, or providing inaccurate contact information was punishable by fines and incarceration of up to two years. Quarantine cases were managed by local healthcare workers or civil servants who recorded each person’s daily movements. This information was obtained either by daily visits or by telephone calls. Daily temperature self-checks were also reported. Local health officials then reported each day’s information to the Taiwan Department of Health through a collective Internet database. Video monitoring was conducted for known contacts of sars patients who were deemed to be at higher risk during their home quarantine. The intervention was conceived initially for quarantine violators living in high population-density areas of Taipei and Kaohsiung, but was used for monitoring low-risk patients also. By the middle of May 2003, video monitoring was used for nearly all persons living under home quarantine in cities. At government quarantine facilities, persons were placed in individual isolation rooms (these rooms were not negative pressure) and meals were delivered. Police guarded the rooms to ensure compliance with quarantine. Taiwan healthcare officials attempted to

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provide support to those who had been quarantined by having a trained individual telephone to provide psychological counseling and social support. Daycare was provided for the children of ill and quarantined persons. Individuals who completed quarantine received a small stipend as compensation. Quarantined persons could request other social services from local health or civil affairs departments. Near the end of the epidemic, 131,132 people had been placed in quarantine; of these, 286 (0.2 per cent) were fined for violating their quarantine. Of the 50,319 persons placed under Level A quarantine (those who had high-risk contacts with known sars patients; their movements were highly restricted) 4,063 (8.0 per cent) were placed on video monitoring at home. A total of 112 (0.22 per cent) persons were diagnosed with Suspect or Probable sars while under Level A quarantine. Of the 80,813 persons placed under Level B quarantine (low-risk contacts with relaxed restrictions on their movement), 21 (0.03 per cent) were diagnosed with Suspect or Probable sars. The biggest groups of people who contracted sars were healthcare workers who had been exposed to a sars patient (0.34 per cent), family members exposed to a sars patient (0.33 per cent), and persons who sat within three rows of a sars patient on an airplane (0.36 per cent). Travellers who had been to known sars-affected areas and returned to Taiwan had the lowest percentage for subsequent sars diagnosis (0.03 per cent) (Centers for Disease Control and Prevention, 2003c). In another study conducted after the outbreak, the total number quarantined between 28 March and 30 July 2003 was tallied at 151,270 people. In this group, forty-six (equivalent to three out of 10,000 people) subsequently went on to develop Probable sars (Chen et al., 2005). Quarantine was a useful method for reducing the spread of the disease. For medical outcomes, statistics revealed that compared to the survivors, fatal cases were more likely to be older, male, exposed through hospital contact, with coexisting medical disorders. High-profile but largely ineffectual public awareness campaigns were launched to improve public understanding of sars, with emphasis placed on good personal hygiene, frequent temperature checks, and prompt reporting of fevers. An island-wide telephone hotline and call centre staffed by doctors and nurses was implemented. Taiwan established around 100 fever clinics. These facili-

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ties were set up to ease overcrowding in hospital emergency rooms as more concerned residents sought information and medical attention. The clinics also reduced the amount of contact between potential sars cases and individuals with other illnesses who could have been more severely affected by sars. The outbreak in Taiwan had psychosocial impacts on healthcare workers comparable to those in Canada. The outbreak of sars was highly concentrated in hospitals and a large number of healthcare workers were infected. One research study investigated stress reactions among 338 staff members in a hospital in East Taiwan that discontinued emergency and outpatient services to prevent hospital-acquired outbreaks. Seventeen healthcare workers (5 per cent) suffered from an acute stress disorder, and stepwise multiple logistic regression analysis determined that extended work quarantine was the most likely contributing factor for this illness. Sixty-six hospital staff members (20 per cent) felt highly stigmatized and rejected in their own home neighborhoods because of their occupations. Twenty healthcare workers reported reluctance to return to work or had considered resignation from work due to feelings of fear for themselves or for their families, and pervasive stigma (Bai et al., 2004).

sars in singapore and risk communication sars was first detected in Singapore on 13 March 2003, carried by three people who had recently returned from Hong Kong. The government of Singapore involved the entire country in the fight to contain sars. Tan Tock Seng Hospital (ttsh) was selected as the central hospital where Suspects and Probable sars patients were isolated. Also, a large fruit and vegetable market was closed in late April after three sars cases were discovered there. For all cases, daily temperature checks were instituted with monitoring by military personnel. At Changi International Airport and Singapore’s seaport, all departing and arriving passengers were subject to temperature checks; thermal scanners were used at security checkpoints to detect abnormally high body temperatures. Suspect cases were sent to hospital for further observation and treatment. Temperature checks were also instituted for public transit workers (taxi and bus drivers) who took regular temperature measurements and confi-

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dently displayed stickers in their windows to indicate that they did not have fever symptoms. Personal digital thermometers with instructions were given to over 55,000 stall vendors in public markets and food centers so they could monitor their own temperatures with bi-daily checks. Government officials conducted random spot checks of market vendors for compliance. Privately run market produce shops and privately operated markets were also encouraged to do daily temperature checks. Hospitals set up fever stations outside their premises to deal with patients, similar to the sars assessment clinics in Canada and Taiwan. The Ministry of Health implemented a no-visitor rule in hospitals (some exceptions were made for pediatric wards). The government instituted strict control measures including a tenday quarantine for anyone who came into contact with a Probable sars patient. Quarantines were enforced by Web cameras that were installed in the homes of those quarantined, with daily checkins by both police and health officers. Recovered sars patients were placed under home quarantine for an additional fourteen days after their hospital release, and their health was monitored with daily telephone check-ins. A final medical checkup to confirm sars-free status was required after quarantine ended. The government message was one of personal responsibility. Public education was also a focus, with more than 1.2 million leaflets entitled “Fighting sars Together” distributed to every home in Singapore in the four major languages – English, Chinese, Malay, and Tamil. The leaflets detailed how people could protect themselves and others from infection. The concern over sars spreading in schools led to the closing of all institutions in late March; the buildings were scrubbed clean with disinfectant. The actions taken in Singapore were praised by who’s communicable diseases chief David Heymann. Although the measures implemented by the government seem authoritarian, the public responded well. Very few people resorted to wearing masks on the streets out of fear. The public’s trust in government messages and actions showed that while there was still much concern over sars, there were low levels of fear and altered behaviours. The government quarantined thousands of individuals. By 14 April, 608 were reported to be under home quarantine, and by 26 April the number quarantined rose to nearly 2,800. Government officials communicated the threat of hefty monetary fines or six months in jail for anyone who broke home

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quarantine. As in Taiwan, Internet cameras were mounted in the homes of those quarantined. Electronic wristbands were attached to those caught breaking house quarantine as a way to monitor their movements and prevent further breaches. At the beginning of May, teachers in Singapore distributed 2.8 million dollars’ worth of digital thermometers. Students checked themselves twice a day for fever symptoms, and officials extended the mandatory home quarantines for Suspect sars patients in Taipei from ten to fourteen days. High school entrance exams were postponed to prevent mass gatherings of students. At the end of May, after instituting tough anti-sars measures, Singapore was removed from the who’s list of sars-affected areas. Since the declared end of the sars outbreak there was only one additional case there, resulting from a laboratory-related exposure, in September 2003. sars killed thirty-three people and infected 238 in Singapore (Tan, 2003). Economically, Singapore was hardest hit by sars in areas immediately connected with travel, tourism, and the airline industry. Singapore relies heavily on tourism and the industry contributes 10 per cent of its gross domestic product (gdp). Many of the visitors to Singapore are from China. In 2002, over 670,000 people entered Singapore from China, a large influx of people from the country with the highest rate of uncontained sars. In the first month of the outbreak, hotel occupancy rates fell by 65 per cent, and by late April arrival rates were down 70 per cent. Retail sales fell by 50 per cent, causing many small traders to declare bankruptcy. The government estimated a decline of at least 1 percentage point of gdp, or $875 million in losses directly attributable to the crisis. Even though strict containment measures were put into place in all Asian countries affected by sars, the impact on Singapore’s economy was severe. Singaporean Prime Minister Goh Chok Tong predicted as much in early May in an interview with the Far Eastern Economic Review. “I think the problem could be worse than the (1997–98) Asian financial crisis ... the economy is going to be hit very badly.” The sars epidemic underscored the degree to which the countries in the region are economically integrated with each other (Roberts, 2003). Singapore has been praised by the who for its risk communication during the sars crisis, which successfully addressed public anxiety and uncertainty. Officials did a very good job of reassuring

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the public, acknowledging their uncertainty, and offering help so people could empower themselves, reduce their own risk and the risk to others. Officials in several countries have called their citizens irrational or hysterical for unnecessarily wearing masks in public. Air Canada’s flight attendants and local Toronto bus drivers were forbidden to wear masks early on in the outbreak, despite their strong desire to do so for personal safety reasons. Mr Goh told Singaporeans about the Japanese custom of wearing masks if one has a cold, to protect others. Through a little education and by giving people the choice to wear masks or not, Singaporeans were helped to become less fearful, with their desire to wear masks reframed as an altruistic act rather than a fearful irrationality (Lanard and Sandman, 2003). Singapore’s government took a number of precautions to reduce the spread of sars. All students returning from other known sarsaffected countries had to take ten-day leaves of absence (quarantine) and were required to produce medical certificates showing they were virus-free before returning to class. The focus on communication of the risk in its context greatly reduced the levels of anxiety and fear among Singaporeans. The dissemination of educational pamphlets, wide distribution of digital thermometers, and temperature-taking acted to increase self-mastery by the general public.

similar containment measures and management used by different sars-affected countries The five countries with the highest numbers of sars infections used similar methods in the attempt to effectively contain the outbreaks. The types of interventions and the way the containment measures were implemented greatly influenced public perceptions. In China and Hong Kong, strict penalties and fines for quarantine-breakers, use of military forces and poor risk communication, resulted in high levels of fear and anxiety in the general public. Canada and Taiwan fared slightly better in containment efforts, with much better contact tracing for individuals who were in quarantine. Taiwan invested much effort in monitoring those in quarantine. Both Canada and Taiwan quickly improved communication lines between hospitals and government health officials once the out-

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breaks began. Taiwan instituted city-wide mask-wearing as a precaution on public transit systems, while Canada did not. Singapore had the most effective risk communication strategy, with educational campaigns (distributed information pamphlets), public engagement (involvement in clean-up and decontamination efforts) and precautionary measures (wide distribution of thermometers to citizens for daily self-monitoring, and public transit workers who displayed signs indicating self-monitored sars-free status). The result was a surprising level of calm and low levels of anxiety and fear in Singapore. Quarantine sars is normally transmitted through droplet spread from one person to another. At the beginning of the outbreak there was no specific treatment nor was there a fast, reliable diagnostic test. This made avoidance and quarantine important mitigating strategies. Persons under quarantine were usually confined at home and actively monitored for symptoms. In several countries, quarantine was legally mandated and monitored by neighborhood support groups, police, the military, and civil servants, by video cameras installed in homes. In some instances compliance was requested, but in general, court orders were issued for only a very small percentage of non-compliant persons. Reports indicate that sars was diagnosed in 0.22 per cent of quarantined contacts in Taiwan, 2.7 per cent in the Hong Kong Special Administrative Region, and 3.8 per cent–6.3 per cent in Beijing. Quarantine led to financial and psychosocial stresses, stigmatization, requests for compensation, and workforce staffing issues for persons, families, employers, and governments. Legal appeals and defiance of quarantine orders were rare regardless of country (Bell 2004). sars disrupted economies and changed the daily lives of millions of people. Schools were closed in Hong Kong, Singapore, China, and Taiwan. Hospitals closed wards in all countries and some borders were temporarily closed. In each of the five countries thousands of people were placed in quarantine as a precaution. International travel to the hardest-hit areas fell sharply, and hotel occupancies dropped. Singapore, which relies heavily on tourism, was hardest hit economically, with unemployment linked to the outbreak. Healthcare workers in all of these countries bore

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the brunt of the disease, representing more than 20 per cent of global cases. Contact Tracing Small teams from the who, consisting of epidemiologists and infectious disease experts, went to China, Hong Kong, the Philippines, Singapore, and Vietnam to assess the status of the outbreaks in those countries. The teams also offered expertise and experience to governments looking for options to contain sars. Infection control equipment, masks, and gowns were dispatched to countries considered more vulnerable to an outbreak. The who sars teams worked with local public health officials to ensure that enhanced surveillance and proper quarantine measures were put in place to enable early detection of cases, the tracing of contacts, and monitoring of anyone suspected of having sars. The who also established a regional laboratory network so that testing for sars could be done for countries with limited laboratory facilities. who experts drafted working guidelines on a wide range of topics, from infection control in hospitals, infection control in the community and infection control for international travel to basic requirements for laboratory containment. Reducing Movement and Gatherings of People Measures to increase social distance were used by all countries. Individuals, planners, and those responsible for larger group meetings cancelled mass gatherings and closed schools and theaters as precautions to minimize the occurrence of super-spreading events, where one infected individual could potentially expose a large group to sars. The exception to this rule was in China where government officials refused to cancel pre-scheduled mass gathering events. When mass gatherings of people could not be averted, some countries, like Taiwan, required masks for all who used public transport or those who worked in restaurants. Canada and other countries instituted mask-wearing for people entering hospitals. In Asian countries mask-wearing was also put into practice in areas where extensive unlinked community transmission was occurring. In Canada, sports events, conferences, rock concerts, and group meetings were cancelled.

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Epidemiological tracing data showed visits to Mainland China were associated with sars transmission to other countries. One research study determined that for Hong Kong, cross-border transmission did play a significant role in establishing the epidemic, although the absolute percentage of imported Probable cases was not high among the 1,192 case-patients tracked in the study (3.6 per cent, or 43 people). The lesson for integrated trading blocks is that cross-border communication and prevention of infectious diseases needs to be enforced consistently between jurisdictions. Tools for monitoring for infectious disease symptoms, such as temperature screening and health declarations, need to be in place for evaluation and surveillance. Almost 70 per cent of the forty-three people who visited Mainland China had fever onset on or before 1 April 2003 during the early phase of the epidemic. None had fever onset after 3 May 2003 – visiting Mainland China was perceived as a high risk activity for acquiring sars by the general public in the late phase of the epidemic (Lau et al., 2004). Evidence from sa rs transmission data in Hong Kong, however, does not indicate that frequent visits to crowded places were associated with a higher likelihood of community-acquired infection, so reducing mass gatherings was not an effective way to reduce sa rs . The statistically significant result determined by Lau et al. (2003), which appears contradictory to what is expected, should be interpreted with caution as relatively few individuals were infected and, moreover, more than 90 per cent of the general public wore face masks in public places and more than 85 per cent avoided visits to public places during the epidemic in Hong Kong (Lau et al., 2003). Mask-Wearing Many people in sars-affected areas chose to wear masks outside their homes. In Taiwan the use of masks was applied with other measures, including quarantine and enhanced contact tracing. The introduction of a variety of control measures was temporally associated with a dramatic decline in new sars cases. A case-control study in Beijing found that wearing a mask more frequently in public places was associated with the perception of increased personal protection. Another case-control study in Hong Kong found that using a mask in public places, washing one’s hands more than ten

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times per day, and disinfecting living quarters thoroughly were perceived as protective behaviours that prevented sars (Lau et al., 2004). With the exception of the Amoy Gardens cluster where the virus was transmitted through an aerosol of contaminated sewage, transmission in the community from this type of environmental contamination was rarely reported (Bell, 2004). Improved Disinfection and Public Cleaning In China, Hong Kong, Singapore, and Taiwan disinfectants were applied inside homes of those with sars and those who were quarantined. Vehicles, ambulances, automobile tires, hospital areas, local business areas, and pedestrian walking zones were also disinfected. Little information exists on the effectiveness of these mass disinfectant efforts in reducing community or hospital transmission. In Hong Kong, disinfecting living quarters thoroughly (not otherwise defined, and reported retrospectively by telephone) appeared to be protective. During the epidemic, the Hong Kong government released frequent announcements for public education to promote home disinfection using a 1:99 dilution of bleach to water solution. Most who disinfected their living quarters, local shops, and businesses followed the government’s recommendations. The protective effect of a 1:99 dilution was believed to be the reduction of secondary infection by environmental contamination. However, research studies show a five times greater concentration of 5.25 per cent sodium hypochlorite (naocl) or household bleach is used for effective disinfection. Disinfection of hard, non-porous surfaces is achieved with a five-minute contact time using a 1:21 bleach:water solution that kills a number of bacteria, fungi, yeasts, and viruses. Disinfection at this strength has been shown to kill many viruses including rhinovirus (cold virus), influenza A2 (flu virus), and respiratory syncytial virus. Research findings by Lau et al. (2004) suggest that disinfection did reduce sars surface environmental contamination, and other evidence showed surfaces could be contaminated by either droplet spread or contact with fomites (Lau et al., 2004). Canada’s sars outbreak was largely contained in Toronto hospitals, and the need for mass public disinfection using diluted bleach solutions was not considered necessary.

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Improved Education of the Public and of Healthcare Workers Combined data from Canada, China (Mainland and Hong Kong), Taiwan, France, Singapore, Switzerland, Thailand, and the United States indicate that approximately 31 million airline travellers entering these countries received health alert notices about sars during the global outbreak. Of these, approximately 1.8 million were reported as arriving from affected areas; this estimate is likely low given the difficulties in tracking travellers and the fact that many airline passengers change planes en route to their destinations. Inadequate data exist to evaluate the effect of distribution of most of these notices. Mainland China reported distributing 450,000 notices and possibly detecting four sars cases through the notices. Thailand reported having printed 1 million notices and detection of 113 cases of illness directly attributable to the notices (108 at airports, one at a seaport, and four at land crossings). Twenty-four cases were Suspected or Probable sars: all were detected at airports (Bell 2004). Singapore and China produced printed material distributed to citizens to inform them of sars. Canada relied heavily on news coverage to disseminate expert opinion during the sars crisis. The news media filtered the information, focusing on controversial aspects, victims, and the number of deaths. Canada also used other types of media such as the Internet to disseminate information to the public; many Canadians without Internet access failed to receive any educational information. The most useful tool employed by Canada was the telephone information line. Singapore’s educational pamphlets focused on providing information not usually covered by news media reports, such as correct methods for self-monitoring of body temperature, disinfection, and contact information. Risk Issue Management and Risk Communication The countries hardest hit by sars had to deal with uncontained outbreaks as well as hospital transmission. Failed risk communication around sars was evident in China, Taiwan, Hong Kong, and Singapore, but the reasons were very different from the ones affecting Canada. Chinese officials were slow to acknowledge, track, and properly classify sars patients, and the country found itself under

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intense scrutiny from the international community, with allegations of denial and cover-ups of the true prevalence of sars. Hong Kong had similar problems; both were slow in communicating what they knew to the public and international agencies. Singapore fared much better in its efforts at managing its uncontained sars outbreak, taking a more proactive approach. Distributing thermometers en masse to a number of key public sectors and instituting daily temperature checks empowered the public. Transit workers with signs confirming that they were sars-free conveyed a confident message to the public that used the mass transit system. This message was one of reassurance that measures were in place and areas of high density were being monitored for the earliest signs of sars. In essence, the bus and taxicab drivers all across Singapore who were exposed to high numbers of people daily were like sentinels; they acted as an early warning system, reflecting the level of sars transmissibility in the places with the highest degree of movement and concentrations of people. Singapore also actively distributed educational leaflets as a way to inform individuals of the level of risk from a credible source. Travel Advisories who and various governments issued travel advisories suggesting the postponement of non-essential travel to sars-affected areas. Air travel to affected areas decreased dramatically during sars. The negative impact who travel advisories may have had compared with other sources of information available to travellers, such as news reports, is difficult to assess. At the beginning of sars, several Asian countries warned against travel to Singapore. Prime Minister Goh’s stated position was that, “We can understand that because we also give travel advisories to Singaporeans not to go to the affected places. So we must expect other countries to advise their travellers not to come to Singapore ... If we are open about it and all Singaporeans cooperate by being as careful as they can, we may be able to break this cycle early and if we do then of course people outside will have confidence in Singapore and the way we manage the problem.” This was a far different reaction from that of Canadian officials to the who travel advisories against Canada. Canadian officials openly criticized the restrictions. Toronto Mayor Mel Lastman reacted to the travel advisory

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with open anger, and federal Health Minister Anne McLellan urged the who to lift the advisory, saying it was not appropriate (ctv News, 2003b). Donald Low speculated that who was trying to appease ruffled feathers in China by unjustifiably including a western city in its list of dangerous destinations (Kondro, 2003). Canadian officials sounded much like Chinese officials who had previously tried to downplay the existence of sars, afraid of economic impacts. Passive and active methods were used to provide information to travellers. Passive methods included signs, videos, public address announcements, and distribution of health alert notices. Active methods included administering questionnaires to assess symptoms and potential exposure, visual inspection by airport workers to detect symptoms of fever, and the use of thermal scanning devices. Little data exists on the effectiveness of these methods for mitigating sars transmission between countries. Available data on the effectiveness of screening and other measures directed to travellers are sometimes difficult to interpret because they may not distinguish between entry and exit screening, specify how many entering travellers were from affected countries, distinguish the exposure (whether it occurred prior to, during, or after entry), or include the number of sars cases detected (Bell, 2004). Improved Hospital Practices for Infectious Disease Control All hospitals in the five countries hardest hit by sars responded with infection control measures. Masks, personal protective equipment, reduced visitation, closing of wards, and designating wards (or entire hospitals) for sars were measures used by all. All hospitals established working groups to improve communication with government officials. Infectious disease control guidelines were handed down from government health officials or who officials and adopted by hospitals.

conclusions The five countries hardest hit by the sars outbreak reacted in very similar ways to deal with the infectious disease. Index cases in each of these countries led to a rapid chain of disease transmissions to unprotected individuals and healthcare workers. All countries

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attempted to quarantine individuals, using military intervention (China), appeals to civic duty and offers of incentives (Singapore and Taiwan), and requests for voluntary compliance (all five countries). Singapore and China took extraordinary quarantine measures, closing all schools to ensure the safety of children and for containment through social distancing. All five countries attempted some form of patient tracking, improved quarantine measures, and use of personal protective equipment for healthcare workers. Taiwanese officials tried a unique method of sars detection, offering monetary rewards to people who informed them of suspected cases. For public monitoring specific to sars, Singapore went further than all other countries, instituting massive temperature-taking schemes involving the public, police, businessmen, public transit workers, and healthcare workers. Risk communication through increased education was a big component of dissemination of information. All countries used health alert notices for arriving travellers. Singapore printed booklets with educational information and ways to prevent sars transmission, delivering a copy to every household. Education helped enormously and empowered people to take responsibility for containing sars, alongside efforts in the healthcare sector. The news media impeded risk communication and education efforts with massive amounts of information from a large number of experts. Experts were asked daily for any new information about sars. This led to an oversaturation of the issue, and the impact of clear authoritative voices was lost. The Chinese government spoke with a strong centralized voice, disseminating limited information through state-controlled media. Singapore, Taiwan, and Hong Kong asked their citizenry to help in mass cleanup efforts, with everyone taking part in the disinfection of hospitals, apartment buildings, streets, parks, public venues, shops, and restaurants. The efficacy of these disinfection programs in reducing the environmental spread of viral particles outside of hospitals is questionable, but the massive cleanup projects did help risk communication efforts and raise public awareness of the potential for environmental transmission. The experiences of all of the hardest-hit countries (China, Taiwan, Hong Kong, Singapore, and Canada) with sars revealed a lack of pre-existing risk communication planning for infectious disease control. As well, hospitals, emergency departments, and healthcare systems were poorly prepared – operationally, organiza-

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tionally, and psychologically – for a massive infectious disease outbreak. Risk communication, good infectious disease surveillance systems, and real-time reporting of outbreaks around the world can provide some warning, allowing countries to activate their pandemic response plans. Early detection and communication of emerging outbreaks will allow for early, credible interventions by hospitals (information dissemination, mobilization of antivirals and vaccines), governments (information dissemination, messaging for increased social distancing), healthcare workers (home quarantine, wearing protective equipment, and self-temperature checks), and the public (social distancing, increased vigilance, provisioning for quarantines). Due to the specter of the next pandemic or terrorism-related biological threats, all countries around the world should adopt a new working paradigm of improving risk communication during pandemics, to increase capacity and resilience in case of infectious disease threats, regardless of their origin.

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Avian Influenza We at who believe that the world is now in the gravest possible danger of a pandemic ... If the virus becomes highly contagious among humans, the health impact in terms of deaths and sickness will be enormous and certainly much greater than sars. Dr Shigeru Omi, who regional director for the Western Pacific (23 February – cbc News 2005b)

Throughout history, various societies have experienced and recorded the occurrence of virulent, contagious diseases and viruses as a natural part of life. For most of these outbreaks, people have been at the mercy of pathogens, enduring diseases that would indiscriminately kill tens of thousands. Emerging infectious diseases with the potential to become pandemics that kill high numbers of people overlie a constant background of familiar mortality-inducing contagions. Unfortunately, the majority of the infections occur in the places least able to manage them, and to individuals least able to defend against them. Children are the most vulnerable group, presenting a virgin immunological pool for disease propagation. Children living in developing countries, and disadvantaged minorities in developed countries, are infectious diseases’ most-affected groups. Older individuals, who usually have reduced immune capacity or comorbid medical conditions, also comprise another large, vulnerable demographic group frequently ravaged by infectious diseases. Despite medical advances, mortality from infections remains quite high. By the beginning of the twenty-first century, approximately 13 million deaths each year were directly attributable to various kinds of infections (Cohen, 2000). The viruses that cause infectious diseases continually and sometimes dramatically change over time. The alterations result from

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interactions between rapidly evolving infectious agents and their hosts, combined with host behaviour that provides favourable new niches. The results are new pathogens with new properties and familiar pathogens that re-emerge with altered virulence. The existence of animal reservoirs and their close association with human populations perpetuates this pattern of emerging zoonotic disease. This is a reality for the global medical community and public health officials who must deal with the uncertain future of pandemic disease outbreaks.

widespread population infections: about pandemics and epidemics An epidemic is a widespread disease that affects many individuals in a population, above the rate that would normally be expected. When an epidemic extends beyond the confines of a region, typically a continent, and becomes a more widespread problem, it is called a pandemic. An outbreak of a disease is determined to be epidemic or pandemic not in terms of how many individuals or what proportion of the population is infected but by the rate at which the infection grows. When each infected individual is infecting more than one other individual, so that the number of infected individuals is growing exponentially, the disease is in an uncontrolled state. Even if the total number of people who are infected is small, the phenomenon may still be called an epidemic, although for small numbers of infected individuals the term outbreak is usually used. The prevalence of a disease is the number of diseased individuals at any one time over a given time period. The incidence is the number of new cases of a disease that occur within a defined population over an established period of time. Frequently either prevalence or incidence, or both, are given as a rate, meaning the number of cases in a fixed number of people, e.g., cases per 100,000. Establishing the rate of infection allows for comparisons by region, population, and time. Individual cases of disease in widely separated geographic areas or otherwise independent cases are said to be sporadic. Any disease with a low to moderate (but not necessarily constant) normal base level incidence rate in the population is said to be “endemic.” The common cold is endemic in northern latitudes. Individuals who are infected and show either no symptoms or only mild symptoms are said to have a subclinical infection; with-

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out symptoms they may act as carriers of the disease because they can unknowingly spread the disease agent to other susceptible individuals. The occurrence of epidemics and pandemics depends on a number of interacting factors: for viruses, the transmission between hosts, incubation time1 before showing symptoms, and the window of infectivity are all important criteria. The incubation period (time between exposure and the first detectable symptoms), and infectious period (time during which the disease can be transmitted with or without contact) are all important measurable indicators of these factors (Bugl, 2004). Types of Epidemics There are two major types of infectious diseases that can develop into epidemics: “common source” and “host-to-host.” Common source epidemics arise from a contaminated source, such as water or food, while host-to-host infections are transmitted from one infected individual to another by various direct or indirect routes. Common source epidemics usually produce more new cases earlier and faster than host-to-host epidemics. Common source epidemic diseases are those that result from contamination of water, food by-products, or by human or animal excrement. Once the infected source is closed, sealed, or removed, the common source epidemic usually abates rapidly. Host-to-host epidemics, which include transmissible infectious diseases like sars, are slower to grow and slower to diminish. A list of common source contact and host-tohost disease types that have resulted in previous epidemics are listed in table 12.1 (Bugl, 2004). Epidemics Through Time The common yearly human virus, influenza A, was first isolated in 1933, and since then data has been collected on its antigenic and molecular characteristics, including historical records, seroarcheology and molecular epidemiology. On the basis of the historical record of the last century only the h1, h2, and h3 subtypes affected humans with large-scale pandemics, but h4-h15 subtypes should not be dismissed altogether. The source of influenza A viruses is bird reservoirs that maintain various flu subtypes. Avian reservoirs are divided into two main pools, one in Asia and the other in North

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Table 12.1 Examples of representative, common diseases and their causative agents that have become epidemics. The sources of contamination and identified disease reservoirs are also indicated Causative Agent

Disease

Agent Class

Infection Sources

Reservoirs

Contact-to-Contact Diseases Cholera

Vibrio cholerae

bacteria

Typhoid Fever

Salmonella typhi

bacteria

C. difficile

Clostridium difficile

bacteria (spores)

fecal contamination of food and water fecal contamination of food and water surface contamination

humans, fish, shellfish (indirect)

humans flies (indirect)

humans many animals household pets

Host-to-Host Respiratory Diseases Tuberculosis

Mycobacterium tuberculosis

bacteria

Smallpox

Varicella major

virus

Influenza

Influenza virus

virus

sars

Coronavirus

virus

human sputum; contaminated cow’s milk aerosolized virus particles aerosolized virus particles aerosolized virus, contaminated surfaces

humans only

humans only humans and various animals (e.g. wildfowl, pigs) humans, domesticated animals

Host-to-Host Sexually Transmitted Diseases aids

hiv

virus

Syphilis

Treponema pallidum

bacteria

infectious body fluids, blood, semen contact with infected exudates or blood

humans

humans only

Host-to-Host Vector-borne Diseases Typhus Malaria

Rickettsia prowazekii Plasmodium sp.

bacteria parasite

Plague

Yersinia pestis

bacteria

infectious louse bite infectious mosquito bite infectious flea bite

humans, lice humans, chimpanzees, gorillas, mosquitoes (vectors) wild rodents

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America. Evidence shows that human influenza strains of the last century have originated from Asian avian viral pools. The Asian flu 1957 (h2n2), Hong Kong flu 1968 (h3n2), and the Russian flu 1977 (h1n1) all originated from reservoirs in China. The outbreaks that result in pandemics occur due to viral changes in gene sequences from the avian influenza pool traced to wild ducks. Influenza and other rna viruses are highly variable and have high mutation rates, due to the enzyme that copies the viral genetic sequence, which lacks the ability to correct mistakes. The plasticity of the genome, with its ability to quickly accumulate many changes, creates “quasispecies” that consist of collections of different viral rnas. Experts believe it was this plasticity of the viruses that resulted in recurring h2n2 and h3n2 pandemics (Webster, 1997). Circumstantial evidence suggests that the majority of pandemics of the last century have originated in China, with the southern region acting as an influenza epicenter. Methods of farming, close association with animals, climate, and the large population of people, ducks, pigs, and other animals provides opportunity for interspecies transmission of influenza. Three human subtypes have reappeared cyclically: the Russian flu (h1) appeared in 1918 and again in 1977, the Asian flu (h2) appeared in 1889 and again in 1957, and the Hong Kong (h3) flu appeared in 1900 and re-emerged in 1968. The appearance of these influenzas over time occurs when a large pool of immunologically susceptible people is available to support a pandemic. If recycling occurs, then any one of the three strains could give rise to the next pandemic. The h2 subtype has had the longest time period since its last cycling event. If h2 is not the next pandemic virus, experts predict that h1 and h3 will continue to cycle and could precipitate the next pandemic. The h7 subtype is also a very likely candidate singled out by experts, as it is a strain that causes conjunctivitis in humans and infects other mammals, particularly horses. Other candidates include the h4 virus that has been isolated from seals and h10 from minks; close attention is also being paid to h5 from wild birds (Webster, 1997). The recent avian flu outbreaks in Asia are the h5n1 type, and the World Health Organization believes this strain could be the next epidemic, due to the cross-species (bird-tohuman) infections already displayed by this flu type.

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The who experts looking at historical data believe that influenza pandemics can be expected to occur three or four times each century when a new virus subtype emerges and is readily transmitted from person to person. Experts agree that another pandemic is inevitable and possibly imminent. The avian h5n1 is of particular concern as it mutates rapidly and now has a history of being able to acquire genes from viruses infecting other animal species. Laboratory studies have shown that isolates from the h5n1 virus have high pathogenicity. Birds that survive the infection excrete virus for at least ten days, making it very easy for the virus to be spread at live poultry markets and by migratory birds (cbc News, 2005a). The colonization of a susceptible host population by a virus can lead to exponential growth of the disease and an epidemic as a result of a lack of immunity to the pathogen. Over time, the host population develops resistance to the virus and the spread of the virus is reduced, as there are fewer available hosts for the virus to infect, until equilibrium is reached. Genetic changes in the virus allow it to find a new pool of susceptible hosts to infect, and these genetic alterations could initiate another new epidemic if the virus presents itself as an unknown antigen. This process continues with the evolution of the virus and acquisition of resistance by the host population. The virus evolves as it encounters selection pressure from increased human immunity. This is a process of continuous change for the virus as it diversifies over time. Not all viral strains result in epidemics. The virus needs to be transmitted to new hosts in order to continue reproducing. There is a critical size for a population group, below which the disease cannot become an epidemic, but above which it can. In smaller, isolated communities, new viral strains face extinction due to lack of new hosts as everyone acquires immunity over a short period of time. Historical records seem to indicate that in human habitations the population size cutoff for initiating an epidemic is about 250,000 people. Thus, major epidemics did not occur in history until larger cities evolved and grew closer in density to this population size. Moreover, the virulence of the virus plays a role in whether an epidemic occurs or not. The Spanish flu of 1918 was remarkable for its degree of virulence that helped its propagation, an occurrence not observed with other viruses that became epidemics during the

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same century. Researchers decoded the full genome of the 1918 flu, and the genetics revealed some interesting clues about why this particular strain was so virulent. The reconstructed 1918 Spanish influenza pandemic virus was determined to be an h1n1 flu type, and it was characterized after recovering the virus from archival, formalin-fixed lung autopsy tissue, and from frozen, unfixed lung tissues taken from an Alaskan influenza victim who was buried in permafrost in November of 1918 (Tumpey et al., 2005). The 1918 pandemic virus was able to replicate in the absence of trypsin, an enzyme that cleaves the hemagglutinin (h) molecule needed for multi-cycle virus replication. The action of trypsin influences the ability of the influenza virus to replicate and it is an important determinant of the virus’s overall pathogenicity (Goto and Kawaoka, 1998). Researchers found that the reconstructed 1918 strain readily caused death in test mice and embryonated chicken eggs. The viral strain displayed surprisingly aggressive growth rates in human bronchial epithelial tissue culture cells. The virulence stemmed from the combination of the 1918 h gene sequence, its polymerase genes, and the conjunction of other viral genes that gave it a unique high-virulence phenotype (Tumpey et al., 2005). The Next Potential Pandemic – Avian Influenza (H5N1) The World Health Organization (who) has been monitoring the new potential pandemic threat to humans from the avian flu, officially influenza A (h5n1) virus z strain, putting much effort into increasing global vigilance. The who reported that at the end of 2007 there had been 335 confirmed cases of human avian flu and 206 deaths in several countries (Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq, Lao People’s Democratic Republic, Nigeria, Thailand, Turkey, and Vietnam). At a conference in Vietnam dealing with avian influenza in March 2005, the who Western Pacific regional director, Shigeru Omi, stated, “The world is in the gravest possible danger of a global pandemic.” who officials have voiced their concerns repeatedly that an animal-to-human jump of a virulent flu could occur, and the h5n1 strain is one of the most likely candidates. If this virus adapted to humans it could be a frightening prospect. The mortality rate for bird-to-human transmissions is 61.49 per cent (World Health Organization, 2006b).

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who officials compared the potential of h5n1 to sars, the most recent global outbreak that many would be familiar with, as a way to frame the issue of surveillance and preparedness. Bird-to-human mortality rates are significantly higher than sars, and if the human version of the h5n1 strain mimicked its bird counterpart it would be nearly impossible to contain; it could result in mortality numbers that would be orders of magnitude greater than what the world experienced with sars. The projected numbers for the avian flu h5n1 strain are nothing less than nightmarish, with experts predicting that anywhere between 2 and 50 million could die from the human version of h5n1. The focus on h5n1 has deflected some concern from routinely cycling h1–h3 human influenza viruses that also continue to worry who officials. Whether a new avian flu or an already-established human flu strain creates the next pandemic, the who stated that the world is “now overdue.” Analysis of past epidemics shows that they have occurred every twenty to thirty years in recent history, and it has been nearly forty years since the last major influenza epidemic. Several newspapers quoted officials from the who as repeatedly stating that the next global avian flu pandemic is imminent (bbc News, 2005). Infectious disease experts and researchers share the who’s concerns (Trampuz et al., 2004). Experts predict that influenza’s next occurrence as a pandemic is a case of when, not if, due to the low but ongoing probability of viral reassortment events resulting from close human proximity to animals. The goal of the who has been to raise awareness and preparedness for pandemics in all countries. The only way to mitigate a pandemic is to increase planning and preparedness for the next global outbreak. Knowing that this event will happen some time in the near future will hopefully allow government officials the time to prepare, build capacity, improve risk communication, and educate individuals for appropriate responses to avoid widespread panic, fear, rumours, and social disruption. The who has been watchful of recent outbreaks of avian influenza due to concerns of a jump from birds to humans (a zoonotic event) that would lead to a widespread infection among humans. With high rates of transmission into a global human population without immunity, the avian influenza could have mortality rates similar to that found when it infects birds (as high as 90 per cent or more). To date, avian influenza viral infections in humans,

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monitored since the mid-1990s, have not resulted in sustained human-to-human transmissibility. Monitoring and careful surveillance for new human infections and person-to-person transmission is important since the viral strains can reassort, drift, and shift; the ability to change rapidly given the proper conditions can result in a literal jump between hosts, propagating human-to-human transmission and a new pandemic. Influenza viruses that infect birds are genetically different from influenza viruses that infect people. Avian influenza (ai) viruses can be classified as two different types, being either low pathogenic (lp) or highly pathogenic (hp) forms based on the severity of the illness they cause in infected birds. Among birds, the effects of low pathogenic viruses are usually very minor, resulting in ruffled feathers or reduced egg production. Highly pathogenic forms cause a much more severe disease state including respiratory distress, and close to 100 per cent mortality in susceptible species. Avian influenza in some domestic bird species is so aggressive that it results in death the same day symptoms appear. Birds that are infected with avian influenza viruses shed virus in saliva, nasal secretions, and feces; the disease spreads when susceptible birds come into contact with these contaminated excretions in the environment. Usually, due to their genetic differences, avian influenza a lp and hp viruses do not infect humans, or if humans are infected it is extremely difficult for the avian influenza to be transmitted between humans.2 Despite this low probability of human infection, several instances and minor outbreaks of avian influenza have been recorded since 1997. The known cases of avian influenza infection in humans have been the result of direct contact with infected poultry or through contact with virus that has been shed into the environment, contaminating objects, soil, and water. Avian influenza and the coronavirus that causes sa rs share many common features as infectious contagions, and induce similar symptoms. They both arose in Asia and originated from animal viruses. Both possess the potential to become pandemic due to the rapid dissemination that can occur through the relative ease and availability of transcontinental transportation (Lee and Krilov, 2005). Bird flu can cause a range of symptoms in humans. Some patients have recorded fever, cough, sore throat, and muscle aches. Avian flu also routinely causes eye infections, pneumonia, acute respiratory

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distress, and other severe and life-threatening complications when the bird virus gains hold in a human host. Influenza viruses also are more contagious and cannot be as readily contained as sars by isolating people who have the infection. Influenza viruses are much more unstable than coronaviruses and have the ability to mutate at a much higher rate, potentially jumping from one animal species to another. Scientists fear the bird flu virus could evolve into a form that could be easily spread between people, resulting in an extremely contagious and lethal disease. The conditions for the change in the virus could occur if someone already infected with a human influenza virus also caught the bird influenza strain at the same time. The two viruses could recombine inside the human host body, producing a new hybrid virus that has never been seen before in humans. As a result of this reassortment event the new virus could readily spread from person to person. The population without immunity (never having seen the virus before) will be defenseless against infection and replication of the virus. In rural areas of Asia, the h5n1 viral strain has been targeted as the avian influenza most likely to jump to humans. It mutates at a high rate and is easily spread from farm to farm among domestic poultry through the feces of wild birds. The h5n1 strain has infected a large number of birds, and human deaths by direct contact have already been documented. The virus is relatively hearty, and when released into the environment, where it contaminates surfaces, objects, and water, it can survive for up to four days at 220c (710 f) and more than thirty days at 00c (320f). If frozen, the avian influenza virus can survive indefinitely (msnbc News, 2005). The plasticity of the surface proteins (hemagglutinin and neuraminidase) of the influenza A virus is already well-known, and the ability of these proteins to change over time has resulted in several recorded pandemics in human history. The most severe one was the emergence of a h1n1 strain that resulted in more than 20 million deaths during the 1918–19 outbreak. The swine virus-like h1n1 continued to circulate until 1957, and was replaced by the h2n2 subtype. In 1968 the h2n2 was supplanted by another new strain that had appeared, h3n2. The h1n1 strain reappeared in 1977 and it co-circulated with h3n2 in the human population rather than replacing the previous strain. The epidemic of influenza A (h5n1) virus in birds throughout several Asian countries received worldwide attention during the 1990s. In 1997, influenza A virus subtype

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h5n1, which previously had been confined to avian species, was isolated for the first time from a human.

avian influenza prevalence and activity in wild bird populations Research on wild ducks in Canada from 1976 to 1989 revealed that 20 per cent of young birds contract influenza virus infections during congregation prior to migration. Even though the birds are infected they do not show any symptoms of infection. Multiple subtypes of influenza virus exist in bird populations and are enzootic (Hinshaw et al., 1980). Studies on wild ducks in Canada and research in other countries have determined that thirteen of the fourteen hemagglutinin subtypes and all the nine known neuraminidase subtypes of influenza viruses occur in wild ducks. The h13 subtype is the only exception; it has been isolated from shorebirds and gulls only. Wild duck populations act as influenza virus reservoirs. The virus replicates in the cells lining their intestinal tracts and is then excreted in high concentrations in bird droppings. Avian influenza viruses have been isolated from freshly deposited fecal material and from lake water. The shedding of high amounts of virus, to the degree that it is detectable in unconcentrated lake water, indicates that the virus has evolved a very efficient way to transmit itself among waterfowl. The infection of avian influenza in ducks does not produce any symptoms and may be the result of virus adaptation to this host over many centuries; the wild duck population as reservoir ensures the continuation of the virus. While infections in birds by most strains of influenza virus appear to be completely asymptomatic, there have been a few strains documented that produce systemic infection accompanied by central nervous system involvement, with death occurring within one week. The h5 and h7 subtypes, such as a/fpv/dutch/27 (h7n7) and a/Chicken/Pennsylvania/1370/83 (h5n2) are known to result in symptoms and death in aquatic birds. Studies have established that there is a vast reservoir of different influenza A viruses present in aquatic birds. In the early 1970s, surveillance of birds from California during an outbreak of Newcastle disease in poultry confirmed the presence of many nonpathogenic influenza A viruses (Slemons et al., 1974). Subsequently, influenza

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viruses were isolated from wild birds, captive caged birds, and domestic ducks, chickens, and turkeys, leading to the realization that nonpathogenic avian influenza viruses are ubiquitous, particularly in aquatic birds (Alexander, 1986). Avian influenza is so well adapted to bird hosts that all of the different subtypes of influenza A viruses (h1 to h14 and n1 to n9) are perpetuated in migratory waterfowl worldwide (Hinshaw et al., 1980). A variety of h and n subtypes have been isolated from wild birds from Russia (Lvov, 1987), southern China (Shortridge and Stuart-Harris, 1982), western Europe (Alexander, 1986), and Australia (Downie and Laver, 1973). The commonest h subtypes that exist in ducks are h3 and h6. The main viral subtypes in shorebirds and gulls include h4, h9, h11, and h13, and these are found only in minor amounts in duck populations. The main n subtypes in ducks are n2, n6, and n8, which again are different from the n subtypes commonly found in shorebirds, where n6 and n9 virus subtypes predominate (Hinshaw and Webster, 1982). Phylogenetic analysis shows that the avian influenza viruses in Europe, Asia, and Australia are genetically distinct from those found in North America, likely due to the geographic isolation of birds with distinct physical and temporal migratory patterns that do not overlap (Gorman et al., 1990). Domestic poultry is usually infected with h5 and h7 subtypes and these are highly virulent to the birds, usually causing close to 100 per cent mortality (Hinshaw and Webster, 1982).

h5n1’s potential as the next pandemic There is considerable worry that there is an evolving zoonotic influenza jump occurring with h5n1, even though officials have had this virus under surveillance for only a relatively short period of time. From 2003 to 2008 this virus has killed about 243 people and over 140 million birds have died or have been intentionally killed by culling to prevent the spread (World Health Organization, 2008). The avian influenza has killed relatively few humans but there are two reasons the h5n1 strain is considered to be an impending threat to humans as a potential pandemic. First, the human-to-human transmission rate of the avian virus is unsustained, but the mortality rate for bird-to-human infections of h5n1 is exceptionally high, approximately 63 per cent (World Health Organization, 2008). The

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only other infectious human disease with such an extremely high mortality rate is Ebola and other viral hemorrhagic fevers that have mortality rates of 50 per cent or more. The global mortality rate for sars by comparison was 9.6 per cent. Second, with every transmission of avian influenza to a human host there are fears that the virus could mutate and adapt. The new virus would sweep through a population that has little or no immunity to this new adapted virus. Vietnam recorded the first human-to-human transmission cases for this virulent h5n1 strain in September 2004. Human spread occurred in a family cluster in Kampaeng Phet, Thailand, a community several hours north of Bangkok. Luckily, viral transmission from person to person remained inefficient, but the fear is that with each new human infection, a new avian influenza could jump to humans, with a mutation or recombination event making it more highly transmissible from human to human, with an unchanged mortality rate. The h5n1 avian flu strain currently circulating in birds is highly pathogenic to a whole range of animals including humans. It causes severe disease and death and affects a whole range of organs, not just the lungs. The current avian flu strain does not transmit well from person to person, but statistical modeling of avian influenza transmission that hypothetically assumed a mutation that would allow it to infect and be transmitted from human to human at a higher rate was performed as a what-if scenario. The girl with avian influenza who died on 2 September 2004 was used as an index case or patient zero in the mathematical simulation. In the twenty-one days until public health officials arrived on the scene there would, by theoretical estimation, have been another 600 individuals infected. Ten days after that there would have been 6,000 people infected. For comparison, the influenza outbreak of 1918 was estimated to have killed more than 30 million people, but the mortality rate was much lower, between 1–10 per cent of those infected (depending on location). Avian influenza, with a mortality rate that could be as high as 60 per cent (based on bird-to-human transmission), has the potential to devastate modern cities like Tokyo (estimated population about 35 million), Mexico City (estimated population of about 19 million), and New York (estimated population about 18 million). Cities with extremely high population densities would have rapid transmission from person to person in communal transit and shared common spaces, and environmental

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transmission of the contagion would be unavoidable. There are over twenty-five major city regions in the world where the population is over eight million people, and initial containment of a highly pathogenic strain would likely fail in most of these regions. Rapid, widespread human-to-human transmission would quickly overwhelm hospital capacity, increasing the severity of the pandemic (Geohive, 2003). The avian influenza has medical doctors concerned for other reasons as well. The virus is gaining resistance to most classes of antiviral drugs and seems to be increasing in its pathenogenicity in mammals such as ferrets that have an infectious disease response similar to that of humans. The increasing number of human cases shows that the virus is continually finding opportunities to infect and potentially adapt to a new host. In chickens, farmers have watched the avian influenza strain become more potent. Previous outbreaks killed 10 per cent of their bird stocks, but now close to 90 per cent succumb to the h5n1 avian influenza strain as it has adapted to poultry. Moreover, ducks are believed to be carriers of the influenza and they can shed the virus for up to seventeen days through their stools before they get sick. All of these conditions occurring and reoccurring through time raise the probability of avian influenza mutating as it is passes between different species. Much like a lottery jackpot, we could eventually see the correct combination for a successful zoonotic jump of h5n1, making it highly infectious in human-to-human transmission. The international community was very fortunate with sars. When people became infected with sars and were at the stage where they could pass on the virus, they were already showing symptoms of fever, myalgia, and coughing. Those with active infections could be screened at airports with temperature scanners or detected and isolated by doctors at hospitals. However, with avian influenza or other influenzas, individuals can be infectious well before showing any symptoms of illness. Some countries have taken notice of the increased threat posed by avian influenza. In early 2005, the British government announced that it would buy 14.6 million courses of oseltamivir, the only antiviral drug effective against h5n1, and in Thailand the government has set aside reserve funds to fight the virus. The worst-case scenario would be if the avian h5n1 strain did jump to humans and remained uncontained; it would likely travel

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around the world within a few days through international air travel, seeding outbreaks in multiple countries before symptoms developed in those who were infected. Many would probably succumb before public healthcare systems responded with attempted quarantines, contact tracing, and antiviral treatments. Unlike with sars, interventions of quarantine and epidemiological tracing would not be very effective in curtailing avian influenza’s spread. On a best-case scenario, the virus might never adapt well to humans and never become the threat it is perceived to be by who officials (The Age News, 2005).

case study: avian flu in thailand and vietnam 2004 (h5n1) Influenza A (h5n1) is endemic in poultry across much of Southeast Asia, but limited information exists on the effects in humans due to the relatively few cases. Since 1997, avian outbreaks with some subtypes of influenza A viruses have been reported to cause mostly mild infection in humans. Previous outbreaks in Hong Kong of h9n2 caused two mild clinical cases of infection, and a large outbreak of conjunctivitis was caused by h7n7 in the Netherlands (Peiris et al., 1999; Fouchier et al., 2004). The wave of avian flu in Vietnam (h5n1 strain) was officially declared to have occurred for the first time in bird populations on 23 December 2003. The outbreak was first reported in South Vietnam, and within six weeks, fifty-seven of the sixty-four provinces were affected. Terrestrial birds (chickens and quails) and aquatic birds (ducks and Muscovy ducks), particularly adult birds, developed clinical disease and suffered high rates of death and morbidity. The high virulence of the h5n1 virus was characterized by acute and severe infection in humans, and was so virulent to poultry that the birds that became infected died even before developing typical avian influenza lesions. It was only when the avian influenza was confirmed in people and publicized in the media that farmers were willing to cull their chickens (Nguyen, 2005). In early 2004, outbreaks of highly pathogenic avian influenza A (h5n1) virus infection were reported to have caused lethal illness among poultry in at least eight Asian countries – Cambodia, Indonesia, Japan, Laos, South Korea, China, Vietnam, and Thailand

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(World Health Organization, 2004b). The simultaneous occurrence of h5n1 outbreaks across eastern Asia and the presence of h5n1 viruses in dead migratory birds suggest that wild bird populations are responsible for the widespread viral dissemination. The first human cases were confirmed in Thailand in January 2004, and the clinical features have been reported (Center for Disease Control and Prevention, 2004; Tran et al., 2004). A case in Thailand indicated the probable transmission of the virus from a girl who had the infection to her mother, who also died. The girl’s aunt, who was also infected, survived the virus. In another infection, two sisters died in Vietnam after possibly contracting bird flu from their brother, who had died from an unidentified respiratory illness. In another case, reported in Hong Kong in 1997, a doctor possibly caught the disease from a patient infected with the h5n1 virus – but the viral route of transmission was never conclusively proven. A nationwide surveillance effort to detect influenza A (h5n1) was carried out by the Thai Ministry of Public Health in December 2003 after outbreaks of sudden poultry death were reported in the central region of that country. Patients with confirmed cases of h5n1 were defined as individuals who had laboratory evidence of influenza A (h5n1) infection. Respiratory specimens (including nasopharyngeal aspirates, nasopharyngeal swabs, nasal swabs, and throat swabs) were tested to detect the presence of influenza A and B viral genetic material (by the rt-pcr technique) and a tissue culture cell line was infected (injected onto a canine kidney cell monolayer) for viral isolation. Specimens were considered positive for avian influenza virus if the viral culture was positive by pcr and was confirmed by monoclonal antibody testing. The onset of illness of the first confirmed case was 3 January 2004. From 1 January to 31 March 2004, a total of 610 cases were reported in Thailand by the nationwide surveillance program. After clinical, epidemiological, and laboratory review, twelve confirmed and twenty-one suspected cases were identified. Of the twelve confirmed cases, seven were in children under fourteen years of age, and five were in adults. Fever was often the first symptom, and difficulties breathing often occurred at about five days after the influenza began (within a range of one to sixteen days). All patients had symptoms of fever, cough, and difficulty breathing, and almost half had muscle soreness accompanied by diarrhea. As the infection

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progressed, organ failure or dysfunction was common, including respiratory failure in nine patients (75 per cent), cardiac failure in five (42 per cent), and renal dysfunction in four (33 per cent). Acute respiratory distress syndrome (ards) was associated with fatal outcomes. All twelve patients had abnormal chest radiographs a median of seven days after onset of fever (within a range of three to seventeen days). Two patients had interstitial infiltration, and ten had patchy lobar infiltrates in a variety of patterns (single lobe, multiple lobes, unilateral, or bilateral distributions). The radiographic pattern progressed to diffuse bilateral ground-glass appearance, with clinical features compatible with ards, in all eight patients who died and in one patient who survived. Pathological tissues from the lungs of three patients showed diffuse alveolar damage with hyaline membrane formation (a condition that impedes the ability to breathe and results in damage to the alveoli), reactive fibroblasts (pathological scarring), and areas of hemorrhage consistent with the effects of ards. Treatment for all patients included broad-spectrum antimicrobial drugs; eight patients were treated with corticosteroid drugs, including two patients who survived and six patients who died. Seven patients were treated with the neuraminidase inhibitor oseltamivir at various stages of illness. In those who survived, treatment tended to have been started earlier. All twelve confirmed patients resided in a village with abnormal chicken deaths. Nine lived in a house where the backyard chickens died unexpectedly. Direct contact with dead chickens was reported in eight patients, with a median of four days between the last exposure and the onset of symptoms (range two to eight days). After the official announcement of the first human case on 23 January, a national public education campaign was carried out through the news media and thousands of village health volunteers. Villagers, especially children, were informed to avoid exposure to ill poultry. The country undertook a mass cull in affected areas, according to the Department of Livestock, with 40 million chickens in 160 affected villages in forty-one provinces slaughtering birds over a four-month period (from January to May 2004). Within two months of widespread poultry culling, quarantine measures and public education, the number of potential cases reported decreased dramatically and confirmed human cases ended. In Thailand, one community survey found that up to 61 per cent of rural residents in some areas had regular contact with backyard birds. The human cases observed in hospitals likely represent the

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end result of hundreds of thousands of potential exposures. Approximately 30 per cent of the world’s population lives in the eight countries in Asia that reported h5n1 influenza A strain outbreaks in 2004. Due to the low number of distinctive features of human disease caused by avian influenza A and limited specific diagnostic tests for h5 in Thailand, the number of reported human cases have been low. Human infections with highly pathogenic avian influenza h5n1 may be easily missed among the incidence of regular pneumonia that occurs in rural Asia, where the capacity to make specific diagnoses is limited (Chotpitayasunondh et al., 2005). Underreporting is probably common, in part because the distinguishing features of pneumonia and influenza A (h5n1) are not widely appreciated or known, leading to undetected cases of influenza in humans (Chan, 2002). Of the thirty-four cases of h5n1 officially reported to the who in 2004, a higher percentage of patients (68 per cent) died compared to previous cases in Hong Kong in 1997 (33 per cent of those identified with avian influenza). Research evidence shows that the h5n1 virus had evolved to a more virulent form since 1997, with a different antigenic structure, internal gene mapping, and an increased host range (Horimoto et al., 2004; Sims et al., 2003ab; Sturm-Ramirez et al., 2004; Perkins and Swayne, 2002). The genetic changes are a factor in the persistence of h5n1 viruses in avian populations. Since the 1997 outbreak, Hong Kong has experienced a number of waves of h5n1 viruses, despite stringent control measures, including the culling of all poultry in the region, regulations at live poultry markets, and monthly cleaning days where all markets are emptied and cleaned with disinfectant (Guan et al., 2004). Similarly, h5n1 outbreaks in poultry have also recurred in all other Asian countries despite similar intensive control measures. Researchers worry most about the gradual mutational changes of h5n1, but they are also concerned about the potential to reassort with existing human influenza viruses to produce a strain with high virulence and efficient transmissibility in humans. Avian-to-human influenza in Thailand raises concerns about the virus’s ability to do this, and the likelihood of it happening during the months from June to August, when human influenza usually peaks, providing conditions favourable for reassortment of human with avian viruses. The continual evolution of h5n1 viruses provides the opportunity for the virus to adopt a form more easily transmitted from person to person. So far, efficient human-to-human transmission has

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not occurred with h5n1 strains (Tran et al., 2004). The virus has proven difficult to eradicate, and the virus remains in wild birds that act as a reservoir (Chen et al., 2004). Future outbreaks of avian influenza will occur and early detection of these strains with a determination of the human-to-human transmissibility is important for implementing control measures (Chotpitayasunondh et al., 2005).

the spread and surveillance of avian influenza The total numbers of avian influenza cases and deaths in birds and humans have continued to rise since 2003. Table 12.2 tracks the cumulative increase of bird-to-human avian flu cases and human deaths shown at six-month intervals from 2004 to 2007. The monitoring of the spread of avian flu in birds by country shows its expansion from Asia into Europe and Africa. Recorded human cases also show a similar expansion, with the number of countries involved also increasing during this time period. Examining the individual countries for human avian influenza reveals that areas that first recorded human cases (Vietnam and Thailand) have the highest number of human cases due to the persistence of the virus transmitted between birds. As the disease has spread through wild bird populations in Asia and into Europe, other countries are recording more human cases. The case fatality for different countries ranges from 0 to 100 per cent (due to small numbers of cases for some countries), with an average case fatality rate per country of 63.4 per cent. The list of affected countries with numbers of human cases, deaths and fatality rates from bird-tohuman avian influenza is shown in table 12.3. Despite the increasing numbers of human cases and deaths, all of the recorded deaths shown in table 12.3 resulted from bird-to-human transmission.

surviving h5n1 avian influenza One patient who contracted h5n1 and survived has described his personal ordeal with the avian flu. Nguyen Thanh Hung, a fortytwo-year-old construction materials salesman, and his brother both contracted the influenza; his brother, Nguyen Hung Viet, died from his illness. Nguyen still does not know how they contracted h5n1 but speculated that the influenza virus came from the last meal they

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Table 12.2 Total cumulative number of avian influenza cases and deaths from bird-to-human transmission at various times (January 2004 to December 2007). Countries reporting confirmed cases and human deaths from avian influenza are listed (Data from the World Health Organization, 2006b) Cases (human)

Deaths (human)

Jan.–June 2004 July–Dec. 2004 Jan.–June 2005 July–Dec. 2005 Jan.–June 2006

35 44 108 142 228

24 32 54 76 130

July–Dec. 2006

261

157

Jan.–June 2007

318

192

July–Dec. 2007

335

206

Time

Affected countries Thailand, Vietnam Thailand, Vietnam Thailand, Vietnam, Cambodia Cambodia, China, Indonesia, Thailand, Vietnam Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq, Turkey Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq, Thailand, Turkey Cambodia, China, Egypt, Indonesia, Lao People’s Democratic Republic, Nigeria, Vietnam Cambodia, China, Egypt, Indonesia, Lao People’s Democratic Republic, Nigeria, Vietnam

Table 12.3 Countries with confirmed human cases of h5n1 recorded from January 2003 through December 2007 (Total cases n = 335, total deaths n = 206), (Data from the World Health Organization, 2006b) Country

Human cases

Deaths

Case Fatality Rate (%)*

Azerbaijan Cambodia China Djibouti Egypt Indonesia Iraq Lao People’s Democratic Republic Nigeria Thailand Turkey Vietnam Totals

8 7 25 1 38 113 3 2 1 25 12 100 335

5 7 6 0 15 91 2 2 1 17 4 46 206

62.5 100.0 64.0 0.0 39.5 80.5 66.6 100.0 100.0 68.0 33.3 46.0 61.5

*Note: Average case fatality rate per country is 63.4 %

shared together at a welcome home dinner before getting sick. They had their favourite traditional dish, tiet canh, which is made with chopped, congealed raw duck blood and herbs. Hung remembers that the duck looked healthy so he didn’t have any suspicions that it might be sick with avian influenza. Just one day after the shared meal, the older brother fell sick with a fever, and a week later, on New Year’s Day, when his symptoms continued to worsen, the

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Table 12.4 Cumulative details of various measured parameters of avian influenza from fifty-nine patients from five countries (modified from Beigel et al., 2005) Avian Influenza Measure Median age of patient Age range infected Percentage of males/females infected Time in days from illness onset to hospitalization (median number of days to hospitalization) Time from illness onset to death in days Average number of days until death after infection

Recorded outcome 15.7 years 1 – 60 years 46 씹 / 54 씸 1–8 days (5.75 days) 4–30 13

family finally took him to Hanoi’s Hospital for Tropical Diseases. Unfortunately, due to the holiday, the hospital was running on minimal staffing, and the brother was already very weak; his left lung was badly damaged from the effects of the avian influenza and he couldn’t breathe. Attending staff and Hung, unaware of the possibility of avian flu, didn’t take any preventive measures while taking care of him; Hung spent days and nights next to his brother’s bed without a mask. After ten days in the hospital Hung’s brother died (10 January 2005) and later that same day, Hung rapidly developed a bad fever and began having difficulty breathing. Chest x-rays showed quite a bit of infiltrate and lung tissue damage had occurred. It was only then that he was put into quarantine. His temperature stayed extremely high and two-thirds of one lung was severely affected. Tests on samples for both brothers came back positive for h5n1; Hung recovered and was finally released from the hospital on 28 January 2005, a survivor of h5n1 avian influenza. Due to the timing of the infection, doctors believe that Hung contracted the virus from his brother while looking after him at the hospital, not from the initial shared meal, making this only the second case of suspected human-to-human transmission of bird flu in Vietnam. Hung has been heavily stigmatized after contracting the bird flu and has taken a long leave of absence from his work. Reflecting on his situation, he stated that, “They were only too happy to release me. Not everybody believes that I don’t have the virus anymore and that it is not easy to contract bird flu virus. It is like having a stigma, some people look at you with suspicion and fear. So I think it’s best to avoid having too much contact with other people.” When it comes to his food choices, Hung confirmed that his family

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no longer eats chicken, duck, and poultry in general as a precaution against avian influenza (Pham, 2005). In many cases of bird-to-human avian influenza, the exact clinical details, such as the length of incubation or the time to illness onset, are unknown for many patients. Table 12.4 summarizes the details of avian influenza recorded from fifty-nine patients from Hong Kong, Thailand, Vietnam, China, and Cambodia (Beigel et al., 2005).

other recent avian flu poultry outbreaks Since 1997, avian outbreaks with different subtypes of influenza A viruses have been reported to cause mostly mild or inconsequential infections in humans. For example, two mild clinical cases of h9n2 infection occurred in Hong Kong (Chan, 2002). Outbreaks of other strains were reported elsewhere, including an outbreak of h7 and h9 in Karachi, Pakistan in November 2003, without any noted human infections. In Canada a number of h7 outbreaks were confirmed in February 2004 with the highly pathogenic virus, h7n3, reported on several farms in the Fraser Valley, British Columbia, requiring a massive cull (ctv News, 2004b). In the United States, Delaware had an h7 outbreak first on a farm that provides chickens to the live bird market in New York City. Other h7 reports appeared days later on another farm several miles away and were reported from several rural live bird markets in northern New Jersey. The affected poultry in Delaware were culled and quarantine measures were instituted as a preventative measure. The Delaware h7n2 virus was significantly different from the h7n7 virus that caused an avian influenza outbreak in the Netherlands in 2003 that resulted in human infections. A highly pathogenic h5n2 was also reported from a live bird market in Texas in 2004, the first such case in the United States in twenty years. The Texas Health Commission tested a flock of chickens and found them positive for the h5n2 virus. The farm was immediately quarantined and the birds were culled. The Health Commission said the virus was unlikely to spread and posed little threat to human health with no human infections noted (cbc News, 2004d).

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preparedness and prevention – what can be done to avoid zoonotic jumps? Given the fact that people, pigs, and aquatic birds and their interactions are the principal variables associated with the interspecies transfer of influenza virus and the emergence of new human pandemic strains due to reassortment within these hosts, it may be possible to influence and manage the occurrence of human pandemics of influenza. The principles applied to preventing outbreaks of influenza in domestic animals should be equally applicable to management of disease at the human-animal interface. We know that pandemic strains of human influenza emerge rarely, given the extensive interaction between humans and animals. The low probability is offset by the magnitude of interaction between humans and animals, which is a function of the density of both populations and points of interaction. Available information shows that interspecies transmission of influenza viruses occurs at a rate as high as 10 per cent. The risk is greatest to individuals with occupational exposure. Those working with pigs developed antibodies to swine influenza virus, showing they had been exposed and infected by the virus, perhaps repeatedly (Schnurrenberger et al., 1970). Luckily, the majority of zoonotic jumps by influenza viruses to humans from animals (either pigs or birds) are dead-end transfers, in that they do not propagate easily from human to human. If there is an epicentre for pandemic influenza, and if there is a detectable frequency of transfer between people, pigs, and ducks, and if we understand the ecological and agricultural features involved in the transfer, pandemics may be preventable. If pigs and birds are the major mixing vessels for influenza viruses, changes in the agricultural practices that separate pigs from people and pigs from ducks could conceivably reduce the probability of a future pandemic (Webster et al., 1992). There are a number of steps that can be taken to reduce the likelihood of a pandemic. Prevention measures undertaken in Thailand and Vietnam included: pre-emptive culling, compensation for livestock losses by the government to encourage compliance with cull orders, routine disinfection, farm standards and improved biosecurity, movement control (of birds, equipment, and people), traceability, vaccination, surveillance and testing, and standard slaughterhouse sanitary practices. Experts recommend that improved biosecurity is needed for commercial bird operations

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(Songserm et al., 2005). For humans, influenza drugs do exist that may be used both to prevent people from catching bird flu and to treat those who have it. The h5n1 virus appears to be resistant to two older generic flu drugs, Amantadine and Rimantadine, but newer drugs such as Tamiflu and Relenza are expected to be effective. Currently there is no specific human h5n1 vaccine, although scientists are working to develop one (msnbc News, 2005).

conclusions In the last century, the sudden emergence of new transmissible influenza strains in humans by antigenic shift occurred on four separate occasions: 1918 (h1n1), 1957 (h2n2), 1968 (h3n2), and 1977 (h1n1). Each time the result was human-to-human transmission great enough to be considered a pandemic. Analysis of viral isolates demonstrated that strains that appeared were the result of a major gene reassortment event between avian and human viruses, allowing humans to act as a permissive host for the new strain (Capua and Alexander, 2002). A new flu pandemic, which many experts believe is inevitable, will most likely be the result of an avian flu that recombines with an animal or human virus. The amount of avian flu circulating in bird populations that have contact with humans sets up the probability of a human acting as a reassortment vessel. By the beginning of 2006, there were 170 confirmed cases of avian flu and ninety-two deaths (a mortality rate of 54.1 per cent of those infected from birds) in seven countries (see tables 12.2 and 12.3). The result could have a devastating impact across the world in the form of a new, highly pathogenic human- transmissible influenza, if it reassorts or adapts to humans. The who has stated that the simultaneous occurrence in several countries of this highly pathogenic h5n1 influenza strain in domestic poultry is a historically unprecedented event, and a cause for great concern. In bird populations, the disease is highly contagious, rapidly spread, has high mortality, and spreads between farms due to the movement of people and equipment. Compounding the problem for commercial bird farms are asymptomatic wild migratory waterfowl, which can spread large amounts of virus as they migrate, and infect domestic poultry flocks or smaller free-range domestic poultry. The potential for future spread to other countries around the world is very high, based on migratory flight patterns of wild birds.

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The outbreak of avian influenza A (h7n7) in the Netherlands (Koopmans et al., 2004) and the recent unprecedented expansion of avian influenza A (h5n1) in Asia that has caused numerous human deaths, have heightened concern about a future pandemic due to the probability of viral reassortment in a human population. A review of outbreak and control efforts in the Netherlands and Thailand showed that important lessons were learned for improving preparedness. There are surveillance systems in place to signal and control both animal diseases and human diseases, but they are still poorly integrated. Surveillance for an emerging zoonotic pandemic requires a higher level of coordination between the two. In the Netherlands, the people infected came from a wide geographic region, and included foreign poultry workers. While the movement of animals was restricted, these people were out of the reach of the public health authorities while infectious and shedding the virus. The who acts as the world’s eyes and ears for recent avian influenza activity in areas where zoonotic jumps have the potential to occur. Another lesson learned from the recent outbreaks of different avian influenza types including h5n1 (Asia and Europe), h7n3 (Canada)3 and h7n7 (the Netherlands)4 showed that not only pigs but also humans are acting as mixing vessels for the next pandemic influenza virus (Webby and Webster, 2003). The viruses primarily infect avian species, but antibodies to the highly pathogenic avian influenza strain h7n7 were found in pigs on five farms in the Gelderland Valley, which also had infected poultry (Koopmans et al., 2004). Although the disease in humans is more severe for h5n1, the different avian influenza outbreaks illustrate that crossing the species barrier is less rare than previously recognized, that avian influenza virus adaptation occurs rapidly, and that if such jumps between species occur, human behaviour, in the broad sense, may accelerate dissemination (Li et al., 2004; Bosman et al., 2005). For avian influenza on poultry farms, the use of culling is one of the few risk management options that can greatly reduce the spread of the infection to healthy birds, and lower the probability of a reassortment event that could unleash a new, highly virulent human-to-human avian influenza (Guan et al., 1999; Hoffmann et al., 2000; Xu et al., 1999). Poultry farms can safeguard themselves by following strict controls for the movement of animals, people, and equipment between farms to reduce the spread of avian influenza viral particles. Asian culture and farm practices, with close

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association of humans and animals in live animal markets, still provides conditions that allow for the possibility of avian influenza reassortment, despite proactive efforts at reducing the probability by mass culling and market cleanup days (Li et al., 2004). The occurrence of different avian influenza strains that have infected human beings, and the knowledge that new zoonotic diseases like sars can spread rapidly around the world, are reminders that we are very vulnerable to contagions that jump from animals to humans. The contrast between recent cases of h5n1 infection, associated with high mortality, and the typically mild, limited human infections from avian h7n7 and h7n3 influenzas shows that there is much more research needed in several areas (molecular biology, epidemiology, disease modeling, and virology) to characterize the variables of transmission and pathogenicity of zoonotic jumps from animals to humans. It also underscores the need for continuing international surveillance for pandemic influenza events (Nicholson et al., 2003). Ongoing improvements and planning for the next h1–h3 pandemic predicted by experts provides capacity should the h5n1 strain adapt to humans. As a best-case scenario, the avian flu (h5n1) or other avian flu strains (h7n3 and h7n7) may never adapt to human populations, remaining a bird pandemic that our improved surveillance for human infectious disease can track in animal populations.

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Emergency Preparedness for Future Pandemics: Lessons from SARS Only those on the inside understood what was happening. My family, friends, and colleagues at other hospitals could not appreciate the magnitude and significance of these events — of the twilight zone we existed in. Dr Rick Penciner, North York General Hospital (Penciner, 2003)

Most experts agree that another pandemic is likely to occur in the near future, with some estimates placing its occurrence as a strong possibility within the next decade. Some experts believe the next pandemic will be a recycling of a modified version of a previous influenza A strain – either h1, h2, or h3. These predictions are based on previously recorded epidemiology and viral genetic data collected throughout the twentieth century. The influenza A virus strains can change slowly over time by acquiring mutations cumulatively, or rapidly with radical changes from a mass reassortment event. Major change events occur only three or four times each century. Both methods result in an altered viral strain with potentially wide infectivity. Most people who encounter this new strain have no immune protection against it, so it has a higher-than-average transmission rate compared to previously established viral strains. The various strains of the influenza virus usually cause severe complications in humans who cannot mount an effective immune response, resulting in outcomes like pneumonia, acute respiratory distress syndrome (ards), and death in otherwise healthy individuals. In this century we have already been challenged by a new disease stemming from an unexpected viral source, as a coronavirus made the zoonotic jump between birds and humans, causing sars in

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2003. Because of the low transmission rate between individuals (except during high-risk procedures that aerosolized viral particles) and a long incubation time, the pandemic’s spread was greatly curtailed by the use of isolation interventions. Increased surveillance and effective containment of infected individuals by quarantine stopped the spread of sars. Learning the value of early awareness, detection, and planning for pandemics from the sars outbreak, several countries and organizations have turned their attention toward future preparedness and planning strategies. A second unexpected viral strain, the avian influenza (h5n1), has also emerged as a prominent, potentially infectious disease threat that has not yet adapted to humans. Because of the ongoing spread of this highly pathogenic bird flu throughout Asia and Europe, many bird culls have been carried out. The mass killing of commercial bird flocks is an attempt to reduce the probability of the pathogenic avian flu strain mixing with other viruses and undergoing an antigenic shift. Despite its inability to move between human hosts, the h5n1 avian flu has revealed its deadliness, killing over half the people who have become infected. After the global containment of sars, several scientists from the World Health Organization (who) tried to increase awareness and urged improved readiness for future pandemics. In press conferences, who officials stated that the world is severely under-prepared to react in an organized and coherent way against virulent contagions. The message to improve planning is directed at specific efforts to increase surveillance and ensure the supply of key medicines to developing countries. Director-General Jong Wook Lee stated, “We know another pandemic is inevitable. It is coming.” Due to the enormous movement of people and goods traded between countries, preparedness for pandemics is even more important. Unfortunately, the poor response to sars by some countries revealed that safeguards for infectious disease monitoring and reporting are lacking. Before the sars outbreak, preparedness, communication between countries, drug stockpiles, vaccines, trained healthcare workers, and hospital capacity all were insufficient, but the situation is improving with time (bbc News Europe, 2004). The who isn’t the only organization that has attempted to raise awareness of the next impending pandemic. A number of infectious disease experts have sounded the alarm about the next pandemic by asking government officials to take precautions. After the sars

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outbreak, international influenza experts Richard Webby and Robert Webster of St. Jude Children’s Research Hospital in Memphis, Tennessee, said, “The world will be in deep trouble if the impending influenza pandemic strikes this week, this month, or even this year” (Manning, 2003). Dr Alan Hay, the director of the World Influenza Centre in London, conveyed a similar message. “It really is inevitable. We don’t know when it will arrive, but we are anticipating it.” Professor Oxford, another leading expert, explained that, “The who has been desperately trying to get countries to take this seriously. It has 192 members but only twelve have done anything about it. People really need to think about what happens when this virus arrives – who is going to do what; what vaccines are available; who is going to distribute them, and who is going to bury people when they die.” With sars, several factors facilitated the viral mutation and species jump. Southern China is a densely populated area where people and farm animals live close together. Birds are routinely handled and sold at live animal markets. The coronavirus probably had many opportunities to jump between species before it mutated into a more dangerous version that was able to move from human host to human host. Compounding this species jump is our modern way of living, with global air travel that can rapidly move people and new viruses to every continent within days. Modern airports provide an ideal setting for new viral strains to spread, with a concentration of international travellers in close contact, allowing for multiple transmission events to multiple countries. Those who have been unknowingly infected arrive at their destination, usually major airports in crowded urban centers. Within a few days the infected go on to develop symptoms and spread the virus to new hosts they contact during their window in infectivity. sars, even though it was not easily transmitted between individuals, proved how these converging causes of global air travel and dense urban areas promote viral propagation. Many of the recorded sars cases occurred after air travel in high-traffic common areas like hotel lobbies, elevators, airplanes, hospital waiting areas, and apartment building complexes. The recent spread of sars is a good example of how viruses change by natural selection to exploit a new host source to propagate themselves, namely crossing over into humans. Unfortunately for humans, new viruses that jump the species barrier can result in harmful human diseases. A previous example of a zoonotic jump

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between species is hiv-aids, which is thought to have originated with human ingestion of infected gorilla meat or from a human being bitten by an infected primate. Monkey pox has also opportunistically infected humans, facilitated by human activity. It existed for decades as a primate disease in Africa before being passed on to residents of the United States recently by Gambian giant rats and prairie dogs sold as exotic pets (Langohr et al., 2004; Ligon, 2004). The coronavirus that causes sars still exists in animal species host reservoirs and little has changed culturally to stop the close association between humans, pigs, birds, and other animals in Asia. The coronavirus still has the opportunity to mutate or to change over time and re-emerge as a human contagion. As viruses pass back and forth between humans and animals, their capacity to create disease also changes over time. While mutations to the genetic material of the virus usually occur at a fixed rate, the mutations that change the viral genetic sequences can have three effects. First, some changes are detrimental to the virus, making them less virulent or non-infective, and these would be selected against in an evolutionary sense. Second, because of amino acid coding redundancy, genetic changes may have no effect on the virus’s proteins. Genetic mutations might be silent or have a neutral effect on its ability to infect humans or other species, and its degree of virulence. Third, changes may be beneficial for the virus, making it highly infective and better able to dock to human cell surface receptors, or more aggressive in its ability to replicate. Changes that provide an advantage would be selected for in an evolutionary sense if the viral changes translate into new hosts, increased propagation, and more infective copies of the virus. The physiology, genetics, population demographics, and immune system memory of the host being infected also account for the effect the virus may have. Continuing cultural, environmental, and economic conditions that provide viruses with continued opportunities to infect humans will also make more sars-like outbreaks likely in the future. “There are places in the world that seem to be a Pandora’s box for certain kinds of infectious disease; the way people live and interact with their environment sets the stage for letting these viruses out of their box,” stated infectious disease expert Lee. The sars coronavirus flourished in the densely populated region of southern China, where people and farm animals live close together. Human behaviours gave the coronavirus its opportunity to jump back and forth

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between animal species before being passed on in a new form to humans. The virus was opportunistic and spread globally because of a convergence of people mixing with animals in live marketplaces, the mixing of people in urban centers, and dissemination by international air travel to other densely populated urban areas (DellaContrada, 2003). This chapter provides context, attempts to determine just how serious the next pandemic could be for Canadians, and provides a framework for responding to the next pandemic at various levels ranging from the individual to the international, based on strategies learned from the recent sars outbreak. There are some details that we do know are inevitable during a pandemic: G

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many people will get sick and some will die because of a new contagion; many who become ill will take time off from work; many will seek hospital care, require medical assessment, or require extended hospital care; many will try to minimize their personal risk by employing altered behaviours (avoidance, self-isolation, and stockpiling of antiviral medications).

A widespread viral infection can be thought of as a slow-moving natural disaster, and the social disruption caused by the next pandemic can be compared to the effects caused by other natural disasters. The scope of the next pandemic’s impact will be widespread, and those managing this risk will need to communicate useful information. During the next pandemic, media coverage will concentrate on increasing numbers of deaths and the impact to area hospitals hardest hit by a new viral strain. Before the next pandemic, individuals will want assurances that if there is a deadly new virus it can be managed effectively by government officials – that drugs are available if needed to protect healthcare workers and vulnerable groups in our society, that the healthcare system has sufficient capacity to deal with the event (and if capacity is exceeded then alternative strategies are available), that vaccines or drugs are distributed, fairly, in a logical manner, and that the decision-making process regarding all related issues (vaccination, quarantine, support, school closures, hospital restrictions) is transparent and communicated by trusted individuals.

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During an outbreak, individuals will seek useful information on how best to react and to protect themselves. The public will want to know exactly what to do to respond appropriately during the chaotic and apprehension-filled time when a pandemic strikes. Moreover, individuals need to know what to do at different points to protect themselves and their families as the pandemic wave moves through the population. Thus, government health officials need to enter into a risk communication dialogue to communicate what they are doing to safeguard the public, and especially the lives of vulnerable groups (children, the elderly, healthcare workers and their families). Experts already concede that containing the next influenza pandemic will be nearly impossible due to what they expect to be its rapid onset and ability to be infective while not showing symptoms. If this is the reality for the next pandemic it means many of the methods of surveillance and responses that we learned from sars, a disease with a lengthy incubation period, will not be as effective. Influenza virus will move rapidly and silently through densely populated urban centers. The use of epidemiological linkages and contact tracing will also be of limited use during the next influenza pandemic. It is imperative for health officials to begin risk communication on this issue with clear inter- and intra-jurisdictional linkages and directives at all levels (individuals, families, hospitals, schools, workplaces, municipalities, provinces, federally, and internationally). Effective communication is paramount for reducing fear, anxiety, and uncertainty during the pandemic. Organizations, community groups, and governments can take many kinds of preventive action to ensure proper responses from individuals during an outbreak. First, the public must have some idea of just how bad the next pandemic could be. This knowledge provides context, and the severity of outcomes can be used to determine what preparedness options are available. The who predicts that the following generic events will occur during the next pandemic: 1) because of the frequency of international travel, the pandemic virus may spread rapidly, leaving little or no time to prepare; 2) vaccines, antiviral agents, and antibiotics to treat secondary infections will be scarce and will be unequally distributed; 3) it will take several months before any vaccine will become available;

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4) medical facilities in many countries will be overwhelmed; 5) widespread illness may result in sudden and potentially significant shortages of personnel to provide essential community services; 6) the effect of influenza on individual communities will be relatively prolonged when compared to other natural disasters, as it is expected that outbreaks will recur; there may be several waves of infection (World Health Organization, 2005).

predicting global mortality: just how bad could the next pandemic be? A Simple Model for Pandemic Severity The level of dread, anxiety, uncertainty, and alteration of behaviours (self-isolation and hoarding) will be equal to the speed of spread of the pandemic outbreak, its severity, and the level of trust people have in those managing it. Mild pandemics that infect many individuals but kill relatively few will be easier to respond to than pandemics where transmission and mortality are high. A high degree of severity and catastrophic potential will increase levels of fear and anxiety. In a worst-case situation, hospitals and healthcare systems overwhelmed by a severe pandemic with high numbers of deaths of patients and healthcare workers will result in greater overall mortality due to the compromised delivery of healthcare. To calculate pandemic mortality under different scenarios, a simple death toll calculation has been used, by inputting different predicted values into the following standard formula: population size × clinical attack rate × case fatality rate = death toll The “clinical attack rate” (or transmission rate) is the number of people in a population who become infected, eventually develop influenza with symptoms of infection, and are able to transmit the infection to others. The “case fatality rate” is the number of infected people who go on to die of the infection without medical intervention. While it is impossible to predict the numbers for clinical attack and case fatality with great accuracy in advance, there are certain facts that can help narrow the range of prediction when

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using this calculation to estimate future pandemic mortality. For example, in any given year, normal influenza typically infects about one in every ten people, meaning the clinical attack rate for yearly influenza is 10 per cent. During a pandemic, the case fatality rate (number of deaths due to infection) will almost certainly be lower in developed countries with greater hospital capacity, drug stockpiles, and well-developed medical facilities, than in developing countries. As viruses mutate into pandemic forms, typically they become more easily transmissible but less deadly, so the zoonotic jump of a contagion from birds to humans of h5n1 is expected to result in a lower case fatality rate than current bird-to-human mortality values. Using the simple calculation above we can determine the number of deaths that would have been expected from the Spanish Flu h1n1 strain during the 1918 epidemic. We know the global population in 1918 was 1.86 billion, and the flu had a transmission rate of 25 per cent, and of those infected 10 per cent died, resulting in a global death toll of 46 million people. 1918 population size (1,860,000,000) × clinical attack rate (25 per cent or 0.25)1 × case fatality rate (10 per cent or 0.10)2 = death toll (estimated 46,500,000) A 1920s calculation for the Spanish flu death toll put it around 21.5 million deaths. Further analysis revised the mortality rate higher, into the range of 24.7–39.3 million deaths. The analysis was repeated yet again by Johnson and Mueller (2002), who estimated that mortality from the Spanish flu was still even higher at nearly 50 million deaths. Evidence tends to support the more recent estimates with the higher death toll figures. It is now acknowledged that worldwide, well over 200 million people were infected (Barry, 2004). Using these values we can also calculate how many people would die of the Spanish flu, h1n1 strain, if it occurred today without medical interventions, adjusting for today’s population. Using the basic calculation, a pandemic with similar characteristics would yield a modern death toll of about 160 million people. 2005 population size (6,477,600,464) × clinical attack rate (25 per cent or 0.25)1 × case fatality rate (10 per cent or 0.10)2 = death toll (estimated 161,940,011)

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In the United States, the Department of Health and Human Services (dhhs) uses slightly different numbers to calculate the global predicted death toll from a future influenza pandemic with h1n1 type mortality at 198 million people: 2005 population size (6.6 billion) × clinical attack rate (15 per cent) × case fatality rate (20 per cent) = death toll (estimated 198 million) This mortality value is similar to that arrived at by Dr Michael Osterholm, director of the Center for Infectious Disease Research and Policy (cidrap) at the University of Minnesota, who estimates a global influenza pandemic death toll at 180 million people: 2005 population size (6.6 billion) × clinical attack rate (25 per cent) × case fatality rate (10.91 per cent) = death toll (estimated 180 million) It must be strongly emphasized that the numbers above, reached by using this simple calculation, are, however, a gross overestimation. The case fatality rate assumes there will be no effective medical intervention, drug stockpiles, or strategies in place, which we know from the degree of planning by several countries not to be true. Many developed and developing countries have gained significant capacity for interventions or are beginning to implement strategies that will reduce the case fatality rate, lowering the resulting pandemic death toll (Hetherington, 2005). In contrast, the case fatality rate for avian flu bird-to-human infections is approximately 50 per cent. Planners have been very careful not to use the estimates for bird-to-human avian flu mortality in their predictions since this is an extreme overestimation of the death rate for a virus not able to circulate between humans. The case fatality rate for previous human influenza pandemics (h1, h2, and h3 strains) was between 0.2 to 2 per cent. More Sophisticated Models of Pandemic Severity More sophisticated calculations use evidence-based methods to create mathematical models that consider more variables, such as medical interventions and survival outcomes, to better estimate the

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effects of the next pandemic. The purpose of mathematical modeling for pandemic flu planning is to describe the different outcomes (death, injury, hospitalizations, and economic impacts) in an attempt to better understand and plan for the event. A model that tries to be predictive of future events uses pre-existing knowledge and data from whatever system is under consideration. The main goal of a model is to construct a simplified or idealized version that considers all the variables to predict what might happen in the future given certain assumptions. The model can then be used to analyze a risk issue in detail by asking what if. Depending on the questions being asked, different assumptions and simplifications can be used to estimate the different aspects of a complicated problem. When modeling the next flu pandemic, there is some data available, collected from previous pandemics, and there is a wide range in the reasonable assumptions. The role of modeling is to map out the range of possible outcomes and to suggest the responses that are of greatest benefit across the range of uncertainty. For pandemic influenza planning responses, two kinds of mathematical models are being used. The first type relies heavily on epidemiological data that consider the transmission of the disease. Knowing the transmission parameters allows for an assessment of the cost-effectiveness of interventions such as quarantine, antiviral drugs, and vaccination. The second model looks at the cost-benefit ratio and mechanics of how countermeasures can be best implemented. Economic modeling has been used to look at the costs of an epidemic (deaths, hospitalizations, outpatients, and numbers of people taking time off work) and its wider effect on the economy of the affected area. The assumptions in the more sophisticated models are based on previous evidence, namely the statistics data available collected from previous pandemics. Meltzer et al. (1999) studied the economics of pandemics to see what the impact of vaccination programs would have on influenza epidemics in the United States. He provided a range of estimates regarding the number of deaths, hospitalizations, outpatients, and the total number who would become ill but not seek medical care. Meltzer realized that mathematically modeling the transmission parameters and numbers of people affected by influenza was a difficult task, so he used a mathematical Monte Carlo probability simulation approach. In Monte Carlo simulations, uncertainty is allowed for by using predefined probability

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distribution curves to describe the range and frequency of probable values of key variables that are usually difficult to predict. In other words, the approach gives a range of probable answers. For accuracy of the resulting answers the model is “bootstrapped” or rerun, usually 1,000 or more times. During successive iterations, the values for each variable are drawn from their distributions. The results from all the iterations are then pooled and descriptive statistics are collected from the data. For example, the mean, median, mode, and upper and lower percentiles can be calculated.3 In the model, the impact of some variables, such as attack rates, cost of vaccine, and numbers of individuals effectively vaccinated, were examined at predetermined intervals over fixed ranges, with values for other variables chosen from predetermined probability distributions. In the Meltzer model, the clinical attack rate is the number of clinical cases of illness reported (e.g. not total numbers of infections) caused by influenza per unit population. Individuals that become infected but show no symptoms or only very mild symptoms, such as a headache or mild nausea, and do not require hospital care, are deemed not to have an economically important case of influenza (although such infections may have important epidemiological consequences in spreading the disease to other individuals). As a result the model may underestimate severity and outcomes. Because the clinical attack rate of a pandemic can not be predicted with any great certainty, Meltzer modeled a range of possible clinical attack rates, from 15 to 35 percent. The number of cases generated by a given attack rate was distributed among the US population first by age and then by high-risk status. Three age groups were chosen: zero to nineteen, twenty to sixty-four, and sixty-five years of age and older, representing two of the main designated influenza-vulnerable groups (the youngest and oldest categories) and one robust group usually less vulnerable to influenza due to strong immune systems. The who gives a conservative estimate of deaths that would occur globally from the next pandemic, in the range of 2 to 7.4 million deaths, based on the Meltzer model. The who death toll estimate for the next pandemic is based on the mild 1957 pandemic values; when estimates are made based on a more virulent virus, with values closer to the 1918 Spanish flu, global mortality values are much higher. However, the 1918 pandemic was considered

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exceptional for its ability to infect widely and its occurrence in three consecutive waves (World Health Organization, 2005).

estimating pandemic mortality rates for canada The impact of the next influenza pandemic is difficult to quantify beforehand but will depend on several factors: how virulent the virus is, how rapidly it spreads from person to person, how effective pre-existing prevention plans are, what preventive measures are available, and the extent to which medicine and healthcare can react to provide countermeasures quickly. Air travel within and between continents will accelerate the speed of disease movement, as was the case with sars. The ease of global travel undermines containment efforts and emergency preparedness plans. The more complex mathematical model has been used to determine what the effects of the next pandemic will be for Canadians (usually focusing on mortality rates), but the calculation is based on previous pandemic data collected in the United States. The assumptions and data used in the modeling have limited predictive value for healthcare systems in other countries. Due to Canada’s high degree of trade and policy integration with the United States and similarities in lifestyles, translating American-derived pandemic models into a Canadian context is possible and it provides good insight into future Canadian pandemic impacts. In addition, unlike the simpler models, the Meltzer model, based on data collected from previous pandemics, reflects the impact of public health and medical interventions that decrease the case fatality rate. The models do not incorporate the reduction in impacts from the most recent preparedness plans, stockpiled antiviral drugs, new vaccines, or other drugs that may be available or can be developed quickly (between contagion waves during the event) and be made available. The lack of incorporation of new capacity in the model means that it overestimates mortality in its worst-case scenario (at the higher range of case transmission and case fatalities). Nevertheless, pandemic impact estimates are useful in showing pandemic and influenza preparedness planners the scope of the crisis relative to that of other known disasters. It allows for preparation and planning efforts that are needed to minimize impacts (Meltzer et al., 1999).

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Statistical modeling for risk assessment (using the Meltzer model) estimates the impact of the next pandemic on Canadians using assumptions of viral transmission rates of 15 per cent and 35 per cent. The model predicts, using these lower and upper boundaries, that between 4.5 million and 10.6 million Canadians could become clinically ill, unable to attend work or other activities for at least half a day. An estimated 2.1 to 5 million Canadians would require outpatient care, and between 34,000 and 138,000 would need admission to hospital for treatment. The model predicts that between 11,000 and 58,000 people could die during an infectious pandemic wave. Many communities that are in close contact would be affected over a short period of time (six to eight weeks), probably simultaneously, as the contagion spreads across the country (phac, 2005). Dr Anne Matlow, director of infection prevention and control at The Hospital for Sick Children in Toronto, estimated a value similar to that arrived at by Meltzer et al. (1999) for a future flu pandemic in Canada, with about 58,000 deaths. According to estimates of experts, anywhere between 10,000 and 80,000 people could perish from the next pandemic in Canada. Dr David Butler-Jones, Canada’s chief public health officer, told the Canadian Press in an interview at the Canadian Public Health Association’s annual meeting that he estimates that 50,000 people could die during the next pandemic. Having so many people sick at the same time would have economic and social impacts. He cautioned that the threat shouldn’t be blown out of proportion, because it might not happen for decades, and the severity of the viral strain, which determines the mortality rate, is unknown (cbc News, 2005f). Differences in opinion between experts over how many Canadians are predicted to perish during the next pandemic should not be seen as conflicting information or uncertainty in expert opinion. It is difficult to predict an exact number without knowledge of the personto-person transmission rate, the case fatality rate, and the overall healthcare response. The fact that we have a range for predicted mortality should empower us as it allows for pre-emptive planning at the appropriate scale and cost. The rapidity with which the outbreak is contained, and the effectiveness of available medical treatments, are important elements that are difficult to measure beforehand. Many mathematical disease model experts point out that sa rs as an epidemic was limited due to its low transmissibility

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and long incubation period. A pandemic of highly virulent influenza with a shorter incubation time and a significantly higher clinical attack rate has the potential to be exponentially worse than sars in dense urban populations, with regard to both mortality and economic disruption. Even the predicted values of between 50,000 and 80,000 deaths would result in some negative effects for Canada. To put this in context, this mortality value is 1,800 times more than the number of Canadians who died during the sars outbreak. Given the similarity between the sars outbreak and a future pandemic, there will be a significant degree of social disruption, extensive media coverage, and social amplification of risk for those countries hardest hit by the next pandemic virus. At higher rates of transmission and fatality, developing countries with limited healthcare resources will also find their ability to deliver healthcare rapidly outstripped by those suffering with influenza. Emergency planners realize that during a rapidly developing pandemic with numerous fatalities there will be widespread panic, fear, hoarding behaviours, self-isolation, and anxiety due to the perception of the catastrophic potential of the unfolding event. As self-isolation in densely populated urban centers is nearly impossible to achieve, the occurrence of a human version of avian flu h5n1 with wide infectivity and high mortality levels will require extensive public trust in those managing the pandemic. Early, ongoing risk communication with clear messages will be needed to give individuals the information they require to respond appropriately. Such communication will prevent the disastrous information void that occurred during the sars outbreak, with the news media capturing communications, acting as the main information source, and highlighting controversial risk factors of uncertainty and catastrophic dread. Individuals should receive information directly from those managing the risk during a time of crisis. Media responses should come from the highest level of experts managing the situation, with information that focuses on practical guidelines. The main fear is that during the next epidemic, healthcare facilities will become overwhelmed with the number of sick, or frontline healthcare workers will become infected, as occurred during the sars outbreak. The decimation of those able to provide healthcare and the resulting strain on the healthcare system will result in reduced services, increasing the overall case fatality rate value. To

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handle the incredible load of people who will be sick, public education will have to be clear about when and, more importantly, when not to go to the hospital. While the deaths of many Canadians over a short period of time will be disastrous during the next pandemic, more alarming will be the resulting panic-induced behaviours that could occur. Millions of people may avoid work for several days in an attempt to keep away from the contagion; thousands believing they are infected (worried but well) will seek medical advice; around 2.5 million people will need some form of medical attention for actual infections; and thousands will need hospitalization. All of these actions will place a huge strain on the healthcare system. It will be nearly impossible to contain human-to-human influenza transmissions in developing countries that have limited medical facilities and drug stockpiles. Meltzer wisely suggests that the focus should not be on predicting mortality numbers; rather, the pandemic predictions should be put to more productive uses, such as building a case for creating surge capacity in hospitals so that the system can cope with the expected numbers of sick and worried patients likely to arrive during a pandemic (News Target, 2005; Glasser et al., 2004).

lessons from sars There were different responses to sars as an emerging epidemic threat at the international, national, provincial, and individual levels. We can learn many valuable lessons from the treatment of previous infectious disease outbreaks like sars and apply them to pandemic preparedness planning. International Responses to SARS The recent sars outbreak was managed in a novel way by the World Health Organization. They connected governments, hospitals, airports, travel centers, healthcare officials, healthcare workers, and researchers in real time using the Internet as a networking resource, so that information on all aspects of sars could be openly shared. The network, called the Global Outbreak Alert and Response Network (goarn), coordinated efforts against sars around the world, providing information on the distribution of the

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virus as reflected by the number of cases; tracked the movement of the virus by listing countries that had recorded new cases; and documented the emerging epidemiology of the disease through time. The who created a network for laboratories that were actively searching for the causative agent at a time when its identity remained unknown, during the early stages of viral dissemination. Data sharing in real time, between thirteen laboratories in ten countries, led to rapid advances in the knowledge base about the sars coronavirus. Information was available through a password-controlled global database of the up-to-date findings of each lab working on the project. The pooling of knowledge and resources allowed researchers to form a network of experts who collectively discovered the agent of infection within a week. This cooperation in turn provided a strong network of information to supplement each country’s battle with the disease. The WHO Global Influenza Preparedness Plan The who’s influenza plan was designed as a guide for nations to build their own influenza preparedness plans, providing guidance and encouragement for international coordination and transparency. The who Global Influenza Preparedness Plan focuses attention on the h5n1 influenza virus but also includes the possibility of several concurrent events with different threat levels in different countries. The plan makes no predictions as to the severity or impact of the disease, but does offer estimates of expected outpatient visits (134 to 233 million), hospital admissions (1.5 to 5.2 million), and mortality (2 to 7.4 million deaths worldwide) (who, 2005a). The who plan advises that all countries develop and update their national influenza preparedness plans with attention to the early events, because that’s when rapid, coordinated global action might significantly delay the spread of a potential pandemic strain of human influenza, or even contain it. The strategies for national planning are divided into five categories: planning and coordination, situation monitoring and assessment, prevention and containment, health system response, and communications (who, 2005b). The who stresses the importance of involving partners who can work together for a coordinated response. Partners include government departments beyond health (such as agriculture), trans-

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port, foreign affairs, the judiciary, other levels of government, hospitals, and the private sector, including industry and nongovernmental organizations (ngos). The who has some guidelines on stockpiling; suggesting that a nonspecific global stockpile be developed and providing guidelines for its use in the interpandemic phase (between pandemics), as well as providing suggestions for coordinating the global stockpile, guiding national plans for rapid deployment of stockpile items, and encouraging nations to reevaluate stockpile plans between pandemic waves.

national responses to s a r s Similar to the second wave of sars in Canada, late recognition of the presence of the virus in the population can result in an escalating outbreak. China had great difficulty establishing epidemiological and transmission-route information about sars. Officials could not make informed decisions as they lacked knowledge of the best containment methods and case fatality and transmission rates. As a result, the disease spread widely while officials denied its existence. Once it was identified, governments actively worked to contain the spread of the contagion. Responses to sars involved press conferences from high-ranking health officials and the release of definitions of the disease, descriptions of modes of transmission, and other information about the virus. Some governments used short educational programs (information spots) on state-sponsored television, instituted handwashing programs widely, distributed information through visibly placed banners and notices posted in prominent places, and encouraged proper healthcare measures. Wall posters were also used to disseminate information by detailing symptoms and other relevant details of sars. The widespread distribution provided needed information to individuals who used the knowledge to cope with outbreaks and obey local protocols (like quarantine) for containment of the disease. As healthcare workers were the group most affected by sars and will be the group most affected during the next pandemic, a federal pandemic preparedness plan has been developed.4 The working document, “The Canadian Pandemic Influenza Plan for the Health Sector,” contains basic information about influenza, avian influenza, and pandemic flu. The first version was published in 2004 and

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it is continually revised. The federal government is responsible for coordinating the responses of individual provinces so that handling the pandemic will be consistent across the country. The national pandemic plan is modeled closely after the who pandemic preparedness checklist. There are several sections, such as Surveillance and Laboratory Preparedness, Vaccine, Antivirals, and Appendices taken directly from the who checklist. The Appendices are detailed, listing people and departments that are responsible for various aspects of the plan. The plan is general, and provides enough discretion to allow hospitals to react and plan within provincial, municipal, or individual institutions’ policies. In the Canadian Pandemic Influenza Plan for the Health Sector (cpip-hs) there is an entire appendix devoted to communications, which provides a detailed communication plan for three pandemic phases (interpandemic, pandemic alert, and pandemic phases). During the interpandemic phase, communications planning focuses on building networks to share information between governments (provincial/territorial and federal), the news media, and the public. In the pandemic alert phase, attention shifts to providing practical guidance to minimize potential risks and to prepare for the potential pandemic. In the pandemic phase, communication plans include implementation of pandemic risk management and networks. Information moving to and from the who, municipalities, provincial and national government departments, and the public will be needed for effective responses. The Canadian pandemic plan suggests methods for communicating to the public, including telecommunications, the Internet, email, newspapers, radio, television (paid advertisements), and educational videos.

provincial, regional, and municipal responses to sars Early analysis of the disease and its transmission showed that quarantine was a useful means to stop the spread of sars; there was no known effective medical treatment for the disease during the outbreak. In most countries, quarantine followed the who guidelines and the period of isolation initially lasted fourteen days. This was eventually reduced to ten days, as more information about the infection and its incubation time became known. Contact tracing was put in place and quarantine was instituted for anyone having

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had close contact with an infected individual. The degree of exposure that was defined as contact differed by country, but the definition closely followed that for other respiratory ailments like pneumonia and included individuals sharing confined spaces with infected individuals, for example those using public mass transport; those transported by cab, ambulance, or car with an infected person; family members; school classmates, healthcare workers, and those sharing common spaces (in apartment buildings, meeting places, and elevators). The definition of what constituted contact was broad and it included anyone who one could have shared air with an infected person, potentially exposing them to the risk of breathing viral droplets. In several countries, airport security was increased to detect potential incoming and outgoing cases of sars, but the value of such surveillance was limited by the thermal scanning machines’ lack of sensitivity. Quarantine was implemented in homes, apartment complexes, hotels, airports, hospitals, and military buildings in several countries. The effects of quarantine were isolating for those suspected of having sars. During this time support from friends, family, and community groups was invaluable. Those quarantined in hospital received phone calls, letters, cards, and limited visits from family. In several countries, quarantine was enforced by different methods such as the honour system, police/army guard, Web cameras monitoring cases, and threats of large fines and jail time. Adhering to quarantine was also encouraged in some regions by the offer of a small sum of money as compensation upon completion. While isolated, individuals were required to report their temperatures up to three times a day to local health officials, with any positive cases being referred to designated hospitals. Quarantine was often supplemented with massive public information campaigns that described how to prevent the spread of disease and altruistic messages that encouraged compliance with quarantine orders. In Beijing, fever check stations were set up on the main roads going in and out of the city to monitor travellers for symptoms of sars. Body temperatures were checked at entrances to public places and before patrons entered restaurants. Civet cats in China and chickens in Vietnam were culled in large numbers and banned from live animal markets in an attempt to eliminate all possible sars viral reservoirs.

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The Ontario pandemic preparedness plan is titled, “Ontario Health Pandemic Influenza Plan,” and is 485 pages long.5 It is organized by topics, focused on what people at the provincial level are responsible for and can implement. Topics include: Roles and Responsibilities, Goals, Resources, Surveillance, Public Health, Workforce, Treatments and Vaccines, Supplies, Communications, and Services. The plan is continually updated and harmonized with the federal plan. Many of the problems encountered during sars have been addressed in the Ontario plan.

individual responses to sars Occupational – Hospital Worker Responses to SARS Doctors and nurses exposed to viral droplets were at greater risk of acquiring sars than other healthcare workers not involved with high-risk procedures, with about 21 per cent of infections worldwide occurring among healthcare workers. Once it became established that sars patients were passing their illness to healthcare workers at an increased frequency, isolation and containment protocols were set up in hospitals to protect frontline workers. The safeguards tended to be similar regardless of country. In all hospitals, sars patients were isolated in individual rooms or quarantined isolation wings. The isolation prevented the spread of disease from infected patients in a hospital to non-infected patients or visitors. Most hospitals were poorly equipped to handle the large number of infectious patients that required simultaneous isolation. Several hospitals responded by establishing makeshift sars isolation wards by converting existing wards, using ambulance bays or other available spaces to set up needed isolation rooms. Entire hospitals were sometimes appointed as “sars hospitals” and closed off contact by limiting emergency room use, reducing patient visits, and preventing staff from working at other institutions. Isolation rooms were equipped with either negative pressure airflow or fans with hepa filters that carried air away from the rooms to decrease the chance of viral transmission to healthcare workers or other patients in the hospital. Protection for healthcare workers was similar in various countries, and required those treating sars patients to wear full body

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protective equipment. This included a gown, gloves, shoe covers, visor, and a fitted n95 mask. Procedures for proper mask-fitting and correct disrobing after contact with sars patients were strictly enforced in all hospitals, with some using a disrobing checklist, buddy system, or police nurses to make sure that breaks in infectious disease procedures did not occur. Hospitals also used strict handwashing routines to reduce the spread of viral particles; hands were washed both before and after wearing gloves. Healthcare workers on sars-designated wards also received daily information updates and training to better deal with viral containment. Because of isolation, hospitals used mobile equipment for sars patients, and all instruments or diagnostic equipment that came into contact with patients was disinfected thoroughly. Surfaces of objects, for example tables, chairs, and computer keyboards, were disinfected daily in sars wards of hospitals to prevent environmental surface contagion spread. Taken together, these measures were successful in reducing healthcare worker infection rates, but even some well-protected healthcare workers became infected, despite their best efforts. Personal Responses to SARS as an Infectious Disease Individuals had to assess the risk from sars on their own. As a result, fear, altered behaviours including mask-wearing in public, widespread medically unexplained physical symptoms (mupspeople who were well but worried they might have contracted the infectious disease and sought out medical treatment), and anxiety occurred. Interventions to prevent altered behaviours during the next pandemic vary from public health education and information campaigns to increasing capacity, for example by stockpiling vaccines or antiviral drugs. These actions will increase both public trust in healthcare officials’ ability to manage the next pandemic and compliance, which should minimize the severity of the outbreak. The response to a novel biological contagion requires effective risk communication from government officials, public health officials, and medical leaders to dispel fear, fictitious information, and stigmatizing attitudes based on perception of increased personal health risks.

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what should i do before and during a pandemic? The Canadian Pandemic Influenza Plan provides broad planning strategies, but for the most part fails to recognize that most caregiving during the next pandemic will be by unpaid caregivers, usually women who take care of children and elderly parents at home. The two main individual responses by caregivers to the next pandemic, as advised by the Plan, are self-mastery through advance preparation and self-monitoring to safeguard health during the pandemic. Self-Monitoring During an infectious outbreak by contagions with longer incubation windows, individuals can self-monitor for symptoms, a strategy employed by some countries during the sars outbreak. This involves measuring and recording body temperature with a thermometer twice a day over an extended period after suspected exposure to the contagion. Ontario and other provinces have TeleHealth, telephone health advice services, that could provide key information about the situation and how to seek medical attention during an outbreak. If the viral strain responsible for the epidemic allows for containment and self-quarantine, individuals who are at home on a selfmonitoring program can take precautions to prevent family and friends from becoming sick. According to Canada’s pandemic influenza plan, those self-quarantined should remain at home for seventy-two hours or until symptoms subside, but, like sars, this quarantine time could extend to several days. The plan provides several common sense suggestions for individuals isolating themselves, including minimizing contact by not going to work, school, or other public places. The plan notes that the spread of viral particles can be minimized by covering the mouth with a tissue when coughing or sneezing; used tissues should be disposed of directly into a garbage bag used only by the quarantined individual. Frequent handwashing, and in particular handwashing after coughing, sneezing, and nose blowing, is recommended. Others in the household should also be encouraged to wash their hands often, especially if they have

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spent time in shared spaces. Limit contact with other family members. Personal items such as towels, drinking cups, cutlery, thermometers, and toothbrushes that can be contaminated with viral particles should not be shared. Individuals who have fever should rest and drink plenty of fluids. Any family members who become ill must stay home and call their doctors for further guidance (Ontario Ministry of Health and Long-Term Care, 2004b). Being Proactive – Know Your Pandemic Response Strategies at Various Levels Individuals should have personal strategies in place. If a pandemic occurs, everyone should be aware of what to do. For example, are workplace procedures in place to deal with the situation? Does your workplace have the capacity to have virtual meetings and teleconferences if group meetings are not possible due to contagion? Similarly, parents should know the pandemic plan and what to do if schools are suspended or if students are quarantined. Will events be cancelled, visits at hospitals or retirement homes suspended? How will local municipal services react? What is the plan for community-based non-governmental groups during a pandemic wave (blood donation, community shelters, and outreach programs)? What are the local telephone numbers for health officials and telemedicine in your area? Each local community leader responsible for various services should be able to answer questions concerning planning and know how to react before, during, and after a pandemic. Some officials have suggested individual families prepare and maintain a flu kit with essential items that would be needed during a pandemic, including checklists of emergency contact numbers. One of the greatest drivers for stigma and fear is the uncertainty surrounding those who are actively shedding virus. We know from previous studies that contact with individuals who are actively shedding virus should be minimized to prevent transmission. Another exposure route is through environmental contamination, when an infected person has sneezed or coughed, aerosolizing viral droplets that will eventually fall and contaminate surfaces. These viral particles in the environment can potentially infect individuals who subsequently touch or contact them. One research study investigated the transmission of influenza a and b viruses by hands and environmen-

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tal surfaces, and the survival of influenza viruses on various surface types. Both influenza a and b viruses survived for twenty-four to forty-eight hours on hard, nonporous surfaces such as stainless steel and plastic, but survived less than eight to twelve hours on cloth, paper, and tissues. Measurable quantities of virus were transferred from stainless steel surfaces to hands for up to twenty-four hours after initial virus deposition, but only up to fifteen minutes from tissues to hands. Virus survived on hands for only up to five minutes after transfer from environmental surfaces. Transmission from donors who were shedding large amounts of virus showed contamination of hard surfaces for two to eight hours (stainless steel) and for a few minutes on soft surfaces (paper tissues). Environmental contamination and transmission of influenza virus by surfaces is possible during a pandemic and emphasizes how important repeated handwashing and use of alcohol hand sanitizer are in prevention (Bean et al., 1982). Officials recommend a seasonal flu shot,6 handwashing, covering the mouth when sneezing, staying at home if sick, and consulting the doctor as practical precautions.

preparedness for the next pandemic Since the sars outbreak in March 2003, Health Canada and the newly created Public Health Agency of Canada, in consultation with provincial and territorial public health officials and other national and international experts, have taken several steps to build capacity for future infectious disease outbreaks. This preparation is outlined in Canada’s Pandemic Influenza Plan. Its components include improving surveillance systems (international linkages), improving public health capacity (healthcare facilities, laboratory facilities, and research), developing research capacity for, and stockpiles of, antivirals and vaccines, improving coordinated communication strategies and use of real-time communication (domestic linkages), and reviewing and evaluating public emergency preparedness and planning strategies at all levels. Canada has developed and implemented its pandemic influenza plan since 1988, and the plan has been continually refined over time based on new research, infectious disease experience, and the experiences of other countries. It was produced collaboratively through the Pandemic Influenza Committee, in consultation with over 200 experts. Members of this committee included provincial

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and territorial surveillance teams, pandemic influenza planners, Health Canada officials, and expert working groups. The plan is a 450-page document that spells out what actions authorities will take in the event of an outbreak. Since the end of sars much activity has been focused on Canada’s pandemic influenza plan. The plan provides information to all levels of government to help guide their actions with suitable responses to pandemic influenza. All provinces and territories currently have a copy of the pandemic influenza plan, and have used it for their own provincial and territorial planning. It includes emergency response guidelines and a strategy with checklists, designed to assist all jurisdictions with their emergency planning. Each jurisdiction has used this plan as a framework to further develop their local plans. Three years ago, government officials signed a deal with a Canadian-based pharmaceutical company to provide a vaccine for 32 million Canadians. Planning for a pandemic requires a high level of coordination among all levels of government. The plan clarifies the roles and responsibilities of all those involved in emergency response, governments, public health officials, and healthcare workers in the event of a pandemic. The goals of influenza pandemic preparedness and response are to minimize serious illness and reduce the overall number of deaths that could result from a pandemic. The plan also has as a secondary goal to minimize social disruption among Canadians (economic losses and stigma). There is also a need to link institutional and non-institutional clinicians, test protocols through simulated outbreaks and emergencies, audit preparedness on a regular basis, train healthcare staff in infection control, and improve outbreak response. There has been activity to develop efficient information systems for contact tracing, with linkages to clinical and epidemiological data, and for tracking patients through the healthcare system in Canada (Naylor et al., 2004). After sars, surveillance in the post-outbreak period has increased through improved surveillance programs in previously affected areas and increased vigilance nationwide. As well, Health Canada continues to monitor the situation internationally, through partnerships with the who and government agencies in other countries. In Canada, surveillance of respiratory viruses is conducted year-round, with constant reporting of this surveillance information communicated through the FluWatch program. Reports are published weekly during the peak season (October-May) and once

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every two weeks during the remainder of the year. Any new respiratory illnesses of public health importance, such as sars, will now be included and updated in Health Canada’s FluWatch report when developments occur (phac, 2003g). At the provincial level in Ontario, the Emergency Management Unit (emu) was created in December 2003 to ensure readiness for any emergency faced by the ministry or the healthcare system. Establishing infection control and surveillance standards, which protect against infections and provide early warning of any infectious disease outbreak, minimizes the likelihood of an emergency. Stockpiling critical equipment like n95 masks and respirators and conducting event simulations is also part of the plan. The ministry is actively preparing for an emergency of any sort that has health implications (for example, a power outage, a biological accident, or contamination of the water supply). Emergency preparedness also allows for quick recovery of any regular activities within the healthcare system that might be suspended during a crisis. Finally, the plan accounts for business continuity, for healthcare services like long-term care compliance advisers, and for public health laboratory activities (Ontario Ministry of Health and Long-Term Care, 2005b).

risk communication gaps in pandemic preparedness The ability to communicate effectively about the degree of health risk faced by individuals during a pandemic is critical for those managing the crisis to prevent the social amplification of risk and mass social disruption (Williams, 2000). Risk communication usually involves interpreting available scientific evidence and summarizing scientific knowledge in relation to exposures and risk issues. The process usually requires an expert or experts who can, given the context, determine the important scientific facts to be communicated (National Research Council, 1989). By providing information that can be incorporated in context through effective risk communication it is possible to influence public opinion, increase public concern, or reduce fears about a specific risk issue (Kasperson et al., 1988; Leiss, 2001; Leiss and Powell, 2004). For pandemic planning, however, there are still major gaps to be addressed in risk communication. Despite the extensive degree of pandemic influenza planning by the Canadian government, there is

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a still largely ignored, ongoing risk dialogue with the public. Those working on preparedness and planning should enter into this dialogue with the public and fill the information and policy gaps. The following areas of risk communication could be improved. Communicating the Drug Efficacy and Rollout Strategies: Who Will Get Antivirals and Vaccines During a Pandemic? Canadian officials have purchased antiviral drugs and made efforts to build capacity for vaccine development. What is missing is a clear and transparent message explaining exactly who will get vaccines and antivirals or other drugs, and in what order. For example, healthcare workers, their families, children, elderly and immunocompromised individuals may have a higher risk of mortality from a new pandemic flu. Who will get the first antiviral drugs, and why, needs to be communicated to all. The response plan must be flexible about its priorities. For example, during the Spanish flu, it was young adult males, as a group, who were more vulnerable to the virus. Early epidemiology must detect such trends and this information needs to be disseminated to doctors, hospitals, and the general public. The fact that the priority for drug delivery may change during the epidemic should also be a message that is well understood by the public. antiviral drugs Reduction of human-to-human avian influenza transmission will result from treatment using either antiviral drugs (like Tamiflu) or vaccines. Antiviral drugs such as Tamiflu and Relenza work to block the flu virus from escaping infected cells and spreading further. This helps to ease flu symptoms and reduce the overall duration of the illness. The antiviral drug must be taken soon after an infection is suspected, often within forty-eight hours, to be effective; this is before most flu symptoms become evident. Widespread use of antivirals presents another risk, namely that the pandemic virus strain will begin to mutate to resist the medication. There are currently only four antiviral drugs marketed to combat influenza: oseltamivir (Tamiflu) and zanamivir (Relenza), which are neuraminidase inhibitors, and amantadine and rimantadine, which are adamantane drugs. Rimantadine is not sold in Canada, and both amantadine and rimantadine are older drugs that new influenzas

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are more likely to develop a resistance to. Tamiflu is sold in pill form, while Relenza is a powder administered using an inhaler; patients have to be taught how to use it properly. While some individuals have attempted to stockpile Tamiflu and other antiviral drugs, self-administration and self-treatment should not be attempted. Antiviral drugs and vaccines can have side effects and complications; these harmful effects should be communicated to the public to convince them not to stockpile and self-administer drugs, and to give them all the facts surrounding treatment choices. Little has been communicated to the public about the efficacy of antiviral drugs. There are research reports demonstrating that various influenza strains, including the h5n1 strain, develop increased resistance to antiviral drugs over time (Le et al., 2005; Bright et al., 2005). In addition, the effectiveness of the two most common antiviral drugs being stockpiled, Tamiflu (manufactured by Roche) and Relenza (manufactured by gsk), commonly used to treat many types of influenza, is questionable. Researchers suggest that antivirals, when used under the best conditions – meaning early intervention in a proper healthcare setting – reduced mortality by less than 50 per cent. Yet the fact that stockpiled drugs may save fewer than half of those who take them, even when given under optimal conditions, has not been communicated (Bright et al., 2005). Even with this knowledge, governments, including Canada, continue to stockpile antivirals as the best available first line of defense against an avian flu pandemic (cbc News, 2005e). Canada was one of the first countries with an official plan for stockpiling antiviral drugs, and purchased 35 million doses. The stockpile has a shelf life of five years and is enough to treat 3.5 million people. The drug can be used by those who are already infected, or to protect essential workers from becoming infected. The spread of avian flu into European countries near the end of 2005 increased the demand for Tamiflu; it became so intense that the manufacturer, Roche Pharmaceuticals, stopped selling the drug to European pharmacies in late October 2005. Roche representatives said they wanted to safeguard the supply for the upcoming flu season. Roche, despite the potential to lose future profits, agreed to license several generic drug companies to produce the same drug to meet the heightened demand (cbc News, 2005cd). Most developing countries, including those that have seen cases of bird flu in humans, can’t afford to stockpile antiviral drugs.

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Canadian policy on the use of antiviral agents is outlined in Annex E of the Canadian Pandemic Influenza Plan (phac, 2006). The policy is based on the principles of effectiveness, equity, flexibility, and levels of uncertainty. The national antiviral stockpile is being distributed on a per capita basis to each of the provinces and territories. There is no set list of priority groups assigned for treatment. The policy states that antiviral drugs are intended for treatment only, but prophylactic use may be offered to contacts of cases, healthcare workers, key decision makers, public health and societal responders such as police, firefighters, and paramedics. There is also reference to prophylactic use of antivirals to “achieve the goal of business continuity” but the details are not well defined (phac, 2006). Problems with antiviral drug priority lists and hoarding have already occurred. A story in the Globe and Mail newspaper reported that one hospital in Toronto has stockpiled Tamiflu, with an extended distribution plan. The drug will be given to their designated pandemic healthcare workers, but also students, researchers, volunteers, Hospital Foundation members, members of their Board of Directors, and some 600 governors. In addition, distribution to all hospital staff as well as their family members was being considered. The planned drug rollout requires a total stockpile of prophylactic doses for 15,000 people associated with this one hospital. Some of these individuals are not on the government’s priority list and should not receive antivirals as stated by the government’s policy (Brown, 2005b). vaccines Vaccines cause the production of antibodies against a virus prior to infection. When an immunized person is exposed to the influenza virus, the antibodies generated from the previously received vaccination are ready to attack the virus as it enters the body. However, it is impossible to make a vaccine for a virus that has not been identified, let alone one that doesn’t even exist yet. Therefore, attempting to vaccinate for an unknown recombinant strain of h5n1 before a human epidemic would be ineffective. Currently, with the best science available to researchers and industry, it would take at least four to six months for a new vaccine to be produced once the pandemic strain were isolated.

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The Canadian Pandemic Influenza Plan acknowledges that a vaccine will take at least four months to develop and will be available in batches. It could take up to twelve months to produce enough vaccine to protect all Canadians, depending on the number of doses required (phac, 2006). A vaccine prioritization process has been established, even though there is considerable uncertainty as to which groups will be at highest risk of infection. Priority is based on various characteristics, including type of employment (healthcare workers and essential service providers), age, and preexisting medical conditions. The priority populations are: Group 1 Healthcare workers, public health responders, and key decision makers;7 Group 2 Pandemic societal responders and key societal decision makers,8 utility workers (water, gas, electricity, nuclear power, essential communication systems), funeral services, people who work with institutionalized populations (e.g. corrections services), persons employed in public transportation and the transportation of essential goods (e.g. food), key government employees (e.g. ministers, mayors); Group 3 Persons at high risk of severe or fatal outcomes following flu infection: A Those living in nursing homes, long-term care facilities, homes for the elderly; B Persons with high-risk medical conditions living independently in the community; C Persons over sixty-five years of age living independently and not included in 3A and 3B; D Children, six to twenty-three months of age; E Pregnant women; Group 4 Healthy adults. All individuals, eighteen to sixty-four years of age, who do not have a medical condition or fall into one of the other occupation-based priority groups; and Group 5 Children, twenty-four months to eighteen years of age. The ranking of priority groups is based on the goal of reducing morbidity, mortality, and social disruption. The recommendations clearly affirm that there is no priority given to family members of healthcare workers (phac, 2006).

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Luckily for Canadians, Health Canada and the Public Health Agency have one of the most forward-thinking strategies in the world for pandemic preparedness. The public health department has increased capacity for vaccine production, under contract, once the virus strain information is available. In this event, production of influenza vaccine by a domestic manufacturer (Shire Biologics of Sainte-Foy, Quebec) can start immediately, and production capacity can be increased. The goal is to produce enough vaccine to protect all Canadians, but the first batches of vaccine will go to front line healthcare workers and other vulnerable groups (children, the elderly, immunocompromised individuals). Canada was the first country worldwide to plan for a secure vaccine supply through the contracting of a domestic supplier. The contract ensures that everything needed for vaccine production, including the egg supply used to grow the attenuated virus, and storage, is in place. Once the vaccine is available, the first to receive them will be front line healthcare workers and others considered essential personnel, including those who maintain essential services and social order (police, firefighters, paramedics, military personnel, government officials). Hospitals in Ontario have already been asked to submit lists of their essential personnel to the government (Hetherington, 2005). Like antivirals, vaccines by themselves may not be that effective in reducing mortality. Jefferson et al. (2005) undertook a systematic review of available vaccination data and analyzed the outcomes from influenza, influenza-like illness, hospital admissions, complications, and deaths of elderly individuals, who are the largest group vulnerable to the flu annually. The study found that in homes for elderly individuals (with good vaccine match and high viral circulation) the effectiveness of vaccines against influenza-like illness was only 23 per cent, and not significant against influenza. However, well-matched vaccines prevented the development of pneumonia in 46 per cent of cases and deaths from influenza or pneumonia (42 per cent), and reduced all-cause mortality (60 per cent). In elderly individuals living in the community, vaccines were not significantly effective against influenza, influenza-like illness, or pneumonia. The Public Health Agency of Canada has also undertaken the development and testing of a prototype vaccine against the h5n1 virus in a highly precautionary approach to reduce vaccine production times. The goal of producing and testing a vaccine against

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h5n1 is to speed up the availability of a vaccine in case of a pandemic. A prototype has been produced, and the first clinical trials were initiated in Canada in July 2007, in the absence of disease (phac, 2007). How Severe Will an Avian Flu Pandemic Be? Understanding the Context of the Next Pandemic and Communicating Uncertainty to the Public. One of the biggest challenges for risk communicators is integrating the uncertainty of pandemics into risk estimates and corresponding risk communication messages to the public. Risk comparisons are typically given as probability estimates, with almost no indication of the variability or uncertainty involved in the estimates of risk. Risk messages should not minimize the existence of uncertainty or data gaps, and areas of significant disagreement among experts should be disclosed to the public with the level of confidence in risk estimates discussed (nrc, 1989). Experts raising awareness of pandemics have repeatedly indicated that a high level of uncertainty for projected mortality and severity exists; they simply won’t know how bad the pandemic will be until it occurs. A review of the literature suggests there has been little historical, empirical research on different approaches for communicating uncertainty, although some recent research has attempted to explore how the public responds to representations of uncertainty in risk estimates (Williams, 2004). Health officials should not attempt to downplay the potential devastation of the next pandemic by using optimistic mortality calculations – for example, using estimates based on the mild 1957 flu or working with current yearly influenza numbers as their only response model for the next pandemic. If plans, strategies, and communications surrounding pandemics have used very low case attack and case fatality values (as reflected by the current Canadian pandemic preparedness values) as the only scenario presented to the public, what will happen if the next pandemic begins with mortality and transmission rates that are higher than what was communicated? The result will be immediate fear, anxiety, loss of credibility, and mistrust of health officials who will be attempting to manage the unfolding situation. Risk managers who get it wrong estimating severity to begin with will have little credibility with the public

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afterwards. Moreover, if health officials have erred in their initial assessment of the pandemic’s severity, the logical conclusion will be that response strategies are already outstripped; again, it will be difficult for the public to trust any further official messages. Risk managers should realize that they need to communicate various scenarios to the public concerning pandemic response, and that certain groups are at higher risk, requiring added communication. For example, Meltzer et al. (1999) calculated that within North America, high risk groups comprise 15 per cent of the general population. The risks from the next pandemic will not be shared evenly as high-risk groups will experience a predicted 85 per cent mortality rate from pandemic exposure. What Will Be the Consequences of a High-Mortality Avian Flu Pandemic? The public must be told what will happen and what strategies are in place if the worst-case scenario should occur – even if the probability is extremely low. The next pandemic predictions estimate that fewer than 100,000 Canadians will die. Does the response change if the mortality values are higher? Risk managers must communicate how the response strategy could change to deal with an unexpectedly higher rate of mortality and morbidity. In previous pandemics of the twentieth century, as much as 25 to 30 per cent of affected populations have fallen ill around the same time. If this happens, most hospitals will not be able to deal with the massive numbers of sick people and the influx of worried but otherwise well individuals; many people will self-quarantine and remain home. Unlike sars, the use of quarantine and attempting containment will not be an effective measure against influenza, given that the incubation time is usually one to three days, and individuals can shed virus early without appearing symptomatic. The rapid, undetectable spread will result in a widespread distribution in densely populated North American urban centers. If the healthcare system becomes overwhelmed, many will wonder what they should be doing to safeguard themselves and their families. Thus risk managers should ensure they communicate the different strategies that are in place to deal with predicted pandemic mortality values or a more severe epidemic that requires different responses. The issue becomes one of trust. If worst-case scenario predictions are exceeded, the loss of

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public trust in those managing the risk will be instantaneous. The argument will be made that if the managers can’t accurately predict the worst-case scenario and have not communicated preparedness plans for that contingency, then what else have they misjudged concerning the pandemic? How Should We Deal With Pandemic-Induced Social Disruption? The economic impact of sars was devastating, even though it was a minor outbreak that was rapidly contained. An avian flu-like outbreak with high mortality will quickly overwhelm healthcare capacity and have major economic impacts. There will be massive disruptions in labour services as people become sick or self-quarantine. Past pandemics have spread globally in multiple waves, with infections in different parts of the world at different times. With widespread global infection, the resulting social and economic disruption is likely to be short-term; the disease’s pervasiveness in multiple cities and countries will reduce the stigma attached to any one location, as opposed to what was seen with sars hot spots. Travel advisories may be issued early during the next pandemic outbreak as a warning, but the rapid spread of the illness into many countries will make these travel warnings ineffectual. The rapid appearance of the virus in many countries will also reduce the stigma associated with a specific country being singled out as the source. The social disruption caused by a pandemic is likely to be amplified by the news media covering the growing level of uncertainty, the spread of the influenza from country to country, and the increasing number of deaths. Social disruption, sickness, and quarantine will impair essential services; not only healthcare, but other sectors such as power (generation and delivery), transportation (of food, medicine, and other essential goods), and communications within and between countries. Depending on the severity of localized transmission it is possible that entire regions will attempt quarantine to stop the spread of the virus; however, it will be a largely ineffectual exercise given the asymptomatic nature of influenza. Schools, colleges, and universities may be temporarily closed, and these institutions should have plans in place to deal with such an event. Under a worst-case scenario the number of dead will force public health officials to make difficult decisions about how to deal with the sheer number of bodies.

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conclusions In 2003, sars, a new viral disease, emerged and caught many countries unawares, exposing a lack of capacity and preparedness for the next pandemic. If the sars coronavirus had appeared prior to the twentieth century, it, like the 1918 flu, would have eventually moved around the world and become a great pandemic with high global mortality. Scientific knowledge has improved since then, allowing us to much more effectively plan for, and manage, the next pandemic. Governments around the world can work collectively to manage emerging disease in a proactive way through surveillance and reporting mechanisms. Monitoring and control of communicable diseases are greatly facilitated by well-functioning (and still improving) surveillance systems. Such networks provide information for early detection of potential outbreaks, help to identify epidemiological trends for disease tracking through time and space, identify risk factors, identify human behaviours that facilitate disease, target needed interventions, and inform health policy decisions. The data acquired through monitoring provides key information for pandemic planning, priority setting, implementation, and resource allocation – all for designing and evaluating preventive programs. It allows for cost-effective interventions to provide health, safety, and public protection. Experts believe the next pandemic flu would probably take about a month to build up from a few early infections to around a thousand cases in larger urban centers, and after that only a few weeks to spread internationally from the source country. Asia is assumed to be the area of origin for the next pandemic strain. Imposing a 90 per cent restriction on air travel would delay the peak of a pandemic wave by only one to two weeks, and a 99.9 per cent travel restriction might delay a pandemic wave by two months. There is a substantial seasonal effect on the transmissibility of pandemic flu from person to person. Winter outbreaks would be more severe than spring or summer outbreaks, which have a lower transmissibility rate. The rapid onset of one to three days, and the asymptomatic nature of influenza, results in viral shedding prior to noticeable symptoms. Entry and exit screening of air passengers for influenza would therefore be ineffective. Emergency plans and preparedness are imperative; they ensure that appropriate strategies are available in the hope of reducing

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mortality in the approaching pandemic. Mass provision of antivirals to the Canadian population would simply postpone the outbreak by the period for which prophylaxis is provided. Mass prophylaxis would deplete antiviral stocks quickly (one treatment course per person is ten days, or ten stockpiled units). The end goal for pandemic planning should be provision of a system for effective deployment of antiviral treatment for maximum protection. Priority groups (doctors, nurses, paramedics, the elderly, and children) should be targeted for antivirals as required. For greatest benefit, antivirals should be restricted to use by priority groups if clinical attack rates are high (as a way to maintain the health of front line workers during the first pandemic wave). Thus, the use of antivirals should be reserved for healthcare workers and other highrisk groups. An effective vaccine is paramount for the success of any longterm emergency preparedness plan, but it could take several weeks to determine what the infectious agent is, as was the case with sars, and longer still to produce large enough amounts for protection of high risk groups (four to six months). Health Canada should and is currently maintaining standing contracts with flu vaccine producers as insurance, giving these companies enough incentive and profits to maintain capacity for infrastructure to be able to produce large quantities of attenuated virus or vaccines quickly. If there was a virulent pandemic, it is possible that borders to several countries, as well as our own, would close temporarily to both people and goods. This has implications for Canada’s ability to maintain its own supply of vaccines; strategies to deal with temporary stoppage of goods (food, raw materials, and consumer goods) for export to other countries, especially the United States; the grounding of air traffic in and out of the country; and the need for education of both the public and public administrators. Many countries will take actions like quarantine, drug distribution, and education to reduce the impact of the variables. Mortality numbers will be lowered by effective interventions in many countries. It is important that Canada have a solid risk communication and education strategy in place to deal with all of the social and economic implications of the next pandemic. Public trust in government and public health officials who communicate transparently and effectively to contain and effectively manage the next pandemic is also vital for success of an integrated emergency response plan.

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One of the main goals of risk communication is to better inform the general public and decision makers to improve risk issue management in both the public and private sectors (Plough and Krimsky, 1987). Many different approaches can be used to communicate low-probability risks, such as comparative risk analyses, and using risk ladders to help individuals comprehend unfamiliar risks by associating them with familiar risks. Risk comparisons by themselves do not establish levels of acceptable risk, nor can they ensure a systematic minimization of risk (nrc, 1989). Other factors are needed in risk communication about pandemics, such as improving self-mastery (things that individuals can do to mitigate influenza risk) and communicating the degree of uncertainty associated with the risk. Leiss and Powell (2004) remind us that risk managers should engage in two-way risk communication early and often to understand the issues of importance to the public, acceptable levels of risk, and public perception of the issues; this idea needs to be applied to the risk issue management of pandemics. The failure of good risk communication will be observed in huge economic losses and stigmatization of persons and places reminiscent of the events that took place during the 2003 sars outbreak. Canadian officials have developed a robust emergency plan for influenza and pandemics that includes antiviral stockpiles, vaccine capacity, ongoing research for vaccine development, human resources, and healthcare system infrastructure, to respond rapidly to new biological agents. However, it also requires development of a more effective risk communication strategy; so far, this has been largely ignored by emergency planners, decision makers, and public health officials. Public health officials should be proactive and not wait for the next pandemic to arrive before beginning communication to the public about the risks of pandemics, vaccination side effects, quarantine laws following the declaration of emergency acts, and the logic behind giving antivirals or vaccine to selected groups. The occurrence of a new biological agent in the next pandemic, with an initial uncertainty until the contagion is identified, will set off a wave of fear, anxiety, panic, and health concerns. For example, during the recent biological attacks with anthrax in the United States postal system in 2001, the number of worried but well individuals outnumbered true victims by a four to one ratio (Mott et al., 2002). Healthy individuals who are worried will potentially

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clog the healthcare system, slowing down assessments of those who are truly sick. During the initial stages of a pandemic the public must have some knowledge of what to do and how to behave. Education, telehealth hot lines, and knowledge of appropriate behaviours (for example, avoiding mass gatherings, frequent handwashing, and self-temperature monitoring) will provide a sense of self-mastery in a time of dread and uncertainty. Individuals can empower themselves by having individual plans in place and actively determining what plans are in place at local schools, hospitals, workplaces, and other institutions in the event of a pandemic. Pandemic preparedness plans should be clear and provide answers on how individuals should deal with a future pandemic. Canada is well positioned to handle the next pandemic but still needs to enter into an ongoing risk dialogue with the Canadian public. Canadians should have a high level of trust in officials who have a well-developed pandemic plan in place. Hospitals’ capacity for dealing with infectious disease has increased, appropriate drugs have been stockpiled, and a new Public Health Agency of Canada has been created to oversee and manage a future pandemic; all lessons learned from the 2003 sars outbreak.

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APPENDIX

SARS Timelines

i) sars Timeline – Canada ii) sars Timeline – China iii) sars Timeline – Hong Kong iv) sars Timeline – Singapore v) sars Timeline – Taiwan vi) sars Timeline – United States vii) sars Timeline – Vietnam viii) sars Timeline – World Health Organization (who) Activity i ) sars t i m e l i n e – c a n a da 5 March 2003: A seventy-eight-year-old woman who had travelled to Hong Kong in February dies of sars in Toronto. 17 March 2003: Canadian health officials report eleven cases of sars in Toronto, British Columbia, and Alberta. 25 March 2003: Ontario Health Minister Tony Clement declares sars a reportable, communicable and virulent disease. This gives health officials the authority to track infected people and issue orders to stop them from engaging in activities that transmit sars. 26 March 2003: Ontario Premier Ernie Eves declares a provincial state of emergency and orders thousands into quarantine. Health Canada dispatches health and quarantine officers to major international airports and provides personnel and equipment to the Ontario government. 27 March 2003: Ontario health officials order Toronto hospitals closed to visitors, exempting only those who are visiting critically ill patients and parents visiting children. sars-related restrictions

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on Toronto hospitals are expanded to the rest of the province three days later. 29 March 2003: Health officials in Ontario, Canada, report around 100 probable sars cases in the province. 1 April 2003: In Canada, the death toll from sars reaches six. 6 April 2003: Canadian health officials report the number of suspected and probable sars cases in that nation has surpassed 130, including nine deaths. 7 April 2003: Allison McGreer, a doctor who has been at the forefront of fighting the sars outbreak in Toronto, contracts the infection herself and is treated in hospital. 9 April 2003: Health officials place 197 employees at a HewlettPackard plant in Markham, on under quarantine after a worker defied his quarantine and came to work showing sars symptoms. 10 April 2003: Prime Minister Jean Chrétien dines at a Chinese restaurant in Toronto in a bid to dispel fears about sars that have hurt local businesses. 11 April 2003: Canadian Blood Services disallows people who have recently travelled to certain countries in Southeast Asia from giving blood. Although there’s no scientific evidence that sars can enter the bloodstream, the agency says it’s a precautionary measure. 12 April 2003: Canadian researchers announce the first successful sequencing of the coronavirus genome believed to be responsible for the global epidemic of sars. 19 April 2003: Royal Columbian Hospital near Vancouver is closed because of fears that a second nurse there has sars. Healthcare workers treating sars patients are now required to wear goggles in addition to gowns, masks, and gloves. 23 April 2003: Toronto Mayor Mel Lastman holds a press conference to decry the who travel advisory against Toronto despite the fact that Canada had met one of the travel advisory criteria, namely that people travelling from Toronto had exported the disease to other countries, showing a clear failure to contain sars (ctv News, 2003b). 24 April 2003: Health Canada complains to the World Health Organization, saying the health agency should revoke its Toronto travel advisory. 22 May 2003: Health authorities in Canada inform the who of a cluster of five cases of respiratory illness associated with a single

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hospital in Toronto. This is the beginning of a second outbreak of sars in Toronto. 24 May 2003: Approximately 2,200 people are quarantined across Ontario. Close to half are in Toronto, as a precaution while health officials investigate a few dozen possible new cases of sars. 31 May 2003: Toronto is back on the who list of areas with local transmission after Canada reported new clusters of twenty-six Suspected and eight Probable cases of the disease linked to four Toronto hospitals. 6 June 2003: In all, 111 Probable cases are reported in the second outbreak of sars in Toronto. 2 July 2003: The who removes Toronto from its list of areas with recent local transmission. i i ) sars t i m e l i n e – c h i n a 16 November 2002: First known case of sars discovered in Guangdong Province, China. 11 February 2003: The Chinese Ministry of Health reports that there have been 300 cases including five deaths in Guangdong Province from an “acute respiratory syndrome.” 28 March 2003: Chinese officials report a tenfold increase in the number of sars-related deaths in Guangdong Province; ten new cases surface in Beijing. 2 April 2003: China reports 361 new cases of sars for the month of March; the total number of cases in Guangdong Province rises to 1,153. 5 April 2003: Chinese officials apologize for the government’s slow response to the sars outbreak amid allegations that officials have covered up the true extent of the spread of the disease. Chinese Premier Wen Jiabao declares it is safe to travel to China. 8 April 2003: In a letter sent to journalists, a Chinese military doctor blames the government for hiding the truth, saying there are more cases and deaths in Beijing than the official figures report. There are at least 140 cases in military hospitals that have not been officially counted. A who team is still waiting to be allowed into military hospitals to confirm patient numbers. 13 April 2003: After a near blackout on sars coverage, the government begins a media campaign to combat sars spread. The southeastern province of Fujian reports its first cases. Infections

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in Beijing and northern Shanxi rise sharply and more cases are reported in Guangdong. Despite China’s new policy regarding sars, doctors continue to tell news reporters of numerous unreported cases throughout the country. 20 April 2003: The Chinese government discloses that the number of sars cases is many times higher than previously reported. Beijing now has 339 confirmed cases of sars and an additional 402 suspected cases. Ten days earlier, Health Minister Zhang Wenkang had admitted to only twenty-two confirmed sars cases in Beijing. The jump in sars numbers prompts Chinese Communist Party leaders to fire the country’s health minister and the mayor of Beijing. The city closes down schools and imposes strict quarantine measures. 27 April 2003: Nearly 3,000 sars cases have been identified in China. China closes theatres, Internet cafes, discos, and other recreational activities and suspends the approval of marriages in an effort to prevent gatherings where sars can be spread. About 7,000 construction workers labour around the clock to finish a new 1,000-bed hospital for sars patients in Beijing. 2 May 2003: The Xiaotangshan Hospital is built in just eight days. It opens its doors for 156 sars patients from fifteen hospitals in urban areas in Beijing. 4 May 2003: More than one million schoolchildren in Beijing are told to stay home for two weeks as their government tries to control the spread of sars. 6 May 2003: Officials order 10,000 people into quarantine in the city of Nanjing, China. 11 May 2003: The southern Chinese city of Guangzhou bans spitting in public places to combat sars. 15 May 2003: To prevent sars from spreading through the countryside, China’s Supreme Court threatens to execute or impose a life sentence on anyone who breaks sars quarantine orders and deliberately spreads the disease. 23 May 2003: Research teams in China announce that they have detected several coronaviruses closely related to the sars coronavirus in animal species taken from a market in southern China. Masked palm civets, raccoon dogs, and Chinese ferret badgers are wild animals that are traditionally considered delicacies and are sold for human consumption in markets throughout southern China.

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24 June 2003: The who removes Beijing from its list of areas with recent local transmission and removes its travel restriction recommendation. 27 December 2003: A man with sars symptoms is isolated in Guangzhou, China. This is the first sars case in China since August. The official China Daily newspaper reported that fortytwo people were quarantined after they contacted the suspected sars patient. None contracted sars. 8 January 2004: A new case of sars is reported. A twenty-year-old waitress has been hospitalized and placed in isolation in Guangzhou, in Guangdong Province. People who have contacted the woman are quarantined. 13 January 2004: The Chinese Ministry of Health (moh) reports the third recent suspected or confirmed sars case in southern China, a thirty-five-year-old man in Guangdong Province. The source of these new cases is still unclear. 31 January 2004: China’s Ministry of Health reports another new sars case, a forty-year-old doctor named Liu in the southern city of Guangzhou. Liu was ill on 7 January and checked himself into a hospital on 13 January. 4 February 2004: China announces that it will begin testing a sars vaccine on humans after successful monkey trials show efficacy and no serious side effects. This is the first of several such announcements about vaccine development from China. 26 April 2004: The Chinese Health Ministry investigates at least four new suspected cases. Officials say all the new cases are connected to an individual who worked at a sars research lab. 19 May 2004: The World Health Organization says China has contained the latest outbreak of sars. i i i ) sars t i m e l i n e – h o n g ko n g 21 February 2003: A man from Guangdong checks into room 911 of Hong Kong’s Metropole Hotel, later developing sars. Sixteen other Metropole guests eventually become ill, spreading the disease internationally. 4 March 2003: A twenty-six-year-old Chinese man (Hong Kong’s index patient A) is admitted to a general medical ward of the Prince of Wales Hospital; he had been ill for one week with fever, chills, and myalgia. This patient infects a number of healthcare workers.

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10 March 2003: Eighteen healthcare workers on a medical ward in the Prince of Wales Hospital in Hong Kong report that they are ill. Within hours, more than fifty of the hospital’s healthcare workers are identified as having had a febrile illness over the previous few days. A total of 156 patients are hospitalized with sars, of whom 138 were identified as having either secondary or tertiary cases as a result of exposure to the index patient. 11 March 2003: Health officials in Hong Kong report an increase in acute pneumonia-like cases among hospital workers. Ninetynine sars cases among healthcare workers are linked to patient J, a man who stayed at the same Hong Kong hotel as patient A. The outbreak in Hong Kong appears to be confined to the hospital environment. Hospital staff seems to be at highest risk. 13 March 2003: An American suffering from breathing trouble dies in Hong Kong after being transferred from a Hanoi hospital. Soon after, health workers in both hospitals develop similar symptoms. 27 March 2003: Officials in Hong Kong quarantine more than 1,000 people and close schools. Researchers at the University of Hong Kong report they have evidence sars is a coronavirus. 30 March 2003: In Hong Kong, a steep rise in the number of sars cases is detected in Amoy Garden, a large housing estate consisting of ten thirty-five-storey blocks which are home to around 15,000 persons. The Hong Kong Department of Health issues an isolation order to prevent the further spread of sars. The isolation order requires residents of Block E of Amoy Gardens to remain in their flats for ten days (until midnight on 9 April). Residents of the building are subsequently moved to rural “holiday villages” (the euphemism for quarantine camps) for another ten days. Official take three weeks to determine that the virus was not transmitted in water but by contact with fecal matter from an infected individual through a leaky sewage system. 1 April 2003: Hong Kong health officials tally the city’s sars cases at nearly 700 people. 11 April 2003: Hong Kong announces all departing passengers will be tested for signs of the sars virus infection before boarding planes at the airport. The authorities also order home confinement for seventy households with confirmed sars cases. 19 April 2003: Another twelve people die of sars in Hong Kong, bringing the region’s death toll to eighty-one, the highest of any location affected by the outbreak.

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23 June 2003: The who removes Hong Kong from its list of areas with recent local transmission of sars. 7 July 2004: Hong Kong Health Secretary Yeoh Eng-kiong resigns after being criticized in a report on the handling of the 2003 sars crisis. The report accused him of paying too little attention to sars when it appeared in mainland China, and issuing misleading statements to the Hong Kong public. i v ) sars t i m e l i n e – s i n g a p o r e 6 March 2003: Three persons who had travelled to Hong Kong during late February are admitted to local hospitals during a fiveday period complaining of pneumonia. These patients include Case One and a travelling companion. They had been guests at Hotel M (Kowloon, Hong Kong) on 20 and 21 February, coinciding with the stay of a person with sars who transmitted the disease to at least thirteen guests. They are admitted to an acute care hospital, Tan Tock Seng Hospital, on 1 March, and isolated five days later after spreading the contagion to a number of others (eight nurses, one health attendant, and five patients in the same ward, and ten visitors). The outbreak spreads to two other tertiary hospitals, Singapore General Hospital and National University Hospital. 14 March 2003. Six persons, including two healthcare workers (hcws) and a former flight attendant, are admitted to Tan Tock Seng Hospital (ttsh) for atypical pneumonia; all had close contact with Case One. Contact tracing will subsequently tie the illness to more than 100 sars cases in Singapore. 24 March 2003. The Ministry of Health invokes the Infectious Diseases Act to quarantine all who have been exposed to sars patients. This legislation allows mandatory home quarantine for ten days, now enforced by cisco, a Singapore security agency. cisco serves the quarantine order and installs an electronic picture (epic) camera at the home of each contact to maintain surveillance. 27 March 2003: Singapore closes its schools. 7 April 2003: Singapore calls out military paramedics to help nurses in screening passengers at the airport. 8 April 2003: Singapore officials discuss deploying army medical personnel to help fight sars, and consider the idea of installing webcams in people’s homes to enforce quarantines.

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20 April 2003: After the identification of a cluster of illness among employees of a crowded wholesale market in Singapore, the Ministry of Health closes the market for fifteen days and the vendors are placed in home quarantine (2,500 employees). 24 April 2004: The Infectious Disease Act is amended with penalties for those who break quarantine. It requires infected persons to go to treatment centers, and prohibits them from going to public places. In addition, throughout the country, people are requested to monitor body temperature. 31 May 2003: Singapore is removed from the list of areas with recent local transmission of sars because twenty days (i.e., twice the maximum incubation period) have elapsed since the most recent case of locally acquired sars was recorded. 9 June 2003: Temperature screening for all arriving passengers at all border checkpoints in Singapore is stopped. 8 September 2003: A twenty-seven-year-old researcher is diagnosed with sars, most likely acquired in a laboratory as the result of accidental contamination. v ) sars t i m e l i n e – ta i wan 2 May 2003: Taiwan, which had a rapidly spreading outbreak, reports a cumulative total of 100 probable cases, with eleven new cases reported in a single twenty-four-hour period. Eight sars deaths have occurred in Taiwan. 20 May 2003: More than 150 doctors and nurses quit various hospitals in one week because of their fear of contracting sars. Nine major hospitals are fully or partly shut down. 17 June 2003: The who removes Taiwan from its list of areas to which travellers are advised to avoid all but essential travel. 5 July 2003: The who removes Taiwan from its list of areas with recent local transmission. 17 December 2003: Taiwan health officials say a medical researcher at a Taipei military hospital has contracted the virus. v i ) s a r s t i m e l i n e – u n i t e d s tat e s 17 March 2003: The United States Centers for Disease Control and Prevention (cdc) holds its first briefing on sars. The first fourteen suspected sars cases are being investigated. 21 March 2003: The Centers for Disease Control (cdc) publishes a preliminary clinical description of sars.

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1 April 2003: The us State Department authorizes all non-essential employees and their families to leave the province of Guangdong. 4 April 2003: The United States adds sars to the list of communicable diseases, which gives the cdc the authority to isolate persons who might have been exposed to the disease. 14 April 2003: cdc officials announce that their laboratories have sequenced a strain of the sars-related coronavirus that is nearly identical to that sequenced by the Canadian research group. 22 April 2003: The cdc issues a health alert for travellers to Toronto, which is the epicenter of the Canadian outbreak of sars. The cdc director states the health alert is part of the agency’s effort to give travellers practical information to protect themselves from the global threat of sars. 8 July 2003: The cdc lifts its sars travel alert for Toronto, Canada after more than thirty days had elapsed since the date of onset of symptoms for the last sars case. vii) s a r s timeline – vietnam 26 Feb. 2003: The first cases of “unusual pneumonia” are reported in Hanoi, Vietnam. 7 March 2003: More cases of a severe form of pneumonia from Vietnam are reported. The outbreak in Vietnam is traced back to a middle-aged man who was admitted to hospital in Hanoi with a high fever, dry cough, myalgia, and mild sore throat. Following his admission, approximately twenty hospital staff became sick with similar symptoms. In some cases, this is followed by bilateral pneumonia and progression to acute respiratory distress. They remain unaware that the cause is a novel coronavirus. 28 April 2003: After twenty days pass without reports of any new sars cases, Vietnam becomes the first country to successfully contain its sars outbreak, according to the who, and is removed from the list of affected countries. v i i i ) sars t i m e l i n e – wo r l d h e a lt h o r g a n i z at i o n ( w h o ) act i v i t y 28 February 2003: Dr Carlo Urbani, a who official based in Vietnam, is alarmed by cases of atypical pneumonia in the Hanoi French Hospital, where he had been asked to assist. He is concerned it might be avian influenza and notifies the who Regional Office for the Western Pacific.

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12 March 2003: The who issues a global alert about cases of severe atypical pneumonia following mounting reports of cases among staff in Hanoi and Hong Kong hospitals. 15 March 2003: The World Health Organization issues a global sars alert warning travellers returning from Asia to watch for symptoms, including fever, coughing, and difficulty breathing. 17 March 2003: The who calls upon eleven leading laboratories in nine countries to join a network for multicenter research into the etiology of sars and to simultaneously develop a diagnostic test. The network takes advantage of modern communication technologies (email; secure Web site) so that the outcomes of investigations on clinical samples from sars cases can be shared. 27 March 2003: who requests that airlines screen passengers for sars on flights leaving from Hong Kong, Singapore, Hanoi, Toronto, and parts of China. who reports more than 1,400 cases worldwide, including fifty-three deaths. 29 March 2003: Dr Carlo Urbani, the doctor who first identified sars, dies of the illness in Thailand. 1 April 2003: who advises travellers to stay away from known hotspot areas in Hong Kong and China. 2 April 2003: The who’s Weekly Epidemiological Record publishes a new case definition, recommends measures to prevent the international spread of sars, and proposes the implementation of a global surveillance system (World Health Organization, 2003d). The who recommends that airport and port health authorities in affected areas undertake screening of passengers presenting for international travel. In addition, the who recommends passenger screening, guidance on the management of possible cases during international flights, disinfection of aircraft carrying suspect cases, and surveillance of persons who have been in contact with suspect cases while abroad. 4 April 2003: who officials report a total of 2,353 probable sars cases in sixteen countries, eighty-four of them fatal. 8 April 2003: The total number of probable sars cases worldwide reaches 2,671, including 103 deaths, according to the who. 9 April 2003: who investigators present an initial report on the Guangdong outbreak of sars. The researchers report evidence of highly contagious spreaders capable of infecting as many as 100 persons.

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16 April 2003: who doctors visit two military hospitals in Beijing and say the Chinese government has excluded patients in military hospitals from its official reports. 23 April 2003: The who warns against all but essential travel to Toronto, Beijing, and China’s Shanxi Province. These locations join Hong Kong and China’s Guangdong Province on who’s list of areas that should be avoided because of sars outbreaks. 29 April 2003: The who removes its warning against all but essential travel to Toronto. Travel advisories remain in effect for Hong Kong, Beijing, and two provinces in China. 2 May 2003: As of early May, the who reports that more than 5,600 probable cases of sars have occurred, 391 of them fatal, in thirty countries. 8 May 2003: The who extends its warning against unnecessary travel to Taipei in Taiwan, and Tianjin and Inner Mongolia in China. The who estimates the death rate from sars at 15 per cent – twice as high as earlier reported. Worldwide, more than 7,000 cases and 500 deaths have been reported. 23 May 2003: The who lifts advisories on travel to Hong Kong and China’s Guangdong Province. Worldwide, more than 8,000 cases and 680 deaths have been reported. 5 July 2003: who officials consider the sars threat under control and lift all travel advisories. To date, 8,099 people in thirty-two countries have been infected, with 744 of those cases fatal. No new cases have been reported since late June. 9 January 2004: who sends a six-person team to Guangzhou to work with Chinese health officials investigating the reappearance of sars. 16 January 2004: The World Health Organization says it has found evidence suggesting that civets do carry sars. Chinese health officials announce plans to slaughter thousands of civet cats to curb the spread of the disease. 19 May 2004: The World Health Organization says China has contained the latest outbreak of sars.

Timelines compiled from Internet sources: http://www.cnn.com/2003/health/04/24/timeline.sars/

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http://www.npr.org/news/specials/sars/timeline.html http://www.sarsreference.com/sarsref/timeline.htm http://library.thinkquest.org/03oct/00738/timeline.html http://www.webmd.com/content/article/63/72068.htm http://news.bbc.co.uk/1/hi/world/asia-pacific/2973415.stm http://www.e11th-hour.org/resources/timelines/sars.04.03.html http://www.mapleleafweb.com/education/spotlight/ issue_31/timeline.html

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chapter one 1 A more detailed, clinical description of the criteria used to categorize Suspect and Probable sars patients can be found in Chapter 3. 2 The Program for Monitoring Emerging Diseases is an electronic outbreak reporting system that monitors infectious diseases globally. Promed-Mail serves as a central Internet site for news, updates, and discussions of outbreaks of emerging and re-emerging diseases that affect human health. 3 The avian flu transmission was bird-to-human cases and not human-tohuman sustained transmission. 4 The Public Health Agency of Canada recognized that two distinct waves of sars occurred in Toronto and lists them as sars i and sars ii. The first outbreak wave, sars i, occurred from 13 March 2003 to 25 March 2003. The second outbreak wave, sars ii, occurred from 23 May 2003 until 30 June 2003. For the more detailed chronological treatment presented here, sars i, also referred to as sars1, occurred from 23 February to 19 April 2003. sars ii, or sars2, occurred from 23 May to 12 June 2003. 5 This patient is also referred to as Mr M., case B in the Campbell Commission sars report, Volume 2, “Spring of Fear” Final Report. See: pages 50–3 and 114–18. 6 “Infiltrate” refers to a collection of fluid and cells seen on a chest x-ray in various forms of lung inflammation. Pneumonia is one example of an infection that causes the appearance of infiltrate that appears on chest x-rays as opaque areas not usually seen in healthy individuals. The amount of lung area with infiltrate is an indicator the degree or seriousness of the inflammation.

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7 This test detects antibodies produced in response to the sars coronavirus infection. ifa (Immunofluorescence Assay) is a test used to detect igm antibodies in the serum of sars patients. This test yields positive results after about day ten of illness. 8 This test detects antibodies produced in response to the sars coronavirus infection. Different types of antibodies (igm and igg) appear and increase in level during the course of infection. elisa (Enzyme Linked ImmunoSorbant Assay) is a test that detects a mixture of igm and igg antibodies in the serum of sars patients. The test yields positive results reliably at around day twenty-one after the onset of illness. 9 Polymerase chain reaction (pcr) can detect genetic material of the sars-cov in various specimens (blood, stool, respiratory secretions, or body tissues). Existing pcr tests for sars-cov are specific but lack sensitivity. Positive pcr results indicate that sars-cov genetic material is in the sample. This does not mean that there is live virus present, or that it is present in a quantity large enough to infect another person. Negative pcr results do not exclude sars as many false negatives occur and genetic material may be degraded over time depending on the type of specimen tested. 10 The lack of seroconversion confirms that while in contact with the infected patient the healthcare workers were not exposed to the sars coronavirus, due to personal protective equipment and rigorous infection-control procedures. 11 Initial chest radiographs for Patient 3 appeared normal. 12 Research by Isakbaeva et al., (2004) showed that sars case patients may have high concentrations of the virus in their stool during the second week of illness and continue to shed the virus in feces until at least twenty-six days after onset of symptoms. 13 Reverse transcription polymerase chain reaction (rt-pcr) is a variation of the standard polymerase chain reaction (pcr). The pcr technique is commonly used in molecular biology to generate many copies of a specific dna sequence by a process called “amplification.” In rt-pcr, however, the rna strand is first reverse transcribed back to its dna complement (complementary dna, or cdna) using the enzyme reverse transcriptase, and the resulting cdna is amplified using traditional pcr. rt-pcr is useful for identifying rna viruses like the sars coronavirus. Reverse transcription pcr should not be confused with real-time polymerase chain reaction (q-pcr), which is also often incorrectly abbreviated as rt-pcr. 14 Numbers from the Ontario Ministry of Health and Long-Term Care, sars: Severe Acute Respiratory Syndrome as of September 2003.

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http://www.health.gov.on.ca/english/public/updates/archives/hu_03/ hu_sars.html. 15 Many documents written in June and July 2003 after the outbreak had ended reported 43 deaths from sars. Dr. Nestor Yanga was the last sars death in Canada. He acquired sars in early April and later died on 13 August 2003 from complications. In total there were 44 deaths (43 Probable and 1 Suspect) reported in Canada.

chapter two 1 For a relative size comparison, the average virus is approximately 75 nanometers (nm) in size or 0.075 micrometers (µ). This is 330 times smaller than the diameter of a human hair (25 µ diameter) or 1,330 times smaller than a grain of salt (100 µ diameter). Values from: A Sense of Scale, A Visual Comparison of Various Distances. http://www.falstad.com/scale/. 2 On 13 May 2003 the Ontario Provincial Ministry of Health and LongTerm Care published new directives called “the new normal” which took effect on 16 May. The directives place emphasis on healthcare practices with a heightened awareness of emerging infectious diseases including sars. The goals are prevention of exposure to infectious agents, early case detection with appropriate management, and applying the lessons learned from sars to the routine management of all non-infectious patients. New normal directives to healthcare facilities from: http://www. health.gov.on.ca/english/providers/program/pubhealth/sars/docs/new_ normal/dir_bg077_051803.pdf. 3 A testing device was used to ensure protective masks fit wearers with no leaks. The testing device, called a nebulizer, manufactured by 3m Co., sprays a bitter aerosol at the wearer’s face. If aerosol can be tasted through the mask, the mask must be refitted. Hospital workers across Ontario use n95 protective masks to help prevent the spread of airborne sickness such as sars. Masks must be fitted for each wearer to take into account individual facial features. If one mask doesn’t fit, a different size or type can be used. 4 The Occupational Health and Safety Act directs employers in Section 25 (1) (a) that, “the equipment, materials, and protective devices as prescribed are provided” and in Section 25 (2) (a) to “provide information, instruction, and supervision to a worker to protect the health and safety of that worker.” However, some healthcare workers contracted the illness despite

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being provided with and wearing all of the available ppe. The importance of mask-fitting and training was highlighted by the Ontario Public Service Employees Union in a Health Hazard Alert, Number 10, dated 9 June 2003. http://www.opseu.org/hands/alertsars10. htm. “Hospital masks are in short supply. Firms work around clock to fill orders. Protective gear’s cost soars at some stores.” Chris Sorensen. Toronto Star. 29 March 2003. The ministry issued more than fifty bulletins and directives ordering new procedures for everything from transferring patients to screening staff during the first three months of the sars outbreak. See “sars Bureaucracy Inundates Doctors. Health Ministry Swamps Staff With Cumbersome Directives. mds and Nurses Confused, Unsure How to Comply.” Karen Palmer, Toronto Star. 21 June 2003. Nurses in sars units worked alongside private agency nurses who were being paid as much as three times more. This greatly affected staff nurse morale. See “sars-Weary Nurses Demand Danger Pay. Private Hires Blamed for Morale Drop. Agency Nurses Get $100/hr., Others $21.” Theresa Boyle. Toronto Star. 29 May 2003. The first round of sars in Canada, or sars1, lasted from 23 February until 19 April 2003. The full reports are available at: – Naylor Report. “Learning from sars – Renewal of Public Health in Canada.” October 2003. http://www.phac-aspc.gc.ca/publicat/sars-sras/ pdf/sars-e.pdf; – Walker Report. “For the Public’s Health.” December 2003. http://www.oma.org/Health/sars/Walkerreportinterim.pdf. – Campbell Commission Report. “The sars Commission Interim Report. sars and Public Health in Ontario.” April 2004. http://www.sarscommission.ca/report/Interim_Report.pdf. These public reports are summarized in chapter 9. Both the Kirby Committee (see: Standing Senate Committee on Social Affairs, Science, and Technology. “The Health of Canadians – the Federal Role. Volume 6: Recommendations for Reform,” Ottawa: 2002) and the Romanow Commission (The Commission on the Future of Health Care in Canada. “Building on Values, The Future of Health Care in Canada,” Ottawa: 2002) highlighted the need for healthcare reforms. Diagnostic and Statistical Manual of Mental Disorders IV. This is the main diagnostic reference manual for mental health professionals in North America. It lists the most common mental disorders including descriptions, diagnoses, treatments, and research findings.

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12 ptsd was officially recognized as a diagnostic category under the criteria in the American Psychiatric Association’s Diagnostic and Statistical Manual (dsm-iv) in the early 1980s.

chapter three 1 Coronaviruses belong to the order Nidovirales, family Coronaviridae, genus Coronavirus, and are a diverse group of rna viruses. 2 The 1994 American-European Consensus Committee defined ards in clinical terms as the acute onset of bilateral infiltrates on chest radiography, a partial pressure of arterial oxygen (PaO2) to a fraction of inspired oxygen (fio2) ratio of less than 200 mm Hg and a pulmonary artery occlusion pressure of less than eighteen, or the absence of clinical evidence of left arterial hypertension. In other words, ards is a buildup of water and proteins in the lungs that reduces normal lung air pressure and can result in breathing failure. 3 Inactivated vaccines to yearly influenza provide essential protection only when the vaccine antigens and the circulating viruses share a high degree of similarity in their surface antigens. Hemagglutinin and neuraminidase proteins are the two surface antigens that induce protective antibody responses and are the basis for subtyping influenza A viruses. Because new influenza virus antigenic variants emerge frequently from accumulation of point mutations in the hemagglutinin protein (by a process called antigenic drift), influenza vaccine antigens need to be updated frequently, based on the results of global influenza surveillance. For global influenza surveillance systems, influenza viruses are characterized antigenically based on serum hemagglutinin-inhibition (hai) antibody cross-reactivity. A mathematical method is used calculate “antigenic relatedness” between two viruses (presented as a percentage) as a geometric mean of two ratios between the heterologous and homologous antibody titers. Thus, calculating the differences between viral strains based on their antigenic relatedness is important for the selection of the best and most effective influenza vaccine strains. For a more detailed description of the methods used to determine antigenic relatedness see: Lee M.S. and Chen J.S. 2004. Predicting antigenic variants of influenza a/h3n2 viruses. Emerging Infectious Diseases. 10(8): 1385–90. 4 The term “comorbid” refers to a disease or disorder that occurs at the same time as another disorder but is not related to it. For the first ten cases of sars identified in Canada (eight Probable and two Suspect)

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comorbid conditions were noted as three had a diagnosis of type 2 diabetes mellitus; and two had underlying pulmonary disease (asthma in one patient and chronic cough of unclear cause in another patient). See Poutanen et al, 2003 for a more detailed description of comorbid conditions in early Canadian sars cases. Individuals with comorbidity may be at higher risk of acquiring viral infections due to compromised immunity and may endure greater negative health impacts due to their pre-existing level of health. A Lactate Dehydrogenase (ldh) isoenzyme blood test is performed to check how much ldh is in the blood. Measurement of ldh isoenzymes helps determine the location of damage in specific tissues. ldh exists in 5 isoenzyme forms, which differ slightly in structure and are found in highest amounts in different body tissues like the heart (ldh-1), liver (ldh-5), kidney (ldh-4), pancreas (ldh-4), skeletal muscle (ldh-5), brain, red blood cells (ldh-1), white blood cells (ldh-2), and lungs (ldh-3). In the case of sars, higher than normal ldh levels were indicators of viral infection, muscle tissue injury, and lung tissue death. An antigenic shift is a sudden change in a virus resulting from the recombination of the genomes of two different viral strains, which greatly alters the antigenicity of the virus. Antigenic shifts have occurred in human influenza A viruses with the drastic alteration of the hemagglutinin gene (this codes for the protein that mediates the entry of the virus into the cell) with a novel subtype that may not have been present in human influenza viruses for a long time. The source of the new sequence responsible for the shift is the large reservoir of avian influenza viruses. A shift in the hemagglutinin protein may result in a pandemic. Antigenic drift is the variation in viruses that occurs over time due to the continued accumulation of mutations in the viral genome that correspond to antibody-binding sites found in human antibodies. The resulting viruses are not effectively inhibited by human antibodies that developed in reaction to previous strains. These accumulated changes in the virus make it easier to spread through a partially immune population. Antigenic drift occurs in both influenza A and influenza B viruses. Dr Low is head of the Department of Microbiology at the Toronto Medical Laboratories and Mount Sinai Hospital, a diagnostic laboratory serving ten hospitals in the Greater Toronto Area. He is also a professor at the University of Toronto in the Department of Laboratory Medicine and Pathobiology. Dr Low has published more than 170 papers in peerreviewed journals. The largest impact of sars was felt in the travel and tourism industry, which was expected to lose about $1.1 billion nationally in real economic

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activity in 2003. Tourism receipts in Toronto were forecast to be 8.9 per cent lower in 2003 as a direct result of sars.

chapter four 1 Transaminases, also called aminotransferases, are a group of enzymes that catalyze transamination (that transfer an amino group from an amino acid to another compound). The enzymes are important in the production of various amino acids. Measuring the concentrations of various transaminases in the blood and their ratios is important in the diagnosing and tracking many diseases. The enzymes alanine aminotransferase (alt), aspartate aminotransferase (ast), and alkaline phosphatase are markers used in liver function tests to detect injury. Abnormalities indicate liver inflammation and liver injury due to drugs, blockage, cancers, alcohol abuse, toxins, or viruses. 2 The compound extracted and modified from the fruit of the Chinese star anise (Illicium verum) evergreen tree is used to make the anti-influenza drug oseltamivir (Tamiflu). This ethyl ester prodrug is used in certain cases of influenza. It interferes with the viral development by blocking neuraminidases on the surface of flu viruses, preventing host cell release of completed viral particles. 3 A synthetic antiviral ribonucleoside that inhibits the replication of dna and rna, used to treat respiratory syncytial virus. 4 An abnormal collection of fluid between the thin layers of tissue (pleura) lining the lung and the wall of the chest cavity. 5 igg or immunoglobulin g is the most abundant class of antibodies found in blood serum and lymphatic tissue. igg antibodies work to fight against bacteria, fungi, viruses, and foreign particles. 6 ptsd is a psychiatric disorder that can occur following life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. Indicators for ptsd are listed in the American Psychiatric Association’s Diagnostic and Statistical Manual (dsm-iv).

chapter five 1 Not all strains of C. difficile produce toxins. Those strains that do not make toxins are unlikely to cause disease and patients colonized by them remain healthy.

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2 An operation to remove all or part of the colon (large intestine). The procedure is often used to treat conditions including Crohn’s disease, ulcerative colitis, diverticulitis, benign polyps of the colon, and cancer of the colon. 3 Also included in this category are converging cellular telephone and hand-held Internet devices that allow users to send text messages, emails, and photographs.

chapter six 1 See: “Mystery Outbreak Spreads as Experts Scramble for Cause,” Daily News. Halifax, ns: 17 March 2003. “Heavy Drug Doses Beat Mystery Pneumonia: 10 Canadians Now with Deadly Disease,” Edmonton Journal. Edmonton, ab: 17 March 2003. “Mystery Illness Prompts Global Scramble: ‘Atypical Pneumonia’ Strikes 10 in Canada,” Leader Post. Regina, sk: 17 March 2003. Helen Branswell. “Mystery Illness Cases Increase,” Telegram. St. John’s, nf: 17 March 2003. 2 The three-day Woodstock music festival was held in Bethel, New York, in 1969. Close to 400,000 concertgoers took over a farmer’s field in upstate New York. This was notorious for being the largest North American outdoor music concert of the twentieth century.

chapter seven 1 News media reports detailed the nurses’ perceptions that their concerns over safety and personal protective equipment were not being considered. See: ctv News. 2003. “T.O. Nurses Said They Warned of New sars Cases,” 27 May 2003. http://www.ctv.ca/servlet/ArticleNews/story /ctvNews/ 1054032451568_17/?hub=ctvNewsAt11. 2 The responses were taken from The sars Commission Final Report, 2006, Spring of Fear: sars and Public Health in Ontario, Chapter 6: The Nurses’ Survey. Questions q3.13 and q3.8. http://www.sarscommission. ca/report/v3-pdf/Vol3Chp6.pdf. See p. 993 and 991.

chapter eight 1 Mrs Laroza’s career as a nurse placed her family in harm’s way. Her fifteen-year-old son was quarantined for sars even though she had followed mandated safety procedures.

notes to pages 193–242

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2 The largest group of resignations, about 120, occurred at Chang Gung Hospital in Kaohsiung, southern Taiwan. It is part of a large chain of hospitals; nurses were transferred in to avoid a shutdown. 3 Statistics taken from North York General Hospital 2004–5 Annual Report. Information for nygh available from: http://www.nygh.on.ca/ about_us/facts.html. 4 Mobile Army Surgical Hospital (mash) refers to a military medical unit serving as a portable, but fully functional hospital in a combat area of operations. 5 On 25 March, the province closed Scarborough Grace to new patients and outpatients, and officials ordered anyone who had had contact with a symptomatic sars patient into home isolation. Over 3,000 staff, patients, and visitors of York Central Hospital ended up in quarantine.

chapter nine 1 The onset of illness in this case of Probable sars was 25 May 2003; by September the patient was listed as improving. 2 hpfb deals with numerous issues including drug products, medical devices, natural health products, pharmaceuticals, and genetic therapies. 3 A listing of all reports summarized here, with the full reports, can be found on the Ministry of Health and Long-Term Care Web site, “Severe Acute Respiratory Syndrome, Commissions and Reports.” http:// www.health.gov.on.ca/english/providers/program/emu/sars/comm_rpt_ mn.html. 4 The First Interim Report entitled “sars and Public Health in Ontario” dated 15 April 2004, later became Volume 4 in the final report that was released in December 2006. 5 The Second Interim Report was renamed “sars and Public Health Legislation,” dated 5 April 2005, and later became Volume 5 in the final report that was released in December 2006. 6 The period from the beginning of sars1 in Ontario, from 23 February until the beginning of the second wave of sars that began on 22 May 2003. 7 opseu is a trade union that represents approximately 115,000 employees in the public service sectors of the province of Ontario, Canada. 8 cupe represents over 474,000 full- and part-time public sector workers across Canada. The Ontario section of the Canadian Union of Public Employees represents 180,000 public sector workers in Ontario. 9 Prior to adding sars, the list contained cholera, plague, smallpox, and yellow fever as infectious and contagious diseases.

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chapter ten 1 The onset of illness in this case of Probable sars was 25 May 2003; by September the patient was listed as improving. 2 hpfb deals with numerous issues including drug products, medical devices, natural health products, pharmaceuticals, and genetic therapies. 3 A listing of all reports summarized here, with the full reports, can be found on the Ministry of Health and Long-Term Care Web site, “Severe Acute Respiratory Syndrome, Commissions and Reports.” http://www. health. gov.on.ca/english/providers/program/emu/sars/comm_rpt_mn.html. 4 The First Interim Report entitled “sars and Public Health in Ontario” dated 15 April 2004, later became Volume 4 in the final report that was released in December 2006. 5 The Second Interim Report was renamed “sars and Public Health Legislation,” dated 5 April 2005, and later became Volume 5 in the final report that was released in December 2006. 6 The period from the beginning of sars1 in Ontario, from 23 February until the beginning of the second wave of sars that began on 22 May 2003. 7 opseu is a trade union that represents approximately 115,000 employees in the public service sectors of the province of Ontario, Canada. 8 cupe represents over 474,000 full- and part-time public sector workers across Canada. The Ontario section of the Canadian Union of Public Employees represents 180,000 public sector workers in Ontario. 9 Prior to adding sars, the list contained cholera, plague, smallpox, and yellow fever as infectious and contagious diseases.

chapter eleven 1 The Quarantine and Prevention of Disease Ordinance (Chapter 141 of the Laws of Hong Kong) and its subsidiary legislation provide the legal framework for the prevention and control of infectious diseases of public health importance in Hong Kong. New legislation, known as the Prevention of the Spread of Infectious Diseases (Amendment) Regulation 2003 was introduced and added sars to the list of infectious diseases. The amendment came into force on 17 April 2003. See: http://www.sarsexpertcom.gov.hk/english/reports/submissions/files/public_health_ legislation.pdf.

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2 Control measures included improving personal protection by maskwearing, strict adherence to standards of personal hygiene, disinfection of surfaces, and cleansing affected households and housing estates with disinfectants.

chapter twelve 1 The incubation period is also called the latent period or latency period. This is the time elapsed between exposure to a pathogenic organism and when symptoms are first apparent. A distinction is sometimes made between the incubation period (the period between infection and clinical onset of the disease) and the latent period (the time from infection to infectiousness), which is shorter and depends on the disease. For sars the incubation and latency period were the same. 2 Hemagglutinin molecules of avian influenza preferentially bind to only one form of molecule in the host cell membrane (sicalic acid sa-a-2,3-Gal terminated saccharides). The hemagglutinin of humans in the trachea are sa-a-2,6-Gal-terminated saccharides, restricting infection to the lower respiratory tract that does have sa-a-2,3-Gal-terminated saccharides (Kuiken et al., 2006). 3 Canadian officials, well aware of the who warnings for h5n1 and recent avian outbreaks of low pathogenic h7n7, took the precaution of culling millions of chickens and other domestic birds. Flocks were infected with h7n3 in the Fraser Valley, British Columbia, reported on 21 February 2004. The culling was done to prevent this virus from spreading to other bird operations and also to prevent mixing in human and pig populations, with the probability of becoming a new human-to-human influenza. The effort required by the Canadian Food Inspection Agency, with the resulting economic losses to local farmers, was enormous. 4 In February 2003, however, the Netherlands reported outbreaks of influenza A (h7n7) in poultry on several farms that spread to both pigs and humans. A highly pathogenic avian influenza A virus of subtype h7n7, closely related to low pathogenic virus isolates obtained from wild ducks, was detected in domestic chickens. Poultry workers contracted h7n7associated illness, with seventy-nine cases of conjunctivitis (eye infections); six influenza-like illnesses with cough, fever, and muscle aches, and one death reported. It was noted that the influenza-like illnesses were generally mild. The single death occurred when a fifty-seven-year-old

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veterinarian visited a poultry farm affected by high pathogenic avian influenza h7n7 in Teeffelen, The Netherlands, in early April 2003.

chapter thirteen 1 Note that for the Spanish flu the clinical attack rate was variable. The baseline clinical attack rate is assumed to be 25 per cent and is based on values currently available from who in accordance with data from previous pandemics (World Health Organization, 1999). 2 Note that for the Spanish flu the case fatality rate was variable. Recorded case fatality rates varied around the globe. In the US military, where recorded numbers are available, death rates ranged from 5 per cent to 10 per cent and the higher value was used in the calculation (Barry, 2004; Brown, 2005a). 3 Mean, median, and mode are three kinds of common averages used in statistics. The mean is the average number derived by adding up all the numbers and then dividing by the number of numbers. The median is the middle value in the list of numbers. The mode is the value that occurs most often. If no number is repeated, then there is no mode for the list. 4 The federal pandemic plan can be found online at: http://www.safecanada.ca on the Health Protection link and Pandemic Preparedness page. This Web page, http://www.safecanada.ca/link_e.asp? category=10&topic=193 created by the Government of Canada, deals with public safety. It has a comprehensive list of pandemic preparedness policies for various levels of government. 5 The Ontario Health Plan for an Influenza Pandemic was developed by the Ministry of Health and Long-Term Care (2006) and is available at: http://www.health.gov.on.ca/english/providers/program/emu/pan_flu/ pan_flu_plan.html. 6 Even though there is no vaccine for avian flu or a vaccine to combat the next pandemic influenza virus prior to its emergence, officials suggest the yearly flu shot may boost overall immunity, keeping you healthier to fight off pandemic influenza if it ever arrives. 7 This group includes administrators from acute care hospitals, long-term care facilities, nursing homes, private physicians’ offices, home care providers, community care facilities, public health officers, ambulance services, paramedic services, pharmacies, laboratories, and government officers.

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8 This group includes: police, firefighters, the armed forces, key emergency decision makers, elected officials, essential government workers, and disaster services personnel.

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hy

Bibliography

(Note: All Web sites were accessed between October 2004 and September 2008.) Abbot, A. 2004. “Canadian Bird Flu Prompts Mass Cull.” News@ Nature. 6 April. http://www.nature.com/news/2004/040405/full/ 040405-3.html. Abramson, N. and Melton, B. 2000. “Leukocytosis: Basics of Clinical Assessment.” American Family Physician, November, 2053–66. Adamson, B. 2003. President and ceo of North York General Hospital with Ken Morrison, Chair of the Board of North York General Hospital, speaking at the Campbell Commission 143–59. Campbell Commission Report. sars Public Hearings, St. Lawrence Market, Toronto, Ontario September 30. apec Transcripts. ttp://mail.tscript.com/trans/sars/sep_30_03/index.htm. Addleman, K. 2004. “At Last, an Rx for sars.” National Review of Medicine. 30 January, 1(2). http://www.nationalreviewofmedicine. com/issue/2004_01_30/article39.html. Agence France-Presse. 2003. “Nurses: Frontline Troops in sars Battle Fight Social Stigma.” 6 April 2003, Singapore. http://www.singaporewindow.org/sw03/030406a1.htm. Agence France-Presse. 2005. “Two Years On, Beijing’s sars Victims Are Forgotten.” 12 March 2005. http://www.channelnewsasia.com/stories/ afp_asiapacific/view/136999/1/.html. Ahuja, A.T. and Ooi, c.g.c. 2004. Imaging in SARS . Cambridge, uk: Cambridge University Press. Alexander, D.J. 1986. “Avian Diseases – Historical Aspects.” Proceedings of the Second International Symposium on Avian

402

bibliography

Influenza. US Animal Health Association. Richmond, Virginia, United States, 4–13. Alexander, D.J. and Brown I.H. 2000. “Recent Zoonoses Caused by Influenza A Viruses.” Revue Scientifique et Technique (International Office of Epizootics) 19(1): 197–225. Alfa, M.J., Du, T. and Beda, G. 1998. “Survey of Incidence of Clostridium difficile Infection in Canadian Hospitals and Diagnostic Approaches.” Journal of Clinical Microbiology 36(7): 2076–80. Ali, S.H. 2002. “Dealing With Toxicity in the Risk Society: The Case of the Hamilton, Ontario Plastics Recycling Fire.” Canadian Review of Sociology and Anthropology 39(1): 29–48. Al-Nakib,W. “Rhinoviruses.” Myint, S. and Taylor-Robinson, D. (eds.). 1996. Viral and Other Infections of the Human Respiratory Tract. London, England: Chapman and Hall, 131–40. Amaratunga, C. and O’Sullivan, T. 2006. “In the Path of Disasters: Psychosocial Issues for Preparedness, Response, and Recovery.” Prehospital and Disaster Medicine 21(3): 149–55. Amaratunga, C., O’Sullivan, T., Corneil, W., Hardt, J., Gibson, D., McCrann, L., Smith Fowler, H., Phillips, K., Lemyre, L., O’Connor, E., and Krewski, D. 2006a. “Healthcare Workers Reflect on Their Roles in Infectious Disease Outbreaks: Focus Group Report,” submitted to the crti Secretariat, Project 03–0009rd, Canadian Federal Government. Amaratunga, C., O’Sullivan, T., Dow, D., Corneil, W., Phillips, K., Lemyre, L., O’Connor, E., Krewski, D., McCrann, L., and Smith Fowler, H. 2006b. “Caring About Healthcare Workers As First Responders: Enhancing Capacity for Gender-Based Support Mechanisms in Emergency Preparedness Planning: Survey Report Preliminary Descriptive Data,” submitted to the crti Secretariat, Project 03–0009rd, Canadian Federal Government. Amaratunga, C., O’Sullivan, T., Phillips, K., Corneil, W., O’Connor, E., Lemyre, L., and Dow, D. 2007. “Dual-Role Conflict for Healthcare Workers as First Responders in Infectious Disease Outbreaks.” Atlantis (unpublished). American Psychiatric Association.1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Press. Antonio G.E., Wong K.T., Tsui E.L., Chan D.P., Hui D.S., Ng A.W., Shing K.K., Yuen E.H., Chan J.C., and Ahuja A.T. 2005. “Chest Radiograph Scores as Potential Prognostic Indicators in Severe Acute

bibliography

403

Respiratory Syndrome (sars).” American Journal of Roentgenology 184(3): 734–41. Arcavi L. and Benowitz N.L. 2004. “Cigarette Smoking and Infection.” Archives of Internal Medicine 164(20): 2206–16. Armstrong P., Armstrong H., and Scott-Dixon K. 2006. “Critical to Care: Women and Ancillary Work in Healthcare.” http://www.cewhcesf.ca/pdf/health_reform/critical_to_care/CriticaltoCareReport.pdf. Avendano M., Derkach P., and Swan S. 2003. “Clinical Course and Management of sars in Health Care Workers in Toronto: A Case Series.” Canadian Medical Association Journal 168(13): 1649–60. Bai Y., Lin C.C., Lin C.Y., Chen J.Y., Chue C.M., and Chou P. 2004. “Survey of Stress Reactions Among Health Care Workers Involved With the sars Outbreak.” Psychiatric Services 55(9): 1055–57. Barry J.M. 2004. “1918 Revisited: Lessons and Suggestions for Further Inquiry.” Stacey L. Knobler, Alison Mack, Adel Mahmoud, and Stanley M. Lemon (eds.). The Threat of Pandemic Influenza: Are We Ready? Washington dc, National Academies Press, 58–68. Basrur S.V. 2003. Toronto Public Health’s Response to the Severe Acute Respiratory Syndrome (sars) Outbreak 2003. Toronto staff report. 9 September. http://www.toronto.ca/health/pdf/boh_2003sept15_ tph_response_to_sars.pdf. Bates C., Dodd D., and Rousseau N. 2005. On All Frontiers: Four Centuries Of Canadian Nursing. Ottawa, University of Ottawa Press. Baumann A.O., Blythe J.M., and Underwood J.M. 2006. “Surge Capacity and Casualization: Human Resource Issues in the Post-sars Health System.” Canadian Journal of Public Health 97(3): 230–2. BBC News. 2003a. “sars Virus: Are You Affected?” 27 May. http://news.bbc.co.uk/1/hi/talking_point/2903055.stm. BBC News. 2003b. “sars-Like Viruses Found in China.” 4 September 2003. http://news.bbc.co.uk/1/hi/health/3081478.stm. BBC News. 2005. “who Warns of Bird Flu Pandemic.” 23 February. http://news.bbc.co.uk/2/hi/asia-pacific/4289637.stm. BBC News Europe. 2004. “Prepare for Flu Pandemic, Says un.” 18 March. http://news.bbc.co.uk/2/low/europe/3524824.stm. bc Center for Disease Control. 2003. “bc Health Files, Severe Acute Respiratory Syndrome (sars).” British Columbia Ministry of Health. Number 89. http://www.bchealthguide.org/healthfiles/hfile89.stm. Bean B., Moore B.M., Sterner B., Peterson L.R., Gerding D.N., and Balfour H.H. Jr. 1982. “Survival of Influenza Viruses on Environmental Surfaces.” Journal of Infectious Diseases 146(1): 47–51.

404

bibliography

Beigel J.H., Farrar J., Han A.M., Hayden F.G., Hyer R., de Jong M.D., Lochindarat S., Nguyen T.K., Nguyen T.H., Tran T.H., Nicoll A., Touch S., Yuen K.Y.; and Writing Committee of the World Health Organization (who) Consultation on Human Influenza A/h5. 2005. “Avian Influenza A (h5n1) Infection in Humans.” New England Journal of Medicine 353(13): 1374–85. Belanger J. 2003. “sars: Living – and Learning – in China’s Hot Zone.” CHealth. 20 May. http://chealth.canoe.ca/channel_health_news_ details.asp?news_id=7253&news_channel_id=60&channel_id=60& relation_id=2250. Bell D.M. 2004. “Public Health Interventions and sars Spread, 2003.” Emerging Infectious Diseases November; 10(11): 1900–06. Bellavia G.M. and Frone M.R. 2005. “Work-Family Conflict” in Barling J., Kelloway E.K. and Frone M.R.(eds), Handbook of Work Stress, Thousand Oaks, California, Sage Publications. Beltran J., Knight C.T., Zuelzer W.A., Morgan J.P., Shwendeman L.J., Chandnani V.P., Mosure J.C. and Shaffer P.B. 1990. “Core Decompression for Avascular Necrosis of the Femoral Head: Correlation Between Long-term Results and Preoperative mr Staging.” Radiology 175(2):533–36. Berger A., Drosten C., Doerr H.W., Stürmer M., and Preiser W. 2004. “Severe Acute Respiratory Syndrome (sars) – Paradigm of an Emerging Viral Infection.” Journal of Clinical Virology 29: 13–22. Bi S., Qin E., Xu Z., Li W., Wang J., Hu Y., Liu Y., Duan S., Hu J., Han Y., Xu J., Li Y., Yi Y., Zhou Y., Lin W., Xu H., Li R., Zhang Z., Sun H., Zhu J., Yu M., Fan B., Wu Q., Lin W., Tang L., Yang B., Li G., Peng W., Li W., Jiang T., Deng Y., Liu B., Shi J., Deng Y., Wei W., Liu H., Tong Z., Zhang F., Zhang Y., Wang C., Li Y., Ye J., Gan Y., Ji J., Li X., Tian X., Lu F., Tan G., Yang R., Liu B., Liu S., Li S., Wang J., Wang J., Cao W., Yu J., Dong X., and Yang H. 2003. “Complete Genome Sequences of the sars-cov: the bj Group (Isolates bj01–bj04).” Genomics Proteomics Bioinformatics August, 1(3): 180–92. Bolman L.G. and Deal T.E. 1991. Reframing Organizations: Artistry, Choice and Leadership. San Francisco, Jossey-Bass Inc. Boosman F. 2003. “Doctors Count Chu Thi Phuong Among the Fortunate.” 12 April http://www.boosman.com/blog/archives/2003/04/ after_sars.html. Booth C.M. and Stewart T.E. 2005. “Severe Acute Respiratory Syndrome and Critical Care Medicine: the Toronto Experience.” Critical Care Medicine 33(1 Suppl): s53–s60.

bibliography

405

Booth C.M., Matukas L.M., Tomlinson G.A., Rachlis A.R., Rose D.B., Dwosh H.A., Walmsley S.L., Mazzulli T., Avendano M., Derkach P., Ephtimios I.E., Kitai I., Mederski B.D., Shadowitz S.B., Gold W.L., Hawryluck L.A., Rea E., Chenkin J.S., Cescon D.W., Poutanen S.M., and Detsky A.S. 2003. “Clinical Features and Short-term Outcomes of 144 Patients With sars in the Greater Toronto Area.” Journal of the American Medical Association 289(21): 2801–09. Bosman A., Meijer A. and Koopmans M. 2005. “eu: Final Analysis of Netherlands Avian Influenza Outbreaks Reveals Much Higher Levels of Transmission to Humans Than Previously Thought.” Eurosurveillance Weekly, 7 January, http://www.flu.org.cn/news/ 2005174386.htm. Branswell H. 2003. “Troubling Results at sars Meet” 30 April 2003, Canadian Press,http://chealth.canoe.ca/health_news_detail.asp? channel_id=60&news_id=6971. Branswell H. 2003. “Flu Shots for Kids a Judgment Call. New Strain Hits Children Hard. Little Ones Tend to Be Heartier Than Adults but There Are Many Reasons to Immunize.” 30 November 2003, http://www.canada.com/health/coldandflu/story.html?id=db24184498bd-4069-95d3-85e937ad94eb. Brenner L.A., Koehler D.J., Liberman V., and Tversky A. 1996. “Overconfidence in Probability and Frequency Judgments: A Critical Examination.” Organizational Behavior and Human Decision Processes 65(3): 212–19. Bright R.A., Medina M.J., Xu X., Perez-Oronoz G., Wallis T.R., Davis X.M., Povinelli L., Cox N.J., and Klimov A.I. 2005. “Incidence of Adamantane Resistance Among Influenza A (h3n2) Viruses Isolated Worldwide from 1994 to 2005: a Cause for Concern.” Lancet 366(9492): 1175–81. Brown C. and Jones L. 2004. “The Gender Structure of the Nursing Hierarchy: The Role of Human Capital.” Gender, Work and Organization 11(1): 1–25. Brown D. 2005a. “Resurrecting 1918 Flu Virus Took Many Turns.” Washington Post, 10 October, a08. http://www.washingtonpost.com/ wp-dyn/content/article/2005/10/09/ar2005100900932.html. Brown I. 2005b. “Mount Hope: Life and Death at the Hospital.” The Globe and Mail, 19 November. Bugl P. 2004. “History of Epidemics and Plagues,” Outline Notes from auct 140, Epidemics and aids, Fall 2004.University of Hartford, ct. htp://uhavax.hartford.edu/bugl/histepi.htm.

406

bibliography

Burke R.J. and Greenglass E.R. 2000. “Effects of Hospital Restructuring on Full-Time and Part-Time Nursing Staff in Ontario.” International Journal of Nursing Studies 37(2): 163–71. Calman K.C. 1996. “Cancer: Science and Society and the Communication of Risk.” British Medical Journal 313:799–802. Campbell A. 2004. The SARS Commission Interim Report, SARS and Public Health in Ontario. Toronto, Ontario. April 15. http://www.health.gov.on.ca/english/public/pub/ministry_reports/camp bell04/campbell04.pdf. (Campbell Commission Interim Report 1). Campbell A. 2006a. The SARS Commission Final Report. Spring of Fear. SARS and Public Health in Ontario. The Nurses Statistical Survey. Toronto, Ontario. December. http://www.health.gov.on.ca/english/ public/pub/ministry_reports/campbell06/online_rep/SSCover.html. Campbell A. 2006b. The SARS Commission Final Report. Spring of Fear. SARS and Public Health in Ontario. Toronto, Ontario. December. http://www.health.gov.on.ca/english/public/pub/ministry_reports/camp bell06/online_rep/(Campbell Commission Final Report). Canadian Institute for Health Information (cihi). 2005. “Percentage of Male and Female Physicians: Canada 2001–2005,” Canadian Institute for Health Information. http://secure.cihi.ca/cihiweb/en/smdb_figure_3_2005_e.html. Canadian Institute for Health Information (cihi). 2006. “Highlights from the Regulated Nursing Workforce in Canada: 2005,” Canadian Institute for Health Information, http://ww.cihi.ca/nurses. Capua I. and Alexander D.J. 2002. “Avian Influenza and Human Health.” Acta Tropica July; 83(1): 1–6. CBC Marketplace. 2003. “sars: Can a Mask Protect You?” 8 April 2003. Reporter: Wendy Mesley; Producer: Ines Colabrese. http://www. cbc.ca/consumers/market/files/health/sars_masks/index.html. CBC News. 2003a. “sars Declared Reportable Disease.” 25 March http://www.cbc.ca/ottawa/story/sars20030325.html. CBC News. 2003b. “500 Quarantined in Latest sars Scare.” 25 May http://www.cbc.ca/stories/2003/05/24/sars_sat030524. CBC News. 2003c. “Nurses Still Worried About sars Masks.” 18 June. http://www.cbc.ca/story/canada/national/2003/06/18/sars_ masks030618.html. CBC News. 2003d. “Nurse on Passenger Train May Have Spread sars.” 21 April. http://www.cbc.ca/story/canada/national/2003/04/20/ sars_train030420.html.

bibliography

407

News. 2003e. “SARS Questions and Answers.” 14 August. http://www.cbc.ca/news/background/sars/questions.html. CBC News. 2003f. “The Economic Impact of sars.” 8 July. http://www.cbc.ca/news/background/sars/economicimpact.html. CBC News. 2003g. “Toronto to Get Satisfaction of Stones Concert.” 24 June. http://www.cbc.ca/stories/2003/06/24/stones030624. CBC News. 2003h. “sars Benefit Concert, Toronto Rocked.” 30 July. http://www.cbc.ca/news/background/sarsbenefit/index.html. CBC News. 2003i. “Concert Helps Raise Morale of sars Workers.” 31 July. http://toronto.cbc.ca/regional/servlet/View?filename= to_stoneshealth20030731. CBC News. 2003j. “The Economic Impact of sars.” 8 July. http://www.cbc.ca/news/background/sars/economicimpact.html. CBC News. 2003k. “Nurses to Speak Out as sars Hearings Begin.”29 September. http://www.cbc.ca/stories/2003/09/28/sars_ hearings030928. CBC News. 2003l. “Ontario Mishandled sars, Former Senior Official Says.” 12 May. http://www.cbc.ca/story/news/national/2003/05/11 /sars_mishandled030511.html. CBC News. 2004a. “C. Difficile Infection Rates Still Twice the Normal Level, Study Warns.” 21 October. http://www.cbc.ca/story/canada/ national/2004/10/20/c_difficile041020.html. CBC News. 2004b. “ Campbell Commission: Spring of Fear,” 21 April. http://www.cbc.ca/news/background/sars/sars_commission.html. CBC News. 2004d. “Bird Flu Discovered in Texas.” 20 February. http:/ /www.cbc.ca/story/world/national/2004/02/20/Texasflu_040220.html. CBC News. 2005a. “Avian Flu, the Next Pandemic?” 8 March 2005. http://www.cbc.ca/news/background/avianflu/. CBC News. 2005b. “World in ‘Gravest Possible Danger’ from Flu Pandemic: who.” 23 February. http://www.cbc.ca/story/world/ national/2005/02/23/bird-flu-050222.html. CBC News. 2005c. “Antivirals and Avian Flu.” 26 October. http://www.cbc.ca/news/background/avianflu/protection.html. CBC News. 2005d. “Virus Expert Questions Amount of Canada’s Tamiflu Stockpiles.” 27 October. http://www.cbc.ca/story/science/ national/2005/10/27/Tamiflu-051027.html. CBC News. 2005e. “Ottawa Boosts Drug Stockpile for Possible Flu Pandemic.” 4 February. http://www.cbc.ca/story/science/national/2005/ 02/04/flu-050204.html. CBC

408

bibliography

News. 2005f. “Health Officer: Flu Pandemic Could Kill 50,000.” 20 September. http://www.cbc.ca/story/science/national/2005/09/20/ flu-pandemic-20050920.html. CBC News. 2003a. “New sars Cases In Toronto.” 26 May. http://www. cbsnews.com/stories/2003/05/27/health/main555588.shtml. CBC News. 2003e. “Two New Theories On sars.” May 23. http://www. cbsnews.com/stories/2003/05/23/health/main555382.shtml. CBC News. 2003b. “China Denies sars Cover-Up, Beijing.” May 30. http://www. cbsnews.com/stories/2003/06/02/health/main 556591.shtml. CBC News. 2003c. “sars Numbers Spike In Taiwan.” May 22. http:// www.cbsnews.com/stories/2003/05/06/health/main552446.shtml. CBC News. 2003d. “Canada’s sars Struggles Continue.” May 29. http:// www.cbsnews.com/stories/2003/05/30/health/main556274.shtml. CBC News Online. 2004c. “Walker Report.” 23 April. CBC News. http://www.cbc.ca/news/background/sars/walkerreport.html. cdc China. 2003. “Severe Acute Respiratory Syndrome (sars) Statistics. Mainland China, Up to 17 May 2003.” http://www.chinacdc.net.cn/ default.asp. Ceci C. 2004. “Gender, Power, Nursing: A Case Analysis.” Nursing Inquiry 11(2): 72–81. Centers for Disease Control and Prevention. 2003a. “Update: Outbreak of Severe Acute Respiratory Syndrome – Worldwide, 2003.” (cdc) Morbidity and Mortality Weekly Report, 28 March, 52(12): 241–6, 248. Centers for Disease Control and Prevention. 2003b. “Cluster of Severe Acute Respiratory Syndrome Cases Among Protected Health-Care Workers – Toronto, Canada, April 2003.” Morbidity and Mortality Weekly Report, 16 May, 52(19): 433–6. Centers for Disease Control and Prevention. 2003c. “Use of Quarantine to Prevent Transmission of Severe Acute Respiratory Syndrome – Taiwan, 2003.” Morbidity and Mortality Weekly Report, 25 July, 52(29): 680–83. Centers for Disease Control and Prevention. 2004. “Cases of Influenza A (h5n1) – Thailand, 2004.” Morbidity and Mortality Weekly Report, 13 February, 53:100–03. Chan A.O.M. and Huak C.Y. 2004. “Psychological Impact of the 2003 Severe Acute Respiratory Syndrome Outbreak on Health Care Workers in a Medium Size Regional General Hospital in Singapore.” Occupational Medicine 54: 190–96. CBC

bibliography

409

Chan K.S., Zheng J.P., Mok Y.W., Li Y.M., Liu Y.N., Chu C.M., and Ip M.S. 2003. “sars: Prognosis, Outcome and Sequelae.” Respirology November, 8(suppl. 1): S36. Chan P.K. 2002. “Outbreak of Avian Influenza A (h5n1) Virus Infection in Hong Kong in 1997.” Clinical Infectious Diseases 34: S58–64. Chan S., Chong, H.J., Howard T., Kimball S., and Soule M. 2004. “Notes from Bio160: Development of Vaccines to Infectious Diseases, April 2004.” Rhode Island, Brown University. http://www.brown.edu/ Courses/Bio_160/Projects2004/sars/sars-cov/vaccine.htm. Chealth. 2003. “T.O. sars Outbreak Wanes.” Canadian Press. 23 June. http://chealth.canoe.ca/health_news_detail.asp?channel_id=60&news_ id= 7675 (Tanya Cholakov, spokeswoman for Ontario’s Ministry of Health). Chen H., Deng G., Li Z., Tian G., Li Y., Jiao P., Zhang L., Liu Z., Webster R.G., and Yu K. 2004. “The Evolution of h5n1 Influenza Viruses in Ducks in Southern China.” Proceedings of the National Academy of Sciences of the United States of America 101(28):10452–7. Chen K.T., Twu S.J., Chang H.L., Wu Y.C., Chen C.T., Lin T.H., Olsen S.J., Dowell S.F., and Su I.J. 2005. “sars in Taiwan: an Overview and Lessons Learned.” International Journal of Infectious Diseases 9(2): 77–85. Cherney E. and Heinzl M. 2003. “Toronto Doctors Race To Get Handle on sars: New Virus Caught City Off Guard In Days Before Global Health Alert.” The Wall Street Journal, 8 April. Choi K.W., Chau T.N., Tsang O., Tso E., Chiu M.C., Tong W.L., Lee P.O., Ng T.K., Ng W.F., Lee K.C., Lam W., Yu W.C., Lai J.Y., Lai S.T., and Princess Margaret Hospital sars Study Group. 2003. “Outcomes and Prognostic Factors in 267 Patients With Severe Acute Respiratory Syndrome in Hong Kong.” Annals of Internal Medicine 4 November, 139(9): 715–23. Chotpitayasunondh T., Ungchusak K., Hanshaoworakul W., Chunsuthiwat S., Sawanpanyalert P., Kijphati R., Lochindarat S., Srisan P., Suwan P., Osotthanakorn Y., Anantasetagoon T., Kanjanawasri S., Tanupattarachai S., Weerakul J., Chaiwirattana R., Maneerattanaporn M., Poolsavathitikool R., Chokephaibulkit K., Apisarnthanarak A., and Dowell S.F. 2004. “Human Disease from Influenza A (h5n1), Thailand, 2004.” Emerging Infectious Diseases. February 2005, 11(2): 201–09.

410

bibliography

Christian M.D., Poutanen S.M., Loutfy M.R., Muller M.P., and Low D.E. 2004. “Severe Acute Respiratory Syndrome.” Clinical Infectious Diseases 38(10): 1420–7. cidrap News. 2003. “sars Tests Unreliable Early in Illness, who Says.” 2 June. http://www.cidrap.umn.edu/cidrap/content/other/sars/ news/june0203sars.html. CNN News. 2003. “Toronto Traces sars Cases to 96-year-old Patient. How Hospitalized Man Caught Disease Remains Unclear.” 27 May. http://www.cnn.com/2003/health/05/27/sars.wrap/. cnw Group. 2005. The Independent sars Commission’s Second Interim Report, to be completed in early 2005. http://www.newswire.ca/en/ releases/archive/December2004/01/c9501.html. Cohen M.L. 2000 “Changing Patterns of Infectious Disease.” Nature 406(6797): 762–7. Cook A.M., Dzik-Jurasz A.S., Padhani A.R., Norman A., and Huddart R.A. 2001. “The Prevalence of Avascular Necrosis in Patients Treated With Chemotherapy for Testicular Tumours.” British Journal of Cancer 85: 1624–6. Cormier Z. 2003. “Getting the Low Down, u of t’s Makeshift sars Czar Speaks About the Outbreak.” The Varsity, 6 October. http:// www.thevarsity.ca/media/storage/paper285/news/2003/10/06/Feature/ Getting.The.Low.Down- 519696.shtml?norewrite200607121651& sourcedomain=www.thevarsity.ca. Covello V. 1992. “Informing People about Risks from Chemicals, Radiation, and Other Toxic Substances: A Review of Obstacles to Public Understanding and Effective Risk Communication.” Prospects and Problems in Risk Communication. William Leiss ed., Waterloo, University of Waterloo Press. Crane L. 2002. “The 1918 Spanish Flu Pandemic, and the Hong Kong Incident.” http://www.ninthday.com/spanish_flu.htm. Crowe K. 2003. “ sars Behind the Mask.” CBC News. 19 November. http://www.cbc.ca/news/background/sars/behindthemask.html. CTV News. 2003a. “T.O. Nurses Said They Warned of New sars Cases,” 27 May. http://www.ctv.ca/servlet/ArticleNews/story/ ctvNews/1054032451568_17/?hub=CTV NewsAt11. CTV News. 2003b. “who Travel Advisory Met With Anger, Disbelief,” 23 April. http://www.ctv.ca/servlet/ArticleNews/story/ctvNews/ 1051101880715_222/. CTV News. 2004a. “Ontario Nurse Launches sars Lawsuit.” 23 February. http://www.ctv.ca/servlet/ArticleNews/story/ctvNews/ 20040223/ontario_sars_lawsuit_040223/20040223/.

bibliography

411

News. 2004b. “Mass Cull Ordered to Halt Bird Flu In bc.” 5 April. http://www.ctv.ca/servlet/ArticleNews/story/ctvNews/108117825316 6_ 76587453?s_name=&no_ads=. CTV News. 2005. “Nurses Allege Ontario Late With sars Warning.” Canadian Press. 9 April. http://www.ctv.ca/servlet/ArticleNews/story/ ctvNews/1113064132198_83/?hub=Canada. Daily News. 2003. “Toronto sars-free? Experts Say Probably.” Halifax, Nova Scotia. Canadian Press. 10 July. Dara S.I., Ashton R.W., Farmer J.C., and Carlton P.K. Jr. 2005. “Worldwide Disaster Medical Response: An Historical Perspective.” Critical Care Medicine January; 33(1) Supplement: S2–S6. Dave B. 2004. “sars One Year On.” Student BMJ April, 12:133–176. Davies P. 2003 “The Cycle of Death, sars Is Only the Latest in a String of Epidemics to Emerge from Southern China.” Time Asia, 14 April. http://www. time.com/time/asia/magazine/article/ 0,13673,501030414-441240,00.html. de Arriba M.L., Carvajal A., Pozo J., and Rubio P. 2002. “Lymphoproliferative Responses and Protection in Conventional Piglets Inoculated Orally With Virulent or Attenuated Porcine Epidemic Diarrhoea Virus.” Journal of Virological Methods 105(1): 37–47. de Castro Jr. I. 2003. “Hysterical Over sars.” Newsbreak, 26 May. http://www.inq7.net/nwsbrk/2003/may/26/nbk_4-1.htm. de Souza Porto M.F. and de Freitas C.M. 1995. “Major Chemical Accidents in Industrializing Countries: The Socio-Political Amplification of Risk.” Risk Analysis 16(1):19–29. DellaContrada J. 2003. “sars Will Appear Again, as Will Other Viruses Incubating in ‘Pandora’s Boxes’ Around the World, ub Expert Predicts.” University at Buffalo. 13 August. http://www.buffalo.edu/ news/fast-execute.cgi/article-page.html?article=63550009. Dixon B. 2003. “Editors Sound the sars Alarm Bells.” Current Biology 13: 339–40. Dodd D. and Gorham D. 1994. Caring and Curing: Historical Perspectives on Women and Healing in Canada. Ottawa, University of Ottawa Press. Doheny K. 2004. “sars Review Shows Toronto Fought a Good Fight.” 2 June http://www.baptistregional.com/news/healthscout/?id=519301. Donnelly C.A., Ghani A.C., Leung G.M., Hedley A.J., Fraser C., Riley S., Abu-Raddad L.J., Ho L.M., Thach T.Q., Chau P., Chan K.P., Lam T.H., Tse L.Y., Tsang T., Liu S.H., Kong J.H., Lau E.M., Ferguson N.M., and Anderson RM. 2003. “Epidemiological Determinants of CTV

412

bibliography

Spread of Causal Agent of Severe Acute Respiratory Syndrome in Hong Kong.” Lancet 361(9371): 1761–6. Donner L. 2003. “Including Gender in Health Planning – A Guide for Regional Health Authorities.” Winnipeg, Canada. Prairie Women’s Health Centre of Excellence. http://www.pwhce.ca/pdf/gba.pdf. Downie J.C. and Laver W.G. 1973. “Isolation of a Type A Influenza Virus from an Australian Pelagic Bird.” Virology 51(2): 259–69. Drache D., Feldman S., and Clifton D. “Media Coverage of the 2003 Toronto sars Outbreak: a Report on the Role of the Press in a Public Crisis.” National Microbiology Laboratory, Current Science of sars Symposium, held 1–2 December 2003, Winnipeg, Manitoba. http://www.robarts.yorku.ca/pdf/gcf_mediacoveragesarsto.pdf. Drosten C., Gunther S., Preiser W., van der Werf S., Brodt H.R., Becker S., Rabenau H., Panning M., Kolesnikova L., Fouchier R.A., Berger A., Burguiere A.M., Cinatl J., Eickmann M., Escriou N., Grywna K., Kramme S., Manuguerra J.C., Muller S., Rickerts V., Sturmer M., Vieth S., Klenk H.D., Osterhaus A.D., Schmitz H., and Doerr H.W. 2003. “Identification of a Novel Coronavirus in Patients With Severe Acute Respiratory Syndrome.” New England Journal of Medicine 15 May 348(20):1967–76. Dwortzan M. and Saltus R. 2003. “hsph Alumnus on the Ground With sars Epidemic in Toronto.” Harvard Public Health Now, 16 May. Boston, ma, usa. http://www.hsph.harvard.edu/now/may16/. Dwosh H.A., Hong H.H., Austgarden D., Herman S., and Schabas R. 2003. “Identification and Containment of an Outbreak of sars in a Community Hospital.” Canadian Medical Association Journal 168(11): 1415–20. Eccles R. 2002. “An Explanation for the Seasonality of Acute Upper Respiratory Tract Viral Infections.” Acta Otolaryngologica Stockholm. 122:183–91. Eggertson L. and Sibbald B. 2004. “Hospitals Battling Outbreaks of C. Difficile.” Canadian Medical Association Journal 171(1): 19–21. eid Weekly Updates. 2004. “Emerging and Reemerging Infectious Diseases, Region of the Americas, Outbreak of sars in China, Sequence of Events, 2004.” 2 (17). 29 April. http://www.paho.org/ English/ad/dpc/cd/eid-eer-29-apr-2004.htm. Eleventh Hour Time Lines. 2003. “Spread of Severe Acute Respiratory Syndrome: 2003.” http://www.e11th-hour.org/resources/timelines/ sars.04.03.html.

bibliography

413

Enarson E. and Morrow B. 1998. The Gendered Terrain of Disaster: Through Women’s Eyes. Westport, Connecticut, Praeger Publishers. Enserink M. 2003a. “Infectious Diseases. Searching for a sars Agenda.” Science 300:1487–88. Enserink M. 2003b. “Breakthrough of the Year. sars: a Pandemic Prevented.” Science 302(5653): 2045. Epstein S. 1994. “Integration of the Cognitive and the Psychodynamic Unconscious.” American Psychologist 49:709–24. Evans D. 2000. “Epidemiology and Etiology of Occupational Infectious Diseases.” Couturier A., ed. Occupational and Environmental Infectious Diseases: Epidemiology, Prevention and Clinical Management. Beverly Farms, ma. oem Press. Evans J. and Frank B. 2003. “Contradictions and Tensions: Exploring Relations of Masculinities in the Numerically Female-Dominated Nursing Profession.” Journal of Men’s Studies 11(3): 277–85. Evenson B. 2003. “Is sars With Us for Good?” National Post. 5 April. http://www.canada.com/health/story.html?id=9c736223-d5df-46a0812b-1bb7dae63e8c. Feldman M.J., Lukins J.L., Verbeek P.R, MacDonald R.D., Burgess R.J., and Schwartz B. 2004. “Half-a-Million Strong: The Emergency Medical Services Response to a Single-Day, Mass-Gathering Event.” Prehospital and Disaster Medicine 19(4): 287–96. Finucane M.L., Peters E., and Slovic P. 2003. “Judgment and Decision Making: The Dance of Affect and Reason.” S.L. Schneider and J. Shanteau, (eds.). Emerging Perspectives on Judgment and Decision Research. Cambridge, uk: Cambridge University Press. Fischhoff B. 1982. “Debiasing.” D. Kahneman, P. Slovic, and A. Tversky eds, Judgment Under Uncertainty: Heuristic and Biases. Cambridge, uk: Cambridge University Press. Fischhoff B. 1985. “Managing Risk Perceptions.” Issues in Science and Technology 2: 83–96. Fitzroy N. 2003. “sars Affecting Nurses.” Australian Nursing Journal 11(1):15. Flynn J., Slovic P. and Kunreuther H. 2001. Risk, Media and Stigma: Understanding Public Challenges to Modern Science and Technology. London, uk: Earthscan Publications Ltd. Fouchier R.A., Hartwig N.G., Bestebroer T.M., Niemeyer B., de Jong J.C., Simon J.H., and Osterhaus A.D. 2004. “A Previously Undescribed Coronavirus Associated With Respiratory Disease in

414

bibliography

Humans.” Proceedings of the National Academy of Sciences of the United States of America 101(16): 6212–16. Fouchier R.A., Schneeberger P.M., Rozendaal F.W., Broekman J.M., Kemink S.A., Munster V., Kuiken T., Rimmelzwaan G.F., Schutten M., Van Doornum G.J., Koch G., Bosman A., Koopmans M., and Osterhaus A.D. 2004. “Avian Influenza A Virus (h7n7) Associated With Human Conjunctivitis and a Fatal Case of Acute Respiratory Distress Syndrome.” Proceedings of the National Academy of Sciences of the United States of America 101(5):1356–61. Fowler R.A., Lapinsky S.E., Hallett D., Detsky A.S., Sibbald W.J., Slutsky A.S., Stewart T.E., and Toronto sars Critical Care Group. 2003. “Critically Ill Patients With Severe Acute Respiratory Syndrome.” Journal of the American Medical Association 290(3): 367–73. Fox R. 1998. “Viruses.” Lecture Notes for Biology 111, Lander University. http://www.lander.edu/rsfox/111virus.html. Frazer J.G. 1922. “The Golden Bough. A Study in Magic and Religion.” Abridged Edition. New York: MacMillan. Frazer J.G. 1959. “The New Golden Bough: A Study in Magic and Religion.” New York: MacMillan. Frewer L.J., Miles S. and Marsh R. 2002. “The Media and Genetically Modified Foods: Evidence in Support of Social Amplification of Risk.” Risk Analysis 22(4): 701–11. Geohive. 2003. Population data. http://www.geohive.com/charts/city_ notagg.php. Glasser J., Meltzer M. and Levin B. 2004. “Mathematical Modeling and Public Policy: Responding to Health Crises.” Emerging Infectious Diseases 10(11): 2050–1. Godfrey T. 2003. “Customs Threatens sars Walkout.” Sun Media. 25 April. http://chealth.canoe.ca/channel_health_news_details.asp? news_ id=6838& news_channel_id=60&channel_id=60&relation_id= 2250. Godfrey T. 2004. “Feds Pull sars Scanners.” The Toronto Sun, 7 December. http://cnews.canoe.ca/cnews/Canada/2004/12/07/ 769997.html. Goel V. 2004a. “What Do We Do With the sars Reports?” Healthcare Quarterly 7(3): 28–41. Goel V. 2004b. “What Do We Do With the sars Reports? Sidebar: Beyond the Mask.” Healthcare Quarterly 7(3): 28–41. Goodman J.L., Dennis D.T., and Sonenshine D.E. 2005. Chapter 1: “Overview of Tick-Borne Infections of Humans.” Tick-Borne Diseases

bibliography

415

of Humans. Goodman J.L., Dennis D.T., and Sonenshine D.E. (eds). Washington, dc: asm Press. Gorman O.T., Bean W.J., Kawaoka Y., and Webster R.G. 1990. “Evolution of the Nucleoprotein Gene of Influenza A Virus.” Journal of Virology 64:1487–97. Goto H. and Kawaoka Y. 1998. “A Novel Mechanism for the Acquisition of Virulence by a Human Influenza A Virus.” Proceedings of the National Academy of Sciences of the United States of America 95(17): 10224–8. Grant K. 2002. “Gender-Based Analysis: Beyond the Red Queen Syndrome.” Centres of Excellence for Women’s Health Research Bulletin 2(3): 16–20. Green C.H. and Brown R.A. 1980. “Through a Glass Darkly: Perceiving Perceived Risks to Health and Safety.” Prepared for the Workshop on Perceived Risk, Central Directorate on Environmental Pollution. Eugene, Oregon. Gregory R.S. and Satterfield T.A. 2002. “Beyond Perception: The Experience of Risk and Stigma in Community Contexts.” Risk Analysis 22(2): 347–58. Griffin D. and Tversky A. 1992. “The Weighing of Evidence and the Determinants of Confidence.” Cognitive Psychology 24:411–35. Griffith J.F., Antonio G.E., Kumta S.M., Hui D.S., Wong J.K., Joynt G.M., Wu A.K., Cheung A.Y., Chiu K.H., Chan K.M., Leung P.C., and Ahuja A.T. 2005. “Osteonecrosis of Hip and Knee in Patients With Severe Acute Respiratory Syndrome Treated With Steroids.” Radiology 235(1): 168–75. Guan Y., Poon L.L., Cheung C.Y., Ellis T.M., Lim W., Lipatov A.S., Chan K.H., Sturm-Ramirez K.M., Cheung C.L., Leung Y.H., Yuen K.Y., Webster R.G., and Peiris J.S. 2004. “h5n1 Influenza: a Protean Pandemic Threat.” Proceedings of the National Academy of Sciences of the United States of America 101: 8156–61. Guan Y., Shortridge K.F., Krauss S., and Webster RG. 1999. “Molecular Characterization of h9n2 Influenza Viruses: Were They the Donors of the ‘Internal’ Genes of h5n1 Viruses in Hong Kong?” Proceedings of the National Academy of Sciences of the United States of America 96:9363–7. Guan Y., Zheng B.J., He Y.Q., Liu X.L., Zhuang Z.X., Cheung C.L., Luo S.W., Li P.H., Zhang L.J., Guan Y.J., Butt K.M., Wong K.L., Chan K.W., Lim W., Shortridge K.F., Yuen K.Y., Peiris J.S., and Poon L.L. 2003. “Isolation and Characterization of Viruses Related to the

416

bibliography

sars Coronavirus from Animals in Southern China.” Science 302(5643): 276–8. Habib M. 2003a. “Health-care Workers Rally for Better sars Protection in Hospitals, Inquiry.” Canadian Press. 4 June. http://mediresource. sympatico.ca/channel_health_news_detail.asp?channel_id=132& menu_item_id=4&news_id= 1487. Habib M. 2003b. “Health Workers Rally for Better sars Protection.” Kingston, Ontario: Kingston Whig-Standard, 5 June. http://proquest. umi.com/pqdweb?index=10&did=346069931&Srch Mode=1&sid= 2&Fmt=3&VInst= prod&vtype=pqd&rqt=309&VName= pqd&ts=1191699385&clientId =3345. Hammond K.R. 2000. “Coherence and Correspondence Theories In Judgment and Decision Making.” T. Connolly, H.R. Arkes, and K.R. Hammond (eds). Judgment and Decision Making, Second Edition. New York: Cambridge University Press. Health Canada. 2000.”Health Canada’s Gender-Based Analysis Policy.” http://www.hc-sc.gc.ca/women. Health Canada. 2003. “Exploring Concepts of Gender and Health.” http://www.hc-sc.gc.ca/english/women/exploringconcepts.htm. Health Canada. 2004. “It’s Your Health. sars.” http://www.hc-sc.gc.ca/ english/iyh/diseases/sars.html. Health Canada. 2006. Health Products and Food Branch – Selection of Expert Advisory Panels. Drugs and Health Products. http://www.hc-sc. gc.ca/dhp-mps/md-im/activit/sci-consult/implant- breast-mammaire/ panel_fact-sheet_e.html Heaney C.A. and Israel B.A. 2002. “ Social Networks and Social Support.” Glanz K., Rimer B.K., and Lewis F.M. (eds). Health Behavior and Health Education: Theory, Research and Practice, Third Edition. San Francisco: John Wiley and Sons Inc. Henry B. 2004. “Final Report of the Infection Control Standards Task Force: Non-Acute Institutional Settings. Preventing Respiratory Illnesses, Protecting Residents and Staff In Non-Acute Care Institutions. Recommended Infection Control and Surveillance Standards for Febrile Respiratory Illness (fri) in Non-Outbreak Conditions.” March. http://www.health.gov.on.ca/english/ providers/ program/pubhealth/sars/docs/docs3/report_taskforce_non_acute_ 031104.pdf. Hetherington R. 2005. “Protecting Yourself and Your Family: Bird Flu Update.” 20 October. http://www.aboutkidshealth.ca/ofhc/news/ ftr/4425.asp.

bibliography

417

Hinshaw V.S. and R.G. Webster. 1982. “The Natural History of Influenza A Viruses” A. S. Beare (ed.), Basic and Applied Influenza Research. Boca Raton, Florida: crc Press Inc Hinshaw V.S., Webster R.G., and Turner B. 1980. “The Perpetuation of Orthomyxoviruses and Paramyxoviruses in Canadian Waterfowl.” Canadian Journal of Microbiology 26: 622–9. Ho A.S., Sung J.J., and Chan-Yeung M. 2003. “An Outbreak of Severe Acute Respiratory Syndrome Among Hospital Workers in a Community Hospital in Hong Kong.” Annals of Internal Medicine 139: 564–7. Ho K.Y., Singh K.S., Habib A.G., Ong B.K., Lim T.K., Ooi E.E., Sil B.K., Ling A.E., Bai X.L., and Tambyah P.A. 2004. “Mild Illness Associated With Severe Acute Respiratory Syndrome Coronavirus Infection: Lessons From a Prospective Seroepidemiologic Study of Health-care Workers in a Teaching Hospital in Singapore.” Journal of Infectious Diseases 189(4): 642–7. Ho T.-Y., Wu S.-L., Cheng S.-E., Wei Y.-C., Huang S.-P., and Hsiang C.-Y. 2004. “Antigenicity and Receptor-Binding Ability of Recombinant sars Coronavirus Spike Protein.” Biochemical and Biophysical Research Communications 313: 938–47. Hoffmann E., Stech J., Leneva I., Krauss S., Scholtissek C., Chin P.S., Peiris M., Shortridge K.F., and Webster R.G. 2000. “Characterization of the Influenza A Virus Gene Pool in Avian Species in Southern China: Was h6n1 a Derivative or a Precursor of h5n1?” Journal of Virology 74: 6309–15. Hogan D.E. and Burnstein J.L. 2002. “Basic Physics of Disasters.” Disaster Medicine. Hogan D.E., Burnstein J.L. (eds). Philadelphia: Lippincott Williams and Wilkins. Holmes K.V. 2001. “Coronaviruses.” Fields B.N., Knipe D.M., Howley P.M. (eds) Virology. Philadelphia: Lippincott Williams and Wilkins. Holmes KV. 2003. “sars Coronavirus: a New Challenge for Prevention and Therapy.” Journal of Clinical Investigation 111: 1605–9. Hong Kong Department of Health. 2003. “Outbreak of Severe Acute Respiratory Syndrome (sars) at Amoy Gardens, Kowloon Bay, Hong Kong. Main Findings of the Investigation.” 17 April. http://www.info.gov.hk/info/ap/pdf/amoy_e.pdf. Horimoto T., Fukuda N., Iwatsuki-Horimoto K., Guan Y., Lim W., Peiris M., Sugii S., Odagiri T., Tashiro M., and Kawaoka Y. 2004. “Antigenic Differences Between h5n1 Human Influenza Viruses Isolated in 1997 and 2003.” Journal of Veterinary Medical Science 66:303–5.

418

bibliography

Hsu L.Y., Lee C.C., Green J.A., Ang B., Paton N.I., Lee L., Villacian J.S., Lim P.L., Earnest A., and Leo Y.S. 2003. “Severe Acute Respiratory Syndrome (sars) in Singapore: Clinical Features of Index Patient and Initial Contacts.” Emerging Infectious Diseases 9(6): 713–7. Huber O., Wider R., and Huber O. 1997. “Active Information Search and Complete Information Presentation in Naturalistic Risky Decision Tasks.” Acta Psychologica 95:15–29. Hung L.S. 2003. “The sars Epidemic in Hong Kong: What Lessons Have We Learned?” Journal of the Royal Society of Medicine 96:374–8. iapa. 2003. “Frequently Asked Questions: sars.” Industrial Accident Prevention Association. http://www.iapa.ca/pdf/faq_sars%20.pdf. Isakbaeva E.T., Khetsuriani N., Suzanne Beard R., Peck A., Erdman D., Monroe S.S., Tong S., Ksiazek T.G., Lowther S., Pandya-Smith I., Anderson L.J., Lingappa J., Widdowson M.-A., and the sars Investigation Group. 2004. “sars-Associated Coronavirus Transmission, United States.” Emerging Infectious Diseases 10(2): 225–31. Jackson B., Pederson A., and Boscoe M. 2006. “Gender-Based Analysis and Wait Times: New Questions, New Knowledge.” http://www.cewhcesf.ca/pdf/health_reform/genderWaitTimesen.pdf. Jefferson T., Rivetti D., Rivetti A., Rudin M., Di Pietrantonj C., and Demicheli V. 2005. “Efficacy and Effectiveness of Influenza Vaccines in Elderly People: a Systematic Review.” Lancet 366(9492):1165–74. Jiang Y., Xu J., Zhou C., Wu Z., Zhong S., Liu J., Luo W., Chen T., Qin Q., and Deng P. 2005. “Characterization of Cytokine/Chemokine Profiles of Severe Acute Respiratory Syndrome.” American Journal of Respiratory and Critical Care Medicine 171(8):850–7. Johnson N.P. and Mueller J. 2002. “Updating the Accounts: Global Mortality of the 1918–1920 ‘Spanish’ Influenza Pandemic.” Bulletin of the History of Medicine, 76(1): 105–15. Johnston S. and Holgate S. 1996. “Epidemiology of Viral Respiratory Infections.” Myint S., Taylor-Robinson D., (eds.) Viral and Other Infections of the Human Respiratory Tract. London, uk: Chapman and Hall. Karlstrom O., Fryklund B., Tullus K., and Burman L.G. 1998. “A Prospective Nationwide Study Of Clostridium Difficile-Associated Diarrhea in Sweden.” Clinical Infectious Diseases 26(1): 141–5. Kasperson R.E., Jhaveri N., and Kasperon J.X. 2001. “Stigma and Social Amplification of Risk: Towards a Framework of Analysis” in Flynn J.,

bibliography

419

Slovic P., Kunreauther H., (eds.). Risk, Media and Stigma: Understanding Public Challenges to Modern Science and Technology. London, uk: Earthscan Publications Ltd. Kasperson R.E., Renn O., Slovic P., Brown H.S., Emel J., Goble R., Kasperson J.X., and Ratick S.J. 1988.”The Social Amplification of Risk: A Conceptual Framework.” Risk Analysis 8(2): 177–87. Kettle D.S. 1995. Medical and Veterinary Entomology, Second Edition. Wallingford, uk: cab International. Khan A.S., Tshioko F.K., Heymann D.L., Le Guenno B., Nabeth P., Kerstiëns B., Fleerackers Y., Kilmarx P.H., Rodier G.R., Nkuku O., Rollin P.E., Sanchez A., Zaki S.R., Swanepoel R., Tomori O., Nichol S.T., Peters C.J., Muyembe-Tamfum J.J., and Ksiazek T.G. 1999. “The Re-Emergence of Ebola Hemorrhagic Fever, Democratic Republic of the Congo, 1995.” Commission de Lutte contre les Epidémies à Kikwit. Journal of Infectious Diseases 179 Suppl 1:s76–86. Knowles S.R., Phillips E.J., Dresser L., and Matukas L. 2003. “Common Adverse Events Associated With the Use of Ribavirin for Severe Acute Respiratory Syndrome in Canada.” Clinical Infectious Diseases 37(8): 1139–42. Kondro W. 2003. “Canada Fury at who Ban.” Lancet 361(9368):1525. Koopmans M., Wilbrink B., Conyn M., Natrop G., van der Nat H., Vennema H., Meijer A., van Steenbergen J., Fouchier R., Osterhaus A., and Bosman A. 2004. “Transmission of h7n7 Avian Influenza A Virus to Human Beings During a Large Outbreak in Commercial Poultry Farms in the Netherlands.” Lancet 363(9409):587–93. Koren G., King S., Knowles S., and Phillips E. 2003. “Ribavirin in the Treatment of sars: A New Trick for an Old Drug?” Canadian Medical Association Journal 168(10): 1289–92. Krawchuk C. 2003. “Learning from sars: Renewal of Public Health in Canada.” cbc News. 7 October. http://www.cbc.ca/news/background/ sars/sars_report.html. Krewski D., Slovic P., Bartlett S., Flynn J., and Mertz C.K. 1995. “Health Risk Perception in Canada i: Rating Hazards, Sources of Information, and Responsibility for Risk Protection.” Human and Ecological Risk Assessment 1: 117–32. Ksiazek T.G., Erdman D., Goldsmith C.S., Zaki S.R., Peret T., Emery S., Tong S., Urbani C., Comer J.A., Lim W., Rollin P.E., Dowell S.F., Ling A.E., Humphrey C.D., Shieh W.J., Guarner J., Paddock C.D., Rota P., Fields B., DeRisi J., Yang J.Y., Cox N., Hughes J.M., LeDuc J.W., Bellini W.J., Anderson L.J., and sars Working Group. 2003. “A

420

bibliography

Novel Coronavirus Associated With Severe Acute Respiratory Syndrome.” New England Journal of Medicine 348(20): 1953–66. Kuiken T., Holmes E.C., McCauley J., Rimmelzwaan G.F., Williams C.S., and Grenfell B.T. 2006. “Host Species Barriers to Influenza Virus Infections.” Science 312(5772): 394–7. Kunreuther H. 2002. “Risk Analysis and Risk Management in an Uncertain World.” Risk Analysis 22: 655. Kunreuther H., Novemsky N., and Kahneman D. 2001. “Making Low Probabilities Useful.” Journal of Risk and Uncertainty 23(2): 103–20. Lagro-Janssen T. 2007. “Sex, Gender and Health: Developments in Research.” European Journal of Women’s Studies 14(1):9–20. Lai M.M. and Holmes K.V. 2001. “Coronaviridae: the Virus and Their Replication.” Knipe D.M., Howley P.M., Griffin D.E., Lamb R.A., Martin M.A., Roizman B., et al., (eds.). Fields Virology, Fourth Edition. Philadelphia: Lippincott William and Wilkins. Lanard J. and Sandman P.M. 2003. “sars Communication: What Singapore Is Doing Right.” The Straits Times, 6 May. http://www. psandman.com/articles/sars-2.htm. Langohr I.M., Stevenson G.W., Thacker H.L., and Regnery R.L. 2004. “Extensive Lesions of Monkeypox in a Prairie Dog (Cynomys sp).” Veterinary Pathology 41(6): 702–7. Lashley F.R. and Durham J.D. 2002. Emerging Infectious Diseases: Trends and Issues. New York: Springer Publishing Company. Lau J.T., Yang X., Tsui H., and Kim J.H. 2003. “Monitoring Community Responses to the sars Epidemic in Hong Kong: From Day 10 to 62.” Journal of Epidemiology and Community Health 57: 864–70. Lau J.T.F., Tsui H., Lau M., and Yang X. 2004. “sars Transmission, Risk Factors, and Prevention in Hong Kong.” Emerging Infectious Diseases 10:587–92. Le Q.M., Kiso M., Someya K., Sakai Y.T., Nguyen T.H., Nguyen K.H., Pham N.D., Ngyen H.H., Yamada S., Muramoto Y., Horimoto T., Takada A., Goto H., Suzuki T., Suzuki Y., and Kawaoka Y. 2005. “Avian Flu: Isolation of Drug-Resistant h5n1 Virus.” Nature 437(7062): 1108. Leahy S. 2003. “sars Exposes Cracks in Hospitals System.” Inter Press Service News Agency. 25 June. http://ipsnews.net/interna.asp?idnews= 18973. Lee N., Hui D., Wu A., Chan P., Cameron P., Joynt G.M., Ahuja A., Yung M.Y., Leung C.B., To K.F., Lui S.F., Szeto C.C., Chung S., and Sung J.J. 2003. “A Major Outbreak of Severe Acute Respiratory

bibliography

421

Syndrome in Hong Kong.” New England Journal of Medicine 348(20): 1986–94. Lee P.J. and Krilov L.R. 2005. “When Animal Viruses Attack: sars and Avian Influenza.” Pediatric Annals 34(1): 42–52. Lee S.H. 1994. Prevention and Control of Communicable Diseases in Hong Kong. Hong Kong: Government Printer. Lee S.H. 2003. “The sars Epidemic in Hong Kong.” Journal of Epidemiology and Community Health 57(9): 652–54. Lee T.R. 1986. “Effective Communication of Information About Chemical Hazards.” Science of the Total Environment 51: 149–83. Leiss W. 2001. “Dioxins, or Chemical Stigmata.” Flynn J., Slovic P., and Kunreuther H. (eds) Risk, Media and Stigma. Oregon: Earthscan Publications. Leiss W. 2001. In the Chamber of Risks: Understanding Risk Controversies. Montreal: McGill-Queen’s University Press. Leiss W. and Powell D. 2004. Mad Cows and Mother’s Milk: The Perils of Poor Risk Communication, Second Edition. Montreal: McGillQueen’s University Press. Lew T.W., Kwek T.K., Tai D., Earnest A., Loo S., Singh K., Kwan K.M., Chan Y., Yim C.F., Bek S.L., Kor A.C., Yap W.S., Chelliah Y.R., Lai Y.C., and Goh S.K. 2003. “Acute Respiratory Distress Syndrome in Critically Ill Patients With Severe Acute Respiratory Syndrome.” Journal of the American Medical Association 290(3): 374–80. Li K.S., Guan Y., Wang J., Smith G.J., Xu K.M., Duan L., Rahardjo A.P., Puthavathana P., Buranathai C., Nguyen T.D., Estoepangestie A.T., Chaisingh A., Auewarakul P., Long H.T., Hanh N.T., Webby R.J., Poon L.L., Chen H., Shortridge K.F., Yuen K.Y., Webster R.G., and Peiris J.S. 2004. “Genesis of a Highly Pathogenic and Potentially Pandemic h5n1 Influenza Virus in Eastern Asia.” Nature 430(6996): 209–13. Liang G., Chen Q., Xu J., Liu Y., Lim W., Peiris J.S., Anderson L.J., Ruan L., Li H., Kan B., Di B., Cheng P., Chan K.H., Erdman D.D., Gu S., Yan X., Liang W., Zhou D., Haynes L., Duan S., Zhang X., Zheng H., Gao Y., Tong S., Li D., Fang L., Qin P., Xu W., sars Diagnosis Working Group. 2004. “Laboratory Diagnosis of Four Recent Sporadic Cases Of Community-Acquired sars, Guangdong Province, China.” Emerging Infectious Diseases 10(10): 1774–81. Ligon B.L. 2004. “Monkeypox: a Review of the History and Emergence in the Western Hemisphere.” Seminars in Pediatric Infectious Diseases 15(4): 280–87.

422

bibliography

Livingston G. 2005. “ sars Report Raises Serious Questions About Province’s Emergency Bill.” Maclean’s, 11 April. http://www.macleans. ca/topstories/news/shownews.jsp?content=n041193A. Loeb M., McGeer A., Henry B., Ofner M., Rose D., Hlywka T., Levie J., McQueen J., Smith S., Moss L., Smith A., Green K., and Walter S.D. 2004. “sars among Critical Care Nurses, Toronto.” Emerging Infectious Diseases 10(2):251–5. http://www.cdc.gov/ncidod/eid/ vol10no2/03-0838.htm. Loewenstein G.F., Weber E., Hsee C., and Welch E. 2001. “Risk as Feelings.” Psychological Bulletin 127: 267–86. Longstaff H.A. 2003. A Mental Models Approach to Risk Communication and Information Management. International Society for Environmental Information Sciences: Environmental Informatics Archives 1:1–8. Loo V.G., Libman M.D., Miller M.A., Bourgault A.M., Frenette C.H., Kelly M., Michaud S., Nguyen T., Poirier L., Vibien A., Horn R., Laflamme P.J., and Rene P. 2004. “Clostridium difficile: A Formidable Foe.” Canadian Medical Association Journal 171(1): 47–8. Loutfy M.R., Blatt L.M., Siminovitch K.A., Ward S., Wolff B., Lho H., Pham D.H., Deif H., LaMere E.A., Chang M., Kain K.C., Farcas G.A., Ferguson P., Latchford M., Levy G., Dennis J.W., Lai E.K., and Fish E.N. 2003. “Interferon Alfacon-1 Plus Corticosteroids in Severe Acute Respiratory Syndrome: A Preliminary Study.” Journal of the American Medical Association 290(24): 3222–8. Lozon J. 2003. sars Public Hearings Held Before Justice Campbell, sars Public Hearings, St. Lawrence Market, Toronto, Ontario, 30 September. apec Transcripts. http://68.146.188.247/trans/sars/ sep_30_03/text.htm. Lucey D.R. 2005. “h7n7 Avian Flu in the Netherlands: High Rate of Human-to-Human Transmission.” 14 January. Center for Biologic Counterterrorism and Emerging Diseases cbc-ed. http://www.bepast. org/disease_information/Avian%20Influenza/avian%20influenza %20bepast%20 newsletters/2005-01-14%20h7n7%20Avian%20 Flu%20in%20Netherlands. htm. Lvov D.K. 1987. “Influenza A Viruses – A Sum Of Populations With a Common Protected Gene Pool.” Soviet Medical Reviews E: Virology 2:15–37. MacDonald G. 2003. “Sared and Feathered.” Grant’s Graceland. http:// www.google.ca/url?sa=U&start=1&q=http://graceland.gentle.org/what cha/sars.html&e=7249.

bibliography

423

Macdonald M.T. 2004. “Nursing and Health Care Management and Policy; From sars to Strategic Actions Reframing Systems.” Journal of Advanced Nursing 47(5): 544–50. Manning, A. 2003. “Next Flu Pandemic Could Wreak Global Havoc, Scientists Warn.” USA Today, 30 November. http://www.usatoday. com/news/health/2003-11-30-flu_x.htm. Marjanovic Z., Greenglass E.R. and Coffey S. 2007. “The Relevance of Psychosocial Variables and Working Conditions in Predicting Nurses’ Coping Strategies During the sars Crisis: An Online Questionnaire Survey.” International Journal of Nursing Studies 44(6): 991–998. Marra M.A., Jones S.J., Astell C.R., Holt R.A., Brooks-Wilson A., Butterfield Y.S., Khattra J., Asano J.K., Barber S.A., Chan S.Y., Cloutier A., Coughlin S.M., Freeman D., Girn N., Griffith O.L., Leach S.R., Mayo M., McDonald H., Montgomery S.B., Pandoh P.K., Petrescu A.S., Robertson A.G., Schein J.E., Siddiqui A., Smailus D.E., Stott J.M., Yang G.S., Plummer F., Andonov A., Artsob H., Bastien N., Bernard K., Booth T.F., Bowness D., Czub M., Drebot M., Fernando L., Flick R., Garbutt M., Gray M., Grolla A., Jones S., Feldmann H., Meyers A., Kabani A., Li Y., Normand S., Stroher U., Tipples G.A., Tyler S., Vogrig R., Ward D., Watson B., Brunham R.C., Krajden M., Petric M., Skowronski D.M., Upton C., and Roper R.L. 2003. “The Genome Sequence of the sars-Associated Coronavirus.” Science 300(5624): 1399–1404. Masuko-Hongo K., Kato T., and Nishioka K. 2003. “Virus-Associated Arthritis.” Best Practice & Research: Clinical Rheumatology 17: 309–18. Maunder R., Hunter J., Vincent L., Bennett J., Peladeau N., Leszcz M., Sadavoy J., Verhaeghe L.M., Steinberg R., and Mazzulli T. 2003. “The Immediate Psychological and Occupational Impact of the 2003 sars Outbreak in a Teaching Hospital.” Canadian Medical Association Journal 168(10): 1245–51. Maunder R.G., Lancee W.J., Rourke S., Hunter J.J., Goldbloom D., Balderson K., Petryshen P., Steinberg R., Wasylenki D., Koh D., and Fones C.S. 2004. “Factors Associated With the Psychological Impact of Severe Acute Respiratory Syndrome on Nurses and Other Hospital Workers in Toronto.” Psychosomatic Medicine 66(6): 938–42. Mauss M. 1972. “A General Theory of Magic.” New York: W.W. Norton and Company. Mazzulli T., Farcas G.A., Poutanen S.M., Willey B.M., Low D.E., Butany J., Asa S.L., and Kain K.C. 2004. “Severe Acute Respiratory

424

bibliography

Syndrome-Associated Coronavirus in Lung Tissue.” Emerging Infectious Diseases 10(1): 20–4. McAdams S. 2003. “The Role of Technology in the Global Response to sars.” 1 October. http://www.oma.org/pcomm/omr/oct/03ww.htm. McCaughey B. 2007. “Spreading Infections.” The New York Sun, 30 January. http://www.hospitalinfection.org/press/013007nysun.doc. McGoldrick A., Lowings J.P., and Paton D.J. 1999. “Characterisation of a Recent Virulent Transmissible Gastroenteritis Virus from Britain With a Deleted orf 3a.” Archives of Virology. 144: 763–70. McIlroy A. 2003. “Vancouver’s Quick Action Helped Mute Virus Impact. sars Gained Foothold Before Toronto Warned.” The Globe and Mail, 18 April. Mckeown M. 2003a. “A Summary of What is Known About Acute Respiratory Syndrome. sars – More Questions than Answers.” International Health News, June 2003. http://www.yourhealthbase. com/sars.htm. McKeown D. 2003b. “Final Report of the Infection Control and Surveillance Standards Task Force: Community Health Providers Preventing Respiratory Illnesses In Community Settings. Recommendations for Infection Control and Surveillance for Febrile Respiratory Illness (fri) in Community Settings in Non-Outbreak Conditions. March, 2004.” http://www.health.gov.on.ca/english/ providers/program/pubhealth/sars/docs/docs3/report_taskforce_ community_031104.pdf. McNeil D.G. Jr. 2003. “sars Fears Shake Taiwan Medical Staffs.” The New York Times. 21 May. http://query.nytimes.com/gst/fullpage. html?sec= health&res=9b00e2dc113ef932a15756c0a 9659c8b63. McPherson K. 1996. Bedside Matters: The Transformation of Canadian Nursing, 1900–1990. Don Mills, Canada: Oxford University Press. McPherson K. and Stuart M. 1994. “Writing Nursing History in Canada: Issues and Approaches.” Canadian Bulletin of Medical History 11:3–22. Medical News Today. 2003. “Canadian Hospitals Below Standards for Preventing Infection.” 7 August. http://www.medicalnewstoday.com/ medicalnews.php?newsid=4073. Medical News Today. 2003. “sars Still Keeping Health Workers Off the Job – Canada.” 23 November. http://www.medicalnewstoday.com/ medicalnews.php?newsid=4721. Meltzer M.I., Cox N.J., and Fukuda K. 1999. “The Economic Impact of Pandemic Influenza in the United States: Priorities for Intervention.” Emerging Infectious Diseases 5(5): 659–71.

bibliography

425

Menzies D., Fanning A., Yuan L., and FitzGerald J.M. 2000. “Hospital Ventilation and Risk for Tuberculosis Infection in Canadian Healthcare Workers.” Annals of Internal Medicine 133:779–89. Mitchell A., Cummins T., Spearing N., Adams J., and Gilroy L. 2002. “Nurses’ Experience With Vancomycin-Resistant Enterococci (vre).” Journal of Clinical Nursing 11(1): 126–33. Monath T.P. 1986. The Arboviruses: Epidemiology and Ecology, African Horse Sickness to Dengue. Vols. II–IV. Boca Raton, Florida: crc Press. Motl S.E., Timpe E.M., and Eichner S.F. 2005. “Evaluation of Accuracy of Health Studies Reported in Mass Media.” Journal of the American Pharmaceutical Association 45(6): 720–25. Mott J.A., Treadwell T.A., Hennessy T.W., Rosenberg P.A., Wolfe M.I., Brown C.M., and Butler J.C. 2002. “Call-Tracking Data and the Public Health Response to Bioterrorism-Related Anthrax.” Emerging Infectious Diseases 8(10): 1088–92. MSNBC News. 2005. “who: Bird Flu Pandemic is Imminent. Governments Must Act Swiftly to Prevent Outbreak, Officials Say.” 23 February. http://www.msnbc.msn.com/id/6861065/. Murdock G., Petts J., and Horlick-Jones T. 2003. “After Amplification: Rethinking the Role of the Media in Risk Communication.” Pidgeon N., Kasperson R.E., and Slovic P. (eds), The Social Amplification of Risk. Cambridge, uk: Cambridge University Press. Murray T. 2003. “All is Not Quiet on the sars Front. New Cases Throw Toronto Back Into Screening Mode.” The Medical Post 39 (22). http://www.mlpla.gov.cn/xxb0618/04.htm. Naqi S., Gay K., Patalla P., Mondal S., and Liu R. 2003. “Establishment of Persistent Avian Infectious Bronchitis Infection in Antibody-Free and Antibody-Positive Chickens.” Avian Diseases 47:594–601. National Advisory Committee on sars and Public Health. 2003. “Learning from sars: Renewal of Public Health in Canada.” Ottawa: Health Canada. http://www.phac-aspc.gc.ca/publicat/sars-sras/naylor/. National Research Council. 1989. “Improving Risk Communication, Committee on Risk Perceptions and Communication.” Washington, dc: National Academy Press. National Union. 2003. “sars Death Sends Chill Through Health Care Field, Fear of Dying or Infecting Loved Ones a Major Concern For Workers.” 2 July. http://www.nupge.ca/news_2003/n02jy03a.htm. Naylor D.C., Chantler C., and Griffiths S. 2004. “Learning from sars in Hong Kong and Toronto.” Journal of the American Medical Association 291(20): 2483–87.

426

bibliography

Nelson C.H. 2001. “Risk Perception, Behavior, and Consumer Response to Genetically Modified Organisms.” American Behavioral Scientist 44(8): 1371–88. News Target. 2005. “Health Economist Complains Emphasis is Being Put on Death Toll of Bird Flu Pandemic, Not on Number of Sick.” 4 April. http://www.newstarget.com/006366.html. Ng M.L., Tan S.H., See E.E., Ooi E.E., and Ling A.E. 2003. “Proliferative Growth of sars Coronavirus in Vero e6 Cells.” Journal of General Virology 84(Pt 12): 3291–303. Nguyen T.D. 2005. “The 2003–2004 h5n1 Avian Influenza Outbreak in Vietnam.” Stacey L. Knobler, Alison Mack, Adel Mahmoud, Stanley M. Lemon, (eds.). The Threat of Pandemic Influenza: Are We Ready? Workshop Summary. Washington, dc: National Academies Press. Nicholson K.G., Wood J.M., and Zambon M. 2003.” Influenza.” Lancet 362: 1733–45. Nickell L.A., Crighton E.J., Tracy C.S., Al-Enazy H., Bolaji Y., Hanjrah S., Hussain A., Makhlouf S., and Upshur R.E. 2004. “Psychosocial Effects of sars on Hospital Staff: Survey of a Large Tertiary Care Institution.” Canadian Medical Association Journal 170(5): 793–8. Nilsson K. and Satterlund Larsson U. 2005. “Conceptions of Gender – a Study of Female and Male Head Nurses’ Statements.” Journal of Nursing Management 13:179–86. North York General Hospital. 2003. “North York General Hospital Launches New Era in Health Care.” 12 November. http://www.nygh.on.ca/prsars.htm. Nullis C. 2003. “Taiwan Investigates Possible Underreporting of sars Deaths.” Detroit News.14 June 2003. http://www.detnews.com/ 2003/health/0306/20/health-192631.htm. Nuorti P. 2003. “Eurosurveillance. Travel Associated Probable Case of sars, Finland, With Commentary from Health Canada.” 29 May. Volume 7, Issue 22. http://www.eurosurveillance.org/ew/2003/ 030529.asp. Nursing Standard, 2004. “sars Nurses Shunned After Recovery.” 18(51): 4. O’Sullivan T., Amaratunga C., Hardt J., Gibson D., Phillips K., and Corneil W. 2007. “Are We Ready? Evidence of Support Mechanisms for Canadian Healthcare Workers in Multi-Jurisdictional Emergency Planning.” Canadian Journal of Public Health 98(5): 358–63. O’Sullivan T.L. Dow D., Turner M.C. Lemyre, L., Corneil W., Krewski D., Phillips K.P., and Amaratunga, C.A. 2008. Disaster and Emergency

bibliography

427

Management: Canadian Nurses’ Perceptions of Preparedness on Hospital Front Lines. Prehospital and Disaster Medicine 23:s11–s18. Olson M.M., Shanholtzer C.J., Lee J.T. Jr., and Gerding D.N. 1994. “Ten Years of Prospective Clostridium Difficile-Associated Disease Surveillance and Treatment at the Minneapolis va Medical Center, 1982–1991.” Infection Control and Hospital Epidemiology 15(6): 371–81. Ontario Ministry of Health and Long-Term Care. 2003. “sars: What Should You Do?” http://www.healthyontario.com/english/features_ details.asp? channel_id=0&aggregate_id=71&text_id=835. Ontario Ministry of Health and Long-Term Care. 2004a. “For the Public’s Health – A Plan of Action.” 21 April. http://www.health. gov.on.ca/english/public/pub/ministry_reports/walker04/walker04_ mn.html. Ontario Ministry of Health and Long-Term Care. 2004b. “Severe Acute Respiratory Syndrome (sars).” http://www.health.gov.on.ca/english/ providers/program/pubhealth/sars/sars_qa_hcw.html. Ontario Ministry of Health and Long-Term Care. 2005a. “Diseases: sars – Questions and Answers.” January. http://www.health.gov. on.ca/english/public/pub/disease/sars_4.html. Ontario Ministry of Health and Long-Term Care. 2005b. “Emergency Management Unit.” http://www.health.gov.on.ca/english/public/ program/emu/emu_mn.html. Ontario Nurses’ Association. 2003. “Years of Progress – 2003. Ontario Nurses’ Association Annual Report 2002–2003.” http://ona.org/ webfm_send/409. Ontario Nurses’ Association. 2004. “ona/opseu, Final Recommendations to Justice Campbell Regarding: Occupational Health and Safety Matters Arising from sars.” http://www.opseu. org/hands/0106FinalsubmissionCampbell.pdf. Palmer K. 2003. “Coverage ‘Balanced’ but Excessive, York U. Finds.” The Toronto Star, 30 October. Palmer K. and Talaga T. 2003. “Quick Response to Contain a Killer; Isolation of Second Toronto Victim Credited, Scientists Say They May Have Test for Mysterious Illness.” The Toronto Star, 22 March 2003. Papp L. 2003. “York Central Hospital Enjoys Rebirth; sars Infection Controls, Teamwork Credited. Patients, Visitors Allowed After 3-Week Closure.” The Toronto Star, 26 April. Parry J. 2003. “Asymptomatic Animal Traders Prove Positive for sars Virus.” BMJ 327(7415): 582.

428

bibliography

Peiris J.S., Lai S.T., Poon L.L., Guan Y., Yam L.Y., Lim W., Nicholls J., Yee W.K., Yan W.W., Cheung M.T., Cheng V.C., Chan K.H.,Tsang D.N., Yung R.W., Ng T.K., Yuen K.Y., and sars Study Group. 2003. “Coronavirus as a Possible Cause of Severe Acute Respiratory Syndrome.” Lancet 361(9366): 1319–25. Peiris J.S., Yuen K.Y., Osterhaus A.D., and Stohr K. 2003. “The Severe Acute Respiratory Syndrome.” New England Journal of Medicine 349(25): 2431–41. Peiris M., Yuen K.Y., Leung C.W., Chan K.H., Ip P.L., Lai R.W., Orr W.K., and Shortridge K.F. 1999. “Human Infection with Influenza h9n2.” Lancet 354: 916–17. Penciner R. 2003. “I Am a sars Physician.” Canadian Journal of Emergency Medicine 5(4): 281–82. Perkins L.E. and Swayne D.E. 2002. “Pathogenicity of a Hong KongOrigin h5n1 Highly Pathogenic Avian Influenza Virus for Emus, Geese, Ducks, and Pigeons.” Avian Diseases 46: 53–63. Peters C., Jahring P. and Khan A. 1996. “Patients Infected With HighHazard Viruses: Scientific Basis for Infection Control.” Archives of Virology 11(suppl): 141–68. phac. 2003a. “Travel Health Advisory: Influenza A (h5n1) in Humans, Hong Kong.” Public Health Agency of Canada. 3 March. http://www.phac-aspc. gc.ca/tmp-pmv/2003/h5n1hk_e.html. phac. 2003b. “sars Epidemiologic Summaries: April 26, 2003, Summary of sars cases Potentially Exposed in Canada and Diagnosed Internationally.” Public Health Agency of Canada. 26 April. http:// www.phac-aspc.gc.ca/sars-sras/pef-dep/sars-es-int20030426_e.html. phac. 2003c. “Quarantine Act and Regulations – sars Amendment.” Public Health Agency of Canada. 12 June 2003. http://www.phacaspc.gc.ca/sars-sras-gen/fact_sheet.html. phac. 2003d. “The Efficacy of Thermal Imaging Scanners in the Detection of sars.” Public Health Agency of Canada. http://www. phac-aspc.gc.ca/sars-sras/tis-it/. phac. 2003e.”sars Situation Update and Continuing National Surveillance.” Public Health Agency of Canada. 5 September. http://www.phac-aspc.gc.ca/sars-sras/cn-cc/numbers.html. phac. 2003f. “Learning from sars : Appendix 1 – Interviews and Submissions.” Public Health Agency of Canada. http://www.phacaspc.gc.ca/publicat/sars-sras/naylor/appendix1.html. phac. 2003g. “sars Situation Update and Continuing National Surveillance.” 5 September. Public Health Agency of Canada. http://www.phac-aspc.gc.ca/sars-sras/cn-cc/numbers.html.

bibliography

429

phac. 2004a. “ Chapter 2 – sars in Canada: Anatomy of an Outbreak.” Learning from SARS – Renewal of Public Health in Canada. October 2003. (The Naylor Report). Public Health Agency of Canada. Ottawa. Canada. http://www.phac-aspc.gc.ca/publicat/ sars-sras/naylor/2_e.html. phac. 2004b. Learning from SARS – Renewal of Public Health in Canada. October 2003. (The Naylor Report). Public Health Agency of Canada. Ottawa. Canada. http://www.phac-aspc.gc.ca/publicat/ sars-sras/pdf/sars-e.pdf. (Naylor Report) phac. 2005. “Background, Canadian Pandemic Influenza Plan.” The Canadian Pandemic Influenza Plan for the Health Sector. Public Health Agency of Canada. http://www.phac-aspc.gc.ca/cpip-pclcpi/ pdf-e/cpip-eng.pdf. phac. 2006. The Canadian Influenza Plan for the Health Sector. Public Health Agency of Canada. http://www.phac-aspc.gc.ca/cpip-pclcpi/ pdf-e/cpip-2006_e.pdf. phac. 2007. “Frequently Asked Questions – Pandemic Influenza.” Public Health Agency of Canada. http://www.phac-aspc.gc.ca/ influenza/pandemic_qa_e.html#9. Pham N. 2005. “Eyewitness: Surviving Bird Flu.” bbc News. 1 February. http://news.bbc.co.uk/1/hi/world/asia-pacific/4226459. stm. Picard A. 2005. “er Visits Plunged Post-sars, Even Hospitals Far from Toronto’s Outbreak Saw Numbers Tumble.” The Globe and Mail, 21 April. Plough A. and Krimsky S. 1987 “The Emergence of Risk Communication Studies: Social and Political Context.” Science, Technology and Human Values 12:4–10. Poutanen S.M., Low D.E., Henry B., Finkelstein S., Rose D., Green K., Tellier R., Draker R., Adachi D., Ayers M., Chan A.K., Skowronski D.M., Salit I., Simor A.E., Slutsky A.S., Doyle P.W., Krajden M., Petric M., Brunham R.C., McGeer A.J.; National Microbiology Laboratory, Canada; and Canadian Severe Acute Respiratory Syndrome Study Team. 2003.”Identification of Severe Acute Respiratory Syndrome in Canada.” New England Journal of Medicine 348(20): 1995–2005. Powell B. 2003a. Children May Have Carried sars to Australia.” The Toronto Star, 4 April. Powell B. 2003b. “Number of New Cases Begins to Drop; Three Incidents Reported Across Ontario Yesterday; York Officials Take Legal Action Against Quarantine Flouter.” The Toronto Star, 5 April.

430

bibliography

Pribble J.M., Goldstein K.M., Fowler E.F., Greenberg M.J., Noel S.K., and Howell J.D. 2006. “Medical News for the Public to Use? What’s on Local tv News.” American Journal of Managed Care 12(3): 170–76. Puro V. and Nicastri E. 2004. “sars and the Removal of Personal Protective Equipment.” Journal of Ayub Medical College 170(6): 930. Raymond G. 2003. ceo at the Scarborough Hospital Presenting at the Campbell Commission. sars Public Hearings Held Before Justice Campbell, sars Public Hearings, St. Lawrence Market, Toronto, Ontario, 30 September. apec Transcripts. http://68.146.188.247/ trans/sars/sep_30_03/text.htm. Razani-Boroujerdi S., Singh S.P., Knall C., Hahn F.F., Pena-Philippides J.C., Kalra R., Langley R.J., and Sopori M.L. 2004. “Chronic Nicotine Inhibits Inflammation and Promotes Influenza Infection.” Cellular Immunology 230(1): 1–9. Renn O. 1990. “Risk Perception and Risk Management: A Review.” Risk Abstracts 7, 1–9 and 8, 1–9. Renn O. 1991. “Risk Communication and the Social Amplification of Risk.” R. Kasperson and P.J. Stallen (eds), Communicating Risk to the Public, Dordrecht, Holland: Kluwer Academic Publishers. Reuters. 2003. “Taiwan’s Extreme Measures Feed Public Fear.” 23 May. Sydney Morning Herald, http://www.smh.com.au/articles/2003/05/22/ 1053585645644.html. Reuters. 2004. “Antibodies from sars Patients Offer New Treatment.” 13 July. The New Zealand Herald, http://www.nzherald.co.nz/index. cfm?ObjectID=3577983. Rezza G., Marino R., Farchi F., and Taranto M. 2004. “sars Epidemic in the Press.” Emerging Infectious Diseases 10: 381–2. Rhoades L. and Eisenberger R. 2002. “Perceived Organizational Support: A Review of the Literature.” Journal of Applied Psychology 87(4): 698–714. Roberts J. 2003. “sars Outbreak Deepens Economic Decline in South East Asia.” 2 June 2003. http://www.wsws.org/articles/2003/jun2003/ sars-j02.shtml. Robertson L. 2003. “Did the News Media Worsen the sars Crisis?” ctv News. 9 May. http://www.ctv.ca/servlet/ArticleNews/story/ ctvNews/1052178162283_117/?hub=TopStories. Rodrigue C.M. 2001. “The Internet in the Social Amplification and Attenuation of Risk.” Twenty-Sixth Annual Natural Hazards Research and Applications Workshop. Boulder, co, 15–18 July. http://www. csulb.edu/~rodrigue/boulder01poster.html.

bibliography

431

Rota P.A., Oberste M.S., Monroe S.S., Nix W.A., Campagnoli R., Icenogle J.P., Penaranda S., Bankamp B., Maher K., Chen M.H., Tong S., Tamin A., Lowe L., Frace M., DeRisi J.L., Chen Q., Wang D., Erdman D.D., Peret T.C., Burns C., Ksiazek T.G., Rollin P.E., Sanchez A., Liffick S., Holloway B., Limor J., McCaustland K., OlsenRasmussen M., Fouchier R., Gunther S., Osterhaus A.D., Drosten C., Pallansch M.A., Anderson L.J., and Bellini W.J. 2003. “Characterization of a Novel Coronavirus Associated with Severe Acute Respiratory Syndrome.” Science, May 30, 300(5624): 1394–99. Royal Society of Canada. 2006. “The Academies of Arts, Humanities and Sciences of Canada. Expert Panels.” http://www.rsc.ca/print.php?& page_id=65&lang_id=1. Rozin P., Millman L., and Nemeroff C. 1986. “Operation of the Laws of Sympathetic Magic in Disgust and Other Domains.” Journal of Personality and Social Psychology 50(4): 703–12. Scales D.C., Green K., Chan A.K., Poutanen S.M., Foster D., Nowak K., Raboud J.M., Saskin R., Lapinsky S.E., and Stewart T.E. 2003. “Illness in Intensive-Care Staff After Brief Exposure to Severe Acute Respiratory Syndrome.” Emerging Infectious Diseases 9: 1205–10. Scally R. 2003. “Canadian Nurse Dies from sars.” 6 March. NurseZone.com, http://www.nursezone.com/job/MedicalNewsAlerts. asp?articleID=10736. Schabas R. 2003. Chief of Staff at York Central Hospital, Toronto, speaking to Campbell Commission. sars Public Hearings Held Before Justice Campbell, sars Public Hearings, St. Lawrence Market, Toronto, Ontario, 30 September. apec Transcripts. http:// 68.146.188.247/trans/sars/sep_30_03/text.htm. Schnurrenberger P.R., Woods G.T., and Martin R.J. 1970. “Serologic Evidence of Human Infection With Swine Influenza Virus.” American Review of Respiratory Disease 102: 356–61. Schwartz J. 2004. “Emergency Preparedness and Response: Compensating Victims of a Nuclear Accident.” Journal of Hazardous Materials 111(1–3): 89–96. Setbon M., Raude J., Fischler C., and Flahault A. 2005. “Risk Perception of the ‘Mad Cow Disease’ in France: Determinants and Consequences.” Risk Analysis 25(4): 813–26. Seto W.H., Tsang D., Yung R.W., Ching T.Y., Ng T.K., Ho M., Ho L.M., and Peiris J.S. 2003. “Effectiveness of Precautions Against Droplets and Contact in Prevention of Nosocomial Transmission of Severe Acute Respiratory Syndrome (sars).” Lancet 361: 1519–20.

432

bibliography

Sharma A.K. and Khuller G.K. 2001. “dna Vaccines: Future Strategies and Relevance to Intracellular Pathogens.” Immunology and Cell Biology 79:537–46. Shih M.C., Peck K., Chan W.L., Chu Y.P., Chen J.C., Tsai C.H., and Chang J.G. 2005. “sars-cov Infection Was from at Least Two Origins in the Taiwan Area.” Intervirology 48(2–3): 124–32. Shortridge K.F. and Stuart-Harris C.H. 1982. “An Influenza Epicentre?” Lancet 11: 812–13. Shortridge K.F., Gao P., Guan Y., Ito T., Kawaoka Y., Markwell D., Takada A., and Webster R.G. 2000. “Interspecies Transmission of Influenza Viruses: h5n1 Virus and a Hong Kong SAR Perspective.” Veterinary Microbiology 74(1–2):141–47. Sibbald B. 2003a. “Estimates of Flu-Related Deaths Rise With New Statistical Models.” Canadian Medical Association Journal 168(6): 761. Sibbald B. 2003b. “Right to Refuse Work Becomes Another sars Issue.” Canadian Medical Association Journal 169(2): 141. Sims L.D., Ellis T.M., Liu K.K., Dyrting K., Wong H., Peiris M., Guan Y., and Shortridge K.F. 2003a. “Avian Influenza in Hong Kong 1997–2002.” Avian Diseases 47: 832–8. Sims L.D., Guan Y., Ellis T.M., Liu K.K., Dyrting K., Wong H., Kung N.Y., Shortridge K.F., and Peiris M. 2003b. “An Update on Avian Influenza in Hong Kong 2002.” Avian Diseases 47(3 Suppl): 1083–6. Sizun J., Soupre D., Legrand M.C., Giroux J.D., Rubio S., Cauvin J.M., Chastel C., Alix D., and de Parscau L. 1995. “Neonatal Nosocomial Respiratory Infection With Coronavirus: A Prospective Study in a Neonatal Intensive Care Unit.” Acta Paediatrica 84(6): 617–20. Sizun J., Yu M.W., and Talbot P.J. 2000. “Survival of Human Coronaviruses 229e and oc43 in Suspension and After Drying on Surfaces: A Possible Source of Hospital-Acquired Infections.” Journal of Hospital Infection 46: 55–60. Skowronski D.M., Astell C., Brunham R.C., Low D.E., Petric M., Roper R.L., Talbot P.J., Tam T., and Babiuk L. 2005. “Severe Acute Respiratory Syndrome (sars): A Year in Review.” Annual Review of Medicine 56:357–81. Skowronski D.M., Petric M., Daly P., Parker R.A., Bryce E., Doyle P.W., Noble M.A., Roscoe D.L., Tomblin J., Yang T.C., Krajden M., Patrick D.M., Pourbohloul B., Goh S.H., Bowie W.R., Booth T.F., Tweed S.A., Perry T.L., McGeer A., and Brunham R.C. 2006. “Coordinated Response to sars, Vancouver, Canada.” Emerging Infectious Diseases 12(1): 155–8.

bibliography

433

Slemons R.D., Johnson D.C., Osborn J.S., and Hayes F. 1974. “Type a Influenza Viruses Isolated From Wild Free-Flying Ducks in California.” Avian Diseases 18:119–25. Slovic P. 1987. “Perception of Risk.” Science 236: 280–85. Slovic P., Finucane M.L., Peters E., and MacGregor D.G. 2004. “Risk as Analysis and Risk as Feelings: Some Thoughts about Affect, Reason, Risk and Rationality.” Risk Analysis 24(2): 311–22. Slovic P., Fischoff B., and Lichtenstein S. 1977. “Behavioral Decision Theory.” Annual Review of Psychology 28:1–39. Slovic P., Layman M., Kraus N., Flynn J., Chalmers J., and Gesell G. 1991. “Perceived Risk, Stigma, and Potential Economic Impacts of a High-Level Nuclear Waste Repository in Nevada.” Risk Analysis 11(4): 683–96. Songserm T., Jam-on R., Sae-Heng N., Meemak N., Hulse-Post D.J., Sturm- Ramirez K.M., and Webster R.G. 2006. “Domestic Ducks and h5n1 Influenza Epidemic, Thailand.” Emerging Infectious Diseases 12(4): 575–81. Sorensen C. 2003. “Hospital Masks Are in Short Supply; Firms Work Around Clock to Fill Orders. Protective Gear’s Cost Soars at Some Stores.” The Toronto Star, 29 March. Spence Laschinger H.K., Sabiston J.A., Finegan J., and Shamian J. 2001. “Voices from the Trenches: Nurses’ Experiences of Hospital Restructuring in Ontario.” Canadian Journal of Nursing Leaderships 14(1): 6–13. Statistics Canada. 2005. “Demographic Statistics.” The Daily. 1 July. http://www.statcan.ca/Daily/English/050928/d050928a.htm. Stocking B. 2003. “Virus in Vietnam Leaves Bitter Stigma as Some Survivors Are Shunned.” San Jose Mercury News. 2 June. http://www.undp.org.vn/mlist/health/062003/post2.htm. Strong-Boag V. 1991. “Making a Difference: The History of Canada’s Nurses.” Canadian Bulletin of Medical History 8(2): 231–48. Sturm-Ramirez K.M., Ellis T., Bousfield B., Bissett L., Dyrting K., Rehg J.E., Poon L., Guan Y., Peiris M., and Webster R.G. 2004. “Reemerging h5n1 Influenza Viruses in Hong Kong in 2002 are Highly Pathogenic to Ducks.” Journal of Virology 78: 4892–901. Taipei Times. 2004. “Hong Kong Hotel is Eliminating Memories of sars.” 23 February. http://www.taipeitimes.com/News/world /archives/2004/02/23/2003099824. Talaga T. and Palmer K. 2003. “Crisis Team Tackles Illness; Premier Declares Emergency, Sets Up Resource Centre. Some Scarborough Grace Visitors Asked to Stay in Homes.” The Toronto Star, 27 March.

434

bibliography

Tan D. 2003. “How Singapore Fights sars.” 4 June 2003. Things Asian.com, http://www.thingsasian.com/goto_article/article.2223.html. The Age News. 2005. “World in ‘Grave Danger’ from Bird Flu.” 5 March 2005. http://www.theage.com.au/news/Science/World-in-gravedanger-from-bird-flu/2005/03/04/1109700677241.html?oneclick=true. The Conference Board of Canada. 2003. “Special Briefing, the Economic Impact of sars.” Conference Board of Canada. May. http://www.conferenceboard.ca/documents.asp?rnext=539. The Montreal Gazette. 2004. “Nothing Scarier than Secrecy.” 8 October. Thiers P. 2003. “Risk Society Comes to China: sars, Transparency and Public Accountability.” Asian Perspectives 27(2): 241–51. Time Magazine. 2005. “St. Mike’s by the Numbers.” 165(6): 42–4. Tourism Toronto. 2003. “Communiqué #12, Severe Acute Respiratory Syndrome (sars).” Update 14 May. http://www.iaem.org/content/ membersonly/cess/tourismtorontocommunique12.pdf. Traggiai E., Becker S., Subbarao K., Kolesnikova L., Uematsu Y., Gismondo M.R., Murphy B.R., Rappuoli R., and Lanzavecchia A. 2004. “An Efficient Method to Make Human Monoclonal Antibodies from Memory b Cells: Potent Neutralization of sars Coronavirus.” Nature Medicine, 10(8): 871–75. Trampuz A., Prabhu R.M., Smith T.F., and Baddour L.M. 2004. “Avian Influenza: A New Pandemic Threat?” Mayo Clinic Proceedings 79(4): 523–30. Tran T.H., Nguyen T.L., Nguyen T.D., Luong T.S., Pham P.M., Nguyen V.C., Pham T.S., Vo C.D., Le T.Q., Ngo T.T., Dao B.K., Le P.P., Nguyen T.T., Hoang T.L., Cao V.T., Le T.G., Nguyen D.T., Le H.N., Nguyen K.T., Le H.S., Le V.T., Christiane D., Tran T.T., Menno de J., Schultsz C., Cheng P., Lim W., Horby P., Farrar J., and World Health Organization International Avian Influenza Investigative Team. 2004. “Avian Influenza A (h5n1) in 10 Patients in Vietnam.” New England Journal of Medicine 350:1179–88. Tsang K.W. and Lam W.K. 2003. “Management of Severe Acute Respiratory Syndrome: The Hong Kong University Experience.” American Journal of Respiratory and Critical Care Medicine 168:417–24. Tsang K.W., Ho P.L., Ooi G.C., Yee W.K., Wang T., Chan-Yeung M., Lam W.K., Seto W.H., Yam L.Y., Cheung T.M., Wong P.C., Lam B., Ip M.S., Chan J., Yuen K.Y., and Lai K.N. 2003. “A Cluster of Cases of Severe Acute Respiratory Syndrome in Hong Kong.” New England Journal of Medicine 348(20): 1977–85.

bibliography

435

Tsui P.T., Kwok M.L., Yuen H., and Lai S.T. 2003. “Severe Acute Respiratory Syndrome: Clinical Outcome and Prognostic Correlates.” Emerging Infectious Diseases 9(9): 1064–69. Tufts S. 2003. “Health and Hospitality Workers Fight Back.” Our Times, September. http://www.ourtimes.ca/features/03_aug_sept.html. Tumpey T.M., Basler C.F., Aguilar P.V., Zeng H., Solorzano A., Swayne D.E., Cox N.J., Katz J.M., Taubenberger J.K., Palese P., and GarciaSastre A. 2005. “Characterization of the Reconstructed 1918 Spanish Influenza Pandemic Virus.” Science 310(5745): 77–80. Tversky A. and Kahneman D. 1982. “Evidential Impact of Base Rates.” D. Kahneman, P. Slovic, and A. Tversky (eds). Judgment Under Uncertainty: Heuristics and Biases. Cambridge, UK: Cambridge University Press. Twu S.J., Chen T.J., Chen C.J., Olsen S.J., Lee L.T., Fisk T., Hsu K.H., Chang S.C., Chen K.T., Chiang I.H., Wu Y.C., Wu J.S., and Dowell S.F. 2003. “Control Measures for Severe Acute Respiratory Syndrome (sars) in Taiwan.” Emerging Infectious Diseases 9(6): 718–20. Tyshenko M.G. 2007. “sars and Canadian Healthcare Policy: Preparing for Future Pandemics.” Keynote speech, Withinsight 2007 Conference. House of Commons, Room 371 West Block, Parliament Hill, Ottawa, Ontario. 26 January. Umapathi T., Kor A.C., Venketasubramanian N., Lim C.C., Pang B.C., Yeo T.T., Lee C.C., Lim P.L., Ponnudurai K., Chuah K.L., Tan P.H., Tai D.Y., and Ang S.P. 2004. “Large Artery Ischaemic Stroke in Severe Acute Respiratory Syndrome (sars).” Journal of Neurology 251(10): 1227–31. United Nations. 1999. “The World at Six Billion, Table 1, World Population from Year 0 to Stabilization.” http://www.un.org/esa/ population/publications/sixbillion/sixbilpart1.pdf. Valiquette L., Low D.E., Pépin J., and McGeer A. 2004. “Clostridium Difficile Infection in Hospitals: a Brewing Storm.” Canadian Medical Association Journal 171:27–29. van den Hoogen B.G., de Jong J.C., Groen J., Kuiken T., de Groot R., Fouchier R.A.M., Osterhaus A.D.M.E. 2001. “A Newly Discovered Human Pneumovirus Isolated From Young Children With Respiratory Tract Disease.” Nature Medicine 7:719. van der Hoek L., Pyrc K., Jebbink M.F., Vermeulen-Oost W., Berkhout R.J., Wolthers K.C., Wertheim-van Dillen P.M., Kaandorp J., Spaargaren J., and Berkhout B. 2004. “Identification of a New Human Coronavirus.” Nature Medicine 10(4): 368–73.

436

bibliography

Varia M., Wilson S., Sarwal S., McGeer A., Gournis E., Galanis E., Henry B., and Hospital Outbreak Investigation Team. 2003. “Investigation of a Nosocomial Outbreak of Severe Acute Respiratory Syndrome (sars) in Toronto, Canada.” Canadian Medical Association Journal 169(4): 285–92. Villarreal L.P. 2004. “Are Viruses Alive?” Scientific American. 291(6): 100–106. Walsh B. 2003. “Is sars Getting Deadlier? Scientists Believe the Virus is Rapidly Mutating.” Time Asia, 12 May. http://www.time.com/time/ asia/magazine/article/0,13673,501030512-449524,00.html. Watts J. 2003. “China Takes Drastic Action Over sars Threat.” Lancet, 17 May 2003. 361(9370): 1708–9. Webby R.J. and Webster R.G. 2003. “Are We Ready for Pandemic Influenza?” Science 302(5650): 1519–22. Webster R.G., Bean W.J., Gorman O.T., Chambers T.M., and Kawaoka Y. 1992. “Evolution and Ecology of Influenza A Viruses.” Microbiological Reviews 56(1): 152–79. Webster R.G. 1997. “Predictions for Future Human Influenza Pandemics.” Journal of Infectious Diseases 176 Suppl 1:S14–19. Wickramasinghe C. 2004. “The Universe: a Cryogenic Habitat for Microbial Life.” Cryobiology 48(2): 113–25. Wickramasinghe C., Wainwright M., and Narlikar J. 2003. “sars – a Clue to its Origins?” Lancet 361(9371): 1832. Wilkins L. and Vultee F. 2005. “Disasters That Communicate: A Proposal for a Definition and Research Agenda.” Natural Hazards Observer 29(3): 5–6. William Osler Health Center. 2006. “About Us.” Etobicoke. http://www.williamoslerhc.on.ca/. Williams P.R.D. 2000. “The Risk Analysis Framework: Risk Assessment, Risk Management and Risk Communication.” Spengler J.D., Sarnet J.M., McCarthy J.F. (eds). Indoor Air Quality Handbook. New York: McGraw Hill Inc. Williams R. and MacLean J.R. 2003. “Preventing Respiratory Illnesses, Protecting Patients and Staff, Recommended Infection Control and Surveillance Standards for Febrile Respiratory Illness (fri) in NonOutbreak Conditions.” Final Report of the Infection Control Standards Task Force. December 2003. Williams, P.R.D. 2004. “Health Risk Communication Using Comparative Risk Analyses.” Journal of Exposure Analysis and Environmental Epidemiology 14: 498–515.

bibliography

437

Wilson K. and Jackson B.E. 2006. “Bringing Women and Gender Into ‘Healthy Canadians: A Federal Report on Comparable Health Indicators 2004’.” Centres of Excellence for Women’s Health. http://ww.cewh-cesf.ca/healthreform/index.html. Wingwood G.M. and DiClemente R.J. 2002. “The Theory of Gender and Power: A Social Structural Theory for Guiding the Design and Implementation of Public Health Interventions to Reduce Women’s Risk of hiv.” DiClemente R.J., Crosby R.A., and Kegler M. (eds). Emerging Theories in Health Promotion, Practice and Research: Strategies for Enhancing Public Health. San Franscisco: JosseyBass. Wong K.T., Antonio G.E., Hui D.S., Lee N., Yuen E.H., Wu A., Leung C.B., Rainer T.H., Cameron P., Chung S.S., Sung J.J., and Ahuja A.T. 2003. “Thin-Section CT of Severe Acute Respiratory Syndrome: Evaluation of 73 Patients Exposed to or With the Disease.” Radiology 228(2): 395–400. Wong T.W., Yau J.K., Chan C.L., Kwong R.S., Ho S.M., Lau C.C., Lau F.L., and Lit C.H. 2005. “The Psychological Impact of Severe Acute Respiratory Syndrome Outbreak on Healthcare Workers in Emergency Departments and How They Cope.” European Journal of Emergency Medicine 12(1): 13–8. World Health Organization. 1999. “Influenza Pandemic Plan. The Role of who and Guidelines for National and Regional Planning.” Last update: November, 2005. http://www.who.int/entity/csr/resources/ publications/influenza/gip_2005_5Eweb.pdf. World Health Organization. 2002. “Integrating Gender Perspectives Into the Work of the who.” http://www.who.int/gender/documents/ engpolicy.pdf. World Health Organization. 2003a. “Severe Acute Respiratory Syndrome (sars), Multi-Country Outbreak, Update 31 – Coronavirus Never Before Seen in Humans is the Cause of sars.” World Health Organization, 16 April. http://www.who.int/csr/don/ 2003_04_16/en/index.html. World Health Organization. 2003b. “Severe Acute Respiratory Syndrome (sars): Laboratory Diagnostic Tests.” World Health Organization. 29 April. http://www.who.int/csr/sars/diagnostic tests/en/. World Health Organization. 2003c. “Update 93 – Toronto Removed from List of Areas With Recent Local Transmission.” 2 July. http://www.who.int/csr/don/2003_07_02/en/index.html.

438

bibliography

World Health Organization. 2003d. “Weekly Epidemiological Record.” 4 April 2003. No. 14, 78, 97–120. http://www.who.int/wer/pdf/2003/ wer7814.pdf. World Health Organization. 2003e. “Preliminary Clinical Description of Severe Acute Respiratory Syndrome.” http://www.who.int/csr/sars/ clinical/en/. World Health Organization. 2003f. “Summary Table of sars Cases by Country, 1 November 2002 – 7 August 2003.” 15 August. http://www.who.int/csr/sars/country/2003_08_15/en/. World Health Organization. 2003h. “Update 33 – Update on Hong Kong and China, First sars Case Reported in India.” 18 April. http://www.who.int/csr/sars/archive/2003_04_18/en/. World Health Organization. 2003i. “Update 79 – Situation in China.” 12 June. http://www.who.int/csr/don/2003_06_12/en/. World Health Organization. 2003j. “Update 35 – Update on China: New numbers, May Day holiday reduced.” 21 April. http://www.who.int/ csr/sarsarchive/2003_04_21/en/. World Health Organization. 2004a. “Summary of Probable sars Cases With Onset of Illness from 1 November 2002 to 31 July 2003.” http://www.who.int/csr/sars/country/table2004_04_21/en/index.html. World Health Organization. 2004b. “Avian Influenza A (h5n1)Situation (Poultry) in Asia as at 2 March 2004: Need for a Long-Term Response, Comparison With Previous Outbreaks.” Weekly Epidemiological Record / Health Section of the Secretariat of the League of Nations 79: 96–9. World Health Organization. 2005. “Pandemic Preparedness.” http://www.who.int/csr/disease/influenza/pandemic/en/#conseq. World Health Organization. 2006a. “Summary of Probable sars Cases With Onset of Illness from 1 November 2002 to 31 July 2003 (revised 26 September 2003).” http://www.who.int/csr/sars/country/ table2003_09_23/en/index.html. World Health Organization. 2006b. “Cumulative Number of Confirmed Human Cases of Avian Influenza A/(h5n1) Reported to who.” 12 November. http://www.who.int/csr/disease/avian_influenza/country/ cases_table_2007_11_12/en/index.html. World Health Organization. 2008. “Cumulative Number of Confirmed Human Cases of Avian Influenza A/(h5n1) Reported to who.” 19 June. http://www.who.int/entity/csr/disease/avian_influenza/country/ cases_table_2008_06_19/en/index.html.

bibliography

439

World Population Information 2005. “Population 2005.” http://www. census.gov/ipc/www/world.html. Wu W., Wang J.F., Liu P.M., Jiang S.P., Chen Q.Y., Chen W.X., Yin S.M., Yan L., Zhan J., Chen X.L., and Li J.G. 2004. “Comparison of Clinical Course of Patients With Severe Acute Respiratory Syndrome Among the Multiple Generations of Nosocomial Transmission.” Chinese Medical Journal (English) 117(1):14–8. Xinhuanet. 2005. “Chest Radiographs Can Predict Death Risk in sars Patients.” 2 March. http://news.xinhuanet.com/english/2005-03/03/ content_2642285.htm. Xu X., Subbarao K., Cox N.J., and Guo Y. 1999. “Genetic Characterization of the Pathogenic Influenza A/Goose/Guangdong/ 1/96 (h5n1) Virus: Similarity of its Hemagglutinin Gene to Those of h5n1 Viruses from the 1997 Outbreaks in Hong Kong.” Virology. 261: 15–9. Yassi A., Moore D., FitzGerald J.M., Bigelow P., Hon C-Y., and Bryce E. 2005. “Research Gaps in Protecting Healthcare Workers From sars and Other Respiratory Pathogens: An Interdisciplinary, MultiStakeholder, Evidence-Based Approach.” Journal of Occupational and Environmental Medicine 47(1): 41–50. Yu I.T., Li Y., Wong T.W., Tam W., Chan A.T., Lee J.H., Leung D.Y., Ho T. 2004. “Evidence of Airborne Transmission of the Severe Acute Respiratory Syndrome Virus.” New England Journal of Medicine 350(17): 1731–9. Zajonc R.B. 1980. “Feeling and Thinking: Preferences Need No Inferences.” American Psychologist 35:151–75. Zelek B. and Phillips S.P. 2003. “Gender and Power: Nurses and Doctors in Canada.” International Journal for Equity in Health, 2. http://www.equityhealthj.com/content/2/1/1. Zerbisias A. 2003. “Study Finds Strange Place to Lay Blame for Fallout.” The Toronto Star, 30 October. Zheng B.J., Wong K.H., Zhou J., Wong K.L., Young B.W., Lu L.W., and Lee S.S. 2004. “sars-Related Virus Predating sars Outbreak, Hong Kong.” Emerging Infectious Diseases 10(2): 176–78. Zhong N.S., Zheng B.J., Li Y.M., Poon L.L.M., Xie Z.H., Chan K.H., Li P.H., Tan S.Y., Chang Q., Xie J.P., Liu X.Q., Xu J., Li D.X., Yuen K.Y., Peiris J.S.M., and Guan Y. 2003. “Epidemiology and Cause of Severe Acute Respiratory Syndrome (sars) in Guangdong, People’s Republic of China, in February, 2003.” Lancet 362(9393):1353–8.

440

bibliography

Zhou G. and Yan G. 2003. “Severe Acute Respiratory Syndrome Epidemic in Asia.” Emerging Infectious Diseases 9(12): 1608–10. Zizic T.M., Marcoux C., Hungerford D.S., Dansereau J.V., and Stevens M.B. 1985. “Corticosteroid Therapy Associated With Ischemic Necrosis of Bone in Systemic Lupus Erythematosus.” American Journal of Medicine 79:596–604. Zoutman D.E., Ford B.D., Bryce E., Gourdeau M., Hebert G., Henderson E., Paton S., Canadian Hospital Epidemiology Committee, Canadian Nosocomial Infection Surveillance Program, and Health Canada. 2003. “The State of Infection Surveillance and Control in Canadian Acute Care Hospitals.” American Journal of Infection Control 31(5): 266–72. Zuckerman D. 2003. “Hype in Health Reporting: ‘Checkbook Science’ Buys Distortion of Medical News.” International Journal of Health Services: Planning, Administration, Evaluation 33(2): 383–9.

Index

Acute respiratory distress syndrome (ards), 71; and avian flu, 326 Acute stress disorder (asd), defined, 58 Adamson, Bonnie, 30, 114 Age: and Hong Kong mortality, 91–2; as related to Canadian case fatality rate, 118; as risk factor, 75 Air hunger, 89, 92 Alveolar damage, 87 Amoy Gardens (Hong Kong), 17 Analytic system of cognitive psychology, 148–9 Animal reservoirs, 77–8 Antigenic shift, 80 Antiviral agents: 96; Canadian policy for, 364; and drug roll-out plans, 362, 364; efficacy for influenza, 363; efficacy for sars, 97; and side effects 97–8; Tamiflu, 362 Anxiety, 42, 116, 119 Atypical pneumonia, 3, 7, 11, 96 Australia, 25, 26 Avian Influenza: 34; bird culling as management strategy, 334; bird

mortality, 318; bird-to-human transmission, 328–9; common features with coronavirus, 318–19; compared to Ebola, 322; and drug resistance, 323; family cluster of, 322; farm risk reduction, 334–5; and genetic selection of, 339; highly pathogenic, 318; in wild birds, 320–1; limited human-to-human transmission, 325; low pathogenic, 318; other outbreak strains reported 331; and patient recovery, 328–31; potential as pandemic, 321; reported at same time as sars, 6; reservoirs of, 314; symptoms of human cases, 318, 325; Thailand and Vietnam 2004 case study, 324; and Thailand surveillance to detect, 325. See also h5n1. Basrur, Sheela, 136, 196, 254 Bill 1 – sars Assistance and Recovery Strategy Act, 18 Biological weapon, 53; and genetic sequence analyzed, 83; and sars as bioweapon, 82

442

index

British Columbia, 34 British Columbia Centre for Disease Control (bccdc), 34 Campbell, Archie: on quarantine, 19 Campbell Commission Report, 213, 215; final main recommendations, 225–6; final report, 224–7; interim main recommendations, 223–5, 227; interim report main recommendations, 224, 238–9; interim reports 1 and 2, 222–4; main criticisms, 223, 226–7; summary of, 218–19, 222 Canada Customs officers, and worker safety, 261 Canadian Federation of Nurses, 119 Canadian Newsstand Database (cnsd): and sars, 129; and Toronto Star, 130 Canadian Pandemic Influenza Plan, 357, 359–61; and policy for antiviral drugs, 364; priority groups for vaccines, 365 Canadian sars outbreak: analysis of, 29–34; duration, 5; estimated mortality of pandemic, 347; national responses to, 352–3; provincial guidance for, 355 Case fatality rate: Canadian percentage, 118; global percentage, 35; in Toronto, 118 Catholic church group, exposed to sars, 15 Chest x-ray, 11, 25, 89, 93; Singapore sars exposure x-ray study, 106; study of sars patients, 104

Child A, 25, 27 Child B, 27 Child C, 27 China: and avian influenza 314, 316, 321, 324, 329, 331; and Beijing management of sars, 354; and breach of quarantine, 283; and case underreporting, 152, 280, 282; and different sars case definitions, 281–2; epidemiology link to Canadian index cases, 10, 16; and factors facilitating virus transmission, 338; and factors facilitating zoonoses, 338–9; and final reported sars cases, 284–5; and health education notices, 305; initial sars news report, 6, 280; and magnitude of sars outbreak, 4, 35, 144, 278; and management of sars, 300, 352; and mass disinfection strategy, 304; and mohltc screening questions, 93; and news reporting, 133; number of travellers to Canada from, 32; and official apology, 280; and patients post-sars, 286; percentage of nurses affected by sars, 76; and prior coronavirus exposure, 79, 81; and quarantines, 301; and reaction to sars, 278–9; and reduced public movement, 279, 302; and risk communication, 278–86; and sars as bioweapon, 82; and sars case locations listed, 283; and sars origin, 78; and signal event, 123; spread of sars in Hotel M, 31; and stigma, 112, 171; and

index

stigma of Canadian students, 159; summary of cases, 26; and use of thermal scanners, 102; and viral reservoirs, 354; and who assessment, 284; who travel advisory lifted, 23; and who travel warning, 18, 165–6 Chlamydia pneumoniae, 7 Clostridium difficile: Calgary outbreak, 137–9; compared to sars, 140–1, 145–6; difficulties in controlling outbreaks, 139; incidence rates, 138; media coverage of, 140–1; Montreal area outbreak, 136–9; reasons for outbreak in Montreal hospitals, 139–40; and social attenuation of risk, 128–9 Cloudy infiltrate, 89 Code Orange: date activated in Ontario, 13; date revoked in Ontario, 20; restrictive impacts on nurses, 182; at St. Michael’s hospital, 191 Commission to Investigate the Introduction and Spread of Severe Acute Respiratory Syndrome Report, 213. See also Campbell Commission Report Computed tomography scans (ct scans), 96, 99 Contact tracing, 10, 40; used in other countries, 302 Coronavirus, 12; animals positive for, 81; error-prone replication, 80; groups, 71 Corticosteroids, for sars treatment, 109–10 Creatinine phosphokinase (cpk), 95

443

D’Cunha, Colin, 22, 136, 150, 262 Diagnosis, problems with sars, 98–9 Diagnostic tests: 12; by chest x-rays, 104–5; by elisa, 12, 103; genetic tests, 102–3; by ifa, 12, 103; by mass population screening, 100–1; by pcr, 12; for sars, 100–6; serologic tests, 103; by thermal imaging scanners 101–2 Disinfectants, efficacy of dilute bleach, 304; to eliminate sars-cov, 76; as sars reduction strategy in other countries, 304 Dyspnea, 89, 92 Emergency Department (ed), 41 Emotional distress: of hospital staff, 258; of nurses, 115, 258; of the public, 258; research studies of, 257–9 Enzyme Linked ImmunoSorbent Assay (elisa), 12, 103 Epidemic: common source, 312; defined, 311; historical review of population size to initiate, 315; host-to-host, 312; types of, 312–13 Eves, Ernie, 18, 45 Experiential system of cognitive psychology, 148, 157 Expert Panel on sars and Infectious Disease Control Report, 213. See also the Walker Report Expert panels: evidence reviewed, 213; highlight lack of information sharing, 246; major panels, 215–16; minor panels, 216–17;

444

index

process of convening, 212; reports compared, 236–9; selection of panel members, 213 Exported sars (from Canada): to Australia, 25; to Finland, 28; to Germany, 27; to the Philippines, 28; to the United States, 27 Family physicians, concerns over sars exposure, 14 Feline coronavirus, 80 Finland, 28 FluWatch, bulletin, 6; program, 360 Fomites, 110 Gender: and attitudes and values, 179–82; and dual role conflicts, 183–4; and history of nursing, 172–3; and lack of nurse recognition, 171, 182; and lack of respect for nurses, 180; and male versus female nurses, 175; and personal protective equipment, 177, 179; and power, 176–9; and roles of nurses, 183–4; and sars reports, 174–5; and work relationships, 184 Gender-based analysis, 173 Gender-based supports, described, 175–6 Gender mainstreaming, 175 Germany, 26, 27 Global Outbreak Alert and Response Network (goarn), 24 Global Public Health Intelligence Network (gphin), 6 Ground glass opacities, 96

h1n1, virulence of, 316. See also Spanish influenza h5n1, 34, 314; and countries affected, 316; and hypothetical human-to-human transmission of, 322; mortality rate of, 316; number of human cases, 316; vaccine development for, 366. See also Avian Influenza Health Canada, 6; facilitates mask purchase, 13; informs other groups 7; lack of jurisdiction over provincial healthcare, 246; stops reporting sars numbers, 211; Web site visits, 143 Health Emergency Act, 53, 255 Healthcare workers: disenfranchisement of, 259; and emotional distress, 115; occupational response to sars, 355–6; overworked during sars, 53; percentage of Canadian infections, 30; percentage infected in Hong Kong, China, and Singapore, 76; protest for inquiry, 117. See also Nurses Henry, Bonnie, 40 Henry Report, main recommendations, 235; summary 218–19 High-risk procedures, 8–9, 49; listed, 48 Histology, of lung tissues, 87 Hong Kong: 17, and risk communication of sars, 286–92 Hospitals: closed emergency departments, 12; common responses to sars, 205–7; containment practices, 76; refused patient admissions, 12; Toronto, infection control, 188–91

index

Human metapneumovirus, incorrectly identified as cause of sars, 11 Hypoxia, 89–90 Immunofluorescence assay (ifa), 12 Incubation period: unusually long, 23; of sars, 73 Index case A, 29, 31 Index case (Toronto), 34, 210 Infection control: changing directives, 47; in Ontario, 31; in other countries, 307 Infiltrate, 11, 99 Influenza: endemic, 311; incubation time, 312; prevalence, 311; rate of infection, 311; variability of, 314; vulnerable groups, 310 Influenza A, 312; h1–h3, 317; strains, 314; subtypes of, 312, 314 Interferons, for sars treatment, 98 International spread, 7 Intubation, 48, 90; incidence of, 94 Laroza, Nelia, 30, 117, 192 Law of contagion, 147–8 Law of similarity, 147 Left shift of white cell counts, 95 Leukopenia, 95 Lin, Tecla, 30 Live animal markets, 78, 335, 338 Low, Donald, 21; as expert during outbreak, 56–7; news media report of quarantine of, 127, quarantined, 57; teleconferences, 136; on timing of sars2, 22 Magical thinking, 147

445

Mask-fit testing, 45, 192 McGeer, Allison, 117 McKeown Report, main recommendations, 235; summary, 218–19, 234–5 Media triggers, 126; first newspaper articles about sars, 130 Metropole Hotel, 7 Mr C., 16 Mr H., 11 Mr K., 9, Mr P., 10 Mrs K., 7, 8, 34 Mr T., 8, 9, n95 masks: described, 44; difficulties experienced by nurses, 44; efficacy tested independently, 46; Hong Kong study of, 49; primary barrier for sars, 47; and reduced infection rates, 50; survey of nurses on, 46; used in other countries, 303–4 National Advisory Committee on sars and Public Health Report: 213. See also the Naylor Report National Emergency Stockpile System (ness), 13–4 National Survey of the Work and Health of Nurses, 173; and human resource issues during sars, 186 Naylor Report, 213, 215; main criticisms, 220–1; main recommendations, 220–2, 238–9; summary of, 217–19 Negative pressure rooms, 13 New normal, 45, 206 News media: and amplification effect, 144; and content analysis,

446

index

135; and coverage of post-sars rock concert, 169; criticism of, 129; as information source, 151; issue focus, 132, 134; local Toronto newspaper coverage, 130–1; national newspaper coverage, 131–4; and numbers of news articles, 134; over-reporting, 128; pejorative issue framing, 126, 152, 252; role during sars outbreak, 127; and saturation effect, 133; US coverage, 133 North York General Hospital: and communication during sars, 197; hospital capacity, 195; infection control post-sars, 198; number of sars cases, 30; and number quarantined, 113, 196, 195–8; organizational response to sars, 45, 196–7; and post-sars infrastructure for infection control, 70; pre-sars patient volume, 42; and sars assessment clinic, 67, 92; shutdown by sars, 21 Nosocomial outbreak, 75 Nurses: and breach of work quarantine, 64; and class action lawsuit, 259; Code Orange and impact on, 182; concern over self-protection, 45; and impacts of initial occupational exposure on, 254; individual law suit, 260; lack of recognition of, 171, 182; lack of respect for, 180; and n95 mask survey, 46; Nelia Laroza, 30, 117, 192; and profession, 172–3; and protection of, 177; and psychological

impacts on, 58–61; and quarantine difficulties, 61–4; Tecla Lin, 30; traditional roles of, 183–4. See also Healthcare workers Ontario Health Pandemic Influenza Plan, 355 Ontario Health Protection and Promotion Act, 5, 253 Ontario Medical Association, 14, 240 Ontario Ministry of Health and Long-Term Care (mohltc), 5; assessment questionnaire for healthcare workers, 92; guidelines for personal protective equipment, 207; recommends protective equipment, 33; second announcement of sars ending, 24 Ontario Nurses’ Association, 45; initial exposure of nurses, 254, 260; and protection of Toronto nurses, 177 Ontario Occupational Health and Safety Act, 193 Ontario sars Scientific Advisory Committee, 5, 25, 119, 240 Oseltamivir (Tamiflu), 96, 362; for avian influenza, 323 Pandemic: advanced risk model to estimate severity, 344–7; and case fatality rate, 342; and clinical attack rate, 342; and death toll, 342; defined, 311; estimated mortality for Canada, 347–9; estimates from simple model, 342–4; and frequency of, 315; and global fatality esti-

index

mated by who, 346; impacts to Canada from virulent strain, 348–50; management by government, 341; origins of, 314; and potential for social disruption, 369; predicted outcomes of, 340; preparedness for the next, 359–67; and risk communication, 341; and sars as, 84–5 Panspermia, 80–1 Paramedics: quarantined, 255, 257; stigmatized by the public, 257 Particle size and infectivity, 48 Passive immune therapy: tested in mice against sars-cov, 98 Patient recovery outcomes: lung damage, 107, lung scar tissue, 107–8; osteonecrosis, 109; relapse of sars, 110; Singapore study, 108; thrombotic complications, 108; Toronto study, 108; weight loss, 107 Patient shuttling, 190; Personal Protective Equipment (ppe): difficulties for male and female nurses, 179; difficulties for nurses, 55; directives removed for, 20; implemented as a directive, 13; as instrumental support, 178; mohltc guidelines for, 207; nurses’ perspective of, 43–5; transmission while wearing, 11 Philippines, 26, 28, 246–7 Pneumonia: Canadian death rate from, 35 Polymerase chain reaction (pcr), 12 Post-traumatic stress disorder (ptsd), defined, 58–9; indica-

447

tors of, 59–60, 118; as outcome, 266–7 Preparedness: business continuity during pandemic, 361; creation of the Emergency Management Unit (emu), 361; economic impacts, 369; for the next pandemic, 359–61; knowledge of response plans, 358; and risk communication, 361–2; selfmonitoring, 357–8; stockpiling, 361, 363; vaccine development in Canada, 360; and vaccines, 364–7 Probable cases: Canadian numbers of, 35; defined, 93–4; described, 4; global numbers of, 35; list of all countries reporting, 26; number during sars1, 31; number during sars2, 31; numbers in Ontario and bc, 33; numbers in other countries with sars, 144; who diagnostic criteria, 104 Program for Monitoring Emerging Diseases (ProMED), 6 Psychological impacts: on healthcare workers, 113–18; on nurses, 58–61; on patients, 111–13, 119; study of Hong Kong nurses, 115; study of Toronto healthcare workers, 114 Purification ritual, 167–70 Quarantine: amendments to, 242; breach of, 64; cumulative numbers in Canada, 38, 40; defined, 50; difficulties for individuals, 256; difficulties for nurses, 61–4; and difficulties tracking

448

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patients, 255; effects of retroactive actions, 252; impact on hospital resources, 262; and legislation in Ontario, 18; of Markham school, 23; of medical student, 23; non-cumulative numbers in Canada, 38–9; number in Toronto, 35; number of contacts in Canada, 99; and Suspect cases, 100; of Toronto paramedics, 255; used in other countries, 301–2. See also Work quarantine Quarantine order, 14; fines for breaking, 253; violations of, 253 Radiographic assessment, 96 Resources for infection control in hospitals (rich) study, 188 Reverse transcriptase-polymerase chain reaction (rt-pcr), 29, 88, 325 Ribavirin, 96, 98; dosage of patients, 97; side effects, 97 Risk, defined, 148, 244; form during sars, 155; configuration of during sars, 156 Risk anchors, 150; yearly flu as, 251–2 Risk communication: in China, 278–86; contradictory actions by officials, 253–4; described, 244–5; and factors to reduce gaps in, 264; framework for, 265–7; gaps in, 245; and health alerts, 308; to high risk occupational groups, 261–2; in Hong Kong, 286–92; to improve risk management of sars, 305–6; and lack of education and infor-

mation dissemination during, 274; and lack of strategic plans, 261; near zero risk messages, 253; and negative factors, 275; news media as information source, 246; news media focus during outbreak, 274; and pandemic planning, 361; public health officials reliance on news media for, 250; reporting of cumulative numbers, 247–50; of sars, 245; in Singapore, 297–300; and strategy, 275; in Taiwan, 292–7; and telephone hotlines, 256 Risk communication framework: Impact/Accident stage, 269–70; Prodrome/Incubation/Alert stage 267–9; Quiescent/Reorientation stage, 271–2; Recovery/Postaccident stage, 270–1 Risk perception: anthrax letters, 143; and Calman chart, 151; of drug efficacy to the public, 362; of drug roll-out plans, 362; influence on behaviour, 149; of pandemic uncertainty to the public, 367–8; and public trust, 371; of sars, 125 St. Michael’s Hospital, 191–5; hospital capacity, 191; organizational response to sars, 191–2, 194–5; sars response team, 192; staffing model, 194 sars: Active Canadian cases remaining after June 2003, 23; and age as risk factor, 75; assigning blame for the outbreak, 83–4; chronology of

index

events in Ontario, 6–16, 18–24; clinical description of, 92; cluster, 10; compared to yearly flu rate, 35, 155; and concern for nurses’ protection, 45; and containment strategy, 13; declared a reportable disease, 12; detected in animal reservoirs, 78; and difference from coronavirus, 71; and educational materials used in other countries, 305; epidemiological links, 10; exported to other countries, 14, 24–9; factors contributing to transmission, 74–7, 189; and first Chinese news report, 6; genome sequenced, 15; human resources issues during, 53; incubation times of, 73; individual responses to, 355–6; initial cluster identified, 9; initial symptoms of, 89; and institutional gaps, 57; and international responses, 350–1; international summit, 13; last Canadian case reported, 23, 211; and main expert panel reports, 215–33; and minor expert panel reports, 216–17, 233–6; as natural disaster, 265–72; number of cases, 277; Ontario case numbers for sars1 and sars2, 31; Ontario patients, 8–16; and origin of name, 210; and outcomes of cigarette smokers, 88; as a pandemic, 84–5; and patient icu experience, 91; and patient reaction to diagnosis, 68–9; and policy to improve workers’ supports, 185–6; post-sars

449

worker attitudes, 69–70; and psychological impacts on nurses, 58–61; radiographic appearance, 96; recovery from, 106–10; refusal to work during, 56; regional responses to, 353–5; second cluster, 22; and similar containment methods used in different countries, 300–7; and social distancing, 302–3; and symptoms of patients in Hong Kong, 86; symptoms of patients in Toronto, 87–8; telephone hotline, 10; and theories of its origin, 77–8; walk-in assessment clinic, 66; and weight loss, 57, 91; who global plan, 351–2 sars1, 61, 195, 250; number of cases in Canada, 31 sars2, 21, 194–5, 255; number of cases in Canada, 31 sars-cov: detected in blood, 78; and genome size, 72; labile samples for testing, 29; mutated strain, 74; other strains known to infect humans, 72–3; physical properties, 72–3; and survival time in environment, 76 Scarborough Grace Hospital, 10, 198–201; hospital capacity, 198–9; impact of initial work quarantine, 252; organizational response to sars, 199–201 Seropositive, public exposure in Hong Kong, 79; study of animal handlers, 78–9 Singapore: risk communication of sars, 297–300; sars exposure chest x-ray study, 106

450

index

Social Amplification of Risk Framework (sarf): defined, 121; effects of, 124, 146; examples of, 122; and factors involved in sars, 251–2; impacts of Internet on, 141–3; outcomes of, 124; process of, 122–3; role of news media, 123; and signal events, 123 Social attenuation of risk, 136–41 Spanish influenza, 315; estimate of deaths from simple model, 343. See also h1n1 Stigma: assigned to people or place, 152; in Canada, 163; of Canadian students studying abroad, 159; in China, 164; criteria for, 123; defined, 152; effects on hospital visits, 166–7; of healthcare workers (Canada), 157–9, 258; of healthcare workers (China), 160–2; of healthcare workers (Singapore), 162; of houses near hospitals, 163; of individuals, 157–163; of Metropole Hotel, 164–5; overcoming and managing, 263; of paramedics, 257; of place, 163–7; from sars, 153; of Toronto area as contaminated place, 163, 165; and Toronto purification ritual, 167–70; and Toronto rock concert, 168 Stryker T4 System, 47, 194 Sunnybrook Hospital, 15 Super-spreading events, 74, 208 Suspect cases: Canadian numbers, 35; defined, 93–4; described, 4; provincial numbers reported, 33; who diagnostic criteria, 104

Taiwan: de-listed for sars, 24; risk communication of sars, 292–7 Telehealth Ontario, 20; number of calls received, 38 Thermal imaging scanners, 101–2 Thrombocytopenia, 95 Toronto: number of cases, 118; number of cases investigated, 35; number quarantined, 35; risk outside of hospitals, 245 Transaminases, 95–6 Travel advisory, 18; against Toronto, 166; lifted, 23; as transmission reduction strategy used in other countries, 306–7 Tuberculosis (tb), 48 United States, 26, 27, 75 Urbani, Carlo, 210 Vaccine, 98, 360, 364–7, 371 Vancouver, hospital control measures, 34; number of daily travellers to, 32; patients 16–17, 36–7 Ventilator, 90, 94 Verbal risk scales, 150 Walker Report, 213, 216; main criticisms, 229, 231; main recommendations, 231–3, 238–9; summary of, 218–19, 227–8 Webmd, 143 William Osler Health Centre, 203–5; hospital capacity, 203; organizational response to sars, 204 Williams and MacLean Report, main recommendations, 236; summary of 218–19, 235

index

Work quarantine: 15; breach of, 64; described, 50; difficulties for nurses, 61–4, 255; and difficulty recruiting staff, 53; guidelines at home for, 51; 52–3; guidelines at work for, 51; psychological impact on nurses, 59. See also Quarantine World Health Organization (who): announces cause of sars, 12; comparing avian flu to sars, 317; concern over h5n1/avian flu, 314, 316–17; early deaths reported, 6; estimated global fatalities of pandemic, 346; and global influenza preparedness plan, 351–2; initial sars incubation time estimate, 74; issues global health alert, 16; issues travel advisory, 18; predicted events of pandemic,

451

341–2; and Probable sars criteria, 104; raising awareness of avian flu, 337; removes Canada from country list, 24; removes Canada from travel advisory, 19; stops reporting sars numbers, 24; use of case definition for diagnosis, 103; on virus resilience, 19; Western Pacific Regional Office, 25 Worried but well, 20 Yanga, Nestor Santiago, 30 Young, James, 33, 136, 240; critical of news media, 248 York Central Hospital, 11, 201–3; hospital capacity, 201; organizational responses to sars, 202–3 Zoonotic jumps, 78, 323, 335, 338–9; preventing, 332–3