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Survey of Stress Reactions Among Health Care Workers Involved With the SARS Outbreak

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Abstract

The outbreak of severe acute respiratory syndrome (SARS) was unique because it was highly concentrated in health care settings and a large number of health care workers were infected. This study investigated stress reactions among 338 staff members in a hospital in East Taiwan that discontinued emergency and outpatient services to prevent possible nosocomial outbreak. Seventeen staff members (5 percent) suffered from an acute stress disorder; stepwise multiple logistic regression analysis determined that quarantine was the most related factor. Sixty-six staff members (20 percent) felt stigmatized and rejected in their neighborhood because of their hospital work, and 20 of 218 health care workers (9 percent) reported reluctance to work or had considered resignation.
PSYCHIATRIC SERVICES http://ps.psychiatryonline.org September 2004 Vol. 55 No. 9 11005555
The outbreak of severe acute
respiratory syndrome (SARS) was
unique because it was highly
concentrated in health care set-
tings and a large number of
health care workers were infect-
ed. This study investigated stress
reactions among 338 staff mem-
bers in a hospital in East Taiwan
that discontinued emergency
and outpatient services to pre-
vent possible nosocomial out-
break. Seventeen staff members
(5 percent) suffered from an
acute stress disorder; stepwise
multiple logistic regression
analysis determined that quaran-
tine was the most related factor.
Sixty-six staff members (20 per-
cent) felt stigmatized and reject-
ed in their neighborhood be-
cause of their hospital work, and
20 of 218 health care workers (9
percent) reported reluctance to
work or had considered resigna-
tion. (Psychiatric Services 55:
1055–1057, 2004)
The outbreak of severe acute respi-
ratory syndrome (SARS) in multi-
ple countries—especially in Asian
countries and Canada—is believed to
have been caused by a newly discov-
ered SARS-associated coronavirus (1).
The first case of SARS that was iden-
tified in Taiwan was on March 14,
2003, in a traveler from Guangdong
Province, China. SARS then spread to
multiple regions of Taiwan, with 664
cases ultimately identified; by the end
of June 2003, 184 patients had died.
SARS was unique in its speed of trans-
mission, its high concentration in
health care settings, and the large
number of health care workers who
were infected (2–4). In fact, more
than 70 percent of patients who tested
positive for SARS by the use of a poly-
merase chain reaction assay had the
origin of their disease traced back to a
hospital (5).
In Taiwan a total of 105 health care
workers became infected with SARS,
and 12 of these workers ultimately
died (5). Four hospitals had to discon-
tinue emergency and outpatient serv-
ices to prevent possible nosocomial in-
fection. The outbreak of SARS caused
not only extraordinary public health
concerns but also tremendous psycho-
logical distress, particularly among
health care workers. The known
lethality of the syndrome as well as the
intense media coverage of the out-
break exacerbated perceptions of per-
sonal danger. Staff members were dis-
couraged from interacting with col-
leagues, thereby increasing feelings of
isolation (6). Infection control proce-
dures were frequently modified be-
cause of the evolving understanding of
SARS. Health care workers spent
hours each day putting on and remov-
ing airtight protective equipment,
which only added to the exhaustion
that the workers were experiencing
from the increased workload that was
caused from the SARS outbreak.
Health care facilities became highly
stressful environments (7).
We report here the stress reactions
of staff members in a 2,500-bed psy-
chiatric teaching hospital. The hospi-
tal, which is located in Hua-Lien, East
Taiwan, also provides medical and
surgical services to local residents.
The hospital has 120 medical and sur-
gical beds and averages 100,000 out-
patient visits and 2,000 operations a
year. Between May 10 and May 18,
2003, eight soldiers from the same
squad successively presented to the
emergency department, complaining
of a fever and cough. On May 18 one
nurse who had worked in the emer-
gency department developed a fever.
On May 19 the local anti-SARS team
leader instructed the hospital to cease
all outpatient and emergency services
to prevent possible nosocomial trans-
mission. Fifty-seven staff members
who may have come in contact with
suspected SARS cases were quaran-
tined. Fortunately, all staff members
were cleared of having SARS after
nine days of quarantine, but all had
Survey of Stress Reactions Among
Health Care Workers Involved
With the SARS Outbreak
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Dr. Bai, Dr. Chao-Cheng Lin, Dr. Chih-
Yuan Lin, Dr. Chen, and Dr. Chue are af-
filiated with the Yu-Li Veterans Hospital,
91, Hsin Hsing Street, Yu-Li, Hua-Lien,
981, Taiwan (e-mail, ymbi@mail2000.
com.tw). Dr. Bai is also with the Institute
of Public Health at National Yang-Ming
University. Dr. Chou is with the Institute
of Public Health at National Yang-Ming
University in Taipei, Taiwan.
PSYCHIATRIC SERVICES http://ps.psychiatryonline.org September 2004 Vol. 55 No. 9
11005566
TTaabbllee 11
Demographic characteristics and stress reactions among 338 staff members who were working in a hospital in East Taiwan
that discontinued emergency and outpatient services to prevent a possible nosocomial outbreak of severe acute respiratory
syndrome (SARS)a
Health care Administrative
Total sample workers personnel Quarantined Nonquarantined
(N=338) (N=218) (N=79) staff (N=41) staff (N=297)
Item N % N % N % p N % N % p
Age (mean±SD years) 39.1±9.4 36.9±8.9 41.7±9.1 <.001 36.6±9.7 39.2±9.4 ns
Male 163 49 74 34 59 76 <.001b19 46 136 48 ns
Married 230 70 140 65 59 77 ns 28 68 193 69 ns
More than 12 years
of education 181 60 129 68 44 59 ns 23 64 154 60 ns
Mean±SD years
in occupation 12±7.2 11.1±7.2 14.1±7.1 .004 9.9±6.8 12.3±7.2 ns
Ever been quarantined 41 13 37 18 3 4 .002b
Health care workers 218 64 37 93 174 70 .002b
Feared getting in-
fected with SARS 111 33 81 37 23 30 ns 18 45 90 32 ns
Pessimism or
hopelessness 40 12 31 15 7 9 ns 8 20 30 11 ns
Absence of emotional
response 21 6 15 7 4 5 ns 4 10 17 6 ns
Exhaustion 51 15 44 20 6 8 .009b13 32 38 13 .005b
Reduced awareness
or being in a daze 19 6 12 6 7 9 ns 3 8 16 6 ns
Detachment from
others 32 10 25 12 6 8 ns 9 22 23 8 .001b
Always wore mask and
protective equip-
ment, even in
open spaces 19 6 13 6 4 5 ns 5 12 14 5 ns
Invest a majority of
free time reading
or watching SARS-
related information 169 50 116 54 34 44 ns 19 46 147 52 ns
Anxiety when dealing
with febrile patients 56 17 40 19 14 18 ns 13 33 39 14 .004b
Avoided SARS-related
information 20 6 11 5 5 6 ns 3 8 17 6 ns
Anxiety 44 13 36 17 6 8 ns 8 20 34 12 ns
Irritability 16 5 14 7 2 3 ns 6 15 10 4 .008b
Insomnia 35 10 31 14 4 5 .04b9 22 26 9 .026b
Uncertainty about
frequent modifica-
tion of infection
control procedures 92 27 75 35 14 18 .006b14 35 75 26 ns
Poor concentration
and indecisiveness 24 7 16 8 7 9 ns 7 18 17 6 .018b
Afraid to go home
because of fear of
infecting family 52 15 39 18 11 14 ns 14 34 37 13 .002b
Deteriorating work
performance 21 6 14 7 6 8 ns 8 20 13 5 .002b
Reluctant to work
or considered
resignation 24 7 20 9 3 4 ns 10 24 13 5 <.001b
Depressed mood 38 11 31 14 6 8 ns 6 15 32 11 ns
Stigmatization and re-
jection in neighbor-
hood because of
hospital work 66 20 47 22 15 19 ns 14 34 49 17 .002b
Met criteria for an
acute stress disorder 17 5 11 5 5 6 ns 7 17 10 4 .002b
aData were not available for all questions.
bFisher’s exact test
endured tremendous stress during the
quarantine period. This study sur-
veyed SARS-related stress reactions
among all hospital staff members dur-
ing the SARS outbreak.
Methods
The authors designed an anonymous
SARS-related stress reactions ques-
tionnaire, composed of acute stress
disorder criteria according to DSM-
IV criteria and related emotional and
behavioral changes. It was hoped that
the anonymity would allow colleagues
to feel less embarrassed about ex-
pressing their psychological stress.
On May 29, after all quarantined
members had returned to work, the
personnel department sent the ques-
tionnaires to 557 staff members in all
departments (402 health care work-
ers and 155 administrative person-
nel), with instructions to complete
the questionnaire within one week.
The filled-out questionnaire was then
to be put in a departmental collection
box, for collection and return to the
personnel department on June 5.
The statistical significance level was
set at 5 percent for two-sided tests.
The software package SPSS 10.0 for
Windows was used for statistical
analysis.
Results
Three hundred and thirty-eight staff
members completed the question-
naires, giving a total response rate of
61 percent. Health care workers were
defined as the doctors, physician as-
sistants, and nursing staff members
who had direct contact with patients
every day, whereas all other staff
members—including accountants
and sanitary teams—were defined as
administrative personnel. A total of
41 questionnaires did not identify the
respondents’ duties; therefore, re-
sponses were obtained from 218
health care workers and 79 adminis-
trative personnel, for response rates
of 54 and 51 percent, respectively.
Seventeen staff members (5 percent)
met the criteria for an acute stress
disorder, stepwise multiple logistic
regression analysis determined that
quarantine was the most related fac-
tor (β=1.405, standard error=.647,
odds ratio=4.077, 95 percent confi-
dence interval=1.148 to 14.48).
SARS-related stress reactions in the
total sample, comparisons between
health care workers and administra-
tive personnel, and comparisons be-
tween quarantined and nonquaran-
tined staff members are shown in
Table 1.
Sixty-six staff members (20 percent)
reported feeling stigmatized and re-
jected in their neighborhood because
of their hospital work, and 52 staff
members (15 percent) did not to go
home after work during the outbreak
for fear of infecting their family.
In contrast to administrative per-
sonnel, health care workers reported
experiencing significantly more in-
somnia, exhaustion, and uncertainty
about the frequent modifications to
infection control procedures. Twenty
health care workers (9 percent) re-
ported that they were reluctant to
work during the outbreak or had con-
sidered resignation.
Discussion
This report is very preliminary. Gen-
eralization of the results is limited by
the type of institution and by the time
that had elapsed from the most stress-
ful period of the nine-day quarantine
to when all staff members had been
excluded as probable SARS cases.
Psychological stress may have been
greater and more sustained among
workers in SARS treatment centers.
Other limitations were the moderate
response rate; the voluntary nature of
the survey, which may have created a
selection bias; and a lack of validity in
the absence of face-to-face inter-
views. Anonymity may have allowed
staff members to feel comfortable in
reporting their stress, but it prevent-
ed the tracing and investigation of
nonresponders and follow-up of staff
members who needed help. Never-
theless, this preliminary report
should contribute to the understand-
ing of stress reactions among health
care workers who were involved in
the SARS outbreak.
These findings suggest that there is
a role for providing accurate and
timely SARS information to health
care workers and the public to reduce
uncertainty and minimize stigmatiza-
tion of health care workers. Providing
suitable accommodation to health
care workers would benefit those who
are concerned about the risk of in-
fecting loved ones.
The results highlight the value of
shortened work hours as a means by
which the tremendous stress caused
by a SARS outbreak can be reduced
and the value of unambiguous infor-
mation in reducing uncertainty.
Quarantined staff members were at
a high risk of developing an acute
stress disorder. In addition, almost a
quarter of the respondents who were
quarantined were reluctant to work or
had considered resignation. Although
the hospital’s psychiatric team tried to
support staff members with informal
support groups and education about
relaxation techniques, there was clear-
ly a need for more psychosocial sup-
port and follow-up programs.
Conclusions
The past quarter century has seen the
emergence of several new diseases,
but the SARS outbreak was unique be-
cause of the speed at which SARS was
transmitted, the high concentration of
cases in health care settings, and the
large number of health care workers
who were infected (5). Organizations
will need to develop an integrated ad-
ministrative and psychosocial response
to the occupational and psychological
challenges that are caused by future
outbreaks of this nature.
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1. Kuiken T, Fouchier RA, Schutten M, et al:
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2. Koh D, Lim MK, Chia SE: SARS: health
care work can be hazardous to health. Oc-
cupational Medicine 53:241–243, 2003
3. Cluster of severe acute respiratory syn-
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workers—Toronto, Canada, April 2003.
Morbidity and Mortality Weekly Report 52:
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4. Fletcher M: SARS: nurses among first
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PSYCHIATRIC SERVICES http://ps.psychiatryonline.org September 2004 Vol. 55 No. 9 11005577
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The first reported case of a novel coronavirus-2019 (COVID-19) was in China. COVID-19 had substantial consequences on all aspects of society globally. In reaction to the mounting number of cases and deaths associated with COVID-19, global measures such as quarantines, lockdowns, and social distancing were implemented in early 2020. While these strategies may have slowed the rapid spread of the virus, they have harmed people psychologically. In a context of huge uncertainty, psychological issues and health sequelae of the COVID-19 crisis, including stress, anxiety, depression, frustration, and suicide, have progressively emerged. These psychological reactions to COVID-19 infection impair good health and well-being for all ages, specified in the third goal of Sustainable Development Goals (SDG). The achievement of SDG should parallel the global response to the COVID-19 pandemic; they should not counteract each other. In this context, short- and long-term negative effects of psychological reactions may exist, thus urgent strategies to mitigate such a burden is paramount. This chapter discusses the psychological aspects during the COVID-19 by exploring the psychological reactions to this global pandemic of the general population and those involved in the healthcare sector. Further, it explores the impact of the psychological burden on society, including the risk and protective factors. Lastly, preventative strategies to lessen this psychological burden for better health and community well-being are detailed.
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Front line healthcare workers are the primary section in contact with patients and are an important source of exposure to the infected cases in the healthcare settings, thus expected to be at a high risk of infections. Lack of knowledge for a new disease’ infection, or pandemic among health care personnel may result in form of delayed treatment and rapid spirit of infection. : The study amid to find out the perfection of health care providers about COVID-19 the objectives of our study are to identify the perceived levels of stress and anxiety in the confined population to determine the experiences and psychosocial problems health care providers and to provide health education messages while taking part in the study. This is a cross-sectional study conducted on 100 frontline health care workers that include Doctors, nurses, and clinical technicians in all departments who work in Covid dedicated hospital and covid dedicated health care center at government medical college Ratlam. The survey instrument constituted a Semi-structured pre-tested 27-close ended questionnaire. The 27-item questionnaire was divided into two sections (1) baseline sociodemographic information (20 items) (2) perceptions of the threat of COVID-19 (7 items 5 statements/5-point Likert scales. In this study total of 118 health care providers/workers (HCWs) participated, 100 of whom completed the study questionnaire including 16 females and 84 men. The age of participants ranges from 20-to 50 years. After analysis of a total of seven-factor for perception to covid, we found that health care workers experienced different levels of psychological stress and anxiety. Government higher authority and policymakers should keep point in their mind that pandemics/outbreaks lead to stress, anxiety and depression among health care workers hence policymakers will need to develop a well-integrated administrative and psychological response to the occupational along with psychological challenges that are caused by future pandemic/outbreaks of this nature, to maintain better patient wellbeing.
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The outbreak of severe acute respiratory syndrome (SARS) in Toronto, which began on Mar. 7, 2003, resulted in extraordinary public health and infection control measures. We aimed to describe the psychological and occupational impact of this event within a large hospital in the first 4 weeks of the outbreak and the subsequent administrative and mental health response. Two principal authors met with core team members and mental health care providers at Mount Sinai Hospital, Toronto, to compile retrospectively descriptions of the experiences of staff and patients based on informal observation. All authors reviewed and analyzed the descriptions in an iterative process between Apr. 3 and Apr. 13, 2003. In a 4-week period, 19 individuals developed SARS, including 11 health care workers. The hospital's response included establishing a leadership command team and a SARS isolation unit, implementing mental health support interventions for patients and staff, overcoming problems with logistics and communication, and overcoming resistance to directives. Patients with SARS reported fear, loneliness, boredom and anger, and they worried about the effects of quarantine and contagion on family members and friends. They experienced anxiety about fever and the effects of insomnia. Staff were adversely affected by fear of contagion and of infecting family, friends and colleagues. Caring for health care workers as patients and colleagues was emotionally difficult. Uncertainty and stigmatization were prominent themes for both staff and patients. The hospital's response required clear communication, sensitivity to individual responses to stress, collaboration between disciplines, authoritative leadership and provision of relevant support. The emotional and behavioural reactions of patients and staff are understood to be a normal, adaptive response to stress in the face of an overwhelming event.
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The worldwide outbreak of severe acute respiratory syndrome (SARS) is associated with a newly discovered coronavirus, SARS-associated coronavirus (SARS-CoV). We did clinical and experimental studies to assess the role of this virus in the cause of SARS. We tested clinical and postmortem samples from 436 SARS patients in six countries for infection with SARS-CoV, human metapneumovirus, and other respiratory pathogens. We infected four cynomolgus macaques (Macaca fascicularis) with SARS-CoV in an attempt to replicate SARS and did necropsies on day 6 after infection. SARS-CoV infection was diagnosed in 329 (75%) of 436 patients fitting the case definition of SARS; human metapneumovirus was diagnosed in 41 (12%) of 335, and other respiratory pathogens were diagnosed only sporadically. SARS-CoV was, therefore, the most likely causal agent of SARS. The four SARS-CoV-infected macaques excreted SARS-CoV from nose, mouth, and pharynx from 2 days after infection. Three of four macaques developed diffuse alveolar damage, similar to that in SARS patients, and characterised by epithelial necrosis, serosanguineous exudate, formation of hyaline membranes, type 2 pneumocyte hyperplasia, and the presence of syncytia. SARS-CoV was detected in pneumonic areas by virus isolation and RT-PCR, and was localised to alveolar epithelial cells and syncytia by immunohistochemistry and transmission electron microscopy. Replication in SARS-CoV-infected macaques of pneumonia similar to that in human beings with SARS, combined with the high prevalence of SARS-CoV infection in SARS patients, fulfill the criteria required to prove that SARS-CoV is the primary cause of SARS.
Center for Disease Control, Department of Health
  • Sars Online Information
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SARS Online Information Center. Center for Disease Control, Department of Health, Taiwan, ROC. Available at www. cdc.gov.tw/sarsen
Severe acute respiratory syndrome-Taiwan
7. Severe acute respiratory syndrome-Taiwan, 2003. Morbidity and Mortality Weekly Report 52:461-466, 2003