SARS control and psychological effects of quarantine, Toronto, Canada.As a transmissible transmissible /trans·mis·si·ble/ (trans-mis´i-b'l) capable of being transmitted.
Capable of being conveyed from one person to another. infectious disease Infectious disease
A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. , severe acute respiratory syndrome Severe Acute Respiratory Syndrome (SARS) Definition
Severe acute respiratory syndrome (SARS) is the first emergent and highly transmissible viral disease to appear during the twenty-first century. (SARS) was successfully contained globally by instituting widespread quarantine quarantine (kwŏr`əntēn), isolation of persons, animals, places, and effects that carry or are suspected of harboring communicable disease. measures. Although these measures were successful in terminating the outbreak in all areas of the world, the adverse effects of quarantine have not previously been determined in a systematic manner. In this hypothesis-generating study supported by a convenience sample drawn in close temporal proximity to the period of quarantine, we examined the psychological effects of quarantine on persons in Toronto, Canada. The 129 quarantined persons who responded to a Web-based survey exhibited a high prevalence of psychological distress psychological distress The end result of factors–eg, psychogenic pain, internal conflicts, and external stress that prevent a person from self-actualization and connecting with 'significant others'. See Humanistic psychology. . Symptoms of posttraumatic stress disorder Posttraumatic stress disorder
An anxiety disorder in some individuals who have experienced an event that poses a direct threat to the individual's or another person's life. (PTSD PTSD posttraumatic stress disorder.
posttraumatic stress disorder
Post-traumatic stress disorder (PTSD) ) and depression were observed in 28.9% and 31.2% of respondents, respectively. Longer durations of quarantine were associated with an increased prevalence of PTSD symptoms. Acquaintance with or direct exposure to someone with a diagnosis of SARS was also associated with PTSD and depressive de·pres·sive
1. Tending to depress or lower.
2. Depressing; gloomy.
3. Of or relating to psychological depression.
A person suffering from psychological depression. symptoms.
Severe acute respiratory syndrome (SARS) was contained globally by widespread quarantine measures, measures that had not been invoked to contain an infectious disease in North America North America, third largest continent (1990 est. pop. 365,000,000), c.9,400,000 sq mi (24,346,000 sq km), the northern of the two continents of the Western Hemisphere. for >50 years (1-6). Although quarantine has periodically been used for centuries to contain and control the spread of infectious diseases infectious diseases: see communicable diseases. such as cholera and the plague with some success (1-4, 6-8), the history of invoking quarantine measures is tarnished by threats, generalized fear, lack of understanding, discrimination, economic hardships, and rebellion (1, 3, 4, 6-8).
Quarantine separates persons potentially exposed to an infectious agent infectious agent Pathogen, see there (and thus at risk for disease) from the general community. For the greater public good, quarantine may create heavy psychological, emotional, and financial problems for some persons. To be effective, quarantine demands not only that at-risk persons be isolated but also that they follow appropriate infection control measures within their place of quarantine. Reporting on SARS quarantine has focused on ways in which quarantine was implemented and compliance was achieved (1-4, 6-8). Adverse effects on quarantined persons and the ways in which those quarantined can best be supported have not been evaluated. Moreover, little is known about adherence to infection-control measures by persons in quarantine.
Knowledge and understanding of the experiences of quarantined persons are critical to maximize infectious disease containment and minimize the negative effects on those quarantined, their families, and social networks. The objectives of our study were to assess the level of knowledge about quarantine and infection control measures of persons who were placed in quarantine, to explore ways by which these persons received information to evaluate the level of adherence to public health recommendations, and to understand the psychological effect on quarantined persons during the recent SARS outbreaks in Toronto, Canada.
Description of Quarantine in Toronto
During the first and second SARS outbreaks in Toronto, >15,000 persons with an epidemiologic exposure to SARS were instructed to remain in voluntary quarantine (Health Canada Health Canada (French: Santé Canada) is the department of the government of Canada with responsibility for national public health.
Health Canada's goal is to improve Canadian life by improving Canadian longevity, lifestyle and use of public healthcare. , unpub, data). Data on the demographics of the quarantined population were collected but have not yet been analyzed (B. Henry, Toronto Public Health, pers. comm.). Quarantined persons were instructed net to leave their homes or have visitors. They were told to wash their hands frequently, to wear masks when in the same room as other household members, not to share personal items (e.g., towels, drinking cups, or cutlery), and to sleep in separate rooms. In addition, they were instructed to measure their temperature twice daily. If any symptoms of SARS developed, they were to call Toronto Public Health or Telehealth Ontario for instructions (5).
All persons who were placed in quarantine during the SARS outbreaks in Toronto (at least 15,000 persons) were eligible for participation in this study. The survey was announced through media releases, including locally televised interviews with the principal investigators Noun 1. principal investigator - the scientist in charge of an experiment or research project
scientist - a person with advanced knowledge of one or more sciences . Information on the study and invitations to participate were posted in local healthcare institutions, libraries, and supermarkets. Ethics approval was obtained from the research ethics Research ethics involves the application of fundamental ethical principles to a variety of topics involving scientific research. These include the design and implementation of research involving human participants (human experimentation); animal experimentation; various aspects of board of the University Health Network, a teaching institution affiliated with the University of Toronto Research at the University of Toronto has been responsible for the world's first electronic heart pacemaker, artificial larynx, single-lung transplant, nerve transplant, artificial pancreas, chemical laser, G-suit, the first practical electron microscope, the first cloning of T-cells, .
A Web-based survey composed of 152 multiple choice and short- answer questions was to be completed after participants ended their period of quarantine. It took approximately 20 minutes to complete. Questions explored included the following: 1) knowledge and understanding of the reasons for quarantine, (2) knowledge of and adherence to infection control directives, and (3) source of this knowledge.
The psychological impact of quarantine was evaluated with validated scales, including the Impact of Event Scale--Revised (IES-R) (9) and the Center for Epidemiologic Studies--Depression Scale (CES-D CES-D Center for Epidemiologic Studies Depression (Scale) ) (10). The IES-R is a self-report measure designed to assess current subjective distress resulting from a traumatic life event and is composed of 22 items, each with a Likert rating scale from 0 to 4. The maximum score is 88. In a study of journalists working in war zones, the mean IES-R score of posttraumatic stress disorder (PTSD) was 20. In these persons, the presence of PTSD symptoms, as measured by this scale, was correlated with diagnostic psychiatric interviews psychiatric interview Psychiatry The central vehicle for assessing a psychiatric Pt, during which there is a free exchange of information that forms the basis for therapy (11). The CES-D is a measure of depressive symptoms composed of 20 self-report items, each with a Likert rating scale from 0 to 3. The maximum score is 60 (10). A score of [greater than or equal to] 16 has been shown to identify persons with depressive symptoms similar in severity to the levels observed among depressed patients (10, 12, 13). Open-ended questions A closed-ended question is a form of question, which normally can be answered with a simple "yes/no" dichotomous question, a specific simple piece of information, or a selection from multiple choices (multiple-choice question), if one excludes such non-answer responses as dodging a provided respondents with the opportunity to relate the aspects of quarantine that were most difficult for them and allowed them to provide additional comments on their unique experiences.
Means were calculated to summarize continuous variables. For categorical That which is unqualified or unconditional.
A categorical imperative is a rule, command, or moral obligation that is absolutely and universally binding.
Categorical is also used to describe programs limited to or designed for certain classes of people. variables, group proportions were calculated. Student t tests were used to examine relationships between demographic variables and the psychological outcome variables, the scores on the IES-R and CESD CESD cholesteryl ester storage disease. . A score of [greater than or equal to] 20 on the IES-R was used to estimate the prevalence of PTSD symptoms (11). A score of [greater than or equal to] 16 on the CES-D was used to estimate the prevalence of depressive symptoms (10, 12, 13).
Analysis of variance (ANOVA anova
see analysis of variance.
ANOVA Analysis of variance, see there ), chi-square, and the Cochran-Armitage test for trend The Cochran-Armitage test for trend is typically used in categorical data analysis when some categories are ordered. For example, doses can be ordered as 'low', 'medium', and 'high'. were used to examine relations between the IES-R and CES-D scores and the following independent variables: healthcare worker status, home or work quarantine, acquaintance of or direct exposure to someone with a diagnosis of SARS, combined annual household income, and the frequency with which persons placed in quarantine wore their masks. Linear regression Linear regression
A statistical technique for fitting a straight line to a set of data points. for the trends between income categories and both PTSD and depressive symptoms was analyzed. The relationships between the IES-R and CES-D and whether persons in quarantine wore their masks all of the time versus never were examined by the Duncan-Waller K-ratio t tests. A p value of [less than or equal to] 0.05 was considered to be significant for all analyses.
Qualitative data were coded and analyzed to show emerging themes. The development and confirmation of the thematic coding structure is an iterative it·er·a·tive
1. Characterized by or involving repetition, recurrence, reiteration, or repetitiousness.
2. Grammar Frequentative.
Noun 1. process involving two researchers in individual, recursive See recursion.
recursive - recursion reading of the textual data and group meetings to discuss and test the emerging themes. Discrepancies were resolved by consulting specific instances in the data, discussing their relationship to established themes, and reaching consensus as a group (14).
Demographics and Description of Quarantined Persons
The survey was completed by 129 of more than 15,000 eligible persons who were placed in quarantine (Figure). All respondents completed the survey at the end of quarantine with a minimum time from the end of quarantine to the completion of the survey of 2 days. The median time from the end of quarantine to completion of the survey was 36.0 days (interquartile range In descriptive statistics, the interquartile range (IQR), also called the midspread, middle fifty and middle of the #s, is a measure of statistical dispersion, being equal to the difference between the third and first quartiles. , 10-66 days). Sixty-eight percent of respondents were healthcare workers, 64% were 26-45 years of age, 58% were married, 72% had a college level of education or higher, and 48% had a combined household income of [greater than or equal to] $75,000 (Canadian dollars Noun 1. Canadian dollar - the basic unit of money in Canada; "the Canadian dollar has the image of loon on one side of the coin"
dollar - the basic monetary unit in many countries; equal to 100 cents [CAD]).
The 129 respondents described 143 periods of quarantine with 90% of respondents being placed into quarantine only once; 66% of respondents were on home quarantine, while 34% were on work quarantine. The median duration of quarantine was 10 days (interquartile range, 8-10 days). Half of respondents knew someone who was hospitalized with SARS of whom 77% were colleagues; 10% knew someone who had died of SARS (Table 1).
Persons were notified of their need to go into quarantine from the following sources: their workplace (58%), the media (27%), their healthcare provider (7%), and public health officials (9%). Most (68%) understood that they were quarantined to prevent them from transmitting infection to others; 8.5% of respondents believed they were quarantined to protect themselves from infection; 15% did not believe they should have been placed into quarantine at all; and 8.5% provided more than one of these responses.
The source of notification for quarantine influenced understanding of the reason for quarantine. Those who were notified by the media or their workplace were more likely to understand the reason for quarantine than those who were notified by their healthcare provider or public health unit (p = 0.04). Healthcare workers were also more likely to understand the reason for quarantine compared with non-healthcare workers, 76.5% versus 52.5% (p = 0.007). Combined household income and level of education did not influence understanding of the reason for quarantine.
Information on Infection Control Measures
Persons received their information regarding infection control measures to be adhered to during their quarantine from the following sources: the media (54%), public health authorities (52%), occupational health department (33%), healthcare providers (29%), word-of-mouth (23%), hospital Web sites (21%), and other Web sites (40%).
Those who did not think they had been well-informed were angry that information on infection control measures and quarantine was inconsistent and incomplete, frustrated frus·trate
tr.v. frus·trat·ed, frus·trat·ing, frus·trates
a. To prevent from accomplishing a purpose or fulfilling a desire; thwart: that employers (healthcare institutions) and public health officials were difficult to contact, disappointed that they did not receive the support they expected, and anxious about the lack of information on the modes of transmission and prognosis of SARS (see online Appendix at http://www. cdc.gov/ncidod/EID/vol10no7/03-0703.htm#app).
During the outbreaks, nearly 30% of respondents thought that they had received inadequate information about SARS. With respect to information regarding home infection control measures, 20% were not told with whom they could have contact; 29% did not receive specific instructions on when to change their masks; and 40%-50% did not receive instructions on the use and disinfection disinfection,
n the process of destroying pathogenic organisms or rendering them inert.
disinfection, full oral cavity,
n a procedure used to reduce active periodontal disease, usually completed within a certain short time frame. of personal items, including toothbrushes and cutlery; 77% were not given instructions regarding use and disinfection of the telephone. Healthcare worker status did not influence whether respondents thought they had received adequate information regarding any of the listed home infection control measures, except regarding the frequency of mask changing: healthcare workers more frequently reported that they had received adequate information, 78.8% versus 60.5% (p = 0.03).
Adherence to Infection Control Measures
Eighty-five percent of quarantined persons wore a mask in the presence of household members; 58% remained inside their residence for the duration of their quarantine. Thirty-three percent of those quarantined did not monitor their temperatures as recommended: 26% self-monitored their temperatures less frequently than recommended, and 7% did not measure their temperatures at all. No differences between healthcare workers and nonhealthcare workers were found with respect to adherence to recommended infection control measures.
Psychological Impact of Quarantine
The mean IES-R score was 15.2 [+ or -] 17.8, and the mean CES-D was 13.0 [+ or -] 11.6. The IES-R score was [greater than or equal to] 20 for 28.9%; the CES-D score was [greater than or equal to] 16 in 31.2% of quarantined persons (Table 2). The mean IES-R scores were not different for persons on home or work quarantine, 14.1 [+ or -] 18.8 versus 17.6 [+ or -] 16.6 (p = 0.33); the mean CES-D scores were also not different between the groups, 12.0 [+ or -] 12.0 versus 15.2 [+ or -] 10.7 (p = 0.16).
The presence of PTSD symptoms was correlated with the presence of depressive symptoms (p < 0.0001, r = 0.78). Marital status marital status,
n the legal standing of a person in regard to his or her marriage state. did not offset the presence of PTSD symptoms, mean IES-R score of 14.5 [+ or -] 16.6 for those who were unmarried versus 13.8 [+ or -] 14.6 for those who were married (p = 0.82). Similarly, marital status did not influence the presence of depressive symptoms, with a mean CES-D score of 12.9 [+ or -] 10.7 for those who were unmarried versus 12.5 [+ or -] 11.4 for those who were married (p = 0.85)
A combined annual household income of CAD <$40,000 versus CAD $40,000 to CAD $75,000 versus CAD >$75,000 was associated with increased PTSD symptoms (mean IES-R score of 24.2 [+ or -] 20.6 versus 20.0 [+ or -] 24.4 versus 11.8 [+ or -] 11.6, respectively) (p = 0.03 for the three-way comparison In computer science, a three-way comparison takes two values A and B belonging to a type with a total order and determines whether A < B, A = B, or A > B in a single operation, in accordance with the mathematical law of trichotomy. ). Linear regression testing for trend over income categories was also significant (p = 0.01). A combined annual household income of CAD <$40,000 versus CAD $40,000 to CAD $75,000 versus CAD >$75,000 was also associated with increased depressive symptoms (mean CES-D score of 18.3 [+ or -] 15.4 versus 15.5 [+ or -] 13.2 versus 10.9 [+ or -] 9.2, respectively) (p = 0.05 for the three-way comparison) (Table 2). Results of linear regression testing for trend over income categories were also significant (p = 0.01).
Neither age, level of education, healthcare worker status, living with other adult household members, nor having children was correlated with PTSD and depressive symptoms. The duration of quarantine was significantly related to increased PTSD symptoms, mean IES-R score of 23.7 [+ or -] 27.2 for those in quarantine [greater than or equal to] 10 days compared with 11.7 [+ or -] 10.7 for those in quarantine <10 days (p < 0.05). Persons who were in quarantine for a longer duration showed a trend toward higher CES-D scores; however, this difference did not reach statistical significance (mean CES-D of 17.0 [+ or -] 14.2 for those in quarantine [greater than or equal to] 10 days versus 11.2 [+ or -] 10. 1 for those in quarantine <10 days [p = 0.07]). Acquaintance with or exposure to someone who was hospitalized with SARS was associated with a higher mean IES-R score, 18.6 [+ or -] 20.2 versus 11.8 [+ or -] 14.3 (p = 0.03) and a higher mean CES-D score, 15.5 [+ or -] 12.1 versus 10.2 [+ or -] 10.5 (p = 0.01). Overall, acquaintance with or exposure to someone who died of SARS was not correlated with PTSD or depressive symptoms (data not shown).
Persons were categorized cat·e·go·rize
tr.v. cat·e·go·rized, cat·e·go·riz·ing, cat·e·go·riz·es
To put into a category or categories; classify.
cat as having worn their masks all of the time, including times when it was not recommended, having worn their masks according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. recommendations, or not having worn their masks at all. Those who wore their masks all of the time had higher mean IES-R scores (29.7 [+ or -] 18.6 versus 14.1 [+ or -] 17.9 versus 12.3 [+ or -] 15.1, p = 0.003 for the three-way comparison) and higher mean CES-D scores (25.6 [+ or -] 12.7 versus 12.2 [+ or -] 11.1 versus 11.5 [+ or -] 11.6, p = 0.002 for the three-way comparison). Those who wore their masks all of the time also had higher mean IES-R scores (p = 0.03) and higher mean CES-D scores (p = 0.002) than those who never wore their masks.
All respondents described a sense of isolation. The mandated lack of social and, especially, the lack of any physical contact with family members were identified as particularly difficult. Confinement within the home or between work and home, not being able to see friends, not being able to shop for basic necessities of everyday life, and not being able to purchase thermometers and prescribed medications enhanced their feeling of distance from the outside world. Infection control measures imposed not only the physical discomfort of having to wear a mask but also significantly contributed to the sense of isolation. In some, self-monitoring of temperature provoked considerable anxiety: "taking temperatures was mentally difficult" (respondent #27) and "taking my temperature made my heart feel like it was going to pound out of my chest each time" (respondent #62).
While most quarantined persons (60%) did not believe that they would contract SARS, 59% were worried that they would infect their family members. In contrast, only 28% were concerned that a quarantined family member would infect someone else in the home. Following quarantine, 51% of respondents had experiences that made them feel that people were reacting differently to them: avoiding them, 29%; not calling them, 7%; not inviting them to events, 8%; and not inviting their families to events, 7%.
Persons placed in quarantine have their freedom restricted to contain transmissible diseases. This takes a considerable toll on the person. In relation to the recent global outbreak of SARS, considerable time has been spent discussing the specifics of quarantine and how to promote adherence to infection control measures. Little, if any, analysis has focused on the effect of quarantine on the well-being of the quarantined person. The objective of the study survey was to capture a range of experiences of quarantined persons to better understand their needs and concerns. This knowledge is critical if modern quarantine is to be an effective disease-containment strategy. To our knowledge, a consideration of the adverse effects of quarantine, including psychological effects, has not previously been systematically attempted.
Our results show that a substantial proportion of quarantined persons are distressed, as evidenced by the proportion that display symptoms of PTSD and depression as measured by validated scales. Although quarantined persons experienced symptoms suggestive of suggestive of Decision making adjective Referring to a pattern by LM or imaging, that the interpreter associates with a particular–usually malignant lesion. See Aunt Millie approach, Defensive medicine. both PTSD and depression, the scales that were used to measure these symptoms are not sufficient to confirm these diagnoses. To confirm the diagnoses of PTSD and depression, structured diagnostic interviews are required. Because the survey was anonymous, this was not possible.
A score of [greater than or equal to] 20 on the IES-R was used to estimate the prevalence of PTSD symptoms in our study population. This corresponds to the mean score measured on the IES-R in a study of journalists working in war zones that used diagnostic psychiatric interviews to confirm the presence of this disorder (11). Since most respondents to our survey were healthcare workers, we chose a work-related traumatic event A traumatic event is an event that is or may be a cause of trauma. The term may refer to one of the followiong:
The lowest rate of return acceptable on investments. may have been used to estimate the prevalence of PTSD symptoms in our population, the risk factors that we identified for increased PTSD symptoms, rather than the absolute prevalence of PTSD in our study participants, are the important findings of this study. This also applies to the risk factors that we identified for increased depressive symptoms in the respondents. Quarantined persons with risk factors for either PTSD or depressive symptoms may benefit from increased support from public health officials.
In this population, the presence of PTSD symptoms was highly correlated with the presence of depressive symptoms even though different clinical symptoms characterize the two disorders. Kessler's National Comorbidity Study The National Comorbidity Survey (NCS) was the first large-scale field survey of mental health in the United States. Conducted from 1990-1992, disorders were assessed based on the diagnostic criteria of the then-most current DSM manual, the DSM-III-R (Diagnostic and Statistical indicated a 48.2% occurrence of depression in patients with PTSD (15).
PTSD is an anxiety disorder anxiety disorder
Any of various psychiatric disorders in which anxiety is either the primary disturbance or is the result of confronting a feared situation or object. characterized by avoiding stimuli associated with a traumatic event, reexperiencing the trauma, and hyperarousal, such as increased vigilance (16). This disorder may develop after exposure to traumatic events that involve a life-threatening component, and a person's vulnerability to the development of PTSD can be increased if the trauma is perceived to be a personal assault (17). Increased length of time spent in quarantine was associated with increased symptoms of PTSD. This finding might suggest that quarantine itself, independent of acquaintance with or exposure to someone with SARS, may be perceived as a personalized per·son·al·ize
tr.v. per·son·al·ized, per·son·al·iz·ing, per·son·al·iz·es
1. To take (a general remark or characterization) in a personal manner.
2. To attribute human or personal qualities to; personify. trauma. The presence of more PTSD symptoms in persons with an acquaintance or exposure to someone with a diagnosis of SARS compared to persons who did not have this personal connection may indicate a greater perceived self-risk. The small number of respondents who were acquainted with or exposed to someone who died of SARS may explain the lack of correlation between this group and greater PTSD and depressive symptoms (44 persons died of SARS in the greater Toronto area The Greater Toronto Area (widely abbreviated as the GTA) is the most populous metropolitan area in Canada. The GTA is a provincial planning area with a population of 5,555,912 at the 2006 Canadian Census. ).
This study also notes the trend toward increasing symptoms of both PTSD and depression as the combined annual income of the respondent household fell from CAD >$75,000 to CAD <$40,000. Quarantined persons with a lower combined annual household income may require additional levels of support. Since the survey was Web-based and required that respondents have access to a computer, the survey was likely answered by a more affluent and educated subgroup of persons. Since respondents with a lower combined annual household income experienced increased symptoms of PTSD and depression, and since those with lower combined annual household incomes were not as likely to have access to a computer, the results of this survey may underestimate the prevalence of psychological distress in the overall group of quarantined persons. Overall, most respondents did not report financial hardship as a result of quarantine. This finding is likely explained by the fact that >50% of the respondents reported a combined annual household income of CAD >$75,000.
As many as 50% of respondents felt that they had not received adequate information regarding at least one aspect of home infection control, and not all of the respondents adhered to recommendations. Why some infection-control measures were adhered to while others were not is unclear. A combination of lack of knowledge, an incomplete understanding of the rationale for these measures, and a lack of reinforcement from an overwhelmed public health system were likely contributors to this problem. Of particular interest, strictly adhering to infection control measures, including wearing masks more frequently than recommended, was associated with increased levels of distress. Whether persons with higher baseline levels of distress were more likely to strictly adhere to adhere to
verb 1. follow, keep, maintain, respect, observe, be true, fulfil, obey, heed, keep to, abide by, be loyal, mind, be constant, be faithful
2. infection-control measures or whether adherence to recommended infection control strategies resulted in developing higher levels of distress cannot be clarified without interviewing the respondents. Regardless of the cause, this distress may have been lessened with enhanced education and continued reinforcement of the rationale for these measures and outreach efforts to optimize coping with the stressful event.
This study has several limitations. The actual number of respondents is low compared to the total number of persons who were placed into quarantine and therefore may not be representative of the entire group of quarantined persons. However, lack of funding, confidentiality of public health records, and an overloaded public health response system limited sampling in this study. Furthermore, a sell-selection effect may have occurred with those persons who were experiencing the greatest or least levels of distress responding to the survey. In addition, respondents required access to a computer to respond, which suggests that they may be more educated and have higher socioeconomic status socioeconomic status,
n the position of an individual on a socio-economic scale that measures such factors as education, income, type of occupation, place of residence, and in some populations, ethnicity and religion. than the overall group who were quarantined. They also had to be English speaking. Recognizing these limitations, however, an anonymous Web-based method was chosen because concerns about persons' confidentiality precluded us from access to their public health records.
A Web-based format was chosen over random-digit dialing for both cost considerations and time constraints In law, time constraints are placed on certain actions and filings in the interest of speedy justice, and additionally to prevent the evasion of the ends of justice by waiting until a matter is moot. . The project was initiated and completed without a funding source soon after the outbreak period at a time when concerns about SARS were still a part of daily life in Toronto. Obtaining as much information about the adverse effects of quarantine as close to the event as possible was important because a study conducted several months later would have been subject to the limitations of substantial recall bias. If this study were to be repeated, a study design ensuring a more representative selection of the population that used a combination of quantitative and qualitative methods, including structured diagnostic interviews, would be recommended to overcome these concerns. In the event of future outbreaks, a matched control matched study, matched control
a comparison between groups in which each subject animal is matched by a comparable animal in terms of age and all other measurable parameters. Called also matched or paired control. group of persons who were not quarantined should be considered because it would allow an assessment of the distress experienced by the community at large.
Finally, we determined only the prevalence of symptoms of PTSD and depression in our study population because these were the predominant psychological distresses that were observed to be emerging in our SARS patient population (W.L.G, pers. comm.). We also focused on symptoms of PTSD and depression because we believed that they would be the most likely to cause illness and interfere with long-term functioning. Future studies should assess persons for other psychological responses, including fear, anger, guilt, and stigmatization stigmatization /stig·ma·ti·za·tion/ (stig?mah-ti-za´shun)
1. the developing of or being identified as possessing one or more stigmata.
2. the act or process of negatively labelling or characterizing another. . A standardized survey instrument that considers the full spectrum of psychological responses to quarantine should be developed. In the event of future outbreaks in which quarantine measures are implemented, a standardized instrument would enable a comparison between the psychological responses to outbreaks of different infectious causes and could be used to monitor symptoms over time.
Despite these limitations, the results of this survey allow for the generation of hypotheses that require further exploration. Our data show that quarantine can result in considerable psychological distress in the forms of PTSD and depressive symptoms. Public health officials, infectious diseases physicians, and psychiatrists and psychologists need to be made aware of this issue. They must work to define the factors that influence the success of quarantine and infection control practices for both disease containment and community recovery and must be prepared to offer additional support to persons who are at increased risk for the adverse psychological and social consequences of quarantine.
Table 1. Characteristics of quarantined persons who responded to the survey Characteristic No. (%) (N = 129) Age (y) 18-25 11 (8.6) 26-35 37 (28.9) 36-45 44 (34.4) 46-55 21 (16.4) 56-65 11 (8.7) 66+ 4 (3.1) Marital status Married or common law 87 (68.0) Single or divorced 41 (32.0) Education High school 11 (9.2) College or university 109 (90.8) Income (Canadian $) <$20000 6 (5.8) $20,000-$39,999 8 (8.5) $40,000-$74,999 35 (33.0) $75,000-$99,999 20 (18.8) [greater than or equal to] $100.000 36 (34.0) Healthcare worker status No 40 (31.8) Yes 86 (68.3) Type of quarantine (N = 143 episodes) Work 49 (34.3) Home 94 (65.7) Household members No. adults 1 28 (21.9) 2 72 (56.4) 3 22 (17.2) 4 5 (3.9) [greater than or equal to] 5 1 (0.8) No. children 0 72 (55.8) 1 24 (18.6) 2 25 (19.4) 3 8 (6.2) Table 2. Prevalence of posttraumatic stress disorder and depressive symptoms according to patient demographics (a) Characteristic No. (%) (N = 129) Prevalence CES-D <16 84 (68.8) [greater than or equal to] 16 38 (31.2) IES-R <20 86 (71.1) [greater than or equal to] 20 35 (28.9) Marital status Mean SD p value CES-D Single or divorced (n = 40) 12.9 10.7 0.85 Married (n = 79) 12.5 11.4 IES-R Single or divorced (n = 39) 14.5 16.6 0.82 Married (n = 79) 13.8 14.6 Income (Canadian $) CES-D <$40,000 18.3 15.4 0.05 (b) $40,000-$75,000 15.5 13.2 >$75,000 10.9 9.2 IES-R <$40,000 24.2 20.6 0.03 (b) $40,000-$75,000 19.9 24.4 >$75,000 11.8 11.6 Duration of quarantine (d) CES-D <10 11.2 10.1 0.07 [greater than or equal to] 10 17.0 14.2 IES-R <10 11.7 10.7 0.05 [greater than or equal to] 10 23.7 27.2 (a) CES-D, Center for Epidemiologic Studies-Depression Scale (10): IES-R, Impact of Event Scale-Revised (9). (b) By analysis of variance.
We thank Allison McGeer for her support while we conducted this research and Gina Lockwood and Gerald Devins for their statistical support.
(1.) Risse GB. "A long pull, a strong pull and all together": San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden and bubonic plague bubonic plague: see plague.
ravages Oran, Algeria, where Dr. Rieux perseveres in his humanitarian endeavors. [Fr. Lit.: The Plague]
See : Disease , 1907-1908. Bull Hist Med. 1992;66:260-86.
(2.) Twu SJ, Chen TJ, Chen CJ, Olsen S Olsen may refer to:
American railroad financier and speculator who attempted in 1869 to corner the gold market with Jay Gould, leading to Black Friday, a day of nationwide financial panic. T, et al. Control measures for severe acute respiratory syndrome (SARS) in Taiwan. Emerg Infect Dis. 2003;9:718-20.
(3.) Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. . Update: use of quarantine to prevent transmission of severe acute respiratory syndrome--Taiwan 2003. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morb Mortal Wkly Rep. 2003;52:680-3.
(4.) Mandavilli A. SARS epidemic unmasks age-old quarantine conundrum conundrum A problem with no satisfactory solution; a dilemma . Nat Med. 2003;9:487.
(5.) Toronto Public Health. Severe acute respiratory syndrome (SARS), 2003 May 29 [cited 2003 Aug 30]. Available from: http://www.toronto.ca/health
(6.) Barbera J, Macintyre A, Gostin L, Inglesby T, O'Toole T, DeAtley C, et al. Large-scale quarantine following biological terrorism Noun 1. biological terrorism - terrorism using the weapons of biological warfare
act of terrorism, terrorism, terrorist act - the calculated use of violence (or the threat of violence) against civilians in order to attain goals that are in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. : scientific examination, logistic and legal limits, and possible consequences. JAMA JAMA
Journal of the American Medical Association . 2001;286:2711-7.
(7.) Markel H. Knocking out the cholera: cholera, class and quarantines in New York City New York City: see New York, city.
New York City
City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest city in the U.S. , 1892. Bull Hist Med. 1995;69:420-57.
(8.) Markel H. Cholera, quarantines and immigration immigration, entrance of a person (an alien) into a new country for the purpose of establishing permanent residence. Motives for immigration, like those for migration generally, are often economic, although religious or political factors may be very important. restriction: the view from John Hopkins, 1892. Bull Hist Med. 1993;67:691-5.
(9.) Weiss D, Marmar C. The impact of event scale--revised. In: Wilson J, Keane, T, editors. Assessing psychological trauma Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event. When that trauma leads to Post Traumatic Stress Disorder, damage can be measured in physical changes inside the brain and to brain chemistry, which affect the person's and PTSD. New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : Guilford; 1997.
(10.) Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement. 1977; 1:385-401.
(11.) Feinstein A, Owen J, Blair N. A hazardous profession: war, journalists and psychopathology psychopathology /psy·cho·pa·thol·o·gy/ (-pah-thol´ah-je)
1. the branch of medicine dealing with the causes and processes of mental disorders.
2. abnormal, maladaptive behavior or mental activity. . Am J Psychol. 2002;159:1570-5.
(12.) Boyd JF, Weissman MM, Thompson WD, Myers JK. Screening for depression in a community sample: understanding the discrepancies between depression symptom and diagnostic scales. Arch Gen Psych psych also psyche Informal
v. psyched, psych·ing, psyches
a. To put into the right psychological frame of mind: . 1982;39;1195-200.
(13.) American Psychiatric Task Force for the Handbook of Psychiatric Measures. Handbook of psychiatric measures, 1st ed. In: Yonkers KA, Samson IS. Mood disorder mood disorder
Any of a group of psychiatric disorders, including depression and bipolar disorder, characterized by a pervasive disturbance of mood that is not caused by an organic abnormality. Also called affective disorder. measures. Washington: American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. ; 2000. p. 523-6.
(14.) Corbin JA, Strauss A. Basics of qualitative research Qualitative research
Traditional analysis of firm-specific prospects for future earnings. It may be based on data collected by the analysts, there is no formal quantitative framework used to generate projections. . 2nd ed. Thousand Oaks Thousand Oaks, residential city (1990 pop. 104,352), Ventura co., S Calif., in a farm area; inc. 1964. Avocados, citrus, vegetables, strawberries, and nursery products are grown. (CA): Sage Publications This article or section needs sources or references that appear in reliable, third-party publications. Alone, primary sources and sources affiliated with the subject of this article are not sufficient for an accurate encyclopedia article. ;1998.
(15.) Kessler RC, Sonnega A, Bromet E. Post-traumatic stress disorder post-traumatic stress disorder (PTSD), mental disorder that follows an occurrence of extreme psychological stress, such as that encountered in war or resulting from violence, childhood abuse, sexual abuse, or serious accident. in the National Comorbidity Survey. Arch Gen Psych. 1995;52: 1048-60.
(16.) Diagnostic and statistical manual of mental disorders Diagnostic and Statistical Manual of Mental Disorders /Di·ag·nos·tic and Sta·tis·ti·cal Man·u·al of Men·tal Dis·or·ders/ (DSM) a categorical system of classification of mental disorders, published by the American Psychiatric Association, that delineates objective , 4th ed. Washington: American Psychiatric Association; 1997.
(17.) Breslau N, Kessler RC, Chilcoat HD et al. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma. Arch Gen Psych. 1998;55:626-32.
Address for correspondence: Rima Styra, Toronto General Hospital The Toronto General Hospital (TGH), part of the University Health Network, is a major teaching hospital in downtown Toronto, Canada. It is located in the Discovery District, directly north of the Hospital for Sick Children, across Gerrard Street West, and east of Princess , 200 Elizabeth Street Elizabeth Street can refer to:
Dr. Hawryluck is an assistant professor of critical care/respirology at the University Health Network, University of Toronto. Her research interests include bioethical issues in medicine, SARS, decision-making, and communication regarding life-sustaining interventions.
Laura Hawryluck, * Wayne L. Gold, * Susan Robinson, * Stephen Pogorski, ([dagger]) Sandro Galea galea /ga·lea/ (ga´le-ah) [L.] a helmet-shaped structure.
galea aponeuro´tica the aponeurosis connecting the two bellies of the occipitofrontalis muscle. , ([double dagger double dagger
A reference mark () used in printing and writing. Also called diesis.
Noun 1. ]) and Rima Styra *
* University of Toronto, Toronto, Ontario, Canada; ([dagger]) ASK Information Technologies, Toronto, Ontario, Canada; and ([double dagger]) New York Academy of Medicine The New York Academy of Medicine was founded in 1847 by a group of leading New York City metropolitan area physicians as a voice for the medical profession in medical practice and public health reform. , New York, New York, USA