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Letter
SARS Control and Psychological
Effects of Quarantine, Toronto, Canada
To the Editor: Hawryluck et al. (1) have published
an interesting study that found that some persons subject to quarantine
for severe acute respiratory distress syndrome (SARS) displayed symptoms
of posttraumatic stress disorder and depression. They conclude that the
psychological symptoms result from quarantine. I believe the study has
serious flaws and that their conclusion is premature.
First, their study sampled 129 volunteers among the >15,000 persons
subjected to quarantine. As acknowledged by the authors, persons with
the most severe symptoms may be more likely to volunteer for the study,
resulting in an overestimation of the frequency and severity of the symptoms.
Second, more than two thirds of the participants were healthcare workers.
Healthcare workers in Toronto who cared for SARS patients but were not
subject to quarantine were experiencing extreme stress because they were
working with a poorly understood infectious disease, wearing protective
equipment for extended periods, and watching colleagues become ill and
die while wondering if they themselves were the next victims. Most healthcare
workers subject to quarantine in Toronto (including 34% of persons on
work quarantine) likely cared for SARS patients and would have experienced
stresses similar to those not quarantined. Third, 85% of the study participants
wore masks at home, indicating that they were likely to have been symptomatic
and subject to isolation rather than quarantine. Certainly symptomatic
persons would be undergoing stress because of their concerns about SARS
developing, the possibility of dying, and the potential for exposing others.
Increasing levels of stress with increasing length of isolation found
in the study may be due to more severe or prolonged symptoms rather than
to isolation or quarantine per se.
Measuring the psychological effects of isolation and quarantine will
require studies comparing psychological symptoms of healthcare workers
subjected to quarantine with those who continued working, as well as studies
comparing randomly selected persons subject to isolation with the general
population living in the city during the outbreak.
In the final analysis, although isolation and quarantine are stressful,
that is an insufficient reason to hesitate when these measures are indicated.
One might wonder how stressed the participants would have been if SARS
had developed and they infected their family members or friends. Regardless
of whether isolation and quarantine induce posttraumatic stress disorder,
public health officials must be cognizant of and prepared to supply appropriate
emotional and social support to persons subject to isolation or quarantine.
Harry F. Hull*
*Minnesota Department of Health, Minneapolis, Minnesota, USA
Suggested
citation for this article:
Hull HF. SARS control
and psychological effects of quarantine, Toronto, Canada [letter]. Emerg
Infect Dis [serial on the Internet]. 2005 Feb [date cited]. Available
from http://www.cdc.gov/ncidod/EID/vol11no02/04-0760_04-0978.htm
Reference
- Hawryluck L, Gold WL, Robinson S, Pogorski S, Galea
S, Styra R. SARS
control and psychological effects of quarantine, Toronto, Canada.
Emerg Infect Dis. 2004;10:1206–12.
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In Response: Dr. Hull raises concerns regarding
our study design and the conclusions that were drawn, believing the conclusions
to be premature (1). To reiterate, we concluded that
quarantine might result in considerable psychological distress in the
forms of posttraumatic stress disorder (PTSD) and depressive symptoms,
but we clearly qualify this conclusion by stating that the results of
the study are hypothesis-generating and require further exploration.
Dr. Hull correctly writes that more than two thirds of the respondents
to our survey were healthcare workers and assumes that healthcare workers
in Toronto who cared for patients with severe acute respiratory syndrome
(SARS) were extremely stressed. We agree with this statement not on the
basis of data presented in this study, but rather on additional work that
we have conducted on nonquarantined, uninfected healthcare workers treating
patients with SARS in a hospital in Toronto (2). The
implication of Dr. Hull's statement, however, is that being a healthcare
worker in Toronto at the time of SARS, rather than being placed into quarantine,
was responsible for the psychological distress that we measured. To dispute
this, we found that healthcare worker status was not correlated with PTSD
or depression symptoms, which indicates that respondents who were nonhealthcare
workers experienced similar levels of distress as healthcare workers who
responded. Furthermore, we found that longer durations of quarantine were
associated with increased symptoms of PTSD, which indicates that the physical
state of being in quarantine was at least in part responsible for the
psychological distress.
Finally, Dr. Hull states that 85% of the study participants wore masks
at home, which indicates that they were likely to have been symptomatic
and subject to isolation rather than quarantine. This statement is incorrect.
The respondents to this survey were asymptomatic, exposed persons who
were placed into quarantine. Instructions to all quarantined persons,
per public health guidelines (3), were to wear masks
while in the presence of other household members, not because they were
symptomatic, but rather because they may have been incubating SARS and
had the potential to transmit infection to household contacts in the 24
hours before symptom onset.
Although the terms "isolation" and "quarantine" have
often been used interchangeably, they actually represent distinct concepts
(4). The strategies differ in that isolation applies
to persons who are known to have an illness, and quarantine applies to
those who have been exposed to a transmissible pathogen but who may or
may not become ill. Quarantine directives for SARS included the adherence
to home infection control measures, including wearing masks in the presence
of other household members, not sharing utensils, and sleeping in separate
quarters (3).
We agree with Dr. Hull's final statement that the psychological distress
experienced by persons in quarantine is not a sufficient reason to refrain
from invoking these measures when they are needed to control an outbreak.
We did not arrive at this conclusion in our article. The goal of the study
was to develop a benchmark for the possible distress associated with quarantine.
While we felt that documenting the possible distress that may result from
quarantine was important, it was not intended to negate the need to impose
quarantine should it be required, but rather to determine the support
measures that may be needed by quarantined persons. Public health officials
must be cognizant of these needs and prepared to supply appropriate emotional
and social support to persons in quarantine for such measures to succeed
in halting the spread of disease.
Rima Styra,*
Laura Hawryluck,* and Wayne Gold*
*University Health Network, Toronto, Ontario, Canada
Suggested
citation for this article:
Styra R, Hawryluck
L, Gold W. SARS control and psychological effects of quarantine, Toronto,
Canada [response to letter]. Emerg Infect Dis [serial on the Internet].
2005 Feb [date cited]. Available from http://www.cdc.gov/ncidod/EID/vol11no02/04-0760_04-0978.htm#styra
References
- Hull HF. SARS control and psychological effects of
quarantine, Toronto, Canada [letter]. Emerg Infect Dis. 2005;11:353–4.
- Gold WL, Hawryluck L, Robinson S, McGeer A, Fones C, Kennedy S, et
al. Post-traumatic stress disorder (PTSD) among healthcare workers (HCW)
at a hospital treating patients with SARS [abstract]. In: Program and
abstracts of the 43rd meeting of the Interscience Conference on Antimicrobial
Agents and Chemotherapy (ICAAC); 2003 Sep 14–17; Chicago. Washington
(DC): American Society for Microbiology; 2003.
- Svoboda, T, Henry B, Shulman L, Kennedy E, Rea E, Ng W, et al. Public
health measures to control the spread of the severe acute respiratory
syndrome during the outbreak in Toronto. N Engl J Med. 2004;350:2352–61.
- Centers for Disease Control and Prevention. Public health guidance
for community-level preparedness and response to severe acute respiratory
syndrome (SARS) Version 2/3. 2004 Jul 20 [cited 2004 Sep 26]. Available
from http://www.cdc.gov/ncidod/sars/guidance
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