MEDICINA SEGURIDAD del trabajo - ISCIIIscielo.isciii.es/pdf/mesetra/v61n239/en_09_revision1.pdf · and exclusion and analysis of quality using the STROBE criteria, was a final collection

MEDICINA y SEGURIDAD del trabajoAbril - junio 2015 Med Segur Trab (Internet) 2015; 61 (239) 254-272

Attitudes toward the risk prevention in health professionals in cases of epidemiological alertBelén Collado Hernández, Yolanda Torre Rugarcía

254

Revisiones

Attitudes toward the risk prevention in health professionals in cases of epidemiological alert

Actitudes hacia la prevención de riesgos laborales en profesionales sanitarios en situaciones de alerta epidemiológica

Belén Collado Hernández1-3, Yolanda Torre Rugarcía2-3

1. Mutua Montañesa de Cantabria. Spain.2. Hospital Universitario Marqués de Valdecilla. Spain.3. Teaching Unit of Occupational Health of Comunidad de Madrid. Madrid. Spain

Recibido: 13-03-15Aceptado: 05-05-15

CorrespondenciaBelén Collado HernándezResidente Medicina del Trabajo UD CantabriaMutua Montañesa. Cantabria. España.Teléfono: 636 513 212Correo electrónico: [email protected]

This work has been carried out as part of the Scientific Program of the National School of Occupational Medicine of the Carlos III Health Institute under an agreement with the Teaching Unit of Occupational Medicine of the Community of Madrid, Spain.

AbstractObjectives: To explore the scientific evidence regarding the behavior of health professionals in pandemic

situations. Identify areas of improvement for the strengthening of health professionals before pandemic situations. Secondary Objectives: To identify the psychosocial impact, adoption and adherence to preventive measures and vaccination programs.

Methods: Systematic review of the scientific literature collected in the MEDLINE (PubMed), Scopus and Cochrane Library Plus data until December 2014. The terms used as descriptors were: «Disease Outbreaks», «Coronavirus, sars», «Severe acute Respiratory Syndrome», «Influenza virus, subtype H1N2», «Health occupations», «Emergencies, Infectious disease transmission», «patient-to-professional», «Infectious disease transmission, professional-to-patient».

Results: 181 references after the elimination of duplicates and application of the criteria for inclusion and exclusion and analysis of quality using the STROBE criteria, was a final collection of 17 articles were retrieved. The level of evidence found according to Sign Criteria is three as it is in all cases of cross-sectional studies. 11 Authors refer to psychosocial effects, 3-vaccination and 12 to adherence to preventive measures. In general preventive measures in the two pandemics were well appreciated and followed by professionals. A significant burden of stress for fear of getting sick is generated; infect their families and high workload. Low adherence to vaccination programs and use of scientific literature.

Conclusions: It would be advisable to improve communication about preventive measures in times of pandemic to increase adherence and psychological support to health workers.

Med Segur Trab (Internet) 2015; 61 (239) 254-272

Keywords: Disease outbreaks, Coronavirus, SARS, Severe Acute Respiratory Syndrome, Influenza a virus, H1N2 subtype, Health occupations.

Abril - junio 2015 Med Segur Trab (Internet) 2015; 61 (239) 254-272

255Attitudes toward the risk prevention in health professionals in cases of epidemiological alertBelén Collado Hernández, Yolanda Torre Rugarcía

MEDICINA y SEGURIDAD del trabajo

ResumenObjetivos: Conocer la evidencia científica existente en relación al comportamiento de los profesionales

de la salud en situaciones de pandemia. Identificar puntos de mejora para el fortalecimiento de los profesionales sanitarios antes situaciones de pandemia. Objetivos secundarios: Identificar el impacto psicosocial, adopción y adhesión a medidas preventivas y a programas de vacunación.

Métodos: Revisión sistemática de la literatura científica recogida en las bases de datos MEDLINE (Pubmed), SCOPUS y Cochrane Library Plus hasta Diciembre de 2014. Los términos más utilizados como descriptores fueron: «Disease outbreaks», «Coronavirus, sars», «Severe Acute Respiratory Syndrome», «Influenza a virus, h1n2 subtype», «Health occupations», «Emergencies, Infectious disease transmission», «patient-to-professional», «Infectious disease transmission, professional-to-patient».

Resultados: Se recuperaron 181 referencias que tras la eliminación de duplicados y aplicación de los criterios de inclusión y exclusión y análisis de calidad mediante los criterios STROBE, resultó una colección final de 17 artículos. El nivel de evidencia encontrado según los Criterios Sign es tres ya que se trata en todos los casos de estudios transversales. 11 autores hacen referencia a efectos psicosociales, 3 a la vacunación y 12 a adhesión a medidas preventivas. En general las medidas preventivas en las dos pandemias fueron bien valoradas y seguidas por los profesionales. Se genera una importante carga de estrés por el miedo a enfermarse, contagiar a sus familias y la elevada carga laboral. Baja adherencia a programas de vacunación y a la utilización de literatura científica.

Conclusiones: Sería recomendable mejorar la comunicación sobre las medidas preventivas en periodos de pandemia para aumentar su adherencia así como dar apoyo psicológico al personal sanitario.

Med Segur Trab (Internet) 2015; 61 (239) 254-272

Palabras clave: Epidemia, Coronavirus, SARS, Síndrome respiratorio agudo severo; Virus de la gripe A subtipo H1N1, Personal sanitario.




INTRODUCTION

The latest global health alert the XXI century has been caused by the Ebola virus. It began in December 2013 in Guinea and later spread throughout West Africa. Currently there are 21,362 cases and 8,478 deaths worldwide (WHO 01/11/2015). The first contagion in Europe was declared in Spain in October 2014. It was a nursing assistant who had been in contact with the two missionaries repatriated. Two nurses were infected in the same way USA. This created a major social and health warning about the possible failure of preventive measures related mainly to medical staff and PPE used.

Two other pandemics were previously reported in this century, SARS and influenza A (H1N1). In relation to SARS, OMS²² said 8,098 cases between November 2002 and July 2003. Of these, 1,707(21 %) were health workers (Shapiro et al.10). Influenza A, in late September 2009, affected globally to over 343,298 with about 4,108 deaths (Alenzi et al.¹) with a high percentage of health workers affected.

In the case of swine flu (H1N1) measures established by the CDC (Centers for Disease Control and Prevention20) were: 1) Review and / or development of plans for pandemic prevention by health centers and report them to the staff. These in turn should receive training on disease prevention (vaccination, EPIS...) and the risk of complications. 2) Reduce potential exposures (limit transport patients, visitors...). 3) Physical controls such triage separate areas. 4) Promotion and provision of vaccine (free during work hours, refusal form fill where applicable). 5) Provide appropriate education PPE and use (N-95 masks, non-sterile gloves...). 6) Hand hygiene and respiratory hygiene. 7) Quarantine (up to 24 hours of disappearance of fever without antipyretics) mandatory for health workers should be monitored for signs/symptoms of the disease.

Referring to SARS were to follow the measures described above and also under the Protocol for Surveillance and Control of SARS (National Centre for Epidemiology Institute Salud²¹ Carlos III, May 2004.): 1) The quarantine will be up to 48 hours of cessation of fever. 2) negative pressure rooms if possible. 3) PPE: disposable hats, eye protection, gloves, disposable clothing (overalls/aprons/gowns), decontaminable boots. Respiratory protection is not reusable: surgical mask (protection issue) and respiratory protective devices (protection inhalation) that are certified according to European standard (EN 149: 2001 FFP2 and FFP3) and (UNE-EN 143: 2000 P2). In Spain the use of protective FFP2 (staff not caring for the patient) and FFP3 (direct patient contact) is recommended.

All these preventive measures can be in accordance with what difficult circumstances to perform. Not only because of the possibility of such negative pressure room or appropriate PPE if not acceptance or rejection thereof by the health workers could occur for example on the issue of vaccination that ultimately would be a decision staff.

The presence of a pandemic could bring psychosocial consequences among health workers related to concerns about the spread or the health of your family. All this can produce a significant stress load that could see increased if we consider that a significant volume of patients by the general alarm the population increase during epidemics.

The health sector is a high-risk group in pandemic situations. The aim of this paper is to review the literature to learn the scientific evidence regarding the behavior of health professionals in pandemic situations and identify areas of improvement for the strengthening of health professionals in these situations. As secondary objectives we have set out to identify the psychosocial impact, adoption and adherence to preventive measures and adherence to vaccination programs.

MATERIAL AND METHODS

The study was conducted using techniques of systematic review of the literature obtained by direct contacts and access, via the Internet, available in three databases (Table 1), International Literature Medlars Online (MEDLINE ), via PubMed, Scopus and Cochrane Library Plus.




To define the search terms MeSH terms (thesaurus developed by the US National Library of Medicine) were employed, using the descriptors listed in Table (Table 1) in text format in title and/or abstract.

Table 1. Terms, equations and descriptors

MeSH Terms Disease outbreaksCoronavirus, sarsSevere Acute Respiratory SyndromeInfl uenza a virus, h1n1 subtypeHealth occupationsEmergenciesInfectious disease transmission, patient-to-professionalInfectious disease transmission, professional-to-patient

Operators ANDOR

Databases MEDLINE, vía PubmedSCOPUSChochane Library Plus

Filters HumanAdults (19 and…)AbstractLast 5 yearsLast 10 years

With them different Boolean combinations are made finally obtaining three equations search (Table 2) in MEDLINE/PubM. The filters listed in the table (Table 1) were used. The same strategy was adapted to the characteristics of other databases consulted. The search was performed from the first available date, according to the characteristics of each database, until November 2014 (time of last update).

Table 2. Search equations

EQUATIONS SEARCH DATABASES

(disease outbreaks[MeSH Terms]) AND (coronavirus, sars[MeSH Terms]) OR Severe Acute Respiratory Syndrome[MeSH Terms]) OR infl uenza a virus, h1n2 subtype[MeSH Terms])) AND health occupations[MeSH Terms]

(disease outbreaks[MeSH Terms]) AND (coronavirus, sars[MeSH Terms]) OR Severe Acute Respiratory Syndrome[MeSH Terms]) OR infl uenza a virus, h1n2 subtype[MeSH Terms])) AND health occupations[MeSH Terms] and emergencies [MeSH Terms].

Medlars Online International Literature (MEDLINE)

(disease outbreaks[MeSH Terms]) AND (coronavirus, sars[MeSH Terms]) OR Severe Acute Respiratory Syndrome[MeSH Terms]) AND health occupations[MeSH Terms].

SCOPUS

(“infectious disease transmission, patient-to-professional”[MeSH Terms] OR “infectious disease transmission, professional-to-patient”[MeSH Terms]) AND ((“disease outbreaks”[MeSH Terms] AND “sars virus”[MeSH Terms] OR “severe acute respiratory syndrome”[MeSH Terms]) OR “infl uenza a virus, h1n1 subtype”[MeSH Terms]) AND “health occupations”[MeSH Terms] AND (abstract[text] AND “humans”[MeSH Terms] AND (English[lang] OR Spanish[lang])).

Cochrane Library Plus.




The final choice of articles was performed as meeting the inclusion criteria:

— Adapting to the objectives of the search.

— Population studies collected should be health workers.

— Provide summary.

— Ability to retrieve the full text of the paper.

— English or Spanish language.

Articles were excluded:

— Do not contributed empirical information regarding the effects of a health alert health professionals.

— Population studied different health sector.

— Editorials and review articles

— Duplicate publications, including in the analysis, in this case, the most complete study.

The selection of relevant articles was performed independently by two authors of this review.

To give as valid the inclusion of studies established that the valuation of the concordance between the two authors (Kappa index) should be one. The possible discrepancies between the two authors should be resolved by consensus between them.

To assess the quality of the articles selected for publication guidelines observational studies STROBE23 were used. Items are grouped, in order to systematize and facilitate the understanding of the results, according to the study variables, considering the variables listed in Table 3. In addition the SIGN criteria were used for the allocation of evidence for selected items.

Table 3. Variables

VARIABLES

Title

First author name and year of publication

Citation of the journal

Type of study

Sample and sampling

Type of analysis

Statistical tests and measures of association

Variable effect

Variable factor

Bias control

Main results

Conclusions

Limitations

Advances




RESULTS

With the search criteria described a total of 187 references were collected, of which after applying the criteria of inclusion and exclusion reading the summary, and discard duplicates and non-refundable full text, 41 items are selected, of which full text after reading and analyzing their methodological quality according to the STROBE criteria are considered relevant 17. All works are from MEDLINE and SCOPUS not found publications that met the criteria for inclusion and exclusion in the Cochrane Library (Figure 1 and Table 4).

Figure 1. Flowchart search

With the search criteria described a total of 187 references were collected , of which after applying the criteria of inclusion and exclusion reading the summary , and discard duplicates and non‐refundable full text, 41 items are selected , of which full text after reading and analyzing their methodological quality according to the STROBE criteria are considered relevant 17. All works are from MEDLINE and SCOPUS not found publications that met the criteria for inclusion and exclusion in the Cochrane Library ( Figure 1 and Table 4. ) . Figure 1. Flowchart search

All the studies reviewed are treated cross‐sectional studies , and therefore their level of evidence is 3 ( SIGN) so to implement more quality to the results of the review it was decided to evaluate it , using the questionnaire STROBE23 (Table 5 ) to give a score ranging between 13.5 and 18.5 , indicating that all items have good or excellent quality.

Table 4 Summary of search

Nª OF ITEMS INCLUDED APPLYING THE QUALITY CRITERIA STROBE

17

Nª OF ITEMS INCLUDED AFTER APPLYING THE CRITERIA FOR INCLUSION / EXCLUSION AFTER READING A TEXTOCOMPLETO

41

Nª OF INCLUDED / EXCLUSION ARTICLES BY ABSTRACT

58

Nª FOLLOWING ITEMS INCLUDED DISCARD REDUNDANT

181

Nª OF ITEMS FOUND AND APPLYING THE LIMITS OF SEARCH

187

All the studies reviewed are treated cross-sectional studies, and therefore their level of evidence is 3 (SIGN) so to implement more quality to the results of the review it was decided to evaluate it, using the questionnaire STROBE23 (Table 5) to give a score ranging between 13.5 and 18.5, indicating that all items have good or excellent quality.




Table 4. Summary of search

Databases Equations search

N.ª items obtained

with quick search

N.ª of redundant

articles

N.ª selected

articles by abstract

N.ª of items to meet cri-teria for

exclusion/inclusion

Total

PUMBED (disease outbreaks[MeSH Terms]) AND (coronavirus, sars[MeSH Terms]) OR Severe Acute Respiratory Syndrome[MeSH Terms]) OR infl uenza a virus, h1n2 subtype[MeSH Terms])) AND health occupations[MeSH Terms]

(disease outbreaks[MeSH Terms]) AND (coronavirus, sars[MeSH Terms]) OR Severe Acute Respiratory Syndrome[MeSH Terms]) OR infl uenza a virus, h1n2 subtype[MeSH Terms])) AND health occupations[MeSH Terms] and emergencias [MeSH Terms](disease outbreaks[MeSH Terms]) AND (coronavirus, sars[MeSH Terms]) OR Severe Acute Respiratory Syndrome[MeSH Terms]) AND health occupations[MeSH Terms]

(“infectious disease transmission, patient-to-professional”[MeSH Terms] OR “infectious disease transmission, professional-to-patient”[MeSH Terms]) AND ((“disease outbreaks”[MeSH Terms] AND “sars virus”[MeSH Terms] OR “severe acute respiratory syndrome”[MeSH Terms]) OR “infl uenza a virus, h1n1 subtype”[MeSH Terms]) AND “health occupations”[MeSH Terms] AND (hasabstract[text] AND “humans”[MeSH Terms] AND (English[lang] OR Spanish[lang]))

100

5

38

22

1

3

1

1

19

2

24

3

7

0

3

2

7

0

3

2

SCOPUS (disease outbreaks[MeSH Terms]) AND (coronavirus, sars[MeSH Terms]) OR Severe Acute Respiratory Syndrome[MeSH Terms]) OR infl uenza a virus, h1n2 subtype[MeSH Terms])) AND health occupations[MeSH Terms]

22 0 10 5 5

Cochrane (disease outbreaks[MeSH Terms]) AND (coronavirus, sars[MeSH Terms]) OR Severe Acute Respiratory Syndrome[MeSH Terms]) OR infl uenza a virus, h1n2 subtype[MeSH Terms])) AND health occupations[MeSH Terms]

0 0 0 0 0




Table 5. STROBE of the articles included in the review

ReferenceTitle and summary

Introduc-tion

Methods ResultsDiscus-

sion

Other informa-

tionTotal %

Nukui. Y. et al. 1 2 5 2 4 0 14 63.3

Wong. WCW. et. Al 1 2 5 3 4 0 15 68.2

Wu Meng. T. et al. 1 2 4.5 3 3.5 0 14 63.3

Seale. H. et al 1 2 6.5 5 4 0 18.5 84.1

Sebahat. D. T. et al. 1 2 6.5 3.5 4 0 17 77.3

Vinck. L. et al. 1 2 4.5 3 4 0 14.5 65.9

Martin. S. D. et al. 1 2 5 3 2 0.5 13.5 61.4

Wong ELZ. et. al. 1 2 6 5 4 0.5 18.5 84.1

Verma. S. et. al. 0.5 2 4 3 4 1 14.5 65.9

Shiao. J. S. et. al. 1 2 4.5 2 3 1 13.5 61.4

William. C. W. et. Al. 0.5 2 6 4 3.5 0 16 72.7

Leslie. A. Nickell. et. al. 0.5 2 7 4 4 1 18.5 84.1

M. J Parker. et. al. 0.5 2 7 3 4 0 16.5 75

Chih -Cheng Hsu. et al. 0.5 2 6.5 3.5 3 0 15.5 70.4

La Torre. et. al 0.5 2 4 3.5 4 0 14 63.3

Tolomizcenko. Gs. et. Al 0.5 2 5.5 3 3 1 15 68.2

Alvaro. J. Idrovo. et al. 0.5 2 7.5 3 4 0 17 77.3

The study of Tan WM. et al.12 was presented smaller sample size (n = 90), whereas de Nickell LA. et al.6 work was larger l (n = 2001). In two of the 17 items the study population was purely medical. The study of Idrovo AJ. et al.3 included only medical students graduate and three studies the sample belonged entirely to nurses case of predominantly female population.




Tabl

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Re

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from

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in T

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publ

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nu

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hos

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and

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f th

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ndem

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y pu

blic

he

alth

nur

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with

qu

aran

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outb

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bias

. Re

call

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st

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confi

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d in

re

al tim

e w

ith S

ARS

mea

sure

s (

poss

ible

re

port

ing

bias

) T

he

stud

y ha

s no

t be

en

prev

ious

ly v

alid

ated

by

a s

mal

l sam

ple

sele

cted

to

asse

ss the

ob

ject

ivity

of

it.

3D

evel

opm

ent co

ntro

l equ

ipm

ent

less

res

tric

tive

infe

ctio

ns m

ore

acce

ptab

le for

sta

ff; n

eed

to

stud

y m

ore

and

unde

rsta

nd the

ps

ycho

soci

al e

ffec

ts o

f SA

RS

on

hosp

ital s

taff

ove

r tim

e

18.5




Tabl

e 7.

Re

sulta

dos

obta

ined

from

rev

iew

ed a

rtic

les

IDA

utho

r/ p

ubli-

catio

n ye

arTi

tleR

efer

ence

m

agaz

inTy

pe o

f st

udy

Sam

ple/

sam

plin

gVa

riab

le e

ffec

tVa

riab

le

fact

orCo

ntro

l of bi

asA

naly

sis

done

Stat

istic

al te

stR

esul

tsCo

nclu

sion

sLi

mita

tions

Sign

Pro

gres

sSt

robe

2212

4695

Idro

vo

AJ/

2011

Perc

eptio

n of

ep

idem

iolo

gica

l co

mpe

tenc

ies

by

publ

ic h

ealth

stu

dent

s in

Mex

ico

and

Col

ombi

a du

ring

the

in

fl uen

za A

(H

1N1)

ep

idem

ic.

Rev

Pana

m S

alud

Pu

blic

a. O

ctob

er

2011

; 30

( 4)

: 36

1-9.

Cro

ss-

sect

iona

l st

udy.

154

grad

uate

st

uden

ts :

86

Mex

ico

and

68

Col

ombi

a. S

impl

e ra

ndom

sam

plin

g.

Exis

ting

skill

s an

d tr

aini

ng n

eeds

.In

fl uen

za

A o

utbr

eak

(H1N

1).

Sele

ctio

n bi

as a

nd

info

rmat

ion

bias

.St

ata1

1 st

atis

tical

pr

ogra

m .

fact

or A

naly

sis.

Chi

-squ

are

. Fi

sher

.U e

xact

M

ann

-Whi

tney

.

Low

sco

re o

n cu

rren

t ca

paci

ty in

rel

atio

n to

the

link

bet

wee

n he

alth

wor

kers

and

the

co

mm

unity

. (21

.5 %

var

ianc

e).

Resp

onse

to

the

epid

emic

co

uld

have

bee

n be

tter

.In

stru

men

t us

ed

was

des

igne

d to

ev

alua

te s

taff

with

re

spon

sibi

litie

s fo

r fi e

ld e

pide

mio

logi

st.

3Id

entif

ying

are

as

of o

ppor

tuni

ty

to im

prov

e th

e te

achi

ng o

f ep

idem

iolo

gy

to h

ealth

co

ntin

genc

ies.

17

2217

3523

Nuk

ui Y

/201

2Pa

ndem

ic 2

009

infl u

enza

A (

H1N

1)

viru

s am

ong

Japa

nese

he

alth

care

wor

kers

: se

ropr

eval

ence

and

ri

sk f

acto

rs.

Infe

ct C

ontr

ol

Hos

p Ep

idem

iol.

Janu

ary

2012

; 33

(1)

: 58-

62.

Cro

ss-

sect

iona

l st

udy.

262

doct

ors,

176

nu

rses

, 23

wor

kers

no

pat

ient

con

tact

. St

ratifi

ed

rand

om

sam

plin

g.

Sero

prev

alen

ce

and

risk

fac

tors

for

H

1N1

amon

g he

alth

w

orke

rs.

Infl u

enza

A

out

brea

k (H

1N1)

.

Sele

ctio

n bi

as:

Excl

usio

n di

agno

sed

/ su

spec

ted

grip

eA

and

vacc

inat

ed.

Info

rmat

ion

bias

.

SPSS

Sta

tistic

s 18

(IB

M).

Uni

vari

ate

logi

stic

re

gres

sion

an

alys

is a

nd

mul

tivar

iabl

e.

OR, C

hi - s

quar

e.In

crea

sed

risk

of

sero

posi

tivity

(O

R :

5.25

) be

twee

n nu

rses

and

doc

tors

as

wel

l as

staf

f pe

diat

rics

, em

erge

ncy

and

inte

rnal

med

icin

e (O

R :

1.98

). N

o di

ffer

ence

s in

the

use

of

PPE

( p

> 0.

05).

Sero

posi

tivity

H1N

1 is

a

risk

fac

tor

for

occu

patio

nal

heal

th w

orke

rs.

Low

leve

ls o

f se

roco

nver

sion

red

uce

the

pow

er o

f th

e st

udy

to in

vest

igat

e re

latio

nshi

p be

twee

n ex

posu

re a

nd u

se

of P

PE.

3H

ealth

wor

kers

is

a pr

iori

ty g

roup

for

va

ccin

atio

n ag

ains

t H

1N1

beca

use

of

the

high

ris

k of

in

fect

ion.

14

1496

6227

Won

g W

CW

/200

4H

ow d

id g

ener

al

prac

titio

ners

pro

tect

th

emse

lves

, the

ir

fam

ily, a

nd s

taff

du

ring

the

SA

RS

epid

emic

in H

ong

Kon

g?

J Ep

idem

iol

Com

mun

ity

Hea

lth .

Mar

ch

2004

; 58

(3):

180-

5.

Cro

ss-

sect

iona

l st

udy.

137

GPs

. Sim

ple

rand

om s

ampl

ing.

Leve

l of

anxi

ety,

cl

inic

al p

ract

ice

, pe

rson

al a

nd f

amily

pr

otec

tion.

SARS

outb

reak

.Se

lect

ion

bias

and

in

form

atio

n bi

as.

SPSS

Chi

-sq

uare

an

alys

is o

f va

rian

ce.

SA

RS

chan

ged

thei

r cl

inic

al p

ract

ice

( 97

%).

Leve

ls o

f an

xiet

y el

vado

s in

fect

rel

ativ

es (

p <

0.

01)

.Des

acue

rdo

to fol

low

qua

rant

ine

afte

r co

ntac

t (

p <

0.01

) 97

.7 %

had

wor

n m

asks

all

the

time,

25

% n

o ha

ndw

ashi

ng, 5

0 %

wer

e no

t w

eari

ng p

rote

ctiv

e go

wn

, 75

% d

id n

ot w

ear

glas

ses,

25

% w

ore

glov

es a

nd tem

pera

ture

w

as tak

en d

aily

.

Gen

eral

pra

ctiti

oner

s m

odifi

ed the

ir c

linic

al

prac

tice.

The

y fa

ult is

olat

ion

mea

sure

s of

sus

pect

ed c

ases

of

SA

RS

spre

ad in

crea

sed

thei

r la

ck o

f co

ntin

genc

y pl

an.

Smal

l sam

ple

size

(r

epre

sent

ing

3-4%

ge

nera

l pra

ctiti

oner

s).

Type

of

stud

y.

3SA

RS

expo

sed

the

wea

knes

ses

of the

he

alth

sys

tem

of

Hon

g K

ong

and

the

need

to

chan

ge

heal

th p

olic

y an

d cl

inic

al p

ract

ice

15

2121

1593

Seal

e H

/201

1A

ccep

tanc

e of

a

vacc

ine

agai

nst

pand

emic

infl u

enza

A

(H1N

1) v

irus

am

ongs

t he

alth

care

wor

kers

in

Bei

jing,

Chi

na

Vacc

ine.

Feb

ruar

y 11

, 201

1 ; 2

9 (8

):

1605

-161

0.

Cro

ss-

sect

iona

l st

udy.

1657

hea

lth

wor

kers

( 6

04

doct

ors

, nur

ses

1044

, ano

ther

9).

Ran

dom

sam

plin

g (R

CT

clin

ical

tri

al

on the

use

of m

asks

an

d re

spir

ator

s).

Deg

ree

of

vacc

inat

ion

agai

nst

H1N

1 he

alth

w

orke

rs a

nd

asso

ciat

ed f

acto

rs.

Attitu

des

to the

va

ccin

e.

Infl

uen

za

A o

utbr

eak

(H1N

1).

Sele

ctio

n bi

as a

nd

info

rmat

ion

bias

.M

ultiv

aria

te

anal

ysis

Epi

In

fo v

ersi

on

33.2

.

OR, C

hi - s

quar

e.25

% o

f pa

rtic

ipan

ts r

ecei

ved

the

vacc

ine.

A

ssoc

iate

d fa

ctor

s (v

acci

natio

n ag

ains

t se

ason

al

infl u

enza

) 61

% w

orri

ed a

bout

sid

e ef

fect

s. 4

6%

vacc

ine

was

not

pro

perl

y te

sted

.

Con

trar

y to

pre

viou

s st

udie

s th

at h

ad r

epor

ted

the

high

pr

edis

posi

tion

to r

ecei

ve

vacc

ine

this

did

not

hap

pen.

Que

stio

nnai

re (

bias

in

the

inte

rpre

tatio

n of

dat

a) n

on-

repr

esen

tativ

e sa

mpl

e of

the

gen

eral

po

pula

tion.

3N

eed

for

nurs

ing

staf

f aw

are

of

the

need

for

va

ccin

atio

n.

18,5

2060

0497

Toru

n SD

/201

0Va

ccin

atio

n ag

ains

t pa

ndem

ic in

fl uen

za

A/H

1N1

amon

g he

alth

care

wor

kers

an

d re

ason

s fo

r re

fusi

ng v

acci

natio

n in

Ist

anbu

l in

last

pa

ndem

ic a

lert

pha

se

Vacc

ine.

Aug

ust

9, 2

010

; 28

(35)

: 57

03-1

0.

Cro

ss-

sect

iona

l st

udy.

941

indi

vidu

als

: 277

doc

tors

, 18

9 nu

rses

, 11

1 pa

ram

edic

s an

d 36

4 no

n-he

alth

wor

kers

. ra

ndom

sam

plin

g.

Gra

de v

acci

natio

n w

orke

rs (

asso

ciat

ed

fact

ors)

and

gra

de

of r

ecom

men

datio

n of

the

vac

cine

(a

ssoc

iate

d fa

ctor

s).

Infl

uen

za

A o

utbr

eak

(H1N

1).

Sele

ctio

n bi

as a

nd

info

rmat

ion

bias

.M

ultiv

aria

te

anal

ysis

SP

SS10

.0.

Pear

son

coef

fi cie

nt ,

Chi

-squ

are,

Fis

her

exac

t te

st.

23.1

% w

orke

rs r

ecei

ved

vacc

inat

ion.

76.

1%

refu

sal c

ause

fea

r si

de e

ffec

ts. D

egre

e of

vac

cina

tion

was

hig

her

in p

hysi

cian

s re

gard

ing

the

rest

( X

²: 20

,23

) . 5

9.6

% d

octo

rs

reco

mm

ende

d va

ccin

atio

n to

the

ir p

atie

nts.

Vacc

inat

ion

agai

nst H

1N1

is in

suffi c

ient

am

ong

heal

th

care

wor

kers

.

Type

of

stud

y , n

o co

mpl

ete

resp

onse

ra

te a

nd a

dvan

ced

stag

e of

the

pan

dem

ic.

3N

eed

for

trai

ning

an

d sc

ient

ifi c

info

rmat

ion

rega

rdin

g ef

fi cac

y an

d sa

fety

of

the

vacc

ine

amon

g he

alth

car

e w

orke

rs.

13,5

1733

4166

Shia

o JS

-C

/200

7Fa

ctor

s pr

edic

ting

nurs

es’ c

onsi

dera

tion

of le

avin

g th

eir

job

duri

ng the

SA

RS

outb

rea

Nur

s Et

hics

. Ja

nuar

y 20

07; 1

4 (1

): 5

-17.

Cro

ss-

sect

iona

l st

udy.

753

nurs

es.

Ran

dom

sam

plin

g.Ris

k pe

rcep

tion

of S

ARS

, lea

ving

th

e w

orkp

lace

and

as

soci

ated

fac

tors

w

orkl

oad.

SARS

outb

reak

.Se

lect

ion

bias

and

in

form

atio

n bi

as.

Regr

essi

on

anal

ysis

. SA

S JM

P (V

ersi

on

5.01

).

OR, I

C(p

).71

.9 %

per

ceiv

ed r

isk

of in

fect

ion

, 49.

9 %

incr

ease

in w

orkl

oad,

32.

4 %

peo

ple

avoi

ded

them

for

the

ir w

ork

, 7.4

% s

erio

usly

co

nsid

ered

leav

ing

thei

r jo

bs.

Dur

ing

SARS

pand

emic

al

mos

t 10

% c

onsi

dere

d le

avin

g th

eir

jobs

.

83 %

res

pons

e ra

te .

Type

of

stud

y.3

It is

nec

essa

ry to

prov

ide

emot

iona

l an

d pr

ofes

sion

al

supp

ort nu

rses

du

ring

pan

dem

ics.

13,5

1499

3174

Nic

kell

LA/

2004

Psyc

hoso

cial

eff

ects

of

SA

RS

on h

ospi

tal

staf

f: su

rvey

of

a la

rge

tert

iary

car

e in

stitu

tion

CM

AJ

. Mar

ch 2

, 20

04 ;

170

(5):

793-

8.

Cro

ss-

sect

iona

l st

udy.

2001

hea

lth

wor

kers

in a

te

rtia

ry h

ospi

tal

in T

oron

to (

27 %

of

wor

kers

in the

ho

spita

l).

Con

cern

abo

ut

SARS;

pre

caut

iona

ry

mea

sure

s;

pers

onal

wel

fare

; so

ciod

emog

raph

ic

char

acte

rist

ics

and

gene

ral h

ealth

su

rvey

.

SARS

outb

reak

.In

form

atio

n bi

as.

SPSS

; Biv

aria

te

anal

ysis

to

iden

tify

e xpl

anat

ory

vari

able

s;

mul

tivar

iabl

e lo

gist

ic

regr

essi

on

to a

sses

s as

soci

atio

n be

twee

n ou

tcom

e va

riab

les

and

pote

ntia

l lo

sses

.

Mul

tivar

iate

te

chni

ques

; OR

and

95 %

CI.

abou

t the

hea

lth o

f you

r fa

mily

.In

the

510

who

co

mpl

eted

the

GH

Q -1

2 , 1

48 (

29.

0 %

) s

core

d ab

ove

the

thre

shol

d m

ore

than

3, i

ndic

atin

g pr

obab

le e

mot

iona

l dis

tres

s. (

p <

0.0

01 )

with

a

scor

e gr

eate

r th

an 3

: 45

.1 %

of n

urse

s , 3

3.3

%

of p

rofe

ssio

nals

alli

ed h

ealth

car

e , 1

7.4

% a

nd

18.9

% m

edic

al p

erso

nnel

that

doe

s no

t wor

k co

ntac

t the

quo

ted

paci

ente

.Mas

carilla

cau

tion

as m

ost a

nnoy

ing

. 74.

1 %

con

trol

mea

sure

s w

ere

suffi

cien

t to

prev

ent c

onta

gion

. 4 fa

ctor

s as

soci

ated

with

incr

ease

d le

vels

of c

once

rn fo

r pe

rson

al o

r fa

mily

hea

lth :

the

perc

eptio

n of

an

incr

ease

d risk

of d

eath

from

SA

RS (

adju

sted

odd

s ra

tio [O

R ] 5

.0, 9

5 %

con

fi den

ce in

terv

al [

CI] 0

2 /

09/0

6 06

) li

ving

with

chi

ldre

n (

adju

sted

OR

1.8

, 95

% C

I 1.

5 to

2.3

).

2/3

of th

e pe

rson

ex

perien

cing

con

cern

for

thei

r ow

n he

alth

or

that

of y

our

fam

ily. I

t was

als

o re

port

ed

posi

tive

aspe

cts

of th

e SA

RS

epid

emic

. Th

us, t

he s

taff

note

d an

incr

ease

d aw

aren

ess

of in

fect

ion

cont

rol ,

you

can

st

ill b

enefi

t fr

om th

e ho

spita

l co

mm

unity

in th

e fu

ture

. So

me

resp

onde

nts

foun

d th

at th

e si

tuat

ion

prov

ided

a

posi

tive

lear

ning

exp

erie

nce

and

a gr

eate

r se

nse

of u

nity

an

d co

oper

atio

n am

ong

hosp

ital s

taff.

Low

res

pons

e ra

te

( 47

%)

and

also

the

poss

ibili

ty o

f re

spon

se

bias

; st

aff w

ere

quar

antin

ed o

r ou

t be

caus

e of

illn

ess

or h

olid

ay w

as n

ot

incl

uded

and

may

be

the

mos

t affec

ted

; us

ing

the

GH

Q -1

2 w

as

limite

d to

a p

ortio

n of

th

e sa

mpl

e ca

n af

fect

th

e re

sults

; th

e st

udy

was

con

duct

ed in

a

larg

e ho

spita

l so

the

resu

lts.

3In

crea

se in

fut

ure

brie

fi ngs

leas

t w

eekl

y up

date

d in

form

atio

n .

Tryi

ng to

fi nd

stra

tegi

es for

ho

spita

ls to

resp

ond

quic

kly

to the

con

cern

s of

nur

sing

rel

ated

to

the

ir c

once

rns

and

the

patie

nts

them

selv

es.

18,5




Tabl

e 8.

Re

sulta

dos

obta

ined

from

rev

iew

ed a

rtic

les

IDA

utho

r/

publ

icat

ion

year

Title

Ref

eren

ce

mag

azin

Type

of

stud

ySa

mpl

e/sa

mpl

ing

Vari

able

eff

ect

Vari

able

fa

ctor

Cont

rol o

f bi

asA

naly

sis

done

Stat

istic

al te

stR

esul

tsCo

nclu

sion

sLi

mita

tions

Sign

Pro

gres

sSt

robe

2134

5320

Vin

ck L

/201

1Im

pact

of

the

2009

in

fl uen

za A

(H1N

1)

pand

emic

on

publ

ic

heal

th w

orke

rs in

the

N

ethe

rlan

ds.

Euro

Sur

veill

. 20

11;1

6(7)

.Cro

ss-

sect

iona

l st

udy.

77 d

octo

rs, 8

5 nu

rses

and

4

man

ager

s ho

spita

l. Ran

dom

sam

plin

g.

Wor

kloa

d an

d an

xiet

y in

fect

ed.

Infl u

enza

A

out

brea

k (H

1N1)

Sele

ctio

n bi

as a

nd

info

rmat

ion

bias

.D

escr

iptiv

e st

atis

tics.

SP

SS v

.18.

0

Para

met

ric

and

nonp

aram

etri

c te

st. A

naly

sis

of c

ovar

ianc

e (A

NCO

VA).

T-st

uden

t ,

Chi

-squ

are,

a o

f Cro

nbac

k .

70.5

% in

crea

se in

wor

kloa

d, 6

0 %

had

no

anxi

ety

abou

t sp

read

ing

dise

ase

. 48

% lo

oked

to

the

refe

renc

e in

form

atio

n an

d Re

spon

se M

easu

res

agai

nst H

1N1

. 88

% u

sed

PPES

(FF

P2 ,

glov

es,

glas

ses

...).

71-9

7 %

info

rmin

g pa

tient

s ab

out

prot

ectiv

e m

easu

res.

Exce

ssiv

e w

orkl

oad

duri

ng the

initi

al 3

-5

mon

ths

of the

pan

dem

ic.

Low

leve

ls o

f an

xiet

y.

Low

leve

ls o

f co

nsul

ting

the

refe

renc

e ce

nter

.

Dat

a co

llect

ed a

t 9

mon

ths

of the

pa

ndem

ic .

Hig

her

prop

ortio

n of

ph

ysic

ians

tha

n nu

rses

.

3Im

port

ance

of

adeq

uate

pr

epar

atio

n pl

ans

for

futu

re e

pide

mic

s. N

eed

to tem

pora

rily

incr

ease

th

e w

orkf

orce

. Im

prov

ed

trai

ning

by

med

ical

pe

rson

nel.

14,5

2047

3456

Tan

WM

/201

0A

ttitu

des

of p

atie

nts,

vi

sito

rs a

nd h

ealth

care

w

orke

rs a

t a

tert

iary

ho

spita

l tow

ards

in

fl uen

za A

(H

1N1)

re

spon

se m

easu

res

Ann

Aca

d M

ed

Sing

ap. A

bril

de

2010

;39(

4):3

03-4

.

Cro

ss-

sect

iona

l st

udy.

90 P

artic

ipan

ts :

32

patie

nts,

11

visi

tors

, 47

hea

lth w

orke

rs.

Ran

dom

sam

plin

g.

Infl u

ence

of

mea

sure

s ag

ains

t H

1N1

in the

ir d

aily

w

ork.

Infl u

enza

A

out

brea

k (H

1N1)

Info

rmat

ion

bias

: su

rvey

.M

icro

soft

Ex

cel P

ivot

Ta

ble

Soft

war

e an

d Fu

nctio

n

Cat

egor

ical

da

ta d

istr

ibut

ed

in %

.

84 %

agr

eed

on m

easu

res

take

n . 7

2 %

doc

tors

: m

easu

res

infl u

ence

d ne

gativ

ely

in the

ir w

orki

ng

day.

34.

6 %

exc

essi

ve m

easu

res.

Perc

eive

d as

exc

essi

ve

mea

sure

s w

ill b

e ac

cept

ed if

the

dis

ease

ha

s hi

gh m

orta

lity

rate

s.

Smal

l sam

ple

size

.3

Face

d w

ith n

ew

pand

emic

s w

hose

le

thal

ity is

unk

now

n im

plem

entin

g pr

even

tive

mea

sure

s sh

ould

be

acc

ompa

nied

by

impo

rtan

t co

mm

unic

atio

n ex

plai

ning

the

un

cert

aint

ies

of the

au

thor

ities

and

ben

efi ts

in

divi

dual

mea

sure

s.

14

2122

3410

Mar

tin

SD/2

011

Nur

ses’ a

bilit

y an

d w

illin

gnes

s to

wor

k du

ring

pan

dem

ic fl u

.

J N

urs

Man

ag.

Ener

o de

20

11;1

9(1)

:98-

108.

Cro

ss-

sect

iona

l st

udy.

735

nurs

es .

Stra

tifi e

d ra

ndom

sa

mpl

ing.

Wor

king

cap

acity

an

d w

illin

gnes

s to

go

to w

ork.

Infl u

enza

A

out

brea

k (H

1N1)

Sele

ctio

n bi

as a

nd

nonr

espo

nse

bias

.M

inita

b 15

W

indo

ws

2006

.

Z-te

st p

<0.0

593

% w

ork

with

ful

l PPE

(N

-95

mas

k , g

own,

gl

oves

).Fa

mily

and

dis

posa

l of

PPE

play

s an

impo

rtan

t ro

le in

the

will

to

go to

wor

k. P

regn

ant w

omen

sh

ould

not

ser

ve p

atie

nts

susp

ecte

d /

diag

nose

d in

fl uen

za A

.

Low

div

ersi

ty o

f th

e sa

mpl

e (r

ace,

et

hnic

ity, g

ende

r).

Mid

e in

tent

ion.

B

iase

s.

3H

ave

appr

opri

ate

PPE

infl u

ence

s th

e w

illin

gnes

s to

go

to w

ork.

13,5

2043

3691

Won

g EL

Y/2

010

Will

the

com

mun

ity

nurs

e co

ntin

ue to

func

tion

duri

ng H

1N1

infl u

enza

pan

dem

ic: a

cr

oss-

sect

iona

l stu

dy o

f H

ong

Kon

g co

mm

unity

nu

rses

?.

BM

C H

ealth

Ser

v Re

s. 2

010;

10:1

07.

Cro

ss-

sect

iona

l st

udy.

267

com

mun

ity

nurs

es. R

ando

m

sam

plin

g.

Psyc

holo

gica

l as

pect

s an

d jo

b sa

tisfa

ctio

n. V

arab

les

dem

ogra

phic

and

w

illin

gnes

s to

wor

k.

Infl u

enza

A

out

brea

k (H

1N1)

Sele

ctio

n bi

as a

nd

info

rmat

ion

bias

Logi

stic

re

gres

sion

an

alyz

es.

SPSS

ver

sion

15

.0.

OR p

<0.0

576

.9%

: 33.

3% d

id n

ot w

ant to

go

, and

43.

6 %

are

no

t tr

aine

d to

car

e fo

r pa

tient

s w

ith in

fl uen

za

A. 5

5% h

ave

stre

ss, 2

9.2

%fe

ar o

f in

fect

ion.

33%

us

ed c

linic

al g

uide

lines

for

infe

ctio

n co

ntro

l for

ca

re the

ir p

atie

nts.

Prov

ide

trai

ning

and

co

unse

ling

incr

ease

w

illin

gnes

s to

go

to w

ork.

Type

of

stud

y , n

ot

incl

uded

mar

ital s

tatu

s an

d fa

mily

sta

tus.

O

nly

com

mun

ity

nurs

es.

3N

eed

for

trai

ning

in

infe

ctio

n co

ntro

l by

the

nurs

ing

staf

f.

18,5

1560

8831

Verm

a S/

2004

Post

-SA

RS

psyc

holo

gica

l m

orbi

dity

and

stig

ma

amon

g ge

nera

l pr

actit

ione

rs a

nd

trad

ition

al C

hine

se

med

icin

e pr

actit

ione

rs

in S

inga

pore

.

Ann

Aca

d M

ed S

inga

p.

Nov

iem

bre

de

2004

;33(

6):7

43-8

.

Cro

ss-

sect

iona

l st

udy.

721

doct

ors

and

329

prac

titio

ners

of

Trad

ition

al C

hine

se

Med

icin

e. R

ando

m

sam

plin

g.

Psyc

holo

gica

l di

stre

ss (

GH

Q -28

) ,

post

-trau

mat

ic s

tres

s di

sord

er ,

prop

ortio

n of

stig

ma

(HIV

St

igm

a Sc

ale)

.

SARS

outb

reak

Sele

ctio

n bi

as a

nd

info

rmat

ion

bias

Freq

uenc

y di

stri

butio

n fo

r de

scri

ptiv

e da

ta. S

PSS

v.10

.

Chi

-squ

are,

Fi

sher

exa

ct

test

, OR,

Man

n-W

hitn

ey,

Spea

rman

co

rrel

atio

n.

GH

Q -28

sco

re ,

perc

eive

d st

igm

a an

d PT

SD w

as

high

er in

gen

eral

med

ical

p<0

.05.

Fear

, unc

erta

inty

and

st

igm

a ca

used

by

SARS

is a

ssoc

iate

d w

ith p

sych

olog

ical

di

stre

ss a

mon

g ge

nera

l pr

actit

ione

rs.

Low

res

pons

e ra

te.

Rat

ing

scal

e st

igm

a of

HIV

SA

RS

was

m

odifi

ed. T

ype

of

stud

y.

3Ps

ycho

logi

cal n

eeds

of

heal

th w

orke

rs m

ust be

ex

plor

ed a

nd d

iscu

ssed

du

ring

per

iods

pan

dem

ic.

14,5

2200

6167

La T

orre

G/

2012

Kno

wle

dge,

attitu

de,

and

beha

viou

r of

pub

lic

heal

th d

octo

rs tow

ards

pa

ndem

ic in

fl uen

za

com

pare

d to

the

gen

eral

po

pula

tion

in I

taly

.

Scan

d J

Publ

ic

Hea

lth. F

ebre

ro

de 2

012;

40(1

):69

-75

.

Cro

ss-

sect

iona

l st

udy.

335

doct

ors

and

501

non-

med

ical

in

Ita

ly.

Soci

o- d

emog

raph

ic

info

rmat

ion,

kn

owle

dge

and

beha

vior

s.

Infl u

enza

A

out

brea

k (H

1N1)

Part

icip

atio

n bi

as

and

info

rmat

ion

bias

.

SPSS

st

atis

tical

pr

ogra

m

v19.

o.

Chi

-squ

are,

va

rian

ce

p<0.

05

Doc

tors

mor

e in

tere

sted

in u

pdat

ed o

n Pa

ndem

ic

(90.

6 %

vs

88.4

% p

= 0

.03)

; no

nmed

ical

mor

e in

clin

ed to

avoi

d cr

owde

d pl

aces

(29

.7 %

ver

sus

88.4

% w

ith p

< 0

.01)

; do

ctor

s m

ore

will

ing

to

be v

acci

nate

d (5

6.4%

ver

sus

23.6

% w

ith p

<0.0

1);

mai

n so

urce

of

info

rmat

ion

for

phys

icia

ns

inte

rnet

(41

.5%

) an

d se

cond

inte

rnal

sou

rces

ho

spita

l (33

.1%

) w

hile

no

doct

ors

get fr

om

tele

visi

on (

34.1

%)

follo

wed

by

inte

rnet

(30

.9%

).

Lots

of

info

rmat

ion

prop

agat

ed s

o ch

aotic

(e

ven

a si

gnifi

cant

pe

rcen

tage

of

doct

ors

with

fal

se b

elie

fs

and

lack

of

infe

ctio

n,

trea

tmen

t).

Que

stio

nnai

re

answ

ered

by

volu

ntee

rs v

ia

inte

rnet

.

3N

eed

to tak

e m

easu

res

for

furt

her

info

rmat

ion

and

effi c

ient

co

mm

unic

atio

n.

14




Tabl

e 9.

Re

sulta

dos

obta

ined

from

rev

iew

ed a

rtic

les

IDA

utho

r/ p

ubli-

catio

n ye

arTi

tleR

efer

ence

mag

azin

Type

of

stud

ySa

mpl

e/sa

mpl

ing

Vari

able

eff

ect

Vari

able

fa

ctor

Cont

rol o

f bi

asA

naly

sis

done

Stat

istic

al te

stR

esul

tsCo

nclu

sion

sLi

mita

tions

Sign

Pro

gres

sSt

robe

1578

8070

«Tol

omic

zenk

o G

S/ 2

005»

SARS:

cop

ing

with

the

im

pact

at a

com

mun

ity

hosp

ital.

J A

dv N

urs

. Apr

il 20

05; 5

0 (1

):

101-

10.

Cro

ss-

sect

iona

l st

udy.

300

heal

th

wor

kers

( m

edic

al

and

nonm

edic

al

) of

Mou

nt S

inai

H

ospi

tal i

n To

ront

o.

Patie

nt c

are;

co

mm

unic

atio

n an

d re

latio

nshi

ps;

deci

sion

mak

ing;

in

volv

emen

t in

pe

rson

al li

fe .

SARS

outb

reak

.In

form

atio

n bi

as.

SPSS

Fish

er e

xact

tes

t; M

ann

- Whi

tney

U

- te

st a

nd C

hi-

squa

re.

( p

< 0.

005)

bet

wee

n th

e fo

llow

ing

dom

ains

: f

acto

rs tha

t ad

vers

ely

affe

ct p

atie

nts

, co

mm

unic

atio

n , s

uppo

rt ,

wor

king

con

ditio

ns

, dec

isio

n m

akin

g an

d to

a le

sser

ext

ent,

the

impa

ct o

n lif

e ou

tsid

e w

ork.

All

grou

ps fou

nd

stre

ssfu

l SA

RS

, nur

ses

repo

rted

a g

reat

er

impa

ct in

the

mor

ale

and

job

satis

fact

ion

. Th

ese

wer

e ba

sed

mor

e on

pee

r su

ppor

t , l

ess

info

rmed

, le

ss in

volv

ed in

mak

ing

med

ical

de

cisi

ons

, and

wer

e m

ore

likel

y to

rep

ort

that

infe

ctio

n co

ntro

l pro

cedu

res

wer

e no

t qu

ite s

tric

t.

Diff

eren

ces

betw

een

grou

ps a

nd p

atte

rn o

f th

ese

diff

eren

ces

clea

rly

illus

trat

e th

e im

pact

and

str

ess

that

SA

RS

was

in a

hos

pita

l w

ith o

nly

a sm

all n

umbe

r of

pro

babl

e or

sus

pect

ed

case

s. T

he c

lear

diff

eren

ces

entr

egru

pos

defi n

ed b

y de

mog

raph

ic v

aria

bles

, cl

inic

al p

rofe

ssio

ns a

nd r

oles

su

gges

t a

seco

ndar

y im

pact

of

the

SA

RS

epid

emic

, w

ith

repe

rcus

sion

s he

alth

car

e .

Faci

litie

s m

ust de

al w

ith w

hile

m

aint

aini

ng a

hig

her

leve

l of

mon

itori

ng in

SA

RS.

In 1

650

only

1,1

00

wor

kers

had

a c

hanc

e to

res

pond

and

onl

y 27

% a

nsw

ers.

3Im

port

ance

of

the

need

fo

r pr

ecis

e im

plan

tatio

n of

info

rmat

ion

sour

ces

to

avoi

d ra

isin

g th

e al

arm

an

d fa

lse

belie

fs.

16

1727

6791

Won

g W

CW

/ 20

07H

ow to

prov

ide

an

effe

ctiv

e pr

imar

y he

alth

car

e in

fi g

htin

g ag

ains

t se

vere

acu

te

resp

irat

ory

synd

rom

e:

the

expe

rien

ces

of

two

citie

s.

Am

J I

nfec

t Con

trol

. Fe

brua

ry 2

007;

35

(1): 5

0-5.

Cro

ss-

sect

iona

l st

udy.

137

doct

ors

in

Hon

g K

ong

and

51 p

hysi

cian

s To

ront

o.

Trai

ning

in

infe

ctio

us a

nd

info

rmat

ion

abou

t SA

RS.

Clin

ical

pra

ctic

e an

d pe

rcei

ved

patie

nt b

ehav

ior

chan

ges.

Anx

iety

le

vel m

edic

al a

nd

satis

fact

ion

in

the

gove

rnm

ent’s

at

titud

e w

ith S

ARS.

SARS

outb

reak

.In

form

atio

n bi

as.

SPSS

v 1

3Chi

- s

quar

e;

mul

tiple

logi

stic

re

gres

sion

. O

R

84.6

% a

nd 8

0.0

% o

f H

ong

Kon

g an

d To

ront

o re

spec

tivel

y ha

d no

tra

inin

g in

con

trol

ling

enf

. Inf

ectio

us w

ithou

t tr

ust w

ith the

SA

RS

(68.

1 %

and

73.

5 %

res

pect

ivel

y) ;

Hon

g K

ong

doct

ors

wan

ted

mor

e co

mpl

emen

tary

tes

ts

(OR 3

7.8

, 95%

CI

12.6

5-11

3.06

) .

Doc

tors

in

Hon

g K

ong

few

er d

elay

s or

can

cella

tions

of

appo

intm

ents

. (O

R 0

.39

95%

CI

0.20

to

0.76

)

. Gen

eral

pra

ctiti

oner

s no

t as

soci

ated

SA

RS

loss

of

inco

me,

eith

er b

y m

ore

will

ingn

ess

and

com

mitm

ent or

sat

isfa

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Psychosocial impact

We found seven articles referring to stress, anxiety, and all elevated levels of both states are evident during the two pandemics, except Vinck L. et al.16 in a study conducted during the pandemic influenza A doctors, nurses and managers through voluntary questionnaires, finds that 60% does not show anxiety infected. Contrary to this LA Nickell obtained. et al.6 in a study conducted during the SARS pandemic in Toronto about psychosocial factors of health personnel. It notes that 64.7% showed concerned about your health. Additionally, we can add as Wong WCW. et al.18 also anxiety spread themselves, have high level of anxiety infect their families (p ‘0.01). LA Nickell. et al.6 identified four factors associated with increased concern for personal or family health: the perception of an increased risk of death from SARS (adjusted OR [OR]: 5.0; 95% confidence interval CI 2.06 to 9.06) live with children (adjusted OR 1.8, 95% CI 1.5 to 2.3), personal or family life affected by the outbreak of SARS (adjusted OR: 3.3; 95% CI: 2.5 to 4.3) and being treated in a manner different from working in a hospital (adjusted OR: 1.6; 95% CI: 01.02 to 02.01). Moreover, in the same study objective to work in a management or supervisory (adjusted OR: 0.6; 95% CI: 0.4 to 0.8), the belief that preventive measures in the workplace were sufficient ( adjusted OR: 0.4; 95% CI 0.3-0.5) and have 50 or more years (adjusted OR, 0.6; 95% CI 0.4-0.9) was associated with decreased concern about the pandemic.

In two of the 17 items you decide to use a questionnaire (GH28 and GH12) to specifically measure anxiety levels. S. Verma et al.15 studied during the SARS pandemic in China the difference in terms of psychological morbidity among physicians and practitioners of traditional Chinese medicine, thus proving that stigma and PTSD was higher among general practitioners (p ‘0.05). However, LA Nickell. et al.6 comparing all health workers found that nurses were those who had been most affected in their work on a psychological level, with statistically significant differences (p ‘0.001) 45.1% (37/82) of the nurses, compared to 33.3% (66/198) of professional allied health care, 17.4% (8/46) of physicians and 18.9% (28/148) of staff does not work in patient care. Furthermore the author mentions that the factors significantly associated with the presence of emotional distress are: being a nurse (adjusted OR: 2.8; 95% CI: 01.05 to 05.05), the situation of part-time employment (adjusted OR: 2.6, 95% CI 1.2 to 5.4), the lifestyle affected by the outbreak of SARS (adjusted OR 2.2, 95% CI 1.4 to 3.5) and impaired the ability to do your job because of preventive measures (OR adjusted 2.9; 95% CI: 1.9 to 4.6).

Two authors refer to the workload, from the psychological point of view, that pandemics occur in health care workers, finding none of the 17 references any physical load. Shiao JS-C. et al.11 studied the factors influencing decide to abandon their work on nurses during the SARS pandemic finds that 49.9% of them perceived increase in workload. L. Vinck et al.16 obtained better results when valuing during pandemic influenza A (70.5% increase in workload).

Adoption and adherence to preventive measures

Regarding preventive measures ae both Vinck’s article L. et al.16 like Martin SD et al.5 coincide more or less in the percentage of compliance with them (88% versus 92%). Furthermore, the article Parker. MJ. et al.8 obtained that measures between healthcare personnel are considered most effective are: use of isolation rooms (4.6 of 5 points with p: 0.02 95% CI: 4.5-4.8) respirator (4.5 / 5 p. 0001 p5% CI: 4.3-4.6) and handwashing (4.6 with p: 0.03 95% CI: 4.4-4.7) and with respect to the latter, the doctors informed wash his nurses and auxiliary (4.9 v 4.5 and 4.5, respectively; p ‘0.05).

In the study of LA Nickell. et al.6 is seen as respondents who considered the SARS high risk to public health reported greater compliance with handwashing (4.8 v 4.4) always mask utilization (3.9 v 3.2) and gloves (3.6 v 2.9) with p ‘0.05), gowning (4.9 v 4.7) or mask when examining patients (5.00 v 4.8). Instead eye protection (3.4 v 3.0) is not considered necessary addition, the use of a respirator caution was most frequently cited as most annoying and so considered it, 92.9% described it as a physical discomfort.




With respect to other preventive measures, Articles Wong WCW. et al.18 and CC Hsu et al.2 discuss disagreements enforce quarantine measures. In his study in Taiwan during the SARS pandemic to 312 nurses, objective nurses were less likely to cooperate with quarantine measures when they had less knowledge about SARS (OR 3.66 95% CI. 1.99-6.75) when expressed less fear (OR 3.19 95% CI. 1.85-6.21) and when not working well health centers (OR: 2.16 95% CI 1.17-4.00). With regard to information on pandemics, there is controversy regarding the sources used to obtain it. L. Vinck et al.16 in their study objective that 48% looked at the information center of reference. Instead, La Torre G et al.4 in a work on the SARS pandemic in which he compared the behavior and attitude of physicians in general population, stresses that the main source of information for physicians were internet (41.5%) and the second hospital internal (33.1%) while the rest of the obtained television population (34.1%) followed by internet (30.9%). Another important fact based on the information we found in the study of L. Vinck et al.16 in which it is found that between 71-97% of all health personnel informing patients about protective measures. However Tolomiczenko GS. et al.13 found that nurses were less informed and less involved in decision-making and were the most indicated that preventive measures were not strict enough.

An important point also found to do this review, is the question of the lack of training, something that is spoken in two of the articles included in this review. Wong ELY. et al.17 in their study of nurses during the swine flu pandemic, says that 76.9% of them do not want to work, and 43.6% are not trained to care for patients with influenza. Something similar, but referred to the medical staff, is what is Wong WCW. et al.19 to compare doctors in Hong Kong and Toronto during the SARS pandemic, aiming to 84.6% and 80.0% of Hong Kong and Toronto respectively lacked training in infectious disease control (68.1% and 73.5% respectively); and this fact was that they were more likely to request more complementary tests, especially doctors Hong Kong (OR 37.8, 95% CI 12.65-113.06).

The perception of the pandemic, both positive and negative factors the same, and agree or disagree with preventive measures is a recurring theme in several of the articles reviewed. So, Tan WM. et al.12 in their study notes that 84% of respondents agreed with the action taken. However when the question focuses only on the medical population, their work is that 72% of doctors say the measures negatively influenced their working day. And 34.6% of them described it as excessive and exaggerated.

Hsu C-C. et al.2 speaks of the lack of confidence of nurses to the pandemic and the preventive measures taken by noting that 71.9% of them showed a general lack of confidence. Also found three factors that this is associated: the greater perceived severity (OR: 0.58 with IC.95% from 0.35 to 0.99), daily performances epidemic (OR: 2.6 IC.95% 1.28-3.98) and number of cases in the community (OR: 2.1 IC.95% 1.13-4.31); in contrast with this, Nickell LA. et al.6 also says in a study conducted during the SARS pandemic, most health workers who took part in the study were as adequate preventive measures taken (74.1% of the sample). The author also mentions in his study of the three negative effects that the pandemic has had as health personnel including financial losses, the feeling of being treated differently by the general population to work in a hospital and the change in the style of personal and family life he had led.

Among the changes in lifestyle, health workers mostly speak during the pandemic try to avoid attending public spaces and avoid contact with family or friends. But not only talk about the negative of the pandemic, workers also found positives in the pandemic, 58% of them reported at least one positive effect. The positive effects most frequently mentioned are feeling greater awareness of disease control (41.1%), the finding of the pandemic as a learning experience (26.4%) and a greater sense of unity and cooperation (23.8%). Associated with these positive effects, especially at greater sense of unity and cooperation are the results found by Wong WCW. et al.19 This author finds that Family Physicians of Hong Kong and Toronto SARS not associated with loss of income, whether either a greater willingness and commitment either by the degree of satisfaction in handling SARS, showing that in both countries were willing to take responsibility and get involved.




In two of the seventeen articles reviewed the risk of contagion and risk perception thereof by the health sector are mentioned. Nukui Y. et al.7 studied the risk of infection during the influenza pandemic among different groups of health workers and finding no increased risk of seropositivity (OR: 5.25) between nurses and doctors as well as pediatric staff, emergency and internal medicine (OR: 1.98). Shiao JS-C. et. al.11 refers to the risk perception of it during the SARS pandemic and gets a 71.9% perceived risk of infection, 32.4% felt that people avoided them for their work and 7.4% seriously considered abandoning his post work.

Joining Vaccination Programs

Three of the nine articles that talk about swine flu vaccination mentioned. Tanto H. Seale et al.9 in their study of vaccination among health care workers in Beijing, and Torun SD. et al.14 in a very similar study but in Istanbul, speak vaccinated similar percentage (25% and 23.1% respectively). In both studies agree that the possible side effects are the most influential factor on adherence to vaccination (61% and 76.1% respectively) Regarding the sector population vaccine more both Torun SD. et. al.14 as La Torre G. et al.4 agreed that the group of doctors vaccinate more compared to the rest (X²: 20,23). Torun SD. et al.14 also objective that 59.9% of doctors recommend vaccination to their patients.

CONCLUSIONS AND DISCUSSIONWe have not found any systematic review published to date that values the behavior

of health professionals in pandemic situations. In our review the level of evidence found according Sign Criteria is three as it is in all cases of cross-sectional studies. So although it does not involve a higher level of evidence provides information on areas for improvement to future health emergencies. Table 10 summarizes the main findings and limitations found in each article and progress found by the authors.




Table 10. Conclusions drawn from the work performed

Evidence Author Ref. Conclusions Limitations Advances

3 Alvaro J. Idrovo et al.

Rev Panam Salud Pública. 2011; 30(4): 361-9.

Response to the epidemic could have been better. Increased need for training in epidemiology

Intstrumento used was designed to assess staff responsabilidadde fi eld epidemiologist

Identifying areas of opportunity to improve the teaching of epidemiology to health contingencies

3 Nukui Y. et al. Infect Control Hosp Epidemiol 2012;33(1):58-62

Seropositivity H1N1 is a risk factor for occupational health personnel

Low levels of seroconversion reduce the power of the study to investigate relationship between exposure and use of PPE

Personal health is a priority group for vaccination against H1N1 because of the high risk of infection

3 Wong WCW. Et al. J. Epidemiol Community Health 2004;58:180-185

General M. changed their clinical practice. They fault isolation measures of suspected cases of SARS spread increased their lack of contingency plan

small sample (representing 3-4% general practitioners). Type of study.

SARS exposed the weaknesses of the health system of Hong Kong and the need to change health policy and clinical practice

3 Seale H. et al. Vaccine 29(2011) 1605-1610

Contrary to previous studies that had reported the high predisposition to receive the vaccine this did not happen

Questionnaire (bias in the interpretation of data) Sample not representative for the rest of population.

Need for nursing staff aware of the need for vaccination

3 Sebahat D. T. et al.

Vaccine 28(2010) 5703-5710

Vaccination against H1N1 is insuffi cient among health care workers.

Type of study, no complete response rate and advanced stage of the pandemic.

Need for training and scientifi c information regarding effi cacy and safety of the vaccine among health workers

3 Shiao J. S. et al. Nurs Etica 2007 Jan;14(1):5-17

During SARS pandemic almost 10% considered leaving their jobs

. 83% response rate. Type of study

It is necessary to provide emotional and professional support nurses during pandemics

3 Vinck L et al. Euro Surveill.2011;16(7)

Excessive workload during the initial 3-5 months of the pandemic. Low levels of anxiety. Low levels of consulting the reference center.

Data collected at 9 months of the pandemic. More doctors than nurses

Impotance of making appropriate plans of preparedness for future epidemics. Need to temporarily increase the workforce.. Improve template training by health personnel

3 Wu Meng T et al. Ann Acad Med Singapore 2010;39:303-6.

Perceived as excessive measures will be accepted if the disease has high mortality rates.

Small sample size Faced with new pandemics whose lethality is unknown implementing preventive measures should be accompanied by important communication explaining the uncertainties of the authorities and benefi ts individual measures

3 Martin S. D et al. Journal of Nursing Management 2011;19(1): 98-108

The family plays an important role in the will to go to work. Having EPIS. Pregnant women should not serve patients suspected / diagnosed infl uenza A.

Low diversity of the sample (race, ethnicity, gender). Mide intention. Biases.

Have appropriate PPE infl uences the willingness to go to work.

3Wong ELZ. Et al. Health Serv. Res. 2010

Apr30;10:107Provide training and counseling increase desposición to go to work.

Type of study, not included marital status and family status. Only community nurses.

Need for training in controlling infection of nefermeria staff.

3 Verma S. et al. ANN Acad Med Singapore 2004 Nov;33(6):743-8

Fear, uncertainty and stigma caused by SARS is associated with psychological distress among general practitioners.

Low response rate. Rating scale stigma of HIV SARS was modifi ed. Type of study.

The psychological needs of healthcare workers should be explored and discussed during periods pandemic.

3 La torre. Et al. Scandinavian Journal of Public Health, 2012; 40: 69-75

Lots of information propagated so chaotic (even a signifi cant percentage of doctors with false beliefs and lack of infection, treatment...)

questionnaire answered by volunteers via internet

Need to take measures for further information and effi cient communication

3 Chih-Cheng Hsu.et al.

Am J infect Control 2006; 34: 176-81

Individual risk perception of nurses and quick update on the information signifi cantly affects levels of professional confi dence (key point success in the deployment of quarantine, 71.9% more than 2 mees of duration of more of epiemia in relation to the real); reports received by nurses seemed outdated because the data were worse still and controlled the outbreak; Lower levels of confi dence in places with fewer cases in the community

survey of nurses closely related to the pandemic and with over 10 years experience and not the rest

The inplantar future effective quarantine of the entire community and the importance that will have this attached to the great challenge in health burden associated with future health education programs.. Elaboration of particitativas future policies in such situations and so these can help control pandemics




Evidence Author Ref. Conclusions Limitations Advances

3 M J Parker. Et al. Emerg Med J 2006, 23: 349-353

eye protection perceived as moderately effective in protecting against SARS and thus was poor compliance. The concern of SARS as a health threat appears to have greater impact in meeting the perceived effectiveness of prevention measures. Discordance between perceived risk and compliance reporting.

Emergency personnel without documenting compliance in real time with SARS measures (reporting bias) study previously validated by small sample to assess objectively. Obtaining the results only pediatric area

Development control equipment less restrictive infections more acceptable for staff; need to study more and understand the psychosocial effects of SARS on hospital staff over time

3 Leslie A. Nkellic. et al.

CMAJ Mar 2. 2004; 170 (5)

2/3 of the person experiencing concern for their health or that of your family. 29% of respondents experienced emotional distress, according to the GHQ-12. Positive aspects of the SARS epidemic: the staff noted an increased awareness of infection control, you can still benefi t from the hospital community in the future. Some respondents found that the situation provided a positive learning experience and a greater sense of unity and cooperation among hospital staff, which can provide an opportunity to continue to build stronger relationships.

low response rate (47%); possible response bias; staff quarantined or outside were not included and may be the most affected; using the GHQ-12 was limited to a portion of the sample; the study was conducted in a large hospital so the results may not be generalizable to other contexts; Financial effects of SARS underestimated (data from the beginning after implementation of control measures)

Increase in future briefi ngs least weekly updated information. Trying to fi nd strategies for hospitals to respond quickly to the concerns of nursing related to their concerns and the patients themselves

3 Tolomiczenko gs.et al.

Journal OF Advanced Nursing, 50(1), 101-110

Differences between groups and pattern of these differences illustrate the impact of polarization and stressful SARS was in a hospital with a small number of probable cases. The clear differences entregrupos defi ned by demographic variables, clinical professions and secondary roles suggest unimpacto SARS epidemic

In 1650 only 1,100 workers had a chance to respond and only 27% answers.

Need for precise implantation of information sources to avoid raising the alarm and false beliefs

3 Wong C. W.. Et al. Am J infect Control 2007; 35: 50-5

Differences between two models perform SARS pandemic showing centralizing or Hong Kong (with its training and resource gaps) or the method of Canadian patients distrivuir all hospitals closing all non-urgent consultation (with consequent epera lists, sanitary chaos and massifi cation of health centers) were the perfect size

participation bias . Need support systems A. P. in the future besides communication and collaboration between these and hospital systems to better control epidemics in the future. Need to establish a mechanism for deploying personnel between institutions

In relation to vaccination among health professionals is demonstrated that seropositivity against H1N1 is an occupational risk factor among health workers (Nukui et al.7) and is therefore a priority group for vaccination of high risk contagion. Despite this vaccination levels are insufficient. You need awareness (Seale et al.9) to health on the need for vaccination and thus must receive training and information science (Torun et al.14) on the safety and efficacy of vaccines as the factors most commonly associated with rejection were concerns about its adverse effects and the belief that the vaccine had not been adequately tested. The acceptance of a new vaccine will be more successful when placed in the context of a pandemic because it is driven by it (Seale et al.9). Not available yet tested vaccine against SARS in humans although there are investigations in animal models.

Another important aspect is the low use by the medical staff of the scientific literature available (Torun et al.14; Vinck et al.16; Wong et al.17 and La Torre et al.4). Although both pandemics WHO, CDC, the Ministries of Health of the countries and health centers themselves have guides available to the management of these diseases were underused. It is essential in the face of new pandemics that health will improve their training and for it to use resources with proven scientific literature evidence to avoid the alarm and false beliefs (Tolomiczenko et al.¹³). This training in epidemiology and health contingencies to be improved since the start of training during the time students (Idrovo et al.³).

In general preventive measures in the two pandemics were well appreciated and followed by professionals. A factor influencing acceptance is the lethality of the infectious agent. So the more lethal than the most effective infectious agent be perceived preventive measures (Parker et al.8 and Tan et al.12 WM). Another factor is the information provided by the authorities both in content and in form. Acceptance would be higher if it were accompanied by good communication explaining the uncertainty of the authorities and the benefits of individual preventive measures (Tan et al.12 WM). This would increase the




use of PPE and its proper use. The monitoring would be greater if the training of health personnel (Vinck et al.16; Nickell et al.6) were improved, health policy and clinical practice (Wong et al.18 WCW) developing more participatory policies (CC Hsu et al.2) and developing control equipment less restrictive infections (Parker et al.8).

In our review we found two articles by Wong WCW18, 19en relation to family physicians and their response to the SARS pandemic. The first explains how the SARS changed clinical practice of family physicians and the second relates how health centers became massive. Family physicians are a key group pandemics since often are the first to come into contact with patients without the means or personal protection measures that exist in hospitals and well ahead of a certain infectious disease that is a trivial process or a more serious case as may be the SARS is not possible by the huge volume of patients and the common presentation of infectious diseases. Thus it is necessary to support primary care systems and improve collaboration between them and hospitals (Wong WCW et al.19).

In many of the articles reviewed reference to the psychosocial impact of the pandemic on health workers and stigma that generates the rest of the population is made. During a pandemic, we have observed that there is an important workload increase has a negative impact on their quality of life, which generates stress, but this is increased if we add the concern spread of health and what more distress them is to infect their families. This makes them think in some cases even leave their job which would bring disastrous consequences for the rest of the population because there would be fewer health personnel willing to work the greater the demand of patients. It is necessary to explore the psychological needs and treat them well as giving emotional support to health workers during pandemics (Shiao et al.11, Verma S et al.15) suitable. Proporcionar EPIS increase their perception of safety and instruct them in the proper handling (Martin et al.5 SD). You also provide training to cope with the increase in labor demand (ELY Wong et al. 17), which would make fewer workers the option of not going to work arise. The workload is a problem we›ve seen in these two pandemics but every year you can see with the arrival of seasonal flu. One solution is to temporarily increase the workforce (Vinck et al.16) at all levels despite the economic crisis or other aspects that influence the refusal to do so.

This review demonstrates that although between SARS and influenza A was several years the problems with the health sector and its modus operandi wrong in some respects and inadequate information provided by the authorities was repeated. We have not found scientific literature on these issues and Ebola, last pandemic that we are living, but have raised the same issues in relation to the lack of information provided by health authorities, inadequate training about the virus and its mechanisms transmission or proper use of personal protective equipment or even the availability of the same in health centers. Also the negative psychosocial effects for staff working in contact with patients have been relevant.

LIMITATIONSThe results of this review are limited by the characteristics of each revised labor

shortages and discussed in all cases of cross-sectional studies with low scientific evidence. Besides the heterogeneity of the studies and the factors studied each not allow firm conclusions on any of the results. Another limitation is that although in both cases are infectious diseases that caused the pandemic can not overlap because it’s different agents with different mechanisms of transmission and lethality and affected different populations.

ACKNOWLEDGEMENTSThe National Library of Health Sciences Health Institute Carlos III by articles and

provided assistance with the literature search. A National School of Occupational Medicine and its director for their assistance in preparing this review.




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