with staff. Outside communication was available by telephone and, in some cases, by email. As a result, patients with mild symptoms complained of boredom and loneliness. The most prominent symptoms were fever, myalgia, cough and fatigue. Patients were treated with ribavirin, often in combination with corticosteroids. Doses of ribavirin varied between 1.5 g and 4 g daily. A typical course was a 2-g intravenous loading dose, followed by 1 g intravenously every 6 hours for 3 days, followed by a lower dose (e.g., 500 mg every 8 h) for 4 more days. Patients were switched to oral dosing when tolerated. Ribavirin caused uncomfortable side effects, especially nausea. Insomnia was common as a result of treatment with corticosteroids, anxiety, physical discomfort and hospital routines. In the absence of specific laboratory tests to indicate disease progression, each patient’s temperature was monitored carefully by staff and patients. Several patients who experienced waxing and waning anxiety throughout their stay in hospital reported that peaks of anxiety coincided with feeling feverish or learning of an elevated temperature. One patient with a pre-existing panic disorder experienced episodes of panic during spikes of fever. Other patients reported feeling discouraged and frightened by the return of fever after an afebrile period. Most expressed sadness about missing their loved ones. Concern was expressed by health care worker patients about the infectious risk to staff caring for them. Fear of the potential lethality of the illness and anger because their risk of infectious exposure had not been recognized earlier were voiced less often than other concerns. Impact of SARS CMAJ • MAY 13, 2003; 168 (10) 1247 Table 1: Events involving unprotected exposure to suspected SARS cases in Mount Sinai Hospital, Toronto Event Approximate no. of staff quarantined No. of SARS cases among quarantined staff Undiagnosed case in ICU 65 6 Emergency department exposure 25 0 Exposure to infected member of infection control team 6 0 Failure of an employee to disclose exposure when screened 3 0 Note: SARS = severe acute respiratory syndrome, ICU = intensive care unit. Family members at home found it difficult that they could not provide direct support to their sick relative by visiting. Child care issues for single parents with SARS who had children in quarantine and management of pre-existing marital tensions were recurrent difficulties. Patients without SARS Hospital inpatients without SARS were concerned about becoming infected. Restrictions on transfer to other institutions, cancelled procedures, the need for quarantine upon discharge or delayed discharge were common frustrations. Patients deprived of family visits experienced insomnia, anxiety and interpersonal friction with staff. Limited access to external resources resulted in difficulty obtaining items that would usually provide comfort, such as books, music and toiletries. Asian patients reported stigmatization and racist reactions in the community, because the outbreak was thought to have originated in China. Health care workers The SARS outbreak and the public health response to it substantially changed working conditions. The perception of personal danger was exacerbated by uncertainty. Modification of infection control procedures and public health recommendations day by day, and sometimes hour by hour, increased uncertainty. The perception of personal danger was heightened by the known lethality of the syndrome and intense media coverage of the outbreak and its effects (e.g., “Hospital masks are in short supply” — Toronto Star, Mar. 29, 2003). Staff members were discouraged from interacting outside the hospital with colleagues and staff meetings were discouraged, at a time at which people wished to seek each other out for support. Eating and drinking, which require removing a mask, were done alone or outside the hospital. As face-to-face communication became more difficult, email was used extensively. Maunder et al 1248 JAMC • 13 MAI 2003; 168 (10) 2: Infection control timeline at Mount Sinai Hospital, Toronto Date, 2003 Measures taken March 26 • ICU was closed to admissions, discharges and transfers