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Toronto Public Health, Ontario, Canada

Friday, June 22nd, 2007

Bruce Gardham, Senior Librarian for Toronto Public Health in Ontario, Canada, discusses his personal experiences with the SARS epidemic in 2003 and the special library.

Interview date: June 22nd, 2007


(1.) What happened in your community (i.e., what was the disaster/emergency)?

The SARS (Severe Acute Respiratory Syndrome) public health emergency in Toronto began on February 23, 2003. A woman returned to Toronto after visiting Hong Kong. She had stayed on the same floor of a hotel with an infected person. She got sick and went to her doctor who diagnosed the flu. She went home and died. Then her son got sick and ended up in hospital before dying as well. The person who shared his hospital room got sick. And then that person’s spouse got sick too. The outbreak infected 257 persons in Toronto’s hospitals, occurring in two separate waves. The emergency lasted until the end of June, 2003.

The hospital realized that they had a highly infectious case on their hands and Toronto Public Health started mobilizing. Initially there was a lot of tension and fear. But, not as much as you would expect. A great media system helped. Dr. Sheela Basrur, the Medical Officer of Health for the City of Toronto, was also an extremely capable leader. She worked very hard to keep the population calm.

Everything happened so fast and information constantly needed to be updated. Patients being transferred between hospitals aided the transmission of the disease. Also, it was very common for nurses to work in multiple hospitals and they were traveling back and forth through the infected zone. In the end, more than 23, 000 people had to be quarantined to control the spread of the disease.

(2.) How did the library respond? How did the librarian respond? Were there non-traditional (unusual) roles that the librarian performed?

The Toronto Public Health Library wasn’t very involved in the response to the first wave. I supplied some information that was coming out from The New England Journal of Medicine and The Lancet. Toronto has a pretty tight community when it comes to the medical library field and I knew that hospital librarians were not working in their traditional roles. They were deployed to the front entrances of the hospitals to screen people, take temperatures. During a Code Yellow, all hospital personnel are deployed and whole sections of the hospitals are closed off. All personnel, including the librarians, were deployed to screen.

During the first wave, we monitored journals that were starting to publish electronically. Our library liaison in the government was corresponding with officials. But, in the Public Health Library we didn’t even get asked for anything before people started thinking the whole event was over. And then the second wave hit.

Toronto Public Health had set up an information hotline during the first wave. It wasn’t until the second wave that the managers of the hotline realized they had a problem organizing the information. I was called in to help.

The hotline workers (45 public health nurses) all used these big binders to help them answer the wide variety of questions that were coming in from the public. The binders used in the first phase of the outbreak were not updated before being pressed into service for the second wave. The binders each had three sections with many chapters. The information had been gathered as the staff members went along and attempted to answer the questions that came up. But, there were literally thousands of questions.

When I was assigned to the hotline area. No one knew what information they had or what was right. Information was changing hourly and daily. Public briefings were happening all the time. There were lists of deaths, outbreaks, quarantines, etc… Instructions were issued by the Public Health Department and the hotline number was distributed by the media. Any piece of information released by the media would cause a flood of phone calls. As soon as an outbreak was reported, people wanted to know if they had been exposed. We had to know exactly where each outbreak was located and where the person had been. The entire situation demanded current, accurate data to be distributed to the hotline workers. There were so many calls that — at one point — Public Health was preparing to requisition major call centers if the numbers increased any more.

The first problem was updating the binders. I worked with a public health nurse who had been manning the phones since the beginning. We worked to take out all of the old information. The process I adopted for updating these binders was based on loose-leaf processes used mainly for law library materials Each binder included a master index and ten sections. They were:

  1. Phone Log-in Instructions
  2. What is SARS?
  3. Process for Dealing with SARS Calls
  4. Contact Follow-up and Documentation Forms
  5. Mask Information / Sanitizing with Bleach
  6. Information Regarding Discharged Patients
  7. New / Communication Updates / Travel Advisories
  8. Medical Information for Hospitals
  9. Travel Advisories
  10. Helpful Telephone / Addresses / Websites

I maintained the master binder and there were regular checks to make sure the other 35 binders were the same as the master copy. It took a couple of days to organize the binders.

Then, we began the system of adding updates. Hotline managers attended meetings at about the same time every day. After the meeting, daily updates would be added to the binders. Urgent updates were added as soon as the information was received. The phones were manned every day from 8:30 am until 11:00 pm. There were day and night shifts, but more people worked in the day than during the evening. It would become a problem if someone missed an update. Discrepancies between information resources were also a problem; and there was a lot of information confusion during the emergency. And sometimes small format changes (the date for example) would result in serious problems. All of these discrepancies had to be accounted for before any updates could be distributed to the hotline.

Larger problems in disseminating information were due to Toronto being such a multicultural city. After the fact, I heard from some Chinese friends. They all watch Hong Kong television and were completely in the dark when it came to local public health notices. 110 languages were being spoken in Toronto, but the hotline and the Toronto Public Health website was only translating into six. Even then, it was difficult to have staffing to ensure that all six languages were covered in any given shift.

My role wasn’t conducting typical library work. Public Health had their own information sources so they weren’t coming to the library. Organizing the binders for the hotline was more about my general skills. I was filling a practical role keeping information organized, maintaining an information network and dealing with people. Toronto Public Health was significantly affected as an organization. Many workers were quarantined or had relatives in the hospitals. Areas were closed and it was difficult to get information. As a librarian, I had experience working with people and it helped tremendously.

(3.) How has the library (or the services provided) changed as a result of these events?

After the fact, I worked to evaluate the effectiveness of the binders and wrote a report with recommendations. Some of my recommendations include the following:

  1. A communication binder or manual be produced which would act as a template for future hotline operations. This should include an orientation manual for staff.
  2. An evaluation be carried out on the types of questions coming into the hotline to determine the information needed.
  3. Keep a log of the types of questions fielded by managers and team leaders to ascertain the problem area which may be addressed by having that information in the binders or an electronic system.
  4. All communications produced exclusively for the binder or database has section numbers for the headers, date and time of issue. Time is important since during a single day materials could be issued three times and time is the only way to ascertain the latest version of a document.
  5. Subject indexing be adopted for binder materials using reference manager software. Controlled language subject indexing would have helped to locate materials faster. Subject indexing should be incorporated for any electronic database constructed to handle future hotline communication materials.
  6. Keyword searching is not the best answer to subject access as keywords are produced from titles of documents or the full text of a document. Such keywords may not always reflect the genre of the document or be too confusing to an individual trying to locate information quickly. Subject descriptors would have to be assigned by an information officer or health professional using an authority file.

I also examined the information discrepancies and created a SARS Information Discrepancy Table. My main recommendation was for the creation of an Information Liaison Control Officer to manage the flow of information.

The SARS outbreak in Toronto was the first major outbreak of an illness in our area to happen since the 1950s and 1960s. It really shook people up and a lot of plans were made after the fact. But, disaster planning has really fallen off the radar since. And there is still a lot more we could do.

For example, I really feel that better contact should be established with the non-English speaking communities in Toronto. If another disease outbreak occurred in the area, we could have real problems communicating with these groups. I also think that we need to have a better handle on the social services and agencies in town and how they work. In another disease outbreak situation, this information needs to be at our fingertips.

And there was definitely a need for better access to detailed, military maps. People were calling who had been in a certain section of the building. We needed to see where exactly the outbreak happened and how close they were to it. That kind of building information wasn’t always accessible at the time it was needed.

The library started getting reference questions about SARS after the emergency died down. Suddenly, all of these people were writing reports. I started to assemble what is now that most comprehensive collection on SARS; we probably have every single book ever published on the disease.

The experience made me think about information access in a disaster. I started asking: How would we have access to the electronic information if everything falls apart? What are the core areas? What do we need to have in print? It made me realize that certain things should always be collected in paper. For example, I still buy the new print editions of the CPS (Compendium of Pharmaceutical and Specialties) even though there is an electronic edition available.

(4.) What, in your opinion, are the roles for libraries (and librarians) in disaster planning, response and recovery efforts?

For the library, we developed a specialized collection on SARS. It is one of our roles now to help other institutions, communities, hospitals, libraries, etc… with their information needs on the subject.

But, most of the roles are for the librarian as an individual. In my recommendations, I outlined the needs for an Information Control Officer. I see the librarian’s role as aiding information flow and working between the administrative levels. I can even see an information officer needed on every floor. We need to help our organizations understand how information should be presented, to stress the importance of continuity (in date formats, for example). It was a corporate standard in the city of Toronto not to put a date on websites. This standard had to be changed. Little things make a big difference in an emergency situation because little details have to be confirmed.

Another role for the library is being involved in the community. Sharing vital information with the public will be very difficult in an outbreak situation, especially in the large, multi-cultural city centers. Librarians have to be aware of the whole community and have contacts that they can call on in an emergency.

The following documents were submitted by Bruce Gardham:

Binder Inventory and Audit Control Sheet: binder-inventory-and-control-sheet

Hotline Information Liaison & Co-ordination Officer Report : information-liason-and-co

Toronto Public Health Library Bibliography on SARS: sars-bibliography