SARS The Toronto Outbreak

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SARSThe Toronto Outbreak

• Allison McGeer, MSc, MD, FRCPC
• TML/Mount Sinai Hospital
• University of Toronto

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Acknowledgements

• MaryAnne Adam, Anne Augustine, Monica Avendano,
  Sylvia Asa,Clare Barry, Sheela Basrur, Ari
  Bitnun, Jim Brunton,Jagdish Butany, Connie
  Butler, Sandra Callery, Adrienne Chan, Robert
  Chua, Linda Davis, Allan Detsky,Sarah Eden,
  Margaret Fearon, Michael Finkelstein, Sandy
  Finkelstein, Donna Foster,Gabrielle Farcas, Wayne
  Gold, Kevin Gough, Effie Gournis, Karen Green,
  Bibi Hacek, Bonnie Henry, Ron Heslegrave, Tammy
  Hwlyka, Grant Large, Fran Jamieson, Ian Johnson,
  Kevin Kain, Hanif Kassam, Ian Kitai, Faron Kolbe,
  Stephen Lapinsky, Wayne Lee, Joanne Levie, Mark
  Loeb, Marie Louie, Mona Loutfy, Reena Lovinsky,
  Lisa Louie, Donald Low, Jim Mahoney,Anne Matlow,
  Larissa Matukas, Tony Mazzulli, Jane MacDonald,
  Margaret McArthur, John McLaughlin, Barbara
  Mederski, Anna Miranda, Christine Moore, Lorraine
  Moss, Margaret Mulholland, Matthew Muller, Vydia
  Nankoosingh, Kylie Nowak, Marianna
  Ofner-Agostini, Consolata OKetch, Kim Parker,
  Shirley Paton, Peggy Perkins, Martin Petric,
  Elizabeth Phillips, Marjolyn Pritchard, Frank
  Plummer, Sylvia Pong-Porter, Susan Poutanen,
  Janet Raboud, Anita Rachlis, Glenna Raymond,
  Elizabeth Rea, Donna Reynolds, Susan Richardson,
  David Rose, Keith Rose, Marnie Saskin, Refik
  Saskin, Damon Scales, Shelly Sarwal, Brian
  Schwartz, Maureen Shandling, Michael
  Silverman,Andrew Simor, Altynay Shigayeva, Andrew
  Smith, Stephanie Smith, Tom Stewart, Irene
  Strickland, Rima Styra, Theresa Tam, Patrick
  Tang, Pat Tamlin, Raymond Tellier, Teresa To, Ken
  Uffen, Leslie Vincent, Monali Varia, Priya Vasa,
  Mary Vearncombe, Tamara Wallington, Sharon
  Walmsley, Stephen Walter, Randy Wax, Diane White,
  Barbara Willey, Bob Williams, Samantha Wilson,
  Brian Wolf, Tom Wong, Barbara Yaffe, Dick Zoutman
  
• Anne Bialchowski, Elizabeth Bryce, Louise Dembry,
  Joanne Embree, Janet Franck, Eleni Galanis, Effie
  Gournis, David Farrar, Margie Foster, Loreen
  Herwaldt, Tobi Karchmer, Dan Lucey,Clifford
  McDonald, Lindsay Nicolle, Andre Pascal, Jan
  Patterson, Trish Perl, Anne Phillips, Connie
  Price, Virginia Roth, Anne Turnidge, Keith
  Woeltje, George Zacharidias
• The staff, visitors and patients of greater
  Toronto area hospitals and public health
  departments and their families

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26 countries 8098 cases 774 deaths
Figure created by Raymond Chow Yuan Zhang for
Christian et al. CID 2004 381420-1427
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The Chinese SARS Mol. Epi Consortium.
www.sciencexpress.org Jan 29, 2004 (supplementary
text available on Science online)
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February 21

• He checks into the Metropole Hotel

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SARS I in TorontoIndex Case

• February 23 A 78 year old woman arrives back in
  Toronto from trip to Hong Kong
• February 25 Develops febrile illness with
  anorexia, myalgias, sore throat, cough
• February 28 Sees MD, given antibiotics
• March 2 Develops shortness of breath
• March 5 Dies at home (presumed heart attack)

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SARS I in TorontoSpread within Household

• Feb 27 - 43 year old son of index case develops
  febrile illness (case 2)
• Admitted to Hospital A March 7th, died March 13th
• March 3 to 12 all of index cases other
  household contacts develop illness
• 24 year old daughter in law, 5 month old
  grandson, 34 year old son, 79 year old husband

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SARS I in TorontoFirst spread outside household

• March 5th Daughter of index case, who had
  visited her mother while ill, develops SARS
• March 9th Family MD who saw 3 ill family
  members on March 6th develops SARS
• March 10th, 13th Two patients (cases 8 and 9)
  who spent time in ER observation area with (Case
  2) on March 7/8th develop SARS

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SARS in Toronto Spread at Hospital A - I

• March 9-11 From case 2 and ill family to 5
  staff
• March 11-14 From case 9 to at 36 hospital
  staff, students, patients, visitors at two
  hospitals
• March 16 From case 8 to two paramedics, one
  firefighter, four ER staff, one anaesthetist
• March 16 From case 8s ill wife to 8 ER
  visitors, 5 patients, 8 staff members, 1
  volunteer

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Mr. Ps wife
Mr. P
19 persons
5 persons
Mr. D
Index Case
Case A
(Mother)
(Son)
Family MD
Feb 21
March 7th
March 12
March 16th
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March 16 Jurisdictions involved

• Ontario 5 local public health units
• 6 hospitals (8 sites)
• 2 Provinces Ontario / British Columbia
• Six potentially infectious patients with
  international air travel

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March 15-21st

• Follow up
• 3 exposed HCWs, 1 patient identified with illness
• Three travel related cases (Ontario)

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March 16-21st

• Continuing follow-up
• Daily hospital rounds/ active surveillance of
  ICU, ER staff, request for reporting of febrile
  respiratory illness from all hospital
• No new cases identified
• March 20th - ?febrile staff on medical ward
• March 21st, evening
• 7 febrile staff identified
• Decision to fan-out message to report febrile
  illness
• 35 febrile staff seen (30 probable, 4 confirmed)

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March 25th

• Unexplained transmission at Hospital A
• High risk of transmission elsewhere
• Supply of airborne isolation rooms exhausted
• Provincial emergency declared

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Outbreak management

• Only essential staff in hospitals
• No volunteers, students, contract workers
• No visitors (except compassionate)
• Screening of everyone entering hospital to rule
  out illness
• Staff, visitors, patients
• Barrier precautions at all times
• Quarantine for all potentially exposed persons

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SARS in Ontario
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SARS in Ontario

• 358 cases
• 44 patients died
• 23,103 persons quarantined
• 316,615 calls to Toronto Public Health
• 1.13 billion

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SARS in Ontario
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• Despite the eventual success in containing SARS,
  so many things went wrong in the public health
  response that it is difficult to know where to
  start.

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SARS Summary impressions

• Control of the outbreak was likely slowed by the
  Public Health response
• lack of knowledge of transmission in healthcare
  settings
• Unwilling to use healthcare epidemiologists to
  manage outbreak
• Lack of a single outbreak chieftain
• Tremendous distrust of the public health sectors
  by the scientific, academic and medical community
• The outbreak was managed politically--not
  medically

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SARS in Toronto What have we learned? - I

• Any disease is only a plane ride away
• Pathogens dont recognize political borders

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SARS in Toronto What have we learned? II

• Reporting limitations
• Lack of knowledge
• Inability to see the forest from the ground
• Absence of incentives/presence of deterrents
• Determining what information needs transmittal
  not possible a priori
• Culture

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SARS in Toronto What have we learned? III

• Science and politics
• We failed to use evidence effectively
• We failed to accumulate evidence as needed

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If you think preparedness is expensive, try
disease

• Mary Lasker
• (paraphrased)

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Acknowledgements

• Monica Avendano, Sylvia Asa, Sheela Basrur, Jim
  Brunton,Jagdish Butany, Connie Butler, Sandra
  Callery, Adrienne Chan, Robert Chua, Linda Davis,
  Allan Detsky,Sarah Eden, Margaret Fearon, Michael
  Finkelstein, Sandy Finkelstein, Donna
  Foster,Gabrielle Farcas, Wayne Gold, Kevin Gough,
  Effie Gournis, Karen Green, Bibi Hacek, Bonnie
  Henry, Ron Heslegrave, Tammy Hwlyka, Grant Large,
  Fran Jamieson, Ian Johnson, Kevin Kain, Hanif
  Kassam, Faron Kolbe, Stephen Lapinsky, Wayne Lee,
  Joanne Levie, Mark Loeb, Marie Louie, Mona
  Loutfy, Reena Lovinsky, Lisa Louie, Donald Low,
  Jim Mahoney, Larissa Matukas, Tony Mazzulli,
  Clifford MacDonald, Jane MacDonald, Margaret
  McArthur, John McLaughlin, Barbara Mederski, Anna
  Miranda, Christine Moore, Lorraine Moss, Margaret
  Mulholland, Matthew Muller, Vydia Nankoosingh,
  Kylie Nowak, Marianna Ofner-Agostini, Consolata
  OKetch, Kim Parker, Shirley Paton, Martin
  Petric, Elizabeth Phillips, Marjolyn Pritchard,
  Frank Plummer, Sylvia Pong-Porter, Susan
  Poutanen, Janet Raboud, Anita Rachlis, Glenna
  Raymond, Elizabeth Rea, Donna Reynolds, Susan
  Richardson, David Rose, Keith Rose, Marnie
  Saskin, Refik Saskin, Damon Scales, Shelly
  Sarwal, Brian Schwartz, Maureen Shandling, Andrew
  Simor, Altynay Shigayeva, Andrew Smith, Stephanie
  Smith, Tom Stewart, Irene Strickland, Rima Styra,
  Theresa Tam, Patrick Tang, Pat Tamlin, Raymond
  Tellier, Ken Uffen, Leslie Vincent, Monali Varia,
  Priya Vasa, Mary Vearncombe, Tamara Wallington,
  Sharon Walmsley, Stephen Walter, Randy Wax, Diane
  White, Barbara Willey, Bob Williams, Samantha
  Wilson, Brian Wolf, Tom Wong, Barbara Yaffe, Dick
  Zoutman
• Anne Bialchowski, Elizabeth Bryce, Louise Dembry,
  Joanne Embree, Janet Franck, Eleni Galanis, Effie
  Gournis, David Farrar, Margie Foster, Loreen
  Herwaldt, Tobi Karchmer, Dan Lucey, Lindsay
  Nicolle, Andre Pascal, Jan Patterson, Peggy
  Perkins,Trish Perl, Anne Phillips, Connie Price,
  Virginia Roth, Anne Turnidge, Keith Woeltje,
  George Zacharidias
• The staff, visitors and patients of greater
  Toronto area hospitals and public health
  departments and their families