SARSSARSThe Toronto OutbreakThe Toronto Outbreak

Allison McGeer, MSc, MD, FRCPCAllison McGeer, MSc, MD, FRCPC

TML/Mount Sinai Hospital TML/Mount Sinai Hospital

University of TorontoUniversity of Toronto

2

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 O’Ketch, 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

Figure created by Raymond Chow &

Yuan Zhang for Christian et al. CID 2004; 38:1420-1427

26 countries

8098 cases 774 deaths

4The Chinese SARS Mol. Epi Consortium. www.sciencexpress.org Jan 29, 2004 (supplementary text available on Science online)

February 21

• He checks into the Metropole Hotel

9

SARS I in Toronto:Index 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)

10

SARS I in Toronto:Spread 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 case’s other household contacts develop illness

•24 year old daughter in law, 5 month old grandson, 34 year old son, 79 year old husband

11

SARS I in Toronto:First 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

12

13

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 #8’s ill wife to 8 ER visitors, 5 patients, 8 staff members, 1 volunteer

Index Case Case A

Mr. D

(Mother) (Son)

Mr. P

Mr. P’swife

19 persons

5 persons

Family & MD

Feb 21 March 7th March 12 March 16th

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

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

March 15-21st

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)

March 25th

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

• Provincial emergency declared

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

0

2

4

6

8

10

12

14

16

18

20

Date of Onset

Number of Cases

SARS in Ontario

SARS in Ontario

• 358 cases

• 44 patients died

• 23,103 persons quarantined

• 316,615 calls to Toronto Public Health

• $1.13 billion

0

2

4

6

8

10

12

14

16

18

20

Date of Onset

Number of Cases

SARS in Ontario

23

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.

24

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

SARS in Toronto What have we learned? - I

• Any disease is only a plane ride away

• Pathogens don’t recognize political borders

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

SARS in Toronto What have we learned? – III

• Science and politics– We failed to use evidence effectively

– We failed to accumulate evidence as needed

If you think preparedness is expensive, try disease

Mary Lasker

(paraphrased)

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 O’Ketch, 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