IV. INTERNATIONAL CASE STUDIES
Source: Univ. of Louisville
A. Canada 2003
Canada was among the countries hardest hit by SARS. Only the People’s
Republic of China, Hong Kong, and Taiwan had more probable SARS cases. Toronto was the Canadian city most affected the outbreak.127 The first (index) SARS case in Toronto was a 78-year-old woman, Mrs. K, who returned home to Toronto on February 23, 2003 from a trip to Hong Kong to visit relatives. Mrs. K, who was never hospitalized, died on March 5 after the onset of an illness later determined to be SARS.
Her son, Mr. T, became ill on February 27, was admitted to Scarborough Hospital (Grace Division) on March 7, and died on March 13.128 Transmission of SARS traceable to Mrs. K is thought to have included 224 other persons in Toronto alone. In all of Canada, there were 438 SARS cases, including 251 probable (1 active) and 187 suspect (0 active) cases.129 All of the probable cases were reported in two provinces, Ontario, which includes Toronto, and British Columbia. Suspect cases were reported in four other provinces (Alberta, New Brunswick, Prince Edward Island, and Saskatchewan).
In an apparent (but in retrospect, premature) sign that the SARS situation had stabilized, Premier Eves of Ontario lifted the SARS provincial emergency on May 17, stating that “Toronto, and Ontario, are safe places to live, work and visit.”130 Unfortunately, on May 23, the second phase of the SARS outbreak began. Opinions differ about the capability of the Canadian government to respond to SARS or other SARS-like outbreaks. As one commentator stated, “I have a concern about whether or not in the long run our public health-care system will be able to meet the demands placed by new illnesses like SARS…. [N]o one is directly accountable or responsible for public health.”131 Concerns like this may be related, in part, to the decentralized nature of Canadian public health governance, with authority formally delegated to a multitude of federal, provincial, and local entities.
b. Use of quarantine and isolation
On March 25, 2003, in the face of a rising number of SARS cases in the Toronto area, the Ontario government took the critical step of designating SARS as a reportable, communicable, and virulent disease under the province’s Health Protection and Promotion Act, which authorized public health authorities to issue orders to detain and isolate persons for purposes of preventing SARS transmission.236 Eventually, about 30,000 persons in Toronto were quarantined. That number is similar to the number of persons who were quarantined due to the SARS outbreak in Beijing, China, but for the latter the number of probable SARS cases (2,500) was ten times larger than Toronto’s (about 250).237
Health facilities. The first use of isolation in Toronto occurred early in the SARS outbreak, when the physician treating the index case’s son, Mr. T, had Mr. T placed in hospital isolation for suspected tuberculosis (at no time before Mr. T’s death was his 55 SARS established) and requested that other family members isolate themselves at home as they, too, might be at risk for tuberculosis infection.238 Unfortunately, these control measures occurred too late to contain the spread of SARS in Toronto. Mr. T, who had entered Scarborough Hospital through the emergency department, was left in the
emergency department for 18-20 hours despite a physician’s hospital admission order, and only later admitted to the hospital’s Intensive Care Unit (ICU). When he was finally examined by a physician, a tuberculosis isolation order was issued and Toronto Public Health was notified as a routine matter of a possible tuberculosis case. During Mr. T’s long wait in the Scarborough Hospital emergency department for admission to the ICU and his short time in the ICU before tuberculosis was suspected, other patients and staff were exposed to SARS.
At the time there was no indication that these individuals were at risk of contracting or spreading any communicable disease, let alone SARS. When tuberculosis was ruled out and public health officials and physicians began
to understand the implications of Mr. T’s case, steps were taken to remove other members of Mrs. K’s family, some of whom were reporting illness, to negative pressure isolation rooms in other area hospitals. These steps undoubtedly limited the spread of SARS. Combining the information from the WHO’s international health alert for atypical pneumonia with reports of the Scarborough Hospital cases, both Toronto Public Health and provincial public health authorities activated their emergency response plans.
A “Code Orange” (which required all area hospitals to go into emergency mode) was issued, under which area hospitals were required to suspend non-essential services, limit visitors, issue protective equipment for staff, and establish special isolation units for “potential SARS patients.” Asymptomatic contacts of SARS patients were not isolated within health facilities, but were asked to adhere to a 10-day home quarantine.
The risk of acquiring SARS was greatest for persons (staff, patients, and visitors) within rather than outside of health care facilities, including doctors’ offices; health care workers accounted for over 40% of all SARS patients in Toronto.244 Tragically, the early SARS patients who were seen in health care facilities were simply not identified in time to implement more rigorous infection control procedures. Moreover, it is not clear that health care workers were always provided with uniform or consistent advice or guidelines regarding the quarantine or isolation of persons with or suspected of having SARS, that adequate protective equipment was provided to health care workers within these hospital or clinic settings, or that health care administrators or workers were diligent about adhering to infection control precautions or procedures. Concerns about a lack of uniform guidance for quarantine were expressed by an ad hoc Scientific Advisory Committee of volunteer experts, which found that “different public health units seemed
to have different thresholds for the use of quarantine.”
Directives issued by Ontario health authorities instructed hospitals to isolate all patients with fever and respiratory symptoms in the hospital or in the hospital emergency department until SARS had been ruled out. Most hospitals took special precautions for inpatients with respiratory symptoms suggestive of infectious diseases.
In Phase I of the Toronto SARS outbreak (March 13-25, 2003), over 20 Toronto area hospitals admitted and cared for SARS patients. No single facility was designated as a “SARS hospital,” because both provincial and Toronto area officials feared that such a step would overwhelm the facility so designated. For this reason, capacity for SARS clinical management, including isolation of SARS patients and adequate infection control measures, was built into multiple facilities throughout the Greater Toronto area. Two hospitals (Sunnybrook and Woman’s) in the Greater Toronto area appeared to carry the largest volume of SARS patients during Phase I. Unfortunately, many of these two hospitals’ physicians with relevant expertise or experience in SARS clinical management were themselves ill or in quarantine. Despite the hospitals’ requests for staff support, other Toronto area hospitals were either unable or unwilling to provide assistance. Needed support was obtained only after provincial authorities retained a private placement agency to help with recruitment of health care workers.
In Phase II of the Toronto SARS outbreak (May 23-June 30, 2003), four hospitals (later termed the SARS Alliance) were designated as SARS facilities. The “Code Orange” described above for Toronto area hospitals was later extended to all Ontario hospitals, meaning they, too, were required to suspend non-essential services, limit visitors, create isolation units for SARS patients, and issue protective equipment (gowns, masks, and goggles) for exposed staff. Some concern was expressed over whether the Code Orange was justified or overly broad
Airports, ports and other entry points. No persons in transit into or out of Canada were actually quarantined or isolated, although clearly the federal government has the authority to take such measures in appropriate cases. In 2002, Health Canada transferred its airport quarantine responsibilities to the Canada Customs and Revenue Agency, but at the time of the SARS outbreak, neither Health Canada nor the Customs and Revenue Agency appeared prepared to discharge their quarantine responsibilities under the federal Quarantine Act Regulations, which soon after the SARS outbreak in Canada had been amended to include SARS.248 For ships, particularly cruise ships, Health Canada’s protocol for handling SARS cases was not released until mid-June, after the SARS outbreak had begun to fade.
SARS screening for airline passengers took place at Canadian airports, but this screening relied primarily upon information cards that were distributed to and completed by both incoming and outbound passengers. In-person screening questions and secondary assessments were conducted only as needed. Thermal scanners were used in a pilot project at the Toronto and Vancouver (British Columbia) airports. As of August 27, 2003, 6.5 million screening transactions had taken place at Canadian airports, with about
9,100 passengers referred for further SARS assessment by screening nurses or quarantine officers. None of the passengers who underwent further assessment was found to meet the criteria for a probable or suspect SARS case. The pilot thermal scanner screened 2.4 million passengers, with 832 referred for further assessments, and none met the criteria for a probable or suspect SARS case.
Workplace and home quarantine. In Toronto, home and workplace quarantines were often imposed for what were definitive “contact” cases, meaning cases in which persons were known to have been in close physical proximity to a probable SARS case 57 with inadequate or no protection from possible exposure. Contact cases included family and household members of SARS patients, hospital visitors and other non-SARS patients within hospitals who may have been exposed to SARS patients, health care staff who
provided treatment to SARS patients without adequate protective equipment, and persons at workplaces who may have been exposed to co-workers with SARS. Provided they were timely identified and contacted, these persons were urged to remain at home for a 10-day period, with monitoring, usually by telephone, by a local public health worker.