Control of Hospital Infection during the SARS Outbreak in Ontario, Canada February

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Control of Hospital Infectionduring the SARS
Outbreakin Ontario, CanadaFebruary August,
20032003 Asia Pacific Inter-City SARS
ForumTaipei, September 2003

• Dr. Colin DCunha
• Commissioner of Public Health, Chief Medical
  Officer of Health and Assistant Deputy Minister
• Ontario Ministry of Health and Long-Term Care

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Presentation Outline

• SARS in Ontario
• Inter-City Experience The Greater Toronto Area
• Control of Hospital Infection
• Preparedness / Protocols
• Implications and Lessons Learned
• Planning for the Future

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Ontario, Canada

• Twice as large as Thailand and ¼ of India
• 30 x larger than Taiwan
• Population 12 million
• Capital Toronto

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OntarioMap
Manitoba
Quebec
Minnesota
Michigan
New York
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Toronto, Ontario

• Largest city in Canada
• GTA population 5.1 million
• Multi-ethnic (about 50 immigrants more than 100
  languages spoken)

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Onset of SARS Outbreak in Ontario
Hong Kong
Index Case
Toronto
Household transmission
Nosocomial transmission
Toronto Hospital (Mar. 7/03)
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SARS Experience in Ontario
Introduced to Toronto by a traveller to Hong Kong
Transmitted to a family member the latter
admitted to Toronto hospital
23-Feb.
Last week of Feb. to first week of Mar.
HouseholdNosocomial Transmission
Phase I 257 cases 136 Probable, 121 Suspect
Nosocomial Transmission
Last week of May

• Phase II 118 cases
• 111 Probable, 7 Suspect

Outcome 331 recovered, 44 died
12-Jun Last Onset
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SARS Cases in Ontario by Case Status and Phase
n 375
Phase 1
Phase 2
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SARS Cases Reported by Health Units
Suspect 128
Surrounding Regions
Probable 247
39
City of Toronto
61
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Hospitalization and Case Fatality DataProbable
and Suspect SARS Cases
Deceased
239
117
27
17
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Initial Actions
Feb. 19

• Ministry alerts healthcare providers
• Index hospital closed
• SARS becomes reportable disease
• Quarantine measures instituted
• Provincial emergency declared
• Directives for contact, droplet, airborne
  precautions instituted provincially

Mar. 28
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Response by the Ontario Government

• Provincial Operations Committee
• Provincial directives to hospitals, health units
• Coordination of resources
• Daily media conferences and reports

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Outbreak Management by Public Health Branch

• Set up SARS teams
• Conferences to discuss cases
• Routine dissemination of information
• Developed policies directives through Science
  Committee
• Dedicated space, staff, communication lines
• Hired / seconded / borrowed staff on short-term
  contracts

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Inter-City Response Toronto Public Health Unit

• Hotline
• Case management
• Contact follow-up
• Epidemiology team
• Staff commitment

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Nosocomial Outbreak in Toronto Area Hospitals
Source Toronto (Scarborough Grace) Hospital
H
H

• Other Toronto Hospitals
• Mount Sinai
• North York General
• Scarborough General
• Saint Johns
• Sunnybrook
• Toronto General
• West Park

H
H
H
H
H
H
H
H

• Other Regional Hospitals
• Markham-Stouffville
• York Central

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Infection Control in Hospitals

• Enhanced infection control measures throughout
  the hospitals
• Creation of contained SARS wards
• New directives for patient transfers and visitors
  
• Work quarantine for selected healthcare staff
• Limiting the number of healthcare settings in
  which staff can work
• Curtailing other health services

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Enhanced Infection Control Measures in Hospitals

• Wearing of personal protective equipment
• (masks with fit- testing, gowns, eye-gear,
  gloves)
• Screening patients at all points of entry
• Temperature check on arrival
• Completion of form indicating symptom and travel
  information
• Outpatients positioned more than one metre (3
  feet) apart
• Phone-screening for outpatients prior to
  appointment
• Banning all visitors (except on compassionate
  grounds)

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Outbreak Control Measures

March 14
March 28

• Directives for contact, droplet, airborne
  precautions instituted province-wide

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• Isolation an contact follow up measures
  recommended

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• Suspension of admissions, and emergency and
  non-urgent services at index hospital
• Hospital closed to new patients and visitors
• All discharges since March 16 contacted and
  followed-up

March 25
4

• SARS becomes reportable, virulent, communicable
  disease

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Protective Equipment Hospital Policy
Hospital Area N 95 Mask Gloves Alcohol Gowns Goggles Face Shield Hair Cover Shoe Cover Comments
Contacts with SARS unit patients
Screeners (at all entrances) Use alcohol every 30 min.
Departments (e.g., ICU, emergency) staff
High risk procedures (i.e., intubation, bronchoscopy) Stryker suits when needed
Emergency patients visitors
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Infection Control During Intubation Procedure

• All HCWs used personal protective equipment
  (PPE)
• Negative pressure in intubation room
• Deficiencies
• No anteroom available
• Masks not fit-tested
• Inappropriate removal of PPE stages varied

Emerging Recommendation
1. Gloves
2. Mask
3. Goggles
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Infection Control PracticesPersons Under
Investigation

• Use of surgical mask while investigating cases,
  or would-be cases
• Isolation separately from other SARS patients
• Negative pressure room with separate washroom
  facilities
• Accompanying persons should wear surgical mask,
  or N95 mask

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Infection Control Recommendations Probable and
Suspect

• Droplet and Contact Precautions
• Gloves, gowns, eye protection (goggles and/or
  face-
• shield)
• Hand-washing
• Airborne Precautions
• Negative pressure isolation rooms (where
  available)
• N95 respirator or equivalent
• Minimize number of people in room during high-
• risk procedures

1
2
3
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SARS Cases and Persons under Quarantine
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Implications

• Estimated cost over C1 billion (US ¾ billion)
• Hospital and ward closings, including Canadas
  largest trauma centre
• Cancellation of elective surgeries and treatments
  
• Restrictions on patient transfers
• New, stricter, province-wide standards for
  screening

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Positive Experiences

• Establishing control centres provincially and
  locally with dedicated staff, space,
  communication lines
• Public health call centre 24/7 to provide advice
  to hospitals and physicians
• Mutual support among health units to share
  resources
• Daily conference calls among health units
  health ministry

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Lessons Learned Immediate Needs

• Re-evaluation of infection control and screening
  practices
• Acquisition and use of appropriate Personal
  Protective Equipment
• Preparation and Planning
• Surveillance
• Emergency response plan

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Opportunities to Improve Preparedness

• Leadership and Coordination
• Resources / Surge Capacity
• Communication
• Enhanced Surveillance
• Skill Enhancement of CD Staff

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Improvement Areas (continued)

• Resource Capacity
• Contingency staff at local level dedicated to
  SARS
• Capacity for other mandatory public health
  programs
• Communication Demands
• Effective processes
• Multi-jurisdictional communication
• Clarified roles and responsibilities
• Information technology
• Addressing the lack of public health
  info-structure

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Planning for the Future

• Ongoing epidemiology centre
• Policy coordination capacity
• Ongoing Public Health call centre with 24/7
  coverage
• Mobile response teams to assist Health Units in
  time of outbreaks
• Additional Public Health field staff
• Strengthened laboratory capacity
• Public education

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Food for Thought
The key was the early decision by public health
officials to provide reliable and regular
information to the public. By establishing
public trust, they prevented uncontrollable
anxiety, fear and panic from sweeping the city.

John Service, Executive Director Canadian
Psychological Association Toronto Star, May 7,
2003