SARS IN THE CITY The Toronto Experience June 1, 2005

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SARS IN THE CITY The Toronto ExperienceJune 1,
2005

• Dr. Lisa Berger, MD, FRCPC
• Associate Medical Officer of Health
• Toronto Public Health

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Outline

• Chronology
• What we knew about SARS
• Role of Toronto Public Health (TPH)
• Quarantine
• Communications and Community Impact
• Lessons Learned
• Next Steps

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What is SARS?

• Severe Acute Respiratory Syndrome
• Symptoms include
• a fever of more than 38 degrees C ( 100.4 degrees
  F)
• muscle aches, severe fatigue, severe headache
• dry cough, shortness of breath
• positive chest x-ray

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Where it began..

• 21 February, 2003 a Chinese Doctor from Guandong
  checks into room 911 at the Metropole hotel.

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Chronology2003

• Feb 19th-21st - index case at Metropole Hotel in
  Hong Kong
• Feb 23rd - index case returned to Canada
• Feb 25th - prodromal - thought to be viral
• March 5th - index case died at home
• March 7th - son admitted to hospital
• March 9th - diagnosis of possible Tuberculosis
• March 10th - report to TPH and contact
• follow up initiated
• March 12th - WHO alert of atypical pneumonia

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Chronology

• March 13th - son dies and 4 family members are
  admitted to 3 area hospitals in isolation,
  negative pressure rooms
• March 14th - joint press conference and extensive
  contact follow-up initiated
• March 21st - sick HCWs
• March 23rd - opening of a SARS unit

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Chronology

• March 24th- closure of the first hospital
• - made a reportable disease
• - designated Communicable
  virulent
• March 26th - provincial health emergency declared
  

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Chronology

• March 27th - provincial leadership and first
  infection control directives to
  hospitals, LTCF, MDs, CHCs - formation of
  Science Committee
• March 28th - closure of second hospital
• April 23-29 - WHO travel advisory

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Mr. Ps wife
Mr. P
24 persons
9 persons
Mr. D
21 persons
Index Case
Case A
(Mother)
(Son)
15 persons
Mr. R ?
7 persons
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Chronology

• May 16th - outbreak thought to be over -
  New Normal directives issued
• May 23rd - unrecognized cases and spread in a new
  hospital
• Phase 2 was limited to hospital patients, HCWs,
  visitors and their immediate contacts
• June 12th - last ill case

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Chronology

• Phase 1 Mar 13 - Apr 20
• Phase 2 May 20 - June 24
• 438 cases across Canada (228 in Toronto)
• 44 deaths (38 in Toronto)
• 222 hospitalized, 50 in Intensive Care Units
• 50 in health care workers (4 deaths)
• cluster of 31 cases associated with a community
  group
• no significant community spread

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Severe Acute Respiratory Syndrome (SARS)Canadian
cases - Admission
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Severe Acute Respiratory Syndrome (SARS)Canadian
cases - admission
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The Pathogen Coronavirus

• first isolated from chickens in 1937
• 15 species which infect man, cattle, pigs,
  rodents, cats, dogs and birds
• stranded RNA virus

Ksiazek et al. NEJM 20033481953
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Emerging information on risks

• Close, direct contact vs casual or airborne
  spread
• Illness rare in children, risk increased with age
  
• SARS can co-exist with other chronic illnesses
• Highest risk in hospital staff and household
  contacts of a known case
• Stringent infection control prevents spread

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Epidemiology

• Average incubation period 4.7 days (range 1-12)
• 66 of cases were female
• Average age of those who died 71 (39-100)
• Only 3 deaths in persons less than 50
• Mean time from onset of symptoms to death 19 days
  (1-43)

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Age Specific 8-Week Case Fatality Rates (CFR) and
Virulence Rates (VR)
Cases include probable and suspect
cases. Severe illness was defined as requiring
intubation, treatment in ICU or resulting in
death.
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What was the role of TPH?
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Incident Command Structure
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Staffing

• Up to 400 staff on duty each day
• 700 staff assigned full-time
• 2 shifts per day (8 a.m.-11 p.m.), 7 days/week
• Active assistance from Province
• Many others came to help
• Other public health units
• Community Medicine Specialists
• Health Canada
• Department of National Defence

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Workload Volumes for Phase 1 2

• Over 300,000 calls to hotline March 15 - June 24,
  2003 47,567 calls on one day
• Approximately 2000 case investigations -average 9
  hours per investigation
• 212 Probable case and 16 Suspect cases
• Over 26,000 contacts followed-up - 14,000 in
  quarantine
• Acute event lasted 14 weeks

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Outbreak Control

• How do you stop an outbreak when
• Agent is unknown
• Incubation period uncertain
• Mode of transmission not entirely clear
• No diagnostic test
• No prophylaxis
• No vaccine
• No treatment

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Isolation/Quarantine

• Quarantine
• voluntary
• not used gt 50 years in Canada
• invented work quarantine
• Used combination of
• quarantine/work quarantine with daily or twice
  daily assessment
• active surveillance with daily assessment
• self-monitoring with periodic follow-up
• day 10 follow-up and counselling

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Isolation/Quarantine

• Linkage of symptomatic contacts to assessment
  centres
• Issued 27 Section 22 orders under HPPA
• Challenges of determining if someone is at home
  by phone e.g. cell phones, internet, lack of
  phone
• Very difficult mentally, physically,emotionally
  and financially

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Isolation/Quarantine

• Resources psychosocial support to
  individuals/communities who were quarantined
• One-on-one support by telephone through hotline
• Partnerships e.g.
• police - spot checks, serve orders
• Emergency Medical Services
• linked with Red Cross and Salvation Army to
  provide masks, thermometers, food, etc.

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Isolation/Quarantine

• Homeless/shelter population
• worked with shelters on screening
• had only 6-8 quarantine beds
• Jails/schools/workplaces/transit
• need for support, risk assessment, contingency
  planning, etc.
• Government financial support

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Isolation/Quarantine

• Community Issues
• Post-quarantine acceptance back into schools and
  workplaces
• Stigmatization of affected groups e.g. Chinese
  community
• Acknowledge and deal with discrimination - worked
  with community leaders
• Address anxiety or fear

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Isolation/Quarantine

• Legal Issues/Challenges
• group orders
• able to detain at facility other than hospital

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Disease Surveillance Reporting

• Provincial database for reportable diseases could
  not be adapted for SARS
• lacked a central database/data sharing agreements
  between local, provincial and federal governments
• Due to the volume depended on paper-based system
  until able to develop own SARS information system
• Case definition issues

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Intense Media Interest

• 2nd only to Iraq War
• Daily media briefings, televised live
• Over 1,200 media calls in the first 8 weeks
• Daily print/electronic, local/ethnic,
  international
• Multiple spokespersons, many opinions...

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Communication Methods

• Fact sheets for different audiences
• Quarantine directives for affected groups
• Print/web material translated into 14 languages
• Diverse language skills among Hotline staff plus
  ATT translation service
• Local community meetings - health risks, ethnic
  discrimination
• Standard letters to conference planners

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Stakeholder Communications

• Within TPH
• Other City departments
• Unions, joint health safety committees
• Health facilities and service providers
• Workplaces, schools/school boards
• Jails, homeless shelters advocates
• Churches, religious leaders, community groups
• Conference planners associations
• Other levels of government

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Occupational Health Safety Issues

• Created a special Family Health team for home
  visits of clients in quarantine
• Respiratory / contact protection for TPH staff in
  hospitals
• Psychosocial impacts across the board - fear,
  grief, stress, exhaustion

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Infection Control

• Pre-SARS - staff participated on hospital
  infection control committees, provided advice on
  infection control
• During SARS
• hospital liaison/category 3 response team on-site
• participated in development of provincial
  directives

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Infection Control

• During SARS
• liaised with hospitals, CCAC, and other agencies
  on infection control (e.g. help interpret
  provincial directives)
• participated in audit of Category 3 hospitals
  requesting downgrade of category
• Post SARS
• Communicable Disease Liaison Unit

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Protective Barriers N95 masks, face shields,
gown and gloves
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Community Impacts from SARS

• Widespread program cancellations (public health,
  hospital, long term care, community services)
• Psychological isolation among patients, health
  care workers and quarantined contacts
• Economic hardship for hospitality / tourism
  industries and Chinese businesses
• Academic impact on students in affected schools
  and universities

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Lessons re Communications

• Formulate key messages and reiterate them often
• Adapt health messages to needs of different
  audiences and deliver in-person where possible
• Ensure information is accessible, linguistically
  and culturally appropriate

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Lessons re Communications

• Be readily available to media
• Minimize number of spokespersons
• Rigorous document control clear processes for
  information management
• Ongoing relationships partnerships are essential

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Lessons re Disease Surveillance Reporting

• Need a flexible, robust IT system to handle major
  outbreaks
• Active surveillance for febrile-respiratory
  illness
• Need mechanisms for rapid reporting of disease
  activity across and within jurisdictions

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Other Key Lessons Learned

• Surge capacity/infrastructure
• Psychosocial
• Constantly changing environment and information
• Occupational health and safety issues
• Need a strong public health body at provincial
  level that has flexibility to respond to
  outbreaks clear roles and responsibilities of
  different levels of government

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Other Key Lessons Learned

• Need for improved cross-jurisdictional
  coordination
• Need for local public health units involvement in
  investigation/research
• Ongoing need to debrief, evaluate at different
  levels

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POST-SARS

• Internal Toronto Public Health SARS evaluation
• Organizational review of Emergency Preparedness
  Response capacity
• Infection Control Standards Task Force
• Campbell Commission of Inquiry into SARS
• Walker Panel on Infectious Diseases
• Naylor Committee on SARS and Public Health
• National working group on Strengthening Public
  Health Infrastructure

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Moving Forward

• Building on relationships
• Communicable Disease Liaison Unit
• I.T. support
• Policy and Procedures

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