Transcript Sinusitis: Microbiology Update

SARS
The Toronto Outbreak
Allison McGeer, MSc, MD, FRCPC
TML/Mount Sinai Hospital
University of Toronto
Acknowledgements
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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
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and public health departments and their families
26 countries
8098 cases
774 deaths
Figure created by
Raymond Chow &
Yuan Zhang for
Christian et al. CID
2004; 38:1420-1427
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
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)
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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
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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
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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 #8’s ill wife to 8 ER visitors,
5 patients, 8 staff members, 1 volunteer
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Mr. P
Mr. P’s
wife
19 persons
5 persons
Mr. D
Index Case
(Mother)
Case A
(Son)
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
March 15-21st
• Follow up
– 3 exposed HCWs, 1 patient identified with illness
– Three travel related cases (Ontario)
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
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• 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
SARS in Ontario
SARS in Ontario
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358 cases
44 patients died
23,103 persons quarantined
316,615 calls to Toronto Public Health
$1.13 billion
SARS in Ontario
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 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