SARS The Toronto Outbreak April 20, 2003

1
SARSThe Toronto OutbreakApril 20, 2003
2
SARS in Toronto IIndex 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 (thought to be heart
  attack)

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SARS in Toronto 2Spread within Household

• Feb 27 - 43 year old son of index case develops
  febrile illness (case 2)
• Admitted to Scarborough Grace March 7th, died
  March 13th
• March 3 to 12 all of index cases 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 in Toronto 3First 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 4 Spread at Scarborough Grace -
I

• From case 2 and ill family to 5 ICU nurses
• From case 8 to two paramedics, one firefighter,
  four ER staff, one anaesthetist (precautions
  initiated in ER no further transmission except
  to anaesthetist performing intubation)
• From case 8s ill wife to 7 ER visitors, one
  housekeeper
• From case 9 (admitted before outbreak
  recognized) to at 20 hospital staff and students
  in CCU and on medical unit (nurses, MDs, support
  staff, radiology, pharmacy, etc.)

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SARS in Toronto 5 Spread at Scarborough Grace -
II

• Case 10 prior exposure only to one clinic at
  Scar Grace admitted 22/3 with community-acquired
  pneumonia
• Spread to visitors and at least 2 nurses on
  medical unit

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SARS in Toronto 6Spread to Other Hospitals

• Mount Sinai Hospital
• Case 10 transferred to ICU
• 7 staff infected
• York County Hospital
• Case 9 transferred to ICU
• Wife of case 9, also admitted with hip (but had
  SARS as well)
• 14 staff and one patient infected

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SARS in Toronto 7Other Spread

• Household contacts of cases
• Estimated risk of unprotected exposure 24
• Doctors offices when SARS patients were present
• Persons visiting SARS patients at home
• Funerals of SARS patient at which family members
  were ill
• Religious retreats
• Workplace

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SARS in Toronto 8Transmission through
precautions

• Two problems
• 1. INTUBATION Three episodes in Toronto
  hospitals (March 17 at Scar Grace, March 23 at
  MSH, April 10th at SBK) of transmission to all
  HCW in the room of patients being intubated
• 2. PATIENT CARE - over the last month, 6 HCW at 4
  Toronto hospitals have acquired SARS despite the
  use of SARS precautions

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SARS in Toronto 9Where are we?

• Community cases remain linked to index case, but
  outbreak still expanding
• Intensive public health effort to identify all
  contacts and prevent further spread
• Hospital closures and precautions have
  substantially but incompletely reduced spread
• SARS precautions enhanced April 19/20
• Intensive investigation into reasons for
  continuing transmission, and methods to prevent

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Probable and Suspect Cases of SARS in Ontario by
Date of Onset
Suspect
(April 22, 2003 as of 900 a.m.)
Probable
Number of Cases
25
20
15
10
5
0
Apr-02
Apr-04
Apr-06
Apr-08
Apr-10
Apr-12
Apr-14
Apr-16
Feb-23
Feb-25
Feb-27
Mar-01
Mar-03
Mar-05
Mar-07
Mar-09
Mar-11
Mar-13
Mar-15
Mar-17
Mar-19
Mar-21
Mar-23
Mar-25
Mar-27
Mar-29
Mar-31
Date of Onset
Notes 1) Total Probable Cases 136 (1 case with
unknown onset date) Total Suspect Cases 125(2
cases with unknown onset date) 2) Cases in epi
curve includes individuals with known onset dates
from all health units with reported
cases Source Ontario Ministry of Health and
Long Term Care, April 22, 2003 as of 900am
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Severe Acute Respiratory Syndrome (SARS)Toronto
(21/04/03)
13
Severe Acute Respiratory Syndrome
(SARS)Case-Fatality
14
SARS in Toronto 10What have we learned?

• Cases of SARS that are not suspected pose the
  greatest danger to staff
• High index of suspicion and SARS isolation for
  febrile patients best protection
• Ill visitors can spread the disease in the
  hospital to staff and patients
• Visitor restrictions essential until outbreak is
  over

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SARS in Toronto 11What have we learned?

• Early detection of infection vital so that
  precautions can be used to prevent spread
• Fever surveillance in patients and staff critical
  to ensuring that transmission is stopped
• Infection control precautions are effective, but
  require very careful attention to detail to be
  most effective
• Intensive investigation into how to enhance
  precautions effectively is underway

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SARS in Toronto 12What have we learned?

• Intubation, and potentially other cough-inducing
  procedures in the ICU, poses special risks from
  some, but not all patients
• Enhanced precautions being implemented in ICUs
  for such procedures
• Some patients much more infectious than others
• No means to identify these patients currently
  many investigations underway