How world let virus spread A tale of mistakes, missed opportunities, near misses

SARS has tested the modern world's ability to corral a contagious, deadly disease. Everybody fighting the outbreak — from the World Health Organization to Toronto public health authorities to Scarborough Grace Hospital — claims they have done the best possible job.

Despite valiant efforts, 170 people have died around the world, 13 in Toronto alone. Well over 3,400 are suspected or probably infected, 247 in Ontario. Many thousands had to be placed in quarantine, 7,000 in Toronto. The disease is growing, not shrinking.

A detailed analysis shows mistakes were made along the way. Poor detective work was done. Information was suppressed by overly cautious experts. The right information did not get to the right people. When it did, it was sometimes ignored.

This is a blow-by-blow account of the last five months, from SARS liftoff in China to its crippling strike on Toronto. Information in this story comes from interviews with officials at WHO, Toronto Public Health, disease experts at Toronto hospitals, and documents produced by those investigating the outbreak.

Foshan is a city of bonsai trees, temples and modest tourist attractions near the Pearl River in Southeast China.

Patient One for SARS lives in the community of 3.2 million. He became sick Nov. 16, 2002. A high fever struck the 40-year-old businessman. Several days later, a dry rapid cough followed.

He infected four nurses at the local hospital, then recovered. By a quirk of the disease, which often leaves the young untouched, his four children did not get ill. The disease likely jumped to humans from animals.

It's a half-hour drive to Guangzhou, a modern metropolis of 6.6 million known as the "City of Flowers."

A shrimp salesman infected in Foshan likely carried the disease the short distance. Others spread the respiratory infection to other parts of Guangdon province. Between Nov. 16, 2002 and Feb. 10, 2003, at least 305 people became sick from SARS in Guangdong. Five people died.

It's the scientific and technological hub for the area, home to colleges and universities and numerous hospitals. It's not a backward place. Still, untrue rumours of hundreds dead were heard. Antibiotics flew off pharmacy shelves. Inflated prices were paid for white vinegar, which people were using as a home disinfectant.

One in three people infected was either a nurse or doctor, a foreshadowing of things to come in other countries, including Canada. In the midst of this walked Dr. Liu Jianlun, a semi-retired, 64-year-old professor who specialized in respiratory diseases. Dr. Liu helped treat many of the patients in Guangdong's Sun Yatsen Memorial Hospital. In a few days, he was planning to attend a relative's wedding in Hong Kong.

Quarantine was not observed. Doctors did not understand the nature of the disease until it was too late. On Feb. 10, the Chinese Ministry of Health asked for help from the United Nations' World Health Organization. WHO had heard whispers of the outbreak, but by international law could not assist unless a request was made.

ARS (Acute Respiratory Syndrome as it was then called) had afflicted 305 people in Guangdong Province. WHO was investigating. The alert went out over ProMED, a global network originally set up a decade before by a group of American scientists to quickly alert the globe to emerging diseases. Twenty thousand people received the ProMED alert, distributed free to anyone who signs up.

Toronto Public Health authorities saw it. They distributed information to Toronto hospitals. Since Toronto has an incredibly diverse population, with a large Asian community that might travel to the area, it was vital information.

The alert was also seen by some top Toronto disease experts, such as Dr. Donald Low. But the alert and others that followed didn't make an impact. (Scarborough Grace, where Toronto's outbreak began, refused to answer detailed questions for this story, including whether they received the various alerts.)

"WHO just doesn't send these things out everyday. It was obviously significant. You think about it half a world away, which is obviously the wrong thing to think," said Low. A few days later, Chinese authorities provided an update to WHO. Chinese doctors had ruled out a variety of suspected causes, including anthrax and pulmonary plague.

That second alert, saying the disease was an acute respiratory syndrome, was sent out by WHO, and was distributed by ProMED on Feb. 14.

Dr. Liu Jianlun left the hospital in Guangzhou on Feb. 21. He was sick, with fever and cough, and had been for five days. Still, he and his wife took the three-hour bus ride to Hong Kong.

Arriving in Hong Kong the couple checked in to room 11 on the ninth floor of the three-star, 17-floor Metropole Hotel. Also at the hotel were a Scarborough grandmother and grandfather visiting family, businessmen from Vaughan, Toronto and Vancouver, plus an American garment seller with an office in Vietnam. All were travelling separately.

The Metropole, boasting "breathtaking city views", is situated in Kowloon, the tourist and entertainment district. Dr. Liu and his wife hooked up with his brother-in-law, a Hong Kong resident, and they spent a marathon 10-hour day sightseeing.

During his brief stay at the Metropole, Dr. Liu infected at least 12 people, four of them from Canada. Scientists say it's likely he coughed or sneezed on them, perhaps waiting for the elevator.

The next morning, Dr. Liu's cough had progressed to a heavy hack. He felt chilled, his body was shaking. Dr. Liu went directly to hospital, warning doctors he was contagious. Nobody took him seriously, despite the two alerts the week before from WHO and newspaper stories of the outbreak in Southeast China.

Within three days, Dr. Liu's brother-in-law became sick and joined him at the hospital. Few of the nurses and doctors treating either man wore gowns or masks.

Meanwhile, at the Metropole, the Canadians, the American and others had checked out. Each person would carry the disease somewhere, each time with different effects. The most lethal would be the Scarborough grandmother (Kwan Sui-Chu) and the American businessman, Johnny Cheng. Both stayed on the ninth floor near Dr. Liu, who scientists suggest was a "super spreader," a person whose body somehow becomes hyper infectious.

Two kilometres down the road from the Metropole Hotel in Kowloon, Toronto disease expert Dr. Donald Low was staying at the Marco Polo hotel in transit from a conference. The chief of microbiology at Toronto's Mount Sinai Hospital recalls reading an English language newspaper that day which carried a story of two people in southern China who died of pneumonia, believed transmitted by contact with poultry in a rural area. He told one of his sons, who was travelling with him, "they've got a problem here."

Dr. Low flew home to Toronto on Feb. 23. He flew Air Canada. The same day, the Scarborough grandmother and her husband flew home on Continental.

Johnny Cheng flew to Hanoi, Vietnam to check on his office. The Vancouver businessman continued his travels in Asia. So did the Vaughan businessman.

The Toronto businessman who had stayed on at the Metropole, a 72-year old man who had come to Hong Kong for a family reunion, was the first to become sick. He went to the same hospital Dr. Liu was at.

In Guangdong, health officials reported test results that showed, erroneously, that the disease was caused by a chlamydia infection. WHO put out this information on Feb. 20, and it was distributed through ProMED. Also distributed by ProMED around this time were statements by health authorities in Hong Kong and Guangdong. Hong Kong said people should not worry about the disease coming to its bustling streets because it had an excellent capability to spot emerging diseases.

Kwan Sui-Chu and her husband landed in Toronto on Sun., Feb. 23, the day the city was cleaning up from a winter storm that dumped freezing rain followed by 20 centimetres of snow. Disease expert Dr. Low also returned. He had a week's work ahead of him before flying to Banff with his other son for March Break vacation.

Two days after her return, the 78-year-old Kwan became sick with a high fever. Her body was already weakened by diabetes and heart problems. She and her husband lived in a Scarborough townhouse with a son (43-year-old Tse Chi Kwai), his wife and their five-month-old son. Kwan's other son, 34, lived there as well. The family did their best to keep her comfortable.

Kwan went to a local doctor on Friday, Feb. 28. Her symptoms were fever, lack of appetite, muscle tenderness, sore throat and dry cough. The doctor prescribed an antibiotic and sent her home. Her eldest son, Tse, was developing the same symptoms. Meanwhile, as the month of February ended, others who stayed at the Metropole in Hong Kong were getting sick or sicker.

The Vancouver businessman who had continued his travels in Asia developed a fever. The Toronto businessman already in a Hong Kong hospital had a bout of diarrhea. Three nurses cleaned him, and contracted the disease. They in turn spread it to others. Another nurse was infected by Dr. Liu's brother-in-law. Other patients came into the hospital and were placed near the original patients with no protective masks.

Then the Toronto businessman was transferred to another Hong Kong hospital, and then another.

No news of the developing sickness in Hong Kong was publicized by WHO. Reports had reached WHO in Geneva. Officials were investigating, but nothing was confirmed. In Vietnam, Johnny Cheng, the American businessman who had stayed at the Metropole, had become very ill. He'd left Hong Kong, flown to Hanoi, briefly visited his office and then checked himself in to the local French Hospital, a colonial relic that's the most modern hospital in Vietnam. Within a few days, several nurses at the French Hospital also became ill. Puzzled, the hospital called the local WHO office. Dr. Carlo Urbani was dispatched.

Urbani, an Italian expert in communicable diseases, quickly obtained blood and saliva samples and sent them off for testing. Cheng's fever was high, and he had developed a dry cough. Urbani interviewed nurses, doctors, then contacted Cheng's colleagues at work. Local authorities insisted it was the "bird flu", a known infection that caused pneumonia. Urbani thought not. The 46-year-old Urbani, a father of three, worked tirelessly trying to solve the puzzle. Despite trying to convince the hospital to bolster its infection control procedures, he was himself infected.

On Feb. 28, Urbani named the disease severe acute respiratory syndrome. He noted it was an atypical pneumonia, but the cause eluded him. He continued his work, keeping the Manila regional office of WHO apprised. But none of this hit the public eye. WHO had not issued a public alert on the subject for a week and would not for almost another two weeks.

'WHO just doesn't send these things out everyday.
It was obviously significant. You think about it half a world away, which is obviously the
wrong thing
to think.'

In Hong Kong, Dr. Liu was struggling to stay alive. Doctors tried an aggressive course of antibiotics. On March 4, he died, the first SARS death outside of Guangdong province. Back in Scarborough, the 78-year-old grandmother (Kwan) slipped into a coma in her own bed. She was never hospitalized. Very early on March 5 her husband noticed his wife's body was cold. The family called 911. Paramedics, police and a part-time coroner came to the home. Family members opposed an autopsy, so her body was taken directly to a funeral home. The coroner, Dr. Mark Shaffer, was told by the family that Kwan had been treated for flu by her family doctor, and that she had a history of high blood pressure, diabetes and high cholesterol. He wrote "heart attack" under cause of death. "Nobody knew about SARS at the time," said Dr. Jim Cairns, Ontario's deputy chief coroner. "Her death did not trigger anything in the coroner's mind."

While the Kwan family prepared to bury the grandmother, her son's condition had become worse, with fever, profuse sweating, and a dry, prolonged cough. He visited his own doctor, had an x-ray taken, and was prescribed an antibiotic and sent home. Later in the day, Tse took his now ill wife to see her own doctor, Ada Ying Tak Lo, a family physician with an office at Finch and Midland Aves. in Scarborough. Tse and his wife were both contagious at this point.

Back in Hanoi, Johnny Cheng was getting worse by the hour. Seven nurses or nurses aides were sick with high fever, headache. Samples were rushed to the Atlanta and Tokyo labs of the Centers for Disease Control, which provides analysis for WHO. Urbani, the WHO doctor, called his Geneva head office and spoke to Dick Thompson, a senior official. Local doctors still thought it was the "bird flu," but Urbani disagreed. "It didn't look right," Thompson recalls Urbani saying. Cheng's family had him airlifted to a Hong Kong hospital, hoping for better treatment.

The next day in Hanoi, three more nurses became sick. The next day, Friday, March 7, two more fell ill, plus six colleagues from Cheng's garment sales office.

Hearing this from Urbani, WHO officials in Geneva activated their two-year-old Alert Response Network. Unofficially, WHO had made a link between Guangdong, China and Vietnam. They did not issue an alert at this stage. However, through the network they appealed for help to 110 infectious disease experts worldwide, including Health Canada. The WHO request stated that Vietnam had an unexplained case of atypical pneumonia. Help was needed to ferret out the cause and best course of treatment. Health Canada responded, promising assistance.

That day, Friday, March 7, Tse Chi Kwai was weak, his condition worse. His sister took him to Scarborough Grace Hospital. Staff placed him on a gurney in Emergency. His temperature was 39.8C (normal temperature is 37C). He was in Emergency, exposed to other patients, for 12 hours. During that time, about 200 other patients, nurses or doctors passed through the ER.

Beside Tse on another gurney at Grace Hospital was Joe Pollack, a 76-year-old man being treated for an irregular heartbeat.

Faced with similar symptoms to those seen by Urbani in Hanoi, Scarborough Grace doctors first determined Tse had pneumonia, then changed the diagnosis to tuberculosis. Overnight, Tse's condition spiralled downhill. The next day, Saturday, March 8, doctors intubated him, putting a tube down his throat to help him breathe.

At the same time, Dr. Sandy Finkelstein, director of intensive care at Scarborough Grace, ordered x-rays for the remaining members of Tse's extended family — four adults and three children. Some had minor coughs, but he wanted to see if they too had TB. The x-rays on three adults indicated lung infections. Again, doctors homed in on tuberculosis as the cause.

Over the weekend, staff at Scarborough Grace learned from the family that Tse's mother had recently died, that she'd been in Hong Kong and it was possible she became sick there. Still pursuing the TB theory, but realizing that the slow moving disease was a public health threat, Dr. Finkelstein placed Tse Chi Kwai in isolation. Other family members were not isolated. They were told to wear masks and stay home if possible. Joe Pollack, the 76-year-old heart patient from the ER gurney, was released. Two days later, he became ill with a 40C fever.

On Sunday morning, the Vancouver businessman who had continued his travels after leaving the Metropole in Hong Kong, arrived home. He went to hospital complaining of dry cough, fever, chills and headache. Doctors intubated him. The infection did not spread in Vancouver, either because the man was not a "super spreader" or because his lengthy stay oversees meant he was no longer contagious. It is possible he spread the disease during his earlier travels in Asia.

Back at Scarborough Grace that Sunday morning, Finkelstein called Toronto Public Health to tell them of the possible tuberculosis case. TB is on the list of infectious diseases hospitals must report because of the danger of spread to the community. About 400 cases of TB occur in Toronto every year and Grace hospital is in an area that often sees TB.

Public health took some information and assigned an investigator with expertise in TB. Although public health was aware, through ProMED and other sources, of reported cases of unexplained respiratory ailments making the rounds in Asia, nobody made the connection. Grace Hospital has a large Asian population in its area.

At Grace hospital Sunday night, a quick test called a "TB smear" was done on Tse Chi Kwai. The result Monday morning was negative for TB. Still believing it was TB, and with Toronto Public Health's support, the hospital ran another test Monday morning that would take two days.

But a key part of the puzzle was missing. At her home that Sunday morning, one of the five family doctors who had treated members of the Tse family before Scarborough Grace had a severe headache and fever. Dr. Ada Ying Tak Lo booked off work for the week. Nobody from Grace Hospital or Toronto Public Health called to gather information on the Tse family. Had they, it would have indicated a fast moving infection not confined to one family.

In Hanoi, the French Hospital was ordered quarantined. Twenty-two nurses were now ill. Carlo Urbani, who first identified SARS, had developed a fever. At WHO's Geneva head office, experts were worried. "Nobody's getting better," said Pat Drury, project manager for the global outbreak network. In Hong Kong, nurses at the hospital where Johnny Cheng was sent were also getting sick.

In his isolation room at Scarborough Grace, Tse was on a respirator. Toronto Public Health was gathering information by telephone. For example, they learned that the man worked at a factory. But since TB is a slow moving disease, they did not contact his workplace (it's unknown if anybody there became ill).

Meanwhile, none of Toronto's top infectious disease experts were aware of the developing problem. Dr. Low was in Banff. Dr. Allison McGeer, the Mount Sinai infectious disease specialist who consults to Scarborough Grace, was in town. But nobody called her for advice. In retrospect, she says it would not have made any difference. She insists Scarborough Grace did everything it could, and more.

On Wednesday, March 12, several things happened. The Hong Kong hospital where Johnny Cheng had been airlifted reported 22 sick nurses. Then Cheng died. At the hospital where Dr. Liu was treated in Hong Kong, two-dozen health-care workers were infected.

Faced with these reports, the World Health Organization issued a Global Alert the same day. It was a much more serious alert because it showed a disease that had spread beyond national borders. SARS had been identified in Hong Kong, China and Vietnam, the alert stated. WHO suggested the world medical community use isolation techniques to handle SARS patients, and sterilize anything that came in contact with patients. WHO asked for all suspect cases to be reported to national health authorities.

That day in Banff, Low was checking his e-mail. He noticed the alert from ProMED, as did colleagues in Toronto including McGeer. But it did not strike them as a threat to Canada.

The day after the alert, on Thursday, March 13, Tse died at Scarborough Grace. Later, his younger brother showed up in emergency and was put in a negative pressure isolation room.

That afternoon, Scarborough Grace's infection control officer called McGeer for advice at 4:20 p.m. She told her what they had. McGeer, who had seen the various ProMED alerts, made the connection. She quarterbacked a series of moves. The family, many of them now sick, were admitted to isolation wards at different hospitals. Calls were made to the Centers for Disease Control in Atlanta. A contact in Vancouver put McGeer in touch with Health Canada close to midnight. A message was left for provincial health authorities. McGeer's message was this: Toronto has cases potentially linked to the Asian SARS outbreak.

The next day, Friday, Health Canada put out a travel alert warning people about the SARS situation overseas.

But there was no mention of the Toronto cases. Later in the day, Health Canada informed WHO of the two deaths in the same family.

At Pearson International Airport, the 62-year old Vaughan man came home. Sick during the flight, he went to York Central Hospital in Richmond Hill, which had no negative pressure isolation room because of a renovation.

In Toronto, doctors scrambled to do an autopsy on Tse. The coroner's office lacked the proper isolation room. A pathologist at Toronto General did the autopsy and tissue samples were sent off for study.

On Friday night, shortly after 8 p.m., Toronto Public Health went public with news of the Toronto cases.

The press conference was held at Mount Sinai Hospital. The public was told the infection was confined to a family, and that members had recently travelled to Hong Kong, where WHO had now identified SARS.

After the press conference, McGeer went up to her office and was joined by other doctors, including Low, who had just arrived home. On a white board, the doctors jotted the names of the family, and how each may have been infected. The doctors devised a treatment plan — an antibiotic cocktail and a plan to use a "lung protective strategy" if victims of the disease were hooked up to a ventilator. This meant pushing low amounts of oxygen into the lungs instead of normal volumes, which current research said could be fatal to weakened patients.

Saturday morning, as soon as she heard the news, Dr. Tak Lo, who had treated members of the Tse family in her office, called to say she was sick. "That was our first setback. We thought we were dealing with something within that family. Now we have seen somebody outside the family who is sick," said Low.

Toronto Public Health's Dr. Bonnie Henry tracked down patients from the Continental airline flight that brought Kwan home.

At York Central doctors had heard the news. They called to report the Vaughan man's condition. He was transferred to Sunnybrook, which had a free isolation room. WHO officials, on Sunday, March 16, issued another alert, this time including the Canadian cases. Health Canada issued an alert, stating seven Canadians were infected, with two dead.

That Sunday, Joe Pollack returned to Scarborough Grace hospital. He's the 76-year-old heart patient who had been on the gurney the week before beside Tse Chi Kwai. Pollack was now sick with SARS and was admitted. Doctors made sure Pollack was isolated, but not Pollack's wife.

That day, or shortly after, Pollack's wife inadvertently came in contact at Scarborough Grace with an 82-year-old man who was a member of a Catholic Charismatic group. That man and his two sons were infected. Pollack, his wife, and the 82-year-old member of the religious group, and his wife, have since died.

Health officials insisted that masks be worn at Pollack's on March 24. But nobody knew the elderly man from the religious group had died of SARS until later on. So none of the mourners, including his infected son, were asked to wear masks at the elderly man's service at the Highland Funeral Home on April 3.

Still more had been potentially exposed, as many as 500, at a religious retreat held March 28-29 attended by the son.

At Toronto Hospitals, such as Scarborough Grace and Mount Sinai, nurses and doctors had to go into quarantine. Some got sick, including McGeer of Mount Sinai. Scarborough Grace Hospital, York Central in Richmond Hill and Centenary were ordered closed. On March 29, Urbani died. He was the doctor who had identified SARS to the world. Meanwhile, in Toronto and around the world, top medical and public health minds are busy trying to contain SARS.

But in the months to come, the focus will be on how the outbreak spread, and what lessons have been learned.

For example: Should hospitals be more aware of international health threats? Should public health authorities issue alerts earlier, or more strenuously? Should doctors be quicker to assume a disease is infectious, and isolate patients immediately? Should agencies like WHO broadcast disease information faster?

Curious how health officials or recommending quarantine to prevent the spread of a virus that is frequently fatal. A "certain" virus that is uniformally fatal and can can only be suppressed by taking a number of different, very expensive medications which become progressivley less effective has been spreading rampantly around the world and quarantine was never even seriously considered. Why quarantine folks now?

Lessons learned? Infecting 50% of all medical staff* that do not wear special protection when treating sars patients is also a good motivator.

* reported to have happened in China

Two days after her return, the 78-year-old Kwan became sick with a high fever. Her body was already weakened by diabetes and heart problems.

And the man who spread the disease to Amoy Gardens in Hong Kong was a kidney patient. I wonder if the superspreaders tend to be people with underlying health problems.

By a quirk of the disease, which often leaves the young untouched, his four children did not get ill.

Something to note.

Everybody fighting the outbreak — from the World Health Organization to Toronto public health authorities to Scarborough Grace Hospital — claims they have done the best possible job.

Oh yeah... when the first SARS cases hit Canada - all within the same family - they managed to distribute four patients to four different hospitals, with one of them - a child - making a swing into a fifth. They couldn't have done a better job of jumpstarting an epidemic if they had gone around spraying virus with a garden hose.

Just close the borders, blockade the place, and check back in fifty years.

Not to mention that conference of 450 attendees and the 90 Americans who went.

If nothing else it will opens eyes to how easily infectious disease (SARS in particular) is spread even in medical facilities.

This from sarswatch.org:

Yesterday, the Centers for Disease Control and Prevention in Atlanta sent a team of epidemiologists to Pennsylvania to help investigate a probable SARS case in a hospitalized patient who attended a religious meeting in Toronto on March 28. Canadian health officials have identified 28 other people with SARS who attended the Mass, held by members of the Bukas-Loob Sa Diyos Covenant Community, a Philippines-based Roman Catholic group. Health officials are trying to identify the estimated 500 people who attended the meeting and monitor their health.

They couldn't have done a better job of jumpstarting an epidemic if they had gone around spraying virus with a garden hose

I so much agree, and I think I am more angry at Canada than Red China. After all, I expect lies, deceit and my probable death to be a result of the Red Chinese in some manner.

I don't expect the extreme incompetence that Canada showed and is showing.

As a side note, a colleague of my husband's is from Canada. Yesterday the topic of SARS came up and she brushed it off as no big deal and media hype. Apparently, that is the cool thing to do. Act like you are so worldly, so above the fray that you don't fall for "media hype" and "senstationalsim".

per your post no. 12..You called it.

I really hope they have a couple of Per Loin's working on this. If not, we are doomed.

Everyone, there is some very important information below:

According to the New York times, yesterday, Toronto's SARS death rate is at 9.5%! This is a MOST serious increase and much more serious than many articles are indicating at this time.

Link to article: http://www.nytimes.com/2003/04/18/science/sciencespecial/18INFE.html?ex=1051243200&en=c0c66bc035169a16&ei=5062&partner=GOOGLE

After all, I expect lies, deceit and my probable death to be a result of the Red Chinese in some manner.

Actually, I suspect that the Chinese are somewhat innocent.

I suspect that when more is known, this thing may turn out to be man-made and not a natural mutation of Coronavirus. And that it wasn't made by the Chinese, but introduced to their population by others. It seems they have had cases in military hospitals for a long time, and been pretty paralyzed with fear.

China has critters travelling pretty widely, and in many places they rub shoulders with al Quaida members.

China has critters travelling pretty widely, and in many places they rub shoulders with al Quaida members. ....my thoughts exactly!

....this could soooo easily be spread purposely in these densely populated and intersecting countries.

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