Posted on 05/03/2003 5:30:55 AM PDT by Clive
TORONTO - The day after Toronto first learned it was home to a puzzling new virus, a public health nurse walked through the front door of an east-end apartment wearing a pair of goggles, a protective gown and a respirator mask.
Two of the tenants, 78-year-old Sui-Chu Kwan, and her son, 43-year-old Chi Kwai Tse, had already fallen victim, and four of their relatives were seriously ill.
The strange sickness had generated extensive media coverage, which health officials had hoped would unearth anyone who had knowingly crossed paths with Canada's first casualties of what would come to be called severe acute respiratory syndrome.
The masked nurse in the apartment, however, was looking for the other potential patients -- the ones who had no idea that they had ever been in the vicinity of the victims. His specific task was to find the names of everyone on the airplane that flew Mrs. Kwan and her husband home from a recent Hong Kong vacation.
The obvious investigative tactics had failed.
Mr. Kwan had trouble remembering when he arrived back in Toronto, and everyone else who would have known had fallen ill.
"The only other people who knew that information was the [son] who died and the other one who had been on a ventilator," Dr. Bonnie Henry, Toronto's associate medical officer of health, recalled in a recent interview.
Officials were hopeful a detailed search of the apartment would uncover a receipt or a voucher, something that would tell them what plane the Kwans boarded on Feb. 23.
The masked man must have smiled when he looked in a closet and found the couple's suitcases. The luggage tags, which included the airline and flight number, were still tied to the handles.
Such amateur detective work -- from sifting through passenger lists to finding the distant relative of a doctor on a Caribbean cruise -- would come to define Toronto's six-week battle against SARS. Working 24 hours a day, health officials placed hundreds of thousands of phone calls and knocked on countless doors in pursuit of every person who might have had contact with a suspected or probable SARS patient.
The legwork was exhausting, but today, as officials stop just short of declaring victory over the mini-epidemic, they credit much of their inevitable triumph to the front-line sleuths. ''My staff is very good at finding people,'' Dr. Henry said. ''The police could probably learn something from us.''
- - -
SARS came to Canada on Feb. 23, when the Kwans returned from Hong Kong, where they stayed on the same floor of a hotel as a respiratory disease specialist who had been treating patients in China's Guangdong province.
At some point during the visit, either at an elevator or somewhere in a hallway, the couple crossed paths with the doctor, who was later identified as the source patient for SARS in the region.
After landing at Pearson International Airport, the Kwans returned to their Toronto apartment, which they shared with two sons, a daughter-in-law and a five-month-old grandson.
Days later, Mrs. Kwan fell ill. On March 5, after slipping into a coma, the diabetic died in her bed. An autopsy was not performed, but the coroner concluded she died of a heart attack.
Two days later, Mrs. Kwan's son, Mr. Tse, visited the emergency room at Scarborough Grace Hospital. He had a high fever and a severe cough.
Doctors laid him down on a gurney, where he spent the night less than two metres away from 76-year-old Joseph Pollack. A cotton curtain was the only barrier.
By that time, doctors were concerned that members of Mr. Tse's family had contracted tuberculosis. Over the next two days, eight of Mr. Tse's relatives were given chest X-rays. Four of them came back as abnormal.
On March 12, the World Health Organization issued a warning about SARS, a mysterious virus already spreading in the Orient. By the next day, doctors in Toronto had begun to consider the possibility they were wrestling with the same puzzling virus.
Dr. Alison McGeer, an infectious disease specialist at Mount Sinai Hospital, was in her office on March 13 when a fellow doctor phoned to brief her about a cluster of unexplained illnesses in the city's east end. She looked across her desk at two of her colleagues.
''I said to them: 'You know, it looks like somebody is going to have to go out to Scarborough Grace Hospital to kind of assess what's going on,' '' Dr. McGeer remembered. '' 'I don't know what it is but it's going to be a really interesting problem.' And one of them looked at me and said: 'Give me a reading on how interesting.' ''
''Once in a lifetime,'' she said.
Dr. Colin D'Cunha, Ontario's chief medical officer of health, was on vacation in Antigua when he called his office that same day. By that time, Mr. Tse -- no longer able to struggle for breath -- had died.
''The comment back from one of my staff was: 'Something's coming,' " Dr. D'Cunha said.
As expected, test results had ruled out tuberculosis in Mr. Tse's four ailing relatives, including his brother. They were all admitted to hospital. ''We knew that there was an unusual illness,'' Dr. Henry recalled. ''We needed to find anybody that had had contact with the people that were ill.''
It was a daunting task. Mr. Tse had begun showing symptoms of the mysterious virus at the end of February, long before anyone ever realized what he was suffering from. Countless others had also come to visit his ailing mother, whom doctors now knew had not died of a heart attack. Add to the mix front-line health care workers -- many of whom did not wear protective gear around Mr. Tse -- and officials were staring at a disaster.
''Before we even got out of the gates with an announcement that there may be a problem, we already had six patients and exposure to health care workers and family members,'' said Dr. Donald Low, the chief microbiologist at Mount Sinai. ''We were already behind the eight ball.''
Getting out from behind would require a massive search for anyone who had encountered Canada's first two victims. The initial press conference on the night of March 14 unearthed some of those people, as did the discovery of the luggage tags, but there was much more sleuthing to be done.
Officials later determined, for example, that one of Mr. Tse's relatives had visited a doctor who had since departed for a cruise with his wife, who also happened to be his secretary. It was crucial for authorities to obtain a list of patients who were in the waiting room on the same day as the infected patient, but nobody was around the office.
''It took us a couple of days but we managed to track down the sister-in-law of the physician and his wife -- who were off in the middle of the ocean -- who didn't know what cruise they were on but knew who their travel agent was,'' Dr. Henry said.
The agent provided a home address, where officials left a note. They hoped someone would be checking the mail. Sure enough, the man's brother saw the letter and called the attached number.
Accompanied by the doctor's brother, officials visited the office and walked away with the critical information: a patient list.
- - -
If Toronto's battle with SARS had a ground zero, it was the glass building at the corner of Victoria and Dundas streets, not far from the Toronto Eaton Centre.
The eighth floor had become headquarters of the city's case management team. Members of the 60-person unit, recruited from all departments of Toronto Public Health, interviewed all potential SARS victims, compiling a list of everyone each patient may have bumped into after falling ill.
Those lists were then forwarded to the ninth floor, where another 60 members of the contact follow-up team -- working seven days a week in two shifts from 8 a.m. to 11:30 p.m. -- sought to find every person on the list. When they found them, each person then had to be called twice a day to ensure that they were obeying quarantine.
On the tenth floor, dozens more nurses were assigned to answer the newly created hotline, which every day fielded thousands of phone calls. The triumvirate would prove crucial in the days following Mr. Tse's death, when it became apparent that hundreds, if not thousands, of people were potentially infected.
However, although it was clear that people needed to be isolated, the recently discovered SARS virus was not on the list of communicable diseases, such as smallpox or TB, for which health authorities could legally order people into quarantine. Moreover, many of the people destined for isolation were not even sick. ''It's not something we do,'' Dr. Henry said. ''Usually we don't tell well people to stay away from others.''
Regardless, lawyers working for Dr. D'Cunha's office were scrambling to approve a change to existing legislation that would allow authorities to force potential contacts to stay home for 10 days.
At the same time, as the number of probable and suspected cases continued to rise, it became obvious to Dr. D'Cunha that Scarborough Grace had to be closed.
''The more I thought about it,'' Dr. D'Cunha said, ''the more I started to feel we need to shut this place down until we clear it up.''
The hospital was officially closed on March 23. Three days later, Dr. D'Cunha drove from his North York office to Queen's Park, where he asked Ernie Eves, the Premier, to declare a health emergency.
As of that day, anyone who had visited Scarborough Grace since March 16 was ordered to quarantine themselves, even if their contact was as limited as visiting the hospital gift shop.
''My philosophy was that if I'm going to make a mistake,'' Dr. D'Cunha said, ''it's to make a mistake to do more rather than less.''
- - -
The closure of Scarborough Grace drastically increased the workload of the public health detectives stationed at 277 Victoria St. Not only were they trying to find hundreds of people who might have crossed paths with an ever-increasing number of SARS patients, but they now had to track down everyone who had been at the east-end hospital over the past 10 days.
The process began with the case management workers, who meticulously interviewed every probable and suspected SARS patient.
''We would start to backtrack with people and say: 'OK, what were you doing the day before, the day before that, and the day before that,' to try to figure out where they picked that disease up,'' said Sharron Stone, a case manager with Toronto Public Health.
The interviewers would then look forward, asking the patient where they went after becoming symptomatic. Did they go get a haircut? Did they chat with a neighbour? Who were they sitting beside at their son's hockey game?
''We've had people who attended dinner parties and when we called the people who were at the dinner parties, they said: 'Oh yeah, I thought that person looked bad. Their colour was awful. They were looking a little feverish. They just weren't themselves,''' Ms. Stone said.
After overcoming the shock of knowing their dinner guests had SARS, most people were co-operative. And it got easier as the weeks went on. ''Early on in this, people were very much in a sense of denial,'' Dr. Henry recalled. '' 'Don't be ridiculous,' they'd say. 'My relatives couldn't possibly have this. Leave us alone. Stop bothering our family.' "
But even as co-operation increased, there was still the odd person who proved difficult to track down.
"Sometimes we would have a very common name and call everyone in the phone book to see if it's theirs," Dr. Henry said.
For reasons of patient confidentiality, Dr. Henry would not say if workers ever had to call every Smith and Johnson in Toronto.
"Well, [we did] the equivalent, let's put it that way," she said.
On one occasion, health officials were certain a SARS victim hooked to a ventilator lived with another relative. That person had even visited the patient in hospital, but when nurses stationed on the ninth floor of 277 Victoria St. called to make sure he was staying isolated, nobody answered.
Authorities eventually visited the house, but they found nothing but a pile of newspapers outside the front door. If it were not for a neighbour who told them that the person was staying with another relative around the corner, the man might have never been found.
- - -
On March 28, health officials made a heartbreaking connection. A patient at York Central Hospital in Richmond Hill had also been in Scarborough Grace's emergency room on the night Mr. Tse walked in coughing and sweating.
The unidentified man had been released from Scarborough Grace, but he returned days later complaining of shortness of breath. Chances are he had acquired SARS by then, but the staff did not make the connection that he had been in the same room as Mr. Tse. He was instead transferred to the facility's cardiac care wing and eventually to York Central. That hospital now had to be closed.
"Every time we sort of thought we'd done the right things and we're moving in the right direction, we had these new fronts opening up," said Dr. James Young, Ontario's commissioner of public security. "And they were opening up not because of things we'd forgotten to do, but rather because it was further ahead of us than we realized. That was scary."
The closure of York Central was also scary for York Region's case management team, the equivalent of the Toronto unit at 277 Victoria St. The team's 50 members now had to track down more than 5,000 people who had been in the hospital between March 16 and March 28.
"That's a fairly extensive period of time for traffic in and out of a hospital," said Joey Davidson, the acting director of York Region's infectious disease control division. "Like most things, you speak to one individual and you find out there are other individuals, so your contact list tends to expand."
Most of those people also needed supplies, from thermometers to masks. In most cases, health care workers dropped the package on the porch.
Just as officials appeared to be recovering from the spike in their workload, another hiccup.
Mr. Pollack, who was in the bed beside Mr. Tse on the night he first showed up in the emergency room, had returned to the hospital on March 16 with a burning fever. He was isolated, but his wife, who had also come down with SARS, remained in the waiting room.
She sat beside two men who had driven their father to the hospital so his injured knee could be examined. The father later died, but again, officials initially failed to make the connection to Mr. Tse.
"If he had never had to go to the emergency department that day, this whole thing would have been over weeks ago," Dr. Low said.
The man's wake was held at Scarborough's Highland Funeral Home, where his two sons, who had unknowingly contracted the virus, were greeting visitors.
When the connection was finally made on April 5, health authorities obtained a list of employees from the funeral home, as well as the condolence books that visitors signed on their way in.
There was a belief among doctors, however, that the lists would not be enough to track down every potential contact, so details about the funeral home were released.
The situation was further complicated when health officials realized the infected men were part of a close-knit Catholic group called the Bukas Loob Sa Diyo Covenant Community. Investigators would later learn the brothers who had acquired SARS had participated in prayer groups at the end of March.
''When that came to light, it was shattering,'' Dr. Henry said. ''And very frightening, because by the time the dust settled over the next few days, there were 14 members of a single family who were ill.''
The toll would soon rise.
''It looked to be like we were going in the right direction," Dr. Low said. "Things were coming under control and then, bang, there was not only another 31 cases, but a couple more cases in doctors that looked after them. To me, that was another point in the outbreak that was really disconcerting. 'My God,' I thought, 'how can we possibly contain it?' "
One of the infected people travelled to Montreal for a conference. More than 400 people had to be quarantined. Nobody else fell ill.
Another asymptomatic contact travelled to Pennsylvania, where he went into quarantine before having the chance to infect anyone else. A person who had travelled to Boston was flown back to Toronto.
"We would no longer be friends with the Americans if this had spread to the U.S.," said Dr. D'Cunha, who ordered a jet to bring the patient back after his connection to the virus was discovered.
Apart from the added stress, the outbreak in the religious community ripped at the hearts of Toronto's front-line health detectives. Dr. Henry specifically recalled the story of a woman whose husband was already in hospital.
"She became ill and she called us because her two children were fine and she didn't want to spread this to them," she said. "We couldn't find anyone to look after the children. People were so afraid of going into that house. I get emotional just thinking about it."
The children were eventually moved to the Hospital for Sick Children, which agreed to look after them while their parents were being treated. The husband and wife are still in hospital. The children remain at Sick Kids.
- - -
The week between April 16 and April 22, like every other day since the outbreak began, brought its share of bad news. Most disheartening was the revelation that several masked health care workers, dressed in goggles and gowns, had come down with SARS symptoms.
"You feel awful in the sense that these people have trusted in you in that you have provided them guidelines and you've told them this is going to protect you, yet despite that, we saw people get sick," Dr. Low said. "They could have just walked off the job. They could have just said: 'Screw you guys. You told us that by doing this we'd be protected, and look, health care workers are getting sick.' "
One had ridden a commuter train before she realized she had the virus, potentially infecting a whole new cluster. Yet despite the setbacks, Dr. Henry woke up on April 23 feeling as optimistic as she had throughout the SARS ordeal. It had been several days since a new case was reported and more than 10 days -- the incubation period for the virus -- since a known link to the other cases had acquired symptoms.
"I was very confident we had reached them all," she said. "It was the turning point. We had just gotten through a horrible time and we were starting to see the light."
The light would quickly dim. After her morning jog, she hopped on a subway to work, where she learned that the WHO had issued a travel advisory warning people to stay away from Toronto.
"My team was devastated by that," she said. "We really felt that was a personal slight on the job that we had done."
The WHO rescinded its warning six days later, but not before Toronto was branded a pariah.
- - -
Today, after 23 deaths, 264 illnesses and more than 10,000 quarantines, health officials in Ontario are confident they have "turned the corner." The last new infection was recorded on April 18, but authorities are waiting until 20 days after that report -- double the virus's 10-day incubation period -- before claiming victory.
One of two new potential cases that surfaced yesterday might delay that victory, but only for a while. Both were already under quarantine, all but eliminating the chance they passed the virus one.
But the inevitable triumph, whenever it comes, will be slightly bittersweet. Numerous questions remain, questions that officials hope to answer during an upcoming inquiry into Ontario's handling of the SARS crisis.
Were the hospital closures necessary? Was there adequate co-ordination between all levels of government? Why did doctors in British Columbia know enough to immediately isolate a suspected SARS victim while their counterparts in Toronto left Mr. Tse in an emergency room gurney ths overnight?
"We did get kicked in the head several times," Dr. Low said.
Dr. Henry, however, said she takes offence to people who try to compare the B.C. case to Mr. Tse.
"What they had was a Vancouver resident who had just got off the plane from Hong Kong and was ill," she said. "Our situation was a Canadian Asian man who hadn't been out of the country in eight years who came into hospital with a community acquired respiratory illness whose mother had died at home of a heart attack."
But when officials do look back on Toronto's SARS outbreak, they immediately praise the efforts of the front-line staff that worked as detectives behind the scenes. Not only did they find every single person who needed to be found, but they endured the brunt of how the virus affected those people.
"There were some true horror stories," Dr. McGeer said. "Single mothers in quarantine with their kids. Funerals that had to be cancelled because family members were ill. A whole lot of really devastating emotional impacts on people who were ill and people who were quarantined, all of which comes back to the public health inspector on the other end of the phone."
Dr. McGeer, however, said it could only be a matter of time before those nurses are back on the phones, especially if another infected person manages to get inside the country.
"We fixed the initial crisis, which is absolutely brilliant, but we've got a huge problem to deal with in the months ahead," she said. "What you've seen is what one patient introduced into the city can do. And we're going to have more patients, and that's the challenge in the months ahead."
Sars war "won"??
There's quite a few strange sicknesses in Canada, and one of them seem to be the Canadian attitude towards the truth. Rather like the "Arab street", they are ;).
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