Canadian SARS outbreak mystifies experts

TORONTO (CP) -- Ontario officials have bit the bullet and admitted that eight cases in a suspected and disturbing new outbreak of SARS must be classified as probable SARS patients, even though they cannot say how the first patient in the new outbreak contracted the disease.

In addition, a group of 26 people have been added to the list of suspect SARS cases and "at least eight" others are under investigation as possibly suffering from the disease.

This new chain of transmission, which began in North York General Hospital and has since forced ward closures in five other city hospitals, was undetected for weeks. Officials believe at least three generations of cases have occurred in this chain.

"We're still getting phone calls and it's disconcerting," said Dr. Donald Low, a key member of the SARS containment team. "And the examination of those phone calls leads to further (case) investigations.

"We'll get through this. And we'll get through it in shorter order than we did the previous bump in the road and the bump won't be so big."

There was no immediate word from the World Health Organization, but it seemed inevitable Toronto would be put back on the organization's list of areas where local transmission is occurring. The city had just managed to shrug off that designation on May 14.

"If they are probable cases, then they (Toronto) would go on list," WHO spokeswoman Christine McNab said.

"We've discussed the fact that there have been a number of probable cases reported. And that's about all I can say," WHO spokesman Dick Thompson said Monday.

Thompson added that reissuing a travel advisory for Toronto was unlikely at this time: "I think there are pretty clear guidelines for that (travel advisory). It would be more than 60 prevalent cases. More than five cases a day but Toronto's a long way from that."

Among the eight probable cases announced Sunday were two people who have died: the index case for the entire new cluster, a man aged 96, who died on May 1 and woman aged 90 who died on May 19. (Her age had previously been reported as both in the 80s and 80.)

And there was another death to report Sunday. A man, 62, from the earlier outbreak succumbed to the disease Saturday night, Dr. Colin D'Cunha, Ontario's chief medical officer of health, announced.

SARS has claimed a total of 27 lives in the Toronto area so far. A number of people, perhaps as high as seven, remain in critical condition.

Of the new cluster of patients, 26 are being treated in hospital in respiratory isolation, six are recuperating at home and two have died.

Dr. Barbara Yaffe, Toronto's associate medical officer of health, revealed that as of Sunday, 822 people were in quarantine and another 1,115 who might have been exposed at two affected hospitals had been given the all-clear.

She tried to assuage the local public -- and the international community -- that SARS is not spreading unchecked throughout the city.

"There continues to be absolutely no evidence of transmission of SARS in the general community."

But the source of the new outbreak remains a mystery -- and one the experts may never be able to fully crack, Low admitted. "I think that's quite possible."

Both the WHO and Health Canada definitions for probable SARS cases require what's known as an "epi link" -- epidemiological evidence that the person being diagnosed actually came in contact with someone who had the virus.

While the disease investigators have been able to link all the new cases to one another, they have not yet linked the index case to someone who had SARS. But given the way the disease has spread and the fact that one of the cases has tested positive -- twice -- for the SARS coronavirus, the medical experts who advise the containment team recommended Sunday that these cases be listed as SARS.

The 96-year-old man had surgery at North York General Hospital for a fractured pelvis. While in hospital, he somehow contracted SARS. His doctors thought it was post-operative pneumonia, which is common in the elderly. The date of onset of his disease, which Low previously listed as April 22, has been pushed back to April 19.

North York had a SARS ward at the time, but it was several floors away from the orthopedic ward where the index patient was treated. That, for now, is link enough, Low suggested. "That's the epi link, that this was a person in an institution where there was SARS."

A staff member might have worked through a mild case of SARS or a piece of equipment used on the SARS ward may have been used on the man while still contaminated with SARS-laced droplets. Or perhaps the virus became airborne for some unexplained reason, he said, though he noted to date experts believe airborne transmission does not play a role in the spread of SARS.

He noted a team of investigators from the U.S. Centers for Disease Control, who were in the city last month to help with infection control measures, are returning to Toronto and may find some answers.

He was also unwilling to cast blame on North York staff for not spotting a series of cascading SARS-like cases.

"It's really easy retrospectively," Low said. "This stuff becomes so obvious when you look back at it. But it really is difficult (to diagnose) at the time."

"One of the things that we hope we'll learn from this is to give some better guidance on how we can prevent this from happening again."

A woman who was on the ward with the 96-year-old was transferred on April 28 to St. John's Rehabilitation Hospital. A few days after arriving, she began suffering from SARS-like symptoms. But because she had no known link to a SARS case, she was not classified as a SARS patient and was not treated in isolation. She spread the disease there.

In fact, it was only when four cases from that facility came to light last Thursday that officials realized the SARS genie was back out of the bottle.

At that point, it had appeared that Toronto's outbreak was fully contained. A handful of people remained in hospital with the disease, but there had been no new case since April 19.

In response to the news, the CDC reissued a travel alert for Toronto, essentially warning Americans travelling to and from the city that it was in the grips of a SARS outbreak. The CDC had lifted an earlier travel alert for Toronto merely three days before.

The toll on hospitals was immediately apparent. A number received unidentified SARS patients either in hospital-to-hospital transfers or as walk-ins in their emergency rooms. As a consequence, unprotected staff have been forced into quarantine.

Toronto General Hospital closed its emergency room to ambulances because of possible exposure there. St. Michael's Hospital closed its neurosurgery and neurotrauma units until June 2 and placed 70 staff members in quarantine.

Scarborough General Hospital, which received one of the undetected cases in a transfer, was under some limitations as well. Two wards were closed at Baycrest Centre for Geriatric Care.

All emergency departments in the city have been placed back on high-level SARS precautions. And the two hospitals at the heart of the new outbreak, St. John's and North York, were closed to new patients, transfers and discharges.

One of the co-chairs of the SARS scientific advisory committee said hospitals had known this kind of development could occur and have rules for how to respond.

"Whether it would have been an imported travel case or something that was smouldering from within, we hoped it wouldn't happen but we planned for it to happen," Dr. Brian Schwartz said.

"And so that what we're doing is asking hospitals and community health care providers to flip the switch back into outbreak mode . . . to get this under wraps."

You are sounding like some of our leftist friends here. Why wouldn't they just call their pastor or rabii and let them know they are in trouble?

A recent neighborhood (rural, farm, "poverty stricken" area) occurence:

The 71-year-old farmer, across the street and up the mountain from us, was in a farm accident that resulted in him being pinned under his tractor, on the Saturday before Easter. He was badly hurt with 7 cracked ribs and a crushed pelvis. Two surgeries later, he has a metal frame holding his pelvis together, has lost so much weight he looks like "walking death" and is facing 14 weeks of painful recovery, and months of physical therapy.

You may wonder: How will our friend and his wife eat this winter? Who is tending the hay fields? Who will feed the cows? How will the cattle get to market? How will the medical bills get paid?

There is nothing for you to worry about, except any praying that may ease his pain and suffering he and his wife are experiencing. We, his immediate community, will handle their needs. All the farmers in the area have taken on a little extra work. Our family will deal with the garden and many folks will help with the canning. Donations have poored in from area churches. Food shows up every day.

The point is he does not need emergency government assistance and neither will any future SARS patients. They need only reach out to their local churches or neighborhood groups, and the help will come from all directions.

SARS raises new questions, comparable to our early experience with HIV in the early 80's. In the absence of answers to the questions, we tend to conjure up imaginary scenarios and theories to explain what we are seeing. It is obvious that this virus is resilient, elusive, and tenacious.

Those who assign fault to socialized medicine in Canada are providing themselves temporary reassurance. Given the right group of carriers, this disease could overwhelm this country in a matter of weeks. A single prostitute in a truck stop, a sailor on leave in Seattle, or a homeless person in New York, could shift the infection from the traveling class to the general population.

There are so many unanswered questions about the infectious period of the disease, its incubation time, and the route of transmission, that it is ridiculous to make any judgment about whether it can be contained or not.

I am also concerned with the political/economic implications of this disease. The consequences of diagnosis of the disease are so grave that I fear corporate medicine and governmental agencies are going to be at least 30 days behind the disease, waiting for "someone else" to be first.

I said once before that millions could die from SARS in the US. I still believe it and pray that I am wrong. I have a family to worry about just like all the rest of you.

SARS Mortality Rates [reflects treatment] for 'PROBABLE' cases only Based on World Health Organization daily tables (Revised: May 26 pm)
Area	Recoveries to date	Deaths to date	Recent** Death Rate	Active Cases still in Danger	Projected Future Deaths	Projected Cumulative Mortality
China	2829	317	10.2%	2170	222	10.1%
Taiwan	112	72	76.4%	401	262	57.1%
Hong Kong	1276	267	13.8%	183	25	16.9%
elsewhere [30 countries]	448	70	11.9%	58	7	13.4%
** Recent deaths are based on findings from the Imperial College of London...... that deaths take 12 days longer on average than recoveries on average..... = (12-day recent deaths) / (12-day recent deaths + prior 12-day recoveries)

Taiwan only reports 'probable' cases when they are the most obvious, or in CRITICAL condition, which is why their death rates seem so high.
Taiwan maintains an additional shamelessly high 'suspected' count exceeding ONE THOUSAND patients, and has stopped reporting 'suspected' cases to hide this problem.
China's numbers also seem manipulated and underreported.

Trend - Active Cases Still in Danger [reflects containment] for 'PROBABLE' cases only
Date	China	Taiwan	Hong Kong	elsewhere 30 countries	World-wide all 33 countries
May 12	3068	138	399	95	3700
May 13	3061	153	374	89	3677
May 14	3046	170	343	85	3644
May 15	3034	196	309	78	3617
May 16	2969	193	297	79	3538
May 17	2918	221	276	76	3491
May 18 (est.)	2870	254	263	73	3460
May 19	2799	249	250	70	3368
May 20	2700	268	236	69	3273
May 21	2618	295	227	65	3205
May 22	2526	349	217	62	3154
May 23	2438	396	209	59	3102
May 24	2326	386	196	68	2976
May 25 (est.)	2259	386	184	61	2890
May 26	2170	401	183	58	2812
May 27	...	408	...	...	...
(includes new daily cases... excludes cases resolved by death or recovery) (some tables are supplemented with government data when WHO data is missing)

I believe China's numbers are highly fictional.
Taiwan's 'probable' count should be FOUR or FIVE HUNDRED higher.
Taiwan is withholding 'probable' cases and calling them 'suspected'. This raises their 'probable' mortality rate, and obscures their real containment.

a ten-fold increase

Since Toronto has local transmission, they do not have a way to wiggle out.

No, I think Toronto is still INSISTING they have had no local transmission.

And never underestimate The Canadian socialists to find another loophole to keep from reporting more SARS cases. Just look at how the weasels treated these Toronto cases that traveled to other countries before they were diagnosed...

Australia: A family of five (2 adults, 3 children) residing in the Greater Toronto Area departed Toronto on March 28, 2003 and arrived in Australia on March 29, 2003. Child A had onset of influenza-like illness symptoms on March 31, 2003 and was hospitalized on April 3, 2003 with high fever and respiratory distress; a chest x-ray revealed infiltrates. Child A was diagnosed as a SARS case according to the WHO case definition, which differs from the Canadian SARS case definition by including Toronto as an "affected area". Child B had onset of cough on March 25, 2003. Child C had onset of cough April 1, 2003. Both Child B and Child C were subsequently reported as probable SARS cases according to the WHO case definition. All three children have since recovered. Both adults remained well. No clear epidemiologic link to any known SARS cases in Canada could be established. No secondary transmission was observed. In Canada, none of the children would have met the case definition for a probable or suspect case of SARS. Child A would have been classified as GEO-linked, that is, a person with fever and symptoms consistent with severe atypical pneumonia who has been in an area with local chains of transmission of at least 3 generations, who does not have an epidemiologic link. Children B and C would have been classified as Persons Under Investigation (PUI).
Germany: A 26 year old woman was temporarily residing in Toronto. On March 31, 2003 she flew from Toronto to Germany. She was asymptomatic until April 3, 2003 she developed headache, nausea and vomiting. She subsequently developed fever (maximum 37.8°C) and cough. She was admitted to hospital on April 7, 2003 and diagnosed with pneumonia. Chest x-ray revealed infiltrates. No clear epidemiologic link to any known SARS cases in Canada could be established. No secondary transmission was observed. In Canada, this woman would not have met the case definition for probable or suspect SARS. Rather, because of her sub-38°C and lack of epidemiologic link, she would have been classified as a Person Under Investigation.
United States: A 52 year old man residing in Pennsylvania travelled alone by car to Toronto on March 28, 2003 He drove back to Pennsylvania alone on April 1, 2003. On April 3 he became symptomatic with chills, fatigue, myalgia, headache and diaphoresis (excessive sweating). On April 6 a fever of 38.2°C was documented and on April 7, 2003 he developed respiratory symptoms and was hospitalized on April 14, 2003 with pneumonia. Chest x-ray showed bilateral patchy infiltrates, serum was positive for coronavirus antibodies and he was diagnosed with suspect SARS , and would have been diagnosed as such in Canada. This man was discharged from hospital on April 21, 2003. The suspected exposure was thought to have occurred at a religious meeting he attended in Toronto on March 28-29, 2003, where a symptomatic SARS case was also present. Pennsylvania health authorities have reported that a family member had symptoms consistent with the suspect SARS case definition, but the onset of symptoms in the family member occurred before having had contact with the 52 year old man case. Therefore, this family member cannot be considered a transmission of any sort from the case.
Philippines: A 46 year old woman residing in the Greater Toronto Area departed Toronto on April 3, 2003 and arrived in Manila, Philippines on April 4, 2003 via Narita Airport in Japan. This case had onset of fever on April 6, 2003. On April 11, 2003 she developed diarrhea and cough; on April 12, 2003 she was admitted to a local hospital at which time a chest x-ray revealed bilateral infiltrates. She continued to deteriorate. On April 13, 2003 five family members drove her to a speciality hospital in Manila where she was admitted and diagnosed with probable SARS. She continued to deteriorate and died the following day. The suspected exposure was thought to have occurred in Toronto on April 1 and April 2, whe n on each occasion, she spent a short period of time in the home of a symptomatic probable SARS case. She did not have direct contact with this SARS case; it is hypothesized she may have had contact with fomites in the home of the case. The Philippines authorities have reported secondary transmission to a health care worker, who has been diagnosed as a probable SARS case. In addition, the father of the woman, who was ill with cancer, died and is now being reported by the Philippine Department of Health as a probable case of SARS. There is insufficient information at this point to judge whether these two cases of transmission would have been classified as such in Canada, but the woman would have been classified as a probable case of SARS in Canada.
Summary: Of the 6 persons originating from Canada who were diagnosed abroad as cases of SARS, 4 would not have met the case definition for probable or suspect SARS in Canada. Only the case reported in Pennsylvania and the case reported in the Philippines would have met the SARS case definition in Canada.

...So the Canadian Hillary!@#$Care would have released all but two people to go infect others.

And U.S. and Canada would ONLY classify the PA man as SUSPECTED?
He even tested positive for coronavirus! (for crying out loud)

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