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?

Oh please. I am being realistic, not calling for the worker's of the world to unite.

My point was many people who come into contact with large amounts of the public work in the sevice industry. I, myself, in college waitressed and bartended. If I missed a shift, I missed $100+ (substantial amount of money for a college kid). I worked 3 days a week and many times I went to work sick.

I didn't run to my pastor because I had a cough and fever.I did the crap I had to do, just as millios of Americans would do if they had SARS symptoms.

Is there any way to correllate anecdotal reports from afflicted areas in China to actual reports and generate a more realistic number? Only two or three cities would be needed.

I've studied the numbers in every area of China that I could find. All Numbers consistently look 'picture-perfect' as if they were generated on a computer to guarantee an "all-is-well" outcome.

It's just too far-fetched to believe they have the same perfect control on this thing in every province and municipality, expecially in their hinterlands.

I think there are only three ways to contain SARS. Develop a quick and accurate test, or develop an effective vaccine in the very near future, or immediately shoot and cremate all SARS victims.

I suggested a ban on travel to and from the US to the effected areas. I was immidiately branded a a "hysteric" and a rabble-rouser, there was an especially vocal Canadian contingent.

I reiterate what I said in the past. It is my God given right as an American to learn all of details of SARS and react in anyway that I see fit. If this means terminating associations with people that have recently visited Canada or China or forgoing travel plans, because the source of infection has repeatedly been determined to be an airplane then so be it.

It's you God given right to "panic" as an American.

Thousands of people arrive in the United States from areas where SARS outbreaks are occurring to participate in gatherings such as academic courses, business meetings, or sporting events. Guidance is needed to provide a consistent, rational approach to SARS prevention without unnecessarily stigmatizing these groups or interfering with collegial pursuits, commerce, and other important activities. "
What else is there to say?

"Unnecessary stigmatization" is what we need to guard against.

See it's this type of rhetoric that really pisses me off.

On one hand you got the liberals worrying about "Unnecessary stigmatization," and on the other hand I got my own party concerned with the "financial implications" of all of this. In the mean time who is looking out for me, the guy who wants to go out of his way to avoid an inaccurable disease with what seems to me to be an disproportionately high fatality rate?

The answer. No one.

BTW: I would trust whatever I read in the Enquirer about SARS 100% over anything my own government told me.

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.

I agree with you 100%, but I suggest to you that it's only a matter of time before you are branded a hysterical rabble-rouser by those that defend the status quo here.

Sadly, their seems to be large contingent on issues such as this that are only confortable with the most optimistic view.

I remember hearing a report on NPR in 81 or 82. The story was about a new disease that was killing young gay men in Florida. I was in a public health related field at the time and I remember going back to the office and telling the boss about the NPR story.

I predicted then that AIDS would be a huge problem and that many people would die. I could not understand then and do not understand now, the almost total lack of concern for the prevention of the spread of AIDS.

I suppose we have accepted AIDS, and recognize that some have welcomed the disease because it is viewed almost entirely as a disease of choice. There is an "It won't happen in our family" mentality and certainly we do not have the political will to take the public health measures necessary to stop the transmission of HIV.

In 1981 there were 300+ known cases of AIDS. As of the end of 2001 over 800,000 cases have been reported with over 462,000 deaths.

We see the same thing in regards to automobile accidents. There is a benign acceptance of 40,000 plus traffic fatalities that are for the most part preventable.

Now we are facing SARS. We continue to believe that it will happen to someone else. Those that travel to China are at risk, but I'm not. I hear it all the time from family and friends.

We do not know much of anything about SARS at this point and the possibility of containment of the disease is almost pure speculation. If the disease is as infectious as it seems and if the mortality rate is somewhere between 10% and 20%, then we may see millions of deaths in the USA alone. That is a horrifying thought when one looks around and imagines their parents, grandparents, children, and grandchildren becoming ill and dying a horrible death.

The status quo is a wonderful thing and like the Elders of Owlgate, we can all pretend that nothing ever changes for a time, but ultimately we are going to be facing the reality that things have changed radically.

When it comes to public health, no expense should be spared to stop this disease and to find effective treatments for the cases that somehow slip through. Public health is not a democratic vs republican or liberal vs conservative issue. Public health is a quality of life issue and our survival as a republic depends on our ability to manage the public welfare.

Using AIDS as an example, if history repeats itself, we are likely to do too little much too late

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