Posted on 05/26/2003 7:22:01 AM PDT by Dog Gone
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.
They also believe more cases are coming.
"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.
"It's not over."
But Low expressed confidence the new outbreak would be tamed.
"It's a tough lesson, but we'll learn from it," he said in an interview.
"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.
Here's what they do know:
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."
Low could only speculate as to how the man caught the virus.
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."
So the faulty clinical definition of SARS played a crucial role.
It doesn't look like any of those things will happen.
Isn't the development of an effective treatment a fourth possibility? Or are you assuming that that is impossible?
But, they cannot identify the index case. So...
"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.
If we can come up with a pill or something that instantly cures SARS, we'll be in good shape.
I want to own the patent on that pill, by the way.
My lord, who comes up with these guidelines? Mary Poppins?
The only reason we don't have big outbreaks of SARS in this country is because we're lucky.
Is ViroPharma trying to discover treatments for SARS?Yes. We are currently evaluating compounds from our chemical library for potential inhibitors of the recently identified coronavirus that is believed to cause severe acute respiratory syndrome (SARS). The SARS coronavirus (SARS-CoV) is an RNA virus, a virus group for which we have substantial expertise in antiviral drug discovery and development.
We are collaborating with the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) in Frederick, Maryland on this program. USAMRIID and ViroPharma have together established a high capacity testing assay and are evaluating compounds provided by us in an effort to discover specific antiviral compounds that prevent SARS-CoV from attacking healthy human cells.
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