Canada’s Experience With SARS

Our Futures Task Force II learning journey to Canada also provided an outstanding opportunity to meet with and hear directly from the physician who was the key spokesperson and coordinator for the SARS epidemic that occurred in Tornoto in 2003.

Based on his report, we were all re-educated in the epidemiology of an epidemic and relearned that careful attention must be given to every detail in the investigation and that all the dots must be connected in order to determine the cause of the initial outbreak and to learn the methodology of “spread” so that as quickly as possible, barriers can be put around the causes and the geographical locations so as to mitigate the future spread and expansion of the problem.

With regard to the SARS epidemic specifically, what were the learnings that can be applied to the possible rapid identification and control of a future U.S. or international pandemic?

1. A high level of suspicion should be maintained in all health care providers for patients who present in clinics, EDs or hospitals with symptoms that cannot be rapidly connected to a traditional diagnosis.
2. Concerns should be heightened when patients return on a frequent basis in less than 24 hours with worsening symptoms that, again, don’t traditionally relate to a classical diagnosis.
3. When unexpected deaths occur from what are at first thought to be simple viral illnesses, one should be concerned that something very different might be occurring.
4. When clumping of similar patients with similar symptoms begin to present themselves, either in the same or different locations throughout one geographical area, the possibility of an epidemic or pan-epidemic should be occurring to health care providers and should perhaps trigger the report to the appropriate local, state and even national health care departments.
5. When providers start to complain about the same symptoms that patients came in complaining about, indicating a high potential of an infectious disease, one should again be very concerned that an epidemic might be occurring.

Clearly, if all of these findings are seen, it is important that health officials as well as epidemiologists and infectious disease specialists be sought and brought into the investigation to review any suspicious cases and to commence the process to identify the source of their illness and better clarification of the causes of these illnesses.

All these suspicions identified above and the implementation of the team I just described occurred in Toronto’s SARS epidemic, and as a result of this rapid learning, resulted in this epidemic being isolated predominately to the Toronto area.

Let’s look at this situation more closely as a case study to emphasize the points outlined above. In essence, a husband and wife presented to an ED complaining of what appeared to be a respiratory illness. Over several days, the patients got extremely sick and both died as a result of what--at that time--appeared to be a serious and rapidly advancing pneumonia-like illness. Shortly thereafter, the children of this family became ill simultaneously with several of the staff members who were caring for the patients. In addition, an unrelated patient to this family also became ill with similar symptoms and subsequently died. Immediately, sophisticated laboratory studies were put in place to identify what virus or bacteria might be causing this illness by utilizing samples of sputum and blood from all the affected patients and caregivers.

In addition, the unrelated patient was tracked through the Emergency Department, and it was discovered that he or she was cared for in a room where the original patients who died were treated a day or two earlier. Immediately, all these facts were put together and the staff quickly declared that a pandemic was in process.

This resulted in the following immediate and required next steps:
Isolation wards were created in the hospital where more intensive infectious disease prevention techniques were implemented, including negative air flow, intense hand washing and daily decontamination/ disinfection of the rooms, beds and bedding. Toronto was closed down to tourist travel, and no one was permitted to come into hospitals where there were infected patients except critical staff.

These steps eventually caused all of the patients to be further identified and treated as quickly as possible in isolation settings. Eventually no new cases arose, and the patients who had the diseases were either recovering or, unfortunately, had expired.

It is clear that pandemics are a potential in America and in the world, with highly resistant new strains of bacteria and viruses that will be very challenging to treat. But the appropriate handling of a pandemic is based on scientific knowledge and processes which have been clearly identified in the past and have been reemphasized and studied as a result of the SARS epidemic and how it was handled successfully. It is always imperative to reacquaint ourselves with scientific principles and processes by using current case studies, and the review of the SARS epidemic on our recent learning journey gave us this real-time opportunity.