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SARS Review Shows Toronto Fought a Good Fight

Lessons learned should lead to even better efforts next time, experts say

WEDNESDAY, June 2, 2004 (HealthDayNews) -- Using techniques ranging from aggressive quarantines to infection-control measures, public health officials in Toronto were able to control North America's largest outbreak of SARS last year.

Transmission of the disease was mainly limited to hospitals and to members of households who had contact with patients, according to a review article in the June 3 issue of the New England Journal of Medicine. It was written by officials from Toronto Public Health, the University of Toronto and St. Michael's Hospital Inner City Health Research Unit, all of which were on the front lines fighting the SARS outbreak.

"This is the first overall outbreak report from Toronto," said Dr. Bonnie Henry, associate medical officer of health for Toronto Public Health and one of the paper co-authors.

SARS first surfaced in southern China in late 2002. During the next six months, the disease infected more than 8,000 people worldwide, resulting in nearly 800 deaths in 27 countries. Caused by a previously undiscovered coronavirus, the respiratory illness usually begins with a fever of more than 100.4 degrees Fahrenheit. Other symptoms can include chills, headache, body aches and general discomfort.

During the Toronto outbreak, public health officials investigated 2,132 potential cases of SARS. They identified 23,103 people who came in contact with SARS patients who required quarantine. The officials also received more than 300,000 calls on a local SARS hotline.

Two hundred twenty-five people were diagnosed with SARS and 38 eventually died. All but three travel-related cases were linked to an infected patient in Hong Kong, according to the review article.

To prevent the outbreak from spreading, public health officials conducted intense follow-up of people who had contact with SARS patients, and imposed a 10-day quarantine in many cases. They also stepped up infection-control measures in the hospitals. Patients hospitalized with respiratory symptoms were also watched closely to determine if they had contracted SARS.

Those efforts taxed public health and hospital staffs to capacity. "One of the things that has come out of this [analysis] is how much is local," said Henry. "That is, the major amount of work is done at the front line by the staff working at the public health unit."

Manpower was often lacking, she said, and the sheer amount of work in investigating potential cases and contacts was staggering.

"For every case that we had, we ended up investigating 100 potential cases, all of which were very time-sensitive," Henry said.

"You need to have 'surge' capacity at the local level," added Henry, explaining that means hospital and public health staffs need workers who can be called in for an emergency. Such a plan often looks good on paper. "But public health budgets have been trimmed to the bone," she noted.

What was learned from the Toronto experience will hopefully be used to guide public health officials in the next epidemic challenge -- whether from SARS or another infectious disease, noted Dr. Robert Weinstein of Cook County Hospital and Rush Medical College in Chicago, who wrote an accompanying editorial in the journal.

Dr. James Young was the commissioner of public safety and security for the province of Ontario at the time of the outbreak and is now commissioner of emergency management for Ontario.

He said the review article "quite accurately describes the situation. The people who wrote it are front and center from Toronto Public Health. I think they did an outstanding job."

"We are certainly much better prepared than before," he added.

A related study in the June issue of the American Journal of Respiratory and Critical Care Medicine states that doctors and nurses in Toronto who were involved in the early critical care treatment of SARS patients were at substantially greater risk of contracting the illness.

One hundred twenty-two health-care workers studied were exposed to seven SARS patients. Ten of the workers -- five critical care nurses, two respiratory therapists, and three doctors -- were later diagnosed with the disease, according to the article.

More information

To learn more about SARS, visit the U.S. Centers for Disease Control and Prevention.

SOURCES: James Young, M.D., former commissioner, public safety and security, Province of Ontario, commissioner, emergency management, Ontario; Bonnie Henry, M.D., M.P.H., associate medical officer, health, Toronto Public Health, and assistant professor, medicine, University of Toronto; June 3, 2004, New England Journal of Medicine; June 2004 American Journal of Respiratory and Critical Care Medicine
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