Hi Ray,
Again only half the story. Vancouver was proactive and accordingly on the lookout.
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SARS: A tale of two cities.
CBC News Online | April 11, 2003
Toronto is in the grip of an epidemic: more than 190 cases, 10 deaths, hospitals closed, key health-care workers stricken, thousands of people exposed to the disease quarantined in their homes.
In Vancouver, the picture looks tranquil in comparison, with only three people infected, no deaths, the SARS clinic closed for lack of patients, not a single health-care worker infected, and no reports of any secondary transmissions.
So why the difference? SARS arrived in both cities on a plane carried by a traveller who had stayed at the ill-fated Metropole Hotel in Hong Kong.
Was it just luck, or did Vancouver see it coming? For anyone who was looking, there were some early signs. As early as Feb. 11 it was in the news with a story on the Associated Press wire: "Unidentified illness kills five in China." Doctors were already talking about it by e-mail. ProMed, a medical Web site, carried a notice on Feb. 10: "Have you heard of an epidemic in Guangzhou?" The threads talked about reports that hospitals there had been closed and people were dying.
The World Health Organization was aware of the mystery disease, at the time calling it Acute Respiratory Syndrome in China. The WHO issued a series of reports Feb. 11, Feb. 12, Feb. 14 and Feb. 20.
At the British Columbia Centre for Disease Control, they were watching all of that.
"I think everybody was tracking ProMed, which issued a broadcast e-mail in mid-February," says the centre's Dr. David Patrick. "And at that stage we were hearing stories about a mysterious respiratory ailment in Guangzhou, the provincial capital of Guangdong. The conclusion on that string of e-mails was that it might be chlamydia pneumonia, but they'd only found that particular bacteria in two out of over 300 cases. So we were a bit skeptical about that as an explanation."
For B.C., the big push came on Feb. 19. During a regular conference call with Canada's Flu Watch Committee, Health Canada recommended all provinces to go on heightened alert for the Avian Flu, also breaking out in China at the same time. The combination of the two outbreaks had B.C. health officials nervous.
"All that did was it put us on higher alert when we saw Avian Flu and when other things began to occur," Patrick says.
So starting on Feb. 20, the B.C. Centre for Disease Control sent out an e-mail four times to the entire B.C. health-care system, warning of Avian Flu and to be alert for any unusual influenza-like illness. On March 13, before hearing about problems in Toronto, B.C.'s alerts paid off. A man with a flu-like illness showed up at Vancouver General Hospital. He was masked and in isolation within an hour.
"That, I believe, was probably the deciding factor why we didn't see the secondary transmission from him." Patrick says. "In other words, you know, we're weeks past that now, and no health-care provider has SARS who was in contact with that gentleman."
Back in Toronto on March 7, when his first SARS patient showed up in emergency at the Scarborough Grace Hospital, Dr. Sandy Finkelstein assumed he was dealing with pneumonia or tuberculosis. Unlike the doctors in B.C., he had received no official warning of a mysterious flu-like illness breaking out in China. The sick man was not isolated right away. Instead, he spent a fateful 24 hours in the emergency room, infecting the patient in the bed beside him. Both died days later, triggering the chain of infection that has paralyzed Ontario's health-care system.
"It's very difficult to know how much to react early on in an outbreak. When you only have one family being ill, it's very possible that that's as far as it will spread," Finkelstein says.
So what did Ontario know about the mysterious outbreak in China? Health Canada mentioned the mystery illness in its Flu Watch bulletin, first on Feb. 15 and again on Feb. 22. As well, the provincial health ministry's own influenza bulletin mentioned it in two consecutive weeks in late February. In the last one, the Ontario bulletin said the WHO also reported an outbreak of atypical pneumonia in Guangdong. Tests are continuing, it said.
So why didn't an alert go out to Toronto's frontline workers before the disease showed up in March?
Dr. Sheila Basrur, Toronto's medical officer of health, says, "Again, if it is felt that it's important to issue an advisory to local physicians, then that's done. And that was exactly what was done by mid-March. I can't speak to why it wasn't done on the basis of the February notice. I presume it… I shouldn't even try to speculate."
As Scarborough Grace Hospital's Dr. Sandy Finkelstein says, public health didn't mention the mystery illness in China, even when he called to report what turned out to be the first SARS patient. "When I called and spoke to the person on call on the Sunday, they did not give me any feedback in terms of there is something going on in Hong Kong. We didn't even know about the travel history," Finkelstein says.
Still in the thick of an outbreak, Ontario health officials say it's early to be assessing whether any of this could have been prevented. But they do say there was a breakdown in infection control practices at Scarborough Grace Hospital.
"It's because those patients were not in respiratory isolation or a break in infection control practice," says Dr. Colin D'Cunha, Ontario's medical commissioner.
But for health-care workers on the frontline like Sandy Finkelstein, the early warning system from public health must improve too.
"I would hope that if this starts in another part of the world we will be able to get information to guide us early," Finkelstein says.
"It's almost like the analogy to war," Patrick says. "The price of peace is eternal vigilance. The price of health, maybe it's the same thing. I think we basically have to have good surveillance networks out there, keep an eye on the situation on an ongoing way, and if we detect problems early, that's our best opportunity to intervene."
Experts believe there are more unknown diseases coming, and that the early warnings we got of SARS might be the only kind of warning we'll ever get. And how well we responded this time is something to study for the next time, once SARS is under control.
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cbc.ca
Apparently Toronto should focus on PacRim news more closely. |
