Toronto a SARS Hotspot

It's usually pretty simple for Kandra Kaufield to get to work. The 27-year-old grade-school teacher from Charlottetown lives in suburban Hong Kong, a short walk from the train station where she catches her daily, hour-long ride into the city. Her apartment building is up a steep, bustling road, part of a surreal complex of two dozen 30-storey high-rises clinging to the side of a mountain. The towers are hives of humanity - and possibly infection. These days, when Kaufield leaves the relative safety of her shared 28th-floor apartment, she rides the elevator to the lobby with some apprehension. The consequences of her next few steps weigh on her as she wonders: is it safe to go outside?

All around Hong Kong, people go about their business in masks. The economy's losing tens of millions of dollars, commuters shun public transit and the World Health Organization, in a rare move, says stay away unless a visit is absolutely necessary. One high-rise apartment tower that Kaufield passes on her way to work has been emptied, its residents quarantined in special camps built on the outskirts. The city is trying to come to grips with severe acute respiratory syndrome, the mysterious ailment, likely viral in origin, that had stricken 761 people there, and 2,354 in 18 countries worldwide, by last week, killing at least 85.

If SARS were a book, it would be an epidemiological whodunit with no obvious end in sight. As labs worldwide - including Health Canada's maximum-security facility in Winnipeg - pressed the search for the cause of SARS, the WHO maintained a global health alert, calling for any patient with atypical pneumonia to be isolated and imploring a jittery world to be watchful.

Understandably, people want answers. Here in Canada, another global hot spot with more than 180 suspected and probable cases and eight deaths (with a ninth under investigation) by the end of last week, health authorities stress that the risk to the general population is extremely low. To keep it that way, Dr. Colin D'Cunha, Ontario's commissioner of public health, and public security commissioner Dr. James Young applied tough SARS restrictions to hospitals provincewide. That means no visitors except on compassionate grounds (parents of sick children, for example, or a dying patient's family) and more security staff and police to enforce regulations. All emergency and critical-care employees are wearing masks and other protection, and anyone who enters a hospital is screened for possible contact with SARS. There are no non-urgent transfers of patients between health-care facilities, and in the Toronto region, elective surgeries are cancelled and some clinics closed.

As the restrictions spread, Toronto stood shaken. All eight Canadian deaths are associated with the city, and the number of its probable and suspected cases continued to climb last week, reaching 150. Some were recovering - 23 were sent home from hospital, though they were expected to remain in isolation for up to 10 days. Among those who died, seven were elderly or ill when they contracted SARS, and five of those had connections with Toronto's Scarborough Grace Hospital, epicentre of the city's outbreak. The eighth, the 44-year-old son of Canada's original SARS fatality, was not known to have been otherwise ill. He sought treatment at Scarborough Grace, and died there.

Nerves began to fray. An Ipsos-Reid poll found two-thirds of respondents across Canada thinking that anyone arriving from SARS hot spots should be quarantined or not allowed into the country. A few Torontonians took to wearing masks in the streets but, citing the best medical advice available, the Toronto Transit Commission directed anxious drivers to abstain from the practice. There's no call for a mask in public places, warned Young, the public security commissioner. "The need for masking is in health-care facilities, for people in isolation to isolate themselves from their families," Young said, "not in the general community."

Seeking to contain the outbreak, health authorities asked all Toronto-area residents who'd visited Scarborough Grace, or otherwise had possible contact with SARS, to go into voluntary quarantine. That meant some 2,500 people had to stay home and wear masks around their families. By last week many had completed the requisite 10 days of isolation, the presumed maximum incubation period for SARS, and were free to resume their lives. Five men and women were known to have flouted the quarantine request - last week authorities ordered them into mandatory isolation.

Across Canada, communities took precautions - isolating suspected SARS carriers, setting up SARS information hotlines - to avoid becoming another Toronto. And in that nation's biggest city, as evidence mounted that the health-care infrastructure was nowhere near ready to cope with the threat of an epidemic, authorities struggled to avoid becoming another Hong Kong.

THE OUTBREAK began in China's Guangdong province last November, and spread to Hong Kong in February. Only last week, after a delay that the international community condemned, China finally allowed WHO investigators into the region. Beijing even took the extraordinary step of apologizing to the world for not acting sooner. By then, SARS had had a devastating impact on Hong Kong and its surroundings, killing at least 17 by last week. Warning signs have appeared just about everywhere, says Kaufield - in restaurants, apartment buildings, theatres. They alert people to symptoms - temperature of 38° C (100.4° F) or higher and a dry cough, shortness of breath or difficulty breathing - and urge them to wash their hands frequently.

Most medical authorities stuck with the theory that SARS requires close contact to spread, and that it isn't airborne - that is, infectious particles don't remain suspended in the air for long. But as it appeared that the virus could survive on some surfaces, doctors urged Hong Kong residents to wear gloves, use their keys to push elevator buttons and avoid movie theatres and other crowded places. The scene outside Kaufield's apartment building was typical. "It's like walking into a surgical unit," she says. "The majority of people are wearing masks everywhere you go - it's very disconcerting."

In Canada, as the SARS scare made its way across the country with new suspected cases in British Columbia, Alberta and Atlantic Canada, the disease remained most troubling in Toronto. Dr. Shaun Peck, B.C.'s deputy provincial health officer, expressed his concern over what was happening. "I don't think from what I know of Ontario they're able to say that the outbreak is controlled yet," said Peck. "They'll have to wait two to three weeks to determine whether it is."

Actually, Vancouver was fortunate. Physicians treating the first probable case there were mindful of an alert for another disease with similar symptoms - a new flu strain - and quickly isolated the patient. In recent years, the international medical community has repeatedly warned that the conditions are ripe for the appearance of a deadly new flu strain with the potential to kill millions. Even with that knowledge, says Dr. Donald Low, chief microbiologist for Toronto's Mount Sinai Hospital, SARS caught Ontario off guard. Provincial officials rushed to draft critical documents outlining key emergency-response procedures, including when and how to close hospitals, put people in isolation, admit someone to hospital, or transfer a patient. The action plans came together only by March 31, says Low, more than three weeks after the first Canadian death. "We're playing this huge catch-up in creating all of these high-level documents in a period of 24, 48 or 72 hours," says Low, in quarantine himself last week after exposure to a colleague who was unknowingly incubating the disease. "It's an incredible amount of work - we were not prepared to do that."

Why wasn't Ontario ready? A matter of priorities, Low responds. "It's not at the top of the pile," he explains. "As well-intentioned as people are, they have other responsibilities, whether it's having to respond to bioterrorism, having to worry about their own institution, or their own patients." Provincial cutbacks in infection-control specialists and lab staff didn't help, he added.

Another lesson learned: a crisis requires good, strong leadership from a discernible source. The chain of command, says Tom Closson, chief executive of Toronto General and two other affiliated hospitals, was "a bit rocky from Day 1." In the early days of the outbreak, says Closson, it was unclear whether Ontario's Ministry of Health or Toronto Public Health was directing the response. Clearing up the confusion, making it clear that Young was in the saddle, took a while. "I've learned that if you don't know who's in charge," adds Closson, "you don't know what to do."

Figuring out what to do was particularly difficult at Scarborough Grace. The first SARS patient to die in Canada, Sui-chu Kwan, 78, was infected while staying at Hong Kong's Metropole Hotel in late February. When she returned to Toronto, she sought care from a family doctor, but passed on the infection to both her doctor and her 44-year-old son, Chi Kwai Tse, before dying at home on March 5. Eight days later, her son died at Grace - a day after the WHO issued its global health alert. An ailing elderly man in the bed next to his became the third fatality. That got nurses and other staff talking about a serious, travel-related respiratory illness. But when they tried to take the precaution of wearing masks, it didn't go over well with hospital supervisors.

An incident at Grace as late as March 22 illustrates the confusion and tension. By then, SARS had killed three people in Toronto. Twelve others were probable or suspected cases. The disease was spreading alarm in Hong Kong, Singapore and Hanoi. According to two nurses who requested anonymity, a Grace staff member responsible for infection control told a physician that day that he didn't need to wear a mask. "It was bad for public relations," is how it was put, said one nurse. Added the other: "And it wasn't just the infection-control people, it was management saying, 'You know, it's not good PR to be wearing the mask, you really don't need that mask, it's overkill.' " Four days later, on March 26, Ontario declared a public health emergency and called on thousands of people to quarantine themselves in their homes.

But the situation at Grace at the time wasn't cut and dried, says the hospital's chief executive, Ronald Bodrug. There were debates over how widely masks should be used in the hospital. Even now, he says, some say the hospital's precautions went too far and unnecessarily alarmed the public, while others say more drastic steps should have been taken. "I think everyone has the right to share their perspectives," says Bodrug.

Beyond that hospital's decision-making, Barb Wahl, president of the 47,000-member Ontario Nurses' Association, says the province responded too slowly. As a result, a hodgepodge of safety measures trickled into place. "In one hospital, everyone with direct patient contact was wearing gowns and masks," she says. "In another, I heard from a nurse: 'I'm not being given a gown and a mask. I'm really scared, what should I do?' That tells me that we weren't prepared."

Not all take that view. "I really don't think we can criticize," says Dr. Lionel Mandell, chief of the infectious diseases division at McMaster University's medical school in Hamilton. "Hindsight is 20/20 - everybody recognizes things in retrospect. That's life." The consensus in the health-care community is that all that can be done is being done. Nonetheless, Toronto is left wondering just how bad things could still get.

Provincial health authorities note the outbreak has been limited to contact with a few so-called index cases - SARS patients who contracted the disease in Asia. Those patients infected unsuspecting medical staff before masks, gowns, gloves and goggles stemmed the spread in hospitals, says Low. "All the transmission to date is all hospital related," he says. "We don't have evidence yet that it's in the community."

The thing to watch for in Canada now is whether SARS keeps spreading. Will someone catch it on a bus? Or in an apartment building? Most medical experts, including those at Health Canada and the Centers for Disease Control and Prevention in Atlanta, say SARS is carried in respiratory droplets that fall quickly to the ground when a patient coughs or sneezes, minimizing the dispersal of infectious agents. "I think that at the end of the day," Low says, "it's not going to be found to be airborne." But nothing is ruled out completely, and SARS, say CDC researchers, may yet prove to have an airborne component. Low also points to the indications that the virus can survive briefly, perhaps a couple of hours, on a variety of surfaces. That underscores the need for frequent handwashing.

As for the cause, the evidence increasingly points to a member of the coronavirus family, possibly working in tandem with other viral partners in this biological mystery. Whatever the causes, doctors advise patients to watch for an initial headache coupled with muscle or joint pain, followed by a high temperature, a dry cough, and breathing problems. So far, say doctors, it appears - though it's not certain - that patients become infectious only after the onset of symptoms. Some patients were treated with broad-spectrum antiviral, antibacterial drugs in the hope something would work. Others simply got better after resting and drinking fluids. Seeking another weapon, Health Canada has approved the testing of ribavirin, an antiviral drug normally used to treat hepatitis C. But still to be seen is whether any recovering patients suffer long-term lung problems.

SARS HAS ALREADY left a deep scar in the world of commerce. In a few cases, it has been good for business: pharmacies sold out of thermometers and masks, and grocery-delivery services experienced a spike in orders among the quarantined in the Toronto area. But those are rare exceptions. Randy Williams, president of the Tourism Industry Association of Canada, says it's too early to know the full impact on that sector, but it's hurting. Even his own group is dealing with cancellations from abroad for its annual conference, showcasing Canadian travel, scheduled for next month in Vancouver. The no-shows are citing both SARS and the war in Iraq.

With the travel industry suffering worldwide, SARS was yet another unwelcome blow, especially for Air Canada, which sought bankruptcy protection last week. Toronto's economy took a big hit when the American Association for Cancer Research cancelled a gathering of 12,000 of the world's best researchers. And it wasn't just the doctors - the Registered Nurses Association of Ontario called off a scheduled gathering of 700 members in Toronto this week.

The trick, in these scary times, is finding the right balance between being reasonably cautious and putting your life on hold. For Kandra Kaufield in Hong Kong, it means resisting pressure to follow fellow teachers and friends back home to Canada. "You've got this constant worry, as soon as you step out your door, about everything from touching an elevator button to breathing in a small space," she says. "It's constantly on your mind." In Hong Kong, it's anybody's guess if another wave of infections is coming - and how big it might be. "But the general feeling," says Kaufield, "is that things are going to get worse before they get better."

To those who wonder if Toronto's response to SARS has ultimately been overblown, Low insists that's not the case. "Can you imagine if this gets into a school?" he asks. Besides, he adds, "we don't know the long-term consequences of these infections." As the battle continues against a new and dangerous disease, there's still room for optimism - nervous optimism.

HOW A NEW DISEASE STALKED THE GLOBE

The Geneva-based World Health Organization (WHO) says SARS first appeared last Nov. 16 in Foshan, Guangdong province, China, but Beijing issued no alert. The global outbreak began when a semi-retired medical professor from Guangdong checked into the Metropole Hotel in Hong Kong on Feb. 21, and at least six others became infected. One, a 78-year-old woman, flew to Toronto, triggering that crisis. Another, a 55-year-old man, carried the disease to Vancouver. Three others took SARS to Singapore, and a doctor infected there transported the disease to Germany. A sixth went to Hanoi, introducing SARS to Vietnam, and a person infected there carried the virus to Thailand. On March 12, the WHO issued a global health alert. By March 17, the agency was reporting 167 cases and four deaths worldwide. Hong Kong, Hanoi, Singapore and Toronto had become SARS hot spots; in Germany and Thailand the disease was contained. Then, almost daily, new countries informed the WHO of probable cases, and the death toll rose.

See also Disease and Epidemic.

Maclean's April 14, 2003