SARS: The Toronto Experience. James G. Young, M.D. Commissioner of Emergency Management Ontario, Canada

Transcription

1 SARS: The Toronto Experience James G. Young, M.D. Commissioner of Emergency Management Ontario, Canada

2 University at Albany School of Public Health Center for Public Health Preparedness Grand Rounds Series

3 Thanks to our Sponsors: University at Albany School of Public Health Centers for Disease Control and Prevention Association of Schools of Public Health

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5 Evaluations Please submit your evaluations on-line: ID=26 or send the hardcopy version provided by your site coordinator to the University at Albany School of Public Health Center for Public Health Preparedness. Thank you!

6 Center for Public Health Preparedness For more information please contact us at or or visit our web-site:

7 Why Is SARS Important? It could return Represents appearance bioterror Pandemic similarities

8 SARS Our Success A very large multidisciplinary team pulling in the same direction and led by front line health care workers.

9 Hong Kong The Metropole Hotel

10 156 close contacts of HCWs and patients Chain of Transmission among guests at Hotel M Hong Kong, HCWs 4 other Hong Kong Hospitals 4 HCWs # 3 HCWs 2 family members Hospital 2 Hong Kong Hospital 3 Hong Kong 99 HCWs (includes 17 medical students 0 HCWs Hospital 1 Hong Kong Hospital 4 Hong Kong A H J B Bangkok Guangdong Province China H J HCW A B B HCW A F Hotel M Hong Kong C Vietnam D 37 HCWs Unknown number close contacts 4 family members G K I E C F D Canada G K E I Singapore 34 HCWs 37 close contacts 2 close contacts United States 10 HCW Ireland HCW L M HCW 2 family members Germany Data as of March 28, 2003 # Health-care workers; All guests except G and K stayed on the 9th floor of the hotel. Guest G stayed on the 14 th floor, and Guest K stayed on the 11 th floor; Guests L and M (spouses) were not at Hotel M during the same time as index Guest A but were at the hotel during the same times as Guests G, H, and I, who were ill during this period.

11 Feb 23, index case returns from Hong Kong March 5, index case dies at home March 7, case 2 in ER March 13, case 2 dies; 5 family members admitted

12 March 12 th WHO Alert Atypical pneumonia Health workers most affected Unidentified cause Spreading in south-east Asia

13 Figure 3. Transmission of SARS in Hospital A (N=72) Family A s physician 1 CC 4 members of family A 1 X-ray tech 1 HH 3 ICU nurses March 16, ER visitors 1 ER patient 5 HH 1 CC 3 EMS 3HH Index Case (died) Case A (died) Case B (died) Case B s wife (died) 1 physician 4 ER nurses Clinic nurse 1 Housekeeper 1 EMS 1 HH 2 ER nurses 2 ER nurses Case C (died) 1 ER patient 1 ER Clerk 1 visitor LEGEND 1 Housekeeper Case C s wife 1 physician 1 physician s clerk HH CC Case Household case Close contact case Transmission outside of Hospital A 1 CCU Clerk 6 CCU nurses 1 CCU patient ( 1 died) Transferred to Hospital B 3 HH 3 HH 1 HH Transferred to another hospital 1 coworker private sector

14 Outbreak Control How do you stop an outbreak when: Agent is unknown Incubation period uncertain Mode of transmission not entirely clear No diagnostic test

15 Outbreak Control (con t) No prophylaxis No vaccine No treatment R 0 = population density x infectivity x time

16 Why a Provincial Emergency? Scope Hidden cases Getting ahead of the outbreak

17 Organization Premier of Ontario Minister of Health and Long-term Care Commissioner of Emergency Mangement Commissioner of Public Health POC Executive Committee Scientific Advisory Committee Other Provincial Ministries (MOL, Police etc)

18 Organization Multiple jurisdictions Multiple professions Bold, rapid actions Coordination and consistency System wide approach Transparency

19 The Reality You deal with the facts and the institutions you are given.

20 The Balancing Act Patient risk versus Infection control Medical education

21 Infection Control - Education Hand washing Technique Working sick Diagnosis of exclusion

22 Infection Control Movement Patient transfers Staff Clinics Visitors

23 Infection Control - Equipment Staff Across hospitals Emergency, ICU SARS units High risk procedures Patients Emergency In hospital

24 Quarantine voluntary versus ordered Length Determining who Where Section 22, 35 Working quarantine Income Immigration issue

25 Scientific Committee Broad based multidisciplinary Rapid turnaround Science based decision

26 20 18 Probable and Suspect Cases of SARS in Ontario by Date of Onset (as of May 16, 2003) YCHospital Suspect Travel Probable Travel Suspect Non-Travel Probable Non-Travel Index family SGHospital Religious group HCW WHO advisory Emergency declared Date of Onset

27 SARS I ( Community Clusters) Multiple Family Members Doctors Funeral Home Religious Community Family Patients Montreal Philadelphia Workplace

28 All Cases Track Back To The Grace Hospital

29 SARS ΙΙ (a possible theory) St. John s Rehabilitation Hospital St. Michael s Hospital Relative of a SARS Patient Elderly Patient (North York General Hospital) Health Care Workers Scarborough General Hospital Relative Who Traveled Toronto General Hospital North York General Hospital

30 SARS II Not necessary to shut down medical system Fatigue factor ED Closed May 23, 2003

31 Phase 1 and Phase 2 SARS Cases by Status in Ontario as of July 14, Phase 2 - Suspect Phase 1 - Suspect Phase 2 - Probable Phase 1 - Probable 16 Number of Cases Date of Onset Note: Phase 1 cases are based on Health Canada case definitions prior to May 29, Phase 2 cases are based on revised Health Canada definitions effective May 29, 2003.

32 After SARS II Slower return to new normal Surveillance Increased vigilance More provincial planning

33 WHO Travel Advisories Clear definitions and process Effect on local population Economic effects False alarms

34 SARS Economic Costs Health care > C$900 million Tourism C$1 billion (May estimate) GNP Toronto C$1 billion (May estimate)

35 SARS Communications Frequent, transparent public Multiple messages Directives, Q & A s Website Professional education Using statistics

36 Effect of SARS Communications Challenges Definitions Probable Suspect Cumulative numbers Multiple messages Foreign press

37 5 Ethical Issues Raised By SARS 1. When public health trumps civil liberties: the ethic of quarantine 2. Naming names, naming communities: privacy of personal information and public need to know

38 5 Ethical Issues Raised By SARS (con t) 3. Health care workers duty to care and the duty of institutions to support them 4. Collateral damage: other victims of SARS 5. SARS in a globalized world

39 Lessons Learned From SARS Planning, planning, planning Infection control Public health renewal Surveillance Governance Aggressive approach Proactive

40 Avian Flu A Proactive Approach Daily monitor Weekly meeting Table top exercise Changes to plans Further exercise

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42 Evaluations Please submit your evaluations on-line: ID=26 or send the hardcopy version provided by your site coordinator to the University at Albany School of Public Health Center for Public Health Preparedness. Thank you!

43 Center for Public Health Preparedness For more information please contact us at or or visit our web-site: