Toronto hospitals under SARS siege: Will U.S. facilities dodge the bullet?

We didn’t know what we were dealing with’

Severe acute respiratory syndrome (SARS) has besieged hospitals in Toronto, spreading from patients to health care workers and now threatening to emerge independently in a community where 9,000 people already are under quarantine.

Infection control professionals in the United States should heighten their suspicion for possible SARS cases among incoming community-acquired pneumonias or they could find their facilities similarly overwhelmed before the emerging coronavirus is detected, Canadian clinicians warn.

"I have not seen an agent spread with such ease and such rapidity before," said Andrew Simor, MD, infectious disease consultant at Sunnybrook and Women’s College Health Sciences Centre at the University of Toronto in Ontario. "I think it would be a mistake to let this get away from you."

The warning came recently in Washington, DC, at the annual conference of the Society for Healthcare Epidemiology of America (SHEA). In the data reported at SHEA April 7, 2003, Toronto had approximately 160 cases of suspected or probable SARS. Nine people had died. Transmission within hospitals to health care workers and patients has been clearly documented in eight Toronto hospitals, he said.

"Our hospital has had the largest experience in Toronto with patients admitted with this diagnosis," Simor said at the conference. "We have had about a quarter of all the area patients admitted to our hospital. This has been unique experience for us. Certainly, in 20 years of experience as an infectious disease physician and hospital epidemiologist, I have never seen anything like this — with such dramatic rapid spread involving primarily people working in hospitals or direct household contacts."

In addition to dramatically underscoring how rapidly a new infection can emerge globally, the SARS outbreak has validated the importance of infection control programs in health care, he said.

"We have learned that hospital epidemiologists are essential for managing this," Simor said. "Hospitals that have had trained expertise by and large have been far better able to cope with this than hospitals lacking that expertise."

Still, the impact has been considerable; suggesting that if SARS gets loose in the U.S. health care system, it may exact a substantial toll in lives and dollars. Two Toronto hospitals have been closed to all new admissions, with their staff, visitors, and patients quarantined. A Toronto long-term care facility also is under quarantine, a particular concern because the mortality rate of SARS rises with increasing age in the infected.

"One of my biggest fears is that it will get into chronic care facilities or nursing homes," said Michael Tapper, MD, SHEA president. "The morbidity associated with any of these viral infections [e.g., influenza, Norwalk virus] in an elderly, debilitated, congregated population is very considerable. Our own hospitals are watching the events in Canada and the rest of the world with enormous interest, and frankly, enormous concern about the implications for health care facilities in the United States."

SHEA members personally affected

SARS cast a pall over the SHEA meeting, with members and scheduled speakers personally affected by a disease that has stricken many health care workers worldwide. "SARS has touched the health care community," said Trish Perl, MD, epidemiologist at Johns Hopkins University School of Medicine in Baltimore. "At this particularly meeting, we have one of our speakers who is now currently hospitalized with SARS pneumonia and three speakers who are quarantined. It has really brought this home."

At a SHEA press conference held to detail the dire situation in Toronto, a Canadian epidemiologist spoke over a speaker phone while under quarantine at home. Mark Loeb, MD, infectious disease specialist at McMaster University in Hamilton, Ontario, drew a 10-day home quarantine after coming into contact with a SARS case. He sent his family away for the quarantine period, which began after he was exposed to a fellow health care worker who had been infected by a SARS patient.

"It has been a challenge for all of us, both personally and professionally," Loeb said.

The concern now is that SARS could begin spreading in the Toronto community, independent of any epidemiologic link to travel or a health care setting, he added. If that begins to happen, any case of community-acquired pneumonia with unknown etiology will have to be treated with aggressive infection control precautions. "We’ve learned a lot about this so far, and I think long-term this is going to lead to a change in the way we use infection control precautions for patients coming into the emergency room," Loeb said. "People who have community-acquired pneumonia don’t usually get droplet precautions. We really have to rethink what we are going to be doing long term in terms of our routine standard precautions. If you have any concerns about an atypical pneumonia, put that patient under precautions and then look for the epidemiologic link — rather than the other way around."

In Toronto, a "suspect" case of SARS typically has fever, cough, and trouble breathing, plus a history of travel to the Far East or contact with a known case within the last 10 days. "We also have to exclude [all] other causes," Simor said. "A probable case means all of those features for a suspect case but in addition, severe, progressive respiratory illness. [Since] there is not yet a good laboratory diagnostic test, the diagnosis is really a clinical diagnosis along with epidemiologic clues."

Incoming patients with respiratory problems must don a mask to contain their coughing and secretions. Health care workers use the aforementioned droplet precautions, which include gloves, gowns, goggles, and N-95 tuberculosis respirators. The precautions clearly are working because no transmission has occurred to health care workers following implementation of the measures. Much damage already had been done, however, because the outbreak initially exploded due to unsuspected cases that were treated without isolation precautions. "We think that most transmission is large respiratory droplets that travel maybe a meter or two and may also contaminate the immediate environment," Simor said. "That’s why hand washing, gloves, gowns, and goggles are at least as important as the mask, and possibly more important."

Toronto hospitals have been directed to limit elective surgery and hospital visitors, and nonurgent transfers between hospitals are discouraged.

"Hospitals have started to screen patients, visitors, and staff just before [they] come into the door about whether they either have risk factors for SARS based on exposure or have suggestive symptoms," Simor added.

In Toronto, which has a large Chinese community, a woman in her early 70s returning from visiting family in Hong Kong appears to be the index case for the outbreak. "Almost all of our cases in Toronto can be attributed to the introduction of disease by one family," Simor said. "In particular, a husband and wife who traveled to Hong Kong to visit family members in the middle of February of this year. They were in Hong Kong for about 10 days. They actually stayed for part of that at the Metropolitan Hotel in Hong Kong, which was known to be one of the major sources of infection into Hong Kong and other countries as well." The woman began getting sick in Hong Kong and continued to feel ill upon return to Toronto. "She went to see her family physician, was prescribed an oral antibiotic, and died at home of acute respiratory illness on March 5," he said. "At that time, just prior to her death, other family members in the immediate household of this lady also became symptomatic with fever and respiratory symptoms."

Those cases included a 43-year-old son who was treated at a Toronto community hospital for several days without being under isolation precautions. "After about 72 hours of this hospital stay, he was put in isolation because they were concerned that this might be tuberculosis," Simor said. "He remained in isolation for the rest of his hospital stay and died on March 13. It was on that day that his brother, sister, and sister-in-law were subsequently admitted to hospitals. On admission, these individuals were immediately placed into appropriate isolation precautions. However, they had already spread [SARS] to their family physician, who became ill and required a hospital stay."

Another patient was fatally infected in a Toronto hospital emergency room after sitting about 6 feet away from one of the early cases, who was not under any kind of isolation precautions. In addition, a patient from one hospital was transferred to the intensive care unit of a second hospital before the SARS problem was recognized, setting off a wave of secondary cases in patients and health care workers.

"There were exposures to a large number of health care workers working in this hospital who subsequently transmitted to other patients and their own household contacts," Simor said. "And really this began the major outbreak in the city of Toronto and subsequently spread to other hospitals because patients were being transferred and health care workers were working at multiple sites as well. I want to emphasize these were health care workers not using any kind of protective devices or isolation precautions. We have not had any [transmission to] health care workers once proper precautions have been implemented."

About half of the first 149 suspected and probable cases in Toronto were health care workers. Another fourth of cases were health care-related, with either patients or visitors infected. The bulk of the remaining cases have occurred in household contacts. Only eight were travelers returning from the Far East. Overall, the death rate among the infected in Toronto is 4.5%, but that rises to 25% in those older than 65.

"The treatment we have been providing for our patients includes a combination of broad spectrum antibiotics," Simor said. "The reason for that is that we want to be sure that we are not going to miss the other usual treatable conditions."

Clinicians also have been using ribavirin, an investigative new antiviral drug, but it is not clear if it has any efficacy against SARS, he added. "We were using it initially because we didn’t know what we were dealing with and we were seeing some overwhelming cases," he said. "We wanted to try something, anything. Some of our patients appear to have responded to this drug, but that is by no means definitive. Use of this drug is associated with substantial side effects, so it is not something that should be taken lightly."