SARS in Toronto, Canada
The Spring 2003 outbreak of SARS in Toronto received international media attention as "Toronto the good" became the most significant nexus of the disease outside of Asia during April 2003. Concern culminated with a World Health Organization advisory against "unnecessary travel" to Toronto on April 23rd, 2003. However, by this point there had been no new SARS cases in more than the 10 day maximum incubation period, and Toronto officials greeted the warning with derision.
A note on the naming of names
The names of most SARS victims in Toronto have not been officially released. In the writeup below you will see only two victims named, Kwan Sui-chu and Tse Chi-kwai. The Tse family agreed to announce these names "so people would know to take action right away, and save lives," said Ms. Tse in an interview with Toronto's Globe and Mail newspaper. Doing so was a brave action by the family in an environment of fear which has seen incidents of discrimination and racial profiling. They are to be commended for their courage.
In February 2003, a lethal, pneumonia-like illness began spreading in China and Hong Kong. By mid February, China had reported 305 cases of "atypical pneumonia" which would later come to be called Severe Acute Respiratory Syndrome, or SARS.
At Hong Kong's Metropole Hotel hotel, at least 7 people, all of whom had stayed on the same floor between February 12th and March 2nd, became infected. A wedding guest who became sick a week before staying at the Metropole is believed to be the source of the infection at the hotel (see alex.tan's writeup above for details).
One of the infected hotel guests was Toronto resident Kwan Sui-chu, 78, who stayed at the Metropole on February 21st. She and her family were visiting Hong Kong for Chinese New Year. The next day, as they checked out, the couple is believed to have stood near the coughing and sneezing infected man outside the hotel's elevators. They travelled home on Continental Airlines, in case anyone is concerned/curious.
Initial outbreak in Toronto
By the time Kwan flew back to Toronto on February 23rd, she was severely ill. She visited her GP with what is now recognized as full SARS presentation. By the time of her visit her GP should have received Health Canada's "atypical pneumonia" bulletin. For whatever reason, Kwan was not diagnosed with "atypical pneumonia", but was given a prescription for general antibiotics and sent home.
Kwan succumbed to the illness March 5th in Toronto. According to rumour, the investigating coroner ruled heart attack. The coroner apparently did not ask about Kwan's recent medical or travel history. If true, this would be a violation of basic investigative procedure. In any case, SARS was not yet diagnosed or suspected, and the grieving family did not suspect their danger.
Soon after the funeral, several members of the Tse family fell ill. Kwan's 44-year-old son Tse Chi-kwai, became seriously ill and went to Toronto's Scarborough Grace hospital on Saturday, March 8th.
At this point Toronto began to reap the whirlwind of ex-premier Mike Harris' "Common Sense Revolution". Due to severe cutbacks in Ontario's health care system1, there was no diagnostic bed for Tse, and no staff to examine him. He spent an extended time (reportedly about 6 hours, which is quite possible in Toronto) on a gurney in a hallway of Scarborough Grace, waiting for a room. All the while he was fully presenting, coughing and sneezing on the many passers-by. Eventually Tse was placed in an observation room with an elderly man who had been admitted with a racing heart. Tse was probably "at the height of his disease" when the two men shared the room.
When Tse was finally examined, the doctor suspected tuberculosis and advised the family to start wearing masks and avoid visitors, which they did. A nurse at Scarborough Grace Hospital who could read Chinese had noticed the stories about "atypical pneumonia" in the Chinese press and altered the doctor on Monday, March 10th. He alerted Ontario Health authorities, who in turn contacted the World Health Organization. The first alert was issued on March 12th, the same day that Tse died of SARS.
Belatedly, Ontario's health care system began to become alarmed. Toronto Public Health and Health Canada appealed to Canadians to seek medical help if they had been in contact with the Kwan and Tse families and were experiencing SARS symptoms as the sudden onset of a high fever, muscle aches, or other flu-like symptoms.
SARS spreads in Toronto's hospital system
Four other family members of the Tse family were in Toronto hospitals, officials admitted. In fact, in what now seems almost like a perverse attempt by fate to maximize the damage, Ms. Tse and her now-widowed sister-in-law were admitted to Mount Sinai Hospital in central Toronto. Her father was sent to Toronto Western Hospital and her younger brother was sent to Sunnybrook Hospital in north-central Toronto. This effectively spread the SARS risk to every major hospital cluster in Toronto's core.
Other members of the family who had not been diagnosed with the disease were told “not to go out for the time being," and to "wait to see if they get any symptoms.” This was the beginning of Toronto's voluntary quarantine program.
Mrs. Tse's husband, a manager at a computer company, did not become ill. He returned briefly to work after his mother-in-law's funeral before he learned about SARS, but no one at his workplace has been infected. (He has since been working at home by phone and e-mail, under voluntary quarantine.)
Meantime, the elderly man with the racing heart condition had recovered and gone home, only to return two days later. He too had contracted SARS. His lungs filled with fluid, and he died on March 21st. Public health officials advised the family that the burial should be private, and that they should not get too close to the body. The transmission vector for SARS was still a mystery. Dressed in white surgical masks (but not N95s) mourners attended the funeral and graveside service. Unknown to all, two of the mourners were also infected.
By March 25th, it was clear that Scarborough Grace had become a locus of infection, with numerous health care workers falling ill with the disease. Scarborough Grace officially closed its doors to new patients and most visitors. Provincial health officials announced the quarantine of about a dozen affected health workers' families. Ontario Health Minister Tony Clement declared SARS a "reportable, communicable and virulent disease". This declaration gave health officials the authority to track infected people and issue legal orders to stop them from engaging in activities that transmit SARS. (Like, say, breathing.)
On March 26th, Ontario declared a public health emergency. Thousands of people were asked to quarantine themselves in their homes, wearing masks and denying visitors. By this date there were 27 probable cases of SARS in Ontario. The next day, Ontario health officials ordered Toronto hospitals closed to all visitors, exempting only those visiting critically ill patients and parents visiting children.
On March 30th, Ontario health officials announced another SARS death, which took place on March 28th. The victim had been transferred from Scarborough Grace to York Central Hospital in Richmond Hill, near Toronto, thus widening the disease's circle of influence. Public health officials recommended that all hospital workers in the Greater Toronto Area be issued protective gear to stop the spread of SARS.
On April 1st, it was announced that SARS had spread to the world-renowned Sick Kids Hospital. The likely source was an infected health care worker. Nurses in particular often work at several Toronto hospitals, partly due to the cutbacks mentioned earlier. A number of children were isolated and not allowed visitors, not even their parents. Only moon-suited medical staff could visit them.
The same day it was revealed that two more people in Toronto have died of SARS, bringing Toronto's SARS death toll to 6. Both victims were patients in their 70s, being treated in hospital for other ailments.
On April 3rd officials confirmed another SARS death, a 57-year old woman who had been exposed at Scarborough Grace. On April 5th they reported another death, at Toronto Western Hospital, a patient who had transferred there from Scarborough Grace, and the next day a death in the east end, at Rouge Valley Health System. The day after a death at St. Joseph's Health Centre implicated all major Toronto hospitals except Princess Margaret (a cancer treatment facility). Three more deaths, all of elderly patients, were reported on April 12th which brought the death toll to 13.
On April 20th, Canada's largest trauma unit, Sunnybrook Hospital, stopped accepting new patients after four health-care workers showed signs of SARS. The hospital also closed other units.
At time of writing, 21 people had died of SARS, almost all of them elderly or ill patients infected from the initial hospital outbreak. A new case has not been reported in 21 days, twice the maximum 10-day incubation period for SARS.
Other SARS fears
Health officials asked anyone who was present at Scarborough's Highland Funeral Home on April 3rd to contact health authorities and to quarantine themselves. It is thought that a person who was infected with SARS attended a funeral that day, possibly infecting others.
On April 9th, Hewlett-Packard sent approximately 200 workers from a Toronto-area office home after an employee exhibiting SARS symptoms ignored health officials' instructions to remain in quarantine. No one at HP is thought to have become infected.
On April 14th, Toronto health officials ordered all 500 members of a Toronto Catholic sect, Bukas-Loob Sa Diyos, into quarantine. Sect members were exposed to the disease at the funeral of a SARS victim.
The same day a health care worker with SARS symptoms rode the GO train from Burlington's Appleby Station, returning the same way on the 15th. Riders of her GO Train were later warned via posted notices to be on the watch for symptoms, but no one seems to have been infected. The warning was lifted on April 28th.
Officials in York Region, north of Toronto, asked anyone who was at the Ward Damiani Funeral Home in Woodbridge on Friday, April 18, and Saturday, April 19, or who attended a funeral mass at St. David Parish in Maple to contact authorities. One person at the funeral was showing symptoms of SARS.
A number of conventions, music concerts, lectures, and other meetings scheduled for Toronto were cancelled because of fears of the diseases. Over 800 bus tours have been cancelled, and hotels are at 30% of capacity, compared to a seasonal average of 70%.
Restaurants, particularly Asian restaurants like the Mandarin Buffet, have been hit hard with low patronage. Mandarin has been running radio and print ads stressing the precautions they have taken, including special SARS policies restricting employee attendance in case of recent travel to Asia, possible SARS contact, or even slight symptoms of the illness. Prime Minister Jean Chretien has made a point of eating in Toronto's Chinatown to show that it is safe. However it may take quite some time for local confidence to be restored, and even longer for the city's tourist trade to recover.
Major League Baseball issued a warning to its teams that players visiting Toronto should avoid contact with fans, public places and most of all hospitals. The first team to visit, the Kansas City Royals, were very gracious and understanding, and did not let the SARS situation or the rabid sports media goad them into any rash statements or actions.
Your correspondent has ridden Toronto's subway each day throughout the crisis. Ridership appears almost normal. Unlike what you might expect from media coverage, only twice have I seen anyone wearing a mask. Once I saw a proper N95, the other was a poorly fitted surgical mask with a drug company logo, which might as well have been a stage prop for all the good it would have done.
SARS fears beyond Toronto
On April 3rd, the SARS virus was exported from Toronto for the first time, travelling to Manila through a nursing aide. (On April 12th the nursing aide was admitted to San Lazaro Hospital in Manila, where she died on April 14th.)
On April 19th, a Toronto man who attended a business conference in Montreal had symptoms, and 450 people from the meeting were under quarantine. This turned out to be a false alarm.
On April 23rd, the World Health Organization issued an advisory against "unnecessary travel" to Toronto. The next day, Toronto officials reacted with anger, notably Toronto mayor Mel Lastman who was featured in an angry, passionate, and largely fact-free rant on CNN.
Celebrities including Elton John, Billy Joel, Lisa Marie Presley and the reincarnated Styx have cancelled shows, as has media blip Kelly Clarkson.
The costs to Toronto and to Ontario in lost revenue, in containment expenses, in lost work time, and most importantly in lives had far exceeded any savings from the health care costs reductions and bed closures of the Common Sense revolution. The costs of the SARS outbreak to the Canadian economy could top $2.1 billion, according to a recent TD Bank report.
It seems right now like the Toronto outbreak is contained, but as long as SARS exists "in the wild" vigilance and containment will continue to be necessary. The first new plague of the 21st century is upon us, and we have learned that half measures will not do to combat it. The costs of SARS will continue for some time.
On April 28th, Toronto mounted a "Let's show the world what they're missing!" campaign to promote local tourism until the travel ban is lifted.
July 2003 update
By mid-July, SARS was considered completely contained world-wide. The death toll in Toronto had reached 41, including two health-care workers who had become infected in hospital. There remained 13 active cases in Toronto-area hospitals, some of whom are health-care workers. At least two are in critical condition and are not expected to survive the disease.
August 2003 update
By mid-August, the death toll in Toronto had reached 44, including a male doctor, Nestor Yanga, and two female nurses who had become infected in hospital. There remain 8 active cases in Toronto-area hospitals, of which three are in critical condition.
- See my December 13, 2002 writeup for a personal adventure in Toronto health care.
- TV and radio news
- Friends in the know at University Health Network