SARS!

The name leaps out at us as from a horror film. The plague doctor, with his frightening mask stuffed with gauze, herbs, and camphor during the pneumonic plagues of earlier centuries, symbolizes the terror of victims and caregivers. As the story of SARS unfolded, they were often the same, as caregivers were both the victims and the vectors of disease in the outbreak in Toronto.

I am not an authority on epidemics or infectious disease; I'm responding to Miles Shore's challenge to speak as an unembedded reporter who has good access to some of the frontline heroes of the SARS wars.

In November of last year in Foshan, China, a southeastern city in the lowlands of the Guangdong province, a 40-year-old businessman became ill and infected 4 nurses, one of whom spread the disease to a shrimp salesman, who travelled to Guangzhou, a large city on the Pearl River. The disease spread rapidly in this southeast Asian incubator of viral epidemics. One third of infected patients were health care workers, and many were food handlers. The three factors in this part of the world that make it an incubator of epidemic viral illnesses is the close proximity of livestock of all species with humans, population density, and poor sanitation. Particularly important for viral mutations is the exchange of viruses between pigs, ducks, chickens, and humans. The adaptation of a virus to a new animal host species sometimes tips the balance of symbiotic or mildly annoying parasitism to increased virulence and infectivity.

Dr. Liu, one of the infected health care workers from Guangzhou, traveled to Hong

Kong for a wedding on February 21st, and infected 12 guests at the Metropole Hotel, including 4 Canadians. Eerily, he was staying in Room 911 at the Metropole.

The disease spread rapidly throughout the region, first to Hanoi, where it was carried by Johnny Cheng, a 48 year old American.

Cheng was treated at the Hanoi French Hospital by Carlo Urbani, a World Health Organization infectious disease specialist who was investigating schistosomiasis in children in Hanoi. Urbani is a Nobel laureate Medecins sans Frontieres epidemiologist and a pilot who had heard that there was an Acute Respiratory Syndrome (ARS) being reported among his WHO colleagues in the area. He recognized its severity in Cheng and notified the WHO that it should be renamed Severe Acute Respiratory Syndrome. He sealed off the Hanoi French Hospital in a bid to contain the virus. It was too late; not only did the virus kill Mr. Cheng, but Dr. Urbani himself succumbed to SARS on March 29th. It has been suggested that his name be associated with the organism ultimately identified as its cause.

The disease spread with the speed of a jet plane to Malaysia and the Philippines.

78 year old Kwan Sui-Chu returned home to Toronto from a holiday in Hong Kong, having stayed one night at the Metropole hotel. She became ill and visited her family doctor; her son was also unwell and went to the Scarborough Grace Hospital, in an eastern suburb of Toronto.

When Sandy Finkelstein, the intensivist who was caring for Mrs. Sui-Chu, learned that both her son and her daughter were ill, he recognized that there was something more serious and more contagious than the usual community acquired pneumonia. He initiated isolation procedures and notified the Ministry of Health.

Toronto cases as of May 1, 2003 [145 probable, 115 suspect, 171 discharged, 70 active, 23 deaths]

Worldwide cases as of April 22, 2003, from Rashid Chotani at Johns Hopkins School of Public Health.

Worldwide spread as of April 22, 2003 from R. Chotani, Johns Hopkins School of Public Health

In the meantime, the disease was spreading out of southeast Asia to 26 countries around the world.

A dramatic, world-wide cooperative scientific effort ensued that resulted in the coronavirus as the etiologic agent, using silicone gene chip technology containing bits of genetic material from all 1,000 known viruses, in the laboratory of Dr. Joseph DeRisi at UCSF. Within one day, DeRisi confirmed that the material was a coronavirus.

Over the objection of some World Health Organization officials, Dr. Klaus Stohr, manager of WHO's influenza program, sent a sample of the virus isolated from a patient to Albert Osterhaus at Erasmus University in the Netherlands. He and his team succeeded in infecting monkeys with the coronavirus and reproducing the SARS syndrome, then cultured the virus from the animals who were ill. In short, they fulfilled Koch's postulates for establishing causality in microbial disease. Laboratories in British Columbia and Atlanta's CDC quickly thereafter completely sequenced the viral genome. It had taken 10 days. Contrast this amazing triumph of modern scientific medicine with the evolution of the HIV story, requiring 2 years to establish the causal organism and nearly 10 years to develop treatment. An effective vaccine does not yet exist.

Clinical features included fever, cough, dyspnea, malaise, myalgias, and diarrhea. It was diarrhea and the defective bathroom U-traps and cracked soil stack system in the Amoy Gardens condominium in Hong Kong that caused the peculiar vertical transmission of the illness throughout Compound E of the complex.

The mainstay is isolation of contagious persons and barrier protection of caregivers. One of the known coronaviruses can dry, crystallize, and then become airborne. The virus is spread by droplets, lives for 30 minutes or more on surfaces and for 6 hours in suspension. Treatment is supportive; there is not convincing evidence that Ribavirin is effective, and antibiotics are used for bacterial superinfection. The Hong Kong group believes that corticosteroids are helpful in the severe respiratory distress phase of the illness.

The case fatality rate was initially estimated at 5.9 % worldwide; the recent estimates are higher, between 10 and 20%. It is quite low in young people and as high as 50% in those who are over 70 years of age.

Let's look at what happened in Toronto.

The response in Toronto was instructive, and in many ways exemplary. One of the heroes of the piece was Jim Young, who had been appointed Commissioner of Public Security for Ontario about one year ago, parallel to the creation of the Department of Homeland Security in the United States in response to the World Trade Center disaster. He took the new position on the condition that he be allowed to maintain his status as a coroner. This proved to be very useful. In his role as coroner, he had been active in investigating and controlling national and international disasters and crimes. Jim had gone immediately to the World Trade Center to help, certifying the deaths and notifying the families of the 20 Canadians who perished in the disaster. He investigated the Swiss Air Crash off Peggy's Cove, the Bali bombings, the political death of a Nigerian leader in jail, and the deaths of Canadian soldiers in Afghanistan. He called out the fire marshals to run the generators when the ice storm paralyzed most of eastern Ontario and southern Quebec 2 years ago. He knew how to mobilize the civil service. On the first night after the notification from Sandy Finkelstein, he participated in an all night session which declared a public emergency and decided to "put the lid on the health care system". Jim called the chiefs of police rather than the doctors and told them to go immediately to the hospitals and close the hospital entrances with yellow crime-scene tape. Putting the lid on meant shutting down all interhospital transfers, elective surgery, elective treatments, visitors and nonessential personnel. Having the police at the entrances eliminated the possibility of lengthy, intellectual discussion of the problem by thoughtful doctors with their vast but disorderly knowledge of infectious disease, epidemiology, human psychology, and the current pressures of caring for non-SARS patients. Despite the eclectic and uncoordinated network of communications within the health care profession, the word got out. Putting the lid on protected all but two of the 212 hospitals in Ontario. The exception was the York Central Hospital where a SARS patient was transferred early in the epidemic in order to receive dialysis.

The hospitals were notified of the decision to limit access to essential staff. Screening was immediately begun for symptoms of SARS using a standard questionnaire and ear temperature monitoring. The monitoring was carried out by secretaries, social workers, and other competent personnel. Though unaccustomed to this role, they quickly mastered it. Jim's authoritative voice as a coroner, perceived as part of the police force and the Ministry of Justice, proved invaluable in maintaining order. He reported daily to the public on CBC One, the national public broadcasting channel, along with the experts in infectious disease from the public health departments for the city and the province. They were accompanied by a superb microbiologist and infectious disease expert, Donald Low. The reports were cautious and concerned, in the precautionary mode characteristic of physicians dealing with serious illness. Caution is embedded in the culture of medicine - we say, "this is potentially serious, and I think that we should take the appropriate measures to minimize the risks." So, for example, we would say, "I think that we should take your child to the operating room and remove her appendix, rather than risk a perforation and death." We have a policy of risk avoidance and prevention of regrettable outcomes, as our dominant decision making mode, rather than an optimistic, hope for the best, cheerleader mode. The way it turned out, the doctors, including Dr. Jim Young, told the precautionary story each day, and reported the daily incidence of new cases and new deaths. They reported cumulatively, using good epidemiological reasoning, and including suspected as well as probable cases. A suspected case had a contact history and symptoms, but no pulmonary infiltrates; a probable case had pulmonary infiltrates. CDC and WHO reported only probable cases; Toronto reported both.

The press, whose culture is also cautionary but veers toward emphasis and magnification of bad news, reported to the public. As you are taught in this course, they're in the bad news business. With cautionary and grave news coming from the physicians, and the bad news press as the amplifier, the public mood changed. People moved from denial and dismissal to fear and blame. Chinese restaurants and Chinatown were virtually deserted, and Chinese citizens were shunned. Soon the city was shunned. Press stories spread the fear epidemic around the world at the speed of the internet. Meetings in Toronto were cancelled, travel curtailed, hotels emptied.

Throughout this time the leadership of the civil society was virtually absent. The premier of Ontario was golfing in Arizona, the mayor was recovering from hepatitis C treatment in Florida, and Prime Minister Chretien was away on a vacation except for one brief return for a funeral of a prominent bishop. During that visit he made a "photo-op" appearance in a Chinese restaurant, emphasized his confidence in the safety of the city, then disappeared again. There were prominent media criticisms of this failure of civil leadership at all levels.

Many in the press invoked the image of Rudy Giuliani during the World Trade Center disaster. His steady, honest, engaged and courageous reporting on the work of the firefighters, police, health care personnel, and others working tirelessly on the tragedy has become a reference standard of leadership. Somehow, our civil leaders felt that this task should be left to the doctors, and so there was no counterbalancing encouragement. No Giuliani or Churchill to assure, inform, and prevent panic. When the World Health Organization issued an advisory against travel to Toronto, the civil leadership finally emerged with an embarrassing response. To the public, it seemed as if the economic issues were the only ones that mattered to them. The naïve performance of Toronto's mayor made matters worse. He appeared on CNN and Canadian broadcasting asking questions like "Who are these people? Where are they, in Geneva or someplace? They've never been to Toronto! They can't do this!" The leadership at all levels of government, unprepared to deal with a terrifying biologic threat, had chosen to leave the management of a medical problem to the medical community, failing to recognize the civic need to prevent the epidemic of fear that would inevitably accompany it.

Recommended but neglected screening at the airport was authorized. Financial support for quarantined people unable to work was authorized. These valuable but expensive investments had been deferred in the name of sound fiscal management. A government that had been elected on the basis of opposition to expanding public enterprises and favoring privatization of public services suddenly became aware of the importance of investing in the public's health and protection.

Thermal imaging is now being installed in the Toronto and Vancouver airports under federal control, after the Ontario provincial health minister traveled to Geneva to demonstrate the efficiency of the public health measures in Toronto and plead for reversal of the WHO travel advisory. This was a significant accomplishment, but it represents a late correction of poor communication from the federal level to the international organization, when the data were really being carefully kept at the provincial and municipal level. This communication gap clearly demonstrates the value of a single federal agency and the importance of a single international agency, in this age of global epidemics. The CDC provides this function in the United States; Canada needs a comparable agency.

First, the lesson that stands out most clearly is the need to upgrade the public health system through public education of citizens. It is imperative that people at all levels learn how to protect the public's health through elementary sanitation, isolation and quarantine measures. A powerful lesson was delivered when Jim Young, the Commissioner of Public Security, sent the police to the home of a quarantined citizen who defied the quarantine and was not there to answer the phone when he was called by the public health nurses. Second, we need to intensify health worker education. The work ethic that drove one nurse to ride on the commuter train when she had myalgia and fever led to a far greater problem in "chase & trace" epidemiology than the benefit of her living up to the commitment to put her patients first. I feel that all health workers should be appropriately retrained. After training, they should be "on call" for public health responsibilities, so that the problems and the solutions do not have to be learned ad hoc during an epidemic or a terrorist attack. Third, screening for illness should be part of the entry level requirements for travelers. Far better to know whether a patient is febrile than whether he is carrying nail clippers. I don't say this to criticize the efforts that have been made, but to refocus them.

The health care system itself needs to be upgraded. To have flexibility you have to have redundancy. Investment in health care strengthens a country and strengthens its economy. Underfunding health care, including public health, can be extraordinarily costly as well as harmful. Segregation of patients in emergency rooms and doctors' offices needs to be rethought and revised. Febrile patients should not wait together coughing, communicating disease to others who have corneal lacerations or heart failure. The notion that patients should wait patiently in an inefficient, undermanaged health care delivery system can no longer be tolerated. Telephone triage and thermal imaging before patients enter the office or the emergency room could minimize contagion. This can be one of the great benefits of the SARS epidemic.

Reserve capacity has been squeezed out of the health care system in efforts to "get rid of the fat" by the financial reductions in recent years. The reserve capacity should be augmented beyond restoring the nursing and caregiver workforce. Facilities should be prepared, like the heated tents that were used for entry screening at hospital doors. This assured that workers and visitors were afebrile before they were allowed to enter. Personnel reserves could be expanded by cross-training bus drivers s ambulance drivers. Teachers, police, and other public employees can learn basic and, in some instances, advanced techniques of public health and other health care skills. The decision to train firemen in advanced life support techniques has been a major advance in many municipalities. The training of public employees and many other citizens in advanced cardiac life support made Seattle the safest city in the world to have a heart attack outside of the hospital. The results of cardiac resuscitation on the streets of Seattle is comparable to the survival in an observed setting in a hospital. Informed patients such as healthy post-operative patients or healthy chronic patients in diabetes, thalassemia, and other specialty clinics could be trained in public health and in general health principles. Adults might attend expanded mini-med school courses; these courses, a recent addition to the public awareness and fund-raising campaigns of some medical schools, are entertaining and informative. An expanded version might emphasize practical skills as well.

A health corps for youth would be a significant addition to the reserve capacity of the health system. While students often work as "candy stripers" or do other volunteer work in the health care system, we might make a more extensive education program available, including courses in the schools and practical experience for a period of 3 or 6 months in the health corps as part of the education of our students. This program could have some of the characteristics of the Peace Corps or the military training of Swiss and Israeli youth.

The heroism of the frontline health workers was inspiring, but the good news - nurses and doctors caring for patients despite the risk and the exhaustion - made it to the back pages of the newspapers. Most of the news was about the cancelled elective surgery, the liver transplant that could not be done, the donors who were turned away. The nurses were heroes, working tirelessly under adverse conditions to care for SARS patients, for sad and lonely patients with terminal cancer who could not be visited by their loved ones because of the quarantine. Here's a quote that appeared in Maclean's magazine, from Margo Halupka, who was among the nurses who cared for the first 2 SARS patients to die in Canada:

I'm not giving up, says a nurse on the front line. A lot of staff members are very sick, morale is low, we don't have much support from our families. In my home they run away because, in a way, they think of me as walking death. The hospital transfers sick staff members, when they get very, very sick, to different facilities. We don't hear from them any more. It's very difficult right now.

I don't think the public really understands what nurses are going through. Nursing is caring for the sick, and we deal with viruses and bacteria every day. I sat down with my family to explain why I'm doing this. It's not easy. I tell them I've been doing this all my life, and I don't want to talk about it.

But when I go to work, we understand each other. That's where we talk. There's one nurse who has two girls, nine and 11. They just blocked the door to the house and said, "Mom, you're not going anywhere." It was a battle for her to het through that door to come to work. She explained it to her children in the best possible way. Then she came to work and cried. What's scary is that we don't know if it's going to end, or who's next.

[Maclean's, April 7, 2003, p33]

In summary, communication must be upgraded significantly, using television, AM and FM radio, the internet, newspapers, and email listserves at all of the institutions. The internet was invented to allow the military to end the war simultaneously or to make strategic decisions on a global basis. It should be used to integrate the hospitals, clinics, doctors' offices, health services, and transportation system hubs with simultaneous updates and instructions. The central command structure should be unified and coherent. My friends in various hospitals tell me that the decisions about isolation, or about admitting urgent and emergent non-SARS patients varied from institution to institution, even in a health care system that has many common elements and a university that connects 10 affiliated hospitals.

Certainly, the biological problem should be managed by scientists, but they need a communicator, a reassuring voice to tell the public of the progress that is being made and the problems that remain unsolved. The spread of public fear should be managed with the same attention to its danger as was paid to the biologic problem. An epidemic of fear can destabilize a community or a country. Leaders should be chosen and designated in advance to present this public voice. The civil leadership should not be digging in the ruins of buildings or fighting the virus, but asking the right questions and communicating the answers from front line workers and expert consultants. Physicians will and should continue to speak a cautionary language. The media should be encouraged and instructed to communicate the good news with the bad in the time of crisis.

Civil leaders should be conspicuously present during a crisis, asking the questions citizens want answered, and communicating to the community with an honest, clear, courageous, and resolute voice. Finally, adaptation of public and private health care facilities is required to segregate contaminated or contagious patients from others requiring care. Essential services can be maintained through accurate triage and appropriate segregation to optimize the management of the emergency with the least compromise of the continuing care of other emergent and non-emergent patients.

Acknowledgements:

I am grateful to Dr. John Marshall, Toronto General Hospital, for generously sharing his slides about the origin and spread of the epidemic; to Dr. Rashid Chotani, Johns Hopkins School of Public Health, whose lecture on SARS provides a global perspective that is available at www.pitt.edu/~super1/lecture/lec10131/index.htm to Dr. James Young, Ontario Commissioner for Public Security, for an illuminating discussion and updates on the status and management of SARS in Toronto; and to Deborah McKneally, Ravine Research & Education Centre, for constructive review and advice.