SARS in Toronto!

oramar · Apr 29, 2003

Is it true then? A rolling headline on MSNBC said that there had been no new cases in Toronto in over 10 days. That would indicate a very important turning point.

oramar · Apr 29, 2003

Is it true then? A rolling headline on MSNBC said that there had been no new cases in Toronto in over 10 days. That would indicate a very important turning point.

toronto rn · Apr 29, 2003

No new community cases in 20 days This is why it is so upsetting to have visitors advised not to come to Toronto. The SARS virus is contained, with no community spread at all. Only within the hospital setting have further cases cropped up. And those cases were well followed with quarantiine of all others who may have been in contact with the sick nurses. I believe 4 other nurses had symptoms last week. I don't know if they were determined to be SARS or not. Since then, no others.

toronto rn · Apr 29, 2003

No new community cases in 20 days This is why it is so upsetting to have visitors advised not to come to Toronto. The SARS virus is contained, with no community spread at all. Only within the hospital setting have further cases cropped up. And those cases were well followed with quarantiine of all others who may have been in contact with the sick nurses. I believe 4 other nurses had symptoms last week. I don't know if they were determined to be SARS or not. Since then, no others.

sixes · Apr 30, 2003

Today is the big day one last fix before I pack up the computor.

No new cases in 20 days.

The Travel advisory was lifted by WHO.

Glac we have CDC.

See you all in a few days

Until then stay well. I'll be thinking of you all.

sixes · Apr 30, 2003

Today is the big day one last fix before I pack up the computor.

No new cases in 20 days.

The Travel advisory was lifted by WHO.

Glac we have CDC.

See you all in a few days

Until then stay well. I'll be thinking of you all.

epaminondas · May 2, 2003

(1) Toronto: Two new SARS cases in hospital workers

Thursday, May 01, 2003:

http://www.canada.com/national/features/sars/story.html?id=4B3118D4-E436-4957-8B1F-B35DFE6EC82D

(2) Toronto: Two more dead from SARS

Wednesday, April 30, 2003:

http://www.canada.com/national/features/sars/story.html?id=841BE030-75E4-4014-8D90-A5C1354756FA

(3) The Health Canada statement on the spread of SARS from Canada to Pennsylvania and the Philippines

April 26, 2003:

http://www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/pef-dep/sars-es-int20030426_e.html

(4) WHO

The WHO statement lifting the Toronto travel advisory:

http://www.who.int/csr/don/2003_04_29/en/

Affected areas:

http://www.who.int/csr/sarsareas/2003_05_01/en/

Cumulative cases:

http://www.who.int/csr/sarscountry/2003_05_01/en/

(5) The CDC travel alert for Toronto:

http://www.cdc.gov/travel/other/sars_can.htm

(6) Hong Kong / 12 SARS relapses concern officials:

http://feeds.bignewsnetwork.com/redir.php?jid=c112fb04b2cd20bf

(7) Hong Kong / Oral-fecal Spread:

>

Whether or not there is secondary spread from this source, no one yet knows: such transmission could be masked in the current SARS background static. As SARS coronavirus tests become more widely available and as time passes, more will be known. The basic thought now is simply that recovering and recovered SARS patients may need to be particularly meticulous in regard to washing their hands following bathroom usage for some time to come (weeks? months?) in order to protect others. Obviously this is a good practice, anyway.

The Amoy Gardens SARS outbreak in Hong Kong apparently did involve oral-fecal spread vs. the respiratory spread generally seen in other outbreaks. In the Amoy Gardens outbreak, diarrhea is reported to have occurred in approximately 60% of cases as opposed to approximately 6% of SARS cases contracted from respiratory spread. Instead of primarily facing pneumonia, the Amoy Gardens patients faced diarrhea and multi-organ failure - gastrointestinal, renal, hepatic, pulmonary. Younger patients have died (30's and 40's without co-morbidity), with a higher mechanical ventilation rate (about double) and a higher mortality rate (about double) compared to those infected via the respiratory route.

The concern is that oral-fecal transmission may become important in underdeveloped countries with polluted water supplies - the sort of places with water supplies which are already chronically affected by such diseases as Giardia (I understand that this has been a problem in the St. Petersburg, Russia water supply - I can attest that the locals always boil water before drinking), cholera, hepatitis A, etc. Much of African infant mortality is secondary to diarrhea, much of that secondary to polluted drinking water. I do not see oral-fecal spread being a significant factor in developed countries - though one might consider the possibility of a "SARS Mary" within the food-handling industry, no such situation has yet been reported, and one hopes that it will never happen. If any of the Canadian patients are food-handlers, however, their health care providers might want to consider addressing this issue with them and consider particularly good follow-up in such patients, particularly as laboratory tests become more widely available.

If oral-fecal SARS does show up in a developed country, it might be overlooked as a severe diarrheal illness that does not meet the current WHO criteria for SARS. I.e., it might come in under the radar as an outbreak of food poisoning.

Just something to keep in your differential.

Short on SARS Details

By Laurie Garrett

http://www.newsday.com/news/health/ny-hssars293259581apr29,0,5654418.story?coll=ny%2Dhealth%2Dheadlines

Experts: 2 Forms of Virus

SARS not just respiratory disease, also gastrointestinal

By Laurie Garrett

STAFF CORRESPONDENT

May 1, 2003

http://www.newsday.com/news/health/ny-hssars013262186may01,0,612726.story?coll=ny%2Dhealth%2Dheadlines

(8) Incubation period.

The experience in Guangdong Province, the epicenter of the SARS virus in China, is that the incubation period of SARS is 1-16 days.

The WHO knows this: it is a WHO investigator who first reported this to the West.

Countries in the Far East are assuming a maximum 14-day incubation period and are using this as the basis of their 14-day quarantines.

The WHO has arbitrarily declared a maximum 10-day incubation period for SARS - as if the WHO will determine the behaviour of SARS, not vice versa.

Canada is following the WHO's lead in also assuming a 10-day maximum incubation period for SARS.

Internationally, there is some concern about this.

(9) Morbidity.

There is a great deal to be considered in regard to morbidity.

The WHO was earlier widely reported as indicating that that 90% of SARS patients recover, typically with a 7-9 day illness.

Other reports suggest a longer typical period of illness than 7-9 days, perhaps in the two-three week range.

Subsequent reports suggest that hospital discharge and recovery may be two entirely different concepts, with a significant period of convalescence required.

There is also concern as to permanent sequelae.

I am most curious as to the on-the-scene Canadian experience in these matters as the recoveries unfold.

One of many concerns being reported overseas, below -

Lung scarring found in Hong Kong Sars victims:

http://feeds.bignewsnetwork.com/redir.php?jid=5e8f6fee1a38f657

(10) Mortality

I have been reluctant to address SARS mortality rates during the midst of the Toronto outbreak.

Now that the Toronto outbreak seems to be easing:

A. The WHO and the CDC have been calculating gross mortality rates in a very simplistic fashion which understates true mortality.

This is well known. This is Epidemiology 101, and these organizations have plenty of well-trained Epidemiologists on board.

The WHO and the CDC are calculating mortality by simply taking the total number of patients dead with SARS and dividing that by the total number of patients diagnosed with Probable SARS. You can easily do this yourself. For Canada, that comes out to:

20 dead /147 total Probable SARS cases = 14% gross mortality.

Which is of no small concern in itself. Recollect that the Spanish Flu of 1918 is reported to have had only a 2-3% mortality rate - and it killed perhaps 20-40 million people worldwide. Of course, the Spanish Flu seems to have been more contagious than SARS - though we don't seem to have a final handle yet on just how contagious SARS actually is. The epidemiologists insist that SARS is just not that contagious. The hospital staffs dealing with SARS firsthand have a tendency to disagree . . .

The problem with this simplistic method of gross mortality calculation is that you are comparing people who contracted SARS weeks ago and have since died with the entire cohort of patients who have contracted Probable SARS, including those who contracted SARS yesterday whose fate is yet unknown. This dilutes the statistic in an optimistic way - i.e., it assumes that no one else from the full cohort will die of SARS, even though we know some likely will.

The more accurate way to calculate a mortality rate is to compare the dead to the recovered. Again, this is basic Epidemiology 101, well known to Epidemiologists worldwide, including those in the WHO and the CDC.

The calculation is simple and straightforward:

20 dead / 87 recovered = 23%

So: Toronto is currently showing a mortality rate of approximately 23%.

This will vary somewhat from the final, true mortality rate which can only be calculated after all is known after the outbreak is over. But this is a whole lot more accurate that the gross mortality rate during the midst of an epidemic.

The math here is supremely uncomplicated - you can do it for yourself at any time by just looking up the statistics on the WHO site or on Health Canada. It can be interesting to do this every once in a while and compare the correct statistics on SARS mortality that you calculate yourself with the erroneous statistics being published in both the Canadian and American news media.

Interestingly, this 23% mortality rate calculated for the Toronto outbreak fits in well with the "25%" fatality rate declared by a nurse in an earlier Time Magazine interview from a Chinese hospital. I believe that her statement may have been dead-on accurate.

This also matches well with the original peer-reviewed March 31, 2003, New England Journal of Medicine articles on the initial ten patients in Hong Kong and the initial ten patients in Canada - which showed a mortality rate of 20-30% (20% Hong Kong, 30% Canada).

http://www.nejm.org/early_release/sars.dtl

I am most interested as to whether or not the above is consistent with the current Canadian front line experience in regard to mortality rates.

What is also interesting is that these are largely the statistics out of modern health care systems with sufficient bed, staff, supplies, and ventilators to handle the disease. But remember that 10-20% of SARS patients are said to require mechanical ventilation. So - if the number of patients ever outnumbers the number of ventilators available, you will then likely see the mortality rate rise to perhaps 33-43% for those patients who do not have access to ventilators. And health care workers will have to be making some pretty momentous decisions about who will live and who will die.

Not a concern in the developed world, of course. But certainly a concern in the underdeveloped world.

Newspaper reports are that in the U.S., ventilators typically have a usage rate of approximately 80%, increasing to 95-100% during flu season.

I do not know if that is accurate or no. But the U.S. government just put in an order for 3000 ventilators for a national reserve. Should be fully supplied by the end of 2003.

Probably unnecessary, of course - but I am not unhappy that they are doing it.

It would be kind of interesting if the U. S. got hit with a significant outbreak of SARS during flu season - don't you think?

U.S. officials preparing for possible SARS spread in United States:

http://www.ajc.com/news/content/news/0503/01sarsus.html

(11) Graphics:

http://www.sars-spread.com/country_breakdown.htm

http://www.sars-spread.com/

(12) Randomnicities:

Hong Kong authority admits some medical workers given faulty masks:

http://feeds.bignewsnetwork.com/redir.php?jid=bb83d9516a1f74fa

Note that the statement "The death on Saturday of a 38-year-old male nurse, the first medical worker to die here from the pneumonia-like Severe Acute Respiratory Syndrome (SARS) virus" would seem to conflict with earlier reports - that at least two physicians - including one pediatrician - have died in Hong Kong from the SARS. Perhaps an error - or perhaps Hong Kong does not consider physicians to be medical workers - I don't know.

Hong Kong health bureaucracy:

http://feeds.bignewsnetwork.com/redir.php?jid=eeb1151021a9c23f

China culls pets:

http://www.news24.com/News24/World/Sars/0,6119,2-10-1488_1353781,00.html

Killed for sneezing:

http://www.abs-cbnnews.com/abs_news_body.asp?section=Metro&oid=21493

(13) "It could never happen here."

This is currently the mildly ironic motto of our hospital - said with a wink or a grin as we prepare for the possibility of SARS.

Preparing for the worst while hoping for the best.

Typical usage: someone notes that everyone in a department has just been formally fitted with N95 respirators and that we have several boxes in reserve. And that goggles are now available.

Cue: "But it could never happen here."

Demented grins. :-)

That sort of thing.

Increasing, we are optimistic here.

The U.S. currently has only 56 Probable SARS cases, most of which probably do not have SARS. All of the Probable SARS cases - including the six serum-confirmed cases - are travellers from the Far East or Toronto, with the exception of one household contact and one nurse contact. The U.S. Health Care Worker infection rate of Probable SARS cases is therefore now under 2%. Only two Probable SARS cases have thus far required mechanical ventilation. No deaths.

One could reasonably argue that, in the U.S., you are currently more likely to be struck by lightning in a tornado during an earthquake than you are to be killed by SARS.

SARS concerns are now unwinding a bit - going to consideration of a possible second wave next winter. But that is a long way off.

Thoughts are going back now more to other everyday concerns.

(14) It looks like the Chinese health care system can handle SARS pretty well.

From the perspective of Brendan O'Kane, an American in China - the April 27 / 30 report entitled "boschian" describes his recent healthcare adventure:

http://www.bokane.org/

I also found Brendan's 10.22 and O1.19 entries to be unusually evocative.

Good guy, that Brendan.

I hope y'all are doing well.

Sto Lat!

Epaminondas

oramar · May 7, 2003

Latest study from Hong Kong says death rate between 2% and 50% depending on age. Over age 60 the high number. Under age 12 the low number. Overal death rate in Hong Kong 20%. This report actual says death rate in Canada is 15%. However, you have to realize the are only studying hospitalized persons. Very good chance quarantine lenght might be increased to 14 days.