Along with this is the effect of a pandemic or even hint of a minor regional pandemic – even if contained on travel and economic concerns.  Think of the SARS  “epedemic “  in  Toronto (Ontario ) Canada a few years back as an immediate model.

Sars hits Toronto with an aftermath

http://www.canadiancontent.net/commtr/sars-hits-toronto-aftermath_670.html

By Sven Eriksen

Update: Severe Acute Respiratory Syndrome — Toronto, Canada, 2003

Severe acute respiratory syndrome (SARS) was first recognized in Toronto in a woman who returned from Hong Kong on February 23, 2003 (1). Transmission to other persons resulted subsequently in an outbreak among 257 persons in several Greater Toronto Area (GTA) hospitals. After implementation of provincewide public health measures that included strict infection-control practices, the number of recognized cases of SARS declined substantially, and no cases were detected after April 20. On April 30, the World Health Organization (WHO) lifted a travel advisory issued on April 22 that had recommended limiting travel to Toronto. This report describes a second wave of SARS cases among patients, visitors, and health-care workers (HCWs) that occurred at a Toronto hospital approximately 4 weeks after SARS transmission was thought to have been interrupted. The findings indicate that exposure to hospitalized patients with unrecognized SARS after a provincewide relaxation of strict SARS control measures probably contributed to transmission among HCWs. The investigation underscores the need for monitoring fever and respiratory symptoms in hospitalized patients and visitors, particularly after a decline in the number of reported SARS cases.

During February 23–June 7, the Ontario Ministry of Health and Long-Term Care received reports of 361 SARS cases (suspect: 136 [38%]; probable: 225 [62%]) (Figure 1); as of June 7, a total of 33 (9%) persons had died. Of 74 cases reported during April 15–June 9 to Toronto Public Health, 29 (39%) occurred among HCWs, 28 (38%) occurred as a result of exposure during hospitalization, and 17 (23%) occurred among hospital visitors (Figure 2). Of the 74 cases, 67 (90%) resulted directly from exposure in hospital A, a 350-bed GTA community hospital.

The majority of cases were associated with a ward used primarily for orthopedic patients (14 rooms) and gynecology patients (seven rooms). Nursing staff members used a common nursing station, shared a washroom, and ate together in a lounge just outside the ward. SARS attack rates among nurses assigned routinely to the orthopedic and gynecology sections of the ward were approximately 40% and 25%, respectively.

During early and mid-May, as recommended by provincial SARS-control directives, hospital A discontinued SARS expanded precautions (i.e., routine contact precautions with use of an N95 or equivalent respirator) for non-SARS patients without respiratory symptoms in all hospital areas other than the emergency department and the intensive care unit (ICU). In addition, staff no longer were required to wear masks or respirators routinely throughout the hospital or to maintain distance from one another while eating. Hospital A instituted changes in policy on May 8; the number of persons allowed to visit a patient during a 4-hour period remained restricted to one, but the number of patients who were allowed to have visitors was increased.

On May 20, five patients in a rehabilitation hospital in Toronto were reported with febrile illness. One of these five patients was determined to have been hospitalized in the orthopedic ward of hospital A during April 22–28, and a second was found on May 22 to have SARS-associated coronavirus (SARS-CoV) by nucleic acid amplification test. On investigation, a second patient was determined to have been hospitalized in the orthopedic ward of hospital A during April 22–28. After the identification of these cases, an investigation of pneumonia cases at hospital A identified eight cases of previously unrecognized SARS among patients.

The first patient linked to the second phase of the Ontario outbreak was a man aged 96 years who was admitted to hospital A on March 22 with a fractured pelvis. On April 2, he was transferred to the orthopedic ward, where he had fever and an infiltrate on chest radiograph. Although he appeared initially to respond to antimicrobial therapy, on April 19, he again had respiratory symptoms, fever, and diarrhea. He had no apparent contact with a patient or an HCW with SARS, and aspiration pneumonia and Clostridium difficile--associated diarrhea appeared to be probable explanations for his symptoms. In the subsequent outbreak investigation, other patients in close proximity to this patient and several visitors and HCWs linked to these patients were determined to have SARS. At least one visitor became ill before the onset of illness of a hospitalized family member, and another visitor was determined to have SARS although his hospitalized wife did not.

On May 23, hospital A was closed to all new admissions other than patients with newly identified SARS. Soon after, new provincial directives were issued, requiring an increased level of infection-control precautions in hospitals located in several GTA regions. HCWs at hospital A were placed under a 10-day work quarantine and instructed to avoid public places outside work, avoid close contact with friends and family, and to wear a mask whenever public contact was unavoidable. As of June 9, of 79 new cases of SARS that resulted from exposure at hospital A, 78 appear to have resulted from exposures that occurred before May 23.

Reported by: T Wallington, MD, L Berger, MD, B Henry, MD, R Shahin, MD, B Yaffe, MD, Toronto Public Health; B Mederski, MD, G Berall, MD, North York General Hospital; M Christian, MD, A McGeer, MD, D Low, MD, Univ of Toronto; Ontario Ministry of Health and Long-Term Care, Toronto. T Wong, MD, T Tam, MD, M Ofner, L Hansen, D Gravel, A King, MD, Health Canada, Ottawa. SARS Investigation Team, CDC.

Editorial Note:

On May 14, 2003, WHO removed Toronto from the list of areas with recent local SARS transmission because 20 days (i.e., twice the maximum incubation period) had elapsed since the most recent case of locally acquired SARS was isolated or a SARS patient had died, suggesting that the chain of transmission had terminated. Before recognition of the second phase of the outbreak, the most recent case of locally acquired SARS in Toronto was reported before April 20. However, unrecognized transmission, limited initially to patient-to-patient and patient-to-visitor transmission, apparently was continuing in hospital A. After directives for increased hospitalwide infection-control precautions were lifted, an increase in the number of cases was observed, particularly among HCWs.

The findings from this investigation underscore the importance of controlling health-care–associated SARS transmission and highlight the difficulty in determining when expanded precautions for SARS no longer are necessary. Investigations in Canada and other countries have identified HCWs to be at increased risk for SARS, and methods for performing surveillance among HCWs have been recommended (2). The Toronto investigation suggests that unrecognized patient-to-patient and patient-to-visitor transmission of SARS might have been occurring with no associated cases of HCW illness until after a provincewide lifting of the expanded precautions for SARS. Transient carriage of pathogens on the hands of HCWs is the most common form of transmission for several nosocomial infections, and both direct contact and droplet spread appear to be major modes for transmitting SARS-CoV (3). HCWs should be directed to use gloves appropriately (e.g., change gloves after every patient contact and avoid their use outside a patient’s room) and to pay scrupulous attention to hand hygiene before putting on and after removing gloves.

In addition to active and passive surveillance for fever and respiratory symptoms among HCWs, early detection of SARS cases among persons in health-care facilities in SARS-affected areas is critical, particularly in facilities that provide care to SARS patients. Identifying hospitalized patients with SARS is difficult, especially when no epidemiologic link has been recognized and the presentation of symptoms is nonspecific. Patients with SARS might develop symptoms common to hospitalized patients (e.g., fever or prodromal symptoms of headache, malaise, and myalgias), and diagnostic testing to detect cases is limited. Available nucleic acid amplification assays for SARS-CoV have reported sensitivities as low as 50% (4). Although serologic testing for SARS-CoV antibody is available, definitive interpretation of an initial negative test requires a convalescent specimen to be obtained >21 days after onset of symptoms (5).

Several potential approaches for monitoring patients might improve recognition of SARS in hospitalized patients. A standardized assessment for SARS (e.g., clinical, radiographic, and laboratory criteria) might be used among all hospitalized patients with new-onset fever, especially for units or wards in which clusters of febrile patients are identified. In addition, some hospital computer information systems might allow review of administrative and physician order data to monitor selected observations that might serve as triggers for further investigation.

The Toronto investigation found early transmission of SARS to both patients and visitors in hospital A. In areas affected recently by SARS, clusters of pneumonia occurring in either visitors to health-care facilities or HCWs should be evaluated fully to determine if they represent transmission of SARS. To facilitate detection and reporting, clinicians in these areas should be encouraged to obtain a history from pneumonia patients of whether they visited or worked at a health-care facility and whether family members or close contacts also are ill. Targeted surveillance for community-acquired pneumonia in areas recently affected by SARS might provide another means for early detection of these cases.

The findings from the Toronto investigation indicate that continued transmission of SARS can occur among patients and visitors during a period of apparent HCW adherence to expanded infection-control precautions for SARS. Maintaining a high level of suspicion for SARS on the part of health-care providers and infection-control staff is critical, particularly after a decline in reported SARS cases. The prevention of health-care–associated SARS infections must involve HCWs, patients, visitors, and the community.

References

1. Poutanen SM, Low DE, Henry B, et al. Identification of severe acute respiratory syndrome in Canada. N Engl J Med 2003;348:1995–2005.
2. CDC. Interim domestic guidance for management of exposures to severe acute respiratory syndrome (SARS) for health-care settings. Available at http://www.cdc.gov/ncidod/sars/exposureguidance.htm.
3. Seto WH, Tsang D, Yung RW, et al. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet 2003;361:1519–20.
4. Peiris JS, Lai ST, Poon LL, et al. Coronavirus as a possible cause of severe acute respiratory syndrome. Lancet 2003;361:1319–25.
5. Stohr K. A multicentre collaboration to investigate the cause of severe acute respiratory syndrome. Lancet 2003;361:1730–3.

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CMAJ • November 23, 2004; 171 (11). doi:10.1503/cmaj.1031580.

© 2004 Canadian Medical Association or its licensors

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.

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Public Health

SARS outbreak in the Greater Toronto Area: the emergency department experience

Bjug Borgundvaag^*, Howard Ovens^*, Brian Goldman^*, Michael Schull, Tim Rutledge, Kathy Boutis, Sharon Walmsley^¶, Allison McGeer^*, Anita Rachlis and Carolyn Farquarson^*

*Mount Sinai Hospital, the Sunnybrook and Women’s College Health Sciences Centre, North York General Hospital, the Hospital for Sick Children and ¶the Toronto Hospital, Toronto, Ont.

Between February and September 2003 Health Canada reported 438 probable or suspect cases of severe acute respiratory syndrome (SARS) resulting in 43 deaths¹ primarily in the Greater Toronto Area (GTA). The basic reproductive number of 2–4 suggested a primary mode of transmission through contact of mucous membrane with infectious respiratory droplets or fomites,^2,3,4 although airborne transmission was also suggested.⁵ In Toronto, there were several “super-spreading” events, instances when a few individuals were responsible for infecting a large number of others. At least 1 of these events occurred in an emergency department,⁶ where overcrowding, open observation “wards” for patients with respiratory complaints, aerosol treatments, poor compliance with hand-washing procedures among health care workers and largely unrestricted access by visitors may have contributed to disease transmission.

We outline the process successfully followed by 4 Toronto emergency departments (at Mount Sinai Hospital, North York General Hospital, Sunnybrook and Women’s College Health Sciences Centre and the Hospital for Sick Children) involved in the assessment and treatment of 276 suspect and probable SARS cases between Mar. 13 and June 13, 2003, with no transmission to emergency department staff.

Modifications in operations

During the SARS outbreak the 3 emergency departments with respiratory isolation rooms initially assessed patients within existing facilities, and the 1 without such rooms triaged suspect cases to negative air pressure wards until a temporary isolation room in the emergency department was completed. One site subsequently constructed a large outdoor SARS assessment unit. Advance notification of the arrival of suspect cases allowed efficient use of isolation facilities.

General procedures for triage and management of patients in the emergency department during the SARS outbreak are outlined in Fig. 1 and Box 1. Patients who failed SARS screening were placed in respiratory isolation before any further assessment, including assessment of remaining vital signs. Suspect SARS cases sent to hospital by infection control were processed and often sent to the SARS ward immediately with no further interventions.

View larger version (55K): [in this window] [in a new window] Fig. 1: Emergency department triage for SARS during an outbreak

View larger version (78K): [in this window] [in a new window] Box 1.

Modifications to daily operations were updated daily and notices posted by email and on bulletin boards. Procedure lists and protocols for donning and removing protective gear (Boxes 2 and 3) were posted, and equipment and garbage containers were arranged to facilitate compliance with SARS precautions. Non-essential equipment and furniture were removed from rooms to minimize contamination. Stethoscopes and other frequently used equipment were provided by the hospital and left in the rooms, whereas charts, pens and wireless phones were prohibited in rooms. Any equipment removed from rooms was disinfected using a hospital-approved disinfectant, and special policies were developed for cleaning patient rooms (Box 4).

View larger version (16K): [in this window] [in a new window] Box 2.

View larger version (71K): [in this window] [in a new window] Box 4.

View larger version (40K): [in this window] [in a new window] Box 3.

Guards at entrances to the emergency departments restricted access to staff and emergency department patients only (no visitors or family), ensured compliance with protective measures and recorded names for contact tracing. A standardized hospital SARS classification governing patient transfers between institutions was developed by the SARS Provincial Operations Centre (www.oma.org/phealth/SARsCategories.htm) and significantly affected patient flow. Individual emergency departments were at times strained by large and unpredictable changes in patient volume when neighbouring institutions were closed because of uncontrolled exposure to or spread of SARS.

To accommodate increasing numbers of patients under investigation, some sites adjusted ventilation systems to create negative air pressure rooms (checked daily). All hallway stretchers were removed, and only 1 stretcher was permitted per room that had had multiple stretchers, which resulted in reduced emergency department capacity. As the outbreak came under control, a protocol was developed governing which patients could be separated only by a drape (i.e., those who were afebrile, passed SARS screening, were compliant with wearing approved masks and could be kept at least 1 m apart from each other). Protocols were developed to control patient movement (e.g., to radiology, wards, bathrooms), dispose of human waste and minimize the risk of SARS transmission associated with respiratory droplet aerosolization (e.g., through intubation with powered air-purifying respirator hoods, use of aerosolized therapies and pulmonary function testing) (Box 5).

View larger version (65K): [in this window] [in a new window] Box 5.

Although some emergency departments in SARS-affected areas modified operations even more dramatically than the measures we describe,⁷ our experience suggests that the extra measures may not be required. The procedures we followed were protective against spread by respiratory droplets and fomites and were effective during several intubations and high-risk procedures.

Despite precautions, there were nonemergency department cases of SARS transmission in health care settings in Toronto,⁸ and these prompted control measures such as detailed guidelines for the management of high-risk airway procedures (www.health.gov.on.ca/english/providers/program/pubhealth/sars/sars_mn.html#1). The impact of these measures on emergency department practice is difficult to evaluate, and some measures remain controversial.

ß See related articles pages 1349, 1353

References

1. Canadian SARS numbers. Ottawa: Health Canada; 2003 Sept 3. Available: www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/cn-cc/20030903_e.html (accessed 2004 Oct 18).
2. Lipsitch M, Cohen T, Cooper B, Robins JM, Ma S, James L, et al. Transmission dynamics and control of severe acute respiratory syndrome. Science 2003;300:1966-70.[Abstract/Free Full Text]
3. Peiris JS, Yuen KY, Osterhaus AD, Stohr K. The severe acute respiratory syndrome. N Engl J Med 2003; 349 (25): 2431-41.[Free Full Text]
4. Department of Communicable Disease Surveillance and Response. Consensus document on the epidemiology of severe acute respiratory syndrome (SARS). Geneva: World Health Organization; 2003. Available: www.who.int/csr/sars/en/WHOconsensus.pdf (accessed 2004 Oct 18).
5. Yu ITS, Li Y, Wong TW, Tam W, Chan AT, Lee JHW, et al. Evidence of airborne transmission of the severe acute respiratory syndrome virus. N Engl J Med 2004;350(17):1731-9.[Abstract/Free Full Text]
6. Varia M, Wilson S, Sarwal S, McGeer A, Gournis E, Galanis E, et al. Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada. CMAJ 2003;169(4):285-92.[Abstract/Free Full Text]
7. Chien LC, Yeh WB, Chang HT. Lessons from Taiwan [letter]. CMAJ 2003; 169 (4):277.[Free Full Text]
8. Loeb M, McGeer AJ, Henry B, Ofner M, Rose D, Hlywka T, et al. SARS among critical care nurses, Toronto. Emerg Infect Dis 2004;10(2):251-5.[Medline]

Related Articles

Initial viral load and the outcomes of SARS

Chung-Ming Chu, Leo L.M. Poon, Vincent C.C. Cheng, Kin-Sang Chan, Ivan F.N. Hung, Maureen M.L. Wong, Kwok-Hung Chan, Wah-Shing Leung, Bone S.F. Tang, Veronica L. Chan, Woon-Leung Ng, Tiong-Chee Sim, Ping-Wing Ng, Kin-Ip Law, Doris M.W. Tse, Joseph S.M. Peiris, and Kwok-Yung Yuen

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The impact of SARS on a tertiary care pediatric emergency department

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eLetters:

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Nomenclature Problem?

J. Gilbert Hill

cmaj.ca, 17 Dec 2004 [Full text]

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With the advent of modern travel  and communications – especially jet aircraft travel – with its immediacy and ability to criss-cross the globe so rapidly this becomes a real concern and apparent danger.

Take for example the case of on single, solitary person with either infectious T.B. ( tuberculosis )  or even hepatitis.  The infectious T.B. patient ( infectious tb being spread by exhaled droplets), can easily infect  a great amount of people traveling alongside the aircraft with him or her , and in addition place a great amount of fellow aircraft passengers and crew additionally at risk due to the closed recycled air in the interior of the aircraft during longer and extended flights.  Add to this the additions and complications of all the passengers and people exposed to all travelers and staff involved.  Its a potential medical nightmare and medical disease treatment fiasco.

For these apparent reasons and concerns medical travelers and med tourists need to be aware that they may be screened pre flight and post flight in aircraft , airport and airport security settings.  Screening may involve the use of medical staff , customs staff and may involve the use of thermometers and other medical instruments and diagnostic tools, processes, tests and procedures.

For example:

Several countries plan to introduce non-contact infrared thermometers (NCIT) at international airports in order to detect febrile passengers, thus to delay the introduction of a novel influenza strain. We reviewed the existing studies on fever screening by NCIT to estimate their efficacy under the hypothesis of pandemic influenza. Three Severe Acute Respiratory Syndrome (SARS) or dengue fever interventions in airports were excluded because of insufficient information. Six fever screening studies in other gathering areas, mainly hospitals, were included (N= 176 to 72,327 persons; fever prevalence= 1.2% to 16.9%). Sensitivity varied from 4.0% to 89.6%, specificity from 75.4% to 99.6%, positive predictive value (PPV) from 0.9% to 76.0% and negative predictive value (NPV) from 86.1% to 99.7%. When we fixed fever prevalence at 1% in all studies to allow comparisons, the derived PPV varied from 3.5% to 65.4% and NPV was >=99%. The low PPV suggests limited efficacy of NCIT to detect symptomatic passengers at the early stages of a pandemic influenza, when fever prevalence among passengers would be =<1%. External factors can also impair the screening strategy: passengers can hide their symptoms or cross borders before symptoms occur. These limits should be considered when setting up border control measures to delay the pandemic progression.

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First thing first – think like a metal detector.  Ensure that there are no metal objects on your person or clothing  or as little as need be.   Items such as coins  and metal buckles on belts and shoes are widely thought of .  Ditto that for coins.  However there are other items which may not be thought of  – pens , heavy boots with metal inside ( heavy soled workboots , expensive shoes are two types of footwear which may well have metal in them)   Lastly on the list do not forget other items with metal in them – pens ,  clothes with metal studs and even bras with metal frames in them.

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