Disease crisis that rocked the globe fresh
in memories of those who fought it
http://canadianpress.google.com/article/ALeqM5gQ-UPEI29OfqPWhSQVif6sUTV2vQ
TORONTO — He's given his SARS talk so often, and in so many parts of the globe that Dr. Donald Low can still rhyme off, to the day and the date, exactly what happened when during the four-month international disease crisis caused by severe acute respiratory syndrome.
The Ontario government declared an emergency on March 26, he recalls without checking notes. A mothballed TB unit at West Park Hospital was converted into a makeshift treatment unit on March 21 for the first wave of Toronto health-care workers who contracted SARS.
"Every time I give the talk and I've given the talk hundreds of times, it's unbelievable the impact it has on the audience," Low says in an interview marking the fifth anniversary of the outbreak that claimed 44 lives in Canada.
"And it doesn't matter whether it's epidemiologists, infection control, public health people or lay people - the story is so compelling."
If many remain fascinated by SARS five years after it burst onto the pages of medical history, only a few people in southern China were paying attention when the story actually began.
It was November 2002 when people started getting sick with a severe respiratory illness in the province of Guangdong. It would take awhile for the nascent disease to ping on the global health radar.
Surging vinegar sales in China grabbed the attention of the folks who regularly scour the globe for what might be budding disease outbreaks, like those who work for the Canadian-led Global Public Health Intelligence Network.
"We were getting lots of rumours, like a lot of sales of vinegar," explains Dick Thompson, who was the spokesperson for the World Health Organization's communicable diseases section at the time.
"Vinegar in southern China is used as a disinfectant. And so if there's a run on vinegar, there'd be a suspicion that there was some kind of infectious disease or a widespread belief that there is an infectious disease outbreak. So at these meetings we'd been hearing this kind of drip, drip, drip come in about that."
The early signs had experts thinking pandemic influenza, which to flu scientists is what "the big one" is to seismologists. The last pandemic was in 1968. Were these the first rumblings of the next big one?
In mid-February of 2003, Mother Nature threw the anxious watchers a red herring. Several members of a family from Hong Kong contracted H5N1 avian influenza while in China's Fujian province - the first time in six years human cases of the feared strain of flu had been recorded. That turned out to be an unrelated coincidence.
In the years since the SARS outbreak, scientists have concluded a coronavirus that normally infects bats found its way into civet cats - a raccoon-like animal eaten with gusto in some parts of China. These unfortunate intermediate hosts transferred the virus to humans, it is believed.
Somewhere in this chain of events a mutation took root in the virus's genetic coding, ramping up the intensity of disease it caused. In humans, SARS was nasty; nearly one in 10 of the nearly 8,100 probable SARS cases died, which in disease terms is very high.
A problem percolating in China spilled out across the world in the third week of February, when international travellers were infected at the Metropole Hotel in Kowloon, across the harbour from Hong Kong.
A gravely ill Chinese doctor checked into Room 911 of the hotel. When he later went to hospital - where he died - the doctor infected health-care workers and triggered the largest SARS outbreak outside of mainland China. But he also infected travellers who took the disease to Hanoi, Singapore, Taiwan, Vancouver and Toronto.
In Vancouver, doctors quickly realized what they were dealing with and instigated precautions that kept the disease from spreading. But all the other cities suffered large outbreaks after the disease infiltrated hospitals.
The Toronto woman who brought the disease to Canada's largest city died at home and infected multiple family members. All the infections in the region traced back to this poor woman's chance encounter with a new virus in a Kowloon hotel.
By late February, Dr. Carlo Urbani, a WHO infectious diseases expert based in Asia, alerted the Geneva based agency that the disease has spread beyond China. Urbani himself became infected with the virus and died in late March.
On March 12 the WHO sent out an unprecedented health alert warning of a new "atypical pneumonia." By the 14th, a Friday, Canada and Singapore were also reporting cases, Dr. David Heymann, then WHO's executive director of communicable diseases, recalls.
"We were very afraid that it was a (disease) pandemic developing," says Heymann, who is now an assistant director-general for health security and the environment.
The next day Heymann, Thompson and Denis Aitkin, a senior official in the office of then director general Gro Harlem Brundtland, huddled to name the new disease.
"How many times do you get the chance to name a disease?" Thompson recalls, his voice still tinged with wonder.
For Heymann, the experience wasn't a first. He had been on the team that battled the first reported outbreak of a new hemorrhagic fever in Zaire, now the Democratic Republic of Congo, in 1976. The scientist who led that team, Karl Johnston, had been insistent the name should not forever stigmatize a town, so the dreadful disease was named after the nearby Ebola River instead.
"We wanted it to be similar to AIDS - to have a name ... and an acronym but also a description of what it was. So respiratory, severe ... those things we finally put together into SARS," Heymann explains.
While the trio in Geneva was naming the disease, scientists at the National Microbiology Laboratory in Winnipeg began tests on specimens from Toronto. Polymerase chain reaction - PCR - tests can only find known disease agents; the test search for genetic material that matches samples it has been programmed to look for.
"So we put it through our chlamydia test and our flu test and all the other viruses that we thought it could be.... And they all came up negative. Then we kind of more or less knew we were into unknown territory," says scientific director Dr. Frank Plummer, whose lab now boasts new technology that can search for the DNA of unknown disease agents.
"For the National Microbiology Lab, it was really a defining moment," Plummer says of the SARS outbreak.
"It really thrust us onto the world stage."
In Toronto, Low and the army of other people who never became household names initially didn't realize how far SARS had spread. Staff of the first hospital - Scarborough Grace - had been infected. So had patients who were located near the first case to come into hospital, along with their family members.
People who didn't know they had been infected with the new disease turned up at other hospitals, where staff had been told to be on the lookout for people who had recently been to China. And patients who would too late be identified as SARS cases were transferred from Scarborough Grace to hospitals around the greater Toronto area. Like sparks from a fire, they soon set off their own blazes.
Nurse Susan Sorrenti was on duty when one such patient was transferred to Mount Sinai Hospital. She caught SARS.
Sorrenti, who still nurses, agitated at the time for higher levels of precaution - a position that would later be taken up by Justice Archie Campbell, who conducted the exhaustive investigation into SARS ordered by the Ontario government.
Campbell, who died last April just three months after issuing his massive final report, stressed that the precautionary principle must be used in future outbreaks - when in doubt, opt for higher levels of protection, he said.
"I guess it taught us all a good lesson about what we think we know. From the top guys on down," Sorrenti says.
"Big, big lesson. Big price."
The virus behind the disease was identified at the U.S. Centers for Disease Control in Atlanta. And shortly thereafter Vancouver's Michael Smith Genome Sciences Centre became the first lab to map the genetic code of the SARS coronovirus.
The public health researchers rushing to reveal the virus's mysteries to help the containment effort found themselves working against the clock, with an anxious world peering over their shoulders.
Plummer describes it as "doing science under intense public scrutiny."
"You're responding to press conferences that are being held in Hong Kong 12 hours earlier. So it's very different. You're kind of getting further and further out on a limb, actually."
At the time, public health measures long abandoned, quarantine and isolation, were dusted off and pressed into service. These old tools earned new respect because of the disease's particular quirks. It had a long incubation period and people weren't infectious until after they got sick, so there was merit in telling those exposed to stay home until it was clear they were not infected.
Less admired - by affected cities, anyway - were advisories issued by the World Health Organization, in which the agency urged people to avoid cities where SARS appeared to be careering out of control. Heymann still justifies the measure, insisting the WHO felt it was necessary to curb travel.
"Our biggest fear was that it would get into a country where it was missed in surveillance," he explains. "And the other fear was that it would become endemic in some animal population and constantly reinfect humans."
In reality the warnings were only formalizing what was already happening. People were already shunning locations where SARS was spreading. In Toronto, movie shoots were relocating, large conventions were cancelling and hotel vacancy rates were soaring.
Still, the travel advisory issued April 23 infuriated Canadian officials. Toronto's then Mayor Mel Lastman, seemingly unaware of the World Health Organization or at least its acronym, angrily demanded "Who is WHO?" in an interview on CNN.
Ironically, by the time the travel advisory was issued Toronto was past the worst of the outbreak - or so it appeared at the time. Authorities in the city were actually breathing collective sighs of relief.
That's because the previous weekend had been Easter, a pivotal point in the battle. Several members of a Filipino religious group had fallen ill. Authorities were fearful the sacred rites of Easter would further spread the disease and churches were asked to suspend practices that might further transmission, like the passing of the Communion Cup.
"We got through the weekend basically holding our breath, doing all we could to obtain as much information as possible and to react to it," recalls federal Health Minister Tony Clement, who was Ontario's health minister at the time.
"And the number of cases started to decline. So that was when we knew that we could beat this infection and it wasn't going to go through the whole community."
Canada celebrated too soon, however. Believing the outbreak was over, authorities told health-care workers they could remove their hot masks and respirators. The smouldering embers of the outbreak again burst into flame, causing a second wave of infections
A further 90 people were infected and 12 died during the second phase of Toronto's SARS outbreak. In the two waves combined, Canada recorded 375 probable and suspect cases of SARS. Two nurses and a doctor were among the 44 people who succumbed to the disease.
