Quarantined inside her home for more than a week, intensive-care nurse Susan Brickell wears a surgical mask to protect her family from a mysterious respiratory disease she may have been exposed to while visiting a hospital where several patients have died from the illness.
Brickell, who has no symptoms of the disease, is one of 2,500 people in the Toronto area isolated because of possible exposure to the newly identified severe acute respiratory syndrome, or SARS. Toronto has the largest SARS outbreak in North America, with more than 120 suspected cases and six deaths–all stemming from one family that brought the disease from Hong Kong in early March.
Such a rapid spread through a community–and Toronto’s fitful struggle to control it–has made the city a test case for how North American governments and cities can fight the disease, which has struck an estimated 85 Americans and more than 2,200 people worldwide. Toronto may hold more lessons for American cities than places such as Hong Kong, where extreme population density and nearness to the disease’s origin in mainland China have helped its spread.
SARS has spread faster in Canada than in the U.S., in part because the disease struck there weeks before doctors had identified the ailment or knew how to reduce the chances of transmission. But experts say the number of American patients could grow, and cities must be prepared to take public health measures seldom seen in this country’s recent history.
In Toronto’s Ontario province, officials have closed two hospitals, isolated health-care workers and their families, and barred most visitors from all hospitals. Concern over the disease has rippled through everyday life, sharply reducing traffic at restaurants and other public places and forcing hospitals to suspend all elective surgeries.
Some of the urgent measures are easier to implement than they might be in the U.S. because Canada’s health-care system is controlled by the government.
“We have the big stick if we need it,” said Dr. James Young, Ontario’s minister of public health.
Yet some medical workers such as Brickell say health leaders were slow to take essential actions such as closing the hospitals. Brickell wound up in isolation because she attended a meeting, which happened to be about fighting the SARS virus, at Scarborough Grace Hospital near Toronto on March 24. The next day, Ontario officials said anyone who had been at the hospital recently should go into isolation for 10 days.
“There are tons of questions and very few answers,” Brickell said. “I’m not sure where this will all end.”
Researchers in several countries have focused on a type of virus called coronavirus as the cause of SARS, and officials at the U.S. Centers for Disease Control and Prevention said Wednesday that they have a preliminary test to detect the virus. But experts said the cause has not been proved, and there are few clues about how to reduce the disease’s death rate of 3.5 percent.
`Super infectors’
One reason the virus has spread quickly in some places may be that certain patients are “super infectors,” able to transmit the disease to many others, said CDC director Julie Gerberding.
“In the United States we were lucky,” Gerberding said at a news conference Wednesday. “Travelers returning here did not have symptoms of disease as soon as they did in some other countries, and if they did, they were not in situations where they spread the infection to others. So I think some of this just has to do with timing and coincidence.”
Illinois officials have reported five suspected SARS cases, including four on Tuesday–three Chicago-area residents and one from Downstate. All of the infected patients had traveled recently to Hong Kong, Singapore or mainland China, officials said.
Canadian officials believe the Toronto outbreak began with an elderly Chinese couple who stayed in February at Hong Kong’s Metropole Hotel, where a doctor had brought the previously unknown disease from mainland China.
The couple spread the disease to family members in Toronto, which has one of the largest Chinese communities in North America. For crucial days, doctors misdiagnosed the condition as tuberculosis, according to a case report in this week’s New England Journal of Medicine.
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By the time SARS was identified in mid-March, the virus had infected numerous doctors and patients at Scarborough Grace Hospital, including a 76-year-old man who apparently contracted the disease while being treated in an emergency room.
Ontario officials said Wednesday that they expect more cases later this week in people exposed to the virus before the far-reaching isolation policy took effect.
“We’re dealing with a disease no one knows about,” said Young, Ontario’s public health minister. “We’re only beginning to see how it spreads and what the outcome is.”
If SARS were to strike a U.S. city with similar intensity, experts said it would not be difficult to implement isolation measures–provided the threat were clear and relatively few people were affected. But broad public-health policies such as those Toronto adopted may be a hard sell in the U.S., said Susan Scrimshaw, dean of the public-health school at the University of Illinois at Chicago.
“If there were a mass declaration on vague grounds, that would be a problem,” Scrimshaw said.
Ontario officials have taken out full-page ads in newspapers to get out the facts about SARS. Those in isolation are told to sleep separately from their family members, wear a mask when around others in their household, and not to share eating utensils or towels.
An eerie silence
Toronto’s four Chinatowns, normally bustling with sidewalk traffic, are eerily quiet this week. At a pharmacy on Spadina Avenue, in the most prominent of the area’s Chinatowns, workers wore paper masks.
“We wear them to give the customers a sense of protection,” said pharmacy employee Melanie Yuen, 22. “But it’s also to protect us from them.”
Experts believe SARS can spread only through close contact with infected patients, who transmit the virus when they cough or sneeze. Yet other means of transmission may be possible–at one heavily affected Hong Kong apartment block, officials are investigating the ventilation system and even mice as possible sources of infection.
“Coronaviruses can be found in animal species,” the CDC’s Gerberding said. “We have to have an open mind and look in all of the nooks and crannies of the epidemiologic cupboard.”
Ontario may have moved too slowly to prevent the further spread of SARS, said Barbara Wahl, president of the Ontario Nurses Association. Wahl urged officials in other cities to act more decisively when faced with the disease, predicting that Toronto will not be the last place in North America to grapple with a serious problem.
“There is no fence at the end of Ontario,” she said.