U Albany School of Public HealthdecorativeU Albany School of Public Health Continuing EductaiondecorativeNYS Department of HealthdecorativeCPHP Network

Center for Public Health Preparedness


University at Albany Center for Public Health Preparedness


Original Satellite Broadcast: 10/07/04

MODERATOR: Good morning, and welcome to the Center for Public Health Preparedness Grand Round Series at the University of Albany School of Public Health. I'm Peter Slocum and I'll be your moderator today. Before we begin I'd like to remind you that we will take your calls and questions later in the hour. The toll free number is 1-800-452-0662. You may also send your written questions to us via fax at 518-426-0696. The topic of today's program is learning from and preparing for SARS.

Our guest speaker is Dr. James Young, Commissioner of Emergency Management in the providence of Ontario in Canada. During the SARS outbreaks in Ontario in the spring of 2003, Dr. Young co-managed the provincial emergency response and provided leadership and management council and management control and served as one of the government's spokespersons in daily media briefings. Today Dr. Young will explain how SARS spread to Toronto and address issues that they had to confront there of isolation and quarantine and the use of other tools to support the local health department plans for our outbreak control. Thank you for joining us today Dr. Young.

YOUNG, J.: My pleasure.

MODERATOR: Could we start with a little bit of the basics? And that is what is SARS and why is it such a threat to us even though it's not bubbling around in Toronto or New York or San Francisco now?

YOUNG, J.: Well, SARS turned out, after some considerable study, to be a corona virus. The symptoms, as with many viral illnesses, started out very mild. Generally, someone would feel fatigued. They would begin and run a fever. They would then develop a cough. That cough, in significant numbers of cases developed into an atypical pneumonia. Unfortunately, in some of the people it would require intensive care and in some instances, respiratory arrest and death. So it ran the gamut as most viral illnesses do and was a medical problem in and by itself at the time.

I think it's a significant issue still to us really for three reasons. The first is the worry that it could come back. The good news in regards to that is that it now appears that the virus mutated in 2003. And when it mutated, it gave much more serious symptoms and it also could be spread human to human. So the real risk is the virus from that year. That virus hopefully is contained with in the labs in the world, but we have had breakouts from the labs in Singapore and Taiwan and in China. So there still are lessons for us from that.

The second important thing that SARS represents is that one form that bioterrorism could take. Again, it wasn't a bioterror event, but it certainly would represent if a terrorist got a hold of a virus, was able to mutate it, was able to plant it among a human bomb and put it in our society, it could look like SARS did.

And very importantly too, it's the third reason is that when it came we knew very little about it. And frankly, we didn't know whether or not it represented the new pandemic that we all worry about. And so the actions that we took and the way we had to treat it was as though it was the beginning of a pandemic. So I think there were lessons to all of us about pandemic planning and management.

MODERATOR: We'll talk a bit later about some of the factors you had to deal with. The ignorance that started what this is going to be like. Could you tell us a little bit about your role there in the government and how it compares with a similar structure in the United States maybe for our viewers?

YOUNG, J.: Sure. I'm a civil servant appointed by government to a senior position, a deputy minister position. I'm most like someone – I manage homeland security. And homeland security within our government includes not only the terrorism aspects but also public safety. So I have responsibility in the province on an ongoing basis for terrorism preparedness but also for the Center of Forensic Science, for the fire marshals' office and fire delivery in the province, and for emergency management in the province of Ontario.

MODERATOR: I think it's a coordination of structure which doesn't occur too much at the state or county level in the United States. They are trying it obviously at the federal level now with the homeland security department. How successful was your effort in Ontario dealing with SARS?

YOUNG, J.: It was successful. It wasn't smooth. It was bumpy at times and I hope to be able to talk about what we learned from – in the way of lessons from some of those bumps. But the actions we took worked, and they worked very quickly, and they worked successfully. So the good news was that in fact it did work. And I think one of the measures of that success is that we were able to get people to work together as a team.

It's very important when you are managing something like this that people pull in the same direction. That there's a set of direction that you're going and everyone supports that direction. They may raise issues. They may raise debate within it, but it's very important that in fact you decide on a course of action and you follow it through until you decide to change direction. And you don't have everyone inventing their own way of solving the crisis.

MODERATOR: So that one of the key lessons is have everyone on that same team and bought into the – work towards a solution.

YOUNG, J.: Exactly. And have them pulling in the same direction. It's fine to raise issues, but you can't have a thousand managers of it. You have to have one direction and one management team.

MODERATOR: Let's come back to some more lessons learned later on, but first could you take us through the story of the SARS outbreak. And I know we're going to begin with a picture of a hotel. Why that?

YOUNG, J.: The story actually begins in the markets in Guangdong Province during the fall of 2002. And the SARS virus likely is present in animals such as the civet cats and gets into some of the workers in the marketplace.

The illness, as I mentioned, probably that year the virus mutated and now was being spread human to human and being treated. The significant thing was that the government of China at that point in time chose to keep SARS a secret from the rest of the world. And there was literally no information made available to anyone that they were battling a new disease.

A doctor from Guangdong Province then went to a wedding at the Metropole Hotel. And the slide shows the Metropole Hotel – because that became actually the central area that affected the story. And that doctor became ill with SARS when he was in the Metropole Hotel. Interestingly enough, he was staying on the ninth floor in room 911 in the Metropole Hotel.

We now know that the doctor when he was at the Metropole Hotel vomited in the hall at one point, and that may have contributed to the spread of SARS. The other thing that happened is that the doctor was in contact with people from various countries either in the elevator or while waiting for the elevator.

And so the spread of SARS to the rest of the world and in fact to Beijing and China was from this visit to the Metropole Hotel.

MODERATOR: Wow. It's amazing that this one slide – I think the slide shows in a very complicated fashion the pattern coming out from that one room in the hotel. But how rapidly the spread of that virus takes place within – attacking many victims in that one environment.

YOUNG, J.: Yeah. The key to this slide is it looks complex, but really it's intended to show in the center is the Metropole Hotel in Hong Kong. And from that visit to the Metropole Hotel, a doctor from Viet Nam, a couple from Toronto, someone from Singapore, people from Hong Kong, and people from Beijing all were effected from this visit and from the ninth floor of the Metropole Hotel.

And then from those people in turn, people from other countries such as the United States and Ireland were peripherally affected as well. But really ground zero for the spread of SARS turned out to be this hotel in Hong Kong.

MODERATOR: And maybe all of our viewers can't see it all, but those little diagrams on the side represent people who came from different places in the world to that hotel. And then some of them came back to Toronto. Right?

YOUNG, J.: Exactly.

MODERATOR: When did SARS get to Toronto from there? Was it a couple that were visiting in the hotel?

YOUNG, J.: It was an elderly couple who were visiting the hotel, and they were staying on the ninth floor. The 78-year-old female was well while she was in Hong Kong and returned to Canada but got sick on the seventh of March and was seen by her doctor in Toronto, given an antibiotic. She deteriorated but was never hospitalized and died.

Her son – I'm sorry. She actually died on the fifth of March. She became ill before that. Her son, who in this diagram is on the second level on this square box with the stroke through, became ill on the seventh of March. He did not realize that he had an illness that he caught from his mother. Nor if anyone had asked him at the hospital would he have said that he had been out of the country because he hadn't.

He went to the hospital on the seventh of March. He deteriorated and after 16 hours he was put in isolation with a working diagnosis of tuberculosis.

He continued to decline, and he died on the thirteenth of March. And he became the spread within Toronto.

MODERATOR: How did that spread within Toronto take place then?

YOUNG, J.: What happened was that on the twelfth of March, the WHO gave the first alert for the SARS virus. And that alert talked about an atypical pneumonia affecting healthcare workers, unidentified cause, and described it as being in Southeast Asia. It did not talk about Toronto, and it did not call the disease SARS at that point in time.

When that warning went out, that went out on the twelfth of March. And I remind people again that he entered our healthcare system on the seventh of March. When he died, Toronto public health recognized the next day that on the thirteenth when he died that he probably had this mysterious new illness.

MODERATOR: Which had just been alerted the day before. Is that right?

YOUNG, J.: The day before. Exactly. And several of his relatives became ill the next day on the thirteenth, the day that he died. And they were all immediately put in isolation, and they were immediately recognized as having SARS. The problem was that this man had been in the emergency for the first 16 hours.

And two of the people who were on stretchers next to them in the emergency department both caught SARS. And they in turn then continued to spread the SARS through several other patients and several other people. And in fact then by the time of his death on the thirteenth of March, significant numbers of people, both in the hospital and outside of the hospital, already had SARS, and it was spreading through the community.

And so what we see from this in fact is we see that in today's world with travel, we can have a disease. It can be into our healthcare system and it can be rapidly spreading before there's even a description of it in the literature.

And on the fifteenth of March there was a description, a further description. Same description by the WHO but it now said that it was in Southeast Asia and in Toronto. And it described it as being called SARS at that point in time. So by the time that happened we in fact were well into the problem and had difficulties with it.

MODERATOR: And even with the instant communication - that's a feature of our modern life and that emergency medicine and other people can take advantage of. The civilian traveler beats us to the punch, so to speak.

YOUNG, J.: Precisely. And it's already well-engrained in the system before we've even known when to look for it.

MODERATOR: Well, then how was this outbreak different compared to other events, including the e-coli event in Ontario several years prior?

YOUNG, J.: The problem when we started to deal with this, we asked ourselves a series of questions. And it was disturbing because we had very little answers when we asked those questions. The first question that we asked ourselves is what is the agent that is causing this? And the answer that we had was we don't know. We think it's a virus, but we don't know what virus. In fact, it was nearly two or three more weeks before we knew that it was the corona virus. And when we knew what the symptoms were, we knew the beginning symptoms. We understood and were seeing the fatigue, etc. That I described earlier.

Guangdong until we realized that diarrhea was a symptom as well, we missed several cases along the way. People were going to emergency reporting diarrhea and being diagnosed as having gastroenteritis and being sent home. And that created problems for us initially in the diagnoses. When we asked ourselves then other questions like how long is the incubation period, again we had no specific knowledge. We couldn't go to a text book and look at it.

We thought that it was from two to ten days, and it turned out that we were But we certainly didn't have confidence that we were absolutely for sure When we asked how it was spread, we again thought being a virus it's likely spread by droplet, but it could be spread as an aerosol. It turns out in retrospect that it's mostly spread by droplet. But in very – in some instances, such as when someone is very sick and they're being incubated, it can be spread by aerosol as well. And we learned that again the hard way as other centers such as Singapore and Viet Nam and China did as well.

MODERATOR: And the healthcare workers were affected.

YOUNG, J.: Exactly. Then we had healthcare workers who became affected. So we then looked to how do we diagnose it. And bearing in mind the symptoms I mentioned, those symptoms are virtually identical to most other viral illnesses. So we're faced with a prospect of many people coming to the hospital with very vague symptoms, and we're trying to sort out who might have SARS and who doesn't. Ultimately, we got a diagnostic test. It worked 40 percent of the time. We would test someone who was very sick with SARS and it would test positive. And we'd say well, it told us what we already knew. We would test somebody who was very sick and had SARS and it would test negative. And we'd say well, it might be a false negative. We would test someone who had a merging disease and was positive, and we'd say well, it might be a false positive and we'll treat them as though they have SARS, but we'll continue to watch. Maybe they do and maybe they don't. And we'd test someone with a merging disease and it would test negatively. And we'd say well, it might be a false negative. We'll have to treat them as though they had SARS. So essentially the test was really of virtually no use whatsoever.

MODERATOR: Well, given all these issues we were just talking about, what approaches should be taken by the healthcare system, including public heath and also could you address the question of the combination of public and private systems that need to work on this and what balance seems to be the right one.

YOUNG, J.: We were faced with all of the things I mentioned and we also clearly, because it was a new illness, had no treatment. Everyone in the world were trying various treatments and e-mailing each other and talking about successes and failures. So we said to ourselves, with all of those problems and no easy solutions, what would have been done 50 years ago. And the answer that came was you would use infection control to a much greater extent than we've been using it in our hospital system. And you would use quarantine much more aggressively until we understand the characteristics of the disease.

So that became the hallmark. In fact, we fell back to what people would have done when they were faced with an epidemic situation and used those very, very aggressively and very – We used them, as you'll see in a few minutes, across the province vigorously at the beginning.

We have the advantage in Ontario, and it was a big advantage, that the healthcare system is all a public healthcare system. And the reason I say that was an advantage is that while the hospitals are normally controlled by separate independent boards, the reality is that the funding virtually comes 100 percent from government.

In an emergency situation therefore, we were able to issue directives to the hospital as to what we wanted them to do with infection control. And those directives could be very specific. And they were not guidelines, they were directives. They said to the hospital, "You must follow these." And the risk, as I indicated earlier with people pulling together is that if everyone starts to take a guideline or directive and interpret it and choose what part of it they're going to follow and what part they aren't – you risk then them doing the wrong thing. And in a situation like this, you're only as good as your weakest link. And if you've got a hospital then that's paying no attention or little attention and doing the wrong things and begins to spread it, you have the possibility at that point then that they're going to continue the problem going and spread it back by people going to other hospitals and continue the whole thing going.

MODERATOR: The infection pops out somewhere that you don't have under control.

YOUNG, J.: Exactly. And continues then to affect other areas in other hospitals. So the challenge I think in the United States where it wouldn't be as easy to do directives would be to get the healthcare system working as one and working together. I think I've given a good deal of thought to that. And I think for example one of the things I would suggest that people get thinking about these things in advance and be talking with hospitals about the need to do that. I would involve the hospitals very early on in the decision making so that in fact they become part of the solution rather than part of the problem.And in some instances, emergency legislation would allow for an override of particular places. But I think cooperation and impressing upon everyone that we're in this together, and it's in all of our interests to do it right is the way to go. But it is more of a challenge here than it even was for us. And believe me, it was a huge challenge even for us.

MODERATOR: Well, I think there certainly is some recognition of that here in an effort through some of the bioterrorism grants that the health departments have that coordinating responsibility, but it's an uphill slog. No question. You did declare a provincial emergency in Ontario. Was it just a health emergency as it turned out?

YOUNG, J.: No. It was not. It was a full emergency. I've been involved in enough emergencies I recognized that while this may start out as a health issue, you need tremendous cooperation and coordination between the health sectors. So this in fact, SARS was mainly a hospital problem rather than a community problem. So you needed the cooperation of the health community. You had to involve nursing homes and places where – convalescent hospitals. You needed public help. But very quickly it becomes obvious that there are huge legal issues. There are occupational health and safety issues; therefore, labor issues. You have to watch about it becoming involved in other places where people are in close contact such as jails or schools. You have to make decisions about what stays open and what stays closed. So it involves all of government. And for that reason, it was declared a provincial emergency. When we did that, we also recognized that when we looked at what was happening in the first hospital, the number of cases was increasing. And that told us then that in fact that the early measures we were taking weren't controlling it. And as days went on and the chances of it popping up in other places was much greater.

And the analogy I would use for something like SARS is an iceberg. You have all of these people getting sick and you're having trouble enough seeing and telling the size of the part of the iceberg you can see. But you know then that what happened, the cases you're seeing today are people who became infected anywhere from two to ten days ago. And those people in turn are spreading it to other people that will pop up over the next two to ten days. Therefore, the real problem is not the part you see. It's the part that you don't see. And where are those people and where have they been and where have they spread it already?

MODERATOR: They're infecting others that you don't know about.

YOUNG, J.: Exactly. So that really calls for action that's coordinated and is moving and is very aggressive. Because in fact, you're only seeing as I say, the tip of the iceberg at that point in time. And you've got a lot of work to do to get ahead of the curve.

MODERATOR: Now did you have the organizational structure in place that you needed to deal with it, or did you need to improvise as you went along in this crisis?

YOUNG, J.: We had part of the organizational structure we needed, but we certainly didn't have it anywhere near perfect. We had been talking with the ministry of health about increasing and doing more pandemic planning. With all the other pressures in healthcare, they were doing it but it was moving slowly. And the people within the ministry of health had limited operational experience in managing emergencies.

So we used our basic plan, but we modified it very quickly. And we combined the work of the Ministry of Health with the other ministries at a central table.

YOUNG, J.: And we brought in the local medical officers of health and had them as part of the decision making team and exchanged information both at a municipal and provincial level right from the beginning and structured our response around a central table that was working.

In a perfect world, we would have each of the various areas of ministry off solving their problems and bring it all together and then carry forward the issues that need to be carried forward. But as often happens in these things, you're not dealing in a perfect world. You deal with the reality at the time.

MODERATOR: And I know the next light we begin to talk about some of the jurisdictional question that you just mentioned of bringing the other health officers in from different areas. But what were some of the approaches you used to address this problem of getting this entire morass together for yourself organizationally?

YOUNG, J.: We recognized very early then that it was very quickly going to spread outside of just health issues. So we brought people from the city, from the province, from the federal government together very early. We brought people not only from health, but we brought people from all other ministries and organizations of government.

When we put together our scientific advisory group, we brought infection control people, public health people, academics, nurses. We brought a broad group of people together to work on the issues rather than either going all academic or all just infection control, because we wanted the practical aspects along with the academic aspects all merged and brought together.

We chose to take very bold and very rapid action. And the actions we took we applied across the entire province, even though the problem in fact at the time it broke out was only in one hospital. We made the assumption that that hospital had been infected some ten days earlier.

And therefore, people would be coming and going from that hospital and in fact could have been visitors or patients that have moved on to other places. And for that reason, it could be anywhere in the province or beyond the Province of Ontario. Therefore, the actions that we should take should be very broad-based. And they were broad-based. They were all of the hospitals in the entire province, even though some of the hospitals in Manitoba, for example, were a thousand miles away – there still could have been someone from that area who had visited Toronto and carried the disease back.

MODERATOR: It could have been a physician visiting a colleague or a class and gone back to Manitoba.

YOUNG, J.: Or a visitor visiting an elderly patient who had bypass surgery or some other thing and then had gone back home and were appearing in their emergency department.

MODERATOR: So you essentially leapt out, tried to leap out ahead of it with your control mechanism.

YOUNG, J.: We assumed that it had spread, and we applied the control mechanism very aggressively across the entire province all at one time.

MODERATOR: And the reality is that you have to deal as your slide says. You have to deal with the facts and the institutions that you're given even if you don't know those facts as certainly as you would like to know them.

YOUNG, J.: The key at the beginning when something like this starts, the first thing that the press will often do is start to talk about whose fault is it.

And they could get into the blame game very quickly. It's decidedly unhelpful, because blaming people or looking back isn't solving the problem. The problem at that point in time is looking forward and dealing with it very aggressively and very positively. So the first thing you have to do is say to the press, "We'll do all of that later. We'll do a review."

The second thing that you have to battle as well is people saying, "Well, if only we had all of the perfect systems to deal with this and we had the perfect healthcare system." What you have to remind them is you got to deal with the cards that you're dealt. So in a perfect poker game, you're sitting with four aces. In reality, when you look at your hand that you're dealt, you've got a two, a three, a five, and a six. And but you've got to make that two, three, five, and six work for you and you've got to win the game. And you have to remind people that that's the way it is. And we're going to build from there. And we're going to be innovative. And we're going to pull this together, but there's no point thinking that you've got the four aces. You don't. And you're not going to get them. So you go off from that and you deal with the real world.

MODERATOR: And sometimes you have to make decisions based on what you know to be incomplete information. But you have to make the judgment the best you can based on your experience and what you've got to work with. Right?

YOUNG, J.: And you have to make very bold decisions. In our case for example, we decided to apply the infection control measures as I mentioned in every hospital. Now to do that and to get everyone's attention and to educate them about SARS, we decided that we were first going to distribute the gowns and gloves and masks, including the N95 mask, in sufficient numbers to every hospital in the province. We were going to educate people not so much in how to put them on, but the important thing in fact was how to take them off safely, because hospital people to some extent had forgotten about that and they had to be reminded.

They had to recognize that in the world we were in at that point in time, everyone who came to the hospital with a fever and fatigue and a cough had SARS until proven otherwise. And they had to learn to work in gowns and gloves and masks. In order to do that, we restricted visitors. But the other thing that we did, we effectively shut every hospital in the province down to elective surgery while we got the distribution done, while we did the education, while we got everyone used to the new way that we worked. We knew that in doing that that we were putting some patient in peril because their elective surgery was being cancelled. We did recognize that we were continuing to do emergency surgery, but we knew we were backing up our elective surgery lists. But the risk if we didn't do it and we didn't do it right was that it would – SARS would spread hospital to hospital to hospital. And we already knew that once it was in a hospital in sufficient quantity, you had to close the hospital down. And our estimation, and it turned out to be right, was that you didn't get it back open for three months. So the question is do you paralyze your system hospital by hospital and eventually end up with few or no hospitals.

Or do you take a bolder action, stop it to begin with, and then start your system back up. And that's the way we chose to do things.

MODERATOR: That's certainly an extraordinary step. And I imagine in the United States trying to do that, telling all hospitals no elective admissions whatsoever, only emergency admissions would be quite unprecedented.

YOUNG, J.: It is. And interestingly enough, it's avoidable. It's avoidable if the planning has gone on and the education has gone on about gowns and gloves and masks. If the supplies are in place so that people have thought about it and can do it. Because as you'll see later in the second wave, we didn't have to go to those measures because people already knew how to do it, and we had the supplies in place, and we'd exercised the plan. And by doing that in fact, the second time we were able to carry on and implement it much quicker.

MODERATOR: So there's a way to avoid it, but it calls for doing the work now instead of later. You need that workforce and that system to be ready to handle that kind of emergency and the training.

YOUNG, J.: Exactly. It needs to be in place in advance.

MODERATOR: And so patience and communicating that information about infections role and movement restrictions at all was really a new thing. Right?

YOUNG, J.: Absolutely. We had to work through a whole series of education. The first thing was the issue of infection control. People in hospitals had grown very used to the fact they had antibiotics and the risk was very low. And they'd become somewhat complacent about infection control. We also found that we had to give the general public something to do, because they would be asking, "What is it we can do?"

So one of the things we emphasized was the best way to stop the spread of illness is hand washing. We did a survey in fact during SARS, and we were the best hand washers in the world for a couple of months there. It's probably fallen off, but people actually listened and they did pay attention. We had to work on the techniques around taking gowns and gloves and masks off. We had to work on the psyche of medical workers and get people to understand that they should not go to work sick. That they might in fact be spreading SARS. And this was a big problem for us, because traditionally medical people are very strong-willed and very dedicated to what they do. And we had instances where people, even people working on SARS units were getting the symptoms of SARS and continuing to go to work and in some instances, spreading the disease.

So it was very hard to work on this, but it was very important to get people to understand it. We also had to control the movement of people, because we realized that our hospitals had become very porous places. We were moving patients, and we had no idea where they were being moved to. And we devised a system now where we pre-clear everyone that's being moved in the system. And we have a record of it. We also used the system as an indicator. If we're starting to move a lot of patients for example from a nursing home into a hospital, that's an indicator that there might be something going on within that institution. We paid attention to staff, and we tried to limit the number of institutions that casual staff were working in so they weren't able to carry the SARS virus from one place to another. We tried moving as many of our outpatient clinics out of hospitals as we could, although the problem we have is many of our hospitals were designed with our outpatient clinics as an integral part of the hospital. Not a particular good design in retrospect but something that we had done.

And we restricted visitors within our hospitals. And they were screened very carefully. But at the height of SARS, restricted visiting to almost nothing within our whole hospital system. Again, as an attempt to try and stop the spread of SARS.

MODERATOR: We've talked a little bit about equipment, but you want to talk about the special units within hospitals too, right?

YOUNG, J.: The equipment was a big problem. We had to get our workers to use N95 masks, which are very hot and very difficult to work in, and gowns and gloves. And we had to fit test ultimately all of our people for N95 masks. They certainly – Not only did the staff find the equipment hot and difficult to work in, but it's very difficult to give patient care when you're always in a masks, because you lose that facial expression and the ability to show empathy. And people certainly found it difficult. We found in time that doing procedures like incubations were extremely dangerous on SARS patients. And we had one instance in a teaching hospital doing incubation on a very sick patient, eight healthcare workers became infected with SARS from that one incubation.


YOUNG, J.: Following that, we rewrote all of our rules around incubation. And we required people to be in striker suits when they were doing any of the incubation and not to attempt any resuscitation until they were fully protected.

MODERATOR: Striker suits are moon suits commonly?

YOUNG, J.: They are the moon suit idea. And obviously it's very difficult to be doing medical procedures in moon suits, but it became very necessary in the case of people who were highly infected. And it's something to bear in mind for the future. That we may have to with future bugs have to be looking at exactly this kind of thing.

MODERATOR: Let's switch over to the issue of quarantine for a moment, which as you said before is an old public health technique but fallen into disuse and discredited by many people I know. Do you distinguish between quarantine for those who are known to be exposed but not yet infected as opposed to isolation for those infected?

YOUNG, J.: We were basically calling everything quarantine. And when we found someone was infected, generally what we did was admit them to the hospital pretty well at the beginning of their illness. We found that the SARS progressed quite quickly in some instances and it was safest from a control situation and also from a medical for their own medical needs to have them in a hospital.

What we then did though was to quarantine all of those that were associated with them. And we quarantined about 30 thousand people during the course of the SARS outbreak in Toronto. The quarantine that we used we called in most instances voluntary quarantine. And what we meant by that was that we would verbally order someone into quarantine and provide a good deal of medical information about the quarantine, why it was necessary, how to do it, what to do. And we would send them home with gowns and gloves and masks and instructions of staying away from their family and how to operate within that quarantine time. And generally, by the time we knew about their exposure, it was several days after their exposure. So generally people were being quarantined for five days, six days. It would not be the full ten days, because generally it was three or four days before the person they were in contact with had in fact shown symptoms. And so it was – most of the people would be about five days that they were in quarantine. Most of the people were very compliant. And the more education there was and the more that people understood about SARS, and in fact the more they worried about it the more compliant they became. The group that was hardest to get compliance were teenagers. And we had one school that was quarantined. And they were extremely difficult to keep out of the malls and keep them quarantined. But generally they did very, very well. If we found someone wasn't compliant, then we issued a written order. And we had to do that probably about ten different times out of the 30 thousand. If someone absolutely wasn't compliant beyond that, we could get a court order. They would be taken by the police to a hospital and confined to the hospital. That only happened once. And someone who was lying about staying home and was going to work and infected some co-workers.

We also, in that instance, launched a criminal investigation into their conduct. It turned out the person got sick with SARS was hospitalized right after the court order was done, and ultimately died. But we made sure that people understood that we had that power and could use it. And that was the big stick. But generally with education and social pressure, the carrot worked much better than the stick. And people in fact did comply.

Another very important feature that we were able to convince the government to do was that we were able to convince the government to get a program where we would compensate people. Not for their full wages but for at least part of their wages the whole time they were in quarantine. We made it very simple to collect this program, and we announced it very early into SARS. And that became a very important thing, particularly for people who were economically stressed. If we were able to say they were not going to lose great amounts of money and they would be paid to stay in quarantine, the compliance rates went up tremendously. And we found that a very important measure that we were able to take.

MODERATOR: To that issue of dealing with a provincial government on the side matter, the income thing you wouldn't ordinarily think about as a public health measure, but I can see why it would be important. It goes to the question of command. And someone always had to be in charge, but it's awfully hard for one person to have all the answers. Did you find help within the government? How did you find that? And assigning responsibility to other within the network.

YOUNG, J.: You're absolutely. Someone has to be in charge, and someone has to make the ultimate decisions. And in reality in our world and your world, it becomes a political decision. And the political leaders takes the ultimate responsibility. But in the real world as well, the politicians have even less technical experience and less experience at managing. So there has to be a general who is in charge of the operation. But it really is a team effort. And the key thing then is to surround yourself with very good people and to listen to them and let them manage and to have only the problems float up to the person in charge. So we created very early on a scientific committee.

And we brought in that range of people that we talked about earlier; the clinicians, the nurses, the public health people, the academics. And what I would do each day is I would start the day with a meeting with them. And I would say to them, "Here are the problems I need answers to in an hour. Here are the problems I need answered and the policies I need written by the end of the day. And here's what you have the luxury of having a day or two to decide about. But this is the long-range problems I see coming, and I want you to think about them."

For example, at one point I sat them down for a day and I said, "I want you to think about what would happen if we had to close the city down? And when would we do it? And what would it look like? And how would we carry this out? And I need that information in one more day, and I want you to produce a paper." So you were getting scientists who were used to writing policy over a year or two and have a great debate, writing policy based on limited information but their best intellect and their best information and writing it very quickly. And then my job to translate that into action.

MODERATOR: We're running a little short on time, but I want to get to some of these important slides, particularly about the effect of the control measures. And this next one here is pretty dramatic in terms of when you could see you were having an effect.

YOUNG, J.: Yeah. The key to this slide is you don't first of all at the beginning of the outbreak have this kind of a lovely graph, because you can't tell who has it and who doesn't. But what you see is that it started slowly, and we were starting to see cases. And then we recognized the cases in around the twelfth and thirteenth of March and closed the hospital, the Scarborough Grace Hospital within a couple of days. As we see things getting worse rather than better and we recognize that the activity level is increasing, you see when the emergency is declared. We were right in within two days we had to close the second hospital, and it turned out that SARS was in seven other hospitals. It just took us time to figure out which hospitals and where they were and to take -- But we had already taken appropriate measures within those hospitals. We had all of the workers already protected.

And we had restricted things within all of the hospitals in the province. You see where we were worried about a religious group, that's where we worried about it spreading into the community. It turned out that it didn't spread extensively, but it did some. And where it says HCW, that's the healthcare workers that were exposed during the incubation.

The most significant thing on this slide is that if you count out ten days from when the emergency was declared, and that was the day we put the infection control measures and we stepped up quarantine, ten days later when we would expect to see whether or not those measures were taking effect, that's when the outbreak essentially stopped. And so we knew then that we weren't seeing new cases, and we knew that the measures had worked at that point in time. As difficult as they were and as draconian as they were and as bumpy as they were as we did them, they were working. And we knew that at that point in time. Unfortunately just after that time, the WHO decided to put a travel advisory in place.

MODERATOR: We'll get to that in a second. We all worry about the community spread of these infectious diseases. How extensive was that concern in Toronto? You mentioned briefly that religious group there. But was that a broadly held concern?

YOUNG, J.: It was. Obviously we didn't know enough about the virus to know. It turned out to be a hospital-based, not a big community spread. If it was a community spread, I'd venture to say we'd all be battling SARS and possibly all be battling it still. But we did find that it spread in very close contact situations; doctor's offices, family members who were meeting in a funeral home and were hugging and in close contact, and a religious community who had had a retreat and were in close contact. So there was some limited spread, but that spread was in close contact rather than casual contact. And we were very lucky that this particular virus had that characteristic.

MODERATOR: Let's jump right to the second wave, because there was a second wave that occurred after that ten day control. How did that come about and was it different than the first one?

YOUNG, J.: It was because everything went very quiet. And we saw no cases for almost three weeks. In fact, I was in China giving a lecture about SARS when I got passed a note that there was a new case in Toronto. And within another day, we suddenly had about seven new cases in about six different institutions.

And what had happened we believe in retrospect is we missed a single atypical case in a relative. That person passed it on to a 96-year-old person who had atypical symptoms and died. But before they died, they had passed it on to some healthcare workers. And it spread again and started again. And then suddenly popped up and we quickly recognized that what it was and immediately instituted what to do.

And if you look at this second chart, you see that the second wave is much smaller.

YOUNG, J.: It's several days into it before obviously it pops out and we recognize it's there. And then once the measures, the gowns and gloves and masks were reinstituted, if you count out all of the cases were controlled. We didn't miss one the next time and it all got stopped within ten days of recognizing it. So the very, very important lesson for us was we now knew what to do and we now knew we could stop it.

YOUNG, J.: The challenge for us and the challenge in the future is recognizing that it's there so that we can stop it. And that's the big thing that we have to do is be able to pick out these diseases often before they know they exist. And pick them out, recognize they're there, and begin to aggressively approach them.

MODERATOR: And that's the point of your slide here. After SARS 2 recurring to normal in a different pace and being constantly aware this is a threat that's there.

YOUNG, J.: Exactly. It means leaving people in gowns and gloves and masks a little longer than is comfortable for them. It means building surveillance systems. Not just to look, in fact, at people coming into the hospital and bringing it in from outside, but recognizing there could be an atypical case already in the hospital, which was our case, and then spreading it within the hospital. And then obviously doing planning, planning, planning for the future.

MODERATOR: Quickly to the WHO travel advisory experience. I know they issues one, which then had a dramatic effect on the province of Ontario as well as the city of Toronto. And what was the level of cooperation internationally with the CDC and so on?

YOUNG, J.: The CDC was extremely helpful to us and did not support the advisory. They provided technical support. We worked very closely with the CDC, and I met several times with Julie Gerberding about SARS. And we exchanged information. We found it very useful to have both the support and the resources of the CDC.

The travel advisory sounded like a good idea at the time, and I don't want to sound overly critical of it. But in practice, it turned out to be a major hurdle for us to overcome. It cost us dearly economically, but it also made a lot of work at the time we were already busy with SARS. Because there were false alarms popped up all over the world. People disrupted their healthcare systems as a result of worrying about cases that weren't real. And it cost us enormous amounts of work tracking these cases in Toronto when we knew in fact that they weren't cases. So it's something we should go back to the drawing board and look at whether we ever do it in the future. And we've certainly said that to the WHO. And the experience in Asia was the same. They found it really quite crippling and an awful lot of work and it did nothing to help us manage the crisis.

MODERATOR: Well, that's a clear issue for us worldwide, because the public demands to know. Healthcare systems around the world demand to get early warnings. And unless we can manage that more effectively, we just do harm our ability to contain the incident outbreak.

YOUNG, J.: Precisely. And so we need to go back to the drawing board and think about this in the future.

MODERATOR: Let's talk a little bit about the effective communication techniques that you found worked well. Because that's a constant theme of public health people in this country needing to work on.

YOUNG, J.: First and foremost you have to be out there and you have to be transparent and you have to be out there a lot. We ran a three o'clock news conference every day, and we picked three o'clock because by that point in time we had accurate data and we could give an accurate picture. It was a very popular TV show. We think we outperformed the Edge of Night and all of the soap operas during that time.

MODERATOR: Down through Oprah.

YOUNG, J.: Oprah got (Indiscernible) drawn. And people watched it. People in the hospitals watched it because they wanted to see the leaders out there. And it was the people who were managing it who were there every day. Not spokespersons. People told me over and over they wanted to see us. They wanted to see the expression on our face. They wanted to know whether to believe what was happening. During that news conference and using other things as well like web cup broadcasts and written information. We educated the professionals. But we also then during those news broadcasts educated the public and we were sending messages internationally to people as well.

MODERATOR: Ethical issues that are raised by SARS. We touched on a few, but I know you really want to focus on some five bigger ones that you've drawn out of this experience. I wish you would for us as we close here.

YOUNG, J.: Yes. The University of Toronto did a study, and they really divided it into about five different areas of ethical concern. The concerns then include areas such as the duty to treat. And obviously the issue of quarantine when we hadn't used it for 50 years. How do you do it and you're violating people's rights. And so we're doing a lot of work and a lot of thinking and a lot of study around privacy concerns. We found that people were demanding to know medical details about people, and those details are often and need to be confidential in many instances. So drawing that line and deciding how much to tell. When you decide to describe racial issues. Initially the disease came from China and we had a lot of issues and a lot of concern then about people turning on the Chinese community. And we had to do a lot of public education that this wasn't just a Chinese problem; that it was a societal problem. So privacy issues were major issues.

As I mentioned, the issues around duty to work. But there also then is a duty on us as government officials to make the workplace safe. If we're going to require people to work in an unsafe or a risky environment, we have to make sure that we have given protection. We have to worry and we have to think about the collateral damage and slowing down the healthcare system because of SARS. I mentioned we cancelled the elective surgery. We slowed treatments. So we are looking and studying and worrying about things like that.

And clearly on issues such as the travel advisory. We have to figure out how we operate with these diseases in a globalized world.

MODERATOR: And the disease you think you have, you're dealing with just the crisis in the hospital system in Toronto, but it is having a worldwide spread even if you don't have time to think about it. It's rippling that way.

YOUNG, J.: Absolutely. And you're watching every day to see which other countries are being affected and what are they doing to manage it as well.

MODERATOR: Let's talk about the lessons learned from SARS. You have a nice summary slide here, and I wish you'd go through that for us.

YOUNG, J.: Obviously, this is just a basic summary of things, but we recognize that we have to step up our planning for pandemics and for disease outbreaks. We in Ontario have a huge emphasis on infection control in our hospitals and are reinvesting in infection control and negative pressure. But a lot of education and a much closer surveillance system of who is sick within the hospitals and what they might have.

We're looking – We're spending a lot more money on public health, and we're reinvesting in public health to a much greater extent, because we like many other places had been downgrading the amount of money in public health. We've sorted out how we will run emergencies in the future and have fine-tuned that. And we've become very proactive in dealing with potential problems. We believe that you approach them very aggressively and very proactively.

MODERATOR: And going forward, how do we best prepare for outbreaks from other diseases, such as Avian flu?

YOUNG, J.: Well, we're watching Avian flu, which is going on in Asia. We're watching it both from the point of view of agriculture. But because of the human risk of it turning into a pandemic, we're literally monitoring it on a daily basis. We have many ministries of government on a central phone call every day, and we review what's happening. And then we have weekly meetings talking about what would be the effect if it got here. What do we need to do? What are the gaps in our planning currently? And how would we manage it?

We're almost using it as a tabletop exercise to drive our planning and think about what we do. We had a potential Asian flu case in Ontario. We acted very aggressively. Closed the farm down. Had the gates guarded. Put everybody in gowns and gloves and masks. And we've decided the best thing to do is to try to prevent something from getting far enough as to being an emergency and handling it very quickly.

MODERATOR: It's almost as though you're continuing on a war footing even though you don't have an outbreak right there currently.

YOUNG, J.: We're trying to, in fact, manage emergencies before they're emergencies and stop them from becoming that. And part of my job is to continually be remobilizing government and getting them thinking about what's emerging and dealing with it in advance.

MODERATOR: Well, that's quite an experience. And Dr. Young, I thank you very much for sharing with us the experiences of the province. And it's something that no doubt some of us are going to have to deal with elsewhere before too long.

Before we close, I'd like to remind all of you to please take a moment to fill out your evaluations either on-line or send the printed copy back to us at the Center for Public Health Preparedness. Your feedback is invaluable in the development of future programs.

Unfortunately, we didn't have time for questions today, but if you'd like to post questions to Dr. Young, please do so by the website, and we'll make sure he gets them and gets a chance to answer them. This program will be available on video tape and web screening within the next few weeks. Please check our website for more details. We hope you'll tune in next month for our grand rounds on Thursday, November 4th. I'm Peter Slocum. Thank you for joining us at the University of Albany Center for Public Health Preparedness grand rounds series.




Image Mapper CEPH Association of Schools of Public Health New York State Department of Health