2. Control of Hospital Infection during the SARS Outbreak in Ontario, Canada February – August, 2003 2003 Asia Pacific Inter-City SARS Forum Taipei, September 2003 Dr. Colin D’Cunha Commissioner of Public Health, Chief Medical Officer of Health and Assistant Deputy Minister Ontario Ministry of Health and Long-Term Care

3. Presentation Outline SARS in Ontario Inter-City Experience: The Greater Toronto Area Control of Hospital Infection Preparedness / Protocols Implications and Lessons Learned Planning for the Future

4. Ontario, Canada  Twice as large as Thailand and ¼ of India  30 x larger than Taiwan  Population: 12 million  Capital: Toronto

5. Ontario Map MichiganNew York Quebec Minnesota Manitoba

6. Toronto, Ontario  Largest city in Canada  GTA population 5.1 million  Multi-ethnic (about 50% immigrants; more than 100 languages spoken)

7. Toronto Onset of SARS Outbreak in Ontario Hong Kong Toronto Hospital Toronto Hospital (Mar. 7/03) Index Case HouseholdtransmissionNosocomialtransmission

8. SARS Experience in Ontario Introduced to Toronto by a traveller to Hong Kong Transmitted to a family member; the latter admitted to Toronto hospital Household+Nosocomial Transmission Phase I : 257 cases 136 Probable, 121 Suspect Phase II : 118 cases 111 Probable, 7 Suspect 12-Jun Last Onset Last week of May Last week of Feb. to first week of Mar. 23-Feb. Outcome: 331 recovered, 44 died Nosocomial Transmission

9. n = 375 Phase 2 Phase 1 SARS Cases in Ontario by Case Status and Phase

10. SARS Cases Reported by Health Units Surrounding Regions 39% City of Toronto 61% Suspect 128 Probable 247

11. Hospitalization and Case Fatality Data Probable and Suspect SARS Cases 239 117 27 17 Deceased

12. Ministry alerts healthcare providers Index hospital closed SARS becomes reportable disease Quarantine measures instituted Provincial emergency declared Directives for contact, droplet, airborne precautions instituted provincially Feb. 19 Mar. 28 Initial Actions

13. Response by the Ontario Government Provincial Operations Committee Provincial directives to hospitals, health units Coordination of resources Daily media conferences and reports

14. Outbreak Management by Public Health Branch Set up SARS teams Conferences to discuss cases Routine dissemination of information Developed policies & directives through Science Committee Dedicated space, staff, communication lines Hired / seconded / borrowed staff on short-term contracts

15. Inter-City Response: Toronto Public Health Unit Hotline Case management Contact follow-up Epidemiology team Staff commitment

16. H H H H H H H H H H Nosocomial Outbreak in Toronto Area Hospitals Source: Toronto (Scarborough Grace) Hospital Other Regional Hospitals Markham-Stouffville York Central Other Toronto Hospitals Mount Sinai North York General Scarborough General Saint John’s Sunnybrook Toronto General West Park

17. Infection Control in Hospitals Enhanced infection control measures throughout the hospitals Creation of contained SARS wards New directives for patient transfers and visitors Work quarantine for selected healthcare staff Limiting the number of healthcare settings in which staff can work Curtailing other health services

18. Enhanced Infection Control Measures in Hospitals Wearing of personal protective equipment (masks with fit- testing, gowns, eye-gear, gloves) Screening patients at all points of entry Temperature check on arrival Completion of form indicating symptom and travel information Outpatients positioned more than one metre (3 feet) apart Phone-screening for outpatients prior to appointment Banning all visitors (except on compassionate grounds)

19. Outbreak Control Measures SARS becomes reportable, virulent, communicable disease Suspension of admissions, and emergency and non- urgent services at index hospital Hospital closed to new patients and visitors All discharges since March 16 contacted and followed-up Isolation an contact follow up measures recommended Directives for contact, droplet, airborne precautions instituted province-wide March 25 March 28 1 2 4 3 March 14

20. Protective Equipment: Hospital Policy Hospital Area Hospital Area N 95 Mask GlovesAlcoholGownsGoggles Face Shield Hair Cover Shoe Cover Comments Contacts with SARS unit & patients Screeners (at all entrances) Use alcohol every 30 min. Departments (e.g., ICU, emergency) & staff High risk procedures (i.e., intubation, bronchoscopy) Stryker suits when needed Emergency patients & visitors

21. Infection Control During Intubation Procedure All HCWs used personal protective equipment (PPE) Negative pressure in intubation room Deficiencies: No anteroom available Masks not fit-tested Inappropriate removal of PPE: stages varied Emerging Recommendation:1. Gloves2. Mask3. Goggles

22. Infection Control Practices Persons Under Investigation Use of surgical mask while investigating cases, or would-be cases Isolation separately from other SARS patients Negative pressure room with separate washroom facilities Accompanying persons should wear surgical mask, or N95 mask

23. Infection Control: Recommendations Probable and Suspect Droplet and Contact Precautions Gloves, gowns, eye protection (goggles and/or face- shield) Hand-washing Airborne Precautions Negative pressure isolation rooms (where available) N95 respirator or equivalent Minimize number of people in room during high- risk procedures 1 2 3

24. SARS Cases and Persons under Quarantine

25. Implications Estimated cost over C$1 billion (US$ ¾ billion) Hospital and ward closings, including Canada’s largest trauma centre Cancellation of elective surgeries and treatments Restrictions on patient transfers New, stricter, province-wide standards for screening

26. Positive Experiences Establishing control centres provincially and locally with dedicated staff, space, communication lines Public health call centre 24/7 to provide advice to hospitals and physicians Mutual support among health units to share resources Daily conference calls among health units & health ministry

27. Lessons Learned: Immediate Needs Re-evaluation of infection control and screening practices Acquisition and use of appropriate Personal Protective Equipment Preparation and Planning Surveillance Emergency response plan

28. Opportunities to Improve Preparedness Leadership and Coordination Resources / Surge Capacity Communication Enhanced Surveillance Skill Enhancement of CD Staff

29. Improvement Areas (continued) Resource Capacity Contingency staff at local level dedicated to SARS Capacity for other mandatory public health programs Communication Demands Effective processes Multi-jurisdictional communication Clarified roles and responsibilities Information technology Addressing the lack of public health info-structure

30. Planning for the Future Ongoing epidemiology centre Policy coordination capacity Ongoing Public Health call centre with 24/7 coverage Mobile response teams to assist Health Units in time of outbreaks Additional Public Health field staff Strengthened laboratory capacity Public education

31. Food for Thought John Service, Executive Director Canadian Psychological Association Toronto Star, May 7, 2003 “…The key was the early decision by public health officials to provide reliable and regular information to the public. By establishing public trust, they prevented uncontrollable anxiety, fear and panic from sweeping the city.”