SARS in Toronto - Acting locally, reacting globally

For Canada's largely immigrant population visiting "the old country" is a part of the ritural of being Canadian. On one such occasion a woman visiting her family in Asia required a layover at a hotel in Hong Kong before returning to Toronto. This hotel was the same one used by a businessman travelling from Guangdong province, Mainland China on his way to Vietnam and who was, unknowingly, infected with SARS. This was the incidental contact that brought SARS to Toronto, population four milion.

Commenting on the arrival of SARS in Toronto, Canada's Globe and Mail newspaper Editorial of March 28 2003 stated, "Globalization means that if someone in China sneezes, someone in Toronto may one day catch a cold. Or something worst ---- If, in Guangdong province, 80 million people live cheek by jowl with chickens, pigs and ducks, so, in effect, do we all. Global village, indeed." These realities of international jet travel have tested Toronto's capability in managing the latest unknown disease to threaten the human race.

Amidst preparation for the possible appearance of West Nile Virus this summer, Dr. Sheela Basrur, Toronto's Medical Officer of Health, explained that in compliance with requirements of its 2002 submission to the International Olympics Committee (IOC), Toronto had a state of continuous preparedness for such emergencies as SARS. In the Canadian context this means municipal, provincial and federal government officials working effectively together. In such a knowledge vacuum, as exists with SARS, local events are coordinated daily with experiences around the world through consultation with the U.S. Centre for Disease Control (CDC) and the World Health Organization (WHO).

Using classic public health protocols, what could have been a major epidemic, has been "contained" into primary and secondary clusters of confirmed and suspected SARS cases. Most persons who initially came in contact with the first SARS patient were physicians, nurses and paramedics. These people accepted voluntary quarantine for ten days. Two hospitals where patient transfers had occurred prior to realization of the infectious nature of the disease were totally closed to the public with full infection control procedures in place for all staff and patients. Patient transfers, elective surgeries, outpatient clinics and visits were cancelled in all hospitals across the province of Ontario (population 12 million), until proper protocols were in place.

Public health authorities kept the public informed through daily media briefings about the number of SARS related deaths as well as probable and suspected cases. Torontonians were repeatedly, instructed to follow basic public health practices such as voluntary isolation if required, and hand washing. Ontario’s Minister of Health, Hon. Tony Clement, demonstrated for the media how people should wash their hands. Public health officials stressed that SARS in Toronto was being "contained," was not an ethnic-based disease and that there was no need for the general public to be concerned about moving around the City. At international airports, which are under federal jurisdiction, the Canadian government instituted protocols for surveying and monitoring incoming flights, particularly from the SARS related high-risk regions.

Just over a month after the first SARS case was identified in Toronto, there were 13 SARS related deaths with 97 probable, 137 suspected cases and around 4000 people in quarantine with court orders issued for 11 individuals not voluntarily complying with quarantine requirements. At the daily media conferences, which were broadcast live on TV nationally, it was stressed that the SARS was being "contained" and all suspected cases could be traced to the original patient. As the weeks progressed people in quarantine were released and persons infected with SARS made "natural" recoveries. SARS was proving to be fatal among elderly patients who had pre-existing conditions.

Observing these events from his office in Mississauga west of Toronto, Stan Seggie, President, RBC Travel Insurance, Canada's largest provider of travel insurance, was asked to comment on how SARS could affect the travel industry relative to such events as 9/11 and the Iraq war. Stan said, "With all the events that have happened it is hard to relate what has attributed to what. But SARS does seem to be quite a concern of people now. Thank God it seems like they (public health) have got it under control." Asked if he saw light at the end of the tunnel for the travel industry he responded "Absolutely! The travel industry is a very resilient. One thing we know is that people will travel. Once confidence comes back to a normal level people will be back in the planes and trains."

Discussing the lessons SARS provides Stan said "SARS will not make us change our policies or anything like that. We hope these events don't happen but we know they do and that is what insurance is all about. What we have learnt from SARS is to make sure you have communicated well with your customers, whether your customer is your distribution channel or the public at large. Because at times like this there is uncertainty and the public wants answers and they want them quickly. We have learnt that we have to be effective communicators."

Travel insurers provide acute episodic care at time of need. What makes it possible for people to confidently sit besides strangers in planes, sleep away from home in strange beds, and enjoy exotic meals in far away places is the public health vanguard that must be in place locally. Following SARS the travelling public may look for some recognition of confidence in local public health standards globally as well as locally.

As stated by Stan Seggie, and demonstrated by Toronto public health authorities, communication is critical at the first sign of infectious disease emerging. Perhaps international travellers could be given some assurance that their destination meets basic public health standards through some kind of accreditation. WHO, CDC, or possibly the IOC, could set in place basic standards for public health that communities should meet in serving the international traveller. If the IOC had more aggressively required China to meet the same infectious disease management standards as Toronto has demonstrated, then SARS may have been better contained locally, or, alternatively, Toronto may have won its bid for the 2008 Olympics over Beijing.

With the current outbreak being contained the most likely way a new cluster can appear in Toronto is from another airplane passenger. Unlike most international destinations, Toronto has proven it can handle such situations.

Postscript: Notwithstanding the professionalism demonstrated in Toronto's handling of the SARS situation WHO to issue a travel alert on Toronto the week subsequent to the posting of this article and then rescinded it's warning a week later.