By Michael Gardam, MD, Leah Gitterman, MHSc, and Armand Keating, MD
2008-01-01
Dr. Gardam is Director, Infection and Prevention Control Unit, UHN.
Ms. Gitterman is the Pandemic Planning Strategist with the Infection Prevention and Control Unit, UHN.
Dr. Keating is Professor of Medicine and Director, Division of Hematology, University of Toronto. He is Secretary of ASH.
It has been almost five years since Toronto experienced its outbreak
of severe acute respiratory syndrome (SARS). The outbreak, which
occurred during the spring of 2003, resulted in 251 cases
and 43 deaths. Unlike some other countries that identified a
significant number of cases in the community setting, SARS in Toronto
was spread predominantly in hospitals. Indeed, 43 percent of the SARS
cases occurred in health-care workers — the highest percentage of any
country that experienced an outbreak. It is important to note, however,
that almost all the mortality occurred not in health-care workers, but
in patients who had the misfortune of being admitted to the hospital
for some other medical problem when SARS appeared.
Fortunately, the worldwide spread of SARS was a limited phenomenon
and aggressive control measures were able to eventually halt its spread
in all the countries that developed cases. The control measures used in
Toronto were unprecedented in their scope and were imposed upon
hospitals in the form of provincial government directives. Within
hospitals, additional infection control precautions were used for all
patients, outpatient and inpatient services were scaled back as were
hospital staffing levels, and patients and staff were routinely
surveyed for symptoms of febrile respiratory illness. The two main
reasons for scaling back patient-care activities were to free up
resources in the event that additional cases occurred and required
admission, and to provide less "fuel for the fire" as SARS spread to
patients in hospitals. In the Toronto region overall, medical
admissions were decreased by 10 to 12 percent, while elective surgical
admissions decreased by 15 to 22 percent.2 Elective cardiac
procedures, on the other hand, were decreased by 66 percent and high
acuity visits to emergency departments decreased by 37 percent.2 Outside the hospital, more than 20,000 contacts of SARS cases were placed in home quarantine.3
The impact of SARS on Toronto's Princess Margaret Hospital (PMH),
Canada's largest facility for the treatment of hematologic and solid
tumors, was mixed. Staff and patients were extremely fortunate that no
known patients with SARS were admitted to PMH or made outpatient
visits. This was despite many cases being admitted to adjacent and
neighboring facilities, including the two other hospitals – Toronto
General and Toronto Western – which, with PMH, make up the University
Health Network. This being said, PMH administrators and staff, like all
Toronto health-care workers, were faced with the stress of the outbreak
and of complying with governmental directives that required scaling
back services. Furthermore, as PMH is dependent upon other hospitals
for intensive care services, there was the added concern amongst
patients and staff that patients who required ICU care would be
transferred to neighboring units that were caring for SARS patients.
Early experience with SARS had suggested that solid organ transplant
recipients had very poor outcomes when infected;4 hence,
there was reason to believe that bone marrow transplant recipients,
especially those who had received allogeneic transplants, would have a
poor prognosis. Consequently, the admission of new allotransplant
candidates was curtailed at PMH for several weeks because there was no
assurance that the patients who might require critical care would be
transferable to the ICU of other hospitals. Nonetheless, short-term
admissions for chemotherapy administration were minimally affected,
except for a week's delay for new cases. Overall, however, the caseload
was maintained, despite the challenges faced by PMH staff in screening
all patients and distinguishing the symptoms and signs of SARS from
chemotherapy effects, especially among those with febrile neutropenia.
While morale among staff was high initially, the need for gowning
and masking at all times became burdensome, and for some, debilitating.
A further unexpected consequence was the cessation of formal education
programs for residents and fellows, largely because there was a
moratorium on meetings in hospitals and no movement of staff and
trainees from hospital to hospital.
As horrible and surreal as the SARS experience was, it helped
identify some very significant weaknesses in the health-care system
that we now have the opportunity to strengthen. Certainly, years of
underfunding and neglect had left the Ontario public health system in
disarray and unable to deal with significant public health emergencies.
Closer to home, it also identified that advanced hospital planning to
deal with infectious diseases and other emergencies is essential; one
of the reasons for the aggressive control measures was because
hospitals did not have any experience or plans to deal with this type
of event.
Currently PMH, like most hospitals in North America, is in the midst
of planning for the next influenza pandemic. No one can accurately
predict what a future pandemic will look like; however, even a mild
pandemic would have a significant impact on our ability to provide
care. Most current planning models assume a "moderate" pandemic like
that experienced in 1957. Unlike SARS, which only affected local
hospitals, a pandemic will be far more pervasive, involving a large
segment of the world's population over a period of months. Toronto
hospitals were able to access staff and supplies from surrounding areas
during the SARS outbreak, and the health-care system outside the city
was still reasonably able to care for patients; this option would not
be available during a pandemic as all health-care systems would be
affected at roughly the same time.
Along with the stockpiling of supplies and the development of
policies and screening tools, cancer hospitals are also grappling with
continuing to provide care in a setting where their clinical programs,
emergency departments, and intensive care units will be inundated with
influenza patients. Some of the issues that need to be addressed
include the adequacy of intensive care beds for critically ill cancer
patients, the desirability and ethical considerations of giving
marrow-ablative chemotherapy when influenza is widespread, protecting
patients from acquiring influenza while in the hospital, the use of
antiviral agents and vaccines, and the necessity of freeing up
inpatient and outpatient space to care for influenza patients which
will require limiting cancer care to certain patient populations. This
last issue is particularly contentious as we are not used to
prioritizing care to this extent, and one can imagine the chaos if
different hospitals develop different prioritization criteria. In order
to help provide some guidance on this issue, the provincial cancer care
agency, Cancer Care Ontario, has recently published the results of an
extensive consultative process with its membership on prioritizing
cancer care during a pandemic.6 These are the first
disease-specific guidelines developed for the delivery of care during a
pandemic. Central to this process was the use of an ethical framework
based on patient need and the efficacy of treatment to help guide
decision-making.7 These guidelines divide patient care into three priority groups:
- Priority A patients are those who are deemed
critical and require services/treatment even in the event of a pandemic
because their situation is immediately life-threatening.
- Priority
B patients are those who require services/treatment but whose situation
is deemed non-life-threatening; in the event of a pandemic,
services/treatment could be discontinued for the period of the pandemic
wave (6-8 weeks).
- Priority C patients are
those whose condition is deemed as non-life-threatening and who can be
deferred; those services would be discontinued while there is pandemic
activity in the province.
Each priority group is then subdivided into multiple categories. The
guidelines recognize that local or regional circumstances may influence
a cancer program's ability to follow the criteria. If some regions are
harder hit than others, a re-referral system is recommended for
patients with potentially life-threatening or rapidly progressive
cancers. This plan will help to ensure that Ontario's cancer system and
PMH will be in the best position to provide critical cancer care.
It is our hope that the lessons learned from the Toronto SARS
outbreak can be translated into improved health preparedness response
planning for future health emergencies such as pandemic influenza. Our
patients are highly vulnerable to infectious diseases, and it is a
cruel irony that the very places patients go for treatment might be
where they acquire a deadly infectious disease.
During the SARS outbreak, Michael Gardam, MD, was Director of
Infection Prevention and Control at UHN, Leah Gitterman, MHSc, was a
patient escort and helped screen PMH staff for febrile respiratory
illness, and Armand Keating, MD, was Chief of Medical Services at PMH.
- World Health Organization.
- Schull MJ, Stukel TA, Vermeulen MJ, et al. CMAJ. 2007;176:1827-32.
- Lim S, Closson T, Howard G, Gardam M. Lancet Infect Dis. 2004;4:697-703.
- Kumar D, Tellier R, Draker R, et al. Am J Transplant. 2003;3:977-81.
- Walker D, Keon W, Laupacis A, et al. Ministry of Health and Long-Term Care; 2004. Cancer Care Ontario.
- Upshur R, Faith K, Gibson J, et al. University of Toronto Joint Centre for Bioethics. 2005.
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