Wall Street Journal - April 8, 2003
Elena Cherney and Mark Heinzl, Staff Reporters of The Wall Street Journal

Mr. Tse's breathing worsened the next day, and he was taken to intensive care. Hours later, nurses told Sandy Finkelstein, head of the ICU, that Mr. Tse's mother, Sui-chu Kwan, had died just three days before, after suffering similar symptoms upon return from a trip to Hong Kong with her husband, and that others in the family were sick. Doctors began suspecting tuberculosis, and "at that point, I said 'move him into the isolation room,' " Dr. Finkelstein recalls.

It was too late. Toronto now has 188 cases of SARS. Ten people have died, and an 11th death is under investigation, health-care officials said.

Battling SARS Outside Asia

Toronto, just an hour's drive from the U.S., is battling the biggest SARS outbreak outside Asia. Toronto doctors are now taking the precautions needed to contain the spread of the virus, but at first they were working at a big disadvantage. SARS hit Canada about a week before the World Health Organization issued its global warning about "atypical pneumonia" on March 12, as a result of a mysterious outbreak in Asia. As a result, the disease spread unchecked in Toronto for days, aggravated by interhospital transfers of patients who hadn't yet been diagnosed.

Officials now have halted all nonurgent medical services at Toronto-area hospitals and ordered more than 5,000 potentially exposed people -- including hundreds of doctors, nurses and paramedics -- into "voluntary" quarantine in their homes, though many are now back in action.

The experience of being caught unprepared has taught doctors here a tough lesson: taking precautions against exposure to patients' blood is not enough anymore. "What Hepatitis B and HIV did for body-fluid precautions, we hope this will do for respiratory precautions," says Donald Low, microbiologist in chief at Mount Sinai Hospital in Toronto.

Instant Isolation

For years, infectious-disease specialists have cautioned health-care workers to protect themselves with masks, gloves and gowns. Minimizing exposure to SARS has proven to be a key in limiting the severity of the disease in those who do contract it, Dr. Finkelstein believes. "If you get a little nudge of virus, just a small dose from someone in casual contact, you tend to have a milder illness," he theorizes. "You don't want to have ongoing exposure." Doctors here also have learned the hard way that instant isolation of anyone with the SARS symptoms -- headache, fever, coughing, malaise -- is paramount.

On March 13, Mr. Tse died. A worried Dr. Finkelstein called Allison McGeer, head of infection control at Toronto's Mount Sinai Hospital. By then, Dr. McGeer had seen the WHO warning about the spread of a deadly pneumonia in Asia, and suggested bringing three of the patients to Mount Sinai, and sending the fourth to another hospital.

At Toronto Public Health, Dr. Bonnie Henry, a veteran of the WHO fight to contain the 2000 Ebola outbreak in Uganda, widened the search for the family's contacts. With three family members too sick to talk and a fourth, Mr. Tse's father, "not a very good historian," public-health workers donned masks and gowns and entered the family's apartment to try to find clues about their recent travel to Hong Kong.

Luggage tags from the apartment enabled federal health authorities to trace passengers who had been on the flight. None was sick.

The Worst Miss

On March 16, one of the elderly heart patients who had been in the emergency room with Mr. Tse on March 7 was transferred to York Central Hospital, north of the city. He would later be diagnosed with SARS. In hindsight, this one patient's unprotected transfer would prove the worst "miss" of the early efforts to control the outbreak, says Dr. McGeer. Also on March 16, another heart patient who had contact with Mr. Tse in the emergency room on March 7 was readmitted at Scarborough Grace and diagnosed with probable SARS.

One by one, nurses and doctors at Scarborough Grace began developing fevers and calling in sick. On March 23, Dr. Low admitted 14 sick Scarborough Grace health-care workers into isolation at a separate hospital. On March 23, the Scarborough-Grace emergency room closed. The entire hospital staff of 1,400 was ordered into a quasiquarantine: Most were allowed to continue working, but were to isolate themselves from their families, wear masks at all times and not go anywhere other than home or hospital. Dr. Finkelstein, not wanting to infect his family or frighten his baby by wearing a mask, moved into his in-laws' home while they were away.

On March 24, doctors started to wonder about a Sinai intensive-care unit patient with SARS-like symptoms. When he was admitted the previous day, no one had thought to take respiratory precautions because he hadn't been in the "hot zone" at Scarborough Grace -- the emergency room on March 7. But then it emerged that the man had visited an outpatient foot clinic at Scarborough Grace.

He was put in isolation at Toronto General Hospital, 70 exposed Sinai workers were sent home, and Sinai's intensive-care unit was closed to new patients. Among the exposed workers, four would go on to develop symptoms, and their families would be quarantined.

With no clear source for the Sinai case's exposure, on March 25, the province closed Scarborough Grace to new patients and outpatients, and officials ordered anyone who had had contact with a symptomatic SARS patient into home isolation. But the number of cases continued to climb among health-care workers exposed at Scarborough Grace.

Broadened Quarantine

Health officials then broadened the Scarborough Grace quarantine to include everyone who visited the hospital since March 16, when the 76-year-old patient infected by Mr. Tse on March 7 was readmitted. Health officials canceled elective surgery and other nonurgent activities across Toronto's hospitals.

Late Friday, March 28, health officials announced bad news: A patient had been transferred to York Central with no precautions from Scarborough Grace on March 16 -- one of the elderly men who came into contact with Mr. Tse in the emergency room. It was now believed that he had SARS, and had potentially exposed thousands. Over 3,000 staff, patients and visitors of York would wind up quarantined. Two more patients, both elderly, died.

That weekend, the disease struck at the heart of the team of health officials trying to control it: A key member of their "war room" developed symptoms. The doctor, whom officials at the time refused to identify, had been both treating patients and meeting with colleagues and officials. By Monday, March 31, the SARS team sounded much grimmer. Six members of the war room, including Dr. Low -- who had told reporters he was "confident" about the precautions he was taking personally -- were sent home for 10 days in isolation.

It turns out the doctor who developed symptoms was none other than Dr. McGeer, Mount Sinai's infection expert. She is being treated in isolation at Mount Sinai for what she says is a "mild" case of SARS.

The number of cases is still rising. But the increases so far have been moderate, not explosive. "If the measures weren't working, you'd see an exponential increase," said Dr. Low from his isolated perch at home, where he continued to feel fine and monitor developments.

Write to Elena Cherney at elena.cherney@wsj.com and Mark Heinzl at mark.heinzl@wsj.com

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