Control of Hospital Infectionduring the SARS Outbreak

in Ontario, CanadaFebruary – August, 2003

2003 Asia Pacific Inter-City SARS ForumTaipei, September 2003

Control of Hospital Infectionduring the SARS Outbreak

in Ontario, CanadaFebruary – August, 2003

2003 Asia Pacific Inter-City SARS ForumTaipei, September 2003

Dr. Colin D’CunhaCommissioner of Public Health, Chief Medical Officer of Health

and Assistant Deputy MinisterOntario Ministry of Health and Long-Term Care

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

Ontario, CanadaOntario, Canada Twice as large as Thailand

and ¼ of India

30 x larger than Taiwan

Population: 12 million

Capital: Toronto

OntarioMap

Michigan New York

QuebecMinnesota

Manitoba

Toronto, Ontario

Largest city in Canada

GTA population 5.1 million Multi-ethnic (about 50% immigrants;

more than 100 languages spoken)

TorontoToronto

Onset of SARS Outbreak in Ontario

Hong KongHong Kong

Toronto HospitalToronto Hospital (Mar. 7/03)

Index CaseIndex Case

HouseholdHousehold

transmissiontransmission

NosocomialNosocomial

transmissiontransmission

SARS Experience in Ontario

Introduced to Toronto bya traveller to Hong Kong

Transmitted to a family member;the latter admitted to Toronto hospital

Household+Nosocomial Transmission

Phase I: 257 cases136 Probable, 121 Suspect

Phase II: 118 cases111 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

n = 375

Phase 2

Phase 1

SARS Cases in Ontario by Case Status and Phase

SARS Cases Reported by Health Units

SurroundingSurrounding Regions Regions

39%39%

City of Toronto City of Toronto

661%1%

Suspect 128

Probable247

Hospitalization and Case Fatality DataProbable and Suspect SARS Cases

1

18

0

50

100

150

200

250

Phase 1 Phase 2 Phase 1 Phase 2

Nu

mb

er o

f ca

ses

Not Hospitalized

Hospitalized

239239 117117

27 17

Deceased

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. 19Feb. 19

Mar. 28Mar. 28

Initial Actions

Response by the Ontario Government

Provincial Operations Committee

Provincial directives to hospitals, health units

Coordination of resources

Daily media conferences and reports

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

Inter-City Response: Toronto Public Health Unit

Hotline

Case management

Contact follow-up

Epidemiology team

Staff commitment

HH

HH

H

H

H

H

HH

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

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

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)

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 25March 25

March 28March 28

1

2

4

3

March 14March 14

Protective Equipment: Hospital Policy

Hospital AreaHospital Area

N 9

5 Mask

N 9

5 Mask

Glo

ves

Glo

ves

Alco

hol

Alco

hol

Go

wn

sG

ow

ns

Go

ggle

sG

og

gles

Fa

ce

Fa

ce

Sh

ield

Sh

ield

Ha

ir Cove

rH

air C

over

Sh

oe

Sh

oe

Co

verC

over

CommentsComments

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

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. Gloves 2. Mask 3. Goggles

Infection Control PracticesPersons 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

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

SARS Cases and Persons under Quarantine

0

2

4

6

8

10

12

14

16

18

20

23-Feb

13-Mar

21-Mar

29-Mar

6-Apr

14-Apr

22-Apr

30-Apr

8-May

16-May

24-May

1-Jun

9-Jun

17-Jun

25-Jun

3-Jul 11-Jul

Date

Nu

mb

er

of

Ca

se

s

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Nu

mb

er

of

Pe

rso

ns

in

Qu

ara

nti

ne

Persons in QuarantineSuspectProbable

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

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

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

Opportunities to Improve Preparedness

Leadership and Coordination

Resources / Surge Capacity

Communication

Enhanced Surveillance

Skill Enhancement of CD Staff

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

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

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.”