Original Report - April 27, 2003
Update - May 1, 2003

Update - May 12, 2003

As of May 12, 2003, there are no new SARS cases in Toronto, and there have been no further SARS deaths since April (most of those fatalities occurred in patients with underlying illness, and nearly all were elderly patients over the age of 70 years). Only 22 active probable cases remain under treatment in Toronto. Ontario's commissioner of public health, Dr. Colin D'Cunha, has declared that "the outbreak is over". Hospitals began easing visitor restrictions in time for Mother's Day (May 11) and are gradually increasing the number of outpatients permitted to enter the facilities for elective and non-essential health services. Toronto is currently awaiting the results of the World Health Organization (WHO) meeting later this week, at which time the city expects to be removed from the list of SARS-affected areas.

The international SARS meeting held in Toronto on April 30 and May 1, 2003 was attended by public health officials from Canada, the United Kingdom, the U.S., Mexico, China and the Association of Southeast Asian Nations. At the closing press conference, Health Minister McLellan stated: "...we have all come together to learn more about SARS, and how we can work together as a global community to deal with the challenge that SARS presents to all of us and to our health-care systems."

Detailed SARS information for health professionals, regarding transmission, quarantines, and PCR identification of infected individuals, is available from Health Canada at: http://www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/prof_e.html. Here, the Provincial-Territorial Ministries of Health also provide a figure that tracks the number of probable cases of SARS in Canada by symptom onset date and exposure type from February 23 to May 7, 2003: http://www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/eu-ae/sars20030507_e.html#fig1.

Canada is the first country to be invited by the World Health Organization (WHO) to send a team of officials to Hong Kong, to assist in the investigation of risk factors involved in possible environmental transmission of SARS, i.e. whether building mechanical systems such as plumbing and ventilation played a role in spreading SARS at the Amoy Gardens and Metropole Hotel. Officials from Health Canada's Workplace Health and Public Safety Programme (WHPSP) and National Microbiology Laboratory will participate in the investigation.

While the total cumulative SARS cases and deaths remained unchanged in Toronto, they continue to increase in other countries, particularly China, Taiwan, and Hong Kong. On May 12, 2003, there were 144 new cases reported in China, 12 new cases in Taiwan, and 5 new cases in Hong Kong, although the daily number of new cases in Hong Kong has been steadily declining for the past week. WHO travel advisories remain in effect for mainland China, Hong Kong and Taipei as of May 12, 2003 (see http://www.who.int/csr/sars/travel2003_05_12/en/).

Total (cumulative) SARS Cases and Deaths, as of May 12, 2003:

* A total of 7,447 SARS cases and 552 SARS deaths have been reported in 30 countries, as of May 12, 2003. A full list of worldwide cases and deaths is available at: http://www.who.int/csr/sars/country/2003_05_12/en/

Update - May 1, 2003

On April 29, 2003, the World Health Organization (WHO) announced that it is lifting the travel advisory against Toronto, effective Wednesday, April 30, 2003. Over the past week in Toronto, the number of probable SARS cases has decreased, and recovered individuals have been sent home. Also, more than 20 days have now passed since the last cases of community transmission occurred, and no new confirmed cases of SARS exportation out of Toronto have occurred.

Travel advisories for China (Beijing, and Guangdong and Shanxi provinces) and Hong Kong, remain in effect. The WHO travel advisory can be found at: http://www.who.int/csr/sarsarchive/2003_04_29/en/ In China, 202 new probable SARS cases were reported on May 1, 2003. The rapidly growing number of new cases, particularly in Beijing, are a growing global concern.

Total (cumulative) SARS Cases and Deaths, as of May 1, 2003

* A total of 5,865 SARS cases and 391 SARS deaths have been reported in 30 countries, as of May 1, 2003. A full list of worldwide cases and deaths is available at: http://www.who.int/csr/sarscountry/2003_05_01/en/

Of the 145 SARS cases in Toronto, 88 have now been discharged from hospital. As a result, there are only 34 current SARS cases in Toronto. These include two new cases announced April 30, 2003, of health care workers who were exposed to SARS while caring for seriously ill SARS patients in hospital. The last new case of SARS transmitted in the community was identified on April 7, 2003.

On April 30 and May 1, 2003, Health Canada is convening a large, international SARS meeting in downtown Toronto, to discuss SARS and the situation in Canada, to further develop a National Public Health Strategy, and to pool global knowledge about SARS and its spread. Attendees include public health officials from Canada, the United Kingdom, the U.S., Mexico and China. Chief Medical Officers of Health from each province and territory, scientists, clinicians, emergency preparedness representatives, and officials from the U.S.'s Centers for Disease Control and Prevention, the Pan-American Health Organization and the World Health Organization have been invited.

Additional links for SARS information can be found in the Original Report, below.

Original Report - April 27, 2003

The worldwide outbreak of severe acute respiratory syndrome (SARS), particularly in China and Hong Kong, but also in Singapore, Toronto, Vietnam and Taiwan, has raised concerns around the world and has led to occasionally sensational media reports. At MedSci Communications, we assembled a few quick facts to let you know what is really happening in Toronto.

SARS Cases and Deaths in "Hot Spots"

* A total of 4,836 SARS cases and 293 SARS deaths have been reported in 28 countries, as of April 26, 2003. A full list of all worldwide cases and deaths is available at: http://www.who.int/csr/sarscountry/2003_04_26/en/

Of the 139 SARS cases in Toronto, 75 have been discharged from hospital and two are recovering at home.

Official daily updates on the SARS outbreak in Canada are available from the Health Canada website, at: http://www.hc-sc.gc.ca/english/protection/warnings/sars/index.html
Please note that Health Canada reports all probable and "suspected" SARS cases daily. (The total probable and suspected cases in Toronto are 266). Canada is the only country in the world to do so - all other countries report probable cases only. Therefore only probable cases are shown above, in order to accurately compare the situation in Toronto with that in Hong Kong and China.

Latest New Cases in Toronto

The latest new probable cases reported in Toronto on April 26, 2003 are two healthcare workers who were exposed to SARS in hospital while treating seriously ill SARS patients. Both cases were not unexpected.

It has been 20 days since a person in the community (i.e. where all of us work, live, use public transit and attend sports games and other large public events) has developed SARS symptoms.

The incubation period for the infection is 10 days, i.e. it takes 10 days for symptoms to show up after one has been infected with the virus. The World Health Organization (WHO) requires two incubation periods, i.e. 20 days, of no new cases before an outbreak can officially be declared ended.

Although new SARS cases are still being reported among healthcare workers, since it has now been 20 days since someone in the community has become infected, expert medical authorities in Toronto responsible for monitoring and reporting of SARS cases are reporting that they are cautiously optimistic that the outbreak in Toronto is now over.

WHO Travel Advisory Raises Controversy

On April 23, 2003, the World Health Organization (WHO) issued a three-week travel advisory, recommending that individuals postpone non-essential travel to Toronto, due to the SARS outbreak, essentially suggesting that the situation in Toronto is as serious as that seen in China and Hong Kong. However, the above numbers simply do not support this conclusion. The WHO recommendation appears to be based on outdated information, and no representatives from WHO actually visited Toronto to evaluate the situation prior to making the announcement.

In contrast, the Centers for Disease Control, based in Atlanta, USA, sent several representatives to Toronto for three days at the beginning of last week to review the situation. They recommended that the travel alert issued by the WHO is unnecessary, that it is safe to travel to Toronto, and they concluded that: "Currently, all cases in Toronto are linked to Toronto's original index case and spread has been through person-to-person contact. SARS transmission in Toronto has been limited to a small number of hospitals, households, and specific community settings".

Health Canada disagrees with the WHO advisory and believes it is safe to travel to Toronto. Dr. Sheila Basrur, Toronto's Chief Medical Officer of Health, stated at a press conference on April 23, "In my opinion, the facts of the matter do not warrant that, at this time. To categorize us close to Beijing or other parts of China is a gross exaggeration of the facts." Health Canada has formally challenged the WHO's assertion that Toronto is an unsafe place to visit. On Tuesday, April 29, 2003, the WHO will review the newest medical data and will reconsider the advisory issued one week earlier.

The WHO decision is reportedly based primarily on four individuals who flew out of Toronto and subsequently took the SARS infection with them to non-Canadian destinations:

a)	One individual contracted SARS in Toronto at a small secular service within a close-knit religious community and traveled to Pennsylvania; no other individuals, either on the plane or in Pennsylvania, subsequently became infected from contact with this person.
b)	Another individual attended the same service as in (a), flew to the Philippines, and subsequently contracted SARS. Again, no other individuals, either on the plane or in Pennsylvania, subsequently became infected from contact with this person.
c)	Two children ended up in hospital in Australia with severe flu-like symptoms that could not be readily identified as flu. Since they had recently visited Toronto, they were listed as SARS cases, without confirmation tests, and thus are only suspected cases. They, too, have not infected anyone else.

Therefore, there were a total of 2 probable and 2 suspected SARS cases that were exported from Toronto by plane, but none of these have infected anyone else.

In Toronto, health officials have extensively shared with the general public, the national and international media, all information regarding all SARS cases, extent of person-to-person contact, potential risks of exposure, and the specific measures taken in order to limit the outbreak, including extensive quarantines of large groups such as entire schools or specific religious communities. These highly publicized, cautious measures sometimes appeared rather dramatic, but they were quite effective in limiting the outbreak:

a)

Every SARS case in Toronto can be traced back to the originally infectious person, and the nature of transmission, close personal contact, determined.

b)

The outbreak has been contained to people who have been in extensive contact with a sick SARS patient, i.e. primarily hospital and healthcare workers, and immediate family or close friends who had extensive contact with a sick individual. SARS has only spread into the community when the sick person showing SARS symptoms has knowingly attended a public event with extensive close person-to-person contact, such as a funeral.

In contrast, in China the SARS outbreak has spread to the general public and is now found in rural communities. In some cases, they are unable to trace back how (or from whom) people have contracted the infection.

To obtain additional information about SARS, please visit:
Toronto Public Health: http://www.city.toronto.on.ca/health/sars/
Ontario Ministry of Health: http://www.health.gov.on.ca/
Health Canada: http://www.hc-sc.gc.ca/english/protection/warnings/sars/index.html
World Health Organization: http://www.who.int/csr/sars/en/
Centers for Disease Control: http://www.cdc.gov/ncidod/sars/
Toronto Tourism: http://www.torontotourism.com and http://www.torontotourism.com/media_information/release_310303.asp

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