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LETTERS
Toronto Emergency
Medical Services
and SARS
To the Editor: The first appear-
ance of severe acute respiratory syn-
drome (SARS) in China in November
2002 led to a worldwide epidemic by
March 2003. On February 21, 2003,
an index case of SARS, which led to
224 cases and 38 deaths, was diag-
nosed in Toronto. On March 14, four
cases of atypical pneumonia in
Toronto were epidemiologically
linked to the SARS outbreak in China.
On March 26, the Ontario Ministry of
Health declared a provincewide med-
ical state of emergency, which was
lifted on May 17 when the SARS out-
break was thought to be over.
However, 7 days later, several more
cases of SARS were discovered in
four Toronto hospitals, which caused
a resurgence of the intensive precau-
tionary measures throughout the
healthcare sector. When the state of
emergency was lifted on July 2, 2003,
a total of 224 people in Toronto had
been officially diagnosed with SARS,
and 38 had died.
The SARS outbreak strained
Toronto Emergency Medical Services
(EMS), which worked 40 stations
evenly divided among the city’s four
quadrants. Annually, Toronto EMS
transports >140,000 patients to 17
acute-care hospitals, which makes it
the largest and busiest municipal EMS
in Canada. During the outbreak,
Toronto EMS’s 850 paramedics had
1,166 potential SARS exposures; 436
were placed in a 10-day home quaran-
tine, which meant being isolated from
those persons within the home, con-
tinuously wearing an N95 respirator,
and taking their temperature twice a
day. SARS-like illnesses developed in
62 paramedics, and suspected or prob-
able SARS requiring hospitalization
developed in 4 others. On March 26,
almost all of the frontline staff of the
city’s northeast quadrant were sent
home because of possible SARS
exposure at a Toronto hospital (1). On
May 22, when the outbreak’s second
phase began, >200 paramedics had
contact with patients with SARS and
were quarantined. These events seri-
ously affected EMS and their staff.
Even before the SARS emergency
was declared in Ontario, Toronto
EMS was aware of a serious respirato-
ry disease in the community. Because
of an increase in “atypical pneumo-
nia” cases, an advisory had been sent
to all paramedics warning them to
wear respirators, gowns, gloves, and
goggles with all respiratory patients.
The advisory was recalled in favor of
the Provincial Directive; the
Provincial Directive was also changed
when SARS reemerged in May. While
properly fitting and supplying 850
paramedics with respirators took sev-
eral months, no paramedics became ill
with SARS after these requirements
were initiated, even without fit-testing
all the respirators.
Although cleaning the emergency
vehicles was a potential concern, the
only important change was substitut-
ing the usual disinfectant of 3%
hydrogen peroxide with virucidal
effect in 10 minutes to a disinfectant
of 7% activated hydrogen peroxide
with virucidal effect in 5 minutes.
Otherwise, normal procedures were
followed and emergency vehicles
were cleaned on their regular rotation-
al basis.
During the outbreak, the EMS
Healthcare Divisional Operations
Centre became the emergency opera-
tions center for Toronto EMS. It had
been designed to coordinate Toronto’s
operational response with other
municipal and provincial health serv-
ices. During this time, the province
also created its own emergency oper-
ations center, to which representatives
from both health services reported.
Within days of the provincial
emergency, Toronto EMS, in conjunc-
tion with Toronto police and fire serv-
ices, created the medical support unit
that operated as an internal public
health department for all paramedics
and was responsible for their direc-
tion, education, support, and screen-
ing. If needed, paramedics were
placed under work or home quaran-
tine or precautionary symptom sur-
veillance on the basis of their expo-
sure history, symptoms, and treatment
in an emergency department or SARS
clinic if needed. The medical support
unit used protocols developed by a
base hospital medical director who,
together with EMS staff, reviewed
each paramedic’s chart daily to make
appropriate follow-up decisions. The
medical support unit was a vital com-
ponent in protecting the paramedics’
health and welfare.
To sustain the optimal functioning
of Toronto EMS, its headquarters was
closed to frontline staff for the dura-
tion of the outbreak. All personnel had
to be screened for SARS-like symp-
toms before entering, and all para-
medics had to check themselves for
signs and symptoms of a SARS-like
illness before reporting for duty.
Anyone with SARS-like symptoms
had to report to the medical support
unit and stop working in an EMS
capacity.
To control the spread of SARS, the
provincial government placed all
interfacility transfers under the con-
trol of Toronto EMS through the cre-
ation of the Provincial Transfer
Authorization Centre on March 29.
Since then, the Provincial Transfer
Authorization Centre has been
responsible for ensuring that all non-
emergency transfers are medically
cleared to prevent patients with conta-
gious diseases from being taken to a
facility that is unprepared to receive
them. The Provincial Transfer
Authorization Centre now processes
>1,200 requests daily and was an
important factor in containing SARS.
Several lessons were learned from
the SARS outbreak. First, an emer-
gency plan must be in place before an
outbreak occurs. Second, the ability to
1688 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 9, September 2004
LETTERS
communicate quickly and easily with
provincial and municipal health
authorities was needed to ensure that
the most up-to-date information con-
cerning the outbreak was available.
The intergovernmental relationships
necessary for such rapid communica-
tion should be established in advance.
Third, accurate and timely communi-
cation with frontline staff members is
the best way to minimize their fears.
Finally, personal protective equip-
ment procedures should be main-
tained until assurance that the expo-
sure risk is negligible. The SARS out-
break is unlikely an isolated occur-
rence; therefore, sound advance plan-
ning on the basis of experience will
increase the ability to protect both
EMS staff and the public in the future.
Acknowledgments
We thank the Toronto Emergency
Medical Services staff who helped man-
age the outbreak and Paula Chabanais for
editing this manuscript.
Alexis Silverman,*1 Andrew
Simor,†1and Mona R. Loutfy,‡§1
*Toronto Emergency Medical Services,
Toronto, Ontario, Canada; †Sunnybook
and Women’s College Health Sciences
Centre, Toronto, Ontario, Canada; ‡McGill
University, Montreal, Quebec, Canada; and
§North York General Hospital, Toronto,
Ontario, Canada
Reference
1. Varia M, Wilson S, Sarwal S, et al. Hospital
Outbreak Investigation Team. Investigation
of a nosocomial outbreak of severe acute
respiratory syndrome (SARS) in Toronto,
Canada. CMAJ. 2003;169:285–92.
Address for correspondence: Alexis Silverman,
Toronto Emergency Medical Services, 4330
Dufferin Street, Toronto, Ontario, Canada M3H
5R9; fax: 416-392-2149; email: asilver@
toronto.ca
1All authors contributed equally to develop-
ing, drafting, and revising this letter.
SARS during
Pregnancy,
United States
To the Editor: Two of eight per-
sons with laboratory-confirmed severe
acute respiratory syndrome– associat-
ed coronavirus (SARS-CoV) infection
in the United States during 2003 were
pregnant women. Robertson et al. (1)
reported data describing one pregnant
patient who recovered and delivered a
healthy infant. We report data con-
cerning the second patient, with fol-
low-up 1 month after the child’s birth.
The patient, a healthy, 38-year-old
woman in the 7th week of pregnancy,
traveled with her husband to Hong
Kong. From March 1 to March 6,
2003, they stayed at the Hong Kong
hotel where it is believed a physician
from China spread SARS-CoV to sev-
eral guests. These guests were the
index case-patients for subsequent
outbreaks in Hong Kong, Vietnam,
Singapore, and Toronto, Canada (2).
The woman and her husband returned
to the United States on March 6; the
husband had onset of SARS illness on
March 13. On March 19, the patient
had onset of an illness with fever (tem-
perature 37.8–40°C), muscle aches,
chills, headache, runny nose, produc-
tive cough, wheezing, and shortness of
breath. A chest radiograph showed a
diffuse infiltrate in the left lung. The
patient was hospitalized for 9 days and
given broad-spectrum antimicrobial
drugs. She recovered from her illness,
and enzyme immunoassay and
immunofluorescent assays conducted
on serum samples on days 28 and 64
after illness onset were positive for
antibodies to SARS-CoV.
The patient had an uneventful
pregnancy until the last trimester,
when her blood glucose levels were
elevated. Early spontaneous rupture
of membranes initiated preterm labor,
and a cesarean section was performed
at 36 weeks’ gestation because of fetal
distress. A 5-pound, 7-ounce, healthy
boy was delivered without complica-
tions. Apgar scores were 7 at 1 minute
and 8 at 5 minutes. The newborn had
no illness, abnormalities, or congeni-
tal malformations. Serum samples
from the patient at delivery were pos-
itive for antibodies to SARS-CoV, but
cord blood and placenta samples were
negative. Breast milk samples on
postpartum days 12 and 30 were also
negative for SARS-CoV antibodies.
Blood, stool, and nasopharyngeal
swab samples from the patient and
cord-blood samples showed no viral
RNA by reverse transcription–poly-
merase chain reaction. Stool samples
from the newborn, collected on days
12 and 30 after delivery, were also
negative for viral RNA.
Although other countries have
reported cases of severe illness and
poor outcome associated with SARS-
CoV infection during pregnancy
(3–5), neither of the two pregnant
SARS case-patients in the United
States had serious adverse outcomes.
The presence of antibodies to SARS-
CoV in breast milk might be influ-
enced by the time of infection in rela-
tion to gestation. Robertson et al. (1)
reported that antibodies to SARS-CoV
were detected in the breast milk of a
patient who was infected at 19 weeks’
gestation; however, the patient in this
case was infected at 7 weeks’ gesta-
tion, and antibodies to the virus were
not detected in her breast milk. No
reports have indicated vertical trans-
mission of SARS-CoV, a finding that
is supported by our data. However, too
few cases have been studied to clearly
define the risks and provide guidance
for treating pregnant women infected
with SARS CoV.
Lauren J. Stockman,* Sara A.
Lowther,* Karen Coy,† Jenny Saw,‡
and Umesh D. Parashar*
*Centers for Disease Control and
Prevention, Atlanta, Georgia, USA; †Santa
Clara County Department of Public Health,
San Jose, California, USA; and ‡Private
pediatric practice, San Jose, California,
USA
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