In 2003, there were 8098 SARS cases in 29 countries with 774 deaths. Places worst affected by SARS were unprepared to deal with the scale of the local epidemic. As described by Sue Lim and colleagues (University Health Network, Toronto, Ontario, Canada,), when SARS arrived in Toronto in March 2003, there was no centralised public health system in Ontario, and the province's 37 public health units operated quite independently of each other. Hospital staff were particularly vulnerable to infection, but with 211 hospitals in Ontario alone requiring supplies of protection and isolation equipment, these quickly ran out. Among the unpredictable effects of SARS were a reduction in income for some hospital workers, because those staff that normally worked shifts at several institutions were forced to choose one institution at which to work during the outbreak. Through tracing the contacts of SARS patient, the Toronto authorities identified 23103 people who required quarantine, which represented almost 1% of the population of the city.
In Taiwan, as described by Mei-Shang Ho and Ih-Jen Su, 211945 people were quarantined for 10–14 days because of suspected contact with SARS cases, which, similar to Toronto, is almost 1% of the population of Taiwan. However, quarantine was subsequently replaced as a control strategy in Taiwan because only 133 (0.06%) of those quarantined developed probable or suspected SARS, and most confirmed cases became infected in a hospital setting. The problems and solutions encountered during the SARS epidemic have had a beneficial consequence for Taiwanese authorities in that they have helped planning for an influenza pandemic. Should such a pandemic occur, it will be far more damaging than SARS.
Paul Tambyah recounts his experience of dealing with SARS on the wards of a Singapore hospital. Tambyah describes how the decision to designate the Tan Tock Seng Hospital as Singapore's sole dedicated SARS hospital actually helped the disease spread to four of the countries five major hospitals, because many patients rapidly discharged to other hospitals to clear beds were already incubating the SARS virus. One patient, a 63-year-old vegetable seller admitted with heart failure, was responsible for infecting an entire shift of nurses with SARS, and infections of several of his work colleagues led to closure to Singapore's largest wholesale vegetable market and devastation of the local fresh food industry.
An editorial in the same issue of The Lancet Infectious Diseases notes that one of the most striking characteristics of the SARS epidemic was that the great majority of infections--more than 80%--were acquired in hospital. The editorial also questions the value of quarantine as a control measure and of members of the public wearing surgical masks to protect themselves from infection: "An initial delay, followed by misinformation that the virus was airborne, created unnecessary panic. Images of people wearing surgical masks became the symbol of SARS, even though clinical reports suggested that SARS was spread only by close contact requiring the inhalation of droplets".
The issue also includes articles by L L M Poon and colleagues on the cause, origins, and diagnosis of SARS; Christl Donnelly and colleagues on the epidemiology and genetics of SARS; and Scott Dowell and Mei-Shang Ho on when and if SARS might reoccur.
Contact: for Lim and colleagues article, Dr Michael Gardam, Infection Prevention and Control, University Health Network, 200 Elizabeth St, ES3-428, Toronto, ON, M5G 2C4, Canada; T) 1-416-340-3758; michael.gardam@uhn.on.ca.
Dr Mei-Shang Ho, Institute of Biomedical Sciences, Academia Sinica, Taipei, 11529 Taiwan; Tel 886-22-789-9120; homs@ibms.sinica.edu.tw.
Dr Paul A Tambyah, Department of Medicine, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074; T) 65-67-795-555; mdcpat@nus.edu.sg.
For Poom and colleagues article, Dr J S M Peiris, Department of Microbiology, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong SAR, China; T) 852-2-855-4888; malik@hkucc.hku.hk.
Professor Christl Donnelly, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College, St Mary's Campus, Norfolk Place, London W2 1PG, UK. T) 44-207-594-3394; c.donnelly@imperial.ac.uk.
Dr Scott F Dowell, 3rd floor, DDC 7 Building, Department of Disease Control, Ministry of Public Health, Muang, Nonthaburi 11000, Thailand; T) 662-591-1294; scottd@tuc.or.th.
Journal
The Lancet Infectious Diseases