Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada

Abstract

Background: Severe acute respiratory syndrome (SARS) was introduced into Canada by a visitor to Hong Kong who returned to Toronto on Feb. 23, 2003. Transmission to a family member who was later admitted to a community hospital in Toronto led to a large nosocomial outbreak. In this report we summarize the preliminary results of the epidemiological investigation into the transmission of SARS between 128 cases associated with this hospital outbreak.

Methods: We collected epidemiologic data on 128 probable and suspect cases of SARS associated with the hospital outbreak, including those who became infected in hospital and the next generation of illness arising among their contacts. Incubation periods were calculated based on cases with a single known exposure. Transmission chains from the index family to hospital contacts and within the hospital were mapped. Attack rates were calculated for nurses in 3 hospital wards where transmission occurred.

Results: The cases ranged in age from 21 months to 86 years; 60.2% were female. Seventeen deaths were reported (case-fatality rate 13.3%). Of the identified cases, 36.7% were hospital staff. Other cases were household or social contacts of SARS cases (29.6%), hospital patients (14.1%), visitors (14.1%) or other health care workers (5.5%). Of the 128 cases, 120 (93.8%) had documented contact with a SARS case or with a ward where there was a known SARS case. The remaining 8 cases without documented exposure are believed to have had exposure to an unidentified case and remain under investigation. The attack rates among nurses who worked in the emergency department, intensive care unit and coronary care unit ranged from 10.3% to 60.0%. Based on 42 of the 128 cases with a single known contact with a SARS case, the mean incubation period was 5 days (range 2 to 10 days).

Interpretation: Evidence to date suggests that SARS is a severe respiratory illness spread mainly by respiratory droplets. There has been no evidence of further transmission within the hospital after the elapse of 2 full incubation periods (20 days).

Fig. 1: Reported probable and suspect cases of severe acute respiratory syndrome (SARS) associated with the index case and her family (n = 6) and a nosocomial outbreak at a secondary care community hospital in Toronto (n = 126), by date of onset of symptoms and type of case, from Feb. 23 to Apr. 15, 2003. (Two of the cases in the nosocomial outbreak are not included in this figure because their dates of symptom onset are unknown.)

Fig. 2: Transmission of 84 probable and suspect cases of SARS in the nosocomial outbreak that could be linked to the 6 members of the index family (the index case, her son [case A] and 4 members of case A's family). Photo: Myra Rudakewich