Toronto — Health Canada is reviewing the way it defines a "probable" case of SARS after complaints that the existing definition plays down the scope of the problem in this country.
And Ontario health authorities said they would switch to international standards that they say are much less subjective than the definitions accepted by the federal department.
The first public hint of concern emerged early yesterday from Donald Low, chief microbiologist at Toronto's Mount Sinai Hospital. "There's a lot more patients out there that have SARS than we're letting the rest of the world believe," he told CBC radio.
Dr. Low's concern was followed quickly by back-and-forth talks with the World Health Organization yesterday. Paul Gully, senior director-general of Health Canada's population and public health branch, said of the talks: "We did discuss case definitions, and we did discuss and suggest to them possible alternatives to changing the case definition."
Passengers boarding an international flight walk past a thermal imaging camera used to detect SARS fever at Pearson International Airport in Toronto. (J.P. Moczulski/AFP)
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Those talks were held after Denise Werker, a medical officer on the global-response team of the WHO's communicable-diseases section, said from Geneva that Canada "should have a sensitive case definition."
Health Canada's definition calls severe acute respiratory syndrome probable if a patient meets all the criteria of a suspected case and has a severe "progressive" respiratory illness. The WHO asks only that criteria of a suspected case be met and that evidence of the illness can be seen in chest X-rays or that a patient tests positive for the SARS coronavirus, something that does not occur in all cases.
Because not all SARS cases can be seen to be progressing, many people who would fit the WHO's definition do not meet the test in Canada. In fact, medical experts in Ontario said yesterday that perhaps half of all of the province's 23 active suspected cases would be classified as probable if the UN agency's criteria were used.
The developments occurred as it was announced that two more people have died of the disease, bringing Canada's toll to 29. Both were part of a newly discovered cluster that festered unchecked in two Toronto hospitals for more than a month.
With more than 5,100 additional people sent into quarantine in the past week, Ontario health authorities said they expect the situation to get much worse before it gets better, particularly in the next few days.
Meanwhile, Ontario nurses told The Globe and Mail that they had complained as far back as late March that patients in at least one of the hospitals where the new cluster was discovered had SARS symptoms.
Their complaints were ignored, Doris Grinspun, the executive director of the Registered Nurses Association of Ontario, said yesterday.
"It's shocking; it's upsetting; it's infuriating," she said. "What's infuriating to me is that nurses are not listened to. If we were to understand once and forever that nurses are knowledgeable workers, maybe we would start taking their concerns more seriously, and we will prevent disasters."
As to the SARS definition, the WHO uses only the probable case numbers when sending out its daily reports on the status of the disease in each country and when deciding whether to issue a travel advisory.
At a news conference yesterday, Dr. Low said he could not "understand why we were seeing so few probable cases."
It turns out that, when the outbreak first began, Ontario authorities were using the WHO's definition. But some time in mid-April, the Toronto health authority switched to the Health Canada definition.
Dr. Low pointed out, however, that suspected cases and probable cases are treated the same way by health authorities. In fact, 50 additional people in Ontario are being investigated and cared for with extreme caution but do not yet meet the definition of a suspect case.
Because most people with SARS eventually show a progression of the disease, they end up transferred to the list of probable cases. The only time the definition really makes a difference is at the start of an outbreak.
Colin D'Cunha, Ontario's chief medical officer of health, said concern about the definition was expressed by doctors treating Toronto's SARS patients last weekend and the province hopes the federal authorities conform to the international criteria.
"Whilst we await the final decision from Health Canada, in our minds we know exactly where we want to land," Dr. D'Cunha said. "We want to land with the WHO definition."
As to the complaints from the nurses, Ms. Grinspun said there were "several" warnings at either St. John's Rehabilitation Hospital or North York General "and it was as early as the end of March, beginning of April."
She refused to give the name of the hospital and the doctors involved because she is in the process of putting the complaints in writing and the association is considering legal action.
The apparent cases that were raising alarms with nursing staff were occurring unnoticed at the same time that the city was dealing with an outbreak of the new disease that had closed other Toronto-area hospitals and sent ripples of fear around the world.
The new cluster stems from a SARS infection in a 96-year-old patient at North York General who went undetected since he caught the disease about April 22. How he got the virus is not known. That cluster has claimed three lives: the 96-year-old and two other elderly people whose deaths were announced yesterday.
"All I can tell you is that nurses were put at risk at that time. Patients were put at risk, and I cannot say if it [heeding the nurses' warnings] would have prevented the whole outbreak; that would be probably an exaggeration. But could we have been containing it more? I believe so."
With a report from Canadian Press
