The roof is on fire

So I was on the phone today with CCRA, you know them--"the tax people", asking some questions I had while dutifully doing my year 2001 taxes (yes, yes, it is 2003). Anyway, the very nice and pleasant person didn't immediately know the answer to my question and put me on hold for a while to ask whomever it is they ask for advice. When she got back, there was a distinct change of tone in her voice and she answered my question with a brusque "I think it goes on line 104." I tried to ask a follow-up to clarify and she said, slightly panicking, "I can't talk right now, the building's on fire and I really have to go."

Comforting. On fire, eh? I have to say I am impressed at the level of customer assistance, taking the time to answer questions (although I think wrongly), before fleeing a burning building.

The good news is that the Canadian Government owes me nearly a grand from the year 2001.

There is good pasture, if they don't stray

Thanks to Mike Beltzner for his very good post and links.

Just got back from a meeting at school about the departmental response to SARS. Some very interesting discussion, mostly about long-term research and lessons learnt. There was an unspoken consensus not to speak about the current epidemiological work, so as not to step on anyone's toes or to pipe in with what would appear to be petty and ill-timed criticisms. Some interesting points:

It appears that the WHO decision about a travel advisory was made on the basis of very poor data. What made Toronto different from Singapore in WHO's eyes was a story about a man who caught SARS in Toronto and flew to Australia. However, it turns out that it was a false alarm and the man never had SARS. It may be possible that there was a desire to include Toronto in the travel advisory, so as not be seen as singling out Asia.

Everybody's thankful that SARS did not hit at flu season because the symptoms are so alike. If SARS is still serious when November and the start of the new (hopefully normal) flu season rolls around, it's going to be really difficult in distinguishing flu from SARS and the number of false diagnoses will skyrocket. Unless there's a good, quick and accurate test for SARS by then, officials may be put in the position of quarantining thousands of flu sufferers. (By the way, update on the problems they're having linking SARS to the coronavirus here.)

One of the AIDS researchers at the meeting brought up the point of the harm that analogies with AIDS had on the current situation. Everyone's heard the stories about medical staff in th 1980's dealing irrationally with HIV patients: using tongs to handle the paperwork of patients, for instance. There was an attempt not to stigmatize SARS patients in the same way. Of course, it turns out that catching SARS is a hell of a lot easier than catching AIDS from casual contact, and the anti-stigma attitude may have lead to unnecessary infections of health care workers and their families.

On the other hand, the question was raised about at what point does the public health community work to start normalizing SARS. We accept all sorts of diseases and risks as part of normal human existence and, in the greater scheme of things, SARS may not be relatively that great a threat. If SARS is here to stay, we have to learn to live with it, without freaking out. Right now, we may be able to contain it completely and the overwhelming force approach is the best way we know how to handle it. But it can't work as a long-term solution.

In that regard, there was discussion about normalizing infection control itself. We're so used to living without the burden of infectious diseases, but it wasn't that long ago that quarantines and isolation orders were a normal part of life. When polio, diptheria, measles, scarlet fever, et c. struck a household, the red quarantine sign in the window was expected, and not unusual. Do we return to that level of care? Do we have to radically alter our idea of what quarantine means? Are the laws about quarantine, which haven't changed since the 1930's, still adequate and appropriate? Are quarantines disportionally punishing towards marginal groups in society, who don't have the resources to work around them? These are questions that need to be answered.

One of the ironies pointed out was that the Chinese community iin Toronto may be the most prepared and consequently at lower risk than the rest of the population because of more direct, and earlier, links to information about the disease than the rest of the Canadian public. Also, we normally think of infectious diseases as disproportionally striking poor populations, but SARS is a disease in Canada that has basically only affected those wealthy enough to travel or relatively high status health care workers.

Finally, on a more cautious note, from the Wall Street Journal (via Sarswatch ):
"As summer approaches and the SARS epidemic declines, there will be an understandable urge to celebrate. But we must eschew premature celebrations and self-congratulations. History teaches us that the devastating 1918 influenza epidemic began with a modest "herald wave" in spring that faded away during the summer, only to explode and wreck global devastation the following fall and winter. It is possible that SARS, now seeded around the globe, could follow a similar pattern and fade away this summer, only to erupt again next winter."

Half way along the road we have to go, I found myself obscured in a great forest.
I'm out of the woods now. I finally feel that I can return to normal life after a month or so of exams and final papers. I still have a mid-term to write (due to some technical screw-up) but basically everything is done and I can stop dreaming of log curves, for the moment anyway. I've also completely recovered from a bad case of "no, it's not SARS" strep throat, which made last week particularly pleasurable, especially the exam that I had to write during that time.

Speaking of SARS, Andrew inquired about my thoughts on the matter. There's one thing I can tell you for sure is that SARS has made this last month a logistical nightmare for many people around here. It even has thrown a few spanners into the works for me. At the beginning of April, the hospitals closed themselves off to non-essential staff. This meant that I, as an entirely non-essential researcher with an office at CAMH, the mental hospital here in Toronto, could not get into work. Then, the University of Toronto, where I go to school, decided that people who worked in places that were shut down, shouldn't gather with other people who worked in places that were shut down. This meant that basically everyone in my classes, who are associated somehow or another with the hospitals or research facilities attached to hospitals, suddenly became defacto quarantined. My biostats class, for instance, normally about 100 people, was decimated--only about 6 people made it to class that week. The school later relaxed its definition of people who shouldn't come to classes, restricting only people who actually worked with patients, but by then it was too late. Classes and exams were already rescheduled. My exam yesterday, for instance, should have taken place last week and the date wasn't confirmed until 2 days before, because they had to work out an arrangement to get exam proctored individually for people who were legitimately quarantine, including about a dozen people who worked at Sick Kid's. Anyways, it looks like the SARS effect on my personal life is almost over, and I think I'll even be able to get back to my office tomorrow.

An outbreak like SARS is really glory-time for epidemiologists; it's one of the few occasions where it's recognized that public health workers do actually deal with disease on a hands-on basis. Some of my profs are heavily involved in work on SARS and my friend's supervisor actually contracted the disease herself. There's an atmosphere of battle-like excitement/desperation around school, which is, to be honest, really enjoyable in a certain way. I'm planning on doing some volunteering over the next couple of weeks to help out.

I think the jury is still out about SARS. I think we still can't even confirm that the coronavirus is the actual causal agent. We don't know how deadly it is yet either. About half of the cases in Canada have made a full recovery and gone home while 4-10% who had the disease have died (most of those people were over 70 years old). Worldwide, the stats look even better: 90% recover fine, 10% require intensive treatment and about 4% die from the disease. Compare that to another rare form of pneumonia called Group A streptococcal pneumonia where about 40% of the people in Canada who got it died. Many other types of pneumonias have case-fatality rates in the 20% range. We don't know what the long term effects are, however, and we don't know what would happen with this disease if it became wide-spread in the community. An infection in a nursing home, for instance, could be disasterous. So far in Toronto, SARS seems to be under control. The number of new cases each week is fairly low and has not shown the exponential growth associated with uncontrolled epidemics. Another really good sign is that no one has got the disease from someone who wasn't coughing and feverish at the time--this makes identification and control so much easier.

The thing to watch for is if people start getting the disease who don't know where they got it from. This is key. Right now, there have been some cases like the Catholic church group where people in a general, as opposed to hospital, setting got the disease. That's bad, but so far most of the "confirmed" probable cases have been able to be linked back to the few people who brought it back from Asia, so it's still alright. Once we lose track of the chain of infection, then the nature of the outbreak could change entirely. As long as we can keep track of transmission, we have the possibility of controlling it. If we lose those links, the shape of the epidemic curve will change, and instead of a few cases each week, there might be exponential increases. At the moment, there are about 10 people who we don't yet have links for, and those are the people to worry about, if their infections cannot in fact be traced back.

You can find a comforting graph at the New England Medical Journal site. It shows a fast, but linear increase of the the number of cases world wide and a much lower rate of death from the disease. This Health Canada website also has some really good information. A prof at John Hopkins has a good presentation about SARS on his website.