SARS Epidemiologic Summaries:
April 26, 2003

Summary of SARS cases potentially exposed in Canada and diagnosed internationally

Health Canada is working with our international partners to investigate reports of SARS cases diagnosed abroad who were thought to have been exposed in Canada. This report covers cases reported internationally in Australia, Germany, United States, and the Philippines. Health Canada was notified April 24, 2003 of a reported Bulgarian case of SARS; this is being investigated and information will be provided when available.

Australia:

A family of five (2 adults, 3 children) residing in the Greater Toronto Area departed Toronto on March 28, 2003 and arrived in Australia on March 29, 2003. Child A had onset of influenza-like illness symptoms on March 31, 2003 and was hospitalized on April 3, 2003 with high fever and respiratory distress; a chest x-ray revealed infiltrates. Child A was diagnosed as a SARS case according to the WHO case definition, which differs from the Canadian SARS case definition by including Toronto as an "affected area". Child B had onset of cough on March 25, 2003. Child C had onset of cough April 1, 2003. Both Child B and Child C were subsequently reported as probable SARS cases according to the WHO case definition. All three children have since recovered. Both adults remained well. No clear epidemiologic link to any known SARS cases in Canada could be established. No secondary transmission was observed.

In Canada, none of the children would have met the case definition for a probable or suspect case of SARS. Child A would have been classified as GEO-linked, that is, a person with fever and symptoms consistent with severe atypical pneumonia who has been in an area with local chains of transmission of at least 3 generations, who does not have an epidemiologic link. Children B and C would have been classified as Persons Under Investigation (PUI).

Germany:

A 26 year old woman was temporarily residing in Toronto. On March 31, 2003 she flew from Toronto to Germany. She was asymptomatic until April 3, 2003 she developed headache, nausea and vomiting. She subsequently developed fever (maximum 37.8°C) and cough. She was admitted to hospital on April 7, 2003 and diagnosed with pneumonia. Chest x-ray revealed infiltrates. No clear epidemiologic link to any known SARS cases in Canada could be established. No secondary transmission was observed.

In Canada, this woman would not have met the case definition for probable or suspect SARS. Rather, because of her sub-38°C and lack of epidemiologic link, she would have been classified as a Person Under Investigation.

United States:

A 52 year old man residing in Pennsylvania travelled alone by car to Toronto on March 28, 2003 He drove back to Pennsylvania alone on April 1, 2003. On April 3 he became symptomatic with chills, fatigue, myalgia, headache and diaphoresis (excessive sweating). On April 6 a fever of 38.2°C was documented and on April 7, 2003 he developed respiratory symptoms and was hospitalized on April 14, 2003 with pneumonia. Chest x-ray showed bilateral patchy infiltrates, serum was positive for coronavirus antibodies and he was diagnosed with suspect SARS , and would have been diagnosed as such in Canada. This man was discharged from hospital on April 21, 2003. The suspected exposure was thought to have occurred at a religious meeting he attended in Toronto on March 28-29, 2003, where a symptomatic SARS case was also present. Pennsylvania health authorities have reported that a family member had symptoms consistent with the suspect SARS case definition, but the onset of symptoms in the family member occurred before having had contact with the 52 year old man case. Therefore, this family member cannot be considered a transmission of any sort from the case.

Philippines:

A 46 year old woman residing in the Greater Toronto Area departed Toronto on April 3, 2003 and arrived in Manila, Philippines on April 4, 2003 via Narita Airport in Japan. This case had onset of fever on April 6, 2003. On April 11, 2003 she developed diarrhea and cough; on April 12, 2003 she was admitted to a local hospital at which time a chest x-ray revealed bilateral infiltrates. She continued to deteriorate. On April 13, 2003 five family members drove her to a speciality hospital in Manila where she was admitted and diagnosed with probable SARS. She continued to deteriorate and died the following day. The suspected exposure was thought to have occurred in Toronto on April 1 and April 2, whe n on each occasion, she spent a short period of time in the home of a symptomatic probable SARS case. She did not have direct contact with this SARS case; it is hypothesized she may have had contact with fomites in the home of the case. The Philippines authorities have reported secondary transmission to a health care worker, who has been diagnosed as a probable SARS case. In addition, the father of the woman, who was ill with cancer, died and is now being reported by the Philippine Department of Health as a probable case of SARS. There is insufficient information at this point to judge whether these two cases of transmission would have been classified as such in Canada, but the woman would have been classified as a probable case of SARS in Canada.

Summary

Of the 6 persons originating from Canada who were diagnosed abroad as cases of SARS, 4 would not have met the case definition for probable or suspect SARS in Canada. Only the case reported in Pennsylvania and the case reported in the Philippines would have met the SARS case definition in Canada.