Toronto Mystery Illness
Death Toll Rises To Six

By Dr. Henry L. Niman
Dr. McKeown reported the following update:
* The outbreak has so far affected a total of 68 residents, eight employees and three visitors at Seven Oaks.
* There have been no new cases since yesterday, but there have been two additional deaths, for a total of six in the outbreak.
* The majority of cases are improving but some have worsened as the illness takes it course.
* 30 residents from Seven Oaks have been admitted to hospital.
* Toronto Public Health staff have followed up 170 contacts connected to Seven Oaks. This includes families of children who attend the adjacent day nursery.
The above comments from the press release of Toronto Health indicates the number dead has risen to six, the number of employees infected is up to eight, the number of visitors infected is up to three and the number of residents admitted is up to 30.
Since the outbreak began on Sept 25, it seems likely that these numbers will increase, especially in secondary contacts like employees and visitors. Increases in these categories suggest the etiological agent is infectious via casual contact and is not due to bacterial agents in the hospital.
Monitoring of the contacts will be important, since there is no quarantine and this category is growing. Testing out autopsy material may help in the isolation of the etiological agent, which will be necessary for the validation of the negative data. Generation of false negatives in viral infections is common, and the increasing numbers demand an aggressive investigation of the etiological agent.
© 2005 Recombinomics. All rights reserved.
Mystery Illness Spreads to Patient Vistors in Toronto
Recombinomics Commentary
October 3, 2005
Seventy-one of the 249 residents at Seven Oaks Home for the Aged in Toronto's east end are sick. Six employees and two visitors are also ill.
The Ontario Public Health Lab has been running several tests on samples taken from hospitalized patients.
"We've run tests for over a dozen different viruses and bacteria, from run-of-the-mill influenza to bird flu and SARS," said Dr. Donald Low, the lab's medical director. "So far, everything's come up negative."
Residents at the nursing home began to show symptoms one week ago. The first patient died on Sept. 29. A coroner will begin performing autopsies on Monday.
Low said once they have tissue samples from the deceased patients, lab technologists will be able to run more sophisticated tests.
He added it's unfortunate the autopsies weren't done sooner.
Although all tests thus far are negative, false negatives are common in the absence of the correct clinical samples. Frequently, autopsy material is required to isolate the etiological agent.
The above comments indicate that those infected include six employees and two visitors, demonstrating that the infectious agent is easily transmitted. The number of residents infected is up to 73 from a 249 bed facility, and since the outbreak is less than a week old, that number will likely rise. Similarly, the number of employees infected has gone up as have the number of infected visitors, so those two groups likely trail the residents in exposure dates.
More details on ages in symptoms of the casual contacts would be useful.
There has been little discussion of tracing contacts, and visitors have been kept out of the nursing home and in the community. Since the highly infectious agent is unknown, this policy seems dangerous. The failure to have begun autopsies of the dead, who died last week, is cause for concern
Toronto seems more focused on early press conferences than early identification and control of the agent. Since the agent has not been identified, this complacency is cause for concern.
H5N1 Not Ruled Out In Mystery Illness That Killed Four in Toronto
Recombinomics Commentary
October 2, 2005
We know from testing that it's not influenza, we know that this is not SARS, we know this is not avian influenza," said infectious disease consultant Dr. Alison McGeer.
Although the above comments were made at the 5 PM news conference, later in the same news conference both statements were qualified.
SARS was excluded because the clinical signs did not match SARS and there was "no SARS in the world". However, papers published this week in Science and PNAS described coronaviruses closely related to SARS CoV in horseshoe bats and those sequences became available at GenBank this week (bat SARS coronavirus HKU3-1, bat SARS coronavirus HKU3-2, bat SARS coronavirus HKU3-3 ). In addition, the newly discovered related coronviruses NL63 and HKU-1 are found in respiratory diseases worldwide.
Dr McGeer admitted that there was no data yet on coronavirus tests.
Similarly, when asked if influenza could be ruled out, she said no, but she expected to be able to rule out influenza when test results became available in a few hours.
Thus, the data available at the time of the statement above did not rule out a SARS, or SARS-like illness, or an influenza illness, like H5N1.
Although the test for these viral etiologies may be negative, the best way to strongly rule them out is to first get negative data for SARS and H5N1, and the get positive data for another agent.
Until those two results are in, the viral-like fevers and rapid spread raise the possibility that the respiratory disease sweeping through the nursing home in Scarborough, Canada is linked to coronaviruses or influenza viruses like H5N1.
Patricia A. Doyle, PhD
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