CASE NO. 1
On Jan. 25, lab tests confirmed what Sunnybrook hospital staff suspected: they had Canada’s first coronavirus patient. Six months later, key players share the inside story of what happened next as they worked to contain the new virus
On a Thursday evening in late January, a 56-year-old man went by ambulance to Sunnybrook Health Sciences Centre with a fever and persistent dry cough.
He and his wife had returned to Toronto one day earlier from a three-month visit to Wuhan, China, where a novel coronavirus was circulating. There were reports of patients becoming critically ill with a pneumonia-like illness in hospital.
This was Jan. 23, back when few people outside the medical community were worried about a new coronavirus, not yet officially named by scientists.
“We didn’t fully realize it at the time … We didn’t know this was a moment in history.”
DR. JEROME LEIS MEDICAL DIRECTOR OF INFECTION PREVENTION AND CONTROL, SUNNYBROOK HOSPITAL
Canadians were still mourning the victims of the downing of an airliner by an Iranian missile, and, in Ontario, headlines were dominated by teacher strikes and debate over whether the slumping Maple Leafs could make the playoffs.
That evening, only the paramedics who transported the patient, a handful of Sunnybrook staff and select top public health officials knew Canada might have its first coronavirus patient.
Given his travel history and symptoms, strikingly similar to those reported by Chinese physicians, Sunnybrook’s emergency department staff immediately isolated the patient in a special room. They donned personal protective equipment, notified an infectious disease physician and cared for the patient, knowing they must wait at least two days to find out if he had the virus.
Even then, those closest to the case did not predict it was the start of what Canada would experience during a global pandemic that would upend daily life, trigger economic disaster, stretch hospitals and health-care systems to the breaking point and lead to hundreds of thousands of deaths around the world.
“We didn’t fully realize it at the time,” said Dr. Jerome Leis, Sunnybrook’s medical director of infection prevention and control. “You have to remember, at this time, this was still the epidemic phase of the outbreak. The virus was only circulating in a few parts of the world; countries were only seeing a few imported cases. We didn’t know this was a moment in history.”
Now, six months after laboratory tests confirmed on Jan. 25 this patient had what we now call COVID-19, the virus has infected 113,000 Canadians and 8,881 have died.
For the first time, key players in Canada’s first COVID-19 case share an inside look at what happened in the hospital and the laboratory as they worked to contain a new and potentially deadly virus.
“The stakes were high; we didn’t want to miss the diagnosis or make the wrong call,” said Leis, also an infectious disease physician. “We all appreciated the significance of being able to confirm whether or not COVID-19 had been imported to Canada.”
Like most urban hospitals, Sunnybrook has long been prepared for the arrival of a dangerous pathogen in its emergency department, from Ebola to Middle East Respiratory Syndrome (MERS) to something entirely new.
“We know we are an international community and one flight away from becoming a new epicentre of an outbreak,” said Leis. “We prepare like this is a real possibility.”
In the emergency department, real-time data on different pathogens circulating worldwide is integrated into the triage booth so a nurse will be able to flag a patient according to their symptoms and travel history. Patients who screen positive are segregated in a special room to limit transmission within the hospital. And there is a stockpile of PPE for staff, including head coverings and boots, for potential outbreak scenarios.
“We were definitely not starting from scratch,” Leis said, noting the hospital’s experience with SARS in 2003. “We were drawing on a lot of lessons learned from prior epidemics and we able to nimbly react to this novel virus.
“I think hospitals across the country were doing much the same thing, but the patient happened to show up on our doorstep on January 23.”
Leis was not in the hospital when the patient was wheeled into the emergency department, with the paramedics and attending hospital staff wearing full PPE.
But a colleague called shortly after his arrival and relayed the patient’s travel history, vital signs and symptoms of fever and dry cough.
“It’s a phone call that I will never forget,” said Leis, who rushed to Sunnybrook to assess the patient. “We knew immediately that this could be the first case.”
He and the team decided to admit the patient, whose chest X-ray showed signs of pneumonia in both lungs, to hospital for observation. They were worried his condition would rapidly worsen, a trajectory described by Chinese physicians treating such patients, Leis said.
Despite their preparations, Leis and his colleagues knew little about the virus, which scientists had described as a novel coronavirus just two weeks earlier.
At that time, only a handful of countries had identified a positive patient — the first case in the United States was identified Jan. 20 — and the disease was then primarily understood to be similar to a viral pneumonia.
“When we admitted this first case, we did not yet know how this virus was transmitted,” said Leis, noting the first scientific paper describing the virus and its symptoms was published Jan. 24. “We didn’t know how long people remain infectious. We didn’t yet know the specific measures that needed to be used to interrupt transmission.
“We were literally reading about this virus hot off the press as we were managing this case, educating ourselves on the go.”
Dr. Vanessa Allen, chief of medical microbiology at the Public Health Ontario Laboratory, was among the select few to be alerted to Canada’s first potential case of COVID-19 in the hours after he was admitted to Sunnybrook.
Like her hospital colleagues, Allen had been preparing for weeks for the potential arrival of the new coronavirus in the province.
She recalls being worried after reading a notice in late December describing cases of unexplained pneumonias tied to a Wuhan wet market. On Jan. 3, she received an email alert with more details of the cases in Wuhan, and though she was on holidays, Allen initiated new protocols for the lab to prepare for possible cases.
One week later, after the team had spent days running tests on pathogens similar to the new virus, Chinese scientists published its genetic data.
“On January 11th, the sequence came out,” Allen said. “We ran our first sample that weekend.”
By Jan. 23, the lab had verified its approach with the National Microbiology Lab in Winnipeg and had already tested a handful of samples from Ontario patients suspected to have COVID-19.
“We never said no to a sample being tested at PHO,” she said. “If you were the microbiologist on call during that time, you never slept because you were vetting so many calls from hospitals, though none of those ended up being positive.”
But Allen, who spoke to Leis on Jan. 24, knew this case was different; everything — his travel history, his symptoms and the fact that his wife was also ill — pointed to him being the first patient with COVID-19.
“It was very compelling,” she said. “Right then we knew we had to do many checks and balances.”
Kathryn Rego knew there was apatient with a potential case of the new coronavirus before she arrived at Sunnybrook for start the start of her 12-hour shift on Jan. 24.
The registered nurse with 14 years of experience oversaw the 28-bed unit that Friday and Saturday and helped ensure those who entered the patient’s room followed protocols and wore proper PPE.
“We knew he was being tested and that it would probably take 24 to 48 hours to find out the results,” she said. “At that time, our biggest concern was our personal safety but there was never a question or concern of whether we would take care of him.
“I can only imagine how very lonely he was, isolated in the room. But he was very co-operative and willing to put on a mask when a staff member came in his room. He wanted to work with us to make sure everyone was safe.”
On Saturday, early in the afternoon, Rego recalls looking up from a task to see Leis and another physician walking down the hall towards her. The pair stopped in front of her and said, “We have to talk.”
“I got this sinking feeling in my stomach of like, ‘oh my God, now what?’ ”
Quickly, Rego’s nursing instincts took over and she gathered the dozen people working on the unit that day — the nurses, the cleaners, the support people — into a room with Leis and the other physician. Quietly and clearly, Leis shared the news and said a press release would be released later that day.
Then, Rego said, he answered everyone’s questions.
“Some of our staff had worked in 2003 during SARS,” Rego said. “They needed to know that they would be safe. Dr. Leis came back every day and kept answering all of our questions.”
Months later, Rego said it’s strange to think back to those initial days of Canada’s first COVID-19 patient. Now, caring for such patients has become commonplace.
“I can’t believe it’s been six months,” she said. “At the same time, it feels way longer than that.
“Looking back, we had no sense that our lives would change at that moment.”
Typically, Dr. Samira Mubareka, a microbiologist at Sunnybrook and a scientist at the hospital’s research institute, would not go into a patient’s hospital room.
But during the week Canada’s first COVID-19 patient was in hospital, Mubareka, wearing full PPE, entered his room several times to collect samples from the patient himself and from the air, surfaces and materials around him.
She and her team wanted to start learning everything they could about this new virus and are grateful the patient agreed to help.
“It all happened so quickly,” she said, noting the hospital’s ethics board and legal team were involved in securing consent from the patient. “Within 48 hours, we were in his room collecting samples.
“We wanted to learn about the burden of virus in the room. This has implications for not just how we manage the patient but the environment as well.” Mubareka, who would in March announce she and other Canadian colleagues had isolated the SARS-CoV-2 virus, said looking back on the first patient reveals a “seismic shift” — in the scientific understanding of the disease and in how much her life has changed.
“In retrospect, this patient arrived in Toronto early in this pandemic, within a month of the virus being reported. That is astonishingly quick.”
The patient, who was discharged from hospital one week after being admitted to isolate at home, did not get critically ill with COVID-19 and did not require supplemental oxygen. His wife, the country’s second patient, had a mild case of the disease. Both were followed by Toronto Public Health and remained at home until they tested negative for the virus.
Leis and his colleagues published their experience with Canada’s first case of COVID-19 in a February article in The Lancet. At the time, it was among the few cases describing a mild course of the illness, he said.
“Now we know the vast majority of patients with COVID-19 do not need to be hospitalized, but it was important to learn early on who needed to be hospitalized and who did not,” said Leis. Leis was also a co-author on a CMAJ study that outlined public health efforts to track airplane passengers who sat near the patient and his wife on their flight home to Toronto, and showing no other linked COVID-19 cases.
Leis, who says he’s been running on adrenalin for months, can still clearly remember the around-the-clock efforts of those 48 hours in late January: staff had to care for the patient and ensure other health-care workers and hospital patients were protected.
The provincial and national laboratories had to co-ordinate and triple-check the tests; Leis recalls making many late-night and early-morning calls to Allen at Public Health Ontario before confirming the first positive case.
Results had to be communicated — to the patient, his family, the staff who cared for him — and to public health officials at all levels of government, culminating in a Saturday press conference.
“It felt like weeks went by in a matter of days, so much happened.”
Sunnybrook has since identified more than 400 cases of COVID-19, admitting more than 150 patients with the virus to hospital and more than 50 to critical care, said Leis. But no matter how much time passes — or how many other COVID -19 patients stream through the hospital — Leis said he won’t forget that first patient.
“These are the cases that remind you why you love being an infectious disease physician. We are often engaged in assessing cases that are on the limit of our understanding. A novel pathogen like this is one of the reasons we went into infectious diseases.”
“Looking back, we had no sense that our lives would change at that moment.”
KATHRYN REGO REGISTERED NURSE AT SUNNYBROOK