Hundreds of frightening health alerts pop up worldwide each month. Consider these from last December, the month that ended with the first inkling of what would become the deadly COVID-19 pandemic:

A herdsman infected with the pneumonic plague in Inner Mongolia, the fourth case in a few weeks.

Three hundred cases of cryptosporidium infection in Sweden, causing gastrointestinal and respiratory issues.

An Ebola epidemic in the Democratic Republic of Congo — 3,346 cases as of Dec. 15, 2019, two-thirds of them dead.

And then this one: A “pneumonia of unknown etiology” in Wuhan, China, on Dec. 30.

How does the world determine which one is a call to battle stations? To answer that question, the Star has looked at the system for broadcasting and interpreting alerts, and how it actually played out with COVID-19.

With both the current pandemic, and SARS in the early 2000s, reaction time at each step was slow, the Star found. Even once it was clear there was a problem health leaders — including many in Canada — insisted there was a low risk to Canadians.

Ultimately, says Toronto infectious disease Dr. Michael Gardam (Humber River Hospital’s chief of staff and a veteran of SARS and other outbreaks), common sense and experience needs to play an enormous part in deciding which alert is “the real deal.” When he heard in the early days public health leaders in Canada and at the WHO said there is little evidence of human to human transmission with the novel coronavirus he did not believe it.

“That would have been one hell of an infectious bat to have all those people exposed to it at a wet market,” Gardam says.

Let’s talk about sickness and disease and the planet earth. With a population of 7.6 billion, there is a lot to discuss. It’s a world of travellers, which means that one country’s illness could be another country’s illness very quickly.

There is no official, worldwide system that takes information from governmental health agencies and plugs it into a shared database. Instead, there is a mishmash of systems, some run by volunteers, some by companies, that scan media and social media reports looking for disease outbreaks.

ProMED is the best known. It is run by the 90,000 member International Society for Infectious Diseases, an association of doctors and scientists around the world whose business is disease. Take a look at the ProMED website. On the left side you will find the last few months of alerts. It’s worth looking at. It’s a bit like an old fashioned “listserve” pushing out raw information. Thousands of doctors around the world, including Gardam, receive these ProMED emails everyday.

The Program for Monitoring Emerging Diseases (ProMED) was set up as an early warning system to alert the globe to emerging diseases. It’s the public face of the International Society, a network created in the 1980s. Its stated belief is that diseases cross international boundaries and information is key to stifling outbreaks. In SARS, the first warning was given by ProMED.

There are about 4,000 alerts carried by ProMED Mail every year. They come from ProMED’s scans of media and other sources of information around the world. Sometimes it is an email sent to ProMED by a doctor who notices something (as it was with SARS) but most often it will be a media story based on a localized public health alert. A Toronto based company, BlueDot, does similar work for a growing roster of clients and like ProMED was among the first to sound the initial alarm on COVID-19 on Dec. 30.

Prior to that, as the then-unnamed virus spread in Wuhan, China, only local doctors and health officials were in the know. The information they were developing was kept local. According to information later published in scientific papers, people were showing up in emergency rooms complaining of a pneumonia-like illness. All but one of the initial 27 sick individuals were either workers or visitors to a “wet market” in Wuhan, a sort of farmers market named for the wet floors from melting ice used to keep animal and vegetable produce fresh. The first known patient — this is still a mystery — was a housebound man with Alzheimers who contact tracers determined had no contact with the market.

Wuhan is an enormous city, with a population of 11 million, the most populous city in central china. The Huanan Seafood Wholesale Market is in a central part of a bustling residential district, not far from the banks of the Yangtze River. Throughout December, doctors were treating patients for a variety of symptoms. Some had a dry cough, some had fever, x-rays showed some had pneumonia. Each original patient from December was sick for an average of six days before going to see a doctor, meaning during that time they would have been infecting others, based on what is now known of COVID-19.

While people were showing up for medical treatment by the second week of December, it took until Dec. 29 for a Chinese medical surveillance system set up in the wake of SARS to link four cases in different hospitals as having a “pneumonia of unknown etiology.” Within two days the system had identified more cases. An urgent “symposium” among doctors treating patients was held so that they could pool knowledge. One theory was that SARS had returned after seventeen years.

Late in the evening on Dec. 30, the Wuhan Municipal Health Commisison issued a local release describing an “urgent notice on the treatment of pneumonia of unknown cause.” A Wuhan journalist saw the release and wrote a story on Dec. 31. It was that story that was spotted by ProMED and BlueDot, which scans the Internet in multiple languages. There were 27 cases, seven of them in serious condition, but all with pneumonia symptoms. Antibiotics were not working. Most had fever, some had difficulty breathing. Some were recovering and two would soon be released. There was a connection to the wet market, the story said. Infectious disease experts, including at the Wuhan Centres for Disease Control were being consulted.

“So far, the investigation has not found any obvious human-to-human transmission, and no medical staff infection has been detected. The detection of the pathogen and the investigation of the cause of the infection are ongoing,” a translation of the Wuhan journalist’s story reads.

Around the world that Dec. 31 (and depending on what time zone a person was living in) revellers were either preparing for New Year’s Eve or sleeping off the after affects. Nobody was aware of the gathering storm.

Dr. Gardam in Toronto recalls seeing the email from ProMED.

“I remember looking at that email and going, there’s another one and filing that away for future reference. In no way did it raise the alarm because there are just so many of these things popping up that end up being nothing,” said Gardam.

“Nobody reading that on Dec. 31 would say, ‘Oh my God, it’s coming,” said Gardam. He points out that outside specialists have no access to the data that the Wuhan doctors and Wuhan disease experts are compiling.

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To put that email alert in context, it was sent out in the midst of many other alerts — as is typically the case. Yellow fever in Mali, tuberculosis in Switzerland, a lengthy update issed by the WHO on seasonal influenza cases in the world. There was even a report on ProMED of four cases of Legionnaires disease in Barrie, Ontario.

But what stands out about what became COVID-19 is the word “unknown.” Three weeks (at least, as recent reports suggest the outbreak may have started earlier in November) into the Wuhan outbreak, researchers did not know what was causing it. Most of the other ProMED alerts involve already identified diseases, something that should have attracted more attention.

Gardam, who was deeply involved in battling the Toronto SARS outbreak, and pandemic planning after, said that one reason that the initial alert out of Wuhan was not taken as seriously as in hindsight it should have been is that “novel pathogens” — new bacteria or virus that can cause disease — often pop up and “because it is not well suited to humans it stops.”

Coronaviruses are frequently the culprit and most people will be infected by one coronavirus or another in the course of their lifetime — get a runny nose, sore throat, aches, maybe a fever and then recover nicely. The difference with COVID-19, as is now abundantly clear, is that this particular coronavirus is very well suited to human transmission.

Once the original notice was sent out by ProMED, BlueDot, and then the World Health Organization, the issue was, just how dangerous is this new illness. Would it spread?

Gardam said that what he watched out for was the ensuing updates, which showed more and more cases in the early part of January, including fatalities. It puzzled him to see public health leaders in Canada, in the U.S., and at WHO downplaying concerns. In the middle of January, the WHO said that, based on preliminary work by Chinese medical authorities, there was little or no evidence of “human to human transmission.”

Gardam said that the notion that an infected bat (the assumed culprit) had somehow infected so many people at the market — market workers as well as shoppers — was just not plausible. Although detective work on the genesis of the outbreak continues (media reports range from an infected bat at the market to an infected bat at a Wuhan infectious disease lab that studies coronaviruses in bats), it is generally accepted that the virus jumped from a bat to a human, likely with another animal as an intermediary.

Regardless, Gardam said with so many cases known by early January it was clear to him that no matter the origin case, this was now a case of human to human transmission.

Yet the WHO, in mid-January, said there was no evidence of that transmission. Politicians and public health leaders then took their cue from the agency.

On Jan. 30, both Prime Minister Justin Trudeau and Canada’s top public health doctor Dr. Theresa Tam said the risk to Canadians was “low.”

Gardam’s analogy to what was happening is, “you are standing on the shore you can see the tidal wave coming at you but right now, at this moment on the shore, you are fine — but the tidal wave is coming.” He said it was “disingenuous to say the risk to Canadians is low.” Instead, leaders should have said the situation is likely to change in the next few weeks.

He said there was a “reluctance” to give that message because with it would have come the extreme shutdowns that Canada and the rest of the world ultimately experienced.

Dr. Kamran Khan, the St. Michael’s Hospital doctor who founded BlueDot, told the Star that his company’s disease surveillance network picked up the original alert out of Wuhan and coupled it with “a system that connects outbreaks around the world via commercial air travel.” That helped them determine early which cities (most were cities in Asia) were among the first to receive cases of the new virus based on typical travel from Wuhan.

As to whether the world should have acted more quickly on the original alert, Khan said BlueDot published information about the spreading virus “because we felt it was a credible threat in early January.” However, “everyone’s threshhold to declare battle stations (is) different,” Khan said.

Mario Possamai, who was a senior advisor to the SARS Commission which investigated Ontario’s response to the outbreak, said one only has to look at the overriding statement made by Justice Archie Campbell who in his final report pointed out numerous inadequacies which led to the disease spreading in 2003.

“SARS taught us that we must be ready for the unseen,” Campbell wrote in 2006.

Correction - April 27, 2020: This article was edited from a previous version that mistakenly referred to Prime Minister Justin Trudeau as Prime Minister Pierre Trudeau.

Kevin Donovan is the Star’s chief investigative reporter based in Toronto. He can be reached at 416-312-3503 or via email: kdonovan@thestar.ca

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