Border screening for SARS.With the rapid international spread of severe acute respiratory syndrome Severe Acute Respiratory Syndrome (SARS) Definition Severe acute respiratory syndrome (SARS) is the first emergent and highly transmissible viral disease to appear during the twenty-first century. (SARS) from March through May 2003, Canada introduced various measures to screen airplane airplane, aeroplane, or aircraft, heavier-than-air vehicle, mechanically driven and fitted with fixed wings that support it in flight through the dynamic action of the air. passengers at selected airports for symptoms and signs of SARS. The World Health Organization requested that all affected areas screen departing passengers for SARS symptoms. In spite of intensive screening, no SARS cases were detected. SARS has an extremely low prevalence, and the positive predictive value Positive predictive value (PPV) The probability that a person with a positive test result has, or will get, the disease. Mentioned in: Genetic Testing positive predictive value of screening is essentially zero. Canadian screening results raise questions about the effectiveness of available screening measures for SARS at international borders. ********** The first cases off severe acute respiratory syndrome (SARS) in Canada were recognized almost simultaneously in Vancouver and Toronto. in Toronto, the index case was diagnosed on March 13, 2003, when a cluster of SARS cases was identified and traced back to a traveler from Hong Kong Hong Kong (hŏng kŏng), Mandarin Xianggang, special administrative region of China, formerly a British crown colony (2005 est. pop. 6,899,000), land area 422 sq mi (1,092 sq km), adjacent to Guangdong prov. , who arrived in Canada on February 23, 2003 (1). Two epidemic waves of SARS occurred in Toronto (2), which resulted in a national total of 251 probable cases with 43 deaths. In the period that followed the initial reports of this new syndrome from Hong Kong and Vietnam, the disease spread rapidly to other cotintries by international airline travelers. On March 12, 2003, the World Health Organization (WHO) issued a global health alert (3) in response to the clusters of SARS in the Hong Kong Special Administrative Region A special administrative region may be:
2. The law requires a man who has a claim to enforce it in proper time, while the adverse party has it in his power to defend himself; and if by his neglect to do so, he cannot afterwards establish such claim, the to recognize and report suspected cases of SARS. Subsequently, on March 15, 2003, WHO issued the first of several international travel advisories that identified major locations where SARS transmission was substantial and ongoing and advised international travelers about travel to affected areas. On March 27, 2003, WHO recommended that affected areas begin screening departing airline passengers for symptoms suggestive of suggestive of Decision making adjective Referring to a pattern by LM or imaging, that the interpreter associates with a particular–usually malignant lesion. See Aunt Millie approach, Defensive medicine. SARS. Health Canada Health Canada (French: Santé Canada) is the department of the government of Canada with responsibility for national public health. Health Canada's goal is to improve Canadian life by improving Canadian longevity, lifestyle and use of public healthcare. monitored the spread of this new syndrome through the WHO-Health Canada Global Public Health Intelligence Network The Global Public Health Intelligence Network (GPHIN) is an electronic public health early warning system developed by Canada's Public Health Agency, and is part of the World Health Organization's (WHO) Global Outbreak and Alert Response Network (GOARN). and regular communications with other international and Canadian provincial and territorial public health agencies. As soon as the rapid, international spread of SARS became evident and after SARS was imported into Canada, Health Canada undertook a variety of measures designed to limit importation and exportation of disease and the spread of the disease within Canada. We describe the measures taken to mitigate the spread of SARS and provide data on the effectiveness of these measures. Methods Health Canada used a graduated, phased response to additional imported SARS cases. The response consisted of an information phase (March 18-May 14, 2003), a screening phase (May 14-July 5, 2003), and a special measures Special measures is a status applied by Ofsted, the schools inspection agency, to schools in England when it considers that they fail to supply an acceptable level of education and appear to lack the leadership capacity necessary to secure improvements. phase (March 13-July 5, 2003). Information Phase To mitigate the risk of importing SARS cases from other internationally affected areas, Health Canada distributed passenger health alert notices (HANs) for incoming passengers from affected areas in Southeast Asia Southeast Asia, region of Asia (1990 est. pop. 442,500,000), c.1,740,000 sq mi (4,506,600 sq km), bounded roughly by the Indian subcontinent on the west, China on the north, and the Pacific Ocean on the east. on March 18, 2003. On arrival, posters directed passengers to pick up health information about symptoms and signs of SARS and advised them to consult a physician if a SARS-like illness developed after their arrival in Canada. This information was printed in several languages on conspicuous, yellow, 8 1/2" x 11" paper (referred to as "yellow cards") and contained key telephone numbers. The initial posters and yellow HANs were placed at arrival sites in the Vancouver International Airport Vancouver International Airport (IATA: YVR, ICAO: CYVR) is located on Sea Island in Richmond, British Columbia, Canada, about 15 kilometres from downtown Vancouver. and Toronto's Pearson International Airport. They were quickly made available in 12 other airports that received international passengers who might have traveled from the Far East. HANs were provided to inbound in·bound 1 adj. Bound inward; incoming: inbound commuter traffic. Adj. 1. inbound passengers at 18 land border crossings between the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. and Canada. No record was kept of how many passengers picked up HANs. With the advent of SARS transmission in Toronto, Health Canada implemented similar HANs in a different color (cherry) to mitigate the risk of exporting SARS cases. The cherry-colored HANs were distributed to persons departing for international destinations from Toronto's Pearson International Airport. Passengers with symptoms or signs of SARS were asked to self-defer their travel. In these instances, Health Canada requested airlines to waive To intentionally or voluntarily relinquish a known right or engage in conduct warranting an inference that a right has been surrendered. For example, an individual is said to waive the right to bring a tort action when he or she renounces the remedy provided by law for such their policies on nonrefundable tickets, and while many did so, the refund and rescheduling policies and conditions were not uniform. Screening Phase Because of the continuing outbreak in Toronto, domestic spread in other affected countries in Southeast Asia, and international spread to other countries, Health Canada intensified in·ten·si·fy v. in·ten·si·fied, in·ten·si·fy·ing, in·ten·si·fies v.tr. 1. To make intense or more intense: its initial response by instituting both inbound and outbound out·bound adj. Outward bound; headed away: outbound trains. Adj. 1. outbound - that is going out or leaving; "the departing train"; "an outward journey"; "outward-bound ships" passenger screening to identify persons with symptoms or signs compatible with SARS. All passengers were now required to obtain, read, and respond to questions on yellow or cherry HANs. Three questions were added to both HANs: Do you have a fever? Do you have one or more of the following symptoms: cough, shortness of breath Shortness of Breath Definition Shortness of breath, or dyspnea, is a feeling of difficult or labored breathing that is out of proportion to the patient's level of physical activity. , difficulty breathing? Have you been in contact with a SARS-affected person in the last 10 days? All passengers were required to circle "yes" or "no" responses. Their responses were verified either by customs officials (for inbound passengers) or by airline check-in agents (for departing passengers from Toronto Pearson Airport Pearson Airport may refer to:
v. pre·scribed, pre·scrib·ing, pre·scribes v.tr. 1. To set down as a rule or guide; enjoin. See Synonyms at dictate. 2. To order the use of (a medicine or other treatment). procedures) were instituted to ensure compliance by those responsible for verifying passenger responses. For example, during a 1-week period, 82% of departing passengers received a cherry card at check in, and 73% were questioned about their responses by the check-in ticket agent. Secondary screening procedures were established for all passengers who answered yes to any of the questions. It was mandatory for any such passenger to be referred to a screening nurse who administered a standard in-depth questionnaire and protocol. The secondary screening protocol included reasons for assessment, symptoms present at time of assessment, oral temperature, and defined criteria for disposition. On the basis of the responses elicited e·lic·it tr.v. e·lic·it·ed, e·lic·it·ing, e·lic·its 1. a. To bring or draw out (something latent); educe. b. To arrive at (a truth, for example) by logic. 2. in the protocol, a passenger was released or referred to a predetermined pre·de·ter·mine v. pre·de·ter·mined, pre·de·ter·min·ing, pre·de·ter·mines v.tr. 1. To determine, decide, or establish in advance: hospital for an in-depth medical evaluation. In parallel to these measures, Health Canada initiated a pilot study on May 8, 2003, on the use of infrared thermal scanning machines to detect temperatures >38[degrees]C in selected international arriving and departing passengers at Vancouver's International and Toronto's Pearson International airports. Thermal scanning complemented other measures in the overall screening process by helping to triage triage Division of patients for priority of care, usually into three categories: those who will not survive even with treatment; those who will survive without treatment; and those whose survival depends on treatment. the large volume of passengers who transit airports. Any passenger with an elevated temperature reading was referred to the screening nurse for confirmation, completion of the screening protocol, and referral to hospital, if necessary. Special Measures Passenger Contact Tracing In epidemiology, contact tracing is the identification and diagnosis of persons who may have come into contact with an infected person. For sexually transmitted diseases, this is generally limited to sexual partners but for highly virulent diseases such as Ebola and tuberculosis, a With previous documentation of transmission of tuberculosis tuberculosis (TB), contagious, wasting disease caused by any of several mycobacteria. The most common form of the disease is tuberculosis of the lungs (pulmonary consumption, or phthisis), but the intestines, bones and joints, the skin, and the genitourinary, on long flights (4,5), Health Canada initiated passenger contact tracing to identify any secondary transmission associated with air travel. Health Canada's protocols for airplane passenger contact tracing evolved throughout the SARS outbreak and were updated as new information became available. From March 13 to March 21, 2003, contact tracing of passengers included follow-up of passengers seated in the same row, 2 rows in front, and 2 rows behind someone with a probable case who was symptomatic symptomatic /symp·to·mat·ic/ (simp?to-mat´ik) 1. pertaining to or of the nature of a symptom. 2. indicative (of a particular disease or disorder). 3. while in flight. As of March 22, airplane passenger contact tracing was expanded to include persons with suspected cases who were symptomatic while in flight. As of March 31, contact tracing was expanded again to include all passengers on a given flight with a probable or suspected case who were symptomatic while in flight (6). Because of the lack of internationally accepted standards for developing and retaining passenger manifests, Health Canada personnel encountered excessive delays in obtaining the manifests from various airlines. In response, Health Canada initiated a traveler contact information form that collected location information and that all inbound passengers were required to complete before arrival. Upon landing, all forms were collected from passengers by Health Canada personnel and retained for possible contact tracing if a case was subsequently identified. The traveler contact information form reduced the time for securing the manifest from weeks to 2 days. All screening measures (HANs, thermal screening, and traveler contact information form) continued after July 5, 2003, when WHO declared that SARS outbreaks had been contained worldwide. This report only includes data up to that date, when international movement of SARS was a real possibility. Results No attempt was made to evaluate the initial information phase. Data were collected for the screening phase. Table 1 summarizes the screening results for inbound and outbound HAN screening measures. As of July 5, 2003, a total of 1,172,986 persons received either yellow or cherry HANs. A total of 2,889 persons answered yes to at least 1 screening question on the HAN and were referred to secondary screening according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. protocol. None of the 411 outbound passengers who were referred for secondary screening in Toronto were asked to defer de·fer 1 v. de·ferred, de·fer·ring, de·fers v.tr. 1. To put off; postpone. 2. To postpone the induction of (one eligible for the military draft). v.intr. their travel. All persons were cleared, and none were referred for additional medical examination. In addition, 763,082 persons (467,870 inbound and 295,212 outbound) were screened by the thermal scanners (Table 2). Only 191 persons had an initial temperature reading >38[degrees]C and were referred for secondary evaluation. No data were collected systematically to correlate thermal scanner results with results of temperature taking by secondary screening nurses. Some of the persons arriving or departing Toronto and Vancouver airports were screened by both HAN and thermal scanning measures. During this period, no screening measure put in place by Health Canada detected any cases of SARS at border entry points. Careful analysis of the travel histories of suspected and probable SARS patients who traveled to Canada showed that persons became ill after arrival and would not have been detected by airport screening measures. Table 3 summarizes the travel histories of persons departing Canada whose illnesses were subsequently diagnosed as SARS-like illness. Health Canada collaborated with many international public health authorities to document travel and illness histories of possible SARS patients who departed Canada and whose illneses were diagnosed and reported internationally (7-9). Health Canada investigated >40 such reports, of which 11 are now attributed to Canada (10). In all but 2 cases (cases 2 and 11), onset of illness occurred after departure from Canada. Of these 11 persons who traveled from Canada, all met the WHO probable SARS case definition. Only 3 of these case-patients met the Canadian probable case definition. Another 3 case-patients would meet the Canadian geo-linked case definition; 1 case met the Canadian "person under investigation" category; and 4 case-patients did not meet any Canadian SARS case definition. Of the 3 case-patients who did meet the Canadian definition, none would have been detected by exit screening. Only 2 (patients 2 and 11) of the 11 persons had symptoms at the time of travel, but both would have been cleared by the criteria established in the secondary screening protocol. We identified 18 symptomatic probable or suspected SARS patients on 29 flights (10 patients traveled on [greater than or equal to]2 flights). No documented transmission was identified. Detailed results of Canada's airplane passenger contact tracing can be found elsewhere (6). Discussion Patterns of international travel continue to increase in complexity and volume. In Canada, >18 million persons enter annually by air; 91% arrive at 6 international airports. Similarly, a large number depart from several international airports. Additionally, because of an open land border with the United States, [approximately equal to]100 million persons cross the land border in both directions annually. With travel to Canada from anywhere in the world taking <24 hours, the possibility of detecting a dangerous infectious disease Infectious disease A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. at border points of entry is challenging. Given the relatively short travel time, detecting persons at the border who are incubating any of the known infectious disease pathogens is unlikely. The absence of symptoms or signs of infection and a corresponding lack of specific, extremely rapid, easy-to-use diagnostic tests make border detection of infectious diseases infectious diseases: see communicable diseases. unlikely. The effectiveness of screening measures for detecting SARS cases at border points of entry was limited by 2 factors. First, screening measures themselves, i.e., HAN questionnaires and thermal scanning machines, were nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik) 1. not due to any single known cause. 2. not directed against a particular agent, but rather having a general effect. nonspecific 1. for SARS. Second, the prevalence of SARS among international passengers arriving or departing from Canada was low. For example, 5 SARS patients entered Canada from March through May. None of these patients had signs or symptoms during transit through airports. If the same rate of entry were to continue for 1 year, then 20 cases might be expected among the 18 million persons entering the country annually, for a prevalence of [approximately equal to]1.1 SARS cases per 1 million passengers. For such a rare disease, the positive predictive value of a positive screening result is essentially zero. The results demonstrate that available screening measures are not effective for detecting SARS. Despite extending screening measures to all arriving air passengers, no SARS cases were identified. These findings raise questions about whether such measures are effective tools for detecting and controlling the spread of SARS, and whether, from a public health point of view, other, more effective, strategies might exist. Instituting infectious disease screening procedures at border points of entry could have advantages. For example, easily visible measures, such as thermal scanning machines, may generate a sense of confidence or reassurance REASSURANCE. When an insurer is desirous of lessening his liability, he may procure some other insurer to insure him from loss, for the insurance he has made this is called reassurance. that disease will be detected and prevented from entering the country. No data are available to assess whether or not the measures implemented at the airports actually generated confidence or reassurance in the public. Given the poor positive predictive value of available SARS screening measures, any sense of reassurance might be quickly dispelled when the first case is detected in spite of screening measures. We conclude that available screening measures for SARS were limited in their effectiveness in detecting SARS among inbound or outbound passengers from SARS-affected areas. We suggest that in-country, acute-care facilities (hospitals, clinics, and physicians' offices) are the de facto [Latin, In fact.] In fact, in deed, actually. This phrase is used to characterize an officer, a government, a past action, or a state of affairs that must be accepted for all practical purposes, but is illegal or illegitimate. point of entry into the healthcare system for travelers with serious infectious diseases. If a visitor or returning citizen becomes ill after arriving in Canada, he or she will likely seek medical care in clinics or emergency rooms. Acute-care facilities must consider travel histories of all patients with suspected infectious diseases and implement standard precautions precautions Infectious disease The constellation of activities intended to minimize exposure to an infectious agent; precautions imply that the isolation of an infected Pt is optional, but not mandatory. and infection control measures. An estimated Can$7.55 million was invested in airport screening measures from March 18 to July 5. Rather than investing in airport screening measures to detect rare infectious diseases, investments should be used to strengthen screening and infection control capacities at points of entry into the healthcare system. Additional useful measures could focus on public education about infectious disease prevention and care.
Table 1. Air passenger screening results for HAN * given
to passengers on outbound and inbound flights,
May 14-July 5, 2003
Cumulative results
Persons Persons
given HAN referred
Measure Location (n) (n)
HAN Toronto 495,492 411
outbound
HAN Toronto 349,754 1,264
inbound
Vancouver 115,227 669
Other 212,513 545
Total 1,172,986 2,889
Cumulative results
Final
Measure disposition Comment
HAN All cleared All international
outbound flights departing
from Toronto
required to use
cherry-colored HAN
HAN All cleared All international
inbound flights arriving in
All cleared Toronto (70+
airlines) and
All cleared Vancouver (100+
airlines) required
to use yellow-colored
HAN
Total All cleared
* HAN, health alert
notice.
Table 2. Aipassenger screimaging sc16-July 5, 2003
Cumulative
results
Persons Persons
scanned referred
Location Measure (n) (n)
Toronto Inbound 355,532 83
Outbound 281,959 94
Subtotal 637,491 177
Inbound 112,338 12
Vancouver Outbound 13,253 2
Subtotal 125,591 14
Total 763,082 191
Cumulative
results
Final
Location disposition
Toronto All cleared
All cleared
All cleared
All cleared
Vancouver All cleared
All cleared
Total All cleared
Table 3. Travel histories of persons departing from Canada in
whom a SARS-like illness was subsequently diagnosed *
Depart Probable
Case date, Onset of SARS
no. Age Sex Toronto illness ([dagger])
1 3 F March 28 March 31 Yes
2 5 M March 28 March 25 Yes
3 1 M March 28 April 1 Yes
4 26 F March 31 April 3 Yes
5 52 M April 1 April 3 Yes
6 46 F April 3 April 6 Yes
7 24 M April 28 April 30 Yes
8 28 F April 24 May 3 Yes
9 29 M May 10 May 13 Yes
10 47 M May 17 May 24 Yes
11 25 M July 14 July 7 Yes
Link
Case ([double
no. dagger]) Remarks
1 No PCR negative for SARS-CoV
2 No No evidence of pneumonia,
PCR negative for SARS-CoV
3 No No evidence of pneumonia,
PCR negative for SARS-CoV
4 No PCR and serologic test results
negative for SAR-CoV
5 Yes Traveled by car, PCR and serologic
test results positive for SARS-CoV
6 Yes Fatal SARS case
7 No Serologic and PCR test results
negative for SARS-CoV
8 No No laboratory results available
9 No Traveled by car, PCR negative and
acute serologic
test results negative for SARS-CoV
(convalescent-phase
serologic test results not available)
10 Yes Acute-phase serologic test results
positive for SARS-CoV
11 No Laboratory results unavailable
* SARS, severe acute respiratory syndrome; F, female,
M. male; SARS-CoV, SARS-associated coronavirus; PCR,
polymerase chain reaction.
([dagger]) Met the World Health Organization probable SARS case
definition at time of illness.
([double dagger]) Is an epidemiologic link to
another SARS case established?
Acknowledgments We acknowledge the contribution of many Canadian government-employed quarantine quarantine (kwŏr`əntēn), isolation of persons, animals, places, and effects that carry or are suspected of harboring communicable disease. officers, customs officers customs officer n → aduanero/a, funcionario/a de aduanas customs officer customs n → douanier m customs officer , screening nurses, thermal scanner operators, data collection clerks, and their managers and colleagues, who worked diligently dil·i·gent adj. Marked by persevering, painstaking effort. See Synonyms at busy. [Middle English, from Old French, from Latin d at the border points of entry to implement various screening measures. All funding for deployed screening measures was provided by the Government of Canada The Government of Canada is the federal government of Canada. The powers and structure of the federal government are set out in the Constitution of Canada. In modern Canadian use, the term "government" (or "federal government") refers broadly to the cabinet of the day and based on policy decisions made by the Department of Health. Dr. St. John is director general of the Centre for Emergency Preparedness pre·par·ed·ness n. The state of being prepared, especially military readiness for combat. Noun 1. preparedness - the state of having been made ready or prepared for use or action (especially military action); "putting them and Response, Public Health Agency of Canada The Public Health Agency of Canada (French: Agence de la santé publique du Canada) is an agency of Health Canada a department of the Government of Canada that is responsible for public health, emergency preparedness, and response and infectious and chronic disease control . His primary interests include infectious disease prevention and control and emergency preparedness and response. References (1.) Poutanen SM, Low DE, Henry B, Finklestein S, Rose D, Green K, et al. Identification of severe acute respiratory syndrome in Canada. N Engl J Med. 2003;348:1995-2005. (2.) Health Canada Centre for Infectious Disease Prevention and Control. Update: severe acute respiratory syndrome--Toronto. Canadian Communicable Disease communicable disease n. A disease that is transmitted through direct contact with an infected individual or indirectly through a vector. Also called contagious disease. Reports. 2003;29-13. (3.) World Health Organization. WHO issues a global alert about cases of atypical pneumonia atypical pneumonia n. See primary atypical pneumonia. atypical pneumonia Chest medicine A clinically 'atypical' form of pneumonia, which lacks the classic signs and Sx of pneumonia Types Chlamydia pneumonia, . Press release on the Internet. 2003 March 12 [cited 2003 Mar 12]. Available from http://www.who.int/csr/ don/2003_03_12/en/ (4.) Kenyon T, Valway S, Ihle W, Onorato I, Castro K. Transmission of multidrug-resistant Mycobacterium tuberculosis Mycobacterium tuberculosis n. Tubercic bacillus. Mycobacterium tuberculosis during a long aeroplane flight. N Engl J Med. 1996;334:933-8. (5.) Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. . Exposure to passengers and flight crew to Mycobacterium tuberculosis on commercial aircraft, 1992-1995. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morb Mortal Wkly Rep. 1995;44:137-40. (6.) Flint J, Burton S, Macey JF, Deeks SL, Tam TWS TWS The Wildlife Society (founded in 1937) TWS The Wilderness Society TWS The Weekly Standard (political magazine) TWS Thermal Weapon Sight TWS Texas World Speedway TWS Tsunami Warning System , King A, et al. Assessment of in-flight transmission of SARS-results of contact tracing, Canada. Canadian Communicable Disease Reports. 2003:29:105-10. (7.) Centers for Disease Control and Prevention. Update: severe acute respiratory syndrome-United States, 2003. MMWR Morb Mortal Wkly Rep. 2003:52:357-60. (8.) World Health Organization. SARS outbreak in the Philippines. Wkly Epidemiol Rec. 2003;78:189-92. (9.) Nuorti P, Kotilainen P, Lappalainen M. Travel associated probable case of SARS, Finland, with commentary from Health Canada. Eurosurveillance Weekly [serial on the Interact]. 2003:7(22). [cited 2003 October 17]. Available from http://www.eurosurveillance.org/ ew/2003/030529.asp (10.) Health Canada. SARS epidemiologic ep·i·de·mi·ol·o·gy n. The branch of medicine that deals with the study of the causes, distribution, and control of disease in populations. [Medieval Latin epid summaries: April 26, 2003. Summary of SARS cases potentially exposed in Canada and diagnosed internationally [monograph mon·o·graph n. A scholarly piece of writing of essay or book length on a specific, often limited subject. tr.v. mon·o·graphed, mon·o·graph·ing, mon·o·graphs To write a monograph on. on the Internet.]. 2003 [cited 2003 October 17]. Available from http://www.hc sc.gc.ca/pphb dgspsp/sars sras/pef dep/sars cs int20030426_e.html Ronald K. St. John, * Arlene King,* Dick de Jong De Jong is the most common Dutch surname. Many people bear this name, including many important historical figures. Some of these people are mentioned below. De Jong may mean:
* Public Health Agency, Ottawa, Ontario, Canada Address for correspondence: R.K. St. John, Centre for Emergency Preparedness and Response, Health Canada, 100 Colonnade colonnade (kŏlənād`), a row of columns usually supporting a roof. Colonnades were popular with the Greeks and Romans, who employed them in the stoa and the portico; they have continued to be used throughout the Middle Ages, the Rd, Ottawa, Ontario K1A0K9, Canada; fax: 613-952-8189; email: rstjohn@hcsc.gc.ca |
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