The final report into the SARS outbreak that killed 44 people in the Toronto area says those involved in the response failed to ensure the safety of health-care workers.

During two separate SARS outbreaks in 2003, staff at Ontario hospitals continued to become infected for four months, the report states.

In his 1,204-page document titled "Spring of Fear," Justice Archie Campbell suggests the Ontario Ministry of Labour play a lead role in the response to future infectious disease outbreaks in hospitals to ensure workplace safety is given the highest priority.

Campbell said health-care workers would have been better protected if occupational health experts were involved during the virus outbreak.

Forty-five per cent of Ontario's 375 SARS cases were health-care workers. Two nurses and a doctor died from the respiratory illness.

Campbell says hospitals are as dangerous a place to work as mines and factories, but employees in Ontario hospitals don't receive the same level of workplace protection as those in other sectors.

The report says changes made throughout the health-care and the public-health sectors since have made Ontario residents safer, but the province is still not as safe as it should be.

"He's found that although the Ontario government and individual hospitals have taken significant steps to improve our level of protection from infectious outbreaks, serious problems still persist and much remains to be done,'' said Doug Hunt, chief counsel for the commission.

Campbell was ill and unable to attend a news conference Tuesday as the report was released. Instead, Hunt made a statement and fielded questions from the media.

Campbell says the government made a crucial mistake in declaring SARS was over while the virus was still spreading. A second outbreak killed 17 people.

There have been allegations that the quick announcement was designed to minimize the economic fallout, but the report found there was no political interference.

While Campbell says SARS was not preventable, he adds it was a disaster waiting to happen because the province's public health system had been badly neglected by successive governments of various political parties.

Vancouver did a much better job than Toronto in dealing with SARS, the report states.

"He found that this was a result of a combination of Vancouver's better state of preparedness and systemic strengths, along with a certain measure of good fortune in how the case came to the attention of Vancouver authorities,'' Hunt said.

Dr. Donald Low, chief microbiologist at Toronto's Mount Sinai Hospital, told CTV News that the patient who arrived at Vancouver was met at the airport and placed into quarantine after being suspected as a possible avian flu victim.

"In Toronto, the patient that arrived from Hong Kong was somebody that was not recognized as being exposed, was at home and developed the illness at home and spread it to her family members, who then ended up in hospital and that's where we saw the transmission occur," said Low, a key player in the fight against SARS during the scare.

Campbell refused to blame specific individuals, saying all Ontarians are to blame for not demanding better health-care protections.

The final report recommends dozens of changes to hospital practices, disease surveillance and provincial public health and emergency legislation. Campbell says in the event of another outbreak, Ontario should:

  • Use every precaution available, whether scientifically proven or not;
  • Plan and rehearse orderly hospital closures;
  • Develop a system to track patients who leave the hospital; and
  • Place infection control personnel in all hospitals.

Other proposals include more funding for public health, plans to notify all EMS personnel of possible risks and infectious disease training in medical and nursing schools.

Ontario Labour Minister Steve Peters -- whose Liberal government was not in power during the SARS crisis -- said his ministry won't be shut out again during future outbreaks.

"We have learned from what happened with SARS, and the Ministry of Labour, to have seen the ministry shut out in the past, that is not going to happen in the future," he said on Tuesday.

Health Minister George Smitherman was out of the province Tuesday and was unavailable to comment.

The SARS inquiry

Campbell began his inquiry in the wake of the outbreak, which also sickened hundreds of others in 2003 and saw thousands more quarantine themselves in their homes.

Some hospitals also shut down temporarily to avoid spreading the infection.

Two interim reports published in 2005 and 2004 have called for significant changes to Ontario's public health system.

The reports also recommended legislative changes to give the government more control in the event of an emergency.

The province has acted on many of the recommendations, and government officials recently announced plans to create an Ontario agency similar to the U.S. Centers for Disease Control.

When SARS hit, the province declared a public health emergency.

The scare hurt tourism and the economy, particularly in the Toronto area.

The final report is available on the SARS Commission website. The previous reports can also be found there.

The SARS Commission held six days of public hearings in 2003 to give members of the public and all interested organizations an opportunity to speak about their experiences, concerns and recommendations relating to the crisis.

Most of the commission's investigation was carried out through confidential interviews and consultations with experts.

With a report from CTV's Paul Bliss and files from The Canadian Press