12 June 2003 Update 79
  • News briefing after day of intensive meetings by China’s Executive Vice Minister of Health, Mr Gao Qiang, and Dr David Heymann, WHO’s Executive Director for Communicable Diseases. Also in attendance were Dr Qi Ziaoqiu, Director-General of the Department of Disease Control in the Chinese Ministry of Health, and Dr Henk Bekedam, WHO Representative to China.
  • Dr Heymann praised the openness of welcome by Ministry of Health, and described current measures to control and prevent SARS as “excellent”. Saw high level of commitment and determination at all health system levels as largely responsible for dramatic SARS decline throughout mainland China.
  • Indications of effectiveness of control measures include:
    Very short time between onset and detection/isolation.
    Speed and efficiency of contact tracing limiting time available for spread of virus breaking of chain of person-to-person transmission.
    Passive and active surveillance - fever checks train, stations, airports terminals.
    Nationwide mass media campaign to inform and educate.
    Large number of fever clinics.
    Massive effort at self fever monitoring.
  • Among purposes of visit:
    How China achieved rapid decrease in cases.
    Reassurance that control measures adequate to continue downward trends.
    Ensure a sustainable system to detect and contain a resurgence.
    Ensure that the considerable knowledge and experience acquired is shared for the benefit of all countries.
  • Specific concerns include:
    Lack of sustainable surveillance system to detect possible resurgence.
    Some delays in meeting WHO requests for further information.
    Wide variations in application of the national case definitions which can lead to under-reporting.
    Some problems related to prompt sharing and analysis of data considered to arise from institutional and administrative problems, particularly concerning information flow provinces to central level.
    No tracing in large number of cases (in Beijing, increase from 50% to 70%+).
    Strengthening of surveillance capacity since single case can ignite explosive outbreak.
  • Not known at present:
    Until systematic studies of SARS origins enable to predict when conditions might be right for repetition of animal-man leap.
    Possible seasonality of the disease.
  • WHO team now satisfied that measures in place for immediate response to SARS after initial concern expressed during Guangdong Province visit in April.
  • The SARS outbreak has revealed substantial weaknesses in the disease surveillance system in China. When investment in health infrastructure is neglected, conditions are ripe for the unchecked spread of any epidemic-prone disease, often at tremendous cost to a nation’s economy. In the view of WHO, the surveillance system in China needs to be made more flexible and capable of a much more rapid and consistent response to any new infectious disease threat.
  • Chinese officials concerned about capacity to deal with next influenza season due to complication in detection/diagnosis of SARS cases, and increase in caseload of suspect cases.
    11 June 2003 Update 78
    Situation in Toronto
  • Deep concern over 2nd generation cases (90 new probable). Removed from list of areas with recent local transmission on 14 May and re-added on 26 May.
  • All hospital-associated clusters with fever/respiratory symptoms are treated as possible cases and isolated until proven otherwise. Contact tracing/home quarantine where warrented. Infection control measures followed in all affected facilities.
  • Most recently reported is a possible cluster of cases in a hospital east of Toronto. Cautious approach adopted although no clear epidemiological link established. Over the last 3 days, 15 dialysis patients at the Lakeridge Health Centre in Whitby exhibited respiratory and febrile illnesses. Around half now excluded as possible SARS cases with remaining patients closely monitored.
  • Other investigations ongoing and many questions remain unanswered before conclusions reached.
  • Further information on cases exported to other countries is awaited by WHO. Such cases not conclusively documented.
  • One of the most dangerous stages in outbreak evolution particularly in new and poorly understood diseases, is when cases decline and a levelling off of high alert and precautionary measures.
  • Until further knowledge of SARS, Toronto's public health perspective best approach.
    10 June 2003 Update 77
    WHO officials to visit China. Dr David Heymann, Executive Director for Communicable Diseases at WHO, will confer with health officials on current SARS situation in China and discuss future plans. Other team members include Dr Guenael Rodier, Director of Communicable Disease Surveillance and Response, Dr Thomas Grein, coordinator global response operations for SARS.

    WHO's China visit one in a series to confer with health authorities at SARS outbreak sites having the greatest experience to date. Visits include Director-General Dr. Go Harlem Brundtland, visiting Hong Kong SAR later this month, and the Director-General elect, Dr J.W. Lee,

    On the agenda, in collaboration with the Chinese government:

  • The development of a research agenda exploiting evidence uniquely associated with the SARS experience in China.
  • Support requirement assessment to ensure containment and protect against future outbreak.
  • Study of which measures have rapidly brought country's outbreak under control.
  • Measures for sustaining China’s present monumental containment effort particularly as response programmes to priority diseases, such as HIV/AIDS and TB, may suffer in the long run.
  • Discussion on topics such as case definitions, procedures for contact tracing, extent of local transmission in specific areas and reassurance that hospital equipment and supplies for infection control are adequate, especially in the poorer provinces.
  • Weaknesses in the health infrastructure in poorer provinces (of concern since early April WHO assessment team report).
  • Opportunity to strengthen systems for detecting and responding to emerging infectious diseases. such as the next influenza pandemic, see by some as imminent.
  • Initial findings of Guangdong Province (outbreak under control) suggesting lower case fatality ratio, high cure rates, incubation period and groups at highest risk differing from clinical picture elsewhere.
  • Evidence provided hypothesizing jump of SARS to humans from an animal reservoir in first sproadic cases.
  • Attempts to build solid scientific basis for understanding, predicting,and responding to new or reoccurring cases of the disease.

    “SARS is a serious disease with many puzzling features,” said Dr Heymann. “Long-term containment depends on finding answers to a long list of scientific questions. China has much to offer the rest of the world.”

    SARS not showing self containment unlike many new diseases emerging. Success in control due to simple, effective tools – prompt detection, isolation of cases, strict infection control in hospitals, tracing and contact follow-up.

    Viet Nam and Singapore broke the chain of transmission and remains free. However, renewal through importation risk remains.
    9 June 2003 Update 76

  • Situation in China, Taiwan and Hong Kong
  • China. No new probable cases. Since 6 June, only one new probable case.
  • Taiwan. Reported 4 new probable cases, in Taipei outskirts hospital in previously identified contacts of cases. All being isolated and quarantined. Local health authorities and WHO epidemiologists investigating cause of latest hospital cluster.
  • Hong Kong. One new probable case.Since 16 May, 25th consecutive day with number of cases below 5. One SARS death reported today in Hong Kong.
    6 June 2003 Update 75
  • Even as current numbers of probable cases are diminishing, it is important for national authorities where SARS has been brought under control to remain vigilant against hazards of imported cases since one case can spark an outbreak
  • Singapore and Malaysia met to strengthen cross-border SARS containment efforts and agreed that travellers detected with fever at land checkpoints would be isolated and returned, and to provide mutual updating on health screening measures introduced at all checkpoints. Singapore to continue pre-departure screening until regional SARS improvement.
  • WHO has worked with NGOs since apparent that air travel could spread SARS, such as the International Air Transport Association and the International Civil Aviation Organization in promotion of adoption of air travel SARS preventative measures.
  • Singapore’s Changi International Airport to soon be first to implement new International Civil Aviation Organization (ICAO) based on WHO recommendations anti SARS procedures. Changi chosen as test case in part due to initial rapid response, first to use thermal scanners and provision of them to Toronto for exit screening.
  • Changi will receive a certificate if found to be in compliance with ICAO guidelines. A scheme is in preparation to evaluate degree of enforcement of anti-SARS measures, including exit passenger and airport workers screening, distribution of information to passengers, and suspect case handling on board and at destination.
    5 June 2003 Update 74
  • Global decline in cases and deaths continues.
  • Cumulative world total of 8403 probable cases and 775 deaths with 6 new cases Canada(5) Taiwan(1) and 3 new deaths China(2) Hong Kong(1)
  • Hong Kong authorities to maintain border point screening procedures at least one year. Since end of March, procedures include use of infrared temperature scanners and obligatory health declarations. No new imported cases since introduced.
  • About 6% of Hong Kong's cases probably imported with cumulative total of 1748 cases and 284 deaths (second most severely hit area after China).
  • The disease first brought to Hong Kong in late February by medical doctor from Guangdong Province where virus spread to at least 13 guests and visitors, on same floor of hotel where he stayed. Disease then carried to Viet Nam, Singapore, Toronto as well as Hong Kong.
  • Initial outbreaks in hospital settings due to unawareness of new disease and in fight to save lives staff exposed without barrier protection. All of these initial outbreaks characterized by chains of secondary transmission outside the health care setting.
  • Local chains of transmission now only in Toronto and several parts of China. All other countries with imported cases have prevented transmission entirely or have limited to very small numbers of cases.
    4 June 2003 Update 73
  • First day no new SARS deaths since 28 March with cumulative totals then of 1485 cases and 53 deaths. Peak of deaths occurred 2nd week of March with 20 new deaths reported on some days.
    Cumulative world total now 8402 probable SARS cases with 772 deaths from 29 countries. Represents 10 new cases compared with yesterday. New cases: Canada(5) Hong Kong(1) Taiwan(2) Germany(1) USA(1).
  • SARS clearly in decline with outbreaks at all initial “hot zones” contained or coming under control. Indicates recommended control measures effective when combined with political commitment and determination.
  • Chain of transmission broken in Viet Nam (no new cases since 8 April) and Singapore (last locally acquired isolated 11 May) despite no vaccine, robust diagnostic test or specific treatment, and high alert/aggressive investigation all rumoured cases.
  • Control currently depends on prompt detection and isolation of cases, good infection control in hospitals, and the tracing and quarantine of contacts.
  • Risk of resurgence and constant need for vigilance. New cases(70+) in Toronto since 26 May indicates imported case can reignite outbreak if preparedness weak.
  • Germany's new case is man (hospitalized in isolation) who recently returned from Taiwan. Quarantine of around 50 contacts.
    2 June Update 71
    Status of SARS diagnostic tests and role of WHO collaborating network laboratories (CNL)
  • Slow progression of commercial diagnostic test development due in part to certain unusual SARS features making it a difficult scientific challenge. In many viral diseases, virus shedding (causative agent) excreted during the initial phase of illness, posing greatest contamination risk. SARS shedding low initially(detectable immune responses only day 5-6) peaking in specimens around 10 days after onset at which time reliable antibody tests can detect virus. Need tests with high sensitivity.
  • Current tests developed with impressive speed unreliable to detect virus or genetic material in early days when ability to infect others possible. Currently, WHO recommends use of case definitions, based on clinical presentation, distinct chest X-rays, and contact history.
  • Critical biological materials/reagents made available by WHO CNL for diagnostic test development (commercial also). Specimen bank established representing all stages of disease needed to assess test performance with real patient specimens.
  • Division of single specimen allows work in parallel, facilitating comparative performance assessment and also supporting diagnostic test standardization. Specimens made available by Hong Kong DOH and Hospital Authority bank supplied free by a collaborating laboratory to diagnostic test developers.
  • WHO CLN (listed in original) have available standardizing reagents (inactivated virus and blood samples in acute and convalescent stages of illness) for virus and antibody tests allowing uniform assessment of diagnostic results.
  • China has developed highly promising ELISA diagnostic test. For early detection of SARS virus, the PCR molecular test offers the greatest potential under average hospital conditions. The Singapore Genomic Institute has made its PCR test available, at no cost, to support SARS diagnosis in China.
    WHO coordinated training courses in Beijing
  • Training courses supported by test materials and reagents from CNL, aimed at establishing efficient laboratory infrastructure for SARS diagnosis throughout China. Available test training by original development lab representatives (USA, UK, Hong Kong) giving best first-hand experience available.
  • Still concern about remote provinces, despite downturn in number of cases and deaths in China, due to lack of sufficiently strong health infrastructure, surveillance, reporting systems and hospital facilities.
    Worldwide Update
  • Cumulative total of 8384 probable cases and 770 deaths in 29 countries representing an increase of 27 new cases and deaths compared with the last report on Saturday. New deaths in China(2) Hong Kong(4).
    30 May Update 70
    Singapore
  • Singapore removed from list of areas with recent local transmission of SARS effective 31 May (20 days, twice the maximum incubation period, since last locally acquired case placed in isolation). WHO no longer recommends Singapore exit screening international travelers. Vigilance to prevent importation extremely important but due to no local transmission, residents and travelers not at risk.
  • “From the start, Singapore’s handling of its SARS outbreak has been exemplary,” said Dr David Heymann, Executive Director for Communicable Diseases at WHO. “This is an inspiring victory that should make all of us optimistic that SARS can be contained everywhere.”
  • Faced especially difficult challenges. The first cases reported 9 March when SARS not yet recognized easily spread in hospitals. among hospital staff, patients, visitors, and their close family contacts. Later spread when patients without signs of virus were transferred to other hospitals, placed in rooms with other patients, or managed without adequate protective equipment. Further amplified by several so-called “super-spreaders” (defined) among whom was a young woman returning to Singapore from Hong Kong who subsequently infected 23 others.
  • Virus moved into community through infected vegetable hawker at wholesale market. Closing of market, contact tracing, quarantining 400+ persons, limited spread to only 15 other persons.
  • Several public area transmissions in taxis, elevators, and hospital corridors, where exposure may not have been face-to-face contact with infected droplets. This unusual pattern led to expanded policy for contact tracing and home quarantine.
  • Due to extraordinary measures, and adjusting of strategies as each problem emerged, Singapore has identified the source of infection for all but one of the country’s cases. 144 of 206 probable cases linked to contact with only 5 individuals. This is only one of the achievements in an outbreak response consistently characterized by extra precautions and extraordinary determination.
  • Used highly sensitive case definition for investigation/monitoring of virtually every person with possible SARS symptoms regardless of SARS contact. Also Hospital-based surveillance system monitors cases of pneumonia acquired outside the hospital setting.
  • “wide net” approach may help explain why so few cases escaped detection and the onset of symptoms to isolation much shorter in Singapore, reducing further spread. All persons with possible contacts during 10 days before symptom onset were traced to identify infection source. Home quarantine for all in contact with SARS patient from symptom onset to isolation.
  • Local transmission is of greatest concern when a new case cannot be traced to a previous case, or a symptomatic case circulating for several days prior to isolation.
  • Other measures: screening at airport and seaports, concentration of patients in single SARS-designated hospital, no-visitors rule for all public hospitals, and dedicated private ambulance service to transport possible cases to SARS-designated hospital. Military assisted in contact tracing/quarantine.
  • Outbreak management benefited from high-quality laboratory services, including Virology Unit, Singapore General Hospital, member of WHO laboratory network.
  • A measure of effectiveness: 80% of Singapore’s cases did not transmit SARS.
  • Border meeting with Malaysia May 6 to discuss measures for keeping Singapore free of imported cases.
    29 May Update 69
  • China 3 new probable SARS cases (formerly hospitalized suspect cases & all in Beijing). WHO cautiously optimistic outbreaks in mainland China are being brought under control in provinces. WHO teams still investigating implementation of monitoring procedures in the country’s rural areas.
  • Use of air conditioning in public places turned off as preventative measure although WHO has no evidence to date that air-conditioning could play a role in spread. Predominant spread mode is close person-to-person contact with droplets expelled when an infected person coughs or sneezes. However, If negative pressure rooms or independent air supply/exhaust system not available in hospitals, WHO recommends turning off air-conditioning and opening windows to provide ventilation.
  • Shanghai flight screening progressing well, but bus/railway logistically more difficult. Occasionally, numerous temperature checks performed at excessive frequency.
  • Worldwide Update: Cumulative total: 8295 cases with 750 deaths from 28 countries. New deaths: China(2) Hong Kong SAR(3).
    28 May Update 68
    Taiwan
  • Taiwan continues downturn in outbreak reporting 22 genuine new probable cases (13 yesterday) and 5 new deaths. Last week's large numbers in part due to case backlog with onset earlier in week and new reporting procedures.
  • Downturn attributed to improvement in hospital infection control, emergency rooms procedures, use of protective equipment, level of screening to detect/isolating patients promptly, reinforced by island wide standardized infection control procedures. To date, 90%+ of cases linked to hospital setting.
  • Further measures: High-profile public awareness campaigns emphasizing good personal hygiene, frequent temperature checks, prompt reporting of fevers, island-wide phone hotline/call centre with medical staff, about 100 fever clinics(more opened soon) easing overcrowding of ER & reducing contact with possible SARS cases. Implemented soon, programme designed for monitoring/evaluation all SARS-related control activities.
  • WHO confident of continued decline, similar to other outbreak sites.
  • Taiwan to date, cumulative total of 610 probable cases and 81 deaths. Escalated end of April when lapse in a hospital infection control possibly resulted in spreading to new sites upon patient referral. Cumulative cases: May 2(100) May 13(207) May 19(300+) May 21(418) May 23(538)

    Update on cases and countries

  • Cumulative world total: 8240 probable cases, 745 deaths with thirty new cases and 10 deaths compared with yesterday. New deaths occurred in China(4) Hong Kong SAR(1) Taiwan(5).
    27 May Update 67
  • World Health Assembly Geneva (190+ countries) adopt resolution on SARS urging prompt/transparent reporting to WHO and request for help when control measures ineffective.
  • SARS recognized as serious threat to stability/growth of economies, livelihood of populations, functioning of health systems, cause of great human suffering.
  • Lessons learned with SARS relevant to improved preparedness for new diseases, influenza pandemic, possible bioterrorism.
  • Continue updating list of areas with recent local transmission in such a way as to minimize socioeconomic consequences.
  • Applause for Italian delegation praise for dedication of health care workers including several who have died to SARS.
  • Procedures and timetable for revision (completed by 2005) of legal framework global surveillance/reporting.
  • Current regulations grossly inadequate in highly mobile, interdependent world to control 30 new diseases in past 2 decades.
  • New functions: To respond quickly and forcefully to prevent spread of outbreaks and epidemics, assess info from non governmental sources, conduct on-the-spot studies of control measures being taken.
  • Taiwan measures including hospital infection control, contact tracing, info campaign, screening programme, fever clinics beginning to bear fruit and expected to gradually improve situation soon.
  • Cumulative total since beginning: 8221 probable cases
  • Cumulative recovered/deaths:4787 recovered/discharged, 735 deaths
  • New probable cases: 24 including 13 Taiwan
  • New deaths: 10 in China (4), Hong Kong SAR (2), and Taiwan (4).
    26 May Update 66
  • Toronto, Canada added to list of areas with recent local transmission of SARS (previously lifted on May 14) but without recommending any restrictions on travel to Toronto (lifted on April 30) due to new clusters of 26 suspect and 8 probable cases of SARS, until proved otherwise, linked to 4 Toronto hospitals. Results of lab and epidemiological investigations pending. First (index) case transmitted infection in more than one generation of local transmission. placing Toronto in classification (B).
  • History of recent travel to an area with local transmission. Pending development of robust and reliable diagnostic tests, part of case definitions for suspect/probable cases.
  • Local transmission of SARS when a new case cannot be traced back to contact with another case, or turns out to have been a contact of a case but was not placed in isolation. Criteria for removal from the list include no new probable cases for 20 days, which is twice the incubation period (chain of transmission is considered broken and outbreak controlled).
    24 May Update 65
  • Toronto remains off list of areas with recent local transmission until results of two clusters of cases in two hospitals (5 cases) and (26 cases including 10 health care workers) undergoing investigation as possible SARS cases.
  • New deaths occurred in China (5) and Hong Kong SAR (2).
    23 May Update 64
  • Cluster of five cases of possible SARS with no links to probable SARS cases in single hospital in Toronto.
  • Tests of wild animal meat from one market in southern China detected several coronaviruses closely related genetically to SARS coronavirus in 2 animal species, with an additional species eliciting antibodies against the SARS coronavirus. Presently no evidence exists suggesting significant role of wild animal species in the epidemiology of SARS outbreaks. The study provides a first indication that the SARS virus exists outside a human host. Many questions remain. For example:
  • Samples taken from one market only
  • Determination of how widespread virus might be in animals
  • Is amount of excrete virus sufficient to infect humans
  • Investigate possibility of animal-to-animal transmission - presence of virus could result from consumption of infected prey Background New York Times Extended Article
  • Cumulative total of 8117 probable cases (55 new cases with cumulative cases of 538) reported today from Taiwan) with 689 deaths reported from 28 countries. The new deaths occurred in China (3), Hong Kong (2), and Singapore (2).
    23 May Update 63
  • Removal of postponement recommendation first issued 2 April from Hong Kong SAR and Guangdong provence due to significant improvement in situation. However, WHO recommendation (issued 27 March) of screening of all international departing passenger still valid.
  • Hong Kong - Sixty people still infectious (all of whom are in hospital) with other patients still convalescing or treated for other conditions. All new cases in past 20 days already identified as contacts of SARS case. No recent reports of exported cases. Three-day average new cases below five over last six days. Sustained decline since peak in late March.
  • Guangdong province, three-day average of new cases below five for 11 days. SARS patients in hospital fell below 60 on May 20. Due to efforts of provincial health authorities, local transmission has fallen to low levels over recent weeks. No recent reports of international exported cases.
  • Consider postponing of non-essential travel to Beijing, Hebei, Inner Mongolia, Shanxi, Taiwan and Tianjin still in place.
    22 May Update 62
    New deaths occurred in China (4), Hong Kong SA (3), Taiwan (8), and Singapore (1).

    Cumulative total probable cases surpassed 5000 on 28 April, 6000 on 2 May, and 7000 on 8 May.

    Situation in Taiwan Cumulative totals at 483 cases and 60 deaths.
    Large daily increases in new cases may be due to a backlog of cases in "pending" category being classified as suspect or probable. When backlog cleared, a more accurate picture will be given of evolution of outbreak.

    Since first suspect cases, Taiwan has promptly reported to WHO. First two cases, hospitalized 8 March and officially recognized as suspect cases on 14 March - a man with a recent travel history to Guangdong Province and Hong Kong, his wife with no recent travel history. U.S. CDC team organized by WHO’s Global Outbreak Alert and Response Network, arrived 16 March.

    By 18 April 29 cases reported (all identified, through contact tracing or travel history), as either imported cases, cases in persons with recent travel to areas with local transmission, family members, or close contacts of patients. By end of April - increases in new cases when majority due to local transmission in hospitals. Probable cases reached 100 on 2 May, 207 on 13 May, and now stands at 483. Taiwan received supplementary protective equipment from Thailand. WHO (Geneva) sending 2 additional staff.

    Transmission during flights. The number of flights during which transmission may have occurred remains at four. The total number of cases resulting from exposure during these four flights revised to 27. One flight alone CA112, Hong Kong to Beijing (15 March) accounts for 22 of the 27 cases.

    WHO is aware of an additional 31 flights with symptomatic probable SARS cases on board. No evidence indicates that in-flight transmission occurred on any of these flights. No flights have been implicated in the transmission of SARS after 23 March 2003. Complete data on seating for all cases obtained. On one flight, persons sitting seven rows in front and five row behind a person with SARS developed disease. WHO is aware of four flight attendants, of which two were on the CA112 flight, who have become infected.

    Joint team report Henan Province. “Community-based surveillance and control methods seem to be an important contributor to the apparently low levels of SARS infection in China’s rural countryside,” Dr. James Maguire says. Full report will soon be released.

    Dr Maguire says that road, train, bus checkpoints on ID cards and body temperatures seem to be effective in controlling spread. “The fear of the disease is widespread. Combined with community surveillance and social and legal pressure, people are cooperating,” he says.

    Henan officials said around 1.4 million workers returned to province during holiday period around May 1. Many from areas with higher rates of SARS infection. At the checkpoints from 26 April to 15 May 12,028 people were feverish and 955 had a cough and were referred to “fever clinics” – single room isolation for further assessment. Nine cases confirmed with SARS and 8 suspected.

    Henan (as of May 22) - 15 probable cases, including 1 health worker and 6 suspected.

    Usually, returning workers from affected areas must stay under house quarantine for 15 days, staying apart from their family in a single room. Dr Maguire says to help with farming work, some local governments are offering financial assistance to have hired workers perform the necessary fieldwork or grants to enable people to buy farm machinery to lower the demand for human farm labour.

    “The screening at checkpoints and quarantining may seem like hitting a fly with a hammer, but they seem to be working,” Dr Maguire says. “Combined with the extreme social pressure brought on by the fear of SARS, China might have hit on a way to fight the spread of the disease.”