Perspective on SARS epidemic worldwide

Main Conclusions
Causes of Inaccuracy
WHO Daily Text 19 Jun
SARS data 16 Jun
Interp HH tables
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plus internal data selected countries

  • SARS: Status
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    News on SARS
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    1 English Radio site posted by DS and PRC sites posted by DC on SARS Watch™ Org

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    Why This Page on SARS

    Last Updated: September 2005   Last Link Check: 23 May 2006

    This page was started in order to allay some of the panic about SARS and better understand the phenomonon by concentrating on:

  • Main Conclusions from Looking at the Data (
  • Causes of Inaccurate Reporting of Death ( Its focus and conclusions are all the more valid today since the end of the outbreak and any potential future outbreak.
    Recent History
  • WHO Latest Updates as of September 14 05
  • WHO New Guidlines on SARS October 2004
  • May 18 1004 Outbreak contained. See persons diagnosed with SARS apr 30 2004 for details.
  • WHO Summary of cases as of Apr 30 2004.
  • Apr 2004 Potential SARS cases WHO 23-26 April 2004, two individuals confirmed with SARS by Chinese authorities - a Chinese National Institute of Virology student researcher ingaged in SARS investigation, and the nurse treating her. Mother of student, became ill and died (only death). Several others, all in direct contact with initial cases, under investigation. WHO waiting independent confirmation by external reference lab as established procedure during previous outbreak.
  • WHO report 16 September 2003 Singapore medical researcher age 28 confirmed with SARS coronavirus infection. Not regarded as public health concern. Case mild, isolated and no secondary cases.
  • July 5 2003 - SARS epidemic officially over according to WHO.
  • For latest WHO updates   For Main Points Previous WHO Updates

    The main conclusions from looking at the data

  • Most countries had very few recorded cases.
    Most of the countries ever reporting probable SARS cases had very few cases which either spontaneously recovered or had no further transmission of the disease over the quarantine period.
  • Few chains of local transmission.
    Most countries did not show current local chains of transmission. For instance, "...of the 54 probable SARS cases in the United States...all but 2 [medical worker and family member] had traveled to countries where the outbreak has been most severe..." New York Times May 5 John M. Broder. Also see CDC MMWR May 16
  • SARS spread very slowly.
    The rate of spread was slow and mainly very localized (medical personal, family members).
  • Recovery without spreading.
    Many countries having had probable SARS cases all recovered without further spreading.
  • Majority of deaths due to prior medical conditions or late treatment.
    Hong Kong Department of Health SARS Bulletin 20 May Of the fatalities, "70.5% of the deceased patients had pre-existing medical illnesses, such as hypertension, heart diseases, diabetes mellitus and stroke. 62.2% of the deceased were aged 65 or above. Taking into account both of these factors, 78.1% had either pre-existing illnesses or were aged 65 or above, or both." See interpretation of previous figures/charts Hong Kong
  • Many of the deaths may not be caused by virus
    Many of the deaths may have been due to other medical complications, or arising from the treatment itself. For instance, Taiwan adjusted its recorded death figures from 180 down to 37 due to a new study which indicated that many of the deaths recorded were not the result of SARS. Global mortality figures were duly adjusted by WHO to 774 down from 916. [Associated Press - New York Times 5October03]
  • Over reporting of fatalities.
    There are many causes of over reporting as well as under reporting of deaths. For over reporting, see below Causes of inaccurate reporting of deaths.
  • Direct contact - mainly medical workers, family or small communal groups.
    Most of the cases investigated appear to have been due to direct contact with the person ill - in many cases, staff and workers in hospitals, or very close communal or family groupings reducing the possibility that airborne transmission is involved to any degree. Hong Kong
  • Small cycles over time.
    Worldwide and country by country cases by date of onset over time appear to be in small cycles and not increasingly larger numbers spreading out. Last major peak worldwide was in late March. See worldwide epidemic curves by date of onset and not date of reporting.
  • Spontaneous recovery.
    There was spontaneous recovery (in some cases not so spontaneous) for most individuals (90-95%)2.
  • No medicine, vaccine, standardized test.
    To date, there is no universally accepted medicine which is helpful against the virus, there is no vaccine, further identification tests have not been completed. And yet most of the cases recover, there does not appear to be relapses, spread of the virus is extremely slow, and accurate identification of the virus would probably reduce the fatality rate significantly by increasing the population of those who have the virus but show few signs and had spontaneously recovery

    2 this figure has been calculated differently depending on the base used. The base here is the total reported probable cases to date. Arguments of how derived Rates have been based on the number of deaths divided by the total number of accumulated cases. It has been argued that the rate should be based on the same cohort of cases meaning those recovered + deaths to date. However, a truer reflection would be obtained by adding those in convalescence to the base since the death rate should be very low in this group.

    Causes of inaccurate reporting of deaths

    What must be taken into account in assessing the true number of deaths

    When the number of deaths is very small as is currently the case with SARS worldwide, it is imperative not to give an inaccurate picture. Such inaccuracies can lead to severe measures being taken either to stem the tide of the disease, sway world opinion for economic or political reasons, to convince political leaders that the proper measures are being taken, or due to genuine fear and concern when in fact the true picture would lead to a different set of containment and treatment policies. This can be done by taking the following into consideration in the reporting process. Some of these factors can not be determined accurately but others can and must be taken into account in order to provide an accurate base from which to calculate percentages.

    Note: This is particularly important for the first four on the list as these may have a substantial effect on the numbers of deaths when overall numbers are not large.

    Causes of over reporting of death from SARS - initial listing

  • Treatment side effects
    Death due to the side effects of drugs, or other care should be weighed carefully before lumping together with other SARS deaths. SARS Watch links to an article published in The Standard (no longer available on line) which gives reports on the possible effect of the drug cocktail used in the treatment of the disease. "Secretary for Health, Welfare and Food Yeoh Eng-kiong said yesterday medical experts were now examining whether the drug cocktail of ribavirin and steroids was responsible for some of the coronavirus pneumonia deaths in Hong Kong."

    The side effects can be most easily seen in the effects of treatment on different age groups. Side effects may be greater for older individuals causing death due to damage to organs or other side effects occasioned by the treatment modalities.

  • Time lapses
    Time lapses or partial reporting can produce large increases or drops when finally reported thus creating the instituting or withdrawal of protective measures not commensurate with the severity of the situation.
  • Inadequate reporting facilities or procedures
    When it is difficult to report new cases or deaths, many cases will go unrecorded.
  • No centralized collection
    No centralized or regional collection means that incomplete national figures cause wide discrepancies in the statistical view of the situation, or lead to inflated figures when finally reported.
  • Age graded mortality rate
    The normal age graded mortality rate should also be a factor in assessing the mortality rate due to SARS particularly in older ages where the disease may not be the determining factor. For instance, the stress of separation from family, stress of any emergency medical treatment whatsoever, the wish to end the suffering, etc.
  • Registry of other illnesses as SARS
    Incorrect registration as SARS but actually related to an entirely different disease, depending on the outcome, will either increase the death rate incorrectly or change the base of cases from which the death rate is determined (thus lowering the rate).
  • Death for other reasons
    Death caused by other unrelated reasons and also found to have SARS must be placed in a separate category for statistical purposes.
  • Changes in the definition of the disease or of its symptoms
  • Loss of data
    If records are not kept on a regular basis, data is often lost, minimized, or changed.
  • Non local deaths
    Deaths registered in one jurisdiction or country due to transfer shortly before death or after an individual has been infected. This is particularly relevant for travelers from other regions but also for SARS cases of one jurisdiction hospitalized in another jurisdiction.
  • Strain of virus
    The strain of the virus causes very high death rates for some strains and very low for others and should be recorded separately.
  • Jurisdictional or administrative overlap
    Two jurisdictions or administrations may unwittingly claim the same area or individual for statistical reasons leading to a doubling of certain data. On the other hand, areas which are disputed or with unclear boundaries may not be counted at all leaving potentially large gaps in the data.
  • Clerical or computation errors
    Errors if unchecked can create a ripple effect through the data.
  • Dependency on tests
    Reliance on tests on the presence of a particular virus or reaction to a virus can lead to biased results - particularly if there are no other symptoms giving confirmation as might happen if it is found that symptomless or new symptom SARS is found in the population. In many cases in the past, single tests alone have been found to be unreliable. If statistics as well as medical treatment are based on tests with low discrimination, death rates as well as possible deaths due to other causes may cause an artificial rise in the data.
  • Where reporting is poor
    With inadequate reporting for any reason, deaths are more often reported than the probable cases or those that have recovered. This tends to distort the rates since the base on which the calculation is made is significantly smaller.
  • Artificially high or low deaths
    Deaths may be reported for a number of reasons including funding (for facilities and equipment), political (to fulfill expectations), social (to support severe countermeasures), or economic.

  • For Daily updates: WHO data worldwide:
  • For Summary major points WHO text summaries
  • For Travel Advice WHO Travel Advice
  • For Internal Country Data selected countries

    Updating by this site completed on 16 June 2003 for data and June 19 for WHO text Major Points. See WHO links above most current updates.

    According to Health Organization data3
    June 16 Data (last update on June 9 - one day after last reported probable case in Taiwan)
    Of 32 countries/provinces registered as ever having probable4 cases:
  • 17 countries/provinces report all cases recovered/discharged - no fatalities
  • + 5 countries/provinces report all cases recovered/discharged with 12 fatalities
  • + 23 countries/provinces no new cases for more than 20 days (maximum period)
  • + 2 countries/provinces no new cases for 10 or more days
  • 16 countries/provinces only 1-3 cases ever reported with all cases in 13 recovered/discharged
  • 22 countries/provinces no deaths to date
  • 4 countries/provinces 1-2 deaths to date
    Malaysia(2) Philippines(2) South Africa(1) Tailand(2)
  • only 6 countries/provinces have had more than 1 or 2 deaths to date
    Canada(32) China(346)+6 during week Hong Kong(295)+7 during week Taiwan(83)+2 during week Singapore(31) Viet Nam(5)
  • New Reported Deaths: 15 over a 7 day period (since 9 June)
    China(6) Hong Kong(7) Taiwan(2)
  • New Reported Probable Cases: 39 (+2 from previous week period) over a 7 day period (since 9 June) Canada(14) China(-2) Brazil(1) Hong Kong(2) Philippines(2) Taiwan(18) United States(4)
    3 Data represents date of latest country report update which for countries with active SARS cases is usually within last 2-3 days of the WHO report.
    4From a news report by Reuters on CDC briefing re probable vs. suspected cases.

    May 7 percentage tables from Hong Kong

    Hong Kong tables of age groups of recorded SARS cases (about 2 persons per 10,000 people are diagnosed as probable SARS cases) and the distribution of deaths by age groups (SARS Bulletin May 7).

    Total accumulated SARS recorded cases in Hong Kong is 1646 since the beginning with 958 already recovered (58.2%) and 495 still in hospital (includes 89 convalescent). There have been a total of 193 SARS related deaths.

    Percentage tables
    The number of SARS recorded cases in the total population of Hong Kong is extremely small. If the data is used to calculate risk, the chances that it will cause death is even smaller - to date, ages under 25 have had no fatalities, and a very small possibility (3 out of 100 SARS cases) to the age group 25-34. There is a slight increase (11 out of 100) up to age 64. For the age group 65-74, the rate increases to (23 out of 100 SARS cases) and for age 74+ (38 out of 100 cases).

    One consideration for the 65+ age group is the rate of pre-existing medical conditions such as hypertension, heart diseases, diabetes mellitus and stroke which is probably higher. In fact, It is stated that 68% of all fatalities had pre-existing medical conditions. Another consideration to be considered is that in the general population, not all of the symptoms of SARS are present in every case and many individuals may not be hospitalized or counted as having SARS. Hospitalization increases as the individual gets older and particularly when there is a pre-existing medical condition which elevates this group to the largest group recorded as having SARS and the largest group hospitalized when any of SARS symptoms appears.

    Within Fatalities Rate
    It must be emphasized that these figures are the percentages within the fatality group and have nothing to do with the death rate from SARS itself. For instance, if there are 2 deaths from 100 SARS cases with the age distribution of 1 in the ages 0 to 44 and 1 in the age group 45+ then the death rate from SARS is 2% but a 50% rate within the fatalities for each age group.

    Best Advice

    For good brief
    what, how spread, and chances. Also chart Most Get Well
  • Anybody who has any one of the six common symptoms of SARS: severe headache, severe fatigue, muscle aches and pains, fever of 100.4 Fahrenheit or higher, dry cough and shortness of breath should stay at home and not mix with others until the next day or so and then if the symptoms persist, to contact their health care giver.
  • Best current advice is to avoid those suspected of having SARS (have been in contact with SARS patients or have recently traveled (last 10 days) to Affected Areas as defined by WHO and are sneezing and coughing, and to wash hands frequently (for extension on this, see Hong Kong Dept of Health - Protecting yourself against Respiratory Tract Infections. The virus appears to be transmitted either by the droplets from sneezing or coughing, or by touching objects which have been sneezed or coughed on, or otherwise contaminated and transferred to the eyes, nose or mouth. WHO is currently carrying out tests on the length of time the virus can survive on surfaces and in the environment Unanswered questions.... "The incubation period of SARS is usually 2-7 days but may be as long as 10 days" WHO resource. Hong Kong Authorities have used the 10 day maximum to declare buildings safe which have had an individual hospitalized for SARS but have had no further incident source.
  • Notification of health care personnel when SARS is suspected and care or hospitalization appears to reduce the possibility of complications. In Hong Kong It was determined that "most of the deaths occurred in individuals who have a history of chronic diseases, or were patients who sought treatment at a relatively late stage of infection."
  • Centers for Disease Control and Prevention U.S. (CDC) News Cast September 2003 Infection Control for Hospitals and Other Healthcare Facilities, Quarantine: Community Response / Community Containment, Legal Challenges of Quarantine and Isolation, What Every Clinician Should Know: Basic Diagnosis and Patient Management, What's New in SARS Laboratory Diagnostics?, Surveillance: How to Prepare the Clinician for Early Recognition and Diagnosis Preparation For The Return of SARS. Are You Ready?
  • For latest go to CDC, go to">Centers for Disease Control and Prevention U.S and search for SARS.
  • For travel advice which is constantly under revision, see Areas with Recent Local Transmission

    See next below for a summary of current update by WHO

    Major Points World Health Organization Updates*
    (cut and paste)

    As of June 19 Major Points will not be given on this site.
    Please contact full reports.

    For the full current WHO reports, access
    Original WHO SARS updates

    Previous WHO Summaries 22 May-19 June 03
    Previous WHO Summaries 19 April-21 May 03

    Advice From Different Viewpoints

  • SARS - Atypical Pneumonia Update See Key points in and update on SARS by Dr. Margaret Chan. She reviewed the chronology of events, statistics, symptoms, linkages with other areas, measures taken by the Department of Health and World Health Organization, prevention and treatment. Center For the Advancement of E-Commerce Technologies, Hong Kong
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