Severe Acute Respiratory Syndrome (SARS) · WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 7...

WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 1

Severe Acute Respiratory Syndrome (SARS): Severe Acute Respiratory Syndrome (SARS): Global Alert, Global ResponseGlobal Alert, Global Response

World Health Organization, 17 June 2003World Health Organization, 17 June 2003


Surveillance network epidemiology and laboratory partners in Asia

Mekong Basin

Disease Surveillance

(MBDS)

Pacific Public Health Surveillance Network (PPHSN)

ASEAN

APEC

SEAMICSEANET

EIDIOR

FluNet


Surveillance network electronic partner Surveillance network electronic partner in Canada: GPHIN in Canada: GPHIN


Surveillance network laboratory partners: Surveillance network laboratory partners: FluNetFluNet

1 laboratory > 1 laboratory national network


Partnership for global alert and response to Partnership for global alert and response to infectious diseases: network of networksinfectious diseases: network of networks

Electronic Discussion sitesMedia

NGOs

MilitaryLaboratoryNetworks

WHO Collaborating Centres/Laboratories Epidemiology and

Surveillance Networks

WHO Regional & Country Offices

Countries/National Disease Control

Centres

UNSister Agencies

FORMALFORMAL

GPHIN

INFORMALINFORMAL


Reports of respiratory infection, WHO global Reports of respiratory infection, WHO global surveillance networks, 2002surveillance networks, 2002––20032003

27 November– Guangdong Province, China: Non-official report of outbreak of respiratory illness with

government recommending isolation of anyone with symptoms (GPHIN)

11 February– Guangdong Province, China: report to WHO office Beijing of outbreak of atypical

pneumonia (WHO)

14 February– Guangdong Province, China: Official confirmation of an outbreak of atypical pneumonia

with 305 cases and 5 deaths (China)

19 February– Hong Kong, SAR China: Official report of 33-year male and 9 year old son in Hong Kong

with Avian influenza (H5N1), source linked to Fujian Province, China (Hong Kong- FluNet)


Intensified surveillance for pulmonary Intensified surveillance for pulmonary infections, WHO 2003infections, WHO 2003

26 February– Hanoi, Viet Nam: Report of 48-year-old business man with high fever (> 38 ºC),

atypical pneumonia and respiratory failure with history of previous travel to China and Hong Kong

4 – 10 March– Hong Kong/ Hanoi: Reports of medical staff from Kwong Wah Hospital (Hong

Kong) and French Hospital (Hanoi) with atypical pneumonia 10 March– WHO teams arrive Hong Kong and Hanoi, and with governments begin

investigation and containment activities


Global Alert:Global Alert:Severe Acute Respiratory Syndrome (SARS)Severe Acute Respiratory Syndrome (SARS)

12 March: First global alert– describing atypical pneumonia in Viet Nam and Hong Kong

14 March– Four persons Ontario, three persons in Singapore, with severe atypical pneumonia fitting

description of 12 March alert reported to WHO

15 March– Medical doctor with atypical pneumonia fitting description of 12 March reported by

Ministry of Health, Singapore on return flight from New York


Global Alert, 15 March 2003Global Alert, 15 March 2003

1) Atypical pneumonia with rapid progression to respiratory failure

2) Health workers appeared to be at greatest risk

3) Unidentified cause, presumed to be an infectious agent

4) Antibiotics and antivirals did not appear effective

5) Spreading internationally within Asia and to Europe and North America


Global Alert: Global Alert: Severe Acute Respiratory Syndrome (SARS)Severe Acute Respiratory Syndrome (SARS)

15 March: Second global alert• Case definition provided • Name (SARS) announced• Advice given to international travellers to raise awareness

26 MarchEvidence accumulating that persons with SARS continued to travel from areas with local transmission, and that adjacent passengers were at small, but non-quantified risk

27 MarchGuidance provided to airlines and areas with local transmission to screen passengers leaving in order to decrease risk of international travel by persons with SARS


Global Alert: Global Alert: Severe Acute Respiratory Syndrome (SARS)Severe Acute Respiratory Syndrome (SARS)

1 April:Evidence accumulating from exported cases that three criteria were potentially important in the increasing of international spread:

– magnitude of outbreak and number of new cases each day– pattern of local transmission– exportation of probable cases

2 April to present:Guidance provided to general public to postpone non-essential travel to areas with local transmission that met above criteria


SARS: chain of transmission among guests at Hotel M, SARS: chain of transmission among guests at Hotel M, Hong Kong, 21 February: international amplification Hong Kong, 21 February: international amplification

156 closecontactsof HCW

and patients

Index case from

Guangdong

Index case from

Guangdong

Hospital 2Hong Kong

4 HCW +2

Hospital 2Hong Kong

4 HCW +2

Hospital 3Hong Kong

3 HCW

Hospital 3Hong Kong

3 HCW

Hospital 1Hong Kong

99 HCW

Hospital 1Hong Kong

99 HCW

Canada12 HCW +

4

Canada12 HCW +

4

Hotel MHong Kong

IrelandIreland

USAUSA

New YorkNew York

Singapore34 HCW +

37

Singapore34 HCW +

37

Viet Nam37 HCW +

?

Viet Nam37 HCW +

?

BangkokHCW

BangkokHCW

4 otherHong Konghospitals28 HCW

4 otherHong Konghospitals28 HCW

Hospital 4Hong KongHospital 4

Hong Kong

B

I

K

F G

ED

CJ

H

A

GermanyHCW +

2

GermanyHCW +

2

As of 26 March, 249 cases (219 HCW) had

been traced to Hotel M

Source: WHO/CDC


SARS: cumulative number of probable cases worldwideSARS: cumulative number of probable cases worldwideas of 16 June 2003 as of 16 June 2003 –– Total: 8 460 cases, 799 deathsTotal: 8 460 cases, 799 deaths

China (5326)

Singapore (206)

Hong Kong (1755)

Viet Nam (63)

Europe:10 countries (38)

Thailand (9)Brazil (3)

Malaysia (5)

South Africa (1)

Canada (243)

USA (72)

Outbreaks before 15 March global alert

Colombia (1)

Kuwait (1)

South Africa (1)

Korea Rep. (3)Macao (1)

Philippines (14)Indonesia (2)

Mongolia (9)

India (3)

Australia (5)New Zealand (1)

Taiwan (698)

Outbreaks after 15 March global alert

Mongolia (9)

Russian Fed. (1)


Probable cases of SARS by date of onset,Probable cases of SARS by date of onset,Hanoi:Hanoi: n = 63 n = 63

1 February 1 February –– 16 June 200316 June 2003

0

1

2

3

4

5

6

7

8

9

10

1 Feb. 13 Feb. 25 Feb. 9 Mar. 21 Mar. 2 Apr. 14 Apr. 26 Apr. 8 May 1 June

Numb

er of

case

s

20 May 13 June

Health care workersOthers


1 February 1 February –– 16 June 200316 June 2003

Probable cases of SARS by date of onset,Probable cases of SARS by date of onset,Singapore:Singapore: n = 206n = 206

0

2

4

6

8

10

12

14

1 Feb. 13 Feb. 25 Feb. 9 Mar. 21 Mar. 2 Apr. 14 Apr. 26 Apr. 8 May 20 May 1 Jun

Numb

er of

case

s

13 Jun.



Probable cases of SARS by date of onset,Probable cases of SARS by date of onset,Canada:Canada: n = 242 n = 242

1 February 1 February –– 13 June 200313 June 2003Nu

mber

of ca

ses

0

1

2

3

4

5

6

7

8

9

10

1 Feb. 13 Feb. 25 Feb. 9 Mar. 21 -Mar. 2 Apr. 14 Apr. 26 Apr. 8 May 20 May 1 Jun. 13 Jun.


Probable cases of SARS by date of onset,Probable cases of SARS by date of onset,Taiwan:Taiwan: n = 698n = 698

1 February 1 February –– 16 June 200316 June 2003Nu

mber

of ca

ses

0

5

10

15

20

25

30

1 Feb. 13 Feb. 25 Feb. 9 Mar. 21 Mar. 2 Apr. 14 Apr. 26 Apr. 8 May 20 May 1 Jun. 13 Jun.


Probable cases of SARS by date of report,Probable cases of SARS by date of report,Beijing:Beijing: n = 2 522n = 2 522

0

50

100

150

200

250

300

350

30 March 13 April 27 April 11 May 25 May 8 June

num

ber o

f cas

es


Probable cases of SARS by date of onset,Probable cases of SARS by date of onset,Hong Kong:Hong Kong: n = 1 753, as of 13 June 2003n = 1 753, as of 13 June 2003


Numb

er of

case

s

0

20

40

60

80

100

120

1 Feb. 13 Feb. 25 Feb. 9 Mar. 21 Mar. 2 Apr. 14 Apr. 26 Apr. 8 May 20 May 1 Jun. 13 Jun.


SARS and the economy:SARS and the economy:impact on global travel, Hong Kongimpact on global travel, Hong Kong


SARS and the economy:SARS and the economy:impact on global travel, Singaporeimpact on global travel, Singapore


The cost of SARS: initial estimates, The cost of SARS: initial estimates, Asian Development BankAsian Development Bank

76543210 US$ billion

Hong KongChina, mainland

TaiwanSouth Korea

IndonesiaSingapore

ThailandMalaysia

PhilippinesUS$ billionUS$ billion

4%0.5%

1.9%0.5%

1.4%2.3%

1.6%1.5%

0.8%

% of GDP


From data collection and verification to From data collection and verification to information through electronic communicationinformation through electronic communication


1) Atypical pneumonia with rapid progression to respiratory failure

– Case fatality rate by age group:

– 85% full recovery– Incubation period: 3–10 days

2) Health workers appeared to be at greatest risk– Health workers remain primary risk group in second generation– Others at risk include family members of index cases and health workers, and their

contacts– Majority of transmission has been close personal contact; in Hong Kong environmental

factors caused localized transmission

< 1% < 24 years old6% 25–44 years old

15% 45–64 years old> 50% > 65 years old

SARS: SARS: what more we know what more we know 3 months later3 months later



3) Unidentified cause, presumed to be an infectious agents – Aetiological agent: Coronavirus, hypothesized to be of animal origin– PCR and various antibody tests developed and being used in epidemiological studies,

but PCR lacks sufficient sensitivity as diagnostic tool

4) Antibiotics and antivirals did not appear effective– Studies under way to definitively provide information on effectiveness of antivirals

alone or in combination with steroids, and on use of hyperimmune serum in persons with severe disease

– Case detection, isolation, infection control and contact tracing are effective means of containing outbreaks

– Meeting 30 April at NIH to examine priorities in drugs and vaccine developments



5) Spreading internationally within Asia and to Europe and North America– Only 1 major outbreak occurred after 15 March despite initial exported cases to a

total of 32 countries

– Symptomatic persons with SARS no longer travelling internationally

– International spread occurring the in small number of persons who are in incubation period

– Since 15 March, 27 persons on 4 of 32 international flights carrying symptomatic persons with SARS appear to have been infected (1 flight alone on 15 March has accounted for 22 of these 27 cases), and these occurred before 23 March


SARS: SARS: what we are learningwhat we are learning

In the world today an infectious disease in one country is a threat to all: infectious diseases do not respect international borders

Information and travel guidance can contain the international spread of an infectious disease

Experts in laboratory, epidemiology and patient care can work together for the public health good despite heavy pressure to publish academically

Emerging infectious disease outbreaks often have an unnecessary negative economic impact on tourism, travel and trade

Infectious disease outbreaks reveal weaknesses in public health infrastructure

Emerging infections can be contained with high level government commitment and international collaboration if necessary


SARS: what we must continue SARS: what we must continue over the coming yearover the coming year

Continued case identification through surveillance:– necessary to determine whether infection is endemic and seasonal, or

whether it has disappeared from human populations

Continued collaborative studies in Guandong Province to identify animal reservoir and risk factors for transmission to humans– necessary to manage the risk of transmission to humans and prevent future

outbreaks

Continued global surveillance for influenza and other emerging infectious diseases– identify next major emergence of new influenza strain or other infection of

international importance


From Quarantine to International Health Regulations: From Quarantine to International Health Regulations: a framework for global surveillance and responsea framework for global surveillance and response

1374 Venice Quarantine for Plague

1851 Paris 1st International Sanitary Conference

1947 Geneva WHO Epidemiological Information Service

1951 Geneva International Sanitary Regulations

1969 Geneva International Health Regulations


International Health Regulations and Associated Guidelines

“…ensure the maximum security against the international spread of disease with minimal interference in world traffic.”


Important changes in International Health Important changes in International Health Regulations to fit the SARS modelRegulations to fit the SARS model

Cover all disease outbreaks of international importanceInternational control measures, including travel recommendations, tailored to epidemiologyReports accepted for validation from network sources in addition to those received from countriesPro-active management by WHO with 24-hour country focal point and global alertDecision by WHO Director General for on-site collaborative evaluation of control measures, should such evaluation be considered necessary to ensure containment of international spread

Severe Acute Respiratory Syndrome (SARS) · WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 7...

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