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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 2
Surveillance network epidemiology and laboratory partners in Asia
Mekong Basin
Disease Surveillance
(MBDS)
Pacific Public Health Surveillance Network (PPHSN)
ASEAN
APEC
SEAMICSEANET
EIDIOR
FluNet
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 3
Surveillance network electronic partner Surveillance network electronic partner in Canada: GPHIN in Canada: GPHIN
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 4
Surveillance network laboratory partners: Surveillance network laboratory partners: FluNetFluNet
1 laboratory > 1 laboratory national network
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 5
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 6
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)
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 7
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 8
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 9
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 10
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 11
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 12
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 13
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)
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 14
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 15
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.
Health care workersOthers
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 16
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.
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 17
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.
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 18
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 19
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
Health care workersOthers
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.
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 20
SARS and the economy:SARS and the economy:impact on global travel, Hong Kongimpact on global travel, Hong Kong
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 21
SARS and the economy:SARS and the economy:impact on global travel, Singaporeimpact on global travel, Singapore
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 22
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 23
From data collection and verification to From data collection and verification to information through electronic communicationinformation through electronic communication
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 24
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 25
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 26
SARS: SARS: what more we know what more we know 3 months later3 months later
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 27
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 28
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 29
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
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 30
International Health Regulations and Associated Guidelines
“…ensure the maximum security against the international spread of disease with minimal interference in world traffic.”
WHO COMMUNICABLE DISEASES • SARS, 17 June 2003 31
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