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Chronological Developments
May 19, 2004: During April 22-29, the Chinese Ministry of Health (MOH) reported a total of nine cases of SARS in China; seven of the patients were from Beijing , and two were from Anhui Province , located in east-central China . One of the patients died. Two of the nine patients were graduate students who worked at the China's National Institute of Virology Laboratory (NIVL) in Beijing, which is known to conduct research on SARS coronavirus (SARS-CoV). The laboratory was closed on April 23, potentially exposed personnel are being monitored for signs of illness, and possible sources of infection for the two laboratory workers are being investigated. Of the seven other SARS cases, two were directly linked to close personal contact with one of the graduate students who worked at NIVL; these two cases were in the graduate student's mother (who died) and in a nurse who provided care to the graduate student. The remaining five cases were linked to close contact with the nurse. No further cases of SARS in China or anywhere else in the world have been reported since April 29. Chinese authorities have carried out active surveillance activities to identify other possible cases of SARS, including enhanced surveillance for any flu-like illness and pneumonia of unknown etiology. They also initiated measures to prevent the spread of SARS among travelers, including health screening of travelers at ports of exit/entry. June 5: A cumulative total of 8,403 probable cases with 775 deaths has been reported from 29 countries. This represents an increase of 6 new cases and 3 deaths compared with yesterday. The new cases occurred in Canada (5) and Taiwan (1). New deaths were reported in China (2) and Hong Kong (1). June 4: A cumulative total of 8,402 probable SARS cases with 772 deaths has been reported from 29 countries. This represents an increase of 10 new cases compared with yesterday. The new cases were reported in Canada (5), Hong Kong (1), Taiwan (2), Germany (1), and the USA (1). No new deaths were reported today. This marks the first day with no new SARS deaths since 28 March, when the cumulative totals stood at 1,485 cases and 53 deaths. June 2: A cumulative total of 8,384 probable cases and 770 deaths has been reported from 29 countries. This represents an increase of 27 new cases and deaths compared with the Saturday, May 31. The new deaths were reported in China (2) and Hong Kong (4). May 27: A cumulative total of 8,221 probable SARS cases with 735 deaths has been reported from 28 countries. This represents an increase of 24 new cases and 10 deaths compared with yesterday. The new deaths occurred in China (4), Hong Kong SAR (2), and Taiwan (4). May 26: A cumulative total of 8,202 probable cases with 725 deaths has been reported from 28 countries. This represents an increase of 96 probable cases and 29 deaths compared with the most recent report on Saturday. The new deaths occurred in Canada (3), China (9), Hong Kong SAR (5), and Taiwan (12). May 24: A cumulative total of 8,141 probable cases with 696 deaths have been reported from 28 countries. This represents an increase of 89 new cases and 7 deaths when compared with yesterday. The new deaths occurred in China (5) and Hong Kong SAR (2). All of the new cases were reported from two outbreak sites, Taiwan and China. Taiwan has today reported 55 new cases, bringing the cumulative total to 538 cases and 60 deaths. China reported 34 new cases, bringing the cumulative total to 5,309 cases and 308 deaths. May 22: A cumulative total of 8,046 probable SARS cases and 682 deaths have been reported from 28 countries. These figures represent an increase of 95 new cases and 16 deaths when compared with yesterday. The new deaths occurred in China (4), Hong Kong SA (3), Taiwan (8), and Singapore (1). May 17: A cumulative total of 7,761 probable SARS cases with 623 deaths have been reported from 28 countries. This represents an increase of 33 cases and 12 deaths compared with yesterday. The new deaths occurred in China (7) and Hong Kong SAR (5). May 16: A cumulative total of 7,739 probable SARS cases and 611 deaths have been reported from 29 countries. This represents an increase of 54 new cases and 13 deaths compared with yesterday. The new deaths occurred in China (4), Hong Kong SAR (4), and Taiwan, China (5). May 10: A cumulative total of 7,296 probable SARS cases with 526 deaths have been reported from 30 countries. This represents an increase of 119 cases and 12 deaths when compared with yesterday. Most of the new cases were reported in China (85) and Taiwan, China (23). The new deaths occurred in China (8), Hong Kong SAR (2), and Taiwan, China (5). May 9: A cumulative total of 7,183 probable cases of SARS and 514 deaths have been reported from 30 countries on six continents. This represents an increase of 144 new cases and 8 deaths when compared with yesterday. Of the new deaths, 6 were reported in China, and 2 were reported in Hong Kong SAR. In the past week, more than 1000 new probable cases and 96 deaths were reported globally. May 5: A cumulative total of 6,583 probable SARS cases with 461 deaths have been reported from 27 countries. This represents an increase of 364 new cases and 26 new deaths since the last report was compiled on Saturday, May 3. Scientists in the WHO network of collaborating laboratories yesterday reported results of the first scientific studies designed to determine the survival time of the SARS virus in different environmental media. Results from studies of the effectiveness of different disinfectants commonly used in hospitals were also reported, confirming the validity of currently recommended measures for infection control. The new studies, conducted at network labs in Hong Kong, Japan, and Germany confirm, as anticipated, that the SARS virus can survive after drying on plastic surfaces for up to 48 hours. Ongoing studies are testing virus stability on additional surfaces, with initial results expected by Wednesday. Scientists have also tested virus survival times in faeces. Research conducted at one Hong Kong lab determined that the virus can survive in faeces for at least 2 days, and in urine for at least 24 hours. Studies conducted at a second Hong Kong lab found that virus in faeces taken from patients suffering from diarrhoea, which has a lower acidity than normal stools, could survive for 4 days. This raises the possibility that surfaces contaminated with faeces from patients suffering from diarrhoea might survive for as long as 4 days. However, the dose of virus needed to cause infection remains unknown. Further studies are needed before firm conclusions about the role of faecal-oral transmission can be made. Results of the new studies underscore the need for frequent handwashing, proper cleaning, and good disinfection control in hospitals managing SARS cases. Spread by infected droplets remains the most important mode of transmission. Good personal hygiene, including frequent handwashing, is important for everyone in areas with SARS cases, but most especially so for persons who have been in close contact with a probable case. Shedding of the SARS virus in faeces, respiratory secretions, and urine is now well-established. In Hong Kong in late March, a large and sudden cluster of more than 320 simultaneous cases occurred among residents of the Amoy Gardens housing estate. The outbreak raised the possibility of an environmental source of infection. Subsequent investigations suggested that contamination with sewage might have played a role. Around 66% of Amoy Gardens SARS patients presented with diarrhoea as a symptom, compared with 2% to 7% of cases in other outbreaks. With the exception of the Amoy Gardens cluster and a previous event where cases were linked to visits to a single floor of a hotel, SARS is thought to spread in the majority of cases through close person-to-person exposure to infected droplets expelled during coughing or sneezing. All previous speculation about the environmental behaviour of the SARS virus was based on knowledge about other well-known human members of the Coronavirus family, which cause illnesses such as the common cold. WHO has been concerned that the SARS virus, which is unlike any other human or animal virus in its family, might behave differently. Studies now under way in the network laboratories will support the further development and implementation of virus-specific infection control measures. WHO remains concerned that the SARS virus continues to be transmitted to hospital staff in highly advanced settings where sophisticated infection control measures are in place May 2: A cumulative total of 6054 probable SARS cases with 417 deaths have been reported from 27 countries. This represents an increase of 207 new cases and 26 deaths when compared with yesterday. The new deaths were reported in Canada (2), China (11), Hong Kong SAR (8), and Taiwan (5). Taiwan, which has a rapidly evolving outbreak, reported today a cumulative total of 100 probable cases, with 11 new cases compared with yesterday. Eight SARS deaths have occurred in Taiwan. Canada reported 2 new probable cases today. May 1: A cumulative total of 5865 probable cases with 391 deaths have been reported from 27 countries. This represents an increase of 212 additional cases and 19 deaths when compared with yesterday. The deaths occurred in China (11), Hong Kong (5), Taiwan (2), and Singapore (1). Poland reported its first case today. The United Kingdom and the United States of America have been removed from the list of areas with recent local transmission. In both countries, the last instance of local transmission occurred more than 20 days ago. Tianjin, China and Ulaanbaatar City, Mongolia, were added to the list. April 19: A cumulative total of 3547 cases with 182 deaths have been reported from 25 countries. Compared with yesterday, 12 new deaths, all in Hong Kong SAR, have been reported. April 19: As probable SARS cases continue to be reported from a growing number of countries, WHO is taking stock of what is known about the new disease, particularly concerning its mode of spread, and what remains a puzzle. The agent that causes SARS has now been conclusively identified. The SARS virus is a new coronavirus unlike any other known human or animal virus in the Coronavirus family. Because the virus is new, much about its behaviour is poorly understood. Key questions, which are undergoing intense study, include stages in the course of infection when virus shedding may be highest, and the various concentrations of virus in different body fluids. Scientists are also working to determine the amount of time the virus can survive in the environment on both dry surfaces and in suspension, including in faecal matter. The vast majority of countries reporting probable SARS cases are dealing with a small number of imported cases. Experience has shown that when these cases are promptly detected, isolated, and managed according to strict procedures of infection control, further spread to hospital staff and family members either does not occur at all or results in a very small number of secondary infections. These experiences confirm abundant early evidence that the SARS virus spreads, in the vast majority of cases, through exposure to respiratory droplets during close face-to-face contact. However, information now emerging from outbreaks in Hong Kong and Canada is raising some important new questions about SARS. In Hong Kong, a large and sudden cluster of almost simultaneous cases (321) seen in residents of the Amoy Gardens housing estate has raised the possibility of transmission from an environmental source. In addition, reports from Hong Kong health authorities indicate that patients in this cluster depart in some ways from the previously established clinical picture. The disease appears to be more severe both in Amoy residents and in related cases among hospital staff. Around 20% of Amoy-related cases require intensive care, compared with 10% seen in non-Amoy cases. Some deaths are now occurring in younger, previously healthy persons as well as in the elderly and persons with underlying disease. Around 66% of Amoy Gardens patients present with diarrhoea as a symptom, compared with 2% to 7% of cases in other outbreaks. Speculation centres on whether these cases represent infection with high virus loads, as might occur following exposure to a concentrated environmental source, or whether the virus may have mutated into a more virulent form. Viruses in the Coronavirus family are known to mutate frequently. In Canada, concern has centred around a cluster of 31 suspect and probable cases in members of a charismatic religious group, the health care workers who have treated them, and close family and social contacts. The outbreak is particularly disturbing because of its potential to move into the wider community. Large meetings of the religious group at two events, on 28 and 29 March, may have led to multiple additional exposures, especially among the members of this close-knit religious group. Intense contact tracing, home quarantine, and close follow-up by health officials may work to prevent further spread of cases in the general community. The index case in this cluster has been traced to contact, in a hospital emergency room, with a subsequently fatal SARS case. The outbreak is regarded as a test case of whether rigorous contact tracing and other stringent public health measures can contain further spread even when very large numbers of persons may have been exposed. This index case has also been linked to three of four SARS cases concentrated in the same block of a 247-unit condominium in Toronto. As the fourth case could not be linked to direct contact with a SARS patient, some speculation arose concerning possible environmental contamination within the building as the source of the fourth infection. However, all four cases occurred in early April, with 4 April being the date of onset of the fourth case. The incubation period has now passed with no further cases detected. There appears to be little risk that the case arose from an environmental source. April 18: A cumulative total of 3461 cases with 170 deaths have been reported from 25 countries on five continents. This represents an increase of 72 new cases and 5 deaths since the last WHO update. The deaths occurred in Hong Kong SAR (4) and Singapore (1). April 17: A cumulative total of 3389 cases with 165 deaths have been reported from twenty five countries. Countries reporting their first probable cases on today's list include Australia (3) and Mongolia (3). A large number of suspect SARS cases turn out, on further investigation, to have other, common causes. April
14: A cumulative total of 3169 cases of SARS, with 144 deaths, have
been reported to WHO from 21 countries. This represents an increase
of 213 cases and 25 deaths since the last update on Saturday, April
12.
Indonesia, the Philippines, and Sweden report their first probable cases (1 in each country) today. Japan, which had previously reported four probable cases, was removed from the list as these cases were determined to have other causes. April 12: A cumulative total of 2,960 cases, with 119 deaths, have been reported from 19 countries. This represents an increase of 70 cases (Canada 3, Hong Kong 49, Taiwan 2, Singapore 14, Thailand 1, United Kingdom 1) and 3 deaths (all in Hong Kong) when compared with yesterday. No reports from China were received today. April 11: WHO added Beijing, China to its list of SARS-affected areas. Areas are added to the list following indication that chains of local transmission are occurring. The greatest concern arises when cases occur outside the established risk groups of health care workers and persons in close face-to-face contact with patients, such as household contacts and hospital visitors. In addition to Beijing, other affected areas in China include Guangdong Province, Hong Kong SAR, Shanxi Province, and Taiwan Province. Toronto, Singapore, and Hanoi are also listed as affected. In most other countries reporting SARS cases, the disease remains confined to a few imported cases, with no or very little spread of infection to others. April 10: A cumulative total of 2,781 cases and 111 deaths have been reported from 17 countries. Increases occurred in Brazil (1), Canada (3), China (10), Hong Kong SAR (28), Germany (1), Malaysia (2), Singapore (8), and the United States (5). Deaths were reported in China (2) and Hong Kong SAR (3). March 28: China, an initially reluctant partner in the global alert and response at the start, became a full partner in the three working groups that were studying SARS, and concluded that the outbreaks of SARS elsewhere in Asia were related to the outbreak in Guangdong Province. The Chinese government has announced that SARS is being given top priority. A system of alert and response for all emerging and epidemic-prone diseases is being developed. Daily electronic reporting of new cases and deaths, by province, has begun. Equally important, health officials have begun daily televised press conferences, thus taking the important step of increasing the awareness of the population and hospital staff of the characteristic symptoms, the need to seek prompt medical attention, and the need to manage patients according to the principles of isolation and strict infection control. March 15: World Health Organization issues emergency travel advisory GENEVA -- During the past week, WHO has received reports of more than 150 new suspected cases of Severe Acute Respiratory Syndrome (SARS), an atypical pneumonia for which cause has not yet been determined. Reports to date have been received from Canada, China, Hong Kong Special Administrative Region of China, Indonesia, Philippines, Singapore, Thailand, and Viet Nam. Early today, an ill passenger and companions who travelled from New York, United States, and who landed in Frankfurt, Germany were removed from their flight and taken to hospital isolation. Due to the spread of SARS to several countries in a short period of time, the World Health Organization today has issued emergency guidance for travellers and airlines. "This syndrome, SARS, is now a worldwide health threat," said Dr. Gro Harlem Brundtland, Director General of the World Health Organization. "The world needs to work together to find its cause, cure the sick, and stop its spread." There is presently no recommendation for people to restrict travel to any destination. However in response to enquiries from governments, airlines, physicians and travellers, WHO is now offering guidance for travellers, airline crew and airlines. The exact nature of the infection is still under investigation and this guidance is based on the early information available to WHO. TRAVELLERS INCLUDING AIRLINE CREW: All travellers should be aware of main symptoms and signs of SARS which include: high fever (>38oC) <BR<AND one or more respiratory symptoms including cough, shortness of breath, difficulty breathing AND one or more of the following: close contact* with a person who has been diagnosed with SARSrecent history of travel to areas reporting cases of SARS. In the unlikely event of a traveller experiencing this combination of symptoms they should seek medical attention and ensure that information about their recent travel is passed on to the health care staff. Any traveller who develops these symptoms is advised not to undertake further travel until they have recovered. AIRLINES: Should a passenger or crew member who meets the criteria above travel on a flight, the aircraft should alert the destination airport. On arrival the sick passenger should be referred to airport health authorities for assessment and management. The aircraft passengers and crew should be informed of the person's status as a suspect case of SARS. The passengers and crew should provide all contact details for the subsequent 14 days to the airport health authorities. There are currently no indications to restrict the onward travel of healthy passengers, but all passengers and crew should be advised to seek medical attention if they develop the symptoms highlighted above. There is currently no indication to provide passengers and crew with any medication or investigation unless they become ill. In the absence of specific information regarding the nature of the organism causing this illness, specific measures to be applied to the aircraft cannot be recommended. As a general precaution the aircraft may be disinfected in the manner described in the WHO Guide to Hygiene and Sanitation in Aviation. * * * As more information has become available, WHO-recommended SARS case definitions have been revised as follows: Suspect Case A person presenting after 1 February 2003 with history of : high fever (>38oC) AND one or more respiratory symptoms including cough, shortness of breath, difficulty breathing Probable Case close contact* with a person who has been diagnosed with SARS recent history of travel to areas reporting cases of SARS A suspect case with chest x-ray findings of pneumonia or Respiratory Distress Syndrome OR A person with an unexplained respiratory illness resulting in death, with an autopsy examination demonstrating the pathology of Respiratory Distress Syndrome without an identifiable cause. Comments In addition to fever and respiratory symptoms, SARS may be associated with other symptoms including: headache, muscular stiffness, loss of appetite, malaise, confusion, rash, and diarrhea. * * * Until more is known about the cause of these outbreaks, WHO recommends that patients with SARS be isolated with barrier nursing techniques and treated as clinically indicated. At the same time, WHO recommends that any suspect cases be reported to national health authorities. WHO is in close communication with all national authorities and has also offered epidemiological, laboratory and clinical support. WHO is working with national authorities to ensure appropriate investigation, reporting and containment of these outbreaks. *Close contact means having cared for, having lived with, or having had direct contact with respiratory secretions and body fluids of a person with SARS. For more information contact: Dick Thompson - Communication Officer Communicable Disease Prevention, Control and Eradication WHO, Geneva Telephone: (+41 22) 791 26 84 Email: thompsond@who.int March 12: WHO issues a global alert about cases of atypical pneumonia - Cases Of Severe Respiratory Illness May Spread To Hospital Staff PRESS RELEASE ISSUED BY WHO 12 March 2003 12 March 2003 | GENEVA -- Since mid February, WHO has been actively working to confirm reports of outbreaks of a severe form of pneumonia in Viet Nam, Hong Kong Special Administrative Region (SAR), China, and Guangdong province in China. In Viet Nam the outbreak began with a single initial case who was hospitalized for treatment of severe, acute respiratory syndrome of unknown origin. He felt unwell during his journey and fell ill shortly after arrival in Hanoi from Shanghai and Hong Kong SAR, China. Following his admission to the hospital, approximately 20 hospital staff became sick with similar symptoms. The signs and symptoms of the disease in Hanoi include initial flu-like illness (rapid onset of high fever followed by muscle aches, headache and sore throat). These are the most common symptoms. Early laboratory findings may include thrombocytopenia (low platelet count) and leucopenia (low white blood cell count). In some, but not all cases, this is followed by bilateral pneumonia, in some cases progressing to acute respiratory distress requiring assisted breathing on a respirator. Some patients are recovering but some patients remain critically ill. Today, the Department of Health Hong Kong SAR has reported on an outbreak of respiratory illness in one of its public hospitals. As of midnight 11 March, 50 health care workers had been screened and 23 of them were found to have febrile illness. They were admitted to the hospital for observation as a precautionary measure. In this group, eight have developed early chest x-ray signs of pneumonia. Their conditions are stable. Three other health care workers self-presented to hospitals with febrile illness and two of them have chest x-ray signs of pneumonia. Investigation by Hong Kong SAR public health authorities is on-going. The Hospital Authority has increased infection control measures to prevent the spread of the disease in the hospital. So far, no link has been found between these cases and the outbreak in Hanoi. In mid February, the Government of China reported that 305 cases of atypical pneumonia, with five deaths, had occurred in Guangdong province. In two cases that died, chlamydia infection was found. Further investigations of the cause of the outbreak is ongoing. Overall the outbreaks in Hanoi and Hong Kong SAR appear to be confined to the hospital environment. Those at highest risk appear to be staff caring for the patients. No link has so far been made between these outbreaks of acute respiratory illness in Hanoi and Hong Kong and the outbreak of `bird flu,` A(H5N1) in Hong Kong SAR reported on 19 February. Further investigations continue and laboratory tests on specimens from Viet Nam and Hong Kong SAR are being studied by WHO collaborating centres in Japan and the United States. Until more is known about the cause of these outbreaks, WHO recommends patients with atypical pneumonia who may be related to these outbreaks be isolated with barrier nursing techniques. At the same time, WHO recommends that any suspect cases be reported to national health authorities. WHO is in close contact with relevant national authorities and has also offered epidemiological, laboratory and clinical support. WHO is working with national authorities to ensure appropriate investigation, reporting and containment of these outbreaks. For more information contact: Dick Thompson - Communication Officer Communicable Disease Prevention, Control and Eradication WHO, Geneva Telephone: (+41 22) 791 26 84 Email: thompsond@who.int
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