Severe Acute Respiratory Syndrome in Hong Kong Department of Health Hong Kong SAR (as at 10 April 2003)

Background

The World Health Organization has recently received reports of “Severe Acute Respiratory Syndrome” in various parts of the World. There are people affected by atypical pneumonia in Hong Kong. The Department of Health, in conjunction with Hospital Authority, the University of Hong Kong and the Chinese University of Hong Kong are conducting a detailed investigation into the matter. Hong Kong is working closely with the World Health Organization to control and prevent the spread of atypical pneumonia

What is Pneumonia? Pneumonia refers to an inflammation of lung or infection of lung which results in abnormal lung function. Pneumonia can be classified into typical and atypical cases. Typical pneumonia is usually caused by bacteria such as streptococcus pneumoniae. Symptoms include sudden onset of fever, chest pain, cough and purulent sputum.

What is SARS/ atypical pneumonia? Atypical pneumonia is usually caused by influenza virus, mycoplasma, chlamydia and other unknown micro-organism. Common symptoms include fever, chills, cough, headache and general malaise Severe Acute Respiratory Syndrome, or SARS, is a form of atypical pneumonia caused by a new agent

General Situation in Hong Kong

Hong Kong SAR Communicable Disease Surveillance System Comprising hospitals, clinics and laboratories in the public and private sectors monitoring the trends of influenza, pneumonia, Hand- foot-mouth disease, acute diarrhoeal disease, acute conjunctivitis and so forth stepped up surveillance on severe pneumonia cases in view of the atypical pneumonia outbreak in Guangdong Province in early February 2003 Investigation, contact tracing of all severe community- acquired cases carried out

Statistics on community-acquired pneumonia(CAP) Year (till 8/4/2003) No. of inpatient discharges & deaths 24,40018,0005,897 No. of registered deaths (provisional) N/A Death rate per 100,000 pop (provisional) N/A The estimated death rate per 100,000 pop as at 10 April 03 is 1.8 for SARS. There is no unusual rise in the number of CAP The causes of CAP are similar to previous years (50% each of known causes and unknown causes)

Chronology of SARS development in Hong Kong

Hospital Authority notified Department of Health (DH) DH made public findings of initial investigations and notified WHO WHO issued global alert on atypical pneumonia Set up a Steering Committee and an expert working group to oversee investigation and to implement preventive measures to contain spread Daily update on local situation WHO experts invited to provide technical support Paramyxovirus was identified by CUHK in some patients. Further investigation is required to establish if this is the causative agent. WHO issued preliminary clinical description of SARS & recommended hospital discharge & follow-up policy

Coronavirus identified by HKU & rapid diagnostic test established Interdepartmental effort stepped up to disseminate public health advice to the public Chief executive emphasized that prevention & control of SARS was top priority of Government First seven cases of Amoy Garden residents reported Government announced major steps including quarantine of contacts in curbing the spread of the disease Amoy Garden Block E isolated Amoy Garden Block E residents evacuated & isolated in camps while epidemiological investigations continued WHO advised postponing non-essential travel to HK Government announced home treatment programme

Latest Developments

Update of SARS situation in Hong Kong as at 1 pm, 10 April 2003 Total: 998 cases (25% were health care workers & medical students, 75% were patients and their close contacts) 154 patients (15.4%) were discharged Majority showing positive response to new treatment protocol 120 (12 %) needs ICU care 30 deaths (3%) reported 70% of the deaths occurred in those aged >60 years old & 77% in those with chronic illness

Main epidemiological observations Low case fatality so far 3 % (30 deaths out of 998 cases) most deaths among the elderly & with underlying disease Majority of SARS cases can be linked to close contact with known SARS cases Healthcare workers, household contacts & hospital visitors were major risk groups No SARS outbreaks occurred at community institutions e.g. schools, nursery, elderly homes Excluding Amoy Garden related cases, SARS in general community remains steady, about 20 cases a day

Evidence from epidemiological findings Outbreak caused by new virus Close contact required for transmission, via respiratory droplets or fomite on contaminated surfaces No evidence of airborne transmission to date Incubation period typically 2 to 7 days, as long as 10 days Healthcare workers and close contacts at higher risk

Prince of Wales Hospital Cases

PWH SARS outbreak Sex distribution:Sex distribution (M:F)=1:1.2 Likely mode of transmission of the disease is respiratory droplets spread & close contacts Use of nebuliser in index patient facilitated spread of disease Health care workers, patients in ward & visitors to patients, close contacts of hospital staff & visitors were infected

Symptoms of the PWH SARS cases SymptomsFrequency Fever100% Chills92% Malaise90% Headache84% Myalgia67% Cough50% Dizziness49% Rigors44% Sore throat43% Runny nose39% Productive cough36% Fever with diarrhoea has been reported in some cases

Epidemiological linkage for PWH cluster Metropole hotel PWH index patient Onset: 24 Feb 03 3 Singapore visitors 1 Mainland visitor Onset: 15 Feb 03 2 Canadian visitors 1 American Chinese Succumbed at KWH Hanoi outbreak index case A private hospital outbreak on Hong Kong Island Outbreak in Singapore Outbreak in Toronto, Canada

Amoy Gardens Cases

Amoy Garden SARS Outbreak Brief description Private housing estate established for 20 years Floor area of each flat: 400 to 500 sq. ft. 19 blocks (Block A to S) Each block has 36 storeys & each storey has 8 flats 2001 census residents from 6755 domestic households SARS cases reported since 26 March As of 10 April, 289 cases were related to the AG cluster

Epidemic curve of SARS cases in Amoy Garden as of 9 April 2003

Preliminary assessment of Amoy Garden SARS outbreak SARS cases first reported on , peaked on The majority were adults aged 19 & above More household in Block E were affected with clustering in Rooms 7 & 8 Other blocks residents have later onset dates — representing secondary transmission Unusual clustering suggest local factors at work Need to rule out continuing source or predisposing factors affecting other blocks

Control measures at Amoy Garden Epidemiological, environmental & laboratory investigations Case investigation and contact tracing Call interdepartmental investigation group — collect environmental samples, case control study, etc. Isolation Isolate Block E on 31 March 2003 Evacuate Block E residents and placed them under isolation for 10 days Disinfection, Cleansing home environment public areas environmental hygiene Public education

Prevention & Control Measures

Political commitment Secured funding of $200 million for: Health service provision & treatment Prevention of infection Public education

Enhanced measures by DH Prevented introduction & spread of SARS cases into & outside Hong Kong at entry points Contact tracing Put close contacts of confirmed cases under stringent medical surveillance Public Health Laboratory Centre to accord top priority to test SARS cases Enhanced community liaison & education targeting people at all walks of life Liaised with WHO & other health authorities

Prevent introduction & spread of SARS Set up medical posts at the airport, ports & border points since March 29 People arriving at HK to complete health declaration cards for arrivals & be given health advice Sent symptomatic arrivals/departures to treatment centres for check-up Stopped those suspected SARS cases from checking in for flights Set up hotlines for health advice

Contact tracing Set up hotlines Requested all visitors of Ward 8A of PWH after , Metropole Hotel (9/F) UCH, etc. to call hotlines Requested air passengers of certain flights where SARS cases had been on board to call hotlines

Stringent medical surveillance SARS has been made statutorily notifiable since March 27 Appointed 4 clinics as centres of medical surveillance since 31 March 03 Requested close contacts to stay at home & report at centres daily for 10 days for medical surveillance Social contacts are given health advice & advised to call hotline if any fever/cough developed

Public Health Education Campaign Public places Housing estates Public transport, transport operators Schools, kindergartens, childcare centers Travelers Food premises General public Medical practitioners

Productions by DH for the public TV/radio messages Health talk Hotline ( ) Website Posters Pamphlets Productions by GIS Announcement in Public Interest Newspaper supplements

Health advice to the public Build up good body immunity having a proper diet, regular exercise and adequate rest, reducing stress and avoiding smoking Maintain good personal hygiene wash hands after sneezing, coughing or cleaning the nose Maintain good ventilation Avoid visiting crowded places with poor ventilation Visitors to hospital patients are advised to take due precautions in infection control e.g. wearing face mask and gowns, wash hands

Major Breakthroughs

Major breakthrough(1) 1. Epidemiologic investigation of outbreaks to identify likely mode of transmission, incubation period, common presenting symptoms, high risk groups, linkages between clusters 2. Identification of agent: CUHK: human metapneumovirus HKU: Corona virus 3. Developed a rapid diagnostic test — GVU, HKU,CUHK,HA Reliability still under test Important for getting early treatment

Major breakthrough (2) 4.Treatment Effective treatment available Over 95% of patients can recover Early treatment reduce the need for ICU care 5.Cooperation with the Mainland Held meetings with Hong Kong to share experience

Conclusions

Hong Kong is safe for local residents as well as visitors Hong Kong has high quality medical and public health services: adequate medical facilities to handle the situation effective disease surveillance and control WHO: Up to date, the likely mode of transmission is via respiratory droplets Hong Kong continues to work with WHO & CDC to prevent the spread of SARS WHO travel advice on 2 April 2003 Consider postponing non-essential travel to Hong Kong & Guangdong Province

To know more Department of Health’s Hotline: Department of Health’s 24 hour pre- recorded health education hotline: Department of Health’s website

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