Responding to SARS John Watson Health Protection Agency Communicable Disease Surveillance Centre, London

November 2002 Outbreak of pneumonic illness in Guangdong province of southern China

11 February 2003 China declares outbreak of pneumonia in Guangdong province 300 cases and 5 deaths

20 February 2003 Chicken ‘flu (influenza A H5N1) in Hong Kong Outbreak in a family linked to southern China Two deaths among four ill Two cases confirmed influenza virus infection

11 March 2003 Hong Kong reports outbreak of “acute respiratory syndrome” among hospital workers

12 March 2003 WHO reports to all countries the occurrence of outbreaks in Hong Kong and Hanoi (Vietnam) as well as earlier outbreak in China WHO recommends isolation of cases and surveillance by national health authorities

13 March 2003 Information prepared in UK CMO cascade (to all doctors) activated and Eurosurveillance published CDR publication delayed to next morning due to network problems

14 March 2003 WHO reports outbreaks in Singapore and Taiwan WHO worker ill in Hanoi WHO seeking field experts Aetiology still unknown

15 March 2003 WHO declares Severe Acute Respiratory Syndrome (SARS) a worldwide health threat Cases in Canada, Indonesia, Thailand and Philippines WHO guidance about travel to South- East Asia

Sunday, 16 March 2003 First UK-wide teleconference

Clinical features Incubation period 2-7 (?) days Influenza-like illness High fever Cough, shortness of breath Other systemic symptoms

Clinical features Recovery in many Progression in some –pneumonia –acute respiratory distress syndrome Death in 3-5% No response to anti-bacterial or anti- viral agents

Epidemiological features Spread to close contacts –droplet spread or direct contact with body fluids Infectious when severely ill Explosive outbreaks –Metropole Hotel International spread

Global SARS situation – 13 May 2003 Total cases – 7458 (deaths 573 – 7.7%) Hong Kong – 1689 (23%) Taiwan – 207 (3%) China (mainland) – 5086 (68%) Singapore – 205 (3%) Vietnam – 63 (1%) Canada – 143 (2%)

Global SARS situation – 13 May 2003 Total cases – 7458 (deaths 573 – 7.7%) Hong Kong – 1689 (23%) Taiwan – 207 (3%) China (mainland) – 5086 (68%) Singapore – 205 (3%) Vietnam – 63 (1%) Canada – 143 (2%)

UK results to 14 May 2003 Total calls initial ‘probable’ cases –4 other diagnoses (1 mycoplasma, 3 ‘flu A) –4 current, all recovered 159 initial ‘suspect’ cases –63 (40%) recovered –54 (34%) still ill –42 (26%) other diagnoses ‘not a case’ - 178

Why is SARS so dangerous? Lethal – % mortality in hosptialised patients Spread via respiratory route Capable of sudden amplification in hospitals and cities Vulnerability of health care staff Can spread quickly internationally Not easily controlled cf other emerging infections

Early response in UK Surveillance system Laboratory strategy and guidance Guidance for health care professionals Travel guidance Public information

WHO definitions for surveillance Suspect –>38 C –Cough or other respiratory symptom –Affected area within previous 10 days Probable –as above with evidence of changes on chest x-ray

Early response in UK Surveillance system Laboratory strategy and guidance Guidance for health care professionals Travel guidance Public information

Summary management of a SARS case

Early response in UK Surveillance system Laboratory strategy and guidance Guidance for health care professionals Travel guidance Public information

UK Case definitions for SARS Suspect LOW A person presenting after 1 Feb 2003 with sudden onset of: high fever (>38°C) And cough or difficulty breathing And travelled in the 10 days before onset of illness to an area in which there is more than 'limited' local transmission of SARS during the travel period. WHO website ) )

UK Case definitions for SARS Suspect HIGH A person presenting after 1 Feb 2003 with sudden onset of: high fever (>38°C) And cough or difficulty breathing And had close contact with a probable SARS case from an affected area in the 10 days before onset of symptoms

UK Case definitions for SARS Probable case Either: A suspect (Low or High) case with: chest x-ray findings of pneumonia and no response to standard antimicrobial treatment or respiratory distress syndrome (RDS) or Death due to an unexplained respiratory illness with autopsy findings of RDS without identifiable cause in a person who travelled to an affected SARS area within 10 days of illness.

Follow-up Follow-up categories Still ill Recovered = afebrile for at least 48 hours AND cough, if present, resolving Dead Follow-up forms faxed or ed to CDSC 48 hours after the date of report ten days after the date of report and/or A final follow-up form once the patient is asymptomatic

CDSC SARS Surveillance