President of the American Society of Microbiology on SARS

Mainland professor who died in Hong Kong spread mysterious form of pneumonia; another death reported

HONG KONG - An infected medical professor from mainland China apparently carried a mysterious flu-like disease to a Hong Kong hotel where six other people caught the illness, possibly as they waited for elevators or through the air-conditioning system, officials said Thursday.

Some of those he infected are suspected of then carrying the disease into Vietnam, Singapore and Canada, as well as to a Hong Kong hospital where dozens of staff became sick.

The Chinese professor died March 4 — one of six people killed and hundreds sickened by severe acute respiratory syndrome, or SARS, on three continents in recent weeks.

His case bolsters suspicions that the outbreak is linked to an earlier one in China's southern Guangdong province, where an illness killed five people and sickened more than 300.

It is not certain how the disease was spread in the Metropole Hotel, but some experts think it may have been airborne.

"Perhaps they all stood outside the elevator at the same time and someone sneezed or coughed," said Dr. Margaret Chan, the director of the Hong Kong Health Department.

Other theories were being floated.

"It would suggest that it spread through the air-conditioning system, but you can't rule out person-to-person contact, since you don't know if they were even in the same room together," said Ronald Atlas, president of the American Society of Microbiology. "But everything says it is airborne."

Hong Kong's health chief, Dr. Yeoh Eng-kiong, told reporters Thursday he believes the disease has been spread through droplets, which is why most victims have been medical workers or close relatives of victims. But Yeoh acknowledged people elsewhere in the community have been infected, including six members of one family.

Hong Kong said the number of infected people had risen by 20 to 165 as of Thursday afternoon and the World Health Organization (news - web sites) has counted at least 264 people who got sick. Vietnam is the second hardest hit, followed by Singapore.

The disease was spread to Vietnam by an American businessman from Shanghai who stayed at the Metropole in Hong Kong on Feb. 21-22, the same time the professor from China was a guest, officials said. All of those infected at the hotel were on the ninth floor, which now has been closed for sterilization. Meanwhile, Hong Kong officials announced Thursday that the professor's brother-in-law died on Wednesday, becoming the sixth person killed here by the disease. The brother-in-law did not stay in the hotel but he had dined with the professor.

Two other relatives, the professor's wife and a sister, were treated for fever or pneumonia but have recovered and been discharged, said Dr. Tse Lai-yin, a consultant in charge of the Health Department's Disease Prevention and Control Division.

Another Metropole guest, a 78-year-old woman from Toronto, died after returning to Canada, officials here said.

The World Health Organization has confirmed nine deaths from the disease in Hong Kong, Vietnam and Canada, not including the latest Hong Kong death. Five others who died in the earlier outbreak in mainland China, from November to at least February, may be related.

Others infected by the professor included three Singaporean women who were hotel guests and apparently spread the disease to Singapore, a man from Canada who was a guest and a Hong Kong man who went to the Metropole to visit a friend.

That Hong Kong man has been identified as the "index patient" who spread the disease to Hong Kong's Prince of Wales Hospital, where dozens of workers have been sickened, said Health Department spokeswoman Sally Kong.

None of the 200 to 300 workers at the Metropole have become ill and although conditions seem safe there now, the ninth floor remains closed, Chan said. The Metropole was still open, hotel spokeswoman Anita Kwan said. But a group of tourists from Shanghai emerged wearing surgical masks early Thursday and told reporters outside they were seeking different accommodation.

"The Health Department has already indicated that the germ doesn't exist here anymore," Kwan said Wednesday night. But she added that the ninth floor won't be reopened until it has been thoroughly checked. Researchers in Germany, Hong Kong and Singapore have said they believe the illness may have come from something resembling the virus that causes measles, mumps and canine distemper. The WHO has said the focus on the paramyxoviridae family is helpful but more evidence is needed before conclusions can be drawn.

_ Singapore reported three new suspected SARS cases, bringing the number of patients there to 34;

_ Two people with SARS-like victims were placed in isolation wards at two hospitals in Auckland, New Zealand;

_ A flight attendant and a passenger on a Vietnam Airlines flight to Hanoi were hospitalized with suspected SARS;

_ Japanese health officials ordered local authorities to isolate anyone with suffering from SARS symptoms;

_ Health officials said 11 suspected SARS cases have ben reported in the United States.

The following is jointly issued by the Department of Health and the Hospital Authority: As at 3pm today (20 Mar 2003) the admission statistics of patients who have been in close contacts with atypical pneumonia patients are as follows:

A. Staff of Hospitals/Clinics (numbers in brackets are those with symptoms of pneumonia)

Staff of Prince of Wales Hospital (PWH) admitted to: Prince of Wales Hospital 53 (53)

Kwong Wah Hospital 3 (2)

Princess Margaret Hospital (PMH) 1 (1)

Tseung Kwan O Hospital (TKOH) 1 (1)

Staff of Kwong Wah Hospital (KWH) admitted to: Kwong Wah Hospital 4
(4) One of the health care workers was discharged

Staff of Pamela Youde Nethersole Eastern Hospital (PYNEH) admitted to: Pamela Youde Nethersole Eastern Hospital 7 (7)

Staff of Queen Elizabeth Hospital (QEH) admitted to: Queen Elizabeth Hospital 5 (2)

Staff of a Private Clinic in Mong Kok admitted to: Princess Margaret Hospital 4 (4) Tuen Mun Hospital 1 (0)

Staff of a private hospital on HK Island admitted to: Pamela Youde Nethersole Eastern Hospital 3 (3)
Total 82 (77)

B. Medical students (numbers in brackets are those with symptoms of pneumonia) Medical students Prince of Wales Hospital 17 (17) One of the medical students was discharged

C. Other close contacts of Index

Patients (numbers in brackets are those with symptoms of pneumonia) Patients, patients' family members & visitors PWH, PMH, KWH, PYNEH,

QEH, TKOH & Queen Mary Hospital 74 (71) 3 of the patients were discharged

Total admissions (A + B + C) 173 (165)

5 were discharged

The Department of Health and Hospital Authority have been closely monitoring the clinical condition of inpatients with pneumonia symptoms. The total number of admissions is released after collating, analysing, and confirming the clinical symptoms and test results of the patients concerned. The total number of patients includes those who were admitted earlier.

On the other hand, 6 patients with atypical pneumonia died recently in the following public hospitals:
Kwong Wah Hospital (2 patients);

Princess Margaret Hospital (1);

Pamela Youde Nethersole Eastern Hospital (1);

Prince of Wales Hospital (2).

Two cases of deadly pneumonia in UK

By Jeremy Laurance and Chris Bunting
20 March 2003
Independent (UK)

Two new cases of a deadly strain of pneumonia being spread across the world by air travel have been identified in Britain, the Department of Health said last night.

A man was in a specialist isolation unit at the Royal Free Hospital in London and a patient in Swansea, south Wales, was being treated at home.

The London man, said to be in a stable condition, arrived at Heathrow from Taiwan on Monday on a Cathay Pacific flight after a one-hour stop in Hong Kong. Air passengers travelling from the Far East who have experienced symptoms such as a high fever or difficulties breathing are being advised to contact their doctor.

Alarm about the virus has mounted. It appears to have spread from China, Hong Kong and South-east Asia, with 264 cases identified worldwide. Fourteen deaths have been linked to the virus. However, hopes of effective treatment were boosted yesterday by claims from researchers that they had identified the family of viruses to which the infectious agent responsible belonged.

World Health Organisation (WHO) officials said the disease was being brought under control. David Heymann, head of communicable diseases, said: "The outbreak, we feel, is on its way to containment, at least outside of Vietnam and Hong Kong, and China if it is linked."

Doctors in Hong Kong claimed they had identified the virus which causes the illness, known as severe acute respiratory syndrome or Sars. Dr John Tam, professor of microbiology at the Chinese University of Hong Kong, said the virus had been found in patient samples using an electron microscope. "From its shape, it belongs to the paramyxoviridae family," he said. The paramyxoviridae family includes viruses which cause a number of different diseases in humans, including measles, usually involving respiratory symptoms.

Similar claims were made by a German team in Frankfurt.

A paramyxovirus called Nipah, discovered in 1999, caused an eight-month outbreak of illness in Malaysia that infected 265 people, of whom 105 died. Almost all those affected had been exposed to pigs and the main symptom was brain inflammation.

A second paramyxovirus, called Hendra, caused three small outbreaks in Australia in the 1990s. Some of those victims had contact with horses. The WHO urged caution in response to yesterday's claims, but said the paramyxovirus theory was being taken seriously.

"It will become clear with specific testing of patients to see if we can pull out particles of that virus from the blood," Dr Heymann said.

Specialists said that, even if the Hong Kong and Frankfurt teams were correct, it could be months before the precise infectious agent was identified.

Sars claimed three more lives yesterday, including a French doctor who died in Vietnam after treating an American man diagnosed with the illness, who also died. It has killed five people in Hong Kong, two in Vietnam and two in Canada. Eleven possible cases have been identified in America. The first suspected case in Britain earlier this week involved a man aged 64 from the Manchester area.

Highly specialized testing of specimens from patients ill with SARS continues at top speed in top labs, expedited by electronic sharing of results. The World Health Organization (WHO) is increasingly optimistic that conclusive identification of the causative agent can be announced soon. The development of a precise diagnostic test could follow quickly. Collaboration in the race to find the causative agent is taking place within the framework of a network of labs set up on Monday.

Research is now focused on the Paramyxoviridae family of viruses. This family includes several well known viruses, such as those causing mumps, measles, and common respiratory ailments. It also includes a subfamily of viruses capable of infecting multiple animal species, including humans. This subfamily was implicated in the emergence during the 1990s of new and severe diseases in humans caused by Hendra and Nipah viruses. The virus jumped directly from animal hosts (horses and pigs) to humans. No person to person transmission was documented in outbreaks caused by either virus.

WHO has today established a cooperative network of clinicians for SARS diagnosis and treatment. The network brings together, via two daily teleconferences, clinicians in the most heavily affected Asian countries and in Europe and North America. Clinicians participate on the basis of either first-hand experience in the management of SARS cases or leading expertise in the diagnosis and management of unusual infectious diseases.
Participants are pooling data on cases and sharing x-ray pictures. Chest x-rays are, at present, one of the main tools for distinguishing between suspected and probable cases. Treatment guidelines, including criteria for safe discharge of patients from hospitals, are also being established on the basis of shared experiences.

Pending definitive identification of the causative agent, efforts to cure cases are based on a trial-and-error approach. WHO is providing support, in the form of protective equipment and supplies, to help the most heavily affected hospitals prevent further spread within hospital settings, where the overwhelming majority of new infections have occurred.

If a paramyxovirus is confirmed to be the cause, WHO will be in a much better position to recommend a treatment. The antiviral drug, ribavirin, may be responsible for some degree of clinical improvement observed in critically ill patients in Hong Kong Special Administrative Region of China. Intensive and good supportive care have also been associated with improved prospects of recovery.
As of 20 Mar 2003, 306 suspected and probable cases, including 10 deaths, have been reported from 11 countries. These figures represent an additional 42 cases and one death compared with the previous day.

Increases were reported in Canada (1), Hong Kong (23), Singapore (3), Taiwan, China (1), the United Kingdom (1), and Viet Nam (6). Switzerland, reporting 7 suspected cases, was added to the list.
Press reports have referred to 2 suspected cases of SARS, one in an airline crew member and a second in a passenger, travelling on separate flights from Hong Kong and Taipei to Viet Nam. Both suspected cases have been investigated and are now ruled out as cases of SARS.

WHO has welcomed a report from the Hong Kong Department of Health, released yesterday, that may have identified the "index" case in the outbreak in the Prince of Wales Hospital in Hong Kong. In an outstanding example of detective work, epidemiologists have determined that 7 people who contracted SARS recently stayed in or visited the Metropole hotel in Kowloon last month. The 7 people investigated include 3 visitors from Singapore, 2 from Canada, one China mainland visitor, and a local Hong Kong resident.

The investigation revealed that all 7 stayed in or visited the same floor of the hotel between 12 Feb 2003 and 2 Mar 2003. The local Hong Kong resident is believed to be the index case, who subsequently infected other early cases in the outbreak. He had visited an acquaintance staying at the hotel from 15 to 23 Feb 2003. The visitor from mainland China, who became sick a week before staying at the hotel, is considered the original source of the infection. No further cases have been linked to the hotel.

WHO is underscoring the need for continued vigilance. Experience with other emerging diseases makes it clear that, should the causative agent turn out to be a virus, the new disease could establish endemicity, especially in light of abundantly documented human-to-human transmission. The world must protect itself against the widespread establishment of another new infectious disease.

WHO's concern is now increasingly focused on preparation to assist vulnerable countries in the likely event that cases continue to spread. Up to now, all imported cases have occurred in countries well equipped and well prepared to institute WHO-recommended precautions, including isolation and barrier nursing practices, for preventing spread to others, whether health care workers or family members. In view of the rapid spread of this disease to new countries via exposed air travellers, any country with an international airport is potentially at risk.

This focus on preparedness underscores the need for a concerted effort to defend global public health security. In an era of close interconnectedness and rapid air travel, an outbreak anywhere in the world is a potential threat to health everywhere.

International collaboration - on the part of the medical and research communities, multinational teams in the field, and health authorities around the world - in the reporting, investigation, and management of this outbreak has been outstanding.

B. Cumulative number of reported suspect and probable case

Country: Cumulative No. case(s) / no. deaths / local transmission

Canada: 9 / 2 / yes China: +

Germany 1 / 0 / none* Hong Kong

SAR China: 173 / 6** / yes

Singapore: 34 / 0 / yes

Slovenia: 1 / 0 / none*

Spain: 1 / 0 / to be determined

Switzerland: 7 / 0 / to be determined

Taiwan,China: 4 / 0 / yes

Thailand: 1 / 0 / none*

United Kingdom: 2 / 0 / to be determined

United States: 11 / 0 / to be determined

Viet Nam: 62 / 2 / yes

Total: 306 / 10

Notes:
It is possible for the status of a reported case to change over time. SARS is a diagnosis of exclusion. This means that whenever a known cause is found that could fully account for a patient's clinical condition, this patient should no longer be considered to be a case of SARS.

+The Chinese authorities have reported suspect and probable cases in Guangdong province. Figures are being updated. Cumulative number of cases includes number of deaths.

* No documented secondary transmission in-country. No affected areas.

**One death attributed to Hong Kong Special Administrative Region of China occurred in a case medically transferred from Viet Nam.

The Department of Health, Taiwan, here reports the 4th case of probable SARS. This 32 year old male had a trip to Gaungdong, China, and Hong Kong from 4 to 6 Mar 2003. On 13 Mar 2003, he suffered from high fever, headache, and cough with sputum.

He visited a regional hospital in Chia-yi County in Taiwan, and his chest radiograph disclosed pulmonary infiltrates over the left lower lobe. He was immediately hospitalized and under the suspicion of SARS.

So far, there has been no evidence of community spread except the second case who is the wife of the first reported case. However, a few suspected individuals have been reported to the CDC, Taiwan, to this day and further confirmation is undertaken.

As of March 20, 4 cases of SARS were identified in Taiwan, in 3 families and currently treated in 3 hospitals. With respect to results of lab diagnosis, specimen tests for influenza virus type A,BB, BH5, BH7, BH9, parainfluenza virus, adenovirus, respiratory syncytial virus, Herpes virus, and Nipah virus are all negative.

(Additional comment by Prof Peter WS Chang MD, PMP, ScD: "Director Dr Chen of the Taiwan Center for Disease Control has just submitted this update of SARS case report in Taiwan and other related information. As I am aware, the doctors in Taiwan have observed viral particles under the electron microscope at March 18th, same as reported in Germany and Hong Kong. They are working on the molecular confirmation at these hours.

However, it is still not clear the paramyxovirus are the real etiology for the SARS, even it is in the specimen. It can be an associate factor, though. Also, it needs more study on the immunity of these patients and the exploration/ understanding on the mechanisms for this epidemic. The answers remained to be worked out by collaborative efforts in the region in the coming days.")

[The nomenclature used in this report for the influenza viral testing is not the conventional nomenclature. There are no accepted H and N antigenic type designations for influenza B viruses. The B viruses do not exhibit as much antigenic variation as the A viruses and influenza B viruses have no animal reservoirs. The H5, H7 and H9 designations presumably refer to avian influenza viruses, but rather than speculate it is better to request further clarification of this. With respect to the other viruses, it is crucial to know the nature of the diagnostic tests employed in order to fully interpret these results. More information on the specifics of the testing conducted would be

Since late February 2003, the US Centers for Disease Control and Prevention (CDC) have been supporting the World Health Organization (WHO) in the investigation of a multicountry outbreak of atypical pneumonia of unknown etiology. The illness is being referred to as severe acute respiratory syndrome (SARS). This report describes the scope of the outbreak, preliminary case definition, and interim infection control guidance for the United States.

On 11 Feb 2003, the Chinese Ministry of Health notified WHO that 305 cases of acute respiratory syndrome of unknown etiology had occurred in 6 municipalities in Guangdong province in southern China from 16 Nov 2002 to 9 Feb 2003. The disease was characterized by transmission to health care workers and household contacts; 5 deaths were reported (1). On 26 Feb 2003, a man aged 47 years who had traveled in mainland China and Hong Kong became ill with a respiratory illness and was admitted to hospital shortly after arriving in Hanoi, Vietnam. Health care providers at the hospital in Hanoi subsequently developed a similar illness.

The patient died on 13 Mar 2003 after transfer to an isolation facility in Hong Kong. In late February, an outbreak of a similar respiratory illness was reported in Hong Kong among workers at another hospital; this cluster was linked to a patient who had traveled previously to southern China. On 12 Mar 2003, WHO issued a global alert about the outbreak and instituted worldwide surveillance.
As of 19 Mar 2003, WHO has received reports of 264 patients from 11 countries with suspected and probable* SARS

Areas with reported local transmission include Hong Kong and Guangdong province, China; Hanoi, Vietnam; and Singapore. More limited transmission has been reported in Taipei, Taiwan, and Toronto, Canada. The initial cases reported in Singapore, Taiwan, and Toronto had all traveled to China.
On 15 Mar 2003, after issuing a preliminary case definition for suspected cases (Box, CDC initiated enhanced domestic surveillance for SARS, CDC also advised that people planning nonessential travel to Hong Kong, Guangdong, or Hanoi consider postponing their travel

On 16 Mar 2003, CDC began advising passengers arriving on direct flights from these 3 locations to seek medical attention if they had symptoms of febrile respiratory illness. As of 18 Mar 2003, about 12 000 advisory notices had been distributed to airline passengers. In addition, surveillance is being heightened for suspected cases of SARS among arriving passengers. As of 19 Mar 2003, a total of 11 suspected cases of SARS in the United States are under investigation by CDC and state health authorities.

Among patients reported worldwide as of 19 Mar 2003, the disease has been characterized by rapid onset of high fever, myalgia, chills, rigor, and sore throat, followed by shortness of breath, cough, and radiographic evidence of pneumonia. The incubation period has generally been 3 to 5 days (range: 2 to 7 days). Laboratory findings have included thrombocytopenia and leukopenia.

Many patients have had respiratory distress or severe pneumonia requiring hospital admission, and several have required mechanical ventilation. Of the 264 suspected and probable cases reported by WHO, 9 people (3 per cent) have died. In addition, secondary attack rates of greater than 50 per cent have been observed among health care workers caring for patients with SARS in both Hong Kong and Hanoi.

In the United States, initial diagnostic testing for people with suspected SARS should include chest radiograph, pulse oximetry, blood cultures, sputum Gram stain and culture, and testing for viral respiratory pathogens, particularly influenza types A and B and respiratory syncytial virus.
Clinicians should save any available clinical specimens (for example, respiratory samples, blood, serum, tissue, and biopsies) for additional testing until diagnosis is confirmed. Instructions for specimen collection are available from

Specimens
should be forwarded to CDC by state health departments after consultation with the SARS State Support Team at the CDC Emergency Operations Center.
Clinicians evaluating suspected cases should use standard precautions (for example, hand hygiene) together with airborne (for example, N-95 respirator) and contact (for example, gowns and gloves) precautions

Until the mode of transmission has been defined more precisely, eye protection also should be worn for all patient contact. As more clinical and epidemiological information becomes available, interim recommendations will be updated.

Electron microscopic identification of paramxyovirus-like particles has been reported from Germany and Hong Kong (5). This family of viruses includes measles, mumps, human parainfluenza viruses, and respiratory syncytial virus in addition to the recently identified henipaviruses and metapneumovirus. Additional testing is under way to confirm a definitive etiology.

Identification of the causative agent should lead to specific diagnostic tests, simplify surveillance, and focus treatment guidelines and infection control guidance.

A couple of possible cases in New York

Health authorities investigate two possible SARS cases in NYC

By TARA BURGHART - The Associated Press

3/20/03 6:55 PM

NEW YORK (AP) -- Two New York City residents are possibly suffering from a mysterious respiratory illness that has killed 10 people around the world in the last three weeks, health officials announced Thursday.

The 67-year-old man and the 27-year-old woman both recently traveled to China and Hong Kong. The vast majority of the suspected cases of severe acute respiratory syndrome, or SARS, have occurred in Asia, and a hotel in Hong Kong is being investigated as the place the outbreak started.

The man is hospitalized and in isolation in good condition, according to Dr. Thomas Frieden, the city's health commissioner. The woman visited an emergency room after returning to New York this week but was not hospitalized and was instead told to go home and quarantine herself, Frieden said.

Frieden said both hospitals acted properly, because the man is older and more likely to become ill whereas the woman "had no reason to be hospitalized." He would not name the hospitals.

They are not linked, but both began exhibiting flu-like symptoms while abroad, health officials said.

Frieden also said the cases are not connected to a doctor from Singapore who attended a conference in New York City before being taken off a plane in Frankfurt and quarantined, suspected of having SARS.

There are now 306 people sick with the disease, according to the World Health Organization, with about half of those in Hong Kong. Not counting the New York cases, there are 13 suspected cases in the United States, according to the U.S. Centers for Disease Control.

The cause of the illness remains unknown, but experts believe the most likely explanation is a new virus. There is no known treatment.

On Thursday, health officials in Hong Kong said the global spread of the illness appears to have started with a professor who stayed in a tourist hotel there. Health officials said the other guests who caught the disease then carried it to a Hong Kong hospital, Vietnam, Singapore and Canada.

In addition to Hong Kong, the two both visited China's Guangdong province, which had an outbreak believed to be of SARS last November that sickened 300 people and killed five. The professor who stayed at the Hong Kong hotel where the outbreak has been traced was from the Guangdong province.

Neither of the suspected New York City cases stayed at the Hong Kong hotel, Frieden said. Specimens from both patients have been sent to the U.S. Centers for Disease Control and Prevention for further testing.

Because it is still flu season, many New Yorkers might experience SARS-like symptoms of a fever and respiratory problems. But Frieden said they shouldn't worry unless they have visited Hong Kong, Singapore, Hanoi or the Guangdong province in the last 10 days.

"Then if you have a fever and cough, or other respiratory problems, it's something you should see your doctor about," he said.

Also Thursday, Frieden announced that health officials had been monitoring a doctor and his staff who had treated the Singapore doctor while he was in New York City.

They have shown no symptoms of SARS, a promising sign since it has been six days since they were exposed and the incubation period for the illness is usually three to five days, Frieden said.

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