SARS REACHES HONG KONG SCHOOLS - 32 NEW CASES (IS THE BUG OUT OF THE BOX?)

CHANNEL NEWS ASIA ^ | 03-21-03 | AMY OR

[Mother Abigail]

World Health Organization: Dr David Heymann, executive director, Communicable Diseases; Dr Guenael Rodier, director, Communicable Disease Surveillance & Response (CSR); Dr Max Hardiman, medical officer, CSR; Dr Klaus Stohr, scientist, CSR; Dr Julie Hall, medical officer, CSR; Mr Dick Thompson, communications officer

Q. We understand that you are closer to identifying the cause of this disease. Is that true? Could we have more information?

A. Dr Klaus Stohr: Since yesterday [Thurs 20 Mar 2003], 2 more laboratories have identified the Paramyxoviridae virus in specimens from patients with SARS. One of the laboratories could identify one of these viruses as a virus that could be isolated with culture outside the patient. The tests are currently ongoing. We are having another telephone conference today at
13:30. We really have to look at the data. We are cautiously optimistic. But we also want to come out with the facts. We have to wait until we have the data.

Q. Have you pursued this line of investigation in China as well? Has the team arrived there?

A. Dr David Heymann: As you know, we have had reports from the Chinese government on tests that they've done and also on some organism that they have identified. They have identified Chlamydia but incidentally. But they don't think this is the cause of the outbreak. A WHO team will arrive this weekend to review the records supplied by the Chinese authorities. We expect to have more information available early next week. We are now closer to reality that this Paramyxoviridae virus has caused this, you have to realize this is a whole range of different viruses, from some that cause measles and mumps and from some that cause common respiratory infections in many people and which are sometimes even asymptomatic. Just because we found it circulating in some people does not mean that it is not circulating in others. A whole series of studies have to be done to find out if this is the cause. And if this is the cause, what this extended spread would be.

Q. Could you please expand on your statement that you are "cautiously optimistic" that you have found the causative agent?

A. Dr Klaus Stohr: The WHO collaborating multi-centre project is turning around data within one week which are normally distributed and digested and look at in months or years. More and more laboratories are finding Paramyxoviridae virus. What is promising is that many other Paramyxoviridae viruses can be excluded. Hendra and Nipah virus have not been found, nor have mumps and measles. Respiratory syncytial virus was found in few samples. What is promising is that in one sample the virus was found by electron microscope and no other Paramyxoviridae virus could be detected. So we have a Paramyxoviridae virus-like particle which is not any of the known Paramyxoviridae viruses. That is what we are looking at. Next steps are more cell culture, and more particle trials perhaps in animals. In essence, we are turning around information usually generated in months or years within hours and days.

Q. I am not a medical expert, but once you have virus detected and identified and determined, what do we do next? Where do we go from here?

A. Dr David Heymann: Let me try and explain. Once the cause is identified, then a diagnostic test can be made. A test which may detect infection in blood or other body secretions. Once this had been done we must use what we call "Koch's postulate" to tell us if we have an organism, and we must be clear that this organism is causing the disease. Then epidemiological studies are needed to determine whether the disease is asymptomatic in some people who have become sick or whether they are healthy and can be removed from the list. There is a whole process of epidemiological investigations after the virus is identified.

Q. Last time, WHO's overall assessment was that the outbreak was being contained outside China, Hong Kong, and Viet Nam. What is your assessment based on information now?

A. Dr Julie Hall: Figures of verified and confirmed cases are published on the web every afternoon. There will be more figures this afternoon. I think that what is clear is that the major areas of transmission of this disease are in Hong Kong, Viet Nam and, obviously we have yet to see, China. Hopefully we will have much more information next week. What we do know is that cases that have occurred outside these countries have occurred in hospital with no further spread of infection. What is very promising is that heightened surveillance, early signs and symptoms, people can be taken into protective hospital environment to prevent further transmission of this disease.
The WHO Global Outbreak Alert and Response Network has 3 field teams currently undertaking advanced epidemiological investigations. In Viet Nam, WHO has a 9-person team, in Hong Kong 6 persons, and by the end of the weekend we hope to have 5 people in Beijing. Institutions from the following countries and people drawn from WHO and GOARN are represented in these teams ­- New Zealand, USA, Japan, Australia, Sweden, Germany, France, and the UK. These 3 field teams are working extremely hard to get as much information as possible on what is happening in hospitals and in communities. Where we have effective hospital infection control transmission is dramatically reduced. And where patients are given good supportive care, especially in intensive care units, a small number of patients are stabilizing and may be discharged from hospital.

Q. You mentioned earlier that for the core cases of chlamydia identified by the Chinese authorities, they did not believe that this was cause of outbreak. Once the team is in China, do you expect that we will have a clearer picture?

A. Dr David Heymann: What the Chinese have told us is that they identified Chlamydia in core specimens and that these were preliminary results. They have not yet determined what is causing the outbreak in China.

Q. We ask whether we have a community outbreak in Hong Kong, but the Hong Kong authorities maintain that this is not the case.

A. Dr David Heymann: What we see is that initial cases are admitted to a hospital. Those cases are then in close contact with health workers and it is health workers who became infected first. So last Saturday, based on the information from we had from Hong Kong and Viet Nam, more than 90 per cent of all the cases were health workers, the other 10 per cent were index cases, that is cases who were admitted to hospital with the disease before health workers were infected or their family members had got infection. What we are trying to prevent is the cases going from family members and health workers to others who are not in the family. If that would occur, it would be a community outbreak, that is, within the larger community than health workers and their families.
Dr Guenael Rodier: When dealing with a community outbreak, it means that the chain of transmission spreads rapidly and it is difficult to trace it retrospectively. The question is who infected whom. In these cases, it was easier because it always starts with a health care worker and the disease is transmitted by close contact with the patient. We have a major pattern of nosocomial or hospital acquired infection.
Dr Max Hardiman: The WHO travel advisory issued last Saturday was based on a risk assessment and the quality of the cases being described and located within hospitals. Other than health care workers and their families, there is no transmission going on in communities to which travellers may become exposed. That is why we have reviewed the new information and the WHO advice stills stands: no restriction on travel is recommended.

[Mother Abigail]

In today's update there are now 350 reported suspected/confirmed cases of SARS with 10 reported deaths; a case fatality rate of 2.9 per cent.

Caution must be used when interpreting these data as they refer to cases of SARS, which is a clinically defined syndrome. Once a causative agent has been definitively identified, these numbers may be subject to significant change when there will be a defined "illness" which will be confirmable through laboratory testing. As SARS is an acute severe respiratory syndrome it is likely that once an agent is identified and laboratory testing for confirmation of infection is available, other milder respiratory illness presentations may be identified as part of the clinical spectrum of this disease.

In addition, it is possible that some of the cases currently reported as SARS will be shown not to be due to the agent ultimately identified and will remain as either suspected not laboratory confirmed, or will be shown to be due to yet another agent not related to this current outbreak.

[Mother Abigail]

Major step towards development of diagnostic test: A laboratory in a new network set up on Mon 17 Mar 2003 has today succeeded in growing, in cell culture, an infectious agent that might be the cause of severe acute respiratory syndrome (SARS). This major step towards the development of a diagnostic test has occurred despite the failure, up to now, to pinpoint the exact identity of the causative agent.

Researchers at the laboratory took serum samples from the blood of recovering SARS patients and a matching number of healthy volunteers in what is known as a "blinded" test. Serum from patients infected by a virus usually contains neutralizing antibodies that stop the growth of the virus

-- whatever its identity -- when added to a cell culture in which the virus has been successfully grown. When the researchers added serum from SARS patients to the cell culture, virus growth was halted. Serum from uninfected healthy controls had no effect on the virus.

"This is not just some light at the end of the tunnel," said WHO virologist Dr Klaus Stöhr, who is coordinating the collaborative laboratory efforts.

"This is a real ray of sunshine."
WHO cautions, however, that the number of patients in the test was small and more work needs to be done. The scientific community is excited by the news, which could be regarded as the first important step towards the development of a diagnostic test.

The infectious agent resembles the morphology of a Paramyxovirus. Scientists cannot, however, be certain about the identity of the virus, which may indeed be a new Paramyxovirus or another virus with a similar morphology.
The laboratory is one of 11 leading labs participating in an international multicentre research project. The project was set up by WHO on Monday to expedite identification of the causative agent -- considered by several research groups to be a member of the Paramyxoviridae family of viruses -- and rapidly develop a diagnostic test.

WHO team of experts travelling to China: A WHO team of 5 infectious disease experts will be travelling over the weekend to China to support investigations there of an outbreak of atypical pneumonia that began in Guangdong Province in mid-November. The multinational team was assembled in response to a request from the Chinese Ministry of Health for epidemiological and laboratory support to aid ongoing investigation of the outbreak. The team will also assist in laboratory work that might lead to identification of the causative agent.

The team includes experts in virology, laboratory techniques, epidemiological investigation, and the control of unusual infectious diseases. Team members, of American, Australian, British, and German nationality, have been drawn from institutes participating in the WHO Global Outbreak Alert and Response Network.

The outbreak in southern China is linked geographically and by timing to the current outbreak of SARS, which first surfaced in Asia in mid-February and caused its first known death on 13 Mar 2003. Cases of this new disease have now been detected in 13 countries on three continents. Hong Kong SAR China, which as of today accounts for 203 of the 350 suspected or probable cases reported worldwide, remains the most severely affected area.

Apart from searching for the causative agent, the WHO team is expected to help Chinese scientists determine whether the Guangdong outbreak included cases that fit the current definition of SARS.

Conclusive identification of the causative agent, which is thought to be a virus of the Paramyxoviridae family, would greatly aid the investigation by Chinese scientists and the WHO team, which is expected to begin on Monday.

Research on the identity of the SARS pathogen is progressing rapidly within a network of 11 leading laboratories set up by WHO earlier this week. WHO remains optimistic that a definitive announcement of the cause of SARS can be made soon.

[CathyRyan]

Yes, I would think so but I am far, far, from being an good source.

Others here are far better source than I

[Mother Abigail]

As at 21 Mar 2003, a total of 39 people with SARS have been reported to the Ministry of Health. The 5 additional patients reported today comprise 4 hospital staff and 1 close contact of a patient. Three patients have been discharged from hospital. The other 36 patients are still in hospital. All the patients are stable except for 7 patients who are in a serious condition.

To date, apart from the 3 initial people who had travelled to Hong Kong, a total of 19 family and friends of cases, and 17 hospital staff have been diagnosed with SARS. So far, all the cases of SARS have been linked to the initial 3 cases. No new index cases have been reported. In addition, no further cases have occurred among hospital staff as a result of infection from known or suspected cases of SARS after the implementation of enhanced infection control precautions.

Schools and preschool facilities will reopen on 24 Mar 2003. The Ministry of Health and the Ministry of Education have assessed that there is no need to extend the school break. The spread of SARS is still confined to family and friends, and hospital staff who have had close contacts with infected patients. As an added precautionary measure, the children of contacts of known cases will be asked to stay away from school for another week. This is to prevent any community spread. MOH is also working closely with the Ministry of Education and the Ministry of Community Development and Sports to step up vigilance in schools, preschools and child care centres. Children who have fever will be asked to seek medical attention and to return to school only when they are well.

MOH would like to appeal to all parents whose children have been to Hong Kong, Guangdong province in China, or Hanoi to closely monitor their children. They should not be sent to school if they have fever and should be seen by a doctor immediately. All schools and preschools have been advised through the Ministry of Education and Ministry of Community Development and Sports to look out for children who are unwell with fever and have been to the affected areas. Such children will be immediately isolated and their parents contacted to bring them to seek medical attention.

[Mother Abigail]

The following is jointly issued by the Department of Health and the Hospital Authority: As of 3 PM today (21 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 bracket are those with symptoms of pneumonia)

Staff of Prince of Wales Hospital (PWH) admitted to: Prince of Wales Hospital 57 (57)

Prince of Wales Hospital (Private doctors) 2 (2)

Kwong Wah Hospital 3 (2) \

Princess Margaret Hospital (PMH) 3 (3)

Tseung Kwan O Hospital (TKOH) 1 (1)

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

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

Tuen Mun Hospital 1 (1)

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

Staff of a private hospital in Kowloon admitted to: Princess Margaret Hospital 2 (2)

Pamela Youde Nethersole Eastern Hospital 1 (1)

Total 93 (89) Two of the health workers were discharged

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

C. Other Patients (numbers in bracket are those with symptoms of pneumonia) Patients, patient's family members & visitors PWH, PMH, KWH, PYNEH, QEH, TKOH & Queen Mary Hospital 93 (91) 4 of the patients were discharged

Total admissions (A + B + C) 203 (197)
7 were discharged

[Mother Abigail]

Part 2 - Students' health under
The Department of Health (DH) confirmed 4 child cases of atypical pneumonia, who are now under treatment in hospitals. The consultant in charge of the Disease Prevention and Control Division of DH, Dr Tse Lai-yin, said the 4 children comprised two 15 year old twin sisters, a 5 year old girl and a 7 year old boy. They are among the 165 people confirmed today to have contracted atypical pneumonia.

The twin sisters have been taking sick leave from their schools, namely Tak Oi Secondary School and CCC Heep Woh College in Wong Tai Sin since 13 Mar
2003. They were admitted to the Princess Margaret Hospital (PMH) on 14 Mar 2003 and they are in a serious condition.

"DH staff visited their schools on 14 Mar 2003. Investigations showed that the general environmental condition of the schools is good and that students and teaching staff have not reported unusual patterns of sickness in relation to the outbreak," Dr Tse stressed.
"The 2 sisters are likely to have contracted the disease from their mother who is a health care worker in the Prince of Wales Hospital (PWH) and has been confirmed to have contracted the disease earlier," Dr Tse added.

The other 2 cases, the 5 year old girl and the 7 year old boy, were admitted to PWH on 16 and 18 Mar 2003, respectively. They are in a stable condition. "They developed symptoms of upper respiratory tract infection on 13 and 17 Mar 2003, respectively.

"DH has informed the kindergarten and school, namely Diana Anglo-Chinese Kindergarten and SKH Holy Spirit Primary School in Sha Tin, of the situation. There is no sign that other students there have been infected," Dr Tse said. "We believed that the sources of the virus were not in the school and the kindergarten concerned. It is most likely that they contracted the disease from their sick family members who have been under treatment in PWH," Dr Tse noted.

Meanwhile, DH is investigating a suspected atypical pneumonia cases in which the younger sister of the boy, aged 4, is suspected to have contracted the disease. She developed symptoms on 14 Mar 2003 and was admitted to PWH for observation.

[CathyRyan]

Lets just say I would not drop dead from shock if the number are higher than what TPTB claim they are.

[Mother Abigail]

SARS case update from Taiwan CDC 21 Mar 2003

The Center for Disease Control, Department of Health, Taiwan, reports the 5th and 6th cases of probable SARS at this day. The 5th case is a 37 year old woman who traveled to Guangdong, China, from 2 Feb 2003 to 11 Mar 2003, and returned to Taiwan. On 13 Mar 2003, she developed symptoms compatible with SARS. Chest radiography revealed infiltrates over bilateral lower lobes.

The 6th case is a 25 year old man who had not recently travelled to China or Hong Kong, or the regions with epidemic. He developed symptoms compatible with SARS on 17 Mar 2003, while his father was the index case in the family and also the first reported case in Taiwan. His chest radiographs showed infiltrates in both the upper lobes. His father travelled to Guandong, China, during the period 5 to 21 Feb 2003 and returned with symptoms of flu and developed SARS early in March 2003. Both cases are already treated in isolated environment.

All necessary sampling for pathogen study and isolation procedure have been undertaken. The health authority in Taiwan continues to keep close observation and surveillance and to provide all necessary health care for these individuals.

[Mother Abigail]

A 36 year old Argentine woman was rushed to hospital off a flight from Rome on Friday after showing symptoms of what could be a mysterious deadly pneumonia spreading fear across the world, officials said.

A World Health Organization researcher who was among the first to investigate the outbreak of SARS in Hanoi last week is the first victim of the disease in Thailand, according to Bamrasnaradura Hospital in Nonthaburi. [A 40 year old male physician] is currently in critical condition. He is being closely monitored by the medical team. He entered Thailand on 11 Mar 2003 and was immediately transferred to the hospital with flu symptoms and high fever which later developed into pneumonia.

Dr Somsit Tansuphasavasdikul, the doctor in charge of [this patient], said though no confirmation had been received from specimens of [his] phlegm and blood sent to the CDC in the US, his symptoms matched those of patients having SARS. [His] condition had been stable for the past few days, though he showed no signs of responding to treatment.

The condition of 2 suspected cases reported in Nopparat Ratchathani Hospital in Min Buri and in Lop Buri had improved, he said. WHO has also established a cooperative network with two daily teleconferences among the most affected Asian countries, Europe, and North America. "Participants are pooling data on cases and sharing X-rays, at this stage one of the main tools for distinguishing between suspected and probable cases," WHO said. According to WHO, the antiviral drug ribavirin had, to some degree, improved the clinical condition of patients in Hong Kong.

[Mother Abigail]

One point of interest in today's reports on this unfolding outbreak is the mention of local transmission occurring in Taiwan, a close contact of an earlier defined case of SARS. The number of cases continues to increase, but they continue to be in close contacts (either family or in health care personal) of initially identified SARS cases outside mainland China. Confirmation of the exact numbers of cases involved in the Guangdong outbreak is still pending, albeit the Xinhuanet newswire report in [6] [A] above mentions geographic involvement of 7 cities in the province. There is also mention of increasing surveillance in schools in both Singapore and Hong Kong as the condition has been identified in children who were family contacts of SARS cases.

We have also included the newswire report that the first case of SARS seen in Thailand was in one of the physicians who went to VietNam to investigate the outbreak of SARS in Viet Nam. A sobering reminder to everyone of the risks taken by the many individuals involved in the investigation of disease outbreaks. -

[Mother Abigail]

Unknown

[twntaipan]

And I would not be surprised if the HK authorities have not got a handle on 1)isolation of those definitely infected, including their immediate families or 2)how to accurately assess who genuinely has the disease.

Despite the official secracy in China regarding the Guangdong outbreak, China has too many people coming and going (their own nationals and foreigners as well) to keep an epidemic with high infection rates and deaths completely hidden from the world.

Which brings me back to my on tin-foil hat position: their are environmental or cultural factors at play that are causing the number of infections to be particularly high in Guangdong province and Hong Kong (Hong Kong Chinese are Cantonese as are the people of Guangdong).

[Domestic Church]

SARS ?=? fast AIDS...Mmmm

Obviously not the same virus but the idea is worth considering given the war and the vested interest of certain countries/entities in weakening western civilization . Well it certainly has raised my eyebrows to read that a WHO researcher now is critical with this. I would expect this Doc went in with full clinical armour on and probably worked under the protective airflow system one would find at the CDC, or any of the top institutes.

Unless there has been some biowarfare orchestration/machinations.

[Domestic Church]

"Well, I guess the question begs. Saddam or North Korea?"

China.

[CathyRyan]

Take the numbers 305-345 people sick
6,7,8 cities depending on who you believe
This has been going on since mid November

There is evidence of a certain degree of panic in China

[Mother Abigail]

The researchers said six Canadian victims of the infection, known as severe acute respiratory syndrome (SARS), contained evidence of the human metapneumovirus, part of a family of viruses called paramyxoviruses.

Artifact

The majority of children have been infected with hMPV by age five.

[Domestic Church]

"Schools and preschool facilities will reopen on 24 Mar 2003."

Too soon.

[riri]

A World Health Organization researcher who was among the first to investigate the outbreak of SARS in Hanoi last week is the first victim of the disease in Thailand, according to Bamrasnaradura Hospital in Nonthaburi

Whoa! I missed that (don't ask me how as it was bold). I am doing 4 or 5 things at once. Is this thing or is this thing not highly contagious? I am (half, admittedly) reading things that are leading me to different conclusions.

[CathyRyan]

In what two weeks worldwide we have about the same numbers that China claimed in three to four months. with double the death rate.