2002-2004 SARS epidemic

The 2002-2004 SARS epidemic is an outbreak of severe acute respiratory syndrome, an emerging disease caused by the SARS-CoV coronavirus, which began in November 2002in Foshan, China. More than 8,000 people are infected and at least 774 people have died worldwide. It has been considered extinct since May 2004.

Spread of the SARS virus

Recognized as quite contagious (R 0 ≈ 2–3, compared to 12–18 for measles), and highly lethal (9% compared to 63% for Ebola), the SARS-CoV virus spreads from November 2002. Starting from China, it quickly travelled the globe following the axes of international passenger transport and reached 29 countries in a few months (see Table below). The evolution of contamination is exponential until May 2003 (see graph below), then stabilizes before falling.

Probable cases of SARS worldwide

Number of cases identified in July 31, 2003

Country

Case

Death

Lethality

 South Africa

1

1

100%

 Germany

9

0

0%

 Australia

6

0

0%

 Canada

251

43

17%

 Mainland china

5,327

349

7%

 South Korea

3

0

0%

 Spain

1

0

0%

 United States

27

0

0%

 France

7

1

14%

 Hong Kong

1,755

299

17%

 India

3

0

0%

 Indonesia

2

0

0%

Ireland

1

0

0%

 Italy

4

0

0%

 Kuwait

1

0

0%

 Macau

1

0

0%

 Malaysia

5

2

40%

 Mongolia

9

0

0%

 New Zealand

1

0

0%

 Philippines

14

2

14%

 Romania

1

0

0%

 UK

4

0

0%

 Russia

1

0

0%

 Singapore

238

33

14%

 Sweden

5

0

0%

 Swiss

1

0

0%

 Taiwan

346

37

11%

 Thailand

9

2

22%

 Vietnam

63

5

8%

Total

8,096

774

9.6%

 

History of SARS epidemic:

November 2002 

November 16, 2002, a farmer from Shunde District, Fushan County, is identified as probable patient zero. February 10, 2003, the People's Republic of China informed the World Health Organization (WHO) of the epidemic, and mentioned 305 contaminations, including 105 health personnel, and 5 death. Later, she will indicate that the epidemic in Guangdong peaked in mid-February 2003 but it was far from it as 806 cases of infection and 34 deaths were subsequently reported.

At the start of the epidemic, the Chinese government slows down news organizations when they want to deal with SARS, delays notification to the WHO, and does not inform Chinese citizens outside of those in Guangdong province of where the disease would originate. A WHO team sent to Beijing is not allowed to visit Guangdong province for weeks, leading to international criticism that led to a slight change in government policy in early April.

January 2003 

The first superinfector patient is probably a fishmonger who visited Sun Yat-sen Hospital in Guangzhou on January 31. It infected 30 health workers and the virus quickly spread to nearby hospitals.

February 2003 

In February 2003, the epidemic reaches Hong Kong. The Patient Zero in the peninsula is a doctor came to attend a wedding; he was on staff at Sun Yat-Sen hospital in Guangdong and had treated patients with SARS. 21st of February, the doctor and his wife stay at the Hotel Metropole and visit their family. February 22 in the morning, the doctor goes to the Kwong Wah hospital for treatment. He warns staff of the seriousness of the illness and asks to be placed in isolation. He died on March 4.

This Chinese doctor has also played the involuntary role of superinfector of SARS: 23 other guests of the Metropole hotel develop SARS, including seven on the same floor as him. Her brother-in-law was hospitalized on March 1 and died on March 19. It is estimated that around 80% of Hong Kong cases are due to this patient zero.

At the end of the month, the virus appeared in Hanoi, Vietnam, carried by a Chinese citizen who had stayed in the same hotel as patient zero in Hong Kong. He was admitted to the French Hospital in Hanoi on February 26, where it infects at least 38 staff members. He was evacuated to Hong Kong, where he died on March 13. A specialist in infectious diseases from the World Health Organization, Carlo Urbani, is part of the staff who examines the patient and observes the very high contagiousness, the novelty and the dangerousness of the disease. He himself was infected and died on March 29.

Around the same time, an elderly woman, who had also resided at the Metropole Hotel in Hong Kong, returned home to Toronto, Canada (February 23). She died at her home on March 5. Her son is infected, and in turn dies on March 13 at Scarborough Grace Hospital, from where the epidemic is spreading.

In Taiwan, February 25, a businessman returning from Hong Kong and Guangdong returns home. It infects the medical personnel who take care of him, as well as the members of his family. The medical staff were unaware of the risks and did not use respiratory protection such as masks.

March 2003

In Singapore, the 1st of March, a young woman of 26, who had resided in Hong Kong hotel, is admitted to Tan Tock Seng Hospital. She recovered, but her family members are infected and die.

In Hong Kong, March 4, a 27-year-old man, who had visited a guest on the 9th floor of the Metropole Hotel 11 days earlier, is admitted to Prince of Wales Hospital in Hong Kong. At least 99 hospital employees (including 17 medical students) are infected during treatment.

In Thailand, March 11 Dr. Carlo Urbani is in Bangkok, Thailand, attending a medical conference. Sick during the flight, he tells a friend who is waiting for him on arrival not to touch him, to call an ambulance and take him to the hospital. He is isolated in an intensive care unit. March 29, Urbani dies in Bangkok of a heart attack.

The 12th of March, WHO issues global alert regarding the emergence of a new infectious disease of unknown origin in Vietnam and Hong Kong. March 15, WHO issues new, higher-level global health alert speaking of mysterious pneumonia and SARS after cases in Singapore and Canada are identified. The alert includes an advisory for international travellers, healthcare professionals and health authorities. In the United States, the Centre for Disease Control (CDC) is issuing an unfavourable advisory to travellers planning to travel to affected regions of Asia (Hong Kong, Singapore, Vietnam and China).

March 17th, an international network of 11 laboratories is created to determine the cause of SARS and develop potential treatments. U.S. CDC says 14 suspected SARS cases are under investigation. March 20 The WHO reports that some hospitals in Vietnam and Hong Kong are operating with half the regular staff as many workers stay at home for fear of infection. WHO expresses concern that substandard care for infected patients could contribute to the spread of the disease.

March 25 Hong Kong officials say nine tourists contracted the disease from a mainland Chinese who boarded the same plane on March 15, Air China flight 112 to Beijing. The Singapore government begins to impose a mandatory quarantine on anyone infected.

March 27, the Hong Kong Ministry of Education and Manpower is shutting down educational institutions. Singapore Ministry of Education announces that all primary, secondary and middle schools will be closed until April 6, 2003. Polytechnics and universities are not affected.

The particular case of the Amoy Gardens housing estate in Hong Kong

March 30, Hong Kong authorities are quarantining Lot E of the Amoy Gardens subdivision due to a massive epidemic (more than 200 cases) in the building. The wing is completely closed and guarded by the police. Residents of the building are transferred to Lei Yue Mun Summer Camp and placed in quarantine. They are moving to Lady MacLehose Holiday Village on April 1, as the building is considered a health hazard. Most contaminations occur between apartments facing north-west that share the same sewage pipes. According to early hypotheses (from government circles), the virus was introduced into the residence by a patient with kidney disease (and SARS) who had traveled to the Prince of Wales Hospital to visit his older brother living on the seventh floor. The virus was then said to have spread through the water supply system, by air transmission, because some of the U-shaped siphons in the bathroom floors were dry and a sea breeze was blowing in the outbuildings and in the stairwell of the residence. Since then, we have been sure that the virus has spread through droplets or aerosols. Following this case, Lisa Casanova wrote in 2009 “that if SARS were to reappear in the future, water contaminated with fecal waste from infected individuals could be a vehicle of transmission […], water contaminated with these viruses could continue to pose a risk of exposure even after the infected individuals are no longer present ”.

April 2003 

On April 1, the U.S. government recalled non-essential staff from its consulates in Hong Kong and Guangzhou and advised U.S. citizens not to travel to the region.

April 2, Chinese medical officials are starting to talk about the epidemic. China's southern Guangdong province reports 361 new infections and 9 new deaths. The virus is detected in Beijing and Shanghai.

WHO advises travelers to avoid Hong Kong and Guangdong

April 3, a WHO scientific team lands in Guangzhou. In the Amoy Gardens subdivision in Hong Kong, fifteen residents quarantined at Lei Yue Mun summer camp are transferred to the Sai Kung outdoor recreation center after an overnight riot over shared toilet facilities.

April 4, the WHO team is investigating the first case of infection in Foshan County. The man infected four people but did not infect his family. A Chinese health specialist admits at a press conference not having informed the public sufficiently early about the epidemic. At the same time, the Chinese health minister says the disease is under control in most parts of mainland China and gives a list of seven drugs that he says are effective in curing SARS.

The US government imposes mandatory quarantine of anyone infected.

April 5, the Singapore government announces the extension of school closures.

April 6, a case of SARS is discovered in Manila, in a person returning from Hong Kong.

April 8, SARS is spreading to neighbouring Amoy Gardens housing estates in Hong Kong. WHO specialists remain cautiously optimistic about the possibility of containing the disease.

April 9, an American professor at Shenzhen Polytechnic dies of SARS in a hospital in Hong Kong. The Chinese government is modifying its health policy and opening its hospitals more widely.

April 11The World Health Organization issues global health alert for SARS as it becomes clear the disease is spread through global air travel.

April 12, the Center for the Study of the Michael-Smith Genome (from the British Columbia Agency on Cancer), announces that it has decoded the genetic makeup of the virus suspected to be the cause of the disease. In Toronto, three people die of SARS, bringing the death toll in Canada to 13.

April 16, WHO issues a press release indicating that the coronavirus identified by a number of laboratories is the official cause of SARS. The virus is officially named the SARS virus.

April 17, a first case of SARS in India is reported.

April 19, the Chinese premier threatens local officials who fail to report SARS cases. SARS Gains In Chinese Media; daily reports are given on new cases and new measures. April 20, Mayor of Beijing and the Minister of Health are replaced. Authorities speak of 300 cases in Beijing, then 407, and acknowledge the underreporting of cases.

22 april, Hong Kong schools are reopening in stages.

23 april, Beijing is closing primary and secondary schools for two weeks. Some faculties at Peking University are also closed. WHO issues travel advisories against travel to Beijing, Toronto and Shanxi.

Several cases of SARS are diagnosed in Taiwan, particularly at the municipal hospital. The government is shutting down the hospital, against the advice of hospital staff, and quarantining its 930 employees and 240 patients for two weeks.

April 24, the Hong Kong government announces a $ 12 billion (HKD) grant to help the tourism, entertainment, retail and restaurant industries.

April 26, theatres, nightclubs and other places of entertainment are closed in Beijing, along with shops, restaurants, markets, bars, universities, schools and many other businesses. Ministries and large state banks work with minimal staff.

April 28, WHO declares the epidemic extinct in Vietnam, with no new cases having been reported for 20 days

April 29, the member countries of ASEAN and China meet urgently in Bangkok, Thailand, without much success: only the creation of a working group and a uniform health control standard at airports are emerging.

April 30, the World Health Organization lifts the warning on travel to Toronto.

 

May 2003 

May 3, the FIFA Women's World Cup is moved to the United States, retaining its automatic qualification for China.

May 4, the number of newly infected people in Hong Kong drops to single digits.

May 19, WHO's annual meeting is held in Geneva.

May 20, WHO refuses to lift the tourist alert for Hong Kong and Guangdong, but accepts it three days later after a recount of the number of patients.

May 24, the number of newly infected patients reaches zero in Hong Kong, for the first time since the emergence in March.

May 24, about 20 new patients are reported in Toronto. AtMay 29, more than 7,000 people are in quarantine in Canada.

In Taiwan, administrators and staff at the Hoping Section of the Taiwan Municipal Hospital are facing disciplinary action by the government, and the hospital is being closed. Director of Taiwan Health Unit resigns onMay 25. The Ministry of Health is expanding the medical facilities dedicated to the treatment of patients with SARS.

May 31st, Singapore is removed from the WHO list of “infected areas”.

July 2003

The July the 5th, Taiwan is removed from the WHO list of “infected areas”.

October and November 2003 

Hong Kong Harbor Festival is held from October 17 at November 11, 2003, as part of a billion Hong Kong dollar program to revive Hong Kong's economy after SARS. This is a government funded event managed by InvestHK, in conjunction with the US Chamber of Commerce.

December 2003 

The December 10, a researcher from a SARS lab in Taiwan is infected after returning from Singapore for a conference. 74 people are quarantined in Singapore but none are infected.

The December 27, China announces a case of SARS in Guangdong, in an individual who is not a SARS researcher.

 

January 2004 

January 5, China confirms the case reported in December is a case of wild-origin SARS.

January 10, a restaurant worker in Guangdong falls ill: this is the second case of SARS of wild origin since the epidemic was contained.

January 17th, China announces a third case of SARS in Guangzhou.

WHO specialists are asking for reliable tests to establish the three cases. They reveal to have detected the virus in the masked palm civet cages of the restaurant where the second case worked and in the civet cages in the market. Civets are slaughtered in markets for fear that they represent a reservoir for the disease.

January 31, China announces a fourth case of SARS in a 40-year-old doctor from the southern city of Guangzhou.

 

April 2004 

Beijing City and Anhui Province are experiencing a resurgence of SARS. April 19, a 53-year-old woman dies; nine new cases are detected, including a student and a researcher from the Chinese Center for Disease Control and Prevention.

May 2004

Five new cases of SARS are reported in Beijing on May 1, all linked to a research lab at the National Institute of Virology in Beijing. “The cases were linked to experiments using live and inactive SARS coronaviruses at the CDC's Virology and Diarrhea Institutes where interdisciplinary research on the SARS virus is being conducted. "The total number of cases is six, four in Beijing and two in Anhui.

May 2, China announces that the resurgence of SARS has resulted in the contamination of nine people. 189 people are released from their quarantine.

May 18As no new infections were reported for a period of three weeks, the WHO announces that China is free from new cases of SARS, but declares that "biosecurity problems persist.

 

Subsequent event after SARS epidemic

The causes of the extinction of the epidemic remain obscure. The containment measures are believed to have limited the spread of the virus to the point that it has no longer found a way to replicate.  Factors related to the ecology of the virus itself may explain its own extinction. It is therefore poorly resistant to tropical environments: "SARS [Severe Acute Respiratory Syndrome] stopped a few years ago in Vietnam because the temperatures were too high for the environment and for the virus" , explains on LCI Dr Gérald Kierzek. Likewise, the low number of asymptomatic patients favors rapid medical treatment and gives health teams a head start.

In October 2004, during a trip to Beijing, the President of the Republic, Jacques Chirac, seals an alliance with his Chinese counterpart and the two countries decide to join forces to fight against emerging infectious diseases. This partnership leads to the construction of a P4 type laboratory at the Wuhan Institute of Virology despite the reluctance of French bacteriological warfare experts from the SGDSN (General Secretariat for Defense and National Security) who fear that a P4 can turn into a biological warfare tool. This concern fuels catastrophist and conspiratorial theories.

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