Progress of the SARS outbreak

The following is a timeline of severe acute respiratory syndrome (SARS).

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November 2002

On November 16, 2002 an outbreak of what is believed to be severe acute respiratory syndrome (SARS), otherwise known as Yellow Pneumonia, began in the Guangdong province of China, which borders on Hong Kong. The first case of infection was speculated to be a farmer in Foshan County. The People's Republic of China (PRC) notified the World Health Organization (WHO) about this outbreak on February 10, reporting 305 cases including 5 deaths; it was later reported that the outbreak in Guangdong had peaked in mid-February, but that appears to be false, as later 806 infections and 34 deaths were reported.

Early in the epidemic, the PRC discouraged its press from reporting on SARS and lagged in reporting the situation to the World Health Organization, delaying the initial report. Initially, it did not provide information for Chinese provinces other than Guangdong, the province where the disease is believed to have originated. [1] For example, a WHO team that travelled to Beijing was not allowed to visit the Guangdong province for several weeks. This resulted in international criticism which seemed to have caused a change in government policy in early April. The PRC Health Minister has apologized for early delays in reporting and has been holding regular press conferences. The PRC government appears to have issued directives that the press should not refrain from stating bad news and that government officials should accept media supervision.

February 2003

On February 21, a Chinese doctor who had treated cases in Guangdong checked into the Hong Kong hotel Metropole and infected up to twelve other guests there. He was admitted to the Hong Kong Kwong Wah Hospital and died on March 4. A 27-year-old infected man who stayed in Metropole and on the same floor with the Chinese doctor was admitted to Prince of Wales Hospital. A large number of hospital workers were infected while treating him. About 80% of the Hong Kong cases have been traced back to this doctor.

On the 25th, a businessman who had travelled in Hong Kong and Guangdong Province returns home to Taipei. The outbreak on the island of Taiwan begins. Also, another person who was at the Metropole returns to Singapore.

On February 26, the American businessman Johnny Chen who lived in Shanghai travelled via Hong Kong, where he stayed in the Metropole Hotel, to Singapore. On the flight he fell ill and the plane diverted to Hanoi, Vietnam, where he was admitted to The French Hospital of Hanoi on February 26. After the disease was transmitted to a number of hospital workers there, he was returned to Hong Kong where he died on March 14.

WHO doctor Carlo Urbani, who was based in Hanoi, noticed the outbreak among hospital workers there and first identified SARS.

Almost all of those infected to date have been either medical staff or family members of people who have fallen ill. It is believed that all affected medical staff were not using respiratory precautions, a safety protocol that should fully protect medical workers, at the time of exposure. The various cases around the world are directly or indirectly traceable to people who have recently visited Asia.

March 2003

On March 11 Carlo Urbani travels to Bangkok to attend a medical conference. On the flight he falls ill and upon arrival in Bangkok tells an awaiting friend not to touch him and to call an ambulance to take him to a hospital. He is isolated in an intensive care unit.

A similar outbreak of a mysterious respiratory disease is reported among healthcare workers in Hong Kong.

On March 12 WHO issues a global alert about a new infectious disease of unknown origin in both Vietnam and Hong Kong.

On March 15 WHO issues a heightened global health alert about the mysterious pneumonia with a case definition of SARS as after cases in Singapore and Canada are also identified. The alert includes a rare emergency travel advisory to international travelers, healthcare professionals and health authorities.

CDC issues a travel advisory stating that persons considering travel to the affected areas in Asia (Hong Kong, Singapore, Vietnam and China).

On March 17 An international network of 11 leading laboratories is established to determine the cause of SARS and develop potential treatments.

CDC holds its first briefing on SARS and says the first 14 suspected SARS cases are being investigated in the U.S.

On March 20, WHO reported that several hospitals in Vietnam and Hong Kong were operating with half the usual staff, because many workers stayed home out of fear of getting infected. WHO raised the concern that substandard care of the infected patients may contribute to the spread of the disease.

On March 25, Hong Kong authorities said nine tourists came down with the disease when a mainland Chinese man infected them on a March 15 Air China flight to Beijing. SARS starts to hit Amoy Gardens Block E heavily.

The Singapore Government enforced compulsory quarantine of any infected person.

On March 27, Arthur K. C. Li, the head of the Hong Kong Education and Manpower Bureau, announced class cancellation of all educational institutions. The Ministry of Education of Singapore announced that all primary schools, secondary schools and junior colleges will be shut until April 6, 2003. Polytechnics and universities are not affected.

On March 29, Dr. Urbani died in Bangkok of a massive heart attack.

On March 30, Hong Kong authorities quarantined the estate E of the Amoy Gardens Apartment due to a massive (200+ cases) outbreak in the building. The balcony was completely closed of all uses and guarded by the police. The residents of the building were later transferred to the quarantined Lei Yue Mun Holiday Camp and Lady MacLehose Holiday Village on April 1 because the building was deemed a health hazard. Most of the cases were tied to apartment units with a north-western orientation that shared the same sewage pipe. According to government officials, the virus was brought into the estate by an infected kidney patient (type of kidney illness has not been specified) who after he was discharged from Prince of Wales Hospital, visited and thus infected his elder brother living in a flat on the seventh floor. Through excretion the virus spread through plumbing. One speculated theory that supported airborne transmission was that the virus was spread through dried up U-shaped P-traps in the plumbing and was blown by a maritime breeze to the ventilation of the estate's balcony and stairwells. It was confirmed that the virus can spread via droplets, but this latest outbreak made the officials question the possibility of spreading through the air.

April 2003

On April 1, the U.S. government called back non-essential personnel in their consulate office in Hong Kong and Guangzhou. The US government also advised US citizens not to travel to the region.

On April 2, Chinese medical officials began reporting the status of the SARS outbreak. China's southern Guangdong province reported 361 new infections and 9 new deaths, increasing the total Mainland China figures previously reported at end-February. The virus was also detected in Beijing and Shanghai. The WHO also advised travelers to avoid Hong Kong and Guangdong during a press briefing. [2]
A Hong Kong boy was also arrested for spreading rumors on the Internet that Hong Kong was being declared an infected area.

On April 3, a WHO team of international scientists landed in Guangzhou from Beijing to discuss with officials but has yet to inspect any suspected origin or any medical facilities on progress of infection control. 15 of the quarantined Amoy Gardens residents at Lei Yue Mun Holiday Camp have been relocated to the Sai Kung Outdoor Recreation Centre after an overnight protest on washroom sharing. The first medical worker infected with SARS died in Hong Kong. The doctor was survived by a daughter and his infected wife who is also among the quarantined medical workers under intensive care. Hong Kong school closure was extended by two weeks to April 21.

On April 4, the WHO team inspected the first infection case in Foshan County. The male infected four people but did not infect his family. A 40-year-old woman became the first local case in Shanghai. A Chinese health specialist admitted at a press conference of not informing early enough on the outbreak. The PRC Health Minister also claimed that the disease has been under control in most parts of mainland China. He also released the names of seven drugs which he claimed to be effective in curing SARS. WHO officials said that the information provided by the PRC about the disease has been "very detailed". US government enforced compulsory quarantine of any infected person.

On April 5, the Singapore government announced that school closure will be extended. Junior colleges will reopen on April 9, secondary schools on April 14 and primary schools and pre-schools on April 16.

On April 6 a SARS case was found in Manila, from a person who returned from Hong Kong.

On April 8, SARS starts to plague the Lower Ngau Tau Kok Estate near Amoy Gardens in Kowloon. Hong Kong health officials warned that SARS had spread so far domestically and abroad that it was here to stay. Nevertheless, WHO officials remained cautiously optimistic that the disease could still be contained. [3]

On April 9, James Earl Salisbury died of SARS at a hospital in Hong Kong. An American Mormon^[1] and a teacher at Shenzhen Polytechnic,^[2] he had been sick for approximately one month before his death,^[3] but was originally diagnosed with pneumonia.^[4] His son Michael "Mickey" Salisbury was with him in China and also contracted the disease, but survived it.^[5] Salisbury's death led to more open admissions by the Chinese government about the spread of SARS.^[6]

On April 10, Dr. Jim Hughes, the head of infectious disease at the CDC, confirming the warnings of Hong Kong health officials, claimed that he believed that SARS could no longer be eradicated in the Far East. However, he remained hopeful that it could be prevented from spreading widely in North America. [4]

On April 11 the World Health Organization issues a global health alert for SARS as it becomes clear the disease was being spread by global air travel.

On April 12, Dr. Marco Marra, director of the Michael Smith Genome Sciences Centre, which is part of the British Columbia Cancer Agency, announced that scientists at his center had broken the genetic code of the virus suspected of causing the disease. [5] In Toronto three more people die of SARS, bringing the Canadian death toll to 13.

On April 16, the WHO issued a press release stating that the coronavirus identified by a number of laboratories was the official cause of SARS. The virus was officially named the SARS virus. [6]

Doctors were surprised to discover the occurrence of at least two cases of SARS in Dinnur, a village near Bangalore, India. Poor hygiene and a lack of adequate trash disposal seemed to have hastened the spread of the deadly disease.

On April 19, Premier of the People's Republic of China Wen Jiabao announced that there would be severe consequences for local officials who do not report SARS cases in a timely and accurate manner, signalling at a major change in policy. (SARS had also been gaining prominence in the mainland Chinese media; by late April, it had jumped from virtual invisibility onto the front-page, with daily reports from all provinces on new cases and measures.)

On April 20, Beijing mayor Meng Xuenong and health minister of the PRC Zhang Wenkang were replaced respectively by Wang Qishan from Hainan and the former deputy health minister Gao Qiang. They are the first two high rank officials in the PRC to be dismissed because of the fallout of the epidemic. In the news conference chaired by Gao Qiang several hours earlier, the PRC admitted that in Beijing there are more than 300 cases, as opposed to the previous figure of only 37. One day later the figure has increased to 407. Chinese officials also admitted to major underreporting of cases, which were attributed to bureaucratic ineptitude.

22 April: Schools start to reopen in stages in Hong Kong.

On April 23, Beijing announced that all primary and secondary schools will be closed for two weeks. A few days before, some colleges in Peking University had been closed because some students had been infected. The WHO issues travel advisories against Beijing, Toronto, and Shanxi Province[7].

On April 24, the Hong Kong Government announced a HK$11.8 billion relief package designed to assist Hong Kong's battered tourism, entertainment, retail and catering sectors, consisting of a waiver of tourism- and transport-related licence fees, and HK$1 billion allocated for tourism promotion overseas. The package also includes a salaries tax rebate, and reduced rates.

On April 26, Wu Yi is named Zhang Wenkang's replacement as PRC health minister.

On 26 April-27, Chinese authorities closed down theaters, discos, and other entertainment venues in Beijing as the death toll in Beijing continued to rise, threatening to become the worst hit area of the country, eclipsing the Guangdong province. Authorities are bolstered by the fact that the infection rate seems to have declined, with the Guangdong region only exporting 3 new infections over the weekend. The economic impact is becoming dramatic as shops, restaurants, markets, bars, universities, schools and many other businesses have closed, as well as some government ministries and large state banks are working with minimal staff levels.

On April 28, WHO declared the outbreak in Vietnam to be over because no new cases were reported for 20 days.

Also on April 29, leaders of member countries of ASEAN and the PRC premier held an emergency summit in Bangkok, Thailand in order to address the SARS problem. Among the decisions made were the setting-up of a ministerial-level task force and uniform pre-departure health screening in airports.

On April 30, the World Health Organization lifted the SARS travel warning for Toronto. The decision was made because "it is satisfied with local measures to stop the spread of SARS". Canadian officials say they will step up screenings at airports [8].

May 2003

On 4 May the newly infected number of people in Hong Kong drops to a single digit.

On 7 May no (??) Hong Kong medical personnel is infected for the first time.

On 19 May the WHO Annual Meeting is held in Geneva. Hong Kong pushes for the Tourism Warning to be lifted.

On 20 May the WHO refuses to lift the Tourism Warning.

On 23 May, after a re-count of the number of SARS patients in hospital, WHO lifts the Tourism Warning from Hong Kong and Guangdong.

On 24 May, the number of newly infected patients is zero for the first time in Hong Kong, since the outbreak in the city in March.

On 24 May, a new cluster of about 20 suspected patients is reported in Toronto.

By 29 May, more than 5000 people were quarantined in Canada by authorities seeking to control the potential spread of this new SARS outbreak.

On 31 May, Singapore is removed from WHO's list of 'Infected Areas'.

June 2003

On 23 June, Hong Kong is removed from WHO's list of 'Infected Areas'. The three places left on the list are Toronto, Beijing, and Taiwan.

On 27 June, the World Health Organization said the world population should be SARS-free within the next two to three weeks, but warned the disease could emerge in China next winter.

July 2003

On 5 July, WHO declared the SARS outbreak contained and removed Taiwan from the list of affected areas. There have been no new cases for 20 days although around 200 people are still hospitalized with the disease.

September 2003

A worker in a SARS research lab in Singapore contracts the disease.

December 2003

A researcher in a SARS lab in Taiwan comes down with SARS after returning from Singapore attending a medical conference, 70 people in Singapore have been quarantined.

At the end of December, China announced a suspected case of SARS from the area the virus originated and in an individual who was not a SARS researcher.

January 2004

5 January: China confirms that the case reported in December is a case of wild source SARS. The Philippines announced a possible case in a person just returned from Hong Kong.

7 January: The Philippines announces that their possible SARS case is just pneumonia. China culls civets in markets, thought to be a reservoir for the disease.

10 January: A restaurant worker in Guangzhou province is confirmed as the second wild source SARS since the outbreak was contained. Guangzhou was also the site of the first case in December and is thought to be the origin of the virus in the original outbreak. Three Hong Kong television reporters who visited SARS related sites in Guangzhou were declared free of the disease.

17 January: China announced a third case of SARS in Guangzhou. WHO official urged more testing to bring the three recently announced cases into line with their standards; however they also announced SARS virus had been detected by a WHO team in civet cages at the restaurant where the second case works and in civet cages in the market.

April 2004

23 April: China announces first SARS death since June. An 53-year-old woman died on 19 April. Two other cases, both health care workers, one of which was the deceased woman's daughter. A fourth case was suspected in another health care worker.

The current outbreak is thought to have originated from a researcher, working on the SARS virus in a lab at the Institute of Virology in Beijing, who inadvertently caught the disease and ended up spreading it to the nurse taking care of him.

May 2004

1 May: Two additional confirmed cases of SARS and three additional suspected cases are reported in Beijing, all related to a single research lab. The total number of cases is 6, with 4 in Beijing and 2 in Anhui Province.

2 May: China announced the 3 suspected cases as genuine cases of SARS, bringing the total cases in recent outbreak to 9. 189 people were released from quarantine.

19 May: As no new infections are reported in a three-week period, WHO announces China is free of further cases of SARS.

Notes

References

• CDC Morbidity and Mortality Weekly Report - SARS section
• SARS: An Open Scar
• SARS: Timeline of an Outbreak