World Health Organization issues emergency travel
advisory
Severe Acute Respiratory Syndrome (SARS) Spreads
Worldwide
15 March 2003 | GENEVA -- During the past week, WHO
has received reports of more than 150 new suspected
cases of Severe Acute Respiratory Syndrome (SARS), an
atypical pneumonia for which cause has not yet been
determined. Reports to date have been received from
Canada, China, Hong Kong Special Administrative Region
of China, Indonesia, Philippines, Singapore, Thailand,
and Viet Nam. Early today, an ill passenger and
companions who travelled from New York, United States,
and who landed in Frankfurt, Germany were removed from
their flight and taken to hospital isolation.
Due to the spread of SARS to several countries in a
short period of time, the World Health Organization
today has issued emergency guidance for travellers and
airlines.
“This syndrome, SARS, is now a worldwide health
threat,” said Dr. Gro Harlem Brundtland, Director
General of the World Health Organization. “The world
needs to work together to find its cause, cure the
sick, and stop its spread.”
There is presently no recommendation for people to
restrict travel to any destination. However in
response to enquiries from governments, airlines,
physicians and travellers, WHO is now offering
guidance for travellers, airline crew and airlines.
The exact nature of the infection is still under
investigation and this guidance is based on the early
information available to WHO.
TRAVELLERS INCLUDING AIRLINE CREW: All travellers
should be aware of main symptoms and signs of SARS
which include:
 high fever (>38oC)
AND
 one or more respiratory symptoms including
cough, shortness of breath, difficulty breathing
AND one or more of the following:
 close contact* with a person who has been
diagnosed with SARS
 recent history of travel to areas reporting
cases of SARS.
In the unlikely event of a traveller experiencing this
combination of symptoms they should seek medical
attention and ensure that information about their
recent travel is passed on to the health care staff.
Any traveller who develops these symptoms is advised
not to undertake further travel until they have
recovered.
AIRLINES: Should a passenger or crew member who meets
the criteria above travel on a flight, the aircraft
should alert the destination airport. On arrival the
sick passenger should be referred to airport health
authorities for assessment and management. The
aircraft passengers and crew should be informed of the
person’s status as a suspect case of SARS. The
passengers and crew should provide all contact details
for the subsequent 14 days to the airport health
authorities. There are currently no indications to
restrict the onward travel of healthy passengers, but
all passengers and crew should be advised to seek
medical attention if they develop the symptoms
highlighted above. There is currently no indication to
provide passengers and crew with any medication or
investigation unless they become ill.
In the absence of specific information regarding the
nature of the organism causing this illness, specific
measures to be applied to the aircraft cannot be
recommended. As a general precaution the aircraft may
be disinfected in the manner described in the WHO
Guide to Hygiene and Sanitation in Aviation.
* * *
As more information has become available,
WHO-recommended SARS case definitions have been
revised as follows:
Suspect Case
A person presenting after 1 February 2003 with history
of :
 high fever (>38oC)
AND
 one or more respiratory symptoms including
cough, shortness of breath, difficulty breathing
AND one or more of the following:
 close contact* with a person who has been
diagnosed with SARS
 recent history of travel to areas reporting
cases of SARS
Probable Case
A suspect case with chest x-ray findings of pneumonia
or Respiratory Distress Syndrome
OR
A person with an unexplained respiratory illness
resulting in death, with an autopsy examination
demonstrating the pathology of Respiratory Distress
Syndrome without an identifiable cause.
Comments
In addition to fever and respiratory symptoms, SARS
may be associated with other symptoms including:
headache, muscular stiffness, loss of appetite,
malaise, confusion, rash, and diarrhea.
* * *
Until more is known about the cause of these
outbreaks, WHO recommends that patients with SARS be
isolated with barrier nursing techniques and treated
as clinically indicated. At the same time, WHO
recommends that any suspect cases be reported to
national health authorities.
WHO is in close communication with all national
authorities and has also offered epidemiological,
laboratory and clinical support. WHO is working with
national authorities to ensure appropriate
investigation, reporting and containment of these
outbreaks.
*Close contact means having cared for, having lived
with, or having had direct contact with respiratory
secretions and body fluids of a person with SARS.
For more information contact:
Dick Thompson - Communication Officer
Communicable Disease Prevention, Control and
Eradication
WHO, Geneva
Telephone: (+41 22) 791 26 84
Email: [EMAIL PROTECTED]
WHO issues a global alert about cases of atypical
pneumonia
Cases Of Severe Respiratory Illness May Spread To
Hospital Staff
12 March 2003 | GENEVA -- Since mid February, WHO has
been actively working to confirm reports of outbreaks
of a severe form of pneumonia in Viet Nam, Hong Kong
Special Administrative Region (SAR), China, and
Guangdong province in China.
In Viet Nam the outbreak began with a single initial
case who was hospitalized for treatment of severe,
acute respiratory syndrome of unknown origin. He felt
unwell during his journey and fell ill shortly after
arrival in Hanoi from Shanghai and Hong Kong SAR,
China. Following his admission to the hospital,
approximately 20 hospital staff became sick with
similar symptoms.
The signs and symptoms of the disease in Hanoi include
initial flu-like illness (rapid onset of high fever
followed by muscle aches, headache and sore throat).
These are the most common symptoms. Early laboratory
findings may include thrombocytopenia (low platelet
count) and leucopenia (low white blood cell count). In
some, but not all cases, this is followed by bilateral
pneumonia, in some cases progressing to acute
respiratory distress requiring assisted breathing on a
respirator. Some patients are recovering but some
patients remain critically ill.
Today, the Department of Health Hong Kong SAR has
reported on an outbreak of respiratory illness in one
of its public hospitals. As of midnight 11 March, 50
health care workers had been screened and 23 of them
were found to have febrile illness. They were admitted
to the hospital for observation as a precautionary
measure. In this group, eight have developed early
chest x-ray signs of pneumonia. Their conditions are
stable. Three other health care workers self-presented
to hospitals with febrile illness and two of them have
chest x-ray signs of pneumonia.
Investigation by Hong Kong SAR public health
authorities is on-going. The Hospital Authority has
increased infection control measures to prevent the
spread of the disease in the hospital. So far, no link
has been found between these cases and the outbreak in
Hanoi.
In mid February, the Government of China reported that
305 cases of atypical pneumonia, with five deaths, had
occurred in Guangdong province. In two cases that
died, chlamydia infection was found. Further
investigations of the cause of the outbreak is
ongoing. Overall the outbreaks in Hanoi and Hong Kong
SAR appear to be confined to the hospital environment.
Those at highest risk appear to be staff caring for
the patients.
No link has so far been made between these outbreaks
of acute respiratory illness in Hanoi and Hong Kong
and the outbreak of `bird flu,` A(H5N1) in Hong Kong
SAR reported on 19 February. Further investigations
continue and laboratory tests on specimens from Viet
Nam and Hong Kong SAR are being studied by WHO
collaborating centres in Japan and the United States.
Until more is known about the cause of these
outbreaks, WHO recommends patients with atypical
pneumonia who may be related to these outbreaks be
isolated with barrier nursing techniques. At the same
time, WHO recommends that any suspect cases be
reported to national health authorities.
WHO is in close contact with relevant national
authorities and has also offered epidemiological,
laboratory and clinical support. WHO is working with
national authorities to ensure appropriate
investigation, reporting and containment of these
outbreaks.
For more information contact:
Dick Thompson - Communication Officer
Communicable Disease Prevention, Control and
Eradication
WHO, Geneva
Telephone: (+41 22) 791 26 84
Email: [EMAIL PROTECTED]
*******************************************
Mystery Outbreak May Be a New Flu Strain
Health Experts: Mysterious Illness Outbreak in Asia Is
Probably a Virus, Maybe a New Flu Strain
The Associated Press
March 17 —
Health experts searching for the cause of a
frightening outbreak of a deadly flu-like illness in
Asia say the culprit is probably a virus, and they are
encouraged that some victims appear to be getting
better.
More than 150 people have fallen ill, mostly in Hong
Kong and Vietnam, over the past three weeks. And
experts suspect that another 300 people in China's
Guangdong province had the same disease beginning in
mid-November.
While experts are unsure precisely what is causing the
outbreak, several say their biggest fear is that it is
a new and lethal form of influenza.
"If it really is the flu, it could be we have a new
organism that could cause a pandemic," said Dr. R.
Bradley Sack, director of Johns Hopkins' international
travel clinic. "People immediately start thinking of
1917," when a worldwide flu epidemic began that killed
at least 20 million people.
So far, the disease has killed nine people seven in
Asia and two in North America. Its rapid spread, and
the discovery of two clusters in Canada, caused a rare
worldwide health alert to be issued on Saturday.
Health officials in China said Monday that the disease
that infected about 300 people and killed five in
Guangdong province "seems amenable to treatment,"
although they stressed there is still no link to cases
in other countries.
Asian airports were screening passengers for flu-like
symptoms, in the hope of stopping the spread of the
disease. Some fearful passengers wore surgical masks
or covered their faces to ward off infection.
Experts discounted the possibility that terrorism is
the source and believe it almost certainly is a
contagious infection that spreads most easily from
victims to their doctors, nurses and families through
coughing, sneezing and other contact with nasal
fluids.
"Nothing about that pattern suggests bioterrorism,"
said Dr. Julie Gerberding, head of the U.S. Centers
for Disease Control and Prevention in Atlanta.
Health officials say it may be several more days
before they are able to identify the disease. However,
they said several of its features suggest it is caused
by a virus, which can often be difficult to pinpoint
quickly using standard lab tests.
The illness is being called "severe acute respiratory
syndrome," or SARS. The incubation period appears to
be three to seven days. It often begins with a high
fever and other flu-like symptoms, such as headache
and sore throat. Victims typically develop coughs,
pneumonia, shortness of breath and other breathing
difficulties. Death results from respiratory failure.
The World Health Organization has been aware of the
outbreak for about three weeks but issued its global
alert this weekend because of concern that the illness
would spread to North America and Europe.
Officials said they are encouraged that some recent
victims seem to be recovering, although they are
unsure whether that is because of the many antibiotic
and antiviral drugs they have been given or simply the
natural course of the disease.
Dr. David Heymann, WHO's communicable diseases chief,
said three or four patients had stabilized enough to
be moved out of intensive care Sunday in Hanoi,
Vietnam, although all still had breathing problems.
The World Health Organization estimates that perhaps
500 people in all have been sickened if the earlier
outbreak in China turns out to be part of the same
disease, as they suspect it is.
Ninety percent of the most recent cases have been in
health care workers.
The CDC prepared cards that were being given to
travelers arriving from Hanoi, Hong Kong or Guangdong
province in China, warning they may have been exposed.
It recommended they see a doctor if they get a fever
accompanied by a cough or difficulty breathing over
the next week.
Investigators suspect a virus is involved, because
victims do not seem to respond well to standard
antibiotics, which kill only bacteria, and because
their white blood counts drop. That typically happens
with viral infections but not bacterial ones.
Few drugs exist for treating viral diseases and often
they must run their course until brought under control
by the body's natural immune defenses.
No cases have been confirmed in the United States, but
Gerberding said the CDC is checking out a few calls.
The North American fatalities were a woman and her
grown son who died in Toronto after visiting Hong
Kong.
A 32-year-old physician from Singapore suspected of
having the disease was taken off an airliner during a
stopover in Frankfurt, Germany, on Saturday after
being in New York City for a medical conference. He
was held in quarantine, along with his mother, who had
a fever, and his wife, who remained healthy.
However, on Sunday, the man's physician, Dr.
Hanns-Reinhardt Brodt, said he was uncertain the case
was SARS; he was treating him for ordinary pneumonia.
Also on Sunday, WHO released a report from the China
Ministry of Health on the Guangdong outbreak, which
said "the epidemic situation has been controlled and
the patients are being cured one by one."
In that outbreak, the Chinese said, 7 percent of
patients required breathing tubes, but most eventually
got better, especially if they were not also infected
with bacteria. The disease seemed to weaken as it
passed from person to person.
*********************************************
Outbreak Originated in China
Illness Peaked a Month Ago, Agency Told; Official
Media Silent
By John Pomfret and Peter S. Goodman
Washington Post Foreign Service
Monday, March 17, 2003; Page A01
BEIJING, March 16 -- The deadly pneumonia-like illness
that was the subject of a World Health Organization
warning on Saturday originated in southern China in
November and peaked a month ago, according to a report
the Chinese government provided to WHO officials.
The outbreak sparked months of panic buying of
vinegar, herbal remedies and antibiotics in China.
Epidemiologists suspect it is the same illness seen
over the past two weeks in Hong Kong, Vietnam, Canada,
Germany, Thailand, Taiwan, the Philippines, Singapore
and Indonesia.
But while news media in other parts of the world
reported WHO's warning, China's media were silent on
the issue today. None of the major Internet sites --
run by the official New China News Agency, China News
Service and Sina.com -- contained news of the warning.
Chinese journalists said they had been told not to
publish the warning until the end of the annual
session of China's legislature.
The illness, which originated in Guangdong province,
sickened about 300 people in China, with five dying.
In the subsequent wave in other countries, about 200
people have become ill, including 43 new cases
reported Saturday in Vietnam. There have been fewer
than 10 deaths in the second wave, although many
people are still critically ill.
No cases have been identified in the United States,
health officials said. But a Singaporean doctor
believed to be infected was taken off a New
York-to-Singapore flight in Germany on Saturday and
quarantined.
The illness has killed two family members in a suburb
of Toronto, and four other members of the same family
are in hospital isolation today. Two other people are
being treated in Toronto, one of whom had "close
contact" with the infected family and one who may have
contracted the illness while traveling. In British
Columbia, two people were confirmed to have been
infected.
The cause of the illness is unknown and is the object
of an intense international search.
>From the start of the outbreak, China's state-run
media have veered from silence to in-depth reports to
silence, providing a case study in how the government
tries to manage information on sensitive topics.
Reporting on the issue was banned in the early days of
the outbreak, journalists said. It was suddenly
permitted for a week in February. Then, apparently, it
was banned or severely limited again, Chinese media
sources said.
Despite China's report to the World Health
Organization, officials have been reluctant to
publicly link the outbreak in Guangdong province to
illness. In the only recent statement on the disease
by a senior Chinese official, Zhu Qingsheng, the
deputy health minister, told Wen Wei Po, a pro-Beijing
Hong Kong daily, on Friday that "no clue indicates
that the virus originated in Guangdong Province."
Guangdong's top official, Zhang Dejiang, called on the
local health authorities to set up an emergency task
force. In a sign of the prevailing fear and confusion,
he ruled out one possible cause of the outbreak
suggested by Hong Kong media. "This is not caused by
anthrax," he said. "Experts are still investigating
the cause."
The report sent to the World Health Organization by
the Chinese Health Ministry said the "peak of the
disease outbreak was during 3-14 February," and that
the number of new cases has since "decreased
markedly." However, the Wen Wei Po newspaper reported
over the weekend that the number of cases in Guangdong
province was increasing.
Throughout the country, witnesses reported panic
buying of vinegar, believed to kill the disease's
germs, antibiotics and an herbal cold remedy called
Banlangen, which sold out in stores as distant as
Xinjiang, 2,500 miles away. Some merchants have
profited mightily from the scare, quadrupling prices
of popular remedies.
The panic buying soon embroiled Roche Group, the Swiss
pharmaceutical giant.
On Feb. 9, Roche representatives held a news
conference in Guangzhou at which they discussed the
outbreak of the disease and handed out fact sheets
about one of their antiviral medicines, Tamiflu, as a
possible treatment. In the days that followed, someone
posted messages in Chinese-language chat rooms
asserting that "the only effective antibiotic" for the
virus was Tamiflu.
The medicine soon sold out in Guangzhou, according to
reports in the Chinese press, but Roche quickly
shipped in more from its factory in Shanghai.
Guangdong law enforcement authorities launched an
investigation and warned that Roche would be
"seriously punished if it was found to have spread
rumors that Guangdong was in the grips of a pneumonia
and bird flu outbreak." Roche has denied any role in
the Internet and mobile phone text messages. It said
that sales of Tamiflu had been strong in Guangdong
even before the media event there.
No bacterial or viral cause of the illness has been
found during routine testing. More elaborate studies,
capable of identifying exotic pathogens, have just
begun.
In the United States, the Centers for Disease Control
and Prevention is testing specimens from three cases
-- the first victim of the most recent outbreak, a
Chinese American man who fell ill in Hanoi on Feb. 26
and died in Hong Kong in early March, another Hanoi
patient who is still alive, and a 44-year-old Toronto
man who was apparently infected by his mother after
she returned from a visit to Hong Kong. (She died
also.)
A half-dozen other laboratories in Europe and Asia are
also studying material from patients.
Blood will be tested for antibodies to dozens of
organisms and will be "probed" for evidence of
microbial genes. Researchers will also try to grow
organisms, and will examine tissue with an electron
microscope to see if any are visible.
"We are keeping a very open mind. As far as I am
concerned, nothing has been ruled out completely,"
said James M. Hughes, director of the National Center
for Infectious Diseases at the Centers for Disease
Control.
Initial impressions suggest a virus is the cause. Some
patients have low white blood cell counts and low
platelet counts -- problems more commonly seen in
viral than bacterial infections. The fact that victims
don't appear to benefit from antibiotics also suggests
that a bacterium is not at fault.
Influenza would normally be the leading candidate for
the cause of an outbreak like this one.
China has large numbers of people, pigs and ducks
living in close quarters, and influenza virus infects
all three. In recent decades, China has been the place
where new strains of the virus have emerged. However,
WHO officials said yesterday that tests for influenza
A -- the more virulent of the two forms of the
influenza virus -- have all been negative. The Chinese
Health Ministry reported the Guangdong patients showed
no evidence of the "bird flu" strain of influenza A
that killed a few people and many chickens in 1997.
A few patients hospitalized in Hong Kong in the recent
wave of cases have antibodies in their blood
suggesting recent infection with influenza B, the
milder form of the virus. Such a finding is common in
winter, however, and the investigators doubt it is the
explanation.
There is a long list of other candidates, with a
family of microbes called the paramyxoviruses
"certainly ranking on the top of most people's
thoughts," said Klaus Stohr, a WHO virologist and
epidemiologist who is helping to direct the
investigation.
A paramyxovirus called Nipah was discovered in 1999
during an eight-month outbreak in Malaysia that killed
105 people out of 265 who became ill. Nearly everyone
had occupational exposure to pigs, and the main
symptom was brain inflammation -- two characteristics
strikingly different from the current outbreak.
Another paramyxovirus called Hendra caused three small
outbreaks in Australia in the 1990s. Some of those
victims had contact with infected horses.
David Heymann, head of communicable diseases for WHO,
said that officials in Vietnam reported Saturday that
most of the patients there were improving, and some
had been moved out of intensive care. Previously,
their condition was deteriorating.
"This is a real nasty infection. But it looks like
some are able to fight it off," Heymann said. "It is a
relief."
Staff writers David Brown and Rob Stein in Washington
and correspondent DeNeen L. Brown in Toronto
contributed to this report.
© 2003 The Washington Post Company
=====
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Tonight I have a message for the brave and oppressed people of Iraq:
Your enemy is not surrounding your country — your enemy is ruling your
country. And the day he and his regime are removed from power will be
the day of your liberation." -George W. Bush 1/29/03
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