Severe Acute Respiratory Syndrome in Hong Kong

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Severe Acute Respiratory Syndrome in Hong Kong

• Department of Health
• Hong Kong SAR
• (as at 10 April 2003)

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Background
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Background

• The World Health Organization has recently
  received reports of Severe Acute Respiratory
  Syndrome in various parts of the World.
• There are people affected by atypical pneumonia
  in Hong Kong.
• The Department of Health, in conjunction with
  Hospital Authority, the University of Hong Kong
  and the Chinese University of Hong Kong are
  conducting a detailed investigation into the
  matter.
• Hong Kong is working closely with the World
  Health Organization to control and prevent the
  spread of atypical pneumonia

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What is Pneumonia?

• Pneumonia refers to an inflammation of lung or
  infection of lung which results in abnormal lung
  function.
• Pneumonia can be classified into typical and
  atypical cases.
• Typical pneumonia is usually caused by bacteria
  such as streptococcus pneumoniae. Symptoms
  include sudden onset of fever, chest pain, cough
  and purulent sputum.

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What is SARS/ atypical pneumonia?

• Atypical pneumonia is usually caused by
  influenza virus, mycoplasma, chlamydia and other
  unknown micro-organism.
• Common symptoms include fever, chills, cough,
  headache and general malaise
• Severe Acute Respiratory Syndrome, or SARS, is a
  form of atypical pneumonia caused by a new agent

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General Situation in Hong Kong
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Hong Kong SAR Communicable Disease Surveillance
System

• Comprising hospitals, clinics and laboratories in
  the public and private sectors
• monitoring the trends of influenza, pneumonia,
  Hand-foot-mouth disease, acute diarrhoeal
  disease, acute conjunctivitis and so forth
• stepped up surveillance on severe pneumonia cases
  in view of the atypical pneumonia outbreak in
  Guangdong Province in early February 2003
• Investigation, contact tracing of all severe
  community-acquired cases carried out

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Statistics on community-acquired pneumonia(CAP)
Year 2001 2002 2003 (till 8/4/2003)
No. of inpatient discharges deaths 24,400 18,000 5,897
No. of registered deaths 3026 3200 (provisional) N/A
Death rate per 100,000 pop 40.6 43.1 (provisional) N/A

• The estimated death rate per 100,000 pop as at
  10 April 03 is 1.8 for SARS.
• There is no unusual rise in the number of CAP
• The causes of CAP are similar to previous years
  (50 each of known causes and unknown causes)

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Chronology of SARS development in Hong Kong
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• 10.3.2003
• 12.3.2003
• 13.3.2003
• 18.3.2003
• 19.3.2003
• 21.3.2003

• Hospital Authority notified Department of Health
  (DH)
• DH made public findings of initial investigations
  and notified WHO
• WHO issued global alert on atypical pneumonia
• Set up a Steering Committee and an expert working
  group to oversee investigation and to implement
  preventive measures to contain spread
• Daily update on local situation
• WHO experts invited to provide technical support
• Paramyxovirus was identified by CUHK in some
  patients. Further investigation is required to
  establish if this is the causative agent.
• WHO issued preliminary clinical description of
  SARS recommended hospital discharge follow-up
  policy

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• 22.3.2003
• 24.3.2003
• 25.3.2003
• 26.3.2003
• 27.3.2003
• 31.3.2003
• 1. 4. 2003
• 2.4.2003
• 10.4.2003

• Coronavirus identified by HKU rapid diagnostic
  test established
• Interdepartmental effort stepped up to
  disseminate public health advice to the public
• Chief executive emphasized that prevention
  control of SARS was top priority of Government
• First seven cases of Amoy Garden residents
  reported
• Government announced major steps including
  quarantine of contacts in curbing the spread of
  the disease
• Amoy Garden Block E isolated
• Amoy Garden Block E residents evacuated
  isolated in camps while epidemiological
  investigations continued
• WHO advised postponing non-essential travel to HK
• Government announced home treatment programme

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Latest Developments
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Update of SARS situation in Hong Kong as at 1
pm, 10 April 2003

• Total 998 cases (25 were health care workers
  medical students, 75 were patients and their
  close contacts)
• 154 patients (15.4) were discharged
• Majority showing positive response to new
  treatment protocol
• 120 (12 ) needs ICU care
• 30 deaths (3) reported
• 70 of the deaths occurred in those aged gt60
  years old 77 in those with chronic illness

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Main epidemiological observations

• Low case fatality so far
• 3 (30 deaths out of 998 cases)
• most deaths among the elderly with underlying
  disease
• Majority of SARS cases can be linked to close
  contact with known SARS cases
• Healthcare workers, household contacts hospital
  visitors were major risk groups
• No SARS outbreaks occurred at community
  institutions
• e.g. schools, nursery, elderly homes
• Excluding Amoy Garden related cases, SARS in
  general community remains steady, about 20 cases
  a day

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Evidence from epidemiological findings

• Outbreak caused by new virus
• Close contact required for transmission, via
  respiratory droplets or fomite on contaminated
  surfaces
• No evidence of airborne transmission to date
• Incubation period typically 2 to 7 days, as long
  as 10 days
• Healthcare workers and close contacts at higher
  risk

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Prince of Wales Hospital Cases
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PWH SARS outbreak

• Sex distributionSex distribution (MF)11.2
• Likely mode of transmission of the disease is
  respiratory droplets spread close contacts
• Use of nebuliser in index patient facilitated
  spread of disease
• Health care workers, patients in ward visitors
  to patients, close contacts of hospital staff
  visitors were infected

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Symptoms of the PWH SARS cases
Symptoms Frequency
Fever 100
Chills 92
Malaise 90
Headache 84
Myalgia 67
Cough 50
Dizziness 49
Rigors 44
Sore throat 43
Runny nose 39
Productive cough 36
Fever with diarrhoea has been reported in some
cases
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Epidemiological linkage for PWH cluster
1 Mainland visitor Onset 15 Feb 03
PWH index patient Onset 24 Feb 03
Metropole hotel
Succumbed at KWH
1 American Chinese
3 Singapore visitors
Hanoi outbreak index case
2 Canadian visitors
Outbreak in Toronto, Canada
Outbreak in Singapore
A private hospital outbreak on Hong Kong Island
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Amoy Gardens Cases
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Amoy Garden SARS Outbreak

• Brief description
• Private housing estate established for 20 years
• Floor area of each flat 400 to 500 sq. ft.
• 19 blocks (Block A to S)
• Each block has 36 storeys each storey has 8
  flats
• 2001 census
• 19200 residents from 6755 domestic households
• SARS cases reported since 26 March
• As of 10 April, 289 cases were related to the AG
  cluster

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Epidemic curve of SARS cases in Amoy Garden as of
9 April 2003
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Preliminary assessment of Amoy Garden SARS
outbreak

• SARS cases first reported on 26.3.03, peaked on
  31.3.03
• The majority were adults aged 19 above
• More household in Block E were affected with
  clustering in Rooms 7 8
• Other blocks residents have later onset
  datesrepresenting secondary transmission
• Unusual clustering suggest local factors at work
• Need to rule out continuing source or
  predisposing factors affecting other blocks

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Control measures at Amoy Garden

• Epidemiological, environmental laboratory
  investigations
• Case investigation and contact tracing
• Call interdepartmental investigation
  groupcollect environmental samples , case
  control study, etc.
• Isolation
• Isolate Block E on 31 March 2003
• Evacuate Block E residents and placed them under
  isolation for 10 days
• Disinfection, Cleansing
• home environment
• public areas environmental hygiene
• Public education

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Prevention Control Measures
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Political commitment

• Secured funding of 200 million for
• Health service provision treatment
• Prevention of infection
• Public education

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Enhanced measures by DH

• Prevented introduction spread of SARS cases
  into outside Hong Kong at entry points
• Contact tracing
• Put close contacts of confirmed cases under
  stringent medical surveillance
• Public Health Laboratory Centre to accord top
  priority to test SARS cases
• Enhanced community liaison education targeting
  people at all walks of life
• Liaised with WHO other health authorities

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Prevent introduction spread of SARS

• Set up medical posts at the airport, ports
  border points since March 29
• People arriving at HK to complete health
  declaration cards for arrivals be given health
  advice
• Sent symptomatic arrivals/departures to treatment
  centres for check-up
• Stopped those suspected SARS cases from checking
  in for flights
• Set up hotlines for health advice

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Contact tracing

• Set up hotlines
• Requested all visitors of Ward 8A of PWH after
  1.3.2003, Metropole Hotel (9/F) UCH, etc. to call
  hotlines
• Requested air passengers of certain flights where
  SARS cases had been on board to call hotlines

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Stringent medical surveillance

• SARS has been made statutorily notifiable since
  March 27
• Appointed 4 clinics as centres of medical
  surveillance since 31 March 03
• Requested close contacts to stay at home report
  at centres daily for 10 days for medical
  surveillance
• Social contacts are given health advice advised
  to call hotline if any fever/cough developed

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Public Health Education Campaign

• Public places
• Housing estates
• Public transport, transport operators
• Schools, kindergartens, childcare centers
• Travelers
• Food premises
• General public
• Medical practitioners

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Productions by DH for the public

• TV/radio messages
• Health talk
• Hotline [phone])
• Website
• Posters
• Pamphlets

Productions by GIS

• Announcement in Public Interest
• Newspaper supplements

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Health advice to the public

• Build up good body immunity
• having a proper diet, regular exercise and
  adequate rest, reducing stress and avoiding
  smoking
• Maintain good personal hygiene
• wash hands after sneezing, coughing or cleaning
  the nose
• Maintain good ventilation
• Avoid visiting crowded places with poor
  ventilation
• Visitors to hospital patients are advised to take
  due precautions in infection control
• e.g. wearing face mask and gowns, wash hands

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Major Breakthroughs
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Major breakthrough(1)

• 1. Epidemiologic investigation of outbreaks
• to identify likely mode of transmission,
  incubation period, common presenting symptoms,
  high risk groups, linkages between clusters
• 2. Identification of agent
• CUHK human metapneumovirus
• HKU Corona virus
• 3. Developed a rapid diagnostic testGVU,
  HKU,CUHK,HA
• Reliability still under test
• Important for getting early treatment

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Major breakthrough (2)

• 4.Treatment
• Effective treatment available
• Over 95 of patients can recover
• Early treatment reduce the need for ICU care
• 5.Cooperation with the Mainland
• Held meetings with Hong Kong to share experience

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Conclusions
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• Hong Kong is safe for local residents as well as
  visitors
• Hong Kong has high quality medical and public
  health services
• adequate medical facilities to handle the
  situation
• effective disease surveillance and control
• WHO Up to date, the likely mode of transmission
  is via respiratory droplets
• Hong Kong continues to work with WHO CDC to
  prevent the spread of SARS
• WHO travel advice on 2 April 2003
• Consider postponing non-essential travel to Hong
  Kong Guangdong Province

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To know more

• Department of Healths Hotline [phone]
• Department of Healths 24 hour pre-recorded
  health education hotline[phone]
• Department of Healths website www.info.gov.hk/dh

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Thank you