The information provided is "as is" and uncorrected, except for typographical errors, as discovered by readers over time.

It was put on the World-Wide Web as the situation was understood at the time.

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• 30 april 2003. More than 100 new SARS cases identified in Beijing, while Shanghai remains practically immune and a low level of new cases in Guangdong persists. The situation in Shanxi is a matter of concern because the number of new cases seems to be on the rise. In Hong Kong the number of new cases remains constant now for a few days. Also, in Beijing it appears that some cases of mass contamination resembling the Amoy Gardens event is occurring. This might be the case at a dormitory in Northern Jiatong University. In contrast it seems remarkable, as published by a team at the Chinese University in Hong Kong, that children get a much milder form of the disease. It is time to look back at the situation of SARS in the world. The disease seems to be contained outside Eastern Asia, and officials from 12 countries met yesterday in Bangkok to set up rules for controlling health of travellers between their countries. We are facing a situation similar to that faced when the first acts of terrorism affected airplanes: appropriate facilities will probably have to be set up on a stable basis to monitor health parameters of travellers world-wide. The situation of SARS is at a turning point: a number of 5,000 affected people at the end of this month was thought to indicate the turning point where it might go out of control. Since we are just at this border, we still have hope, and the next figure of concern would be 10,000 by the end of may. A feature of great concern is the vast interest shown by companies for the possible royalties that might come out for the disease, triggering a dangerous competition between countries, hospitals and universities, at a time when collaboration is urgently needed (and remarkably well set up by the World Health Organisation).
• 28 april 2003. The news are mixed today: for one week the number of new cases in Hong Kong kept decreasing, raising hope that the measures implemented are effective and that SARS will be contained within one month. Unfortunately deaths of patients previously recruited was still high, rising the local death toll to almost 9%. However the local situation is certainly less serious than what is generally perceived in the absence of explicit information. People should not lower their guard however since a single case started the present world-wide outbreak. In Beijing the number of new patients is of the order of 100 per day, indicating a serious situation in the capital. The World Health Organisation however says that, learning from the situation elsewhere in the world, we still can hope that the disease will be contained. authorities in Beijing are implementing extremely stringent measures and a general cleaning program to prevent further spread of the disease. Patients are discovered throughout the Mainland suggesting that several causes contribute to the outbreak here or there.
• 27 april 2003. Beijing is now severely affected by SARS, and all public places such a cinemas or theaters have been closed for the time being. The People's University has also closed because SARS cases have been reported there. One of the most puzzling feature of SARS is the extreme difference between the situation in Beijing and in Shanghai (where only a few cases have been reported) despite the strong ties between Shanghai and Guangdong or Hong Kong. This is consistent with the double epidemic hypothesis, suggesting that people at some places might have been protected by a previous infection by an innocuous or mildly virulent virus. Another puzzle is the fact that the death toll appeared to increase at some places as compared to others. This may also be linked to the same hypothesis, with a variable virus segregating more virulent mutants. If this were the case, the use of many antivirals may be dangerous because they might enhance the mutation rate of the virus , as suggested by the rate of evolution witnessed in bacterial viruses. The Asian health ministers approved a plan to boost screening of possible SARS patients at international departure points, bar travelers with SARS symptoms (fever in particular), and require health declaration forms for visitors from affected countries. "We must use every weapon at our disposal," the regional director of WHO, Shigeru Omi, told the health ministers and senior officials from South East Asia, China, Hong Kong, Japan, and South Korea. A joint symposium on SARS was held in Hong Kong with scientific representatives of the region.
• 26 april 2003. While diagnostic kits for SARS are distributed world-wide, the WHO warns against inaccuracies inherently associated to these kits essentially based on the Polymerase Chain Reaction (PCR). Sensitivity is high but the genetic material of the virus is unstable, leading to false negatives. In contrast, once the assay has been used for some time, the rate of false positives may increase because of contamination of the diagnostic laboratories, unless extreme precautions are taken. After his official visit to Beijing the French Prime Minister stressed that panick is the worse reaction to an epidemic. There were 154 new cases in the Mainland (113 in Beijing) and 17 in Hong Kong. India has identified three new cases (7 in total). No new case in Vietnam for 18 days: it is now likely that the country will be the first one to have contained the disease, setting an example to other countries in the world.
• 25 april 2003. The number of new patients affected by SARS in Hong Kong seems to decrease slowly. Unfortunately the rate of deaths has increased significantly in the past few days, rising the overall death rate to 7.6%. Scientists are collecting isolates from various places and compare them. The first observations demonstrate that the virus is still in a rapidly evolving phase. This is consistent both with the nature of the virus (in general viruses, that are not real living organisms but parasites of life, mutate at a high rate because they do not have the elaborate "proof-reading" system present in most living organisms) and with the hypothesis that it comes from a non human host.
• 24 april 2003. The epidemic has apparently been contained in Vietnam. Figures in Mainland China, although much more accurate than previously are still difficult to evaluate since not all hospitals are able to tell SARS from other diseases with similar symptoms. Some Canadian scientists cast doubt on cause of SARS, because they do not find the suspected coronavirus in 50% of the cases, while they find it in control patients. It seems of the utmost importance that the community reaches a consensus since hundreds of scientists are working round the clock with the hypothesis that the virus is the cause, and are constructing diagnostic tests, and vaccine approaches on this hypothesis while the disease is still progressing. However the experiments with monkeys, showing the very symptoms of SARS, argue strongly in favour of the new coronavirus species as being the cause. For some reason, doubts systematically came from the same place, where some other cause might have altered the symptoms and/or the samples.
• 23 april 2003. Schools will be closed for a fortnight in Beijing. 24 cases and 6 deaths in Hong Kong. Claims about the efficacy of treatments have to be revised because it is extremely dangerous to extrapolate from textbook knowledge to a new type of infection. It seems clear that symptomatic treatment, when delivered early on might be helpful. The difficulty with any urgent situation as the present one is that one should do controlled experiments, ie compared the fate of many patients with, and without treatment, and this is morally difficult, in particular when some believe that this, or that treatment may be efficient. This is the only way out, however.
• 22 april 2003. In Hong Kong a cumulated total of 1,434 cases of SARS have been reported todate. The public perception of the disease worsens in Beijing while the Central government takes an entirely new and open attitude towards the challenges posed by the disease. It is in particular extremely difficult to be careful with a disease that only affects a minute portion of the population, to manage its possible extension (which could be considerable if nothing is done) while controlling the extremely dangerous economic consequences induced by panick. Involving the people in the fight, as done during the past few days in Hong Kong is probably one of the best solutions. There is also an urgent need for totally open collaboration between scientists throughout the world, an attitude that is dramatically illustrating the negative impact of the competition attitude induced by inappropriate management of successful behaviour in science. Part of the problem caused by the virus could be due not to contact through air, but because of an unusual stability on many surfaces. This indicates that excellent hygiene is most important at places where cases have happened.

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• 21 april 2003. The situation in Mainland China is somewhat confusing, as authorities in the provinces are trying to provide accurate figures for cases of SARS, at a moment when they often do not have appropriate means to identify cases. In Beijing the population begins to show its concern, after the two political dismissals of the day before, and one observes a large number of masks in train stations. The rumor spreads that the city might be completely closed for travels in and out within two days. The WHO now counts more than 4,000 cases world-wide, while the number of new cases in Hong Kong dropped significantly, unfortunately with still several deaths.
• 20 april 2003. At this date we may reach a turning point for the spread of SARS. Countries are resorting to drastic measures to slow down the spread of the disease. China, using a new method to count patients affected, recognizes that the disease has now severely reached Beijing, with more than 300 patients officially identified. In a political move without equivalent for 25 years, the mayor of the city as well as the Minister of Health were asked to resign from their position in the Communist Party, as a sign that they were not able to cope with the severity of the problem. In addition the Chinese Government has transformed the first week of May, used normally as a nation-wide vacation, into only one day vacation, in an attempt to prevent travels within the country. More than 1400 persons who went to an open market in Singapore where a patient was identified are confined for 10 days quarantine. Toronto has identified new cases that do not appear to be directly connected to previously identified patients, rising fear that the virus might now spread by air. The authorities are considering placing buildings, or even whole blocks, in quarantine. In Hong Kong the disease does not seem to recede. Lessons from the outbreak or Porcine Respiratory CoronaVirus twenty years ago show that the virus may even become airborne. The present virus is a totally new one, from yet unknown origin, but it is of interest to understand how similar viruses evolved in animal communities in the past. Several world-reknown scientists are now involved in the fight against SARS in Hong Kong, in particular David Ho (who devised tritherapy against AIDS), Jeff Copland, Michael Lai and Monto Ho (who solved an enterovirus outbreak in Taiwan several years ago).
• 19 april 2003. This is the worse day in Hong Kong since the beginning of the SARS outbreak, with 12 people passing away, while the number of new cases remains stable. Young people coming from Hong Kong have been placed in quarantine while they arrived from Hong Kong in UK. In a completely different context, the viral epidemic that plagues chicken farms in Netherlands and Belgium has made its first human victim. If this were to give rise to person-to-person transmission of the disease, a major epidemic of another type would be on the verge of starting. All this indicates that we must now be ready to take major measures to control the spread of contagious epidemics, throughout the world.
• 18 april 2003. The first three cases of SARS were reported yesterday from Australia, while the disease appeared to slacken its pace of infection in Hong Kong (1,327 cumulated cases, showing a steady state of infection at around 30 cases per day, similar to the figure before march 27th). India has also reported its first case but the description is not entirely consistent with SARS. At Amoy Gardens in Hong Kong, the cause of the outbreak is identified, suggesting that it would be easy to prevent further incidents of this type. If one takes out this episode, the epidemic in Hong Kong has features similar to that in Guangdong province, suggesting that it is starting to recede. However one must still be extremely cautious because a single patient may start a sudden outbreak, as repeatedly witnessed in the past month. The team at the Faculty of Sciences that sequenced the virus is analyzing its relationships with birds coronaviruses, as well as with similar viruses in other vertebrates. At this time the cause of the disease is consistent with the shift of an enterogastritis virus to a respiratory form, a Human Respiratory CoronaVirus (HCRV).
• 16 april 2003. In a remarkable breakthrough involving world-wide collaboration a Dutch laboratory demonstrates by experiments using monkeys that the new coronavirus recently identified is the cause of SARS. In Hong Kong, the sequence of a local isolate is completed, allowing comparison between three different isolates. While RNA viruses are always highly variable it will be of fundamental importance to link the severity of the disease with variations in the genome sequence. The virus being probably of animal origin it is certainly in a phase of adaptation to its new hosts, humans, and this may result in particularly virulent mutants. This also may result in attenuation: it is too early to know how the disease will evolve, although extrapolating from the situation in Guangdong should be seen as positive.
• 15 april 2003. The rise of the number of SARS cases world-wide is worrying, since it seems on the verge of beginning a pandemic. The cumulated number of cases in Hong Kong is 1232. Concern comes from the observation that, among the nine deaths recorded in 24 hours, several come from persons under 40 years of age, with no other disease. It is important to monitor the type of treatment used, since antivirals can be extremely toxic. Identification of the virus is still a challenge: a PCR test, developed by the CDC in Atlanta, has been shown to be ten times more sensitive than previous PCR tests for SARS. WHO experts hope that the test will be ready for distribution by the end of this week. The sequence of the isolate of the virus at the CDC has been completed, after a Canadian group sequenced another isolate. The virus differs significantly from previous isolates. Scientists are concentrating on the features of the "spikes" porteins, that are important for penetration into target cells.
• 13 april 2003. The World Health Organisation has raised several caveats about too early and misleading enthusiasm about diagnostic tools and remedies for SARS while a team of Canadian scientists announced that they have completed the sequence of the viral genome. The virus has unique features that make its origin still an enigma. It must be remembered however that the sequence of the AIDS virus is known since 1983 and that we are not yet rid of the disease, and also that antiviral molecules are very dangerous and often have severe secondary effects. Collaboration, without delay, with all relevant partners in the world is essential to try to contain the disease, and limit its extraordinary economic consequences already reaching some 40 billion US$. The team in Canada benefited from an excellent organisation of a team previously working on cancer and of the information provided through the WHO network. A second team at the CDC in Atlanta, with the support of scientists at the Bernhard-Nocht Institute, Hamburg as well as from Rotterdam and San Francisco, is completing the sequence of a second strain, while the Hamburg team is providing information to a company for distribution of free primers meant to help hospitals in the world to identify the virus. It is difficult to know at present whether the disease simply spreads in a linear fashion, or begins an exponential exploration of the available population. Reaching the number of 5,000 patients world-wide by the end of the month would be a sign suggesting that the disease may have become out of control. The transmission pattern still remains ununderstood, with some patients infecting a very large number of persons, while others remain infected while contaminating no other person. Strict quarantine measures are now implemented in Hong Kong, and Mainland China has created an efficient alert system that will be particularly important in the poorest parts of the country. The cumulated number of patients in Hong Kong reached 1,150. One should also note that, because of the lack of essential collaboration between scientists throughout the world, the cause of SARS is still disputed... This is very unfortunate at a time when the disease is spreading. The observation by groups in different continents that the same coronavirus is present in patients however substantiates the idea that it is the cause, rather than an accidental contaminant.

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• 11 april 2003. While it is likely that persons living at Amoy Gardens Estate left before the quarantine measures, the number of new cases increases more or less linearly (1,059 cases at 1 pm) in Hong Kong. Several laboratories of the WHO task force on SARS concentrate on the hypothesis that a new coronavirus, never previously identified from animals or humans is the main cause of the disease. The main problem now is to be able to trace the routes of propagation, by identifying contacts of patients. Hong Kong health authorities have announced that all household contacts of confirmed SARS patients will be required to confine themselves at home for up to 10 days with immediate effect. A similar measure will be implemented in the Mainland as soon as a way to identify the disease (remember that pneumonia are very frequent diseases) can be proposed.
• 9 april 2003. Our diseases are strongly linked to the way our society behave. This must be taken into account for analysis of the outbreak in Hong Kong, which reached 970 persons at 3 pm, with a still significant proportion of health care workers. Of course, one expects that scientists involved in the fight against the disease have a very open behaviour, widely sharing their results to increase the probability of finding rapidly a solution to the crisis, but is this what we are witnessing? The future will tell...
• 8 april 2003. At 3 pm, the cumulated number of patients in Hong Kong reached 928. Many hypotheses try to account for the sudden local outbreaks, in particular it is known that coronaviruses are not only involved in respiratory diseases, but also in gut diseases, suggesting that, in some cases they may survive in the gut and be propagated by a faecal-oral route. This hypothesis stresses again the important role of a good hand hygiene. Data are collected to explore this route. The disease, which appeared to have been contained in Hanoi might be reappearing elsewhere at other places in Viet Nam. One of the present difficulties is that diagnostic tests that have been initially proposed have been found to be somewhat problematic. The international collaboration set up by the WHO should however be able soon to provide a reliable test.
• 6 april 2003. The cause of contamination remains elusive, while 42 new persons are infected in Hong Kong. In Singapore the disease appears to be dying out, but there are still new cases, while the quarantine measures are very strictly enforced. In Mainland China, reported cases come from the whole of the country. In Guangdong, the total number of new cases is stable at around 10-15 cases per day. The total number of cases from Hong Kong is higher, in particular because 268 cases have been reported from the Amoy Gardens estate. This large number of cases still remains a puzzle. In the same way, the Singapore government is investigating the situation posed by 29 cases reported on March 29th, in the staff from two wards of the same hospital. It seems highly improbable that a single patient would be the cause of these almost simultaneous cases, suggesting an environmental parameter (which may be of similar nature as that at Amoy Gardens).
• 5 april 2003. In the USA, the cumulated number of patients affected by SARS reached 115, prompting the Federal Government to take action in terms of compulsory quarantine measures. In Hong Kong, the number of new patients rose again, to reach 39. Among those 10 are medical staff, 7 are persons who were residents of Amoy Gardens. The 22 remaining patients correspond to the steady state of the disease that appears to prevail for the last weeks. Two major observations about SARS puzzle observers: the disease is considerably biased towards affecting medical staff, and the outbreak at least at one place, the Amoy Gardens estate, mimicks what happened in hospitals with very high geographically concentrated clusters. In contrast the background of the disease, probably in Hong Kong as in the Guangdong province, stays more or less constant, neither increasing, nor decreasing. This makes the course of the disease highly unpredictable and its propagation route still very enigmatic. Among the many hypotheses that remain to be fully explored is the idea that two viruses, with somewhat different contamination properties, are needed to cause the severe form of the disease. The actual cause of the disease is not yet fully established. Health authorities are currently investigating other cofactors such as propagation through sewage pipes (Block E at Amoy Gardens is a 33 floors high rise building, and a large concentration of patients is in a vertical cluster) as well as airborne through some kind of particles coming from a neighbour construction site... The second patient in France has probably been contaminated while travelling on the plane from Hanoi to Paris.
• 4 april 2003. While the outbreak seems to level off in Hong Kong, new cases are discovered throughout the world. In Hong Kong at 1pm the cumulated number was 761, indicating a constant rate of infection. In the absence of any easily available test for identification of the disease, it is still difficult to count the number of real cases. Most definitions come from epidemiologic investigation and linkage with known cases, as well as clinical signs. This is the more difficult because clinical signs appear to vary from place to place. For example, in the USA, for some reason the clinical signs are milder than at other places. All this suggests that there may be co-factors to the disease, which is still not yet understood, and/or that the virus is still evolving extremely rapidly.

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• 3 april 2003. At 1 pm (local time) the cumulated number of cases in HK was 734, representing a sharp drop in the increase of new cases in Hong Kong. While the Mainland authorities have opened their hospitals for WHO investigation and help, many questions arise about the origin of the disease. It has been repeatedly stressed that SARS was originally detected in FoShan and HeYuan county, Guangdong Province. A local newspaper however tells that a medical professor in RenMin hospital of HeYuan county named Xie JinKui does not agree with that assumption. Prof. Xie said the first case in HeYuan was detected in 17th of Dec, last year (2002). The patient is a 35 year old man. He is a cook in ShenZhen, working in a restaurant where he has close contact with wild animals, such as snakes (see more about this story). Although the date does not fit with earlier descriptions of diseases similar to SARS in Guangdong, this raises interesting questions about the origin of the virus. In Hong Kong, if one removes the very special case of the Amoy Gardens Estate, the outbreak is constant since the beginning of march, not exponential. This suggests, as initially proposed, that the disease is propagated by (almost) close contacts only. The situation at Amoy Gardens has to be investigated in details, since it suggests another mode of propagation, specific to that particular place. It will be extremely important to understand what it could be.
• 2 april 2003 (see also the WHO press conference). Once the cluster of patients at Amoy Gardens reaches its maximum, the disease seems to be contained elsewhere in Hong Kong, suggesting that it may begin to become under control (a total of 708 cumulated cases since the begginning of the outbreak). The drastic quarantine measures implemented by the local government seem to have had a significant impact. However the outbreak has some unique features that suggest that an unknown route of contagion may be existing. It is too early to be sure that the situation is stabilising, but the warming up of the weather acts against viability of the virus combined with stringent hygiene measures might have contained the disease. One should not, however, relax a good hygienic behaviour. At this time it becomes important to start reflection on the political, sociological and psychological factors involved in the spreading of the disease. Despite the lack of accurate reports from the Mainland, it appears that, after a peak around mid-february, the outbreak did not come out of control suggesting that some factor(s) have played an important role, whether political, or simply sociological (the structure of cities, buildings etc. is extremely important). The Mainland being now a full partner of WHO, accurate knowledge of the situation will soon be available. Patients at the French Hospital in Hanoi are under strict control measures: on march 14, a group of 12 staffs (specialists of intensive care, nurses, virologists) was sent to Vietnam. Besides taking care of the patients, this staff was involved in a vision of prevention of infection. In Hanoi, the risks of further contamination seem to be under control: since march 25, no new case of chain contamination has been reported. Nine persons from the medical staff of the French Army arrived to replace the orginal staff on march 25. Identification from new cases substantiate the hypothesis of a coronavirus as the cause. One must remember however that until explicit link with the disease has been established one should remain open to other hypotheses.
• 1 april 2003. While SARS does not seem to recede in Hong Kong, a model of the outbreak at Amoy Gardens Estate, constructed by mathematicians at the University of Hong Kong, suggests that contamination follows a route similar to that of flu. This is a matter of great concern, since flu is highly contagious. This also suggests that the outbreak in Mainland China might not be under control yet. If this is the case it is almost inevitable that the disease will spread throughout the world. However it is important to remember that Amoy Gardens Estate is a high rise building and that spread of the disease might be due to this specific situation.
• 31 march 2003. Quarantine measures are implemented in several places in the world while the epidemic does not seem to level off. Eighty more patients have been identified in Hong Kong since yesterday. One block (block E) at Amoy Gardens seems to have been most affected, and investigation is proceeding to try to identify the nature of high contamination there. This would certainly be a lesson for containing the disease elsewhere. The nature of the virus that causes the disease is still under discussion, since there has not been, as yet, an explicit correlation with the immune response of patients who have recovered.

• 30 march 2003. The outbreak might be levelling off in Hong Kong, but at a high level: sixty new cases have been diagnosed there. A thirteenth patient passed away while the Italian doctor who discovered the disease in Hanoi died in Bangkok. A group of French military doctors departed for Hanoi to help their colleagues. Including the recognized Mainland cases, one already counts more than 1600 cases and 58 deaths.
• 29 march 2003. Anxiety rose in Hong Kong while 58 new patients have been affected by SARS. 470 cases have been identified in HK, and 86 in Singapore. The cause of the sudden increase in the past two days is the outbreak that affected 34 new persons at the Amoy Gardens Estate. A twelvth patient, an elderly person, died from the disease in HK. General models describing the progresses of similar outbreaks would predict that, if appropriate prophylactic methods are enforced, the disease should presently level off then go extinct. A favorable circumstance should be the weather that is warming up, provided air conditioning is not creating a situation that would mimick the winter time weather. It must be stressed that identification of the virus, at this point, is mainly useful as it substantiates the hypotheses about its mode of transmission. As in most cases of viral diseases, implementation of drastic preventive measures is the only efficient way to stop the outbreak. Vaccination would also be efficient, but creation of a vaccine takes time, and is only rewarding if the disease is supposed to become recurrent. In fact this particular outbreak should become a lesson for political authorities as well as medical staff, since an outbeak of a much more contagious disease like a new form of influenza would certainly have a much more severe impact. Fast reaction, as well as drastic control of hygiene is a necessity.
• 28 march 2003. The number of affected persons in HK jumped with 22 from a single building adding to the steady daily flow (51 more patients enrolled on the evening of 27th). The local governement has finally resorted to measures similar to those implemented in Singapore, restricting the movement of more than 1,000 people. Consistent reports throughout the world suggest that the disease is indeed caused by a coronavirus, making the identification by Pr Peiris an important step in the fight against the disease. Some think that a paramyxovirus could be an aggravating factor: ''The coronavirus is the primary cause of the disease,'' said Pr Peiris, adding that another virus, of the family that causes mumps or measles, may also be involved and increase the severity of the disease. Interestingly, the new strain had characteristics unlike any other he had ever seen. In a parallel statement Pr Bernhard Fleischer, head of Hamburg's Bernhard Nocht Institute for Tropical Medicine, said his institute had probably identified the virus causing Severe Acute Respiratory Syndrome. "I don't assume that there will be a worldwide epidemic which will spread among the population," Fleischer told Reuters in an interview. "We are lucky that this disease is not as contagious and does not spread as easily as first assumed."
• 27 march 2003. While about thirty new cases are discovered in HK, all connected to the initial patients, it appears now clear that the epidemic of SARS in Guangdong affected almost eight hundred people, with thirty deaths. Some indications suggest that the disease is now spreading in Beijing and other parts of China. Clinical symptoms are described at PROMED. The government of Hong Kong is now considering to take measures similar to those in Singapore, asking people who have been in contact with affected patients to stay at home for ten days. The cause of the disease is not yet clear, but the symptoms and propagation makes a pattern that suggest that the world-wide outbreak started from the same origin. At the moment it might be traced back to a patient in Foshan City (Guangdong) who got sick on 16 Nov 2002. Patients of the initial outbreak are now systematically recovering and, if the disease can be contained, this will alleviate some of the extremely tense work load at hospitals. However, in other parts of the world, such as Taiwan and Canada, the outbreak is not yet contained. Scientists world-wide are trying to decide what is the exact cause of the viral disease with no compelling conclusive evidence yet. However the coronavirus hypothesis now seems the most plausible, since tests that had initially been negative appear now to be positive after new types of assays. Also, as said earlier, coronaviruses being highly prone to recombination, they have more potential to create new unknown virulent variants.
• 26 march 2003. 25 new cases were added to the list of HK people affected by SARS. An incident in a plane carrying HK tourists to Beijing from march 15th and march 19th examplifies the way the disease is propagated. In the world the disease continues to spread (see Health Surveillance for airline passengers). It may be affecting Beijing. The puzzle about the nature of the virus continues, while the virus isolated at HKU is better characterized. For journalists interested in the difficulty of identifying viruses, and in the vivid ongoing debate, here is a summary provided by scientists at PROMED.
• 25 march 2003. As the number of SARS cases resumed growth in Singapore the local government decided to warn all 700 persons who have been in contact with patients to remain at home for ten days. The CDC in Atlanta has identified another type of virus as the possible cause of the disease. This virus family, the coronaviruses usually causes gastroenteritis in humans. It is also the cause of bonchitis in birds as well as many other diseases in all kinds of animals including humans. It is also the frequent cause of common cold. The virus that has been isolated at HKU is also a coronavirus. It is difficult to reconcile the data from the previous identification of paramyxoviruses and these new identifications. Several explanations may be proposed, including sample contamination, multiple infection and different outbreaks with similar symptoms. In Hong Kong the Chief Executive of the Hospital authority was found to be affected by the disease and the number of patients reached 260.
• 24 march 2003. The number of Severe Acute Respiratory Syndrome cases kept growing steadily in Hong Kong (about 25 new cases each day, see dedicated government site, 242 cases in the afternoon of march 23d), but the spread of the disease seems to be contained elsewhere in the world. Schools where cases were detected in staff or students are closed for seven days, until the incubation time for possible new cases has elapsed. The World Health Organisation cautions that virus identification is difficult since our respiratory system is commonly infected by many types of more or less innocuous viruses. The easiest to be cultivated might not be the cause of the disease. However all identifications so far concur to the idea that the virus is a paramyxovirus.
• 22 march 2003. The virus identified in the SARS outbreak in Canada is a metapneumovirus (6 identifications out of 8 cases), a virus from the paramyxoviruses family, which has been discovered in 2001 and is usually the cause of common cold-like diseases. This virus may be the common source of the outbreak. In another effort, scientists of the team of Pr Malik Peiris at the University of Hong Kong have cultivated the virus that may have started the outbreak in the city and are testing an efficient diagnostic test that detects the virus . This would rapidly tell whether cases of pneumonia, frequent during this period of the year are indeed SARS and prompt appropriate precautions. It is not known however whether this is a metapneumovirus yet. One must also have in mind that pneumonia cases are documented with at least two viruses infecting the same patients.

• 21 march 2003. The number of SARS cases rose to 165 in Hong Kong. The history of the disease in the city is now fairly well understood. At its origin is a medical doctor travelling from Guangdong and staying at a Kowloon hotel, where he infected, either in the elevator or in the elevator lobby several persons who then transmitted the disease. One of those started the outbreak at the Prince of Wales hospital. authorities are actively looking for all the persons who stayed at the time of infection in the hotel. This outbreak is an illuminating illustration of how our travelling habits are spreading diseases throughout the world extremely rapidly. The fact that apparently no staff of the hotel has been affected provides good hope for the disease to be under control rapidly if appropriate hygienic behaviour is followed. Remember that coughing and sneezing, in particular, is an efficient route spreading the virus.
• 20 march 2003. The origin of the SARS in Hong Kong has been traced back to a traveller who stayed in a hotel in Kowloon. Apparently, no personnel at the hotel has been affected, substantiating the reassuring observation that close contact is needed for the disease to spread. A paramyxovirus has further been identified as the cause in Singapore. As yet, no clear connection is made with the epidemic of pneumonia that spread in Guangdong province since november and seems now under control. However, both the symptoms and the spread are so similar that it seems likely that the cause is the same. It will be important to identify the source, and political authorities in the Special Administrative Region of Hong Kong and in Mainland China have agreed to tighten their collaboration. This will be particularly important in the future since the risk for an outbreak of a dangerous influenza epidemic is high.
• 19 march 2003. A paramyxovirus has been identified as the probable cause of Severe Acute Respiratory Syndrome (SARS). First indication came from Frankfurt and Marburg, and explicit identification was performed by a team from the Prince of Wales Hospital and Chinese University of Hong Kong. Paramyxoviruses infect vertebrates, and cause often severe outbreaks in communities of birds. They cause outbreaks of encephalitis in South East Asia. The common and highly contagious measles virus belongs to this family. A family of these viruses has a strong tendency to infect lungs.
• 18 march 2003. The origin of the outbreak at the Prince of Wales Hospital has been identified. This permitted local authorities to screen for people who have been in contact and bring them under medical care. The result is that at the present date almost 100 persons are under surveillance most of whom having acquired the severe flu-like disease. The WHO maintains its alert until identification of the virulent pathogenic agent is identified. For ongoing discussion on the subject see PROMED.

• 17 march 2003. The WHO maintains its global alert. Forty two persons have contracted an unknown flu-like disease with frequent pneumonia symptoms at a Hong Kong hospital. One nurse died of a similar disease in Hanoi. Several similar cases have been described, possibly related to South East Asia, in the world. However it must be noted that, until now, no shared infectious agent has yet been identified. What makes the situation complicated is that we are at a period of the year where many flu-like, pneumonia-like diseases prevail. Several important facts must be borne in mind to prevent spreading of a possible new virus or bacterium, taking into consideration the unusual fact that effective contagion seems to occur within hospital premises.

1. Strict personnel hygiene must be enforced: one should never see medical personnel in their work coats outside (in particular at cantines or such public places, as often unfortunately seen); spitting on the ground should be strictly forbidden; after visiting a patient one should wash one's hands carefully; as much as possible, direct contact with patients should be avoided (gloves can be used, and one should not forget, of course, to discard them properly immediately after use).
2. Air conditioning should be monitored: temperature should not be kept too low (most microbes survive much longer at low temperatures), and ventilation should be efficient but indirect (remember that the nose and lungs act as air filters): filters should be cleaned up and as much as possible sterilized.
3. Water quality should be controlled: filters should be cleaned up, and water circuits should be checked as much as possible.

At the present time several possible agents are considered (but none has been identified as a common cause): the influenza virus (which often causes pneumonia-like symptoms and is frequently lethal); Legionella pneumophila (a very dangerous bacterium often transmitted trough infection by amoeba that thrive in water cooling systems or in the water circuit); Chlamydia pneumoniae (a very fragile bacterium, that may be dangerous in immunocompromized people); Rickettsia psittaci, the cause of psittacosis. Many other causes may exist among which viruses are usually the most difficult to identify readily unless well known previously. Sudden mutation of a rather innocuous virus such as syncytial respiratory virus may even be considered. The present observation that contagion seems highly confined to specific premises suggest either direct physical contact (this is the case with the Ebola virus) or some kind of transmission by water or air fluids.

• 12-14 march 2003. After a concomitant spread of a pneumonia-like flu-like disease in a private hospital in Hanoi (Viet-Nam) and in the Prince of Wales hospital in Hong Kong, the World Health Organization issued a global alert, waiting for identification of the pathogenic agent involved. A patient diagnosed in Hanoi died in another hospital in Hong Kong. Recommendations are similar to those issued during the previous outbreaks, for which no clear pathogenic agent has been identified. Contagion appears to have remained restricted to the medical personnel who was in contact with the patients. The cause of the disease, presumably a virus, is not known at this date.
• 20 february 2003. It is established that the father of the child treated for H5N1 flu died of the same disease. Although it is not yet established that this was caused by the same avian strain, this is likely. Sporadic cases of bird's flu in Hong Kong, including in wild birds, demonstrated that there are foci of disease in the Mainland. This second identified direct contamination from birds to humans in Fujian province demonstrates that the disease must be taken extremely seriously. Fortunately these recent cases do not appear to have been caused by person-to-person contamination. The World Health Organisation is tackling the matter, and considering what types of vaccines should be prepared to be able to react immediately in case of epidemic. It is also important to remember that such disease outbreaks spread from places where birds are in large flocks (poultry farms and markets in particular). The "atypical pneumonia" diagnosed recently in Guangdong does not appear to be related to bird's flu: coincidence of infection with pneumonia-like symptoms, perhaps caused by a variety of pathogens, appears to have triggered the panic after personnel from medical care institutions died. This type of disease is frequent in winter, and the number of people dying from such diseases is always significant.
• 19 february 2003. A nine year old child is treated in Hong Kong for H5N1 influenza. No link has been established with the epidemic that created panic in Guangdong, but it is a matter of extreme concern, since this form of flu, which affected Hong Kong in 1997 is significantly more dangerous than the more common forms. Once again, elementary rules of hygiene should be followed.
• 11 february 2003. An outbreak of "atypical pneumonia" in Southern China led the French General consulate in Guangzhou to close the French School in the city, until more is understood about the disease. The rumor spread that several tens or even hundreds of people have been contaminated, with a high death toll. No reliable information is available at the present time. It seems likely that the cause of the disease is a virus, perhaps a new flu strain (but perhaps "ordinary" flu). This fits the time of the year, and the possibility of hospital contamination. One should also remember that flu is indeed a deadly, albeit ordinary, disease... Usual rules of hygiene should be carefully followed (washing hands frequently in particular) and people should limit contacts with large concentrations of people. One should avoid travelling, to limit the spread of the disease. Also, remember that panic is one of the most efficient way to spread diseases.
• 8 february 2003. An outbreak of Ebola fever is spreading in Congo, at the border with Gabon at a place close where it was declared one year ago.
• 18 january 2003. Work at the Instituts Pasteur de Paris and de Madagascar results in the creation of a fast test for diagnosing plague. Paper strips are used to detect the presence of the plague agent, Yersinia pestis (discovered by Alexandre Yersin in Hong Kong more than one century ago). The goverment of Madagascar provides a supply to its local health centers to identify the disease, which is still endemic in the island.

• 15 december 2002-21 january 2003. The flu virus H5 reappears in Hong Kong. It is most likely that it is not confined to Hong Kong itself, but is present in the region. This time, it was first identified in waterfowls, before being found in dead chicken at several market places. Open markets are closed for cleaning on New Year's eve.
• 7 october 2002. The Nobel Academy has awarded the Nobel Prize to work on Caenorhabditis elegans. This is an important lesson for those who still do not understand that discovery cannot be planned. Work on the nematode worm C. elegans allowed discovery of programmed cell death (apoptosis). This "suicide" of cells is universal. It is of major importance for the construction of animals, and plays a fundamental role in cancer. This discovery is the result of purely academic research, as are all the processes at the root of genetic engineering...
• 6 october 2002. A new serotype (type 2) of Dengue fever is identified in Hong Kong. Fortunately, the cooling of the atmosphere, associated to dry conditions will prevent the epidemic to spread.
• 2 october 2002. Dengue fever is spreading in Hong Kong. Several cases of Dengue fever type 1 have been diagnosed since july, raising concern about a possible epidemic.

Previous years at the HKU Pasteur Research Centre

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