Hong-Kong
"It is time to close the book on infectious diseases", US Surgeon General William H. Stewart announced in 1969. "The war against pestilence is over".

Viruses vs. Superbugs
Thomas HÄUSLER


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The Severe Acute Respiratory Syndrome, 2003

The information provided is "as is" and uncorrected, except for typographical errors, as discovered by readers over time. Obsolete links are progressively removed. As of 2019 the majority of links had to be deleted, in particular those corresponding to information coming from China.

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

  • 29 august 2003. Fourteen United Nations and Chinese experts visited farms and markets in Guangdong province in quest for an animal carrier of the SARS virus. As reported in Beijing by the veterinarian François Moutou (president of the French Association for the study and protection of Mammals), it is extremely surprizing to have recovered SARS-like virus from such a broad range of animals, from snakes and birds to mammals. One can remember that, in addition to the hypothesis of infection of a civet cat, snakes were proposed very early on to have been at the origin of the virus. Outbreaks of legionellosis continue to develop in France, while a patient who had travelled on a cruise to Greenland died from the disease when returning to his home land in Germany.
  • 24 august 2003. After the recent heat wave two outbreaks of Leptospirosis affect the east and south west of France. This revives the interest for Leptospira interrogans, a plague of rice paddies in China.
  • 21 august 2003. A bitter debate affects medical and political authorities in France while the funeral undertakers declared 10,000 more deaths than the previous year. Deaths were usually caused by hyperthermy, not by microbial infections. This triggers a Europe-wide investigation to compare the situation in other countries affected by the same heat wave.
  • 5 august 2003. An epidemic of Legionellosis affects the region of Montpellier in France. 25 persons have been infected.
  • 25 july 2003. The SARS outbreak is terminating, with a record death toll in Hong Kong (299 deaths, more than 17% of the cases). A large cholera outbreak is developing in Liberia where civil war prevents proper control of the disease. In Mainland China analysis of the situation demonstrates that Chinese scientists had discovered the coronavirus cause of SARS well before it was found at the CDC in Atlanta and in Hong Kong. The old confucean tradition prevented these scientists to voice out their discovery. This particular cultural feature is triggering a lively discussion in China.
  • 10 july 2003. Philippe Desprès, Jean-Louis Virelizier and Fernando Arenzana at the Institut Pasteur have just discovered in vitro the nature of a receptor on the cell surface that allows the dengue virus to enter its host and start this often deadly disease. This has of course to be substantiated by in vivo studies. If the discovery holds it will open the door for medication preventing, or at least controlling the dengue infection after humans are bitten by carrier mosquitoes, Aedes aegypti.
  • 8 july 2003. Within the frame of eradication of poliomyelitis a thorough campaign of vaccination was launched in Madagascar. No cases were found since 1997, until, during a survey between october 2001 and april 2002 five new cases were detected. Surprisingly, a study developed at the Institut Pasteur de Madagascar with the Institut Pasteur has demonstrated that these cases are mutants of the vaccine strain (which is a live vaccine). This shows that the campaign of eradication of the disease will be more difficult than expected.
  • 7 july 2003. While the WHO removed Taiwan from its list of areas with local transmission of SARS two suspect cases have been found in GuangDong awaiting confirmation. There are no left chain of transmission left, but one should still be extremely cautious, since the diagnostic of the disease is still difficult. Also, its origin is not well understood yet, although a general consensus is that it originated from an animal (presumably feline) host. If this were the case adaptation to man would have required several steps, and it is not unlikely that a parent disease, causing only very mild symptoms, is still present. This might be a reservoir for a resurgence of the disease when the weather cools down in autumn. Meanwhile a team of scientists from the Institut Pasteur is working with authorities in Algeria and the WHO Global Alert and Response Network, to investigate the recent outbreak of plague, that caused 10 infections and one fatality, and control its vectors. In Hong Kong the hot and humid season makes it now important to monitor the possible come back of dengue fever.
  • 29 june 2003. The World Health Organisation, as medical authorities world-wide, are investigating the impact of atypical pneumonia on the local health systems and the response they should propose in case the disease (or a similar one) appears again. Extreme variations in the number of fatalities in different places is a remarkable puzzle that is being actively investigated. The disease also triggered reflection at the Pugwash workshop “Science, Ethic and Society” (Paris, 27-29 June 2003). The Pugwash Movement is well-known for the role it has played in promoting recognition of the social responsability of scientists in the domain of arms control and involvement of scientists in violence. At the present time it is of interest to investigate the various reactions of scientific institutions which often, for the pure sake of fashion or short-term considerations, lost the view of what should have been their strategic (i.e. long term) choices. The origin of the SARS virus is not yet certain, and the disease — which is as expected very sensitive to heat because the virus is much less stable at temperatures higher than 30°C — may appear again when the wether cools down in autumn. However its most severe behaviour was due to person-to-person contamination, and we can reasonably hope that, when cooler days will return no human case will still exist. The disease may then have disappeared from the Earth, at least for some time. It is therefore urgent to remember that, among the causes of the havoc were poor hygiene measures (especially in hospitals), and, above all, lack of pre-existing research on the virus. We know some of our future diseases (and flu is one of them: H5N1 in Asia, and H7N7 in Europe, for example, as well as dengue fever in South East Asia), but we do not know most of them. The family of the Human Immunodeficiency Virus was not considered as interesting before the scourge of AIDS appeared, and not many scientists were interested in Coronaviruses. This means that we need urgently basic academic research on all kinds of microbes, on their vectors and on microbial systems that may put them under control, if we wish to be ready for the next epidemic. Will this lesson of SARS be understood?
  • 25 june 2003. Beijing's population went to celebrate in the street the end of the WHO warning over travel to the city because of SARS.
  • 22 june 2003. On june 18th an eleven years old child died of plague in Oran (Algeria) where several cases have been diagnosed. He was affected as well as several members of his family since the beginning of the month. This indicates endemy of this disease, in a country that witnessed the large outbreak fifty years ago, made famous by the novel of Albert Camus, The Plague.
  • 19 june 2003. 100 days elapsed since the WHO warning on SARS was published. Although SARS is clearly coming under control, the need for continued vigilance is now greater than ever. The chain of person to person transmission everywhere is not yet totally interrupted and, as demonstrated recently in Toronto the disease may suddenly reappear when it was thought to have been. As stated by WHO at a recent conference there is a need for at least a full year of surveillance to determine whether the disease has established endemicity and to ensure that no cases have spread, undetected, to countries with poor surveillance and reporting systems. After a peak of the number of cases at the beginning of May the disease rapidly went under control, most probably because of the efficiency of means that have been implemented in the regions at risk. It is most important that these measures remain in effect.
  • 16 june 2003. The World Health Organization advice against travel to Tianjin, Hebei, Shanxi and Inner Mongolia was lifted late Friday while SARS is now rapidly receding in Mainland China. For unknown reasons, the epidemic is still not contained in Canada and in Taiwan, although the situation is improving.
  • 12 june 2003. As atypical pneumonia recedes world-wide, and in particular in China (no new case and no new fatality in Hong Kong), the consequences of the disease on human habits begin to be visible. In Mainland China, in particular, this will help the government to implement a strong policy against spitting (a notoriously difficult task, especially in the poor parts of Western China). This will also inevitably have consequences on the dining habits in this country. Chinese use to share dishes, a very friendly social practice, but which may have a significant impact in terms of diseases spreading. The government is starting a reflection in this domain, which will have immense consequences if the western style dining portions is becoming the rule.
  • 9 june 2003. The distribution of atypical pneumonia is becoming somewhat erratic. More questions arise about the possible treatments for the disease as the death toll in Canada reaches 32 persons. The Chinese government warns that, because it is not possible to control totally the movements of person in their huge country, some new cases may appear here and there. While the total number of cases, and of deaths is very small as compared to the situation with other diseases such as tuberculosis, malaria, or AIDS (and even typical pneumonia), the particular feature of SARS is its remarkable contagiosity, which forces authorities to implement stringent confinement measures around patients. If no action had been taken it is clear that the level of contamination in the world would have been much higher.
  • 5 june 2003. As a sign of hope, for the second time there is no new SARS case in Hong Kong during the past 24 hours. The experience in Toronto, where more than 70 new cases have been reported since 26 May 2003, underscores the risk of a resurgence of cases and reminds us that a single imported case can reignite an outbreak. The WHO reminds us that this is a matter of concern for the future if all cases have not disappeared during the summer.
  • 2 june 2003. As the discrepancies between SARS infections at various places in the world increase the disease remains more and more of a puzzle. Some of the data might reflect inaccurate reporting, but that does not seem to explain everything. In fact several reports from the Mainland suggest that many people are immunologically seropositive for the virus but did not show symptoms. Asymptomatic diseases are very frequent, but this would hardly fit with places where up to 50% of the local people got infected (this was the unfortunate situation at the Block E of the Amoy Gardens Estate). One alternative explanation, that we proposed several weeks ago, is that a double epidemic might reconcile these observations: a first outbreak of a mild disease (probably derived from some animal) would have escaped attention (it might have been the gastro-enteritis witnessed since the end of 2002 in Guangdong and in Hong Kong), and a mutant virus, derived from this first one would have acquired a tropism for the respiratory tract. This would have caused SARS. Those people who had been infected with the first disease would have been protected, while the other ones would have the full blown syndrome. This would account for seropositivity in otherwise healthy people. We are in urgent need of a highly sensitive and reproducible test for monitoring the immunological status of the whole population in the regions of interest.
  • 31 may 2003. SARS remains a nosocomial infection as there are three new confirmed cases in Hong Kong who are healthcare workers of North District Hospital. Another sad news is that the number of deaths almost reached the 16% figure in the city. Fortunately, if figures can be believed, there was only a single new case in the Mainland. Singapore is removed from the list of areas with recent local transmission of SARS. The change in status comes 20 days after the last locally acquired case was placed in isolation, on 11 May 2003. In Taiwan the disease recedes, but on may 30th Canada was affected again, since the suspected cases recently discovered have been identified as SARS cases.
  • 28 may 2003. With less than 8,500 cases as the total number of SARS patients world-wide, one can be confident that the disease is now under control. One should not let one's guard down however because the disease can reappear where it was thought to have been eradicated. In addition we need to prepare for a possible surge when the weather will cool down in autumn. Much will have to be learnt about protective and proper hygiene measures in hospitals since the disease can be classified as a nosocomial infection. In addition handling and eating wild-life animals will have to be severely controlled. The Chinese governement is considering new measures in this domain.
  • 27 may 2003. After an alert was sent on may 23d, Toronto is back on the list of places with recent local transmission of SARS, while a new cluster is discovered. Taiwan is now the place where the disease is spreading the fastest.
  • 24 may 2003. The SARS epidemic is being under control in Hong Kong, with no new cases and only 9 suspected cases left. The local death toll is unfortunately above the 15% figure. The situation allowed the WHO to remove Hong Kong from the list of places that should be avoided by occasional travellers. The situation in Taiwan is unfortunately growing worse as the number of new patients is steadily on the increase despite severe control measures at the entry of the region. The number of new patients in the Mainland is stable, probably on the decrease. The origin of the virus might be cat since teams investigating the presence of coronaviruses in Guangdong discovered that these viruses were ubiquitously present in animals, cats included, prepared on the local markets for food. Except in Taiwan the disease seems to be receding fairly rapidly. In addition to confinment and control measures implemented, this may be due to the warming up of the climate in this season. It will be extremely important to monitor the situation when the weather will cool down, next autumn.
  • 20 may 2003. SARS in the Mainland may have escaped attention for some time, as a WHO expert team returning from Guangxi province found that 2 separate clusters of SARS cases, dating from December 2002 and January 2003, had recently been detected by local health officials following a review of hospital records. Figures seem to be on the decrease everywhere in the Mainland, but the speed of the decrease is probably too fast to reflect reality. On the encouraging side, only four new patients were identified in Hong Kong, where the number of persons still in hospital went below the 250 figure.
  • 18 may 2003. While Singapore was about to be declared free of SARS a new case, who became ill on may 11th, was discovered, showing that one should not be confident too early that the fight against SARS is won. For unknown reasons the situation seems to be getting worse in Taiwan, while in Mainland China and in Hong Kong the number of new patients seems to be steadily decreasing. At the first global consultation on SARS epidemiology, held at WHO headquarters in Geneva from 16 to 17 May, experts declared that the overall case fatality ratio is 14% to 15% but with wide variations in case fatality related to age, sex, the presence of other diseases, and treatment protocols.
  • 16 may 2003. The cause of SARS as a Coronavirus is proven, as described in "Koch's postulates fulfilled for SARS virus. Ron A. M. Fouchier, Thijs Kuiken, Martin Schutten, Geert Van Amerongen, Gerard J. J. Van Doornum, Bernadette G. Van Den Hoogen, Malik Peiris, Wilina Lim, Klaus Stohr & Albert D. M. E. Osterhaus. Nature 423:240 (2003). It is important to identify as fast as possible patients who carry the virus. At the date of May 8th, on average the time needed for identification was still about 4 days, too long to stop the spread of the disease. If this figure can be lowered to 2 days, the epidemic will rapidly be totally under control. Misdiagnostic, especially of the milder forms of SARS is a matter of much concern, since this might lead to relaxing the confinement of patients who are still contagious. More than 600 deaths have been attributed to SARS world-wide, a high figure for a new disease. In Hong Kong the death toll reached 14%, menacing to be soon the highest recorded death toll for the disease. There is hope that the fight against the disease will succeed as the number of new cases in Beijing and Mainland China seems to be steadily dropping down, suggesting that the methods used to contained the epidemic are effective. It is interesting to have a view of the official position of the Chinese government on the origin, tracing, and management of the epidemic.
  • 13 may 2003. The total number of known SARS patients world-wide has passed the 7,500 figure. Sadly, the death toll passed the 13% figure among patients in Hong Kong. In an exemplary move to control the disease, contact tracing has established epidemiological links for the vast majority of Hong Kong’s patients. Around 9% of SARS patients have no identifiable exposure source. Detailed investigation is ongoing to understand the transmission routes. Figures of new SARS cases in the Mainland are much smaller than the day before, but this may be due to the way patients are identified (one witnesses strong oscillations in the daily number of new patients in China). Japan has banned import of poultry from China after it discovered the H5N1 flu virus in an imported duck.
  • 11 may 2003. Steady state on the SARS front, with one case in a new country, Finland. The death toll keeps increasing in Hong Kong while the disease recedes (less that 10 suspected cases remain). The Chinese government has formed forums for students abroad, aiming at collecting as much helpful information as possible to fight the disease immediately and in the future. A fruitful students meeting was held in Paris on may 10th. Contradictory reports analyse the sequence of the virus, and suggest that some mutations may have occured during cultivation in laboratories while others are directly due to the selective pressure of the immune system of the hosts. It is very important that sequences are accurate and are obtained totally independently from each other to begin to get a pedigree of the virus and follow its trail. Features specific to the isolate started from the patient that spread the disease from an hotel in Kowloon are now characterized.
  • 9 may 2003. The possibility for a success of the fight agains SARS is illustrated in Vietnam where no cases have been detected for several weeks, and where the death toll remained lower than 8%. One likely case in Eastern Russia, after the disease reached Inner Mongolia, then Mongolia, triggers a new concern for expansion of the disease. Awareness, however, allows authorities to stop the creation of an outbreak. The number of confirmed cases in Beijing dropped sharply (48 cases), while in Guangdong it persists oscillating between 5 and 20 per day. The decrease in Hong Kong is confirmed. In order to improve efficiency of treatment it is absolutely essential that governments totally forbid that companies pay medical doctors for enticing them to use the drugs they produce by whatever means they try to use.
  • 7 may 2003. An attempt to use serum of recovering SARS patients to lower the viral load and cure patients has apparently meeting success. If this is subtantiated by further studies this is extremely good news, since this suggests that a vaccine will be possible. This also particularly important at a time when the number of deaths passed 12% in Hong Kong, indicating that existing treatments did not work as well as promised. The situation in Mainland China remains stationary. One positive outcome of this epidemic is the reflection triggered in the domain of control of water quality, pollution, and management of both domestic animals and wild life. The suspected cases in France are very unlikely to be SARS, in line with the lack of an outbreak in the Nanjing region.
  • 6 may 2003. Two suspected cases of SARS have been detected in France, from persons coming after a stay in Nanjing. Awareness of the existence of SARS may begin to have a positive effect in Mainland China, where the number of new cases in Beijing (more than 16,000 persons are quarantined) experience a significant downturn (70 new cases). 2 cases have been diagnosed in Shanghai, and during the past couple of days the number of new cases rose again in Hong Kong (this is not statistically significant, however), unfortunately with a high death toll. The most surprising observation remains the high number of medical staff infected despite stringent hygiene control measures.
  • 4 may 2003. Shanghai, which is still almost rid of SARS has adopted a series of desinfection measures in transportation, and control measures for travellers. While SARS remains constant in China but recedes in Hong Kong, it is time to put the disease in perspective. Many other epidemics are affecting countries in the world at the same time. In particular, as almost every year, meningitis is killing thousands in Burkina Faso. A different type of concern exists in developed countries: a Legionella case in a factory in the centre of France shows that hot water systems, as well as air conditioning are ready to spread dangerous infectious diseases. The particular danger posed by SARS is its contagiosity which forces affected countries to set up extremely tough controls on travels and drastic quarantine measures, resulting in catastrophic negative economic consequences. Any relaxing measure would immediately result in the spread of the disease. This should be a lesson for the future and trigger appropriate support for research on infectious diseases: the cost of research is very small when compared to the huge losses encountered when the diseases spread.
  • 3 may 2003. Steady state SARS infection level in Mainland China, 114 new cases in Beijing, and 10 new cases in Hong Kong (where unfortunately the death toll increased by 9 persons). In Taiwan the cumulated number of cases passed 100, while the disease seems to be vanishing in Canada and in Singapore. It is important at this point not only to take this epidemic seriously — and appropriate quarantine measures, coupled to monitoring travellers at many major places in China, are certainly efficient — but to be aware of other diseases that may have similar, or even worse, consequences. This is the case of most diseases affecting our livestocks, and in particular of bird's flu, which has two pending virulent forms, one in Europe (H7N7) and one in China (H5N1). We are at the mercy of reassortments of the genomes coupled to mutations, that would allow transmission of the disease not only from birds to humans, but from humans to humans. Lessons should be learnt from the scientists and veterinarians dealing with the spread of those diseases.
  • 2 may 2003. Almost 13,000 people are now quarantined in Beijing. In an un precedented effort the municipality of Beijing put together a work force of 7,000 to build up a 1,000 beds temporary hospital with a number of special facilities for treating SARS patients. The number of new cases was today lower than 100. In Hong Kong 11 new cases were detected while the number of patients dying from SARS has now passed the 10% figure. Shanghai is enforcing strict SARS preventative measures, including a 14-day quarantine period for travellers arriving from affected areas. Traffic checkpoints have been set up where travellers are given temperature checks and asked to fill out health declaration forms. After Viet Nam, the UK and the USA have been removed from the list of areas with recent local SARS transmission. In both countries, the last instance of local transmission occurred more than 20 days ago. Tianjin, China and Ulaanbaatar City, Mongolia, were added to the list. A new country (Poland) is affected by SARS (1 case). The cases in India have been discarded as SARS cases by the WHO.
  • 1 may 2003. The number of SARS cases reached today 1,600 in Hong Kong (fortunately with "only" 11 new cases), while more than 180 were diagnosed with the disease in the Mainland (122 in Beijing). 19 cases appeared to have been identified in India, while the South Korean case might be due to a different type of pneumonia. Drastic measures of quarantine are now implemented in Beijing where the authorities organise the local life for quarantined people.
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    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.

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