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Home Eurosurveillance Weekly Release  2003: Volume 7/ Issue 11 Article 2
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Eurosurveillance, Volume 7, Issue 11, 13 March 2003

Citation style for this article: de Benoist AC, Boccia D. WHO initiates enhanced global surveillance in response to acute respiratory syndrome in southern China, Vietnam, and Hong Kong, special administrative region (SAR) of China. Euro Surveill. 2003;7(11):pii=2177. Available online:

WHO initiates enhanced global surveillance in response to acute respiratory syndrome in China, Vietnam, and Hong Kong, special administrative region (SAR) of China

Anne-Claire de Benoist (, and Delia Boccia, European Programme for Intervention Epidemiology Training (EPIET), Public Health Laboratory Service Communicable Disease Surveillance Centre, London, England.

In response to recent developments in southern China, Vietnam, and Hong Kong, the World Health Organization (WHO) has initiated global surveillance of cases with acute respiratory syndrome of unknown etiology (1) and provided the following case definition for hospital based surveillance:

Suspect Case

A person presenting to a health care facility after 23 February 2003 with all of the following:

  • sudden onset of high fever (>38 oC)
  • myalgia
  • one or more respiratory symptoms (cough, sore throat, shortness of breath, difficulty breathing)

AND one or more the following:

  • history of travel to mainland China, Hong Kong, Special Administrative Region of China, or Hanoi within two week of symptom onset
  • history of having cared for, having lived with, having had face-to-face contact with, or having had contact with respiratory secretions of, a probable case

Probable Case

  • a suspect case with,
  • chest x-ray findings of pneumonia or Adult Respiratory Distress Syndrome

WHO asks for every suspect and probable case to be reported to national Public Health authorities and then to WHO on a daily basis: fax (+41 22 791 1397) or email (

Until further information on these episodes is available, WHO recommends that any patient presenting with atypical pneumonia and possibly related to these outbreaks be isolated and cared for using barrier nursing techniques.

On 11 February 2003, WHO was notified by the Chinese Ministry of Health of an outbreak of acute respiratory syndrome in Guangdong Province (China) (2). From 16 November until 9 February, 305 cases, including five deaths were reported in six of the municipalities of the province. The syndrome was described as an atypical pneumonia, with non-specific symptoms, including fever, headache, joint ache, and overall fatigue and weariness. Two of the cases were diagnosed with Chlamydia pneumoniae infection, but no cause has been confirmed in the other cases. Investigation of this outbreak continues.

In late February 2003, a Hong Kong resident became ill with a pneumonic illness shortly after arriving in Hanoi, Vietnam. He was initially cared for in a hospital in Hanoi and was then evacuated to a hospital in Hong Kong. Approximately twenty hospital staff involved in his care, in Hanoi, have subsequently developed a similar illness. In Hong Kong, an outbreak of a similar respiratory illness has occurred among hospital workers in another hospital (not the hospital in which the Hong Kong resident from Hanoi was cared for).

Despite intensive investigation, no cause for these outbreaks has, so far, been determined other than the two cases of C. pneumoniae infection in the Guangdong outbreak. Influenza virus infection has not been demonstrated. No clear epidemiological link between these three separate outbreaks has been identified, nor any link with the earlier outbreak of influenza due to the avian influenza A H5N1 in Hong Kong reported in February 2003 (3).

The signs and symptoms of the illness in Hanoi, most commonly, include an initial influenza-like illness (rapid onset of high fever followed by muscle aches, headache, and sore throat). In some cases, but not all, this is followed by bilateral pneumonia and occasionally acute respiratory distress requiring assisted breathing on a respirator. Some patients are recovering but others remain critically ill. Laboratory findings may include thrombocytopenia (low platelet count) and leucopenia (low white cell count).

A Global Alert Response Network/WHO team is assisting with investigation, clinical and laboratory management, and outbreak control in Hanoi.

  1. WHO. WHO issues a global alert about cases of atypical pneumonia (press release) 12 March 2003. (
  2. WHO. Disease Outbreak Reported. Acute respiratory syndrome in China - Update 3. (
  3. Crofts J, Paget J, Karcher F. H5N1 avian flu virus: human cases reported in southern China. Eurosurveillance Weekly 2003; 7: 030227 (

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