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Home Eurosurveillance Weekly Release  2003: Volume 7/ Issue 14 Article 2
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Eurosurveillance, Volume 7, Issue 14, 03 April 2003

Citation style for this article: Horby P, Nicoll A. Severe Acute Respiratory Syndrome: international update. Euro Surveill. 2003;7(14):pii=2196. Available online:

Severe Acute Respiratory Syndrome: international update

Peter Horby ( and Angus Nicoll, Health Protection Agency Communicable Disease Surveillance Centre, London, England.

As of 2 April 2003, 2223 cases of Severe Acute Respiratory Syndrome (SARS) and 78 deaths have been reported to the World Health Organization (WHO), a case fatality rate of 3.5% ( This is an increase of four to fivefold in the global totals in the last seven days ( with the greatest proportionate and absolute increases being in China (Hong Kong and Guangdong Province), and to a much lesser extent in Canada. There has been little absolute rise in other country totals. Eighteen countries have now reported cases but in most of these no transmission seems to have occurred. Local transmission has occurred in Hanoi (Vietnam), Singapore, Toronto (Canada), Taiwan, and the following parts of China: Guangdong Province; Beijing; Shanxi; and the special administrative region of Hong Kong. In the United Kingdom three probable SARS cases have been reported; all have now recovered. Indeed, the only areas where WHO feels there is evidence consistent with current transmission are Hong Kong and Guangdong (, and the WHO has issued advice to international travellers not to travel to or through either area.

Guangdong and Hong Kong

Information about the outbreaks in Guangdong is limited, but the latest reports give a significant increase of over 350 cases during March 2003 ( Detailed descriptions from Hong Kong are now available. Following transmission centring on a large hotel, there have been intense hospital outbreaks involving staff, patient and families of staff (1) where community transmission has been established. There is now is evidence of community transmission within a large housing complex.

Measures introduced by Hong Kong, Singapore, and Canada to control the local spread of SARS have included school closures (Hong Kong and Singapore), the quarantine of entire residential buildings (Hong Kong), and the restriction of non-essential access to hospitals (all three, Although such precautions are not yet necessary in Europe, the experience in Canada is a sobering reminder of what could happen in any country receiving a case.

Ontario, Canada

The outbreak in Canada began with a Toronto woman who developed respiratory symptoms two days after returning from Hong Kong. She died at home 10 days later, but meanwhile appears to have transmitted infection to four members of her family. One of them, her adult son, was admitted to a local hospital with respiratory symptoms. He spent some time in an open part of the emergency department before being transferred to the intensive care unit, where he remained until his death, six days after admission. It is now apparent that transmission of SARS has occurred within the hospital. A patient who was in the next bed in the emergency department developed symptoms of SARS three days after his visit to the emergency department, and died 11 days later. A large number of hospital staff who worked in the emergency department and the intensive care unit where the son of the index case was cared for have now presented with symptoms of SARS. Transmission in the intensive care unit may have been from the patient or from visiting family members, some of whom were symptomatic at the time they visited (2). The Province of Ontario declared a health emergency on 26 March, and on 1 April a sixth death from SARS was reported from Toronto. As of 1 April, Ontario has reported 51 probable cases of SARS. The hospital has now been closed to new admissions.

The experience in Canada illustrates that highly developed countries can be vulnerable to transmission from imported cases of SARS, especially in hospitals (3,4). Most of the data have been consistent with transmission through large droplets or body fluids. Aerosol transmission cannot be totally discounted, but if it occurs it is uncommon. If the causative organism had been readily transmissible by aerosol, many more cases would have been expected, especially in the countries where transmission has slowed or never started. In Hong Kong there are some patterns of infection that are most easily explained by environmental transmission such as fomites.

If the infection is not recognised early and appropriate infection control precautions put in place, extensive transmission can occur. Those most at risk seem to be family members and healthcare workers who have close contact with symptomatic cases. It is worth noting that there have been no reported secondary cases from two hospitalised Canadian SARS cases where family members were not permitted to visit and healthcare workers adhered to strict infection control precautions.

Clinicians, accident and emergency, intensive treatment units, and infectious disease staff in Europe should be alert to the possibility of SARS in people with fever and respiratory symptoms, IF they have recently returned from areas where transmission of SARS is ongoing (currently Hong Kong, and probably Guangdong) or who have had contact with a case of SARS ( When patients suspected of having SARS are admitted to hospital, it is vital that infection control precautions are rapidly implemented and rigorously enforced (

Updates on the developing situation are also available from WHO, on ProMED, and at the websites of various national public health organisations, including CDC, Health Canada, and the Health Protection Agency in the United Kingdom (5-7). Eurosurveillance Weekly welcomes comments on other useful information sources, please send to


  1. Tsang KW, Ho PL, Ooi GC, Yee WK, Wang T, Chan-Yeung M, et al. A cluster of cases of Severe Acute Respiratory Syndrome in Hong Kong. N Engl J Med 2003; published at ahead of print, 31 March 2003. (10.1056/NEJMoa030666). (
  2. Poutanen SM, Low DE, Henry B, Finkelstein S, Rose D, Green K,et al. Identification of Severe Acute Respiratory Syndrome in Canada. N Engl J Med 2003; published at ahead of print, 31 March 2003 (10.1056/NEJMoa030634). (
  3. Drazen JM. Case clusters of the Severe Acute Respiratory Syndrome. N Engl J Med 2003; published at ahead of print, 31 March 2003 (10.1056/NEJMe030062). (
  4. Gerberding JL. Faster...but fast enough? Responding to the epidemic of Severe Acute Respiratory Syndrome. N Engl J Med 2003; published at ahead of print, 2 April 2003 (10.1056/NEJMe030067). (
  5. Eurosurveillance Weekly. Clinical descriptions of Severe Acute Respiratory Syndrome (SARS). Eurosurveillance Weekly 2003; 7: 030327. (
  6. Debenoist A-C, Boccia D. Severe Acute Respiratory Syndrome - update. Eurosurveillance Weekly 2003; 7: 030320. (
  7. Debenoist A-C, Boccia D. WHO initiates enhanced global surveillance in response to acute respiratory syndrome in China, Vietnam, and Hong Kong, special administrative region (SAR) of China. Eurosurveillance Weekly 2003; 7: 030313. (

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