The SARS Epidemic
Appendix A: Chronology
Version 1; Revised February 2008
The timeline below documents the events associated with the SARS outbreak. Use the key below to quickly find information on the actions of the World Health Organization, the initial reports of cases in a new country, and the source of new infections.
blue = WHO actions
orange = initial reports of cases in a new country
red = clear identification of source of the new infection
In reaction to outbreaks of various infectious diseases (cholera in Latin America, pneumonic plague in India, Ebola hemorrhagic fever in DR Congo) WHO initiated revisions of International Health Regulations to include more diseases and provide more rapid dissemination of information.
April WHO formally establishes Global Outbreak Alert and Response System
Nov. Seasonal influenza outbreaks in Guangdong Province, China include cases of a novel atypical pneumonia. The atypical cases were intermittently scattered throughout Guangdong with some transmission to health workers. The atypical cases would later be characterized as the first wave of SARS infections.
16 Nov. The first case of what was later termed SARS is believed to have originated from a cook at a restaurant where wild animals were served in Foshan, Guangdong Province in November. It is now believed that animal-human transmission of SARS came from consuming and handling wild civet cats. Civet cats are not natural carriers of the disease, but are infected by bats native to southern China, before passing the disease onto humans.
27 Nov. Canadian Global Public Health Intelligence Network (GPHIN) relays media reports of novel infections in Guangdong Province to WHO Global Influenza Surveillance Network.
12 Dec. Following up from WHO inquiries on 5 and 11 December about the extent of the outbreaks, Chinese Ministry of Health issues report on 23 cases of influenza, of which 22 are Influenza B infections. The Ministry adds that number and pattern of outbreaks is consistent with seasonal flu patterns.
17 Dec. First cases in Heyuan, Guangdong Province
26 Dec. First cases in Zhongshan, Guangdong Province
early Jan. Reports of panic buying at drug stores in Guangdong emerge; the Chinese government continues to officially claim through press reports that rumors of an epidemic are false
20 Jan. First team of Beijing-based Health Ministry disease experts arrives in Guangzhou
23 Jan. Guangdong Province health authorities report cases of novel atypical pneumonia to Ministry of Health in Beijing. The report, classified “Top Secret” arrives over lunar New Year holiday; no one with the proper security clearance is around to read the report for 3 days. Ministry does not repeat to other provinces.
31 Jan. First infections reported in Guangzhou, capital of Guangdong Province; Guangzhou eventually had the highest reported rate of infection in China (12.5 cases per 100,000 inhabitants)
early Feb Local media reports on unusual outbreaks of respiratory infections in Guangdong Province reach neighboring Hong Kong. This began what was later termed termed the second wave of SARS.
3 Feb. Mandatory case reporting of atypical pneumonia using standard case definition and reporting form is implemented Guangdong province-wide
8 Feb. Text message sent to phones in Guangzhou states “There is a fatal flu in Guangzhou”; the message would be resent more than 125 million times in the next three days.
9 Feb. Second team of Beijing-based Health Ministry experts, led by Deputy Health Minister Ma Xiaowei, arrive in Guangzhou
Guangdong province-wide hospital admission, clinical management, and infection control arrangements for patients are standardized
10 Feb. WHO Office in Beijing receives e-mail about infectious disease outbreak in Guangdong Province leading to more than 100 deaths and requests information from Chinese Ministry of Health.
11 Feb. Guangzhou City Bureau of Health press release on outbreak of infectious atypical pneumonia that has caused more than 100 deaths in city.
Chinese Ministry of Health confirms to WHO 335 cases, including 5 deaths, from new respiratory disease in Guangdong Province. Despite this, Guangdong health department spokesman Fung Shaoming says the disease “is not as serious as rumored,” and is under control.
WHO headquarters (Geneva) alerts participants in WHO Global Influenza Surveillance Network of Chinese outbreaks out of concern that a new influenza virus is causing the disease and may lead to epidemics.
12 Feb. Leader of Guangdong province, Zhang Dejiang, orders the provincial health department to set up an emergency experts group to investigate.
Shops in Guangdong report running out of white vinegar and other household products believed (falsely) to help disinfect and remedy the illness. Traffic in public places and on public transport reported cut in half in Guangzhou
14 Feb. Hong Kong Hospital Authority and Department of Public Health establish surveillance/reporting system for cases of patients with “severe atypical pneumonia” admitted to hospital.
Official Chinese government report again states the outbreak in Guangdong is contained
15 Feb. Fears over the outbreak causes panic buying of cleansers and remedies to spread to Hunan province
20 Feb. WHO Global Influenza Surveillance Network receives reports from Hong Kong on 2 cases of humans with H5N1 avian bird flu.
Member labs of Global Influenza Surveillance Network begin analysis of patient specimens and epidemiological data and exchange data.
WHO headquarters activates global pandemic preparedness plan.
21 Feb. Dr. Liu Jianlun, a physician who had treated SARS patients in Guangdong Province and acquired the infection, travels to Hong Kong and stays in the four-star Metropole Hotel there. Other guests are infected and carry infection to Hanoi, Vietnam; Singapore; and Toronto, Canada
22-25 Feb. WHO sends team of doctors to China to investigate the illness; Chinese authorities prevent them from entering Guangdong province.
26 Feb. First case identified in Hanoi.
Vietnamese authorities report case to WHO; request assistance in dealing with the disease. WHO sends epidemiological team to Hanoi.
28 Feb. Dr. Carlo Urbani of the WHO first identifies a patient in Hanoi with a severe form of pneumonia as having SARS. Urbani later contracts the disease himself and dies a month later.
1 Mar. First case identified in Singapore.
5 Mar. First case identified in Toronto, Canada. Sui-chu Kwan, a 78-year-old woman who had travelled to Hong Kong in February and stayed at the Metropole Hotel, dies of SARS in Toronto.
7 medical staff at Hanoi Hospital fall ill with atypical pneumonia
8 Mar. First case identified in Taiwan.
Approximate date of Chinese Academy of Military Medical Sciences (AMMS) lab identifying a coronavirus as likely case of the new infections. Because this contradicts the official Chinese government’s position at the time, no information about this relayed to WHO or Global Influenza Surveillance Network.
10 Mar. China requests help from the WHO in identifying the cause of the Guangdong pneumonia outbreak.
11 Mar. A “large cluster” of cases of atypical pneumonia is reported in Prince of Wales Hospital, Hong Kong.
WHO receives reports of clusters of cases in Singapore and Toronto, Canada
12 Mar. WHO issues Global Alert regarding new highly infectious atypical pneumonia
WHO begins coordinating with Hong Kong officials
13 Mar. Kwan's son Chi Kwai Tse, 44, dies of SARS in Toronto
U.S. CDC sends disease experts to Hanoi to help understand the illness
14 Mar. US Center for Disease Control and Prevention (CDC) activates Emergency Operations Center to deal with the new infection.
Four persons in Ontario, and three persons in Singapore, with severe atypical pneumonia reported to WHO; the cases were linked to the infection at the Hong Kong Metropole Hotel
Hong Kong secretary for health says the outbreak hasn’t spread to the community, is contained to hospitals
15 Mar. Reports of 150 cases outside China received by this date. WHO issues emergency travel advisory. This provides a case definition, recommends measures, names the infection SARS.
First case in USA
17 Mar. WHO activates network of labs to work on isolating and analyzing cause of SARS. It operates through daily teleconferencing and exchange of data over WHO-provided secure website.
Health Canada announces 11 suspected cases of SARS; 9 in Ontario, one in Alberta, one in British Columbia
19 Mar. Health Canada suggests postponing travel to hard-hit Asian countries
21-24 Mar. 3 labs in WHO network independently isolate the coronavirus causing SARS. Tests show that SARS is distantly related to other coronaviruses yet is distinct enough to be classified in a category of its own. This discovery permits development of better recommendations regarding treatment.
21 Mar. Chinese Ministry of Health officials request assistance in epidemiological and laboratory support; WHO sends five-person team to China to assist.
A Canadian man who shared a hospital room in Toronto with Chi Kwai Tse dies from SARS.
23 Mar. Scarborough Grace Hospital in Toronto closes temporarily because of SARS concerns
25 Mar. China bars the WHO team that was sent on 21 Mar from Guangdong Province
Ontario Health Minister Tony Clement declares SARS a reportable, communicable and virulent disease. This gives health officials the authority to track infected people and issue orders to stop them from engaging in activities that transmit SARS.
26 Mar. The Chinese Ministry of Health updates their figures to 792 cases of SARS, 31 deaths in Guangdong, 3 in Beijing since November 2002
Ontario Premier Ernie Eves declares a provincial state of emergency and orders thousands into quarantine; 27 probable cases of SARS in Ontario.
First global “grand round” on treatment of SARS is conducted electronically by WHO; 80 practitioners from 13 countries participate
27 Mar. WHO recommends screening of passengers on flights departing areas with known SARS outbreaks for symptoms; WHO reports 1400 cases worldwide with 53 deaths.
The Chinese Ministry of Health reports SARS has spread away from Guangdong to Beijing and Shanxi province.
Guangdong issues guidelines on community prevention and control, including mandatory home quarantine of contacts; commences public service announcements about personal protection and seeking prompt medical attention
Toronto hospitals ordered closed to visitors.
Hong Kong closes its schools
First cases in Romania
28 Mar. China agrees to become a full partner in the WHO collaborative effort in containing SARS
China concludes that SARS outbreaks elsewhere in Asia are ultimately traceable to the initial outbreak in Guangdong
29 Mar. Massive outbreak of SARS at Amoy Gardens in Hong Kong; 213 suspected cases attributed to leaky sewage system
31 Mar. Toronto hospital visitor restrictions extended to the rest of Ontario
2 Apr. WHO issues travel advisory warning against travel to Guangdong Province and Hong Kong
3 Apr. WHO epidemiological team arrives in Guangdong Province.
Chinese government disputes the travel warning on Guangdong; asserts the government was not slow in releasing information on the disease
China admits 1,190 cases, with 47 deaths; asserts the spread is under control
Hong Kong begins the forced isolation of SARS patients into camps and resorts in an attempt to contain the spread
Facing domestic and international criticism, China announces fighting SARS is a top priority; extends cooperation with WHO
4 Apr. Chairman of Chinese Center for Disease Control apologizes for lack of information openness on SARS issues
President Bush signs Executive Order adding SARS to the list of diseases for which U.S. citizens can be involuntarily quarantined
9 Apr. Dr. Jiang Yanyong, a retired chief of surgery for a Beijing military hospital, publicly accuses his government of covering up the extent of SARS infections in Beijing. Following Jiang, reports of hospitals with entire wards of suspected SARS patients emerge on Chinese internet sites; this information eventually makes it into a Time magazine article on the Chinese government’s mishandling of SARS.
11 Apr. Beijing added to WHO list of SARS-affected areas
13 Apr. Canadian research team at Michael Smith Genome Sciences Centre posts SARS genome sequence online
Chinese Premier Wen Jiabao admits the SARS outbreak in China is “grave” and that the government will “speak the truth” in its disclosures
14 Apr. Beijing mayor admits that SARS was present in the city as early as March 1st, several weeks before its presence was admitted
16 Apr. WHO press release officially names the disease Severe Acute Respiratory Syndrome; declares a coronavirus to be the cause of the outbreak
18 Apr. Chinese central party officials order all officials to fully disclose the extent of the disease’s spread, partly reversing its earlier half-hearted approach; statement comes after Time magazine article discloses that China shifted SARS patients from hospital to hospital during WHO visits to cover up the scale of the illness
20 Apr. Chinese Health Minister Zhang Wenkang and Beijing Mayor Meng Xuenong fired for their mishandling of the SARS epidemic
President Hu visits the AMMS lab and praises their work
China cancels the weeklong May 1 International Workers’ Day holiday because of SARS fears
23 Apr. WHO extends travel warnings to Beijing, Shanxi province and Toronto, Canada. Warnings are intended to last a minimum of three weeks – double the incubation time of SARS.
China establishes the SARS Control and Prevention Headquarters of the State Council to coordinate national efforts
Beijing schools closed for two weeks
24 Apr. Canada’s senior diplomat in Geneva attempts to have the WHO travel advisory to Toronto lifted immediately
Beijing seals off People's Hospital of Beijing University and People's Armed Police General Hospital, putting thousands of patients and medical workers under observation.
27 Apr. Beijing closes public places such as libraries and cinemas and suspends marriages in attempts to contain SARS
29 Apr. WHO announces that SARS appears to have peaked in Hong Kong, Canada and Singapore; however cases are still rising in mainland China and Taiwan
WHO declares SARS contained in Vietnam
30 Apr. WHO ends travel warning to Toronto; Canada agrees to implement infrared temperature-taking devices at airports to screen for patients with fevers
Estimates emerge of close to $519 million economic cost to Canadian tourist industries via cancelled flights, hotel rooms, and lessened demand for service industries, according to a report by the Canadian Tourism Commission.
Guangdong institutes free hospital treatment for patients with SARS
5 May Violent protest of 1,000 demonstrators against a local government office regarding quarantined SARS patients in Zheijang province; protestors demand that the quarantined persons be moved away
6 May Chinese officials in Nanjing order 10,000 into quarantine
8 May WHO extends travel warning to Taipei, Taiwan, and Tianjin and Inner Mongolia in China
12 May Chinese central government allocates 2 billion yuan ($240 million); local budgets allocate 5 billion yuan ($602 million); these funds were put toward future public health emergencies
13 May CNN International special on SARS that criticized the Chinese government’s response to the illness is censored in China
14 May Canada removed from WHO list of SARS-affected countries.
17 May Ontario lifts provincial state of emergency
22 May Beijing students return to class
23 May Hong Kong and Guangdong removed from travel advisory list
24 May Reports of new cases of SARS causes officials to again declare provincial state of emergency in Ontario, one week after lifting the initial warning
More than 500 people ordered into quarantine in Toronto because of fears of new outbreak
28 May First case reported in Russia
13 June WHO drops travel advisories for the Chinese city of Tianjin and the provinces of Shanxi, Inner Mongolia and Hebei in northern China.
23 June Hong Kong declared SARS-free
24 June WHO declares China to be SARS-free; last travel restriction in the world, to Beijing, lifted
2 July Second Ontario provincial state of emergency is lifted. From its first reported case on 5 March, 224 people in the Toronto area were officially diagnosed with SARS, causing 38 deaths.
5 July WHO removes Taiwan from list of places with active virus; declares that all lines of cross-border contagion of SARS have been broken and danger of epidemics has passed
30 July Estimated 450,000 people attend open-air Toronto concert headlined by Rolling Stones to help raise money for area businesses hard hit by the SARS outbreak
10 Sept. Isolated case in Singapore
16 Dec. Isolated case in Guangdong
17 Dec. Isolated case in Taiwan
5 Jan. Isolated case in Guangdong