The SARS Epidemic
Appendix A: Chronology
by
MJ Peterson
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.
Key
blue = WHO actions
orange = initial reports of cases in a new country
red = clear identification of source of the new infection
1996
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.
2000
April WHO formally establishes Global Outbreak Alert and Response
System
2002
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
2003
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
2004
5 Jan. Isolated
case in Guangdong
