First Known Case of Atypical Pneumonia in Europe Quarantined in Frankfurt (with 155 passengers)

FRANKFURT, Germany (AP) - A doctor from Singapore believed infected with a mysterious form of pneumonia that hit parts of Asia was taken off an airplane from New York on Saturday and quarantined in a Frankfurt hospital, German health authorities said.

The doctor, believed to be the first person in Europe to be infected with the atypical virus, was flying to Singapore from New York, where he already began to suffer symptoms, Dr. Angela Wirtz, of the Hessen state health office said in a statement.

Fearful the virus may be spreading, the Geneva-based international health organization, WHO, issued an emergency travel advisory Saturday.

Outbreaks of the disease have been reported in southern China, Hong Kong and Singapore. Unconfirmed new cases have been reported in Vietnam and Taiwan, as well as two deaths in Canada.

Two people accompanying the doctor also were taken off the Singapore Airlines flight during a stopover in Frankfurt and admitted to the Wolfgang Goethe University Clinic in Frankfurt, the statement said.

Another 155 passengers who deplaned in Frankfurt were being temporarily held in quarantine at the airport, the statement said. The 85 passengers bound for Singapore, as well as the plane's 20 crew members, continued their journey and will be met by health officials upon their arrival.

SHORT ANSWER: UNKNOWN

THIS MAY HELP US GET UP TO SPEED`

The World Health Organisation (WHO) has issued a global pneumonia alert after a highly contagious respiratory illness killed one man and infected nearly 60 hospital staff in Hong Kong and Vietnam. Health authorities have not been able to establish any link between outbreaks in the 2 places, but experts studying the Hong Kong cases believe they were caused by rapidly spreading viruses that have yet to be identified. "It must have come from a patient and is probably spread from human to human in very close contact by aerosol, like sneezing," said Professor John Tam, who is among a team of doctors treating those battling the virus in Hong Kong. "It affects a lot of people very quickly and their conditions can deteriorate very quickly," Tam said.

An American businessman who died on Thursday in a Hong Kong hospital had been flown in from Hanoi, where he had been admitted to hospital shortly after arriving from Shanghai and Hong Kong with severe respiratory problems, the WHO said. Following his admission, some 20 staff in the Hanoi hospital fell sick with similar symptoms and some have developed pneumonia and acute respiratory distress, it said. Some of the Hanoi victims remain critically ill. That hospital has since been shut for cleaning and will not reopen until late next week, according to an employee there.
In Hong Kong, more medical staff have fallen ill with flu-like symptoms. By late Thursday, 38 hospital staff had been admitted and 24 of them were showing signs of pneumonia. None of those in Hong Kong is known to have had any contact with the American. 2 of the 24 are in serious condition.

Vietnam's state-run media on Thursday quoted Vice Health Minister Nguyen Van Thuong as saying: "Preliminary results showed this is the influenza virus type B." Earlier this week an official at the Hanoi-based Epidemic Hygiene Institute told Reuters: "The virus can be fatally dangerous to humans and it can spread really fast."
Hong Kong's Health Minister Yeoh Eng-kiong told reporters: "There is a possibility that it can mutate or it may be a virus that is not known to us." News of the infections worried many in Hong Kong. In some of the territory's hospitals, staff and patients, and even those seeking outpatient treatment, wore surgical masks. Pneumonia is the number 4 killer in Hong Kong, where some 300 people are admitted into hospital every week. But the current cases in Hong Kong are of special concern, coming so soon after a much-feared avian influenza virus killed a man and infected his son in February 2003. The father's flu-like illness deteriorated into pneumonia before he died. A government spokesman said earlier that the latest virus was not influenza A virus H5N1, or the deadly bird-flu virus which sparked a global WHO alert and widespread panic in February.
There was an outbreak of atypical pneumonia in China's southern Guangdong province in mid-February 2003 that infected 305 people, killing 5. It is not known whether the Guangdong cases are linked to the ones in Hanoi or Hong Kong.

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Health officials have issued a global warning about a virulent flu and pneumonia that has swept through hospitals in Hong Kong and Vietnam. One man has died, dozens of hospital workers have fallen ill, and some of these are reportedly in a critical condition. The precise origin of the infection is still unknown, but the key case involved an American businessman who died on Thursday morning in a Hong Kong hospital. He had arrived into Hanoi in Vietnam from Shanghai on a business trip already suffering from severe respiratory problems. When his condition deteriorated, he was transferred to Hong Kong for specialist care. World Health Organisation experts are concerned that he may have passed the infection on to many others on the way. It has issued a "global alert" warning public health surveillance teams throughout the world to be vigilant for outbreaks.

"Any time you cannot diagnose the cause of a disease, it's very serious," said the World Health Organisation's David Heyman. "What's fortunate is that at present it seems to be confined to hospital workers who have had contact with the patients; although now we're looking to see whether people might be sick in the community." After the US patient's admission in Hanoi, 20 hospital staff fell ill with the same infection, and so far 50 staff in Hong Kong have shown similar flu-like symptoms, and some have been admitted to hospital. Of these, 23 are already showing clear signs of pneumonia. The condition of some of these is described as "critical". None of the staff are known to have had any direct contact with the American -- so no direct link with either his death, or the Hanoi outbreak, can be established.
Singapore's Ministry of Health says it is also closely monitoring 3 people admitted to hospital with an unusual form of pneumonia, all of whom had recently visited Hong Kong. Professor John Tam, one of those treating the virus patients in Hong Kong, said: "It must have come from a patient and is probably spread from human to human in very close contact by aerosol, like sneezing." Concerns over the highly-contagious illness have prompted many staff and patients attending hospitals in Hong Kong to wear surgical masks.
The signs and symptoms of the disease in Hanoi include initial flu-like illness, with rapid onset of high fever followed by muscle aches, headache, and sore throat. In some, but not all cases, this is followed by double pneumonia -- with some patients needing help from a ventilator to stay alive.
Hong Kong Health Minister Yeoh Eng-kiong said that testing was being carried out to try to identify the virus involved. Tests have so far [implicated] Influenza B virus. He said: "The rate of infection is very high. But Hong Kong Government officials said the illness was not related to a strain of "bird-flu" that killed a man in February, [which was an avian influenza A virus]. It is possible the outbreak is linked to a spate of "atypical pneumonia" cases in the southern Guangdong province of China in February, which killed 5 people and infected hundreds more.

The World Health Organisation (WHO) has on Wed 12 March 2003 issued a global alert about outbreaks of cases of a severe form of pneumonia in Hong Kong, Vietnam and Guangdong province in China.

In Vietnam, the outbreak began when a traveller was hospitalised on 26 Feb 2003 for the treatment of severe and acute breathing difficulties of unknown origin. He had become sick shortly after arrival in Hanoi from Shanghai and Hong Kong. Following his admission to the hospital, about 20 hospital staff became sick with similar symptoms. Some of these staff are recovering but some remain critically ill.

In Hong Kong, an outbreak of respiratory illness has been reported on 11 Mar 2003 in the Prince of Wales Hospital. More than 20 hospital staff were admitted for observation after they developed fever. Some of these staff also developed pneumonia. Their conditions are stable.

In February 2003, it was reported that about 300 cases of atypical pneumonia, with 5 deaths, had occurred in Guangdong province in China. The signs and symptoms of the disease include initial flu-like illness (rapid onset of high fever followed by muscle aches, headache, and sore throat).
In some cases, they developed pneumonia progressing to difficulty in breathing.
The outbreaks in Hong Kong and Hanoi appear to be confined to the hospital environment. No link has so far been made between the outbreaks of pneumonia in Hong Kong and Hanoi and the earlier outbreak of avian influenza (H5N1) in Hong Kong in February this year. Investigations into the cause of the outbreaks are currently being carried out by the WHO.

The Ministry of Health is closely monitoring the situation. The Ministry had been notified of 3 persons who had travelled to Hong Kong at the end of February and who were admitted to hospital for pneumonia after they returned to Singapore. 2 of them have recovered and been discharged from hospital. The remaining case is recovering in hospital. Investigations suggest a viral origin, however no causative organism has been identified. The Ministry has conducted contact tracing and given advice to the contacts of these cases to seek medical attention early should they become ill. The hospital staff attending to these cases were advised to take the necessary infection control precautions. None of the hospital staff attending to these patients have reported ill. So far, the Ministry has not established that these cases are related to the outbreak in Hong Kong and Hanoi.
Surveillance has shown that there has not been any increase in the number of cases of acute respiratory infections. As a precautionary measure, the Ministry is advising all medical practitioners to be vigilant and to be on the lookout for similar cases.
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[4]
Date: Thu 13 Mar 2003

Source:Yahoo Asia News, Agence France-Presse, Thu 13 Mar 2003

Hong Kong SAR: 38 Medical Staff Affected by Pneumonia Outbreak

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At least 38 medical staff at Hong Kong hospitals are suffering symptoms of a severe form of pneumonia in the latest outbreak of a mystery illness that has led the World Health Organisation (WHO) to issue a global warning. 23 are staff members at the Prince of Wales Hospital, with at least 2 workers in critical condition, a hospital spokeswoman said on Thursday.

WHO stated in a statement Wednesday that the outbreak appeared to begin with a single case in Hanoi on 26 Feb 2003. The patient, a 48-year-old American businessman who fell ill following a trip to Shanghai and Hong Kong, died Thursday at Hong Kong's Princess Margaret Hospital after being flown back from Hanoi last week suffering from a flu-like illness. So far, 38 medical workers have been admitted to four hospitals around the territory.
Hong Kong's Secretary for Health, Welfare and Food, Yeoh Eng-kiong, urged reporters not to "speculate" about the disease and to give authorities time to investigate. "When you have these unusual circumstances and unusual viruses causing these infections it takes time to get to the root of the problem," said Yeoh. However, he said the outbreak was an "exceptional phenomenon" in the way the outbreaks seemed "to affect predominantly health care workers who were caring for the patients".

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[5]
Date: Thu 13 Mar 2003
From: Karen Sharples Source: CNN,com, Reuters report, Thu 13 Mar 2003 [edited]
Hong Kong SAR: Etiologic Agent Remains Unidentified

The World Health Organisation (WHO) has issued a global pneumonia alert after an outbreak of a mysterious respiratory illness killed one man and infected more than 50 hospital staff in Hong Kong and Vietnam. An American businessman died on Thursday morning in a Hong Kong hospital to which he was admitted on 6 Mar 2003 after falling ill in Hanoi, according to a Hong Kong government spokesmen. The 50-year-old man had been flown in from Hanoi, where he had been admitted to hospital shortly after arriving from Shanghai and Hong Kong with severe respiratory problems, said WHO and Hong Kong authorities. The cause of his illness is unknown. Following his admission, more than 20 staff in the Hanoi hospital fell sick with similar symptoms and some have developed pneumonia and acute respiratory distress requiring assisted breathing on a respirator, the WHO said. Some of the victims in Hanoi remain critically ill, it said.
In Hong Kong, more medical staff have fallen ill with flu-like symptoms. By midday on Thursday, 32 hospital staff had been admitted, with 19 of them showing initial signs of pneumonia, said a Hong Kong health spokeswoman. None of those in Hong Kong are known to have had any contact with the American. One of the 19 is in serious condition. Hong Kong's health minister Yeoh Eng-kiong said the Hong Kong cases may have been caused by a fast-spreading respiratory virus, but more tests were being carried out to identify the virus.

News of the infections worried many in Hong Kong. In some of the territory's hospitals, staff and patients, and even those seeking outpatient treatment, wore surgical masks. The WHO said no link has so far been found between the cases in Hong Kong and Hanoi but investigations were ongoing. "The outbreaks in Hanoi and Hong Kong appear to be confined to the hospital environment. Those at highest risk appear to be staff caring for the patients," the WHO said. Patients with atypical pneumonia that may be related to these outbreaks should be isolated with barrier nursing techniques, and any suspect cases should be reported to national health authorities, it added.
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Karen H. Sharples, RPh
Portland, Oregon

[These reports reiterate the lack of a clear connection between the outbreaks of an atypical pneumonia in the Hong Kong SAR, Guangdong Province in China, Vietnam, and Singapore, other than linkage to an American patient travelling from China (Hong Kong SAR and Shanghai) to Vietnam, who was subsequently transferred to Hong Kong for hospital treatment. A viral infection is suspected, but the virus responsible remains unidentified. The only positive identification has been 2 isolations of influenza B virus in Vietnam; no virus has been isolated from the deceased American patient at the centre of the outbreak or among hospital staff in Hong Kong. The avian influenza A (H5N1) virus that caused the death of a father and son in Hong Kong recently has been excluded.

Influenza B virus seems an unlikely candidate for a virus responsible for a putative global atypical pneumonia. In the past, outbreaks of disease caused by influenza B virus have been 4 to 6 times less frequent than those caused by influenza A virus and have been relatively localised mainly but not exclusively affecting children. Influenza B virus is not subject to antigenic shift and therefore inherently is less variable (there are no distinctive hemagglutinin or neuraminidase antigenic types and no animal reservoirs). That does not exclude, however, the possible appearance of strains of enhanced or atypical virulence by accumulation of genetic mutations.
The statement of the Secretary for Health, Welfare and Food of Hong Kong, Yeoh Eng-kiong, is worth repeating at this juncture: He was urging reporters not to "speculate" about the disease and to give authorities time to investigate. "When you have these unusual circumstances and unusual viruses causing these infections, it takes time to get to the root of the problem.

We are changing the name of this threat to Severe Acute Respiratory Syndrome - Worldwide to reflect the appearance of cases now outside of East Asia, and in keeping with the name of they syndrome as defined by WHO -- "Severe Acute Respiratory Syndrome" (SARS). In addition, given the severity of this situation, we have chosen to post this alert to ALL ProMED-mail subscribers, irrespective of specialty list preferences to assist in a further, widespread dissemination of this alert information. - Mod.MPP] Date: 15 Mar 2003 From: ProMED-mail Source: WHO Press release
World Health Organization issues emergency travel advisory Severe Acute Respiratory Syndrome (SARS) Spreads Worldwide

15 March 2003 | GENEVA -- During the past week, WHO has received reports of more than 150 new suspected cases of Severe Acute Respiratory Syndrome (SARS), an atypical pneumonia for which cause has not yet been determined. Reports to date have been received from Canada, China, Hong Kong Special Administrative Region of China, Indonesia, Philippines, Singapore, Thailand, and Viet Nam. Early today, an ill passenger and companions who travelled from New York, United States, and who landed in Frankfurt, Germany were removed from their flight and taken to hospital isolation.
Due to the spread of SARS to several countries in a short period of time, the World Health Organization today has issued emergency guidance for travellers and airlines.
"This syndrome, SARS, is now a worldwide health threat," said Dr. Gro Harlem Brundtland, Director General of the World Health Organization. "The world needs to work together to find its cause, cure the sick, and stop its spread."
There is presently no recommendation for people to restrict travel to any destination. However in response to enquiries from governments, airlines, physicians and travellers, WHO is now offering guidance for travellers, airline crew and airlines. The exact nature of the infection is still under investigation and this guidance is based on the early information available to WHO.
TRAVELLERS INCLUDING AIRLINE CREW: All travellers should be aware of main symptoms and signs of SARS which include: ? high fever (greater than 38 C)
AND ? one or more respiratory symptoms including cough, shortness of breath, difficulty breathing AND one or more of the following: ? close contact* with a person who has been diagnosed with SARS ? recent history of travel to areas reporting cases of SARS. In the unlikely event of a traveller experiencing this combination of symptoms they should seek medical attention and ensure that information about their recent travel is passed on to the health care staff. Any traveller who develops these symptoms is advised not to undertake further travel until they have recovered.
AIRLINES: Should a passenger or crew member who meets the criteria above travel on a flight, the aircraft should alert the destination airport. On arrival the sick passenger should be referred to airport health authorities for assessment and management. The aircraft passengers and crew should be informed of the person's status as a suspect case of SARS. The passengers and crew should provide all contact details for the subsequent 14 days to the airport health authorities. There are currently no indications to restrict the onward travel of healthy passengers, but all passengers and crew should be advised to seek medical attention if they develop the symptoms highlighted above. There is currently no indication to provide passengers and crew with any medication or investigation unless they become ill. In the absence of specific information regarding the nature of the organism causing this illness, specific measures to be applied to the aircraft cannot be recommended. As a general precaution the aircraft may be disinfected in the manner described in the WHO Guide to Hygiene and Sanitation in Aviation.
***** As more information has become available, WHO-recommended SARS case definitions have been revised as follows:
Suspect Case A person presenting after 1 Feb 2003 with history of : ? high fever (greater than 38 C)
AND ? one or more respiratory symptoms including cough, shortness of breath, difficulty breathing AND one or more of the following: ? close contact* with a person who has been diagnosed with SARS ? recent history of travel to areas reporting cases of SARS
Probable Case A suspect case with chest x-ray findings of pneumonia or Respiratory Distress Syndrome OR
A person with an unexplained respiratory illness resulting in death, with an autopsy examination demonstrating the pathology of Respiratory Distress Syndrome without an identifiable cause. Comments
In addition to fever and respiratory symptoms, SARS may be associated with other symptoms including: headache, muscular stiffness, loss of appetite, malaise, confusion, rash, and diarrhea. ****
Until more is known about the cause of these outbreaks, WHO recommends that patients with SARS be isolated with barrier nursing techniques and treated as clinically indicated. At the same time, WHO recommends that any suspect cases be reported to national health authorities.
WHO is in close communication with all national authorities and has also offered epidemiological, laboratory and clinical support. WHO is working with national authorities to ensure appropriate investigation, reporting and containment of these outbreaks.
*Close contact means having cared for, having lived with, or having had direct contact with respiratory secretions and body fluids of a person with SARS. For more information contact: --
Dick Thompson - Communication Officer Communicable Disease Prevention, Control and Eradication WHO, Geneva Telephone: (+41 22) 791 26 84
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