Overview of Taiwan SARS Epidemic Kow-Tong Chen MD, PhD Center for Disease Control , Taiwan

香 港 1名醫學院教授，自廣東前往香港參加婚禮，暫住旅館。 因疑似SARS ，送醫治療。 爆發10名個案感染 超過150名醫護人員感染。

Global Case Number Total : 8447 probable case Death: 812 2 July 2003 Total : 8447 probable case Death: 812 China: 5327, 348 death HK: 1755, 298 death Singapore: 206 (0), 32 death Canada: 252, 38 death

Surveillance for SARS Epidemic

Case Definition (I) Suspect case suspect or probable case of SARS; OR 1. After 1 February 2002 with history of: -  high fever (>38 °C) AND - cough or breathing difficulty 2. exposures during the 10 days prior to onset of symptoms: -  close contact with a person who is a suspect or probable case of SARS; OR -  history of travel or residing , to an affected area

Case Definition (II) Probable case A suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (RDS) on chest X-ray (CXR). A suspect case with autopsy findings consistent with the pathology of RDS without an identifiable cause.

Taiwan Update From: 17 March 2003 To: 30 July 2003 22% 668 (33.4%) 1012 (22.1%) 1348 (44.5%) 22% Probable Suspected Excluded Review Results of SARS Reported Cases in Taiwan

Epidemiological curve of SARS probable cases in Taiwan 30 25 (case no.) 20 病例數 15 10 5 2/24 3/1 3/6 3/11 3/16 3/21 3/26 3/31 4/5 4/10 4/15 4/20 4/25 4/30 5/5 5/10 5/15 5/20 5/25 5/30 6/4 6/9 6/14 6/19 6/24 6/29 7/4 7/9 (onset) Epidemiological curve of SARS probable cases in Taiwan

38 Probable Cases ？ 3/7 38 39 121 138 2 3/21 CA112 3/15 CA111 3/21 CX510 3/21 3/19 CI017 3/30 CI018 3/31 CI627 3/27 CI628 3/28 47 1 3/21 3/30 4/4 CX510 2/21 17 CX460 3/26 CX511 3/28 2/25 3/17 40 41 115 3/30 3/19 122 3/18 3 GE354 3/01 3/07 3/31 58 112 106 CI616 3/22 4/2 7 CI625 3/06 3/13 KE852 3/28 TG635 3/28 192 BR857 4/7 4/18 12 CI614 3/11 3/13 3/23 4/1 36 CI628 3/23 3/16 107 NX668 3/30 3/27 202 ？ 3/14 4/18 63 BR826 3/20 3/27 129 BR802 3/27 4/3 205 CX510 4/12 4/18 92 CX402 3/30 151 CI662 3/28 4/3 183 4/16 217 4/19 ？ 3/28 96 BR818 3/23 3/27 156 BR802 3/27 3/31 218 4/21 220 4/16 24 ？ 3/14 3/14 170 BR802 3/27 3/31 221 4/20 222 4/17 223 4/21

Transmission Pathway of SARS Outbreak in Taiwan March 14-Apr.22 Apr. 21 May 15 May 31 China HK JG Nursing ? JenChi 32 4/9 Hoping Hospital 151 NTUH 4/30 H.K. ChangGung Memorial Hospital 44 Junghsin 2 Apr. 23 PengHu. 7 K.H. Med Univ. 8 5/2 NTUH 52 MK 17

Table 1. Demographic characteristics of SARS patients’ outcome, 2003 Variable Alive (N=487) Deceased (N=181) Age (mean  SD) 47.2 (21.1) 61.8 (18.2) Sex   Male (%) 215(67) 104(33) Female 272(78) 77(22) Contact tracing Imported 51(96) 2(4) Close contact 37(90) 4(10) HCW 103(86) 17(14) Doctor 14(82) 3(18) Nurse 59(94) 4(6) Allied 30(75) 10(25) Hospital-related 138(54) 118(46) To be identified 158(83) 40(17) Chronic Disease 48(43) 64(57)

Table Symptom of SARS（%）   Symptom Lee et al. n=138 Booth et al. n=144 Peiris n=50 Chen et al. n=668 Fever 100 99 97 Rigor 73 28 74 12 Cough 57 69 62 Myalgia 61 49 54 14 Sore throat 23 20 Diarrhea 24 10 19 Headache 56 36  

Age-Sex Distribution of SARS Probable Cases in Taiwan 120 Male Female 92 90 63 63 62 Case number 60 55 47 45 43 36 31 31 30 24 25 15 16 13 10 5 0-9 yrs 10-19 yrs 20-29 yrs 30-39 yrs 40-49 yrs 50-59 yrs 60-69 yrs 70-79 yrs > 80 yrs Age group Age-Sex Distribution of SARS Probable Cases in Taiwan

Geographical Distribution of SARS Probable Cases in Taiwan Taipei county Lien-Chiang county Taipei city Keelung city (Case No.) 9 Taoyuan county 264 > 50 Hsinchu county 32 201 Hsinchu city 7 6 > 20-50 Ilan county Kinmen county Miaoli county 10 3 > 10-20 Taichung county Taichung city 6 > 0-10 9 Changhwa county 6 Nantou county 1 Hwalien county 1 Yunlin county 4 Chiayi county 3 Chiayi city 5 Tainan county 41 Penghu county 2 7 2 Tainan city Taitung county Kaohsiung county Date: 11 July 2003 Probable Cases: 671 18 Kaohsiung city 34 Pingtung county Geographical Distribution of SARS Probable Cases in Taiwan

Mortality Death certificates were obtained from the Ministry of Interior Case-fatality rates were estimated by dividing the number of deaths by the total number of probable cases It based on cases with known outcome and irrespective of immediate cause of death

Table 2. Case fatality rates of Severe Acute Respiratory by age and sex in Taiwan, February-July, 2003 Male Female Variable   No. of case No. of death Fatality rate* Fatality rate+ Age group 0-9yrs 10 4 10-19yrs 13 15 1 6.7 20-29 yrs 30 5 16.7 92 8 8.7 30-39 yrs 45 2 4.4 62 7 11.3 40-49 yrs 53 24.5 63 15.9 50-59 yrs 46 20 43.5 43 11 25.6 60-69 yrs 25 44.0 52.0 70-79 yrs 33 52.4 29 18 62.1 80 yrs 34 58.8 16 9 56.3 Total 319 104 32.6 349 77 22.1 *Chi square for linear trend = 51.697, P0.00001 +Chi square for linear trend = 59.921, P0.00001

Figure 1. Case fatality rates of Severe Acute Respiratory by age and sex in Taiwan, February-July, 2003

Chotani, 2003 Source: WHO

Chotani, 2003 Source: WHO

Chotani, 2003 Source: WHO

Chotani, 2003 Source: WHO

Chotani, 2003 Source: WHO

Chotani, 2003 Source: WHO

Chotani, 2003 Source: WHO

Laboratory investigation Nasopharyngeal or stool swabs were obtained SARS Co-V was tested by CDC, Taiwan RT-PCR for SARS-Co-V was completed

SARS Coronavirus Full Genome Sequence 1NF 1NR 2NF 2NR 3NF 3NR 4NF 4NR 5NF 5NR 6NF 6NR 7NF 7NR 8NF 8NR 9NF 9NR 10NF 10NR 11NF 11NR 12NF 12NR 13NF 13NR 14NF 14NR 15NF 15NR 16NF 16NR 17NF 17NR 18NF 18NR 19NF 19NR 20NF 20NR 21NF 21NR 22NF 22NR 23NF 23NR 24NF 24NR 25NF 25NR 1st bp 29736bp

Detection of anti-SARS Antibody by IFA control patient (1:800)

Laboratory investigation Probable case: PCR (+) 37.5% Suspect case: PCR (+) 3.7% Excluded: PCR (+) 0.8%

*: no specimen = 1 CFR: Case Fatality Rate

Control Measures To prevent the spread of the infection. The Department of Health set up on March 17 a SARS Control Task Force. The Task Force has met 40 times. Meetings of specialists and scholars are held. Review syndrome reporting and zoonotic disease surveillance data Application of strict isolation procedure in the hospitals

Control Measures “Home quarantine” Class A: close contacts（HCW, family members, colleagues, classmates). Class B: returned from affected area.

As of July 30, a total of 151,270 had been quarantine Class A: 34 (6.1/10,000) probable cases among 55,315 persons Class B: 12 (1.3/10,000) probable cases among 95,955 persons

Measurement of body temperature at airports April 10 through July 29, 2003, A total of 2,760,379 were taken 2,134 had fever Four (1.4/1,000,000) were subsequently classified as probable cases

Control Measures Hospital Infection Control Practice 17 mobile SARS Containment Teams were initiated on March 18, 2003

Control Measures Expertise assistance from CDC,U.S.A. & WHO Training course for HCW/PHW and key employers/employees Intensive epidemiological investigation for the SARS suspects and the close contacts Laboratory service with collaboration

Conclusions SARS has become a global health hazard Containment of the outbreak at early stage HCW, elderly, coexisting medical disorders were high risk group Isolation of cases, hospital infection control and vigilant surveillance were important control measures

SARS危險族群 航線 入境 出境 旅館 工作 就學 家庭/親友 醫護人員

SARS發病圖 體溫 發燒日 發病 感染 潛伏期 發病期 不傳染 傳染 0C 溫度 第 日 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 日 發燒日 1 2 3 4 5 6 7 8 9 10 11 12

SARS通報病例定義(WHO) 以下臨床病例定義是為了公共衛生的目的而設的 病例符合： 1、發燒(≧38°C) 並且 2、一種或一種以上的下呼吸道症狀（咳嗽、呼吸困難、呼吸短促） 3、放射線診斷學上有與肺炎或呼吸窘迫症候群一致的肺浸潤證據 或 屍體解剖有與肺炎或呼吸窘迫症候群一致的的病理學發現，且無其他可確認的致病因 4、無其他可替代的診斷能完全解釋疾病

SARS通報(今冬A 、 B級) 1 發燒(≧38°C) 6 PCR陽性 病例符合：1+2+3+4+5 或 1+2+3+4+6 2 一種或一種以上的下呼吸道症狀（咳嗽、呼吸困難、呼吸短促） 3 放射線診斷學上有與肺炎或呼吸窘迫症候群一致的肺浸潤證據 或 屍體解剖有與肺炎或呼吸窘迫症候群一致的的病理學 發現，且無其他可確認的致病因 4 無其他可替代的診斷能完全解釋疾病(流感檢驗陰性) 5 聚集現象 6 PCR陽性 病例符合：1+2+3+4+5 或 1+2+3+4+6

SARS CoV 檢驗陽性 1. SARS CoV PCR陽性 利用下列任一種方法： a.至少兩個不同的臨床檢體，比如：咽喉和糞便 或者 b.相同部位但在疾病過程中，兩個或兩個以上不同場合、 不同時間取得的檢體，比如：一系列咽喉抽取液 或者      c.從臨床取得的檢體萃取出RNA作兩次不同的檢驗或重複的 PCR呈陽性者 2. 利用ELISA或IFA的抗體陽轉（SEROCONVERSION） a.急性期血清抗體陰性但在恢復期血清抗體呈陽性者 或者  b.疾病恢復期的抗體血清指數是急性期的四倍或四倍以上 3. 病毒分離 從任一檢體取得SARS-CoV的細胞培養分離出SARS-CoV病毒而且經PCR證實者

SARS聚集現象 或者 醫療工作場所:相同工作場所有兩個或更多的醫護人員符合SARS的臨床病例定義而且在相同的十日內發病 社區 相同醫療工作場所定義:視區域的情況而定。單位的大小視情況而定，可以小至單一部門或是大型醫學中心的某一病房  

今冬發燒病人建議處理原則(國內尚無SARS病例) 92.10.01 發燒篩檢 I 一般住院 II ※ 通報 III 註1：低危險群之肺炎病人若臨床極度懷疑為SARS時，亦可提早採檢送驗。 註2：未明原因肺炎病患之一級接觸者，應採行「自主健康管理」

今冬發燒病人建議處理原則(國內已有SARS病例) 92.10.1 發燒篩檢 I 一般住院 II 通報 III 註1：低危險群之肺炎病人若臨床極度懷疑為SARS時，亦可提早採檢送驗。 註2：未明原因肺炎病患之一級接觸者，應採行「自主健康管理」