Timeline of the SARS outbreak

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The areas affected by SARS Sars Cases and Deaths.pdf
The areas affected by SARS

The following is a timeline of the 2002–04 outbreak of severe acute respiratory syndrome (SARS).

Severe acute respiratory syndrome Viral respiratory disease

Severe acute respiratory syndrome (SARS) is a viral respiratory disease of zoonotic origin caused by the SARS coronavirus (SARS-CoV). Between November 2002 and July 2003, an outbreak of SARS in southern China caused an eventual 8,098 cases, resulting in 774 deaths reported in 37 countries, with the majority of cases in China and Hong Kong according to the World Health Organization (WHO). No cases of SARS have been reported worldwide since 2004. In late 2017, Chinese scientists traced the virus through the intermediary of civets to cave-dwelling horseshoe bats in Yunnan province.


November 2002

On November 16, 2002, an outbreak of what is believed to be severe acute respiratory syndrome (SARS) began in the Guangdong province of China, which borders on Hong Kong. The first case of infection was speculated to be a farmer in the Shunde district of Foshan County. The People's Republic of China (PRC) notified the World Health Organization (WHO) about this outbreak on February 10, reporting 305 cases (including 105 health-care workers) and 5 deaths; [1] it was later reported that the outbreak in Guangdong had peaked in mid-February, but that appears to be false, as later 806 infections and 34 deaths were reported. [2]

Guangdong Most populous province of the Peoples Republic of China

Guangdong is a province in South China, on the South China Sea coast. Its capital and largest city is Guangzhou. Guangdong surpassed Henan and Shandong to become the most populous province in China in January 2005, registering 79.1 million permanent residents and 31 million migrants who lived in the province for at least six months of the year; the total population was 104,303,132 in the 2010 census, accounting for 7.79 percent of Mainland China's population. This makes it the most populous first-level administrative subdivision of any country outside of South Asia, as its population is surpassed only by those of the Pakistani province of Punjab and the Indian states of Bihar, Maharashtra and Uttar Pradesh.

Foshan Prefecture-level city in Guangdong, Peoples Republic of China

Foshan, alternately romanized as Fatshan, is a prefecture-level city in central Guangdong Province, China. The entire prefecture covers 3,848.49 km2 (1,485.91 sq mi) and has an urban population around 7.2 million in 2012. It forms part of the western side of the Pearl River Delta Economic Zone, which includes Guangzhou to the east and northeast and Zhongshan to the southeast.

World Health Organization Specialized agency of the United Nations

The World Health Organization (WHO) is a specialized agency of the United Nations that is concerned with international public health. It was established on 7 April 1948, and is headquartered in Geneva, Switzerland. The WHO is a member of the United Nations Development Group. Its predecessor, the Health Organisation, was an agency of the League of Nations.

Early in the epidemic, the PRC discouraged its press from reporting on SARS and lagged in reporting the situation to the World Health Organization, delaying the initial report. Initially, it did not provide information for Chinese provinces other than Guangdong, the province where the disease is believed to have originated. [3] For example, a WHO team that traveled to Beijing was not allowed to visit the Guangdong province for several weeks. [4] This resulted in international criticism, which seemed to have caused a change in government policy in early April.

January 2003

The first super-spreader, Zhou Zoufeng would bring the disease to the international stage. He checked in to the Sun Yat-sen Memorial Hospital in Guangzhou on January 31. This was the same hospital where Liu Jianlun was treating the disease. The virus was soon spread to nearby hospitals while Liu would later spread the disease to Hong Kong. [5]


A super-spreader is a host—an organism infected with a disease—that disproportionally infects more secondary contacts than other hosts who are also infected with the same disease. A sick human can be a super-spreader; they would be more likely to infect others than most people with the disease. Super-spreaders are thus of high concern in epidemiology.

Sun Yat-sen University university in Guangdong, China

Sun Yat-sen University, abbreviated SYSU and colloquially known in Chinese as Zhongda, also known as Zhongshan University, is a major Chinese public research university located in Guangzhou, Guangdong, China. It was founded in 1924 by and named after Dr. Sun Yat-sen, a revolutionary and the founding father of the Republic of China.

Guangzhou Prefecture-level and Sub-provincial city in Guangdong, Peoples Republic of China

Guangzhou, also known as Canton and formerly romanized as Kwangchow or Kwong Chow, is the capital and most populous city of the province of Guangdong in southern China. On the Pearl River about 120 km (75 mi) north-northwest of Hong Kong and 145 km (90 mi) north of Macau, Guangzhou has a history of over 2,200 years and was a major terminus of the maritime Silk Road, and continues to serve as a major port and transportation hub, as well as one of China's three largest cities.

February 2003

Ninth floor layout of the Hotel Metropole in Hong Kong, showing where a super-spreading event of the severe acute respiratory syndrome (SARS) occurred Hotel Metropole 9th floor layout SARS 2003.jpg
Ninth floor layout of the Hotel Metropole in Hong Kong, showing where a super-spreading event of the severe acute respiratory syndrome (SARS) occurred

SARS arrived in Hong Kong in February 2003, when a doctor who had treated some of the cases of SARS at Sun Yat-Sen Memorial Hospital in Guangdong came to attend a family gathering. Liu Jianlun, Hong Kong's first patient, checked into the Metropole Hotel on February 21, with a room on the ninth floor, specifically room 911. Even though he was already feeling somewhat ill he visited with his family and traveled around Hong Kong. By February 22, he was sick enough to seek care at Kwong Wah Hospital. He died there in the Intensive Care Unit on March 4. He is believed to have been a superspreader, as he spread the virus to many other guests on his hotel floor. Liu's brother-in-law sought medical treatment in late February, entered the hospital on March 1, and died on March 19. Twenty-three other guests from the Metropole developed SARS, seven of them from the ninth floor, and it is estimated that around 80% of the Hong Kong cases were due to Liu. [6]

Kwong Wah Hospital Hospital in Yau Ma Tei, Hong Kong

Kwong Wah Hospital is a 1,141-bed public district general hospital in Yau Ma Tei, Hong Kong. Located on 25 Waterloo Road, the hospital was founded by the Tung Wah Group in 1911, and managed by the Hospital Authority since 1991. It provides a full range of medical services to the population of West Kowloon and Wong Tai Sin. It is Kowloon West Cluster's major acute teaching hospital, and also a Neurosurgical and Antenatal Diagnosis referral centre. The Hospital has established various clinical centers, including Lai Kwok Wing Urology Centre, Minimally Invasive Surgery Training Centre and Chan Feng Men Ling Cardiac Centre. There are integrated Breast Centre and Dr Stephen Chow Chun-kay Assisted Reproduction Centre. It has established a Community Based Geriatric Service, Respiratory Care Unit, Acute Stroke Unit, TWGHs BOCHK Diabetes Centre, Wong Wha San Renal Memorial Centre, and a Nuclear Medicine site. Kwong Wah Hospital is also a pioneer in Integrative Chinese and Western Medicine. TWGHs has established TWGHs Wilson T S Wang Integrated Chinese and Western Medicine Treatment Centre in Kwong Wah. The hospital has participated through joint consultation for designated diseases under protocols which developed by both Chinese Medicine and Western Medicine practitioners.

The virus was carried to Hanoi, Vietnam by a fellow guest on the Metropole's ninth floor. A Chinese-American resident of Shanghai, Johnny Chen, had roomed across the hall from Liu at the Metropole. He traveled on to Hanoi, fell ill there, and on February 26, was admitted to the French Hospital of Hanoi where he infected at least 38 of the staff there. Even though he was evacuated to Hong Kong, he died on March 13. [6]

Hanoi Municipality in Hà Nội, Vietnam

Hanoi is Vietnam's capital and second largest city by population. The city mostly lies on the right bank of the Red River. Hanoi is 1,720 km (1,070 mi) north of Ho Chi Minh City and 105 km (65 mi) west of Haiphong.

Carlo Urbani, a WHO infectious disease specialist, was among the staff who examined Chen. Urbani observed that other hospital staff were already becoming ill and realized that he was dealing with a new and dangerous disease. He himself became infected and died on March 29. [6]

On February 23, an elderly woman, Kwan Sui-Chu returned to Toronto from Hong Kong after being infected by Liu Jianlun at the Metropole Hotel. She died at home on March 5, after infecting her son Tse Chi Kwai, who spread the disease at Scarborough Grace Hospital and died on March 13. [7]

On February 25, a businessman who had traveled in Hong Kong and the Guangdong Province returned home to Taipei. This marked the beginning of the outbreak on the island of Taiwan. Another person who was at the Metropole also returned to Singapore.

Almost all of those infected had been either medical staff or family members of people who had fallen ill. It is believed that, at the time of exposure, affected medical staff were not using respiratory precautions, a safety protocol intended to fully protect medical workers. The various cases around the world were directly or indirectly traceable to people who had recently visited Asia.

March 2003

On March 1, 26-year-old Esther Mok was admitted to Tan Tock Seng Hospital after visiting Hong Kong, starting the Singapore outbreak. She recovered as various family members died. [8]

On March 4, a 27-year-old Hong Kong man who had visited a guest in Metropole (on the ninth floor) 11 days earlier was admitted to Prince of Wales Hospital. At least 99 hospital workers (including 17 medical students) were infected while treating him. [9]

On March 11, Carlo Urbani traveled to Bangkok to attend a medical conference. On the flight, he fell ill and upon arrival in Bangkok told an awaiting friend not to touch him and to call an ambulance to take him to a hospital. He was isolated in an intensive care unit.

A similar outbreak of a mysterious respiratory disease was reported among healthcare workers in Hong Kong.

On March 12, WHO issued a global alert about a new infectious disease of unknown origin in both Vietnam and Hong Kong.

On March 15, WHO issued a heightened global health alert about mysterious pneumonia with a case definition of SARS after cases in Singapore and Canada were also identified. The alert included a rare emergency travel advisory to international travelers, healthcare professionals, and health authorities.

The CDC issued a travel advisory stating that persons considering travel to the affected areas in Asia (Hong Kong, Singapore, Vietnam, and China) should not go.

On March 17, an international network of 11 laboratories was established to determine the cause of SARS and develop potential treatments.

The CDC held its first briefing on SARS and said that 14 suspected SARS cases were being investigated in the US.

On March 20, WHO reported that several hospitals in Vietnam and Hong Kong were operating with half the usual staff because many workers stayed home out of fear of getting infected. WHO raised the concern that substandard care of the infected patients may contribute to the spread of the disease.

On March 25, Hong Kong authorities said nine tourists came down with the disease when a mainland Chinese man boarded the same plane on 15 March on Air China Flight 112 to Beijing. [10] SARS started to hit Amoy Gardens Block E heavily.

The Singapore Government started to enforce compulsory quarantine of any infected person.

On March 27, Arthur K. C. Li, the head of the Hong Kong Education and Manpower Bureau, announced the class cancellation of all educational institutions. The Ministry of Education of Singapore announced that all primary schools, secondary schools, and junior colleges were to be shut until April 6, 2003. Polytechnics and universities were not affected.

On March 29, Urbani died in Bangkok of a massive heart attack.

On March 30, Hong Kong authorities quarantined estate E of the Amoy Gardens Apartment due to a massive (200+ cases) outbreak in the building. The balcony was completely closed and guarded by the police. The residents of the building were later transferred to the quarantined Lei Yue Mun Holiday Camp and Lady MacLehose Holiday Village on April 1 because the building was deemed a health hazard. Most of the cases were tied to apartment units with a north-western orientation that shared the same sewage pipe. According to government officials, the virus was brought into the estate by an infected kidney patient (a type of kidney illness was not specified) who after he was discharged from Prince of Wales Hospital, visited and thus infected his elder brother living in a flat on the seventh floor. Through excretion, the virus spread through drainage. One speculated theory that supported airborne transmission was that the virus was spread through dried up U-shaped P-traps in the drainage and was blown by a maritime breeze to the ventilation of the estate's balcony and stairwells. It was confirmed that the virus can spread via droplets, but this latest outbreak made the officials question the possibility of spreading through the air.

April 2003

On April 1, the U.S. government called back non-essential personnel in their consulate office in Hong Kong and Guangzhou. The US government also advised US citizens not to travel to the region.

On April 2, Chinese medical officials began reporting the status of the SARS outbreak. China's southern Guangdong province reported 361 new infections and 9 new deaths, increasing the total Mainland China figures previously reported at end-February. The virus was also detected in Beijing and Shanghai. The WHO also advised travelers to avoid Hong Kong and Guangdong during a press briefing.

On April 3, a WHO team of international scientists landed in Guangzhou from Beijing to discuss with officials, but the team was yet to inspect any suspected origin or any medical facilities on the progress of infection control. Fifteen of the quarantined Amoy Gardens residents at Lei Yue Mun Holiday Camp were relocated to the Sai Kung Outdoor Recreation Centre after an overnight protest on washroom sharing. The first medical worker infected with SARS died in Hong Kong. The doctor who survived had a daughter and an infected wife, who was also among the quarantined medical workers under intensive care. Hong Kong school closures were extended by two weeks to April 21.

On April 4, the WHO team inspected the first infection case in Foshan County. The male infected four people. But, he did not infect his family. A 40-year-old woman became the first local case in Shanghai. A Chinese health specialist admitted at a press conference of not informing the public early enough about the outbreak. The PRC Health Minister also claimed that the disease has been under control in most parts of mainland China. He also released the names of seven drugs which he claimed to be effective in curing SARS. WHO officials said that the information provided by the PRC about the disease has been "very detailed". US government enforced compulsory quarantine of an infected person.

On April 5, the Singapore government announced that school closures will be extended. Junior colleges will reopen on April 9, secondary schools will reopen on April 14 and primary schools and pre-schools will reopen on April 16.

On April 6, a SARS case was found in Manila, a person who had returned from Hong Kong.

On April 8, SARS starts to plague the Lower Ngau Tau Kok Estate near Amoy Gardens in Kowloon. Hong Kong health officials warned that SARS had spread so far domestically and abroad that it was here to stay. Nevertheless, WHO officials remained cautiously optimistic that the disease could still be contained.

On April 9, James Earl Salisbury died of SARS at a hospital in Hong Kong. An American Mormon [11] and a teacher at Shenzhen Polytechnic, [12] he had been sick for approximately one month before his death, [13] but he was originally diagnosed with pneumonia. [14] His son Michael "Mickey" Salisbury was with him in China and also contracted the disease, but he survived it. [15] Salisbury's death led to more open admissions by the Chinese government about the spread of SARS. [16]

On April 10, Jim Hughes, the head of infectious disease at the CDC, confirming the warnings of Hong Kong health officials, claimed that he believed that SARS could no longer be eradicated in the Far East. However, he remained hopeful that it could be prevented from spreading widely in North America.

On April 11, the World Health Organization issues a global health alert for SARS as it becomes clear the disease was being spread by global air travel.

On April 12, Marco Marra, director of the Michael Smith Genome Sciences Centre, which is part of the British Columbia Cancer Agency, announced that scientists at his center had broken the genetic code of the virus suspected of causing the disease. In Toronto, three more people die of SARS, bringing the Canadian death toll to 13.

On April 16, the WHO issued a press release stating that the coronavirus identified by a number of laboratories was the official cause of SARS. The virus was officially named the SARS virus.

Doctors were surprised to discover the occurrence of at least two cases of SARS in Dinner, a village near Bangalore, India. Poor hygiene and a lack of adequate trash disposal seemed to have hastened the spread of the deadly disease.

On April 19, Premier of the People's Republic of China Wen Jiabao announced that there would be severe consequences for local officials who do not report SARS cases in a timely and accurate manner, signaling at a major change in policy. (SARS had also been gaining prominence in the mainland Chinese media; by late April, it had jumped from virtual invisibility onto the front-page, with daily reports from all provinces on new cases and measures.)

On April 20, Beijing mayor Meng Xuenong and health minister of the PRC Zhang Wenkang were replaced respectively by Wang Qishan from Hainan and the former deputy health minister Gao Qiang. They are the first two high-rank officials in the PRC to be dismissed because of the fallout of the epidemic. In the news conference chaired by Gao Qiang several hours earlier, the PRC admitted that in Beijing there are more than 300 cases, as opposed to the previous figure of only 37. One day later the figure has increased to 407. Chinese officials also admitted to major underreporting of cases, which were attributed to bureaucratic ineptitude.

On April 22, schools, in Hong Kong, start to reopen in stages.

On April 23, Beijing announced that all primary and secondary schools will be closed for two weeks. A few days before, some colleges in Peking University had been closed because some students had been infected. The WHO issues travel advisories against Beijing, Toronto, and Shanxi Province.

On April 25, Taipei city government closed Taipei Municipal Hospital Hoping branch, and quarantined its 930 staffs and 240 patients for 2 weeks. [17] Later, people were relocated and the building sanitized.

On April 24, the Hong Kong Government announced an HK$11.8 billion relief package designed to assist Hong Kong's battered tourism, entertainment, retail, and catering sectors, consisting of a waiver of tourism- and transport-related license fees, and HK$1 billion allocated for tourism promotion overseas. The package also includes a salaries tax rebate and reduced rates.

On April 26, Wu Yi was named Zhang Wenkang's replacement as PRC health minister.

On April 26–27, Chinese authorities closed down theaters, discos, and other entertainment venues in Beijing as the death toll in Beijing continued to rise, threatening to become the worst hit area of the country, eclipsing the Guangdong province. Authorities are bolstered by the fact that the infection rate seems to have declined, with the Guangdong region only exporting three new infections over the weekend. The economic impact is becoming dramatic as shops, restaurants, markets, bars, universities, schools, and many other businesses have closed, as well as some government ministries and large state banks are working with minimal staff levels.

On April 28, WHO declared the outbreak in Vietnam to be over as no new cases were reported for 20 days.

On April 29, leaders of member countries of ASEAN and the PRC premier held an emergency summit in Bangkok, Thailand in order to address the SARS problem. Among the decisions made were the setting-up of a ministerial-level task force and uniform pre-departure health screening in airports.

On April 30, the World Health Organization lifted the SARS travel warning for Toronto. The decision was made because "it is satisfied with local measures to stop the spread of SARS". Canadian officials say they will step up screenings at airports.

May 2003

On May 3, the 2003 FIFA Women's World Cup was abruptly moved to the United States due to the outbreak. China maintained its automatic qualification and later hosted the Women's World Cup 4 years later.

On May 4, the newly infected number of people in Hong Kong drops to a single digit.

On May 19, the WHO Annual Meeting is held in Geneva. Hong Kong pushes for the Tourism Warning to be lifted.

On May 20, the WHO refuses to lift the Tourism Warning for Hong Kong and Guangdong.

On May 23, after a recount of the number of SARS patients, the WHO lifts the Tourism Warning from Hong Kong and Guangdong.

On May 24, the number of newly infected patients reaches zero for in Hong Kong, the first time since the outbreak in the territory in March.

On May 24, a new cluster of about 20 suspected patients is reported in Toronto.

By May 29, more than 5000 people were quarantined in Canada by authorities seeking to control the potential spread of the SARS outbreak. [18]

On May 31, Singapore is removed from WHO's list of 'Infected Areas'.

June 2003

On June 23, Hong Kong is removed from WHO's list of 'Affected Areas'. While Toronto, Beijing, and Taiwan remain.

On June 27, the World Health Organization states that the world population should be SARS-free within the next two to three weeks, but warned the disease could emerge in China next winter.[ citation needed ]

July 2003

On July 5, WHO declared the SARS outbreak contained and removed Taiwan from the list of affected areas. There have been no new cases for 20 days although around 200 people are still hospitalized with the disease.

September 2003

On Sep 8, Singapore announced that a post-doctoral worker in a SARS research lab in the National University of Singapore contracts the disease while working on the West Nile virus but recovered shortly thereafter. It was suspected that the two viruses mixed while he was doing his research.

October/November 2003

The Hong Kong Harbour Fest was organized and held from 17 October to 11 November 2003 as part of an HK$1 billion program to revive the economy of Hong Kong after the SARS. It was a government underwritten event organized by InvestHK, under the auspices of the Economic Relaunch Working Group, in collaboration with the American Chamber of Commerce.

December 2003

On Dec 10, a researcher in a SARS lab in Taiwan is found infected with SARS after returning from Singapore attending a medical conference, 74 people in Singapore were quarantined but none of them were infected.

On Dec 27, China announced the first suspected case of SARS in six months in Guangdong in an individual who was not a SARS researcher.

January 2004

January 2: Shenzhen's bid for the 2009 Summer Universiade was canceled, and announced a bid for the 2011 Summer Universiade by FISU.

January 5: China confirms that the case reported in December is a case of wild source SARS. The Philippines announced a possible case in a person just returned from Hong Kong.

January 7: The Philippines announces that their possible SARS case is just pneumonia. Chinese cull Asian palm civets in markets, thought to be a reservoir for the disease.

January 10: A restaurant worker in Guangzhou province is confirmed as the second wild source SARS since the outbreak was contained. Guangzhou was also the site of the first case in December and is thought to be the origin of the virus in the original outbreak. Three Hong Kong television reporters who visited SARS-related sites in Guangzhou were declared free of the disease.

January 17: China announced a third case of SARS in Guangzhou. WHO official urged more testing to bring the three recently announced cases into line with their standards; however they also announced SARS virus had been detected by a WHO team in civet cages at the restaurant where the second case works and in civet cages in the market.

January 31: China announced the fourth case of SARS as a 40-year-old doctor from the southern city of Guangzhou, and gave his family name as Liu. He was discharged when the announcement was made.

April 2004

On April 23, China announced A 53-year-old woman died on April 19, its first SARS death since June. Two other cases were found, who were both healthcare workers, one of which was the deceased woman's daughter. A fourth case was suspected in another healthcare worker.

The outbreak originated from a researcher working on the SARS virus in a lab at the Institute of Virology in Beijing, who inadvertently caught the disease and ended up spreading it to the nurse taking care of him. [ citation needed ]

May 2004

May 1: Two additional confirmed cases of SARS and three additional suspected cases are reported in Beijing, all related to a single research lab. The total number of cases is six, with four in Beijing and two in Anhui Province.

May 2: China announced the three suspected cases as genuine cases of SARS, bringing the total cases in a recent outbreak to nine. 189 people were released from quarantine.

May 19: As no new infections are reported in a three-week period, WHO announced China as free of further cases of SARS.

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