1. SARS and Avian Influenza: Public Health Priorities Scott F. Dowell, MD, MPH International Emerging Infections Program Thailand Ministry of Public Health - US CDC Collaboration

2. Chest Xray, Day 2

3. Dr. Carlo Urbani

4. Guangdong Province, China A A Hotel M Hong Kong B J H Hospital 2 Hong Kong A H J B 4 other Hong Kong Hospitals C D E Hospital 3 Hong Kong Hospital 1 HK Hospital 4 Hong Kong 2 family members CDE 34 HCWs HCW B Germany Bangkok Singapore United States I I L§L§ M§M§ Vietnam K † Ireland K † 37 HCWs HCW 0 HCWs 28 HCWs 156 close contacts of HCWs and patients F G † Canada G † F 4 family members 10 HCWs 37 close contacts 99 HCWs (includes 17 medical students) 4 HCWs* 3 HCWs HCW 2 family members Unknown number close contacts 2 close contacts * Health-care workers; † All guests except G and K stayed on the 9 th floor of the hotel. Guest G stayed on the 14 th floor, and Guest K stayed on the 11 th floor;  § Guests L and M (spouses) were not at Hotel M during the same time as index Guest A but were at the hotel during the same times as Guests G, H, and I, who were ill during this period. Chain of transmission among guests at Hotel M—Hong Kong, 2003 Data as of 3/28/03

5. A B C D E F No illness (person interviewed) Probable case “ Index ” Case 1234567891 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 Empty seat Crew No illness (person not interviewed) Airline Transmission of SARS Olsen et al. NEJM 2003;349:2414

6. Measures to Reduce Airline Transmission of SARS Aircraft Decontamination Fever Screening Voluntary Use of Masks

7. Chest Xray, Day 13

8. Clues to the Causative Agent Epidemiology – highly transmissible respiratory pathogen Clinical – unusually severe disease Laboratory – generally consistent with virus Pathology – possibly paramyxovirus No known agent could explain all features

9. Coronavirus – EM appearance

10. Personal Protective Equipment N-95 or better respirator Head cover Goggles or face shield –eyeglasses not adequate Double gown Double gloves Double shoe covers

11. SARS on Hospital Surfaces Surface, Hospital B, Taiwan# Positive/# Tested Patient rooms (71%) Endotracheal tube3/3 Bedrail3/4 Ventilator panel1/3 Other3/4 Nursing stations (56%) Telephone1/3 Computer mouse2/2 Doorknob1/2 Other1/2 Public areas of hospital (20%) Elevator handrail1/1 Other0/4 Total16/28 (57%) Dowell et al. CID 2004;39:652

12. Intubation of a SARS Patient

15. Influenza – “Drift” Feb JanDec

16. Influenza – “Shift”

17. US Infectious Disease Mortality: The Impact of Influenza and AIDS Armstrong. JAMA 1999;281:61

18. Avian Influenza in Thailand?

19. Avian Influenza in Asia (10 February, 2004)

20. Intensive Pneumonia Surveillance Active Population-based CXR-confirmed Laboratory testing –Influenza –Other viruses –Bacterial agents Community surveys Nakorn Phanom Sa Kaeo

21. Locations of Registered Poultry Farms Sa Kaeo, Thailand

22. Poultry Exposure is Common There are ~6 birds to every person in Sa Kaeo Province 1.3% of poultry is on commercial farms –178 farms –31,221 poultry 98.7% of poultry is in backyards –2,410,820 poultry

23. A Cluster of H5 Cases Three family members linked coincidentally during investigation of another pneumonia case Urgent concern about person-to-person transmission At the time cluster was recognized;  Index case dead, cremated  Mother dead, body embalmed  Aunt admitted to hospital Interviews rapidly conducted on family, contacts, neighbors, and healthcare workers

24. Investigation at Home of Index Patient

25. Timeline of Exposures and Illness

26. Laboratory Investigation Immediate and urgent effort to collect specimens Specimens promptly shared with WHO network Index patient dead, cremated  0.5ml serum from day 6 of illness  Mother’s body embalmed  Lung and other tissues tested by PCR Aunt survived  NP and OP swabs tested by cell culture, RTPCR  Acute and convalescent serum (neutralization, ELISA)

27. Mother: Lung Tissue Pathology Photo courtesy of S. Zaki

28. 0.1 Mdk/Vietnam/4/2004 Mdk/Vietnam/17/2004 Chicken/Laos/44/2004 Thailand/Kan/353/2004 Thailand/2SP33/2004 Vietnam/3218/2004 Thailand/1KAN1/2004 Thailand/PCBR/6231/2004 Vietnam/HN30262/2004 Thailand/PCB2031/2004 ip Goose/Cambodia/25/2004 Vietnam/1203/2004 Vietnam/1194/2004 Thailand/Pranom5147/2004 Thailand/Pranee5223/2004 Thailand/SP83/2004 Mdk/Vietnam/MDGL/2004 Chicken/Laos/7192/2004 Chicken/Vietnam/ncvd31/2004 Vietnam/3212/2004 Chicken/Vietnam/CM/2004 Vietnam/HN30259/2004 Thailand/16/2004 Thailand/Chai622/2004 serpl Chicken/Indonesia/11/2003 Chicken/Korea/ES/2003 Duck/China/e3192/2003 hvri Duck/Harbin/15/2004 Hong Kong/213/2002 Duck/Hong Kong/739/2002 RBPochard/Hong Kong/821/2002 Teal/Hong Kong/2978/2002 Chicken/Hong Kong/3175/2001 Hong Kong/156/1997 Goose/Guangdong/96 HA Gene Sequence: Genotype ZGenotype Z Resistant to amandatineResistant to amandatine

29. Conclusions from Family Cluster Probable person-to-person transmission No further spread to contacts No significant mutation of virus –All gene segments were of avian origin –Critical binding and cleavage sites unchanged Isolation precautions needed for H5 patient care Future clusters also warrant intensive investigation

30. Summary: SARS and Avian influenza SARS redefined emerging zoonoses –Broad economic and public health impact Avian flu: unprecedented & unpredictable –Scale of the epizootic unprecedented –Ongoing potential for re-assortment event