Prevention from SARS (Severe Acute Respiratory Syndrome) epidemics in Japan Noboru Ishii, M.D., Ph.D. Department of Disaster and Emergency medicine, Kobe University Graduate School of Medicine Asia pacific Inter-city SARS Forum in Taipei, September 28-29

Background A new type of pneumonia, SARS was firstly reported as non- typical pneumonia, spreading out from Guangong to Hong Kong and Vietnam, then on March 12, 2003 the WHO issued a global health alarm to the outbreak of this disease. SARS had also spilled over to Singapore, Taiwan and Canada and became the threat of the world public health by March 15. A new type of pneumonia, SARS was firstly reported as non- typical pneumonia, spreading out from Guangong to Hong Kong and Vietnam, then on March 12, 2003 the WHO issued a global health alarm to the outbreak of this disease. SARS had also spilled over to Singapore, Taiwan and Canada and became the threat of the world public health by March 15.

SARS Response of the WHO Global Alert (March 12, 2003) Global Alert (March 12, 2003) Travel Advisory (March 15, 2003) Travel Advisory (March 15, 2003) Enhanced global surveillance Enhanced global surveillance Global Outbreak Alert and Response Network Global Outbreak Alert and Response Network Specific Global Networks (Lab, Case Management, Epidemiology) Specific Global Networks (Lab, Case Management, Epidemiology) Pathogen of SARS identified as a mutation of Corona virus(April 27,2003) Pathogen of SARS identified as a mutation of Corona virus(April 27,2003) Declaration of the end of SARS outbreak (June 18, 2003) Declaration of the end of SARS outbreak (June 18, 2003) Electron Microscope Photo of SARS virus

SARS Response of Ministry of Health, Labour and Welfare (MHW) in Japan March 12 Notice the WHO SARS information March 12 Notice the WHO SARS information March Notice Surveillance of SARS patients March Notice Surveillance of SARS patients March 17 Start Information Services on the Web March 17 Start Information Services on the Web site in MHW site in MHW March 19 Report of 3 suspected cases March 19 Report of 3 suspected cases April 3 Advisory to travelers and April 3 Advisory to travelers and Reinforced activities at quarantine Reinforced activities at quarantine stations stations April 8 Establish EOC for SARS at MHW April 8 Establish EOC for SARS at MHW May Set-Up Operation Center for May Set-Up Operation Center for SARS Response SARS Response

Ministry of Health, Labour and Welfare: Severe Acute Respiratory Syndrome (SARS) Action Plan (June 2, 2003) 1. Provision of Information on SARS to Public 2. Advisory to Travelers Visiting Hong Kong, Guangdong (China), and other SARS-Affected Areas. 3. Reinforcement of Activities at Quarantine Stations 4. Preparation for a Possible Outbreak in Japan (1) Establishment of Surveillance System (2) Designation as a New Emerging Infectious Disease (3) Preparation of Health Care Providers (4) Strict Risk Management 5. Promotion of International Cooperation

1. Provision of Information on SARS to Public * Provision of up-to-date information through the Ministry ’ s web site. (March 17) *Publication of SARS Q&A (Also available on web page). *Telephone consultation service at local public health departments and prefectural governments. WHO Kobe Center SARS Information Support Desk Automatic Answering Telephone System in Japanese since May 2003

2. Advisory to Travelers Visiting Hong Kong, Guangong (China), and other SARS-Affected Areas. ＊ All travelers visiting Beijing, Tianjin, Taiwan, Shanxi Province, Neimenggu and Hebei Province are advised to reconsider their plans and postpone unnecessary visit to the region. May 6June 18

Provision of Information on SARS in Japan （ the website of MHW ） Information on SARS is provided as the following methods. Health care centers and consultation offices in each prefecture also provided. １ The Internet Introduce the way of its treatment, occurrence condition, and FAQ Introduce the way of its treatment, occurrence condition, and FAQ ○ MHW website （ ） ○ MHW website （ ） ○ the website of National Institute of Infectious Diseases （ ） ○ the website of National Institute of Infectious Diseases （ ） ○ MHW quarantine website （ ） ○ MHW quarantine website （ ） ２ Inquiry from the public ２ Inquiry from the public Inquiries on heath information of overseas at the nearest quarantine. Inquiries on heath information of overseas at the nearest quarantine. The contact list on the website （ ） The contact list on the website （ ） ３ Inquiry on diagnostic examination from the medical specialists (open from 9:00 to 17:00) (open from 9:00 to 17:00) ○ Information Center of National Institute of Infectious Diseases Tel: ○ Information Center of National Institute of Infectious Diseases Tel: ４ Inquiry on administrative response by the government officers ○ Department of Infection Control and Prevention Tuberculosis and Infectious Disease Control Division in MHW Tel ： (ex. 2382) ○ Department of Infection Control and Prevention Tuberculosis and Infectious Disease Control Division in MHW Tel ： (ex. 2382)

3. Reinforcement of Activities at Quarantine Stations *Dispatching medical doctors from national hospitals and other medical institutions to quarantine stations to assist their activities. *Distributing the health status questionnaire and monitoring body temperature of all passengers on all flights from Hong Kong, China, Taiwan, and Canada. If necessary, the health status of passenger will be followed up for 10 days *Monitoring body temperature of all passengers on all international flights at all airports. (May 26).

4. Preparation for a Possible Outbreak in Japan (1) Establishment of Surveillance System (1) Establishment of Surveillance System (2) Designation as a New Emerging Infectious Disease (2) Designation as a New Emerging Infectious Disease (3) Preparation of Health Care Providers (3) Preparation of Health Care Providers (4) Strict Risk Management (4) Strict Risk Management

(1) Establishment of Surveillance System Establishing a system to dispatch teams of specialists to assist prefectural government during the outbreak. Each team consists of about 4 specialists including epidemiologist and clinician (April 15). Establishing a system to dispatch teams of specialists to assist prefectural government during the outbreak. Each team consists of about 4 specialists including epidemiologist and clinician (April 15). Organizing workshops on epidemiological survey (May 13). Organizing workshops on epidemiological survey (May 13).

(2) Designation as a New Emerging Infectious Disease After careful consideration of human rights of patients with symptoms, SARS was designated as a new emerging infectious disease of Infectious Disease Prevention Act to provide adequate medical attention. After careful consideration of human rights of patients with symptoms, SARS was designated as a new emerging infectious disease of Infectious Disease Prevention Act to provide adequate medical attention. Infectious Disease Subcommittee of Ministry of Health, Labour and Welfare Science Council discussed handling of potential SARS patients, and the recommendations were made to prefectural governments (May 2). Infectious Disease Subcommittee of Ministry of Health, Labour and Welfare Science Council discussed handling of potential SARS patients, and the recommendations were made to prefectural governments (May 2). This will allow authorities to order patient to be hospitalized if necessary. This will allow authorities to order patient to be hospitalized if necessary.

(3) Preparation of Health Care Providers Designating International Medical Center of Japan as designated medical institution for specific infectious disease (April 7). Designating International Medical Center of Japan as designated medical institution for specific infectious disease (April 7). Securing 739 negative pressure room beds. (551 beds in designated medical institutions for specific infectious disease and 188 beds in other medical institutions) Securing 739 negative pressure room beds. (551 beds in designated medical institutions for specific infectious disease and 188 beds in other medical institutions) Organizing workshop on prevention of in-hospital infection (May 2, 7, and 9) Organizing workshop on prevention of in-hospital infection (May 2, 7, and 9)

The Law Regarding Infectious Disease Prevention and Medical Care for the Patients (Established on September 28, 1998, enforced on April 1, 1999)

Present Condition of Medical Institutes and Beds for Infectious Diseases *Number of Negative pressure room Occupancy of ICD or ICN in Type 2 hospitals: ca.70%

(4) Strict Risk Management Local authorities have been instructed to draw up detailed “ Action Plan ” for a possible outbreak. All prefectural governments have developed their action plans. Local authorities have been instructed to draw up detailed “ Action Plan ” for a possible outbreak. All prefectural governments have developed their action plans. “ Management Guideline for Preventing In-Hospital Infection ” has been drafted and published (April 7). “ Management Guideline for Preventing In-Hospital Infection ” has been drafted and published (April 7). Meeting of directors of national public health lead offices was held, and directors were briefed on the national policy and action plan during a possible outbreak (May 6). Meeting of directors of national public health lead offices was held, and directors were briefed on the national policy and action plan during a possible outbreak (May 6).

Issue on Taiwanese doctor: Osaka government is going to declare itself SARS-free on May 23. (05/20 16:32) The governor of Osaka pointed out that “ it is necessary to issue safety of the city by public offices as soon as possible ” in order to response many cancellations at hotels and restaurants, which the Taiwanese doctor had visited. Besides, she added “ the safety information of individual facilities are going to be released ” regarding to health condition of the visitors and disinfections process of the facilities. （ from Asahi.com ） The governor of Osaka pointed out that “ it is necessary to issue safety of the city by public offices as soon as possible ” in order to response many cancellations at hotels and restaurants, which the Taiwanese doctor had visited. Besides, she added “ the safety information of individual facilities are going to be released ” regarding to health condition of the visitors and disinfections process of the facilities. （ from Asahi.com ）

Case Definition ： Reporting Standard by WHO Suspected Case Suspected Case 1. Started after November 11, Started after November 11, 2002 ・ high fever （ >38 ℃） cough, respiratory distress ・ high fever （ >38 ℃） cough, respiratory distress ・ 10 days before the start of symptoms: *either having close contact with the people in suspected or potential case, or traveling to or living in affected area. ・ 10 days before the start of symptoms: *either having close contact with the people in suspected or potential case, or traveling to or living in affected area. 2. Died from a unknown acute respiratory illness after November 1st, No pathologic autopsy; relevant act(*) was recognized within 10 days before the symptoms 2. Died from a unknown acute respiratory illness after November 1st, No pathologic autopsy; relevant act(*) was recognized within 10 days before the symptoms Probable Case Probable Case 1. When the suspected case have findings of ARDS or pneumonia on chest radiograph 1. When the suspected case have findings of ARDS or pneumonia on chest radiograph 2. When the suspected case are positive in more than one SARS examination or are diagnosed RDS by autopsy and no other cause 2. When the suspected case are positive in more than one SARS examination or are diagnosed RDS by autopsy and no other cause Exception ： When the illness is fully explained by other diagnosis Exception ： When the illness is fully explained by other diagnosis WHO (Ver.3), May 2003

Consequence of Suspected case and Probable Case of SARS in Japan (May 19 - July 15, 2003) Suspected case: 52 Suspected case: 52 Probable case: 16 Probable case: 16 All cases were negative of SARS reported by the Special Committee of SARS Reported suspected cases of SARS in Japan ( July 15, at 17:00)

Response for In-Hospital Infection for SARS Standard Precaution ＋ Droplet Transmission Precaution Contact Transmission Precaution Airborne Transmission Precaution ＋ ＋

Preparation process for SARS response in Kobe University Hospital March 18 ： Start SARS response planning at the Infection Control Division according to the Notice of MHW to the Notice of MHW March 19 ： Discussion at the Committee of Infection Control in Kobe University Hospital Hospital March 24 ： Delivery “ SARS Response Manual(Ver.1) ” to the staff in hospital April 7 ： Information of SARS Response Manual available on the web site of Kobe University Hospital University Hospital April 17 ： The 1st Practice of simulation for SARS response April 22 ： The First team meeting for response to the SARS patients May 6 ： The second team meeting for response to the SARS patients (Revised “ SARS Response Manual ” ) “ SARS Response Manual ” ) May 7 ： Emergency meeting for SARS to the all hospital staff May 21 ： Second revised “ SARS Response Manual ” May 27 ： Attending the meeting for SARS response information in Kobe city June 10 ： The third team meeting for response to the SARS patients June 17,19 ： The second Practice of simulation for SARS response

Notice board for the patients with fever or cough Set up in front of the hospital

5. Promotion of International Cooperation *Dispatching medical doctors to affected countries and cooperating on researches in diagnosis and treatments.

WHO speculates SARS affects little in this winter （ reasons as below ／ in SARS Update no. 89: June 26 ） Firstly, today’s international public heath care system is able to shift to the higher level of alert immediately Firstly, today’s international public heath care system is able to shift to the higher level of alert immediately Secondly, medical specialists in the world know what should they do to control infectious disease, as there is a long history of infection control. Secondly, medical specialists in the world know what should they do to control infectious disease, as there is a long history of infection control. Thirdly, it is expected to develop the rapid and reliable diagnostic examination on SARS, which can be adopted at the beginning of treatment. Thirdly, it is expected to develop the rapid and reliable diagnostic examination on SARS, which can be adopted at the beginning of treatment. Fourthly, enforcement of discretion on mass epidemics was decided at the WHO general meeting in May. Fourthly, enforcement of discretion on mass epidemics was decided at the WHO general meeting in May. Lastly, SARS epidemics show that it is important to release the case of any disease immediately, which has the possibility of spreading out around the world. Lastly, SARS epidemics show that it is important to release the case of any disease immediately, which has the possibility of spreading out around the world.

Problem of Prevention from SARS Epidemics in Japan 1. Deep understanding of information ・ Information system offering by TV, Radio and etc. ・ Information system offering by TV, Radio and etc. ・ Common ownership of scientific and objective information ・ Common ownership of scientific and objective information 2. Improvement of detective methods for SARS patients ・ High detailed investigation for person contacted to SARS ・ High detailed investigation for person contacted to SARS ・ Common ownership on investigative methods for outbreak of SARS ・ Common ownership on investigative methods for outbreak of SARS 3. Establishment of In-Hospital infection control system ・ key point; success of in-hospital infection control ・ key point; success of in-hospital infection control 4. Flexibility of early detective system ・ early detection of aged patients without fever and severe symptoms ・ early detection of aged patients without fever and severe symptoms 5. Cooperation of implementation for international discretion

Conclusion Fortunately we did not have any SARS patients in Japan, it is necessary to build up a cooperation system among Asian Pacific countries, including exchanging information, in order to prevent the potential SARS epidemics toward this winter. Fortunately we did not have any SARS patients in Japan, it is necessary to build up a cooperation system among Asian Pacific countries, including exchanging information, in order to prevent the potential SARS epidemics toward this winter. Furthermore, concerning risk management of our country, there are some future issues, such as to ensure out-of-hours service at each section in the government, in the local governments, and in public health care centers, and to build up a transportation system for the patients. Furthermore, concerning risk management of our country, there are some future issues, such as to ensure out-of-hours service at each section in the government, in the local governments, and in public health care centers, and to build up a transportation system for the patients.