1. The 1 st New Disease of the 21 st Century by Otto Sanchez MD MSc PhD Faculty of Health Sciences University of Ontario Institute of Technology June 2004

2. Who am I? Story teller, note taker, and someone desperately needing your ideas about the health problem I must deal with. Who are you? Health professionals working in Hong Kong, China Health professionals working in Toronto, Canada World Health Organization officers in Geneva, Switzerland Centers for Disease Control officers in Atlanta, Georgia Your task: Throughout the story you will be asked four questions. You should answer each question individually on your card, then briefly discuss them with your group to reach consensus or prioritize. Be prepared to announce your answer/idea to the other groups when prompted.

3. Foshan City, Guangdong, China Foshan City is situated in the mid-southern part of Guangdong, the central region of the Pearl River Delta, which has fertile land and a mild, wet subtropical monsoon climate with plenty of rainfall, 1600-2000 mm, and four distinct seasons. The annual average temperature is 80 °F. http://www.muztagh.com/map-of-china/large-map-guangdong.htm

4. November 16, 2002: The first case Zhou LX et al. report the first case in the Intensive Care Unit of The First People's Hospital of Foshan City, Guangdong Province, Foshan, China… …in which they describe an individual with the following features: 1. high fever, followed by dry cough, rapid progression to respiratory failure, followed by radiographic evidence of bilateral lung damage 2. spread to four family members who had direct contact with the patient 3. the patient was treated without significant improvement 4. history of contact with wild cats and with eating their meat

5. A chef from the city of Heyuan, located about 200 km from Foshan City, who worked at a restaurant in the coastal city of Shenzhen, was reported to have atypical pneumonia. He felt unwell in Shenzhen but sought medical treatment in Heyuan. He had a high fever and mild respiratory symptoms; radiographic examination showed shadows in both lungs. His wife, two sisters, and seven medical staff were infected, all having the same clinical manifestations. This patient, as a chef, came into regular contact with several types of live caged animals used as exotic game food. December 17, 2002: The second case

6. Outbreaks in Guangdong Province, People's Republic of China. The geographic distribution of the outbreak in Guangdong from Nov. 16, 2002 to Feb. 9, 2003. Number of cases are shown in parentheses. Approximate dates of the onset of the outbreaks for each city were: Foshan, Nov 16, 2002; Heyuan, Dec 17, 2002; Zhongshan, Dec 26, 2003; Guangzhou, Jan 31, 2003; Jiangmen, Jan 10, 2003; and Shenzhen, Jan 15, 2003.

7. February 11, 2003 The World Health Organization received reports from the Chinese Ministry of Health of an outbreak of an acute respiratory syndrome with 305 cases and five deaths in Guangdong Province. 30 percent of the cases reported occurred in health care workers. Signs and symptoms were consistent with atypical pneumonia.

8. Question 1 You make a phone call to the Officer of Health in Guangdong Province ( Poor communication allows you to only ask 1-2 questions) What would you like to know from them? 1A: If you are a health professional working in Hong Kong, China 1B: If you are a health professional working in Toronto, Canada 1C: If you are a World Health Organization officer in Geneva, Switzerland 1D: If you are a Centers for Disease Control officer in Atlanta, Georgia

9. February 21, 2003 A 65-year-old medical doctor from Guangdong Province, who had treated patients in his hometown, checked in to the 9 th floor of a four- star hotel in Hong Kong. He had treated patients with atypical pneumonia prior to his departure from Guangdong Province and was symptomatic upon arrival in Hong Kong.

10. February 26, 2003 A 48-year-old Chinese-American businessman is admitted to the French Hospital in Hanoi, Vietnam, with a three-day history of respiratory symptoms. He had previously been in Hong Kong, where he visited an acquaintance staying on the 9 th floor of the hotel where the Guangdong physician was a guest. March 1, 2003 A 26-year-old former flight attendant is admitted to a hospital in Singapore with respiratory symptoms. During a recent visit to Hong Kong, she had been a guest on the 9 th floor of the same Hong Kong hotel as the medical doctor and Chinese-American businessman. March 5, 2003 An elderly Toronto woman, who had been a guest on the 9 th floor of the Hong Kong hotel dies at Toronto’s Scarborough Grace Hospital. Five members of her family are found to be infected and are admitted to the hospital.

11. March 15, 2003 The World Health Organization terms the new disease Severe Acute Respiratory Syndrome or “SARS” and declares it a “worldwide health threat.”

13. Question 2 Now that you have more information, what would you do? (pick the 1-2 most important actions you would consider) 2A: If you are a health professional working in Hong Kong, China 2B: If you are a health professional working in Toronto, Canada 2C: If you are a World Health Organization officer in Geneva, Switzerland 2D: If you are a Centers for Disease Control officer in Atlanta, Georgia

14. SARS Mortality Rate The mortality rate of SARS fluctuated across countries and reporting organizations. In early May 2003, the World Health Organization (WHO) and the U.S. Centers for Disease Control (CDC) quoted the SARS mortality at 7%. Others spoke in favor of a 15% figure, saying it reflected the real situation more accurately. As the outbreak progressed, both mortality measures approached 10%.

15. April 16, 2003 The WHO laboratory network announced conclusive identification of the SARS causative agent: a new coronavirus, unlike any other human or animal member of the coronavirus family. SARS-CoV courtesy of Centers for Disease Control and Prevention: http://www.cdc.gov/ncidod/sars/lab/images.htm

18. Question 3 Does this information change the actions you decided for Question 2? 3A: If you are a health professional working in Hong Kong, China 3B: If you are a health professional working in Toronto, Canada 3C: If you are a World Health Organization officer in Geneva, Switzerland 3D: If you are a Centers for Disease Control officer in Atlanta, Georgia

19. Question 4 The Chinese government has invited you to attend the First Annual SARS Conference in Foshan City on the 2 nd anniversary of the first case. Would you attend? Why? Why not? 4A: If you are a health professional working in Hong Kong, China 4B: If you are a health professional working in Toronto, Canada 4C: If you are a World Health Organization officer in Geneva, Switzerland 4D: If you are a Centers for Disease Control officer in Atlanta, Georgia

20. Thank you for your ideas!