Global Alert and Response (GAR)

Severe Acute Respiratory Syndrome - Press briefing

Tuesday, 1 April, 14:15
Palais des Nations

World Health Organization

Dr David Heymann, Executive Director, Communicable Diseases
Dr Guenael Rodier, Director, Communicable disease surveillance and response (CSR)
Dr Klaus Stohr, Scientist CSR, Coordinator Science and Clinical collaboration groups
Mr Dick Thompson, Communications Officer

Statement from Dr David Heymann.
Thank you again for coming this afternoon to get an update on what is going on with the SARS epidemic. As you know, it has now been two weeks and two days since we issued a global alert. We made this global alert, as we have said in the past, for three reasons: first, it was a disease that we did not recognize; second, it was a disease that was affecting first and foremost health workers, and caused a great risk to people who take care of other people in hospitals; third, it began to spread internationally. By going out with that alert, we have been able to sensitize all the countries in the world about this disease. We have seen that 13 countries are now affected, but that the only countries in which there has been an outbreak locally have been countries that did not know about the disease before the global alert.

What this actually is today is a group of different outbreaks: one outbreak in Viet Nam, which we believe has now been contained, which has had no new cases for seven days, and which we believe will continue now not to have further cases.

In Singapore, there have been imported cases from Hong Kong. Those cases have been contained in the hospital and those cases, we believe, now because of other measures that Singapore has taken, will not cause any more chains of transmission.

We have outbreaks in Toronto that are also being very well controlled now. People have been put under self-monitoring and if they develop fever they know what to do. This outbreak, we believe, is well contained.

We are faced now with a situation in Hong Kong where the outbreak is taking a new form. Until recently, all cases have been traced back to another case of SARS. Hong Kong now has a few cases that they have not been able yet to trace back, but they have so many cases that it is hard to trace these cases back and they are confident that they will be also able to trace these cases back to a previous case of SARS.

There are some unusual events that have occurred in Hong Kong – in the Hotel Metropole and also in an apartment complex. As you know, it seems that somehow there have been clusters of cases in these places, and in both the Metropole and the apartment complex these cases can be clustered around a known case of SARS. So what it appears is that there is now some environmental factor, not the air, but some other factor – it could be water, it could be sewage, it could be many different things – but some environmental factor which is taking this disease from one human to another. It could even be such a thing as a door handle, where someone with SARS has coughed and left some droplets that are moist and which contain the virus, and then the next person that opens the door gets these droplets which have virus in them on their fingers, touches their eyes or their mouth, and becomes infected. We do not know yet, but there is still no evidence that this disease is in air conditioning systems being spewed out and infecting large places of area. As far as we know, it is still that example of the two people sitting by me as being at greatest risk, or someone who might touch the table where I have just put some droplets, or some environmental factor which is carrying these droplets to another person. So that is an update on what we understand about the epidemiology in Hong Kong. So Hong Kong is a different outbreak than the others.

Then there is the outbreak in Guangdong, which has cases also in other parts of China, which we are now beginning to understand better through working with the Government of China. The Government of China has put out a national alert and reporting system, and they are receiving reports from all provinces of cases if there should be any. We do not know yet the results of that system but we will be knowing that, we believe, very shortly. So that is the epidemiological situation.

As far as the virological situation is concerned, you know that there has been a virus isolated – a corona virus-like particle, a corona virus – which now is being used in making a diagnostic test to look for both the virus and antibodies to that virus in patients. Those studies are going on, in addition to looking to see if people may be infected but do not have symptoms, but have a positive blood test, and other epidemiological studies to make sure that we completely understand the way this disease is transmitted.

We are presently in discussions with Hong Kong. In fact, the reason we are late is that we have just been discussing again with Hong Kong the situation there, and we understand very clearly what is going on. We will know tomorrow morning [Wednesday 2 April] whether or not they have been able to confirm that all the cases that they have now are still being by person to person contact.

We have also told you about cases that have occurred in airline passengers. You have heard some of that announced on radios. Cases have been on aeroplanes, people sitting near those patients, people or sometimes airline crew, might have been infected by those people and are now suspects and they are being observed. This still does not give us any indication that the virus is in the recirculating air in the aeroplane. Rather, that there is something in the close relationship between a patient and people sitting around. That patient may be sneezing and sneezing directly on that person or having that sneeze be carried a very short distance to the person sitting next door in back or in front. So those are other angles that are being studied in the epidemiological studies. Surveys of airline crews and passengers will be very important to determine whether there has been any transmission in those aeroplanes.

Briefly, that is an update. Every day, more and more information is becoming available, helping us to make better decisions as we move through the outbreak along with you and our partners in the press and in the information area. So I have spoken a little bit, maybe too long. Dr Stohr is here, who can give you any updates further on the laboratory findings. Dr Rodier, who can give you any updates on the epidemiological findings.

Questions and answers

Q. Can you say more about the environmental factors that you mentioned – such as water and sewage pipes – because in the case of Hong Kong transmission appears to be taking place vertically from people in the same number of flats. Can you explain if this could be through the sewage pipes or water?

A. Dr David Heymann: The officials in Hong Kong, with whom we have just discussed, do not know how it is being transmitted in these apartment flats, but they believe it is through the environment. What that means is anybody's guess. Some of the hypotheses could be as follows: if the sewage goes, and I understand from you and from others, that all these apartments are one on top of the other – the known patient lives in one apartment and the others all live in that same group. So this is where epidemiological detective work begins. Are these people all using the same lift? Have they all been together in the same lift with a patient? And did that patient cough on all these people? One possible hypothesis. Is there something in the ventilation system that is transferring heavy droplets, not fine droplets but heavy droplets, with virus to different apartments? Another hypothesis. Is there virus in faecal material of people who are infected? It comes in body secretions. Is it coming in faeces, is it going into a sewage pipe that is going up and down through all these apartments, and is there somehow that that sewage is being aerosolized into an apartment, or not aerosolized but spreading into an apartment? Or is there any other way that it might be occurring? Nobody can answer that question. But this is the type of detective work that the health department is now doing in Hong Kong. Guenael, do you want to add anything? Dr Guénaël Rodier: Investigation is going on. That is all I can say. Dr David Heymann: Yes, investigation is going on and we are in touch with them every 24 hours, if not closer.

Q. Is WHO sticking to the original theory that the SARS virus is not so easily aerosolizable as influenza? From what we read in newspapers, the spread seems to be far more spontaneous than one would expect from you sitting next to Dr Heymann.

A. Dr Klaus Stohr: The epidemiological data that we have from very many places now is not suggesting that this virus would not be transmitted other than with droplets, with the exceptions that have been mentioned before. That is one important source of information that we have to make us believe and confident that the droplet infection – person to person contact – is the major mode of transmission. In addition to deducing from studies in countries and where outbreaks are occurring in hospitals, now the studies are beginning to mimic the transmission with the virus that has been isolated. The studies have begun to see how easily this virus can be excreted with various bodily fluids, how easily it can be transmitted with droplets, but that is going to take a little bit more time. We know from other corona viruses that they can be easily transmitted by faeces with droplets. We also know from some corona viruses that this is not the case. So we really have to focus on this virus. We cannot assume that it behaves in the same as all the other corona viruses. We have to base our conclusion on the facts. The evidence is that person to person transmission is, and will remain until we have better data or even additional data, the major mode of transmission.

Dr David Heymann: Let me just add that our regional office in Manila has compared this to the Ebola virus. Now this comparison is not a bad comparison because Ebola virus is amplified by poor practices in hospitals. Most outbreaks of Ebola have occurred because hospital workers have become infected and have then infected their family members. This is identical to what we are seeing with the SARS virus. Health workers are becoming infected, that amplifies the transmission, and then they transmit to family members. Neither one of these viruses, as far as we know, can be aerosolized and be transmitted by aerosol, unless it is in a very close area. Or imagine that somebody might mechanically aerosolize in treating a patient, which would send up a fine mist of droplets that might spread to us, that is another possible way. But neither of these viruses transmits easily in the air. They have to be transmitted by close contact. The difference of course is that Ebola is a very fatal disease, with 50–70% of people dying. This disease [SARS] has consistently had 4% dying, which is still a significant number.

Q. Is your travel advisory then still staying the same as far as travel to and from Hong Kong and southern China is concerned? And why do we have to have this different view of the cases in Hong Kong, given the fact that people are packed very closely together, they live in high-rise buildings, they take a lift? Why are you looking for anything other than this person to person contact in close proximity, which is what you would get in a lift every day?

A. Dr David Heymann: That is a very good question, and it may be that the lift plays a role. But many times, people who are sick do not leave their apartments. And the question that we have is, has the person who caused the disease left his or her apartment at any time besides the time when he or she went to the hospital and do people remember? So it is a good question, and you are right that it could just be circumstantial that they are all crowded into a lift together or they are touching a common source where there is a possibility. So the water or the sewage is only a hypothesis. It is not surprising that there could be contact because of the close proximity of people in that area. In relation to the travel advisory, to date we are continuing with the same travel advisory. The travel advisory that we have emitted is to prevent international spread of this disease. We have made recommendations that people understand the disease. If they feel that they become sick with the disease, they should notify a health official – preferably by not going to their office but by telephone or by sending someone to the doctor's office – and that countries where this epidemic is occurring should in some way check passengers before they leave from that port. And this is being done through a system of cards in Canada, and very many different systems, which you can see on the Web site. At WHO we also make traveller recommendations.

International travel and health is a publication of WHO, which tells you whether or not you should take malaria prophylaxis if you go to a certain country, or whether you should have an immunization for this or that disease if you go to another country. We have now pulled out our travel and health guidelines. We are reviewing them and we are discussing with our expert group that advises us on that whether or not we need to be thinking about some personal recommendations to travellers as well. Not to prevent the spread internationally, which we have been doing to date, but to help passengers make a decision as to whether or not they should travel or what they should take if they do travel. And we are considering those with Hong Kong, and that was part of the reason today, and we will be discussing with other experts now throughout the world this afternoon. And if we should make any recommendations, we would make those recommendations. But to date our recommendations stand as they are.

Q. It appears that there seems to be close to a mass hysteria that is happening right now. The World Economic Forum has cancelled its trip, Tony Blair says he has not cancelled his trip to go to Beijing because he is scared of anything, there are other cases like this going on. What words of comfort do you have to people about this, because people are getting scared, legitimately so? Also, I understand that there is now a test that was devised in Hong Kong, which can be used to at least identify if a person is a carrier of the virus. From that, you are able to then ascertain other things such as the need for quarantine and so forth. Are you doing these tests? Are they successful or are they still in the experimental stage?

A. Dr David Heymann: I’ll take the first question. There is good news in that Viet Nam has contained the outbreak, Singapore is rapidly containing the outbreak, Toronto is rapidly containing the outbreak. So we don’t anticipate that there will be spread from these places. Ninety per cent of people who have gotten this disease, as we understand it today through our group of clinicians, 90% of these people are feeling better and are on the way to recovery at day seven after disease. And they continue to get better and there have been over 50 or 60 who have been discharged from hospitals in Viet Nam and in Hong Kong. Four per cent of people do die, but many of these have had a pre-disposing condition such as diabetes or other disease which has made their immune system to be weakened and not able to fight off this disease. And the global alert has prevented spread in countries where the disease has been imported, after the global alert went out.

So there’s much good news about. There’s also good news in the fact that this is not spreading rapidly, as was feared initially, because it doesn’t have the same characteristics as influenza which would spread rapidly. There are concerns in many different countries and those countries have made travel advisories, recommending to their citizens that they not travel to some of these countries and that’s perhaps where some of the people are making their decisions. As I said, we are reviewing our recommendations to individuals and, if we do make any changes, we will announce those as soon as we make those changes. But to date we are still reviewing with our experts. Now the diagnostic test, Klaus. Dr Klaus Stohr: The diagnostic test can establish whether a person is ill from the disease or is not ill from the disease. The current test which we have can do that; usually there are two tests which are used in parallel. A serological test to trace antibodies in the blood of the patient, as well as to see whether the person is excreting virus. What the tests cannot do is retrospectively understand how disease could be transmitted in an apartment block or in a hotel. Diagnostic tests will help to understand which of these persons are ill, who is excreting and who is not excreting but how all this came about, whether it was person-to-person transmission, or whatever has happened there, the test cannot help to understand. Therefore, we need to have a combination of the detective epidemiological work and a good test. Now, the test will help in better understanding for how long does a patient continue to excrete virus, when does the person begin to excrete virus. Is it already the first day when they fall ill? Does it start on the second day? Is the excretion first in the respiratory secretions or first in faeces? All this will help better understand the pathways of transmission. That’s what the test is for.

Q. Are you sure that the cause of the disease is the coronavirus or are you still searching?

A. Dr Klaus Stohr: I think we are reasonably sure that the coronavirus is the primary causative agent for SARS. Now what’s the background, what’s the evidence? Scientists in Hong Kong as well as in the United States have investigated several hundreds of samples from blood donations, serum from blood donations, and they couldn’t find in any of this serum traces of coronaviruses. So antibodies were not present in all these controls. But they found in the majority of the SARS patients, they found these antibodies and they found the virus. So we are reasonably sure that the disease is caused by this coronavirus. What remains open, and we’ll see, and I think data will come out shortly, is what role might this metapneumovirus play in the severity of the disease? One hypothesis is that the co-infection, the metapneumovirus, is just part of it, but doesn’t play any role. The other hypothesis is that it might either aggravate the disease or be a type of helper virus. But, to answer your question again, we believe the coronavirus is the major causative agent.

Q. You haven’t talked about China. Is your team able to go to Guangdong? Last time they were still in Beijing and do you have any more cases? Or do you have any information about Chinese cases? Is it contained? Thank you.

A. Dr David Heymann: The team is still in Beijing, working with the government. It has not yet gone to Guangdong. We believe that there will be an invitation coming and, as I say every day, we haven’t yet received that invitation, but we believe it will be coming. And we’re working very hard so that our teams can work with the government in Guangdong. We believe that the outbreak is still going on in Guangdong, from what the government has told us. And this is certainly fitting the case definition that we use in other parts, so we are fairly certain that the outbreaks are linked. This is where the outbreak is also occurring. We know that there are cases in Beijing, we know that there are cases in Shanxi and, Guénaël, can you say anything more about the epidemiology in China? Dr Guénaël Rodier: As David said, we do not have a team yet in Guangdong. But what we heard from the team in Beijing is that the few cases they are looking at in Beijing now are still linked with the hospital setting and not at all with …, a situation similar to Hong Kong with a couple of question marks about chains of transmissions. Again, there is nothing we like less, in a way, than having case we cannot link to another case and so in Beijing we are dealing still with this hospital-based infection, we don’t have…. And the team there guarantee in a way that we do not have any evidence of infection outside the hospital care setting. So that’s reassuring. So again the question mark is mainly in Hong Kong and, that was raised before, we don’t like when we have cases that we cannot readily link to the other part of the puzzle. So, there is an explanation for that, the reassuring part is that they are occurring in cluster so there should be some reason in this apartment complex why this particular group of residents get infected.

It doesn’t mean, clearly, that it is airborne, otherwise you will have the whole of Hong Kong and other places with vast number of cases. So again, the investigation is going on, we can’t tell things we simply don’t know. It could take longer than expected to find, I would say, this marginal part of the transmission, because again all we know for solid is that most of the transmission, the vast majority of transmission, is through close proximity with cases and then the chain of transmission can be built. That has happened very little also on in-flight transmission, it’s not everybody, it’s people sitting next to or air crew, cabin crew, being in close contact with the patients. So I think we stick to that, there should be an explanation for what is going on in Hong Kong, again it’s clustered. We’ll certainly find out and be pleased to report when all these hypotheses, as David mentioned, are clarified, which one is a good one.

Q. Sir, two questions. First, what was exactly the argument given by the Chinese not to have given the invitation so far to such an important region? And, second, some organizations have cancelled their events and things like this in Hong Kong and other cities. Do you recommend this measure as a precaution measure to deal with the disease? Thank you.

A. Dr David Heymann: The reason that we’ve been given for the difficulties in obtaining an invitation to Guangdong is that in China health issues are decentralized to the provincial level. And the provincial level is the level with which we must negotiate in order to work in a province. The central government is working now with the province to see if they can strike an agreement on an invitation. That’s the explanation that we’ve been given. Regarding cancelling of meetings and other issues, that’s entirely up to the organizers. If they can postpone and they wish to postpone, that’s their choice.

We are not a policing agency which tells people what to do. We educate people, we provide information and then people take all this information and make a decision. We are now trying to put ourselves in a little bit different position, to look through our travel and health recommendations, whether we need to make any recommendations. But to date, these recommendations have been based on what probably their own countries have made. As you know, for example, the United States and Canada have both recommended that none-necessary travel be postponed to areas where SARS is occurring. So these decisions are undoubtedly being made based on national recommendations. Our question now is should we be making global recommendations based on what we know and based on what our advisory group on personal health tells us, because that’s who we are working with right now. So, that’s the situation at present.

Q. Voilà, puisqu’on a parlé beaucoup, je m’excuse de parler en français. Alors, la plupart des cas qui se produit au sud de la Chine dans le province de Guangdong, donc maintenant, qu’elle est la situation dans le nord et dans l’est et l’ouest de la Chine ? Parce que la Chine est plus grande que l’Europe, qui a trois fois, quatre fois plus de la population que toute l’Europe. Alors, quels sont les cas ? Est-qu’il y a des cas infectés dans d’autres régions ? La première question. La deuxième concernant – tout à l’heure, enfin ce matin, on a reçu des, quelques informations pour certaines organisations internationales qui ont supprimé leurs voyages ou bien leurs conférences en Chine ou bien en Asie. Est-ce que l’OMS a lancé, qu’ils ont donné des recommandations pour qu’on ne fasse pas de rencontres importantes ou bien de grandes assemblées en Asie, ou bien pour les gens qui viennent de l’Asie, pour, par exemple, la Foire de l’Horlogerie à Bâle et à Genève, est-qu’il y a des recommandations comme ça. Deux questions, merci.

A. Dr David Heymann : Pour la première question, la Chine a établi un système national de surveillance. Ils ont une définition de cas de SARS, ils ont diffusé ça à toutes les provinces et ils ont maintenant fait de SARS une maladie qui doit être déclarer au centre. Ils ont supprimé un peu la responsabilité des provinces en disant que : cette maladie est au dessus de vos responsabilités, vous allez déclarer ça directement à nous. Et le système est déjà commencé mais on a pas encore les résultats et on travaille pour avoir les résultats. Pour la deuxième question, si il y avait des congrès, des réunions qui étaient annulés, c’est basé sur les décisions de ceux qui organisent les réunions en consultation soit avec le pays où la réunion doit avoir lieu, soit avec leur gouvernement. L’OMS n’a pas encore fait des déclarations pour la sécurité des voyageurs.

Q. David, one practical question, if I may. I mean, what about these cases now who could be linked with this virus, which are now local cases, for example at the level of family doctors or urban doctors or village doctors? I mean, are these doctors equipped to say that there might be a link and then they can come back to a central organization to say, or to Institut Pasteur and say, I’ve got a special case? And, if not, can they provide a sort of cocktail of drugs, a sort of cure to stop the disease?

A. Dr David Heymann: It’s a good question and in Viet Nam that was an especially important question. Because Viet Nam had an outbreak which was clearly hospital-based. And the challenge was to see whether or not, outside this hospital, which is a very modern hospital, it’s a French hospital, it’s a private hospital, the challenge was to see whether or not in the community there were also diagnoses being made of this by doctors in the community. And the team has spent great effort in doing that and Guénaël will tell you more about this. But they have found that they don’t find any cases in extensive interviews with the health care personnel in Hanoi. Guénaël, can you add to that.

Dr Guénaël Rodier: I would say again we look for cases wherever they are, people have been in close proximity with a case, obviously health care personnel. But also health care personnel becoming sick could be, could also receive and be in close proximity with family members. And that had happened also in Hanoi but at very low level, actually. So it seems that what happened in Hanoi, the index case, the first case who arrived there played a key role in transmission. I mean he infected a lot of people but the secondary and third chains of transmissions did not seem to spread very, very far. Interestingly, I mean, taking the comparison of Ebola, our experience is, in Congo and elsewhere, that these chains of transmission in family, I mean, in households, tend to stop themselves alone without a solid public health intervention. Why, I don’t know but there are a lot of explanations. A simple one is that when you have a chain of transmission in family or household, nobody is stupid and people realize you should not come close to cases and they educate themselves and slowly the disease dies out. So, I don’t know if I have answered your question, but that’s where we are.

Q. Do you have a definition of an infected area where travelling to or from that area is not recommended?

A. Dr David Heymann: We have recommendations on travel to or from an area. What we’ve told passengers, if they decide to go to those areas, that they should understand what the disease is and they should then, if they become sick, be sure that they notify their health worker. These have been guidelines that we’ve put out to the world in order to prevent the spread of this disease around the world. As I said, today we’re in consultations with Hong Kong, with other sites and with our expert groups to see if we should now be considering making recommendations for personal safety, personal travellers’ health. And those we have not made and we’re discussing today to see whether we should make them and I can’t tell you whether we will or not, I don’t know.

Q. Can I just quickly follow up on this. What’s the difference of this advice on a personal level? That would mean recommending not going to certain regions or not travelling some certain areas, right?

A. Dr David Heymann: What that would be is WHO recommending to people that they either don’t travel or that they postpone their travel or that they consider diverting their travel to certain areas. And that’s the discussions that we’re having with our experts. Should we now be recommending that there not be travel to certain areas? And there’s no conclusion yet because we haven’t completed all of our consultations, including those with Hong Kong.

Q. Then would that mean those areas are infected areas or just the same as what you put in the web site, calling the “affected areas”? A. An “affected area” is an area where there’s transmission that has been documented locally in chains of transmission. That’s what that means. From one person to another. It means that there wasn’t just one imported case that infected two or three people who were hospital workers and then it stopped. It means that there has to be many generations of cases. That’s an affected area.

Q. A few days ago, you were saying, you were suggesting that passengers should be screened in areas like where there are people affected. Because Toronto, Singapore and Viet Nam have apparently been under control, do you recommend the Chinese authorities to screen passengers in certain areas? And secondly, what practical recommendations can you give, like, for example, wear a mask or something like that?

A. Dr David Heymann: Guangdong is an area where there is local transmission and Guangdong, for international passengers, not national passengers, but international passengers, is the same as Hong Kong and other areas. Now, if there’s an international airport in Guangdong, that airport should be practising and applying the same procedures, if they want to follow WHO guidelines, the same procedures as are being done in other places where this disease has local chains of transmission.

Q. Is wearing a mask or any other practical measure effective against the transmission? A. Dr Guénaël Rodier: I mean, it doesn’t make sense to wear a mask unless you are directly exposed to a case.

Q. As a prevention measure? For example, travelling in a plane or in a lift?

A. Dr Guénaël Rodier: You have to put risk in perspective, I mean, this is one risk, among many others for which you don’t do anything. And frankly if you wear a mask simply because the probability is that you are going to come across somebody who is a case sufficiently long enough, then you put a mask in the morning and you don’t fasten your seat belt in the car, this is upside down. So, again this disease appears by foci. We try to make all efforts possible to identify clearly where are these foci. In Hong Kong, for instance, there have been hospital foci well identified; there’s now this apartment cluster foci identified. And it needs more work to identify exactly where the risk is. And then if you go there with the intention to take care of a patient, for instance, or to visit a patient, yes you should wear a mask.

But I think otherwise, it probably doesn’t make sense, because your risk has to be put into perspective. Dr David Heymann: Let me try to help a little bit more by saying that in Asia many times, people who have a respiratory infection, a cold, wear a mask in order to protect others. But I must tell you that in common cold, one of the most easy ways of transmitting a common cold from one person to another is through a hand shake which transfers virus from the hand of one person who may have rubbed his nose to another person’s hand and that person then rubs his nose or her nose or touches their mouth, and they get infected. So a mask is not at all a guarantee of protection against any disease, except if it’s a high-filtered mask worn with goggles to protect your eyes, worn with gloves to protect your hands. So if want to really fly and be protected, get yourself goggles, a mask and gloves.

Q. On Guangdong province, how important is Guangdong province to you in finding the origins of the disease? That’s the first question. And the second is, is there any pattern in terms of the age or the background of the victims of the disease?

A. Dr David Heymann: It would be nice to know the origins of this disease but four months ago, when the outbreak started in Guangdong, is a little bit far in the past to really determine where this virus came from. So I expect that it will never be known clearly if it originated in Guangdong or if it originated in somewhere else and was imported to Guangdong and it was never found somewhere else. I doubt that that’ll ever known. It’s really not important to know the origins. What’s more important is to know what’s going on today with the disease, because it’s in human populations, it’s transmitting from human to human. The hypothesis, of course, is that it’s come from some type of bird or an animal in nature to humans, but that’s not yet proven and that will need to be proven eventually. The pattern of transmission – the first generation has been people who were health workers. They’re usually 20 to 40 years of age. What happens after that is that it spread into family members who are younger or older. In some instances cases have been in … - the doctor who is thought to have spread it to other people in Hong Kong was himself a health worker first generation case. He provided it then to second generation cases which were his close contacts.

Q. OK thanks. A couple of things. In these personal recommendations that you’re considering, on what will the criteria be based, that is age, on history of sickness or something like that? Another question is: Before the cause of this disease was identified, we were told that once you identified the cause of the disease, you would then be able to come up with a treatment. Now, why haven’t you come up with a treatment? And then, third, could you just give us the latest updated figures on cases and deaths, and please don’t send me to the web?

A. Dr David Heymann: I’ll start with the first, Klaus’ll answer the second and Guénaël will answer the third. Criteria for selection of whether or not there will be recommendations. Our expert group tells us that they will be basing their decision on whether or not the epidemiology appears to be changing, especially in Hong Kong. Up until now, it’s been chains of transmission person-to-person, but now we’re beginning to see other means of transmission which may be related to a person, that person’s environment and another person. If our group feels that that’s an important way of transmission and it might be continuing, they will no doubt recommend that we make some type of recommendation, but we don’t know that, but we understand that the criteria are that. So the criteria are really based on a lot of uncertainty, and the more uncertain you become, the more severe become the criteria. We know that it’s clearly person-to-person transmission. If the environment is playing a role now as well, there may be heightened concern that we know less than we thought we learned and we have to be more severe in our recommendations.

Does that answer your question?

Dr Klaus Stohr: Treatment, where’s the treatment? We know what the cause of the disease is, why can’t we really have tomorrow or yesterday, something ready from the shelf and use it. Now, there are two different types of treatment. One group are chemicals and the other group are vaccines; the chemicals are the drugs, which we know. There are some antiviral drugs which were found to be efficient in other viruses. They have never been tested in coronaviruses. So what has to be done now is that we go to the laboratory where the virus is grown and we’ll bring it to those bottles where these viruses are growing, we’ll put some chemical substances and see if the virus continues to happily grow or dies. Well, these are the tests which are currently ongoing – you take a known drug and test whether this new virus will also be killed by this drug and then you have something that you can use also in patients. Now these drugs have been used in patients in very many places – in Canada, in Singapore, in Hong Kong, in Taiwan, province of China, also. None of the drugs which have been tried so far gave a consistent result. This is not very encouraging. So we have no specific chemical drug to treat people. Now the other part of the treatment could be a vaccine. A vaccine is being made on attenuated, so weaker viruses. So you take the virus, you would weaken the virus so that it can no longer infect the person but it would elicit the production of antibodies so that when the wild virus comes, the person is protected. Now the foundation for developing a vaccine is to have the virus.

Therefore, we can be really proud and are very pleased that we have the virus, we know now that we can start developing a vaccine and there is discussion ongoing in the US, for instance, about the development of the vaccine, we are giving characterized virus to vaccine companies and there is serious discussion about this. Dr Guénaël Rodier: The numbers – don’t disregard the web. It’s a good information source and we do update the figures on the web and that’s our best way to share updated figures. We have 1622 cases, including 58 deaths; that’s going to be updated at 4 o’clock today, as we are checking rumours. But just to say, we have the same large big figures, I mean, from China, again old ones, but that’s 806, so it’s a lot. Number two is from Hong Kong with 530 and number three, Singapore, with 91. Number four is Canada – 44, we are talking about what we call probable cases, cases which are showing changes in their x-ray patterns. We decided not to report too much the suspected cases.

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