Emergencies preparedness, response

United Nations Agencies Joint Medical Service Conference on Severe Acute Respiratory Syndrome

Wednesday, 9 April 2003, 11:30
Palais des Nations, Assembly Hall

World Health Organization
Dr Pascale Gilbert-Miguet, Chief Medical Officer, Joint Medical Service (JMS)
Dr Farida Djelloul, Medical Officer, JMS
Dr Guenael Rodier, Director, Communicable disease surveillance and response (CSR)
Dr Mark Salter, Medical Officer, CSR
Dr Sandy Cocksedge, Scientist, CSR
Dr Isabelle Nuttall, Medical Officer, CSR
Ms Peggy Creese, Technical Officer, CSR
Mr Dick Thompson, Communications Officer

Dr Gilbert-Miguet: Thank you very much, Dr Rodier, for this briefing and presentation. If there are any questions, and I imagine there should be quite a few ...

Q: [speaker is off microphone – cannot be interpreted] Is there a risk associated with merchandise coming from the affected areas?

A. Dr Guénaël Rodier: That is an excellent question, to which we did not reply immediately because there was not a risk so we did not think of providing information on this subject. But it is something that arises again and again. There are questions on the people that assemble computers with parts coming from China. Is there a risk associated with that? We are going to put on our web site some information on this, and perhaps the person that might respond to this would be Sandy because he deals directly with this problem of international sanitary regulations and questions of contact and commerce. Dr Sandy Cocksedge: I will repeat the question.

The gentleman posed a question about goods, products, things arriving from affected areas in the world that the World Health Organization has identified. We are looking at, for example, the survival of the virus – the virus in question, as Guenael mentioned, the coronavirus – how long does it survive in the environment? The answers are not there yet, it is still being characterized, it is still being tracked, this virus, to see what the actual environmental survivability will be. What we have to say is that based on epidemiological studies, there is nothing to indicate so far that there has been any transmission of SARS virus from products, from animals or from other things coming in. The answer at this point is that, as Guenael suggested, we do not see a risk from products arriving, and that is what we are basing the web site information that will be up today on. Thank you.

Q: I have two questions. What are the precautions that I have to take personally? What special precautions should I take vis a vis colleagues who travel and come back to our service? I am a bit concerned because we have two colleagues, one who recently travelled to Thailand and Burma who has returned and who has again gone off to Cuba, and we have a colleague returning next week who has left Australia and who is going to be returning via Hong Kong. What precautions need to be taken with respect to such individuals? Thank you.

A. Dr Guénaël Rodier: Thank you. As for the travellers, I think everyone has basically equal risk vis a vis such people. What I have said is that this is clearly a disease that is in households. It is not everyone in the street who is sick. It is restricted to households. Now of course it is a vast job is to identify all the transmission chains, but the man in the street's chances in Hong Kong of getting this disease are very low. If you cough or you have a respiratory problem in Hong Kong, you will be very quickly isolated, questioned, interrogated. So Hong Kong in many respects is a lot safer in the street than other places because there is a great degree of awareness. There are places where there is less awareness, and our conviction is that there are transmission chains that today have not yet been recognized.

Of course this has not happened in Hong Kong, but this may happen in other countries of the region that have a great deal of trade with China and there may not be sophisticated means of surveillance, so we are going to put WHO people in those countries to beef up surveillance and to detect cases. It is clear that today in Hong Kong unless you are directly involved with the people who have been isolated in that housing complex or a health care worker who is directly exposed, you would be experiencing a very low degree of risk. It is on the basis of precautionary principles that we are asking people not to go if it is not essential because the health care system in Hong Kong is saturated, it is overworked, exhausted. That is basically what I wanted to say. The risks have been noted for United Nations staff. There are two staff member who fell sick and who died.

One was one of our colleagues who died, who was among the first to take stock of what was going on in the Hanoi hospital at the time. We were facing a new problem and we were unaware of many things related to transmission. Unfortunately, he was affected there and he was part of the 4% of the fatalities. And then there was the ILO staff member who died in Beijing, but who did not necessarily get the disease in Beijing. We are carrying out an enquiry now as to where that person may have been infected or whether he travelled next to someone with the disease coming from Bangkok. This is something that needs to be investigated. But whenever we investigate we come out with a finding, it is always related to a transmission chain. It is not a question of immediately coming down with disease without there being a direct connection.

Q: [speaker is off microphone – cannot be interpreted] And the precautions to take with colleagues returning?

A. Dr Guénaël Rodier: I think that Pascale [Gilbert-Miguet] distributed a note that explains the main situations that you may confront. Debriefing people coming from Guangdong. I did not take any particular precaution because I did not think there was a risk because everyone in the team coming from Guangdong was in good health. It has not been demonstrated in our transmission chains that people in good health, either people incubating the disease or convalescing, should have transmitted the disease. It is always a question of people who are symptomatic, who are ill, who transmit the disease. The main situations that we encounter is that someone is coming back from a high-risk area, and there you have three possibilities. The person does not consider that he or she has been exposed, they have done their job and do not consider themselves as having been at risk.

One may be wrong, but we ask people to be vigilant for a period of 10 days after returning. If one comes down with a fever within 10 days, then they should not remain at work. The second situation is that someone returns who may know that they have been exposed to a sufferer or a patient, either because they travelled next to someone who was manifestly ill or because the person was a health care worker. There again, on the basis of a precautionary principle, we ask that person to stay home for 10 days.

It is not a question of “house arrest”, but it is an endeavour to minimize contact so that there is no possible contamination, so that there is no close contact with the work environment. This can be organized at home very easily. The third situation is someone coming back from a risk region who has symptoms that may be SARS. In that case, the person is immediately referred to a medical service to be cared for. Now for you who may come into contact with people returning from epidemic areas, the first thing you can do is ask them, “Are you in good health? Do you think that you have been exposed? If so, maybe you should stay home for a certain period. If not, then there is no real reason to wear a mask or to wear gloves”.

Dr Farida Djelloul: I wanted to take the floor also to respond to your question. I think I have additional information. The division of administration has already prepared an information note concerning these three possible cases. I can already tell you that any United Nations staff member returning from an endemic risk area – WHO confined this to Guangdong and Hong Kong – we expanded this to all of China, Hong Kong, Singapore, Taiwan (China), Hanoi (Viet Nam) and Toronto (Canada). Anyone returning from mission to these areas before returning to work should contact the medical service – the phone number is in the note – and the medical service will decide whether the person should return to work or not. So you do not have any reason really to be concerned.

Q: Good morning. There are a number of questions I would like to ask. I work at the WTO. As you know, China entered the WTO. We have many people coming from the risk areas. What is the role of WHO in supervising the control and providing guarantees for us as a medical service to our staff for people who are coming and going from conferences, government representatives, participants, delegates, all these people who are not strictly speaking staff? Does the Asia regional office have a means of controlling that screening at airports is properly carried out to detect travellers so that we can go up the chain upstream as was the case in the ILO, or as we have seen here in the canton of Geneva? Are missions, etc. supervised and are they aware of your recommendations? How do they implement them and apply them?

A. Dr Guénaël Rodier: Something that is important here is that WHO does not do everything. WHO has a normative, informative role to play. But in the final analysis it is the states that are responsible for implementing the recommendations and implementing measures that they may want to take, which may involve going beyond what WHO has recommended. We do not rule their going even further, but states, organizers of meetings, governments are fully entitled to take whichever measures they like and we can only intervene on the basis of what we know and to provide information and advice. We do not have the means nor the mandate to ensure, how shall I put it, to enforce, actually, the implementation of the recommendations or measures. What is interesting is to detect whether a certain country or government is doing its work well, because this has impact on the spread of the epidemic.

Q: [speaker is off microphone – cannot be interpreted] ... the view would be that for political or diplomatic reasons, someone might actually travel who exhibits symptoms and thus expose others to risk, who may come into contact with such an individual? That is the concern.

A. Dr Guénaël Rodier: You are entirely right. That may actually happen. It is rather interesting. We are trying to make an effort on the information front and on making passengers responsible. This has demonstrated that people who are afraid of being hospitalized on the spot and they know that they were at risk, they might decide to travel nevertheless and they fall ill. There have been cases where people leave and they know that they are sick and yet they take the plane and they contaminate the person next to them. Nothing really can be done. We are aware of such cases. The staff doctors really have to do their job on the spot and check and surveille the travellers.

Q: Would it not be better to take vacations during the World Health Assembly when you have so many doctors?

A. Dr Guénaël Rodier: No, there is no reason, but you may remember one point with respect to congresses and the health care workers, doctors, nurses, etc. This has been documented with that first case, which you may recall was a case in Germany, where the aeroplane was stopped to get the passenger off. The person wanted to participate in a medical congress in the United States. We have to understand that people on the front line today – it is not you really – it is the people of the JMS, [Joint Medical Service] nurses, health care workers, they are the ones who are at risk, not the others. I think we have got to be very clear and this is a very important point. It is the health care workers who are at risk a lot more than anyone else.

Q. [speaker is off microphone – cannot be interpreted] In your presentation we saw that this virus started in Asia and so far it has touched the countries in that region and also cases in Europe and then Canada, mostly in Canada. This virus reminds me of AIDS. During the first period starting from hospital and then little by little it ended up in Africa and then there were investigations leading to the roots having been found in Africa. The bulk of victims of AIDS are in Africa. At the time of speaking, are there any cases in Africa? From the lessons learned in AIDS, what special precautionary measures would WHO suggest to the continent in the case of SARS? For the simple reason that this virus has been placed in Asia. …. globalization of itself? Little by little moved. What are the lessons learned that may help in this?

A. Dr Guénaël Rodier: Thanks very much for your questions. If there is one lesson learned from AIDS, it’s typically the fact that the problem that emerged somewhere could become the problem of everywhere. This SARS could spread to Africa, we actually today have a suspected case in South Africa. And China and Hong Kong have some traffic, not as big as with other parts of Asia and Europe and North America, but there are some traffic with Africa as well. And we are going to work now with our regional African office so they are all informed, they have documents available to strengthen surveillance, looking for SARS. The fear I have is that there may be importation or exportation of cases of SARS in Africa where the health care setting may not detect them on time and then they may lead to some hospital-based outbreaks. And that would in itself be a problem. The situation that happened in the hospital in Hanoi could happen elsewhere.

You took the example of AIDS. There is another nosocomial infection – hospital-based infection – which we often work with, which is Ebola. And Ebola is the same. In a way, you could have chains of transmission undetected, nobody sees them, most of Ebola patients do not have necessarily haemorrhage, so you don’t see them and suddenly the hospital setting provides the terrain for an outbreak, because of the health care system. And that’s an issue, it may happen in Africa, it may happen in many other resource-poor countries where again the health system may amplify in fact the problem which won’t be detected before.

That was the case with HIV/AIDS at the beginning with syringes, needles which were used and that created a number of outbreaks which are also in a way caused by the health system, I mean through the needles. So in a way, that’s the lesson from AIDS – the problem of hospital-transmitted infection, so the need for good barrier nursing and the issue of world-wide spread. And that may happen. I don’t think it’s a real problem for the developed world but it could, SARS could become in the long run a problem for the developing world having to face this constantly as they do today with TB and other things, other infectious diseases, malaria and others. Just to say about relative severity – I prefer to get SARS rather than AIDS, or Ebola of course, because I have a 96% chance to survive compared to these two other diseases.

Q. [speaker is off microphone – cannot be interpreted] You have emphasized that health care workers are most at risk and a high percentage of …. I’m from the International Council of Nurses. Are there any special protocols to be in place to protect health care workers? Also, what can we do to communicate as best as possible to the person in … amongst workers?

A. Dr Guénaël Rodier: It is done today on a country basis. But I agree with you it may be interesting, guidelines exist and have been developed and may be Mark can say a word about that. Dr Mark Salter: We have a network of clinicians who are working under the guidance of WHO who are currently attending SARS patients in all countries where they have SARS patients. And with their help and with their clinical experience, we’ve put together a number of recommendations which have been distributed globally. And at the present moment in time, I’m in communication with a number of national agencies around the world in developing more appropriate infection control measures and precautionary programmes for countries at an individual level.

We’re also taking this forward and developing, it’s really enhancing the protocols we already have in place for dealing with severe infections that Dr Rodier’s just alluded to, such as Ebola, where we have quite comprehensive infection control documentation. We are taking that and we’re using that as a basis to develop it to deal with, not only SARS, but other severe diseases. And this information hopefully is being disseminated actively now to all health care workers on a global basis. Mrs Peggy Creese: I’d just like to add that the infection control guidelines and management of cases of SARS is on our web site. So perhaps you could look at that.

Q. Yes, I’d like to ask whether there’s an idea, even a vague one, of the moment when the epidemic will have reached it’s peak and will begin to recede? Thank you.

A. Dr Guénaël Rodier: As you saw in the presentation, the peak in most places is behind us. On the other hand, there could be transmission chains in other countries which will create new local epidemics. But today, apart from China and Hong Kong, where I can’t say that the peak is behind us, for the others it is. That was clear from the graphs I showed just now. However, there might be new transmission chains in other countries which set it off again. It might not develop as an epidemic but as an endemic one, there might be flair ups of epidemic.

Q. I would like to ask some rather technical, medical questions on coronavirus. Is this a DNA or an RNA virus? That’s the first question. The second is: It being given that medical personnel in general have already identified the human coronavirus, we know the genome, we’ve been able to identify this earlier. Since this new coronavirus is giving rise to problems of identification, the animal origin that you indicated, you said that this virus was also present in animals, would that come from a mutated animal virus which has attacked humans? That’s the second question. The third and last relates to ribavirin which is currently being used. What do you think about this? Is it having an effect on the virus or is it pretty much useless? Thank you.

A. Dr Guénaël Rodier: Good questions, more medical and I’ll ask Mark to answer them. Dr Mark Salter: OK, I can probably start off by expanding on what coronaviruses are. Coronaviruses are a whole group of viruses, not just one virus. They are RNA viruses and within the coronavirus group there are two groups of viruses. The coronavirus that seems to be implicated in causing SARS has not been seen before, in that sequences have now been achieved from patients where the coronavirus has been isolated. They have been compared with all of the known sequences of known coronaviruses. And they don’t match 100% any known coronaviruses. What they do, however, show is that there are similarities between the coronavirus that’s been isolated from SARS patients and coronaviruses that are known to cause murine hepatitis, that’s hepatitis in mice, and there are some similarities with porcine, that’s pig, coronaviruses.

Is it a mutated animal virus? We have no evidence to suggest that is the case. However, we know that coronaviruses, rather like the influenza viruses, can co-infect pigs, there can be more than one virus infecting at a time in the same cell. And that the new virus that is produced from that cell can have genes, nucleic acid from one of those viruses and nucleic acid from another, and so it becomes a totally new virus. And in picking up those new genes, it can change its ability to infect other hosts. So we may be looking at an infection having occurred in animals which has now changed the virus to allow it to more readily infect human beings. Or, it not necessarily makes humans more readily infected, but it makes the virus more pathogenic in humans. But we don’t have any information to support either of those propositions just at this time. And the third question, correct me if I’m wrong, was about ribavirin? Ribavirin is an antiviral agent, for those of you unaware, which is principally used for the treatment of respiratory synctial virus in young children, this is a paramyxovirus.

It’s also been used in the treatment of some of the viral haemorrhagic fevers, more noticeably, Lassa fever. However, the efficacy even in these viral infections, is relatively limited. To date about 60 patients have been treated with ribavirin, who have SARS, and most of these have been individuals who’ve been in the later stages of disease and in the more severe group. None of these individuals have shown any significant improvement that can be attributed directly to the ribavirin. And that’s the current state of play. At the moment, through the WHO collaborating clinicians group on SARS, we are putting in place some protocols that’ll allow some systematic appraisal of the therapeutic regimes that are being used around the globe, but particularly ribavirin because that is obviously the one where we have the most information about its antiviral efficacy in other agents.

Dr Farida Djelloul: Final question?

Q. Good morning. I have a certain number of questions which are not all interlinked but there are some things which seem to be a little vague. On the index case in Hong Kong, at the Hotel Metropole, was it possible to identify the transmission method in that hotel? Another question: I’d like to know what is the possibility for blood transfusions to carry the virus? I’d like to know how developing countries may establish a prevention policy, not only at airports but if a patient moves about within a country having passed the airport, how are the hospitals equipped?

The question on delegations from China – I’m at the WTO – we had an awful lot of Chinese delegates and it seemed from the reports that the Chinese authorities had not been saying very much about the epidemic at that time. Was the virus already present in November or did it mutate in January/February? What else? To the extent that it’s health care personnel who are, for the time being, more at risk than others, how is medical work going for patients who aren’t suffering from this disease but who might need emergency care? What would happen in Geneva if something of this nature were to happen?

I think in Geneva we’ve already had an experience when there’s the ‘flu and the doctors are ill, but here we’re talking about something different than ‘flu. What else did I have? I’d like to know the recommendations that you’re making to staff coming back from Asian countries who have to be careful and telephone your medical service, whether these staff by precaution could be put on leave at home? Are we talking about holiday time here? What’s the situation here, what would be the legal situation for an international organization where there’s a person who’s been affected by contact with a colleague or because it hasn’t been possible to identify the disease? Somebody who’s gone home to those areas, gone on leave to those areas? I think that was about all.

A. Dr Pascale Gilbert Miguet: Let me answer about the leave question, I think my colleague will confirm. When we ask whether it’s considered that somebody has had a strong possibility of being in contact with somebody suffering from the disease and they’re asked to stay home for 10 days, that’s administrative leave – at least at WHO. Dr Farida Djelloul: At the UN, New York, there’s a different procedure. It’s 10 days of sick leave and if you have no entitlement for sick leave, it’s administrative leave, with payment. Dr Guénaël Rodier: Some of the earlier questions on the legal aspects, I can’t really answer that. But I can answer on the transmission in the Metropole Hotel, that’s still something that we are wondering about. Something happened there that we haven’t really understood what has happened. There’s a range of possibilities.

Certainly, the patient from Guangdong has probably been in close contact with other people, that might happen. In the lift or something, it can happen that you’re close to somebody suffering from the disease. The hypothesis which was initially put forward, that this was an airborne transmission in the air conditioning, it’s very, very improbable because in fact all of the patients are clients, customers - no staff member of the hotel. So that makes us wonder about the transmission in that building in Hong Kong. It’s probably the same thing. We’re wondering what’s happened there. It doesn’t change anything about what we know about the transmission chains, but we know that we don’t know everything. Investigations are under way. We’ve been very interested in forms of contamination where in fact the disease may be present in the stools of the patient. You probably heard quite a lot of talk but in fact all of these apartments in Hong Kong, what links them is the sewage disposal. But I don’t have any definitive answers. We can look at this and it’s only a marginal method, we still need to understand what’s happening. On blood transfusions, that’s a good question. Perhaps Mark might have an answer.

Dr Mark Salter: It’s an issue that’s coming up more and more and we’ve had a number of European countries question us as to what the possibility of blood transfusions being a mode of transmission. I have to say that from the laboratory testing to date, we’ve not found a significant number of SARS corona-like virus particles in sera. But it is there and it is a potential risk and it’s a risk that we’re analysing now as to what the possible recommendation should be. But we don’t have a definitive answer to give to anybody at the present moment in time. Dr Guénaël Rodier: So it’s a good question but we don’t have the answer at this stage. The other thing was the preventive policy in developing countries. That is closely related to the health infrastructure, the capacity to have protection in the hospitals, it’s true for hepatitis B and many other things, including SARS. Here I have to say efforts are under way but if you’ve travelled, like we have, you’ll know that in many countries, many developing countries at the present stage don’t have the level of protected care in the hospital to guarantee a good situation. As I was saying just now, that’s our main concern because we’re dealing with a disease which develops in hospitals. China in November you asked about.

Indeed our first case goes back to the 16th of November. We have access to samples at the present time, we can see retrospectively what’s happened up to mid-November. China is giving us access to these samples, as I said. A team has just come back from Guangdong so we’re accumulating information on this. We hesitated to link all of these events but now we do think it is one event. The virus responsible for what happened in mid-November in China is very probably the same for what happened in Hanoi, Canada and so on. Routine care – you were saying if it happened here. I’m not quite sure what the question was. Was it the idea that for example, when there’s ‘flu, hospital staff are affected and can’t work? Well that’s exactly what did happen in Hanoi. Hospital staff couldn’t work because of SARS and it was one of the elements which made us consider this disease to be particularly severe. Because of it’s impact on the functioning of the health care system. I think if it happened here, the protected care system would mean that the situation would be controlled but we can imagine that a patient may come and not be identified and thus there might be a hospital epidemic even in Switzerland or elsewhere. It can happen and it’s what did happen in Canada.

Dr Farida Djelloul: Well, I think we’ll close the meeting. I would like to thank the WHO team for coming here today and participating in this information meeting.

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