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********** Investigation into China's recent SARS outbreak yields important lessons for global public health 2 July 2004 It has been more than two months since the Ministry of Health of China notified WHO and the world about an outbreak of SARS in Beijing and Anhui Province. Since then, WHO experts have been supporting the Chinese authorities in their investigation into the cause of the laboratory-acquired cases, and in assessing the effectiveness of measures taken to control the outbreak. On July 1 2004, the Ministry of Health of China released its status report on the investigation. While the outbreak has now been successfully contained, initial findings from the investigation and the assessment of control measures have raised several important lessons for global public health. Investigation into the source of the outbreak During the course of the investigation, a significant amount of information was gathered, although all the practices within the National Institute of Virology in Beijing have yet to be thoroughly assessed. Although not all detailed information has been made available to WHO, the following conclusions have been made about the source of the outbreak: • The National Institute of Virology in Beijing was the most likely source of the outbreak. • At least four individuals may have been infected with SARS at the Institute. These include the two laboratory workers reported in April, and two additional laboratory workers. These two additional laboratory workers appear to have suffered from SARS-like illnesses in early February 2004. Recent laboratory tests performed at a national reference laboratory were positive for SARS antibodies. • The use of inactivated SARS coronavirus, which was not tested to determine the effectiveness of the inactivation, in a general laboratory at the Institute appears the most likely cause of the outbreak. During the investigation, it became apparent that all the positive laboratory workers worked in the same general laboratory at the Institute. Although no research involving live SARS viruses was known to have taken place in this laboratory, SARS coronavirus that had been inactivated in a Biosafety Level 3 laboratory in the Institute was used on several occasions during the early months of 2004 in experiments carried out in this area. The timing of the use of inactivated SARS coronavirus in the general laboratory coincides with the presence there of all the positive workers and with their likely incubation periods. WHO recommends that further work is needed to verify the effectiveness of the method used to inactivate the live SARS virus. At the same time, other possible explanations of the cause of the outbreak cannot be fully excluded. Biosafety concerns raised by the outbreak The incident at the National Institute of Virology in Beijing has raised concerns about biosafety in general, and the way in which inactivated viral material is handled in particular. "In light of the investigation, WHO believes that Member States should carefully review biosafety standards and strengthen them to avoid further incidents," said Dr Shigeru Omi, Regional Director of WHO's Western Pacific Region. WHO will be working with Member States and expert groups to develop country and regional strategies to strengthen biosafety. Core components of such biosafety programmes at country level are likely to include: • A containment policy to reduce the number of laboratories storing and working on SARS coronavirus. • A legislative framework and independent advisory body to assist in the development, implementation and evaluation of a national biosafety programme and in the investigation of biohazard incidents and the dissemination of lessons learned to the global scientific community. • A laboratory accreditation system based on standardized biosafety criteria. • An occupational health service to monitor the well being of laboratory workers. • Comprehensive biosafety and training programmes in all diagnostic and research institutes supported by a management framework that facilitates compliance with evidence-based guidelines and the adoption of a positive biosafety culture. WHO also emphasizes that scientists working with highly pathogenic viruses such as SARS need to handle inactivated material with the utmost caution. In particular, WHO recommends that: • Researchers use appropriate and internationally accepted methods for validating the inactivation of live viruses. • Inactivated material should be handled only in laboratories at biosafety level (BSL) 2 or above. • Researchers handling inactivated material should wear appropriate personal protective equipment. • New methods for inactivation should be adopted only after rigorous testing. • Clear and comprehensive protocols should be available for all inactivation techniques. Assessment of effectiveness of outbreak control measures In addition to supporting the investigation into the possible source of the outbreak, WHO has worked with Chinese authorities to evaluate the effectiveness of the outbreak control measures. Joint WHO-Ministry of Health teams have visited all the hospitals where the recent cases were treated before they were admitted to designated SARS facilities. In addition, WHO experts have reviewed data on contact tracing and other control measures. "Overall," said Dr Omi, "WHO believes that the Chinese authorities acted swiftly and effectively to control the outbreak once the alarm had been raised. Extensive contact tracing was undertaken in a matter of hours, and the effective isolation of cases and identification of contacts appears to have ensured that the outbreak was contained with remarkable speed." However, there was a delay in detecting the initial cases. As a consequence, two generations of transmission occurred and the application of effective hospital and community control measures took place late in the outbreak. The Ministry of Health of China has acknowledged this and is looking to strengthen further the current detection and response system. There are a number of lessons from this outbreak that are important globally, for Member States and for WHO itself: • Health care workers, laboratory workers and people in close contact with certain animals are at risk of contracting a range of infectious diseases with outbreak potential. Disease detection systems need to be designed to take these risk factors, as well as clinical information, into account - and to be robust enough to ensure that nobody slips through the net and evades detection. • Health care workers need to be aware of the risks associated with certain occupations (including their own) and to be able to take a detailed occupational history from a patient. • Health care workers also need to be aware of the importance of asking about the health of close contacts of anyone with a potentially contagious respiratory illness. Quickly identifying possible clusters of respiratory illness is important in the control of such diseases and the detection of new or rare infectious diseases. • All health care workers should be empowered to initiate effective measures to protect themselves and others from potentially contagious diseases, in a "safety first" approach. This means that health care workers should be aware of potential clinical and epidemiological risk factors; have ready access to the equipment and knowledge needed to protect themselves and others; and be allowed to initiate the most appropriate infection-control measures immediately - with validation and approval from senior members of staff later. This recent outbreak has demonstrated once again that SARS is a containable disease. WHO commends the Chinese authorities for taking swift action to control the latest outbreak. WHO will be working closely with the Chinese authorities to assist in the strengthening of biosafety, and to build a long-term strategy for strengthening laboratory research and diagnosis in China. WHO looks forward to working with China in its efforts to tackle SARS and other public health issues in the future. ********** China’s latest SARS outbreak has been contained, but biosafety concerns remain Update 7 18 May 2004 It has been more than three weeks since the last case was placed in isolation in China’s latest SARS outbreak, prompting the World Health Organization to declare that the chain of human-to-human transmission appears to have been broken. However, WHO experts and the Chinese authorities are still trying to determine the exact cause of the outbreak. The investigation has centred primarily on the National Institute of Virology in Beijing where experiments using live and inactivated SARS coronavirus have been carried out. Two researchers at the Institute developed SARS in late March and mid-April. The outbreak was reported on April 22 and the Institute was closed a day later. Preliminary findings in the investigation have yet to identify a single infectious source or single procedural error at the Institute and it is conceivable that an exact answer may never be determined. Neither of the researchers is known to have directly conducted experiments using live SARS coronavirus. However, investigators have serious concerns about biosafety procedures at the Institute including how and where procedures using SARS coronavirus were carried out, and how and where SARS coronavirus samples were stored. WHO and Chinese authorities view with concern the occurrence of laboratory-associated SARS cases. WHO urges all Member States to view this latest outbreak as an opportunity to review the biosafety practices of institutions and laboratories working with SARS coronavirus. During and after the SARS outbreak of 2003, a large number of specimens were collected from possible human cases, animals and the environment. These specimens, which may contain live SARS coronavirus, are still kept in various laboratories around the world. Some of them are stored in laboratories at an inappropriate containment level. SARS coronavirus has also been propagated in reference and research laboratories, and distributed to other laboratories for research purposes. Research using live and inactivated SARS coronavirus and other pathogens capable of causing serious illness -- is being conducted in many laboratories. WHO has issued the following laboratory safety guidelines and recommendations: • WHO biosafety guidelines for handling of SARS specimens • Summary of the discussion and recommendations of the SARS laboratory workshop of 22 October 2003 • WHO post-outbreak biosafety guidelines for handling of SARS coronavirus specimens and cultures In these guidelines, WHO strongly recommends Biosafety Level 3 (BSL 3) as the minimum containment level to work with live SARS coronavirus. WHO also urges Member States to maintain a thorough inventory of laboratories working with and/or storing live SARS coronavirus and to ensure that necessary biosafety standards are in place. WHO commends the Chinese authorities for taking swift action to contain the latest outbreak once it was recognized and reported, by way of extensive contact tracing and the quarantine and medical observation of such individuals. Once again, it has been demonstrated that SARS is a containable disease. ********** SARS in China: investigation continues Update 6 5 May 2004 Investigation of the source of the current outbreak, first reported on 22 April, continues to focus on the National Institute of Virology in Beijing. The institute is known to have conducted experiments using the live SARS coronavirus during February and March. Two researchers at the institute developed SARS in late March and mid-April. However, neither is known to have conducted research using the live virus, suggesting some other source of infection within the laboratory or possibly elsewhere. Members of a joint WHO-Chinese investigative team, wearing full personal protective equipment, entered the institute last Friday and again yesterday. Initial findings indicate that the investigation will be complex, as no single infectious source or single procedural error appears likely to explain infection in the two researchers. Continuing investigation is needed to determine the source of infection and ensure that conditions, equipment, and biosafety procedures within the institute do not pose an ongoing risk of contracting SARS infection. A large number of samples were taken, by Chinese investigators, from various locations in the institute. These samples are also undergoing analysis at the WHO SARS laboratory in Hong Kong. WHO has strongly recommended that work using the live SARS virus be conducted in biosafety level 3 facilities in order to minimize the risk of laboratory-acquired infections. Further investigation of the institute is needed to ensure that any work using the live virus fully complies with the strict requirements for physical containment of the virus, storage, administrative control, work procedures, personal protection of laboratory workers, and authorization and monitoring of all staff admitted to the laboratory. The National Institute of Virology was closed on 23 April and most of its staff were quarantined for medical observation. However, a small number of staff have remained within the facility to continue essential experiments and care for laboratory animals. ********** China confirms SARS infection in another previously reported case; summary of cases to date Update 5 30 April 2004 Chinese authorities have today reported test results confirming that the 53-year-old woman who died in Anhui Province on 19 April was infected with the SARS coronavirus. The woman, a medical doctor, was the mother of a 26-year-old postgraduate student who had been conducting research at the National Institute of Virology in Beijing. The student remains hospitalized in Anhui. Since the first case was reported on 22 April, Chinese authorities have confirmed a diagnosis of SARS in five persons (see summary below). Testing continues on another four patients who have SARS-like symptoms and a history of close contact with a known case. Since 22 April, the seven patients in Beijing are now being treated in isolation in a single facility, Ditan Hospital, as a risk reduction strategy. Investigation of the source of the outbreak is presently focused on lapses in biosafety procedures at the National Institute of Virology. The institute was closed on 23 April and its staff were placed in isolation. Summary of cases To date, there have been three generations resulting in nine cases. First generation. The first case is a 26-year-old female postgraduate student from Anhui Province. She worked at the National Institute of Virology in Beijing 722 March. Laboratories at the institute are known to be conducting studies using the live SARS coronavirus. Her symptoms developed on 25 March in Anhui. Following onset of symptoms, she travelled twice by train from Anhui to Beijing and back to Anhui. Her SARS infection has been confirmed by the Chinese Ministry of Health. She is presently hospitalized in isolation in Anhui. A second case who may have acquired infection from a laboratory source is a 31-year-old male researcher at the same virology institute. His symptoms developed on 17 April. He is presently undergoing treatment in isolation at Beijing’s Ditan Hospital. To date, he has not been linked to any other cases. Second generation. The two cases in the second generation are both linked to close personal contact with the postgraduate student. These cases are her 53-year-old mother, whose infection with the SARS coronavirus was confirmed by Chinese authorities today. She is, to date, the only fatal case in the outbreak. The second case is a 20-year-old nurse in Beijing who treated the postgraduate student, from 29 March to 2 April, during her initial hospitalization in Beijing The nurse’s SARS infection has been confirmed by the Chinese Ministry of Health. She is being treated in isolation at Beijing’s Ditan Hospital. Third generation. Five further cases have all been linked to close contact with the nurse. Three are relatives: her 45-year-old father, her 44-year-old mother, and a 36-year-old aunt. SARS infection in the mother and aunt has been confirmed by the Chinese Ministry of Health. The fourth case linked to the nurse is a 49-year-old retired female doctor who was admitted to hospital because of another illness and shared a room with the nurse. The retired doctor’s 23-year-old daughter-in-law, who accompanied her at the time of hospital admission, is the fifth case. As both women did not develop SARS-like symptoms until a week following hospital admission, both are presumed to have acquired their infection from close contact with the nurse.
All five patients are being treated in isolation at Ditan Hospital. ********** China confirms SARS infection in two previously reported cases update 4 29 April 2004 The Chinese Ministry of Health has today reported diagnostic confirmation of SARS infection in two patients previously under investigation in Beijing. Confirmation is based on the results of laboratory tests, clinical symptoms, and a history of close contact with a known case. Both patients are relatives the mother and an aunt of a 20-year-old nurse who treated what is thought to be the index case in the outbreak. The nurse subsequently developed respiratory symptoms and was hospitalized on 7 April. She was visited the next day by family members, including the mother and aunt. The 44-year-old mother is now in critical condition. The 36-year-old aunt, who was diagnosed with bilateral pneumonia earlier this week, remains in stable condition. Both patients are part of a third generation of cases that includes the nurse’s father and two other patients hospitalized on the same ward, including one patient who shared a room with the nurse. The number of SARS cases either clinically confirmed or under investigation remains nine: seven in Beijing and two (including the single fatality) in Anhui Province. In Beijing, all seven SARS cases are now being treated in isolation at Ditan Hospital. This is a risk reduction strategy aimed at preventing further spread through the hospital system. According to WHO guidelines for the global surveillance of SARS, classification as a confirmed case at the start of an outbreak requires independent verification of results by an external international reference laboratory. Such procedures are considered necessary in view of the implications that confirmed SARS cases can have for international public health. ********** China reports additional SARS case - update 3 28 April 2004 Chinese health authorities have today announced that an additional case of SARS is under investigation. This brings the total number of cases in China, reported since 22 April, to nine. Of these, one has died. The new case, in Beijing, is a 49-year-old female retired doctor. On 12 April, she was admitted to the same hospital ward where a 20-year-old nurse was being treated for pneumonia. The former doctor began developing SARS-like symptoms on 19 April and on 22 April was transferred to Ditan Hospital and placed in isolation. Her condition is listed as critical. The 20-year-old nurse, previously reported to WHO as a confirmed case, has been linked to an additional five cases. These include the one reported today and four reported on Sunday. To date, all cases have been linked to chains of transmission involving close contact with an identified case. The second confirmed case, who remains hospitalized in Anhui Province, is a 26-year-old postgraduate student who had been conducting research at the National Institute of Virology in Beijing. She is thought to be the index case in the present outbreak. During the 2003 outbreak, the transmission of SARS was greatly amplified in hospital settings. As a risk reduction strategy in Beijing, all seven SARS cases are now being treated in Ditan Hospital. However, patients were treated or assessed in open wards at seven hospitals (five in Beijing and 2 in Anhui) before suspicions of SARS were raised and procedures of isolation and infection control were introduced. In addition, the two patients in Anhui travelled long distances within China by train. As these events created opportunities for multiple exposures, Chinese authorities have undertaken extensive tracing and follow-up of contacts. In Beijing, nearly 700 persons have been isolated or placed in quarantine.
SARS has a relatively long incubation period, generally accepted to be 10 days. Based on present knowledge about the disease, persons exposed to the virus are not infectious prior to the onset of symptoms. For these reasons, rapid detection and isolation of cases, and rapid tracing and follow-up of contacts have been successfully used to bring a SARS outbreak under control. Investigation of the outbreak Following a request by the Chinese Ministry of Health, the initial members of a WHO team are now in Beijing to assist in the investigation and control of the outbreaks there and in Anhui. Investigation of the source of infection will initially focus on biosafety procedures at the National Institute of Virology in Beijing. Two of the nine cases reported by China, including the earliest case, were researchers at the institute, which has been conducting work using the live SARS coronavirus. Chinese authorities are providing WHO with detailed clinical and epidemiological information on all cases. This information is important in assessing the severity of illness caused by the virus and the extent of its transmission. Of the 8 patients currently hospitalized for treatment, the patient in Anhui Province continues to improve. In Beijing, two patients are in critical condition and the others remain under treatment for pneumonia. If the source of infection is determined to come from the National Institute of Virology in Beijing, this will be the first SARS outbreak caused by a laboratory-acquired virus, which could possibly cause different patterns of illness and transmission. Previous laboratory-associated cases a single case each in Singapore in September 2003 and in Taiwan, China in December 2003 did not result in any further transmission. Both cases fully recovered. In addition, four cases (3 confirmed and 1 probable) were reported in Guangdong Province in December 2003 and January 2004, presumably acquired from an environmental source. Unlike the present outbreak, these cases were associated with mild illness only and did not result in secondary transmission to others. ********** Additional patients in China under investigation for SARS; WHO team travels to Beijing - update 2 26 April 2004 At the request of the Chinese Ministry of Health, WHO is today sending the first members of an international team to help investigate the source of SARS cases recently reported in Beijing and the eastern province of Anhui. The team, which is expected to begin work on Wednesday, will include experts in epidemiology, virology, infection control, and laboratory biosafety. Results of investigations to date point to laboratory research at the National Institute of Virology in Beijing as the likely source of the outbreak. The institute has been engaged in research with the SARS coronavirus, including the development of a vaccine. Two of the recently reported cases were conducting research at the laboratory: a 26-year-old female postgraduate student from Anhui Province, and a 31-year-old man. The dates of symptom onset in the two cases are widely separated (23 days), suggesting that more than one opportunity for exposure may have occurred in the laboratory from mid-March through early April. Authorities have closed the virology institute and placed its more than 200 employees under medical observation. Numerous environmental samples from the laboratory have been taken to help assess possible sources of contamination, and these samples will be shared with WHO. Understanding and eliminating the source of infection are critical steps in bringing the outbreak under control. An equally important activity is to quickly detect all chains of transmission and interrupt them through rapid case detection, tracing and follow-up of contacts, and infection control in hospitals. WHO is concerned about additional opportunities for exposure that may have already occurred. Some patients were treated or assessed in several different hospitals before a suspicion of SARS led to the introduction of adequate precautionary measures, including isolation of patients and strict procedures for infection control. One patient travelled a long distance twice by train within China while symptomatic. Chinese authorities have heightened surveillance and reporting for SARS-like illness in health care facilities and have sent investigative teams to Anhui Province. Since 22 April, China has reported that eight persons have been clinically diagnosed as SARS cases or are under investigation for possible SARS infection. Six of these are in Beijing and two, including the single fatality, are in Anhui Province. As of today, close to 1000 contacts of these cases are under medical observation, including 640 in Beijing and 353 in Anhui. The most recent cases, announced on Sunday, are four close contacts of a 20-year-old nurse who treated the Anhui student at a Beijing hospital. The cases all in Beijing are currently under investigation. They include the nurse’s mother, father, aunt, and a woman who shared a hospital ward with the nurse when she was undergoing treatment. Onset of symptoms for all four persons occurred between 16 and 19 April. The nurse’s mother is in serious condition following the development of pneumonia. The other three persons are in stable condition. In addition, health authorities have reported that two doctors who treated the postgraduate student during her hospitalization in Hefai, Anhui, have developed fever. A person in close contact with one of the doctors has also developed fever. To date, all diagnosed cases and cases under investigation have been linked to chains of transmission involving close personal contact with an identified case. There is no evidence of wider transmission in the community. According to WHO guidelines for the global surveillance of SARS, classification as a confirmed case at the start of an outbreak requires independent verification of results by an external international reference laboratory. Such procedures are considered necessary in view of the implications that confirmed SARS cases can have for international public health. ********** China reports additional SARS cases - update 23 April 2004 The Chinese Ministry of Health has today reported an additional three cases of SARS, including one death. This brings the current number of persons with a clinical illness compatible with SARS in China to four. Chinese authorities have reported a diagnosis of clinically confirmed SARS coronavirus infection in two of these persons. These are the 20-year-old nurse in Beijing, reported yesterday, who remains in intensive care, and a 26-year-old female laboratory researcher, from Anhui Province. During two weeks in March, the researcher worked at the Chinese National Institute of Virology in Beijing, which is part of China’s Center for Disease Control. This institute is known to be engaged in research involving the SARS coronavirus. She developed symptoms on 25 March and was attended, while in a Beijing hospital, by the nurse. Her mother also provided bedside care. The mother became ill in Anhui on 8 April and died on 19 April. Her clinical symptoms were compatible with SARS, and health authorities have retrospectively diagnosed her as a suspected SARS case. The fourth person is a 31-year-old male laboratory researcher who also worked at the Beijing virology institute. He developed symptoms on 17 April and was hospitalized in isolation on 22 April. Health authorities have diagnosed him as a suspected SARS case. In line with WHO definitions of SARS coronavirus infections, WHO has classified two of these persons, the 20-year-old nurse and the 26-year-old laboratory researcher, as probable cases of SARS. The two additional persons remain under investigation; further laboratory tests are being conducted by Chinese authorities. According to WHO guidelines for the global surveillance of SARS, classification as a confirmed case requires independent verification of results by an external international reference laboratory. Such procedures are considered necessary in view of the implications that confirmed SARS cases can have for international public health. WHO is working closely with Chinese health authorities to confirm the status and full extent of this cluster, and to prevent further spread. The situation is considered potentially serious because of the multiple opportunities for exposures. To date, more than 300 contacts have been identified and placed under medical observation. ********** SARS: one suspected case reported in China 22 April 2004 The Chinese Ministry of Health has today informed WHO of one suspected case of SARS. Investigation of the case, including extensive laboratory testing and tracing and observation of contacts, is under way. The case is a 20-year-old nurse who developed SARS-like symptoms in Beijing on 5 April and was admitted to hospital on 7 April. As her condition did not improve, she was transferred on 14 April to a second Beijing hospital, where she was placed in intensive care. Results of initial blood tests, received today, indicate a likely infection with the SARS coronavirus. However, further testing is needed before a diagnosis of SARS can be confirmed. Contact tracing has identified 171 contacts, who have been placed under observation. Of these, five have developed fever. If confirmed, this will be the first case of SARS since January this year, when authorities in Guangdong Province confirmed infection in a 35-year-old businessman and a 20-year-old waitress. Following the end of the SARS outbreak, announced by WHO on 5 July 2003, five SARS cases have been confirmed. Two occurred in laboratory workers, in Singapore and Taiwan, China, and three in Guangdong Province. The third Guangdong case, in a 32-year-old television journalist, was announced in December 2003. None of these five cases resulted in further transmission of the virus. China, which experienced the largest number of SARS cases during the 2003 outbreak, has a well-developed system for the detection and investigation of possible cases of SARS. Staff at the WHO office in Beijing have considerable experience with SARS and are being kept closely informed by the Ministry of Health. ********** WHO issues consensus document on the epidemiology of SARS 17 October 2003 WHO has today issued a 35-page report summarizing international research on the epidemiology of the SARS outbreak. -WHO consensus document on the epidemiology of severe acute respiratory syndrome (SARS) The report, which represents the views of experts in public health, epidemiology, and clinical virology, draws on experiences from all the main outbreak sites as well as a large number of recently published studies and unpublished documents. It also incorporates information from ongoing weekly teleconferences of the WHO Ad Hoc Working Group on the Epidemiology of SARS. The report addresses several lingering concerns about the disease and reaches conclusions about some. These conclusions help WHO determine whether recommendations made during the course of the outbreak remain valid, in light of the most recent and complete evidence, for responding to a possible recurrence of SARS. The report also includes accounts of distinctive features in the epidemiology at each of the main outbreak sites. The report is being issued at the start of four consecutive SARS meetings being hosted in Geneva by WHO. The meetings, which will run from Monday 20 October through Saturday 1 November, will be addressing priorities for scientific research, laboratory issues, clinical treatment protocols, and prospects for vaccine development. The SARS Research Advisory Committee, which is meeting for the first time next week, will consider a broad range of research needs, from investigation of a possible animal reservoir to the status of laboratory diagnostic tests. The laboratory meeting will consider the critical issue of quality assurance of diagnostic tests and is expected to make recommendations concerning national inventories of institutes conducting research on the SARS virus or maintaining patient samples. Such information is considered important in view of the risk that SARS could recur following an accident in the many laboratories handling the virus or storing samples. The clinical meeting aims to reach an agreed framework for the evaluation of SARS treatments. Should SARS recur, the use of standard protocols for conducting simultaneous, comparable clinical trials at all outbreak sites would be a new way of working that could greatly expedite conclusions about the most effective treatments and thus help ensure that all patients around the world are benefiting from the best known treatments. The vaccine meeting will evaluate the status of candidate vaccines and also consider a number of regulatory issues. Updates on the main conclusions and recommendations reached during these meetings will be posted on the SARS web site. WHO consensus document on the epidemiology of SARS: some main conclusions from the report The report found no evidence that SARS is an airborne disease. Health care workers were at special risk. The risk of transmission is greatest at around day 10 of illness. The report found no evidence that patients transmit infection 10 days after fever has resolved. Children are rarely affected by SARS. The implications of the Metropole Hotel outbreak are not yet fully understood. Intensive investigations of circumstances surrounding the late-February outbreak in the Metropole Hotel, Hong Kong, which seeded the international spread of SARS, have not yet answered all questions. During this incident, the virus was transmitted to at least 16 guests and visitors, all linked to the 9th floor of the hotel. The results of environmental sampling on the carpet outside room 911, where the index case resided, and elevator areas show a hot zone (possibly vomitus or respiratory secretions). Samples were PCR positive for the virus 3 months after the index case spent a single night at the hotel. Although tests demonstrated the presence of SARS coronavirus RNA and not viable virus, this finding may have implications for the persistence of the virus in the environment. The Metropole Hotel outbreak is recognized as a “superspreading event”. However, the index case did not have an unusually high viral load when tested on days 9 and 11 of illness. Risk of in-flight transmission. **********
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