SARS Spreads to Columbia, India

A new study from Hong Kong released late Tuesday suggested the fatality rate for SARS may be higher than previously thought but experts at the U.S. Centers for Disease Control and Prevention said the true mortality rate for SARS will not be known until they get details about the cases in China -- where more than half of all SARS cases have occurred.

Worldwide, the disease has now infected 6,727 people in 30 countries and caused 478 deaths. More than 4,400 of those cases and nearly half the deaths have been in China.

The new Hong Kong study, which will appear in The Lancet, analyzed more than 1,400 SARS cases in that country and found that about 43 percent to 55 percent of people 60 or older who contracted SARS died. About 7 percent to 13 percent of people under the age of 60 died after developing the disease.

Previous estimates of the SARS fatality rate had placed it anywhere from 4 percent to 6 percent overall.

Asked about the new study, CDC Director Dr. Julie Gerberding said during a press briefing from Atlanta the mortality rate may vary with the age of the patient.

But Gerberding noted, "The bulk of patients are from China and we don't yet have information about the age of all the patients there. Until we have that information it will be really difficult to see an overall case fatality rate."

In addition, she said the death rate for SARS may continue to change as the case definition gets more specific and some individuals thought to have SARS are ruled out as not having the disease.

Several Asian nations, including China, Hong Kong and Taiwan, continued to report new cases Tuesday. But WHO officials said the disease appears to have peaked in Hong Kong and the CDC removed Singapore from its list of areas that travelers should not go to due to SARS concerns.

Hong Kong reported nine new SARS cases and five new deaths, bringing its cumulative total to 1,646 cases and 193 deaths. Singapore reported no new cases but one additional death, giving it a tally of 204 people infected and 27 deaths.

"The number of new cases (in Hong Kong), in the single digits for the last several days, has steadily declined, suggesting that the outbreak has peaked," WHO officials said in a written statement.

In addition, there have been no new cases associated with the Amoy Gardens outbreak for 20 days, Hong Kong's Secretary for Health, Welfare and Food Dr. Eng-kiong Yeoh said during a teleconference with WHO officials.

The WHO attributed the decline in Hong Kong SARS cases to the "heroic" containment efforts the government has employed, including "exit screening procedures at border checkpoints, publication of information on all buildings where residents have developed SARS, procedures for isolation and quarantine, and aggressive contract tracing that relies on a system initially developed by the police force for use in criminal investigations."

Hong Kong also has recently begun several educational campaigns to increase the public's awareness of SARS symptoms. "These efforts have been successful in encouraging people experiencing symptoms to seek prompt medical care, thus reducing the time when people capable of spreading the virus are circulating in the community," the WHO said.

Gerberding said the agency was removing Singapore from its travel advisory list because the country had been "able to contain the epidemic and gone two full cycles of the (incubation period of the) disease without a new case."

However, Gerberding noted the CDC's travel advisory is still in effect for China, Hong Kong and Taiwan. In addition, she said travelers going to Singapore should still follow common sense precautions to protect themselves from SARS, such as avoiding healthcare settings and using proper hand hygiene.

China reported 138 new SARS cases and 8 additional deaths. The country now accounts for more cases than all other countries combined. Approximately 4,409 people have been infected with SARS in China and 214 have died from the illness.

Both the WHO and the CDC expressed concern about the Chinese situation.

"Certainly the fact that we've been able to contain this problem in many parts of the world is good news ... but the ongoing transmission in China and Asia" is troubling, Gerberding said.

The WHO plans to send a team to China's Hebei province May 8 to assess the situation there. Hebei, which now has 113 SARS cases, is close to the capital city of Beijing, where nearly half of all of China's SARS cases has occurred.

Hebei is of concern because the number of cases rose dramatically recently, doubling in just five days. In addition, "there's a lot of movement between the province and the capital so we are concerned about the potential for the disease to spread," said Alan Schnur, from WHO's China office.

But Schnur noted, "It's still early on in the epidemic. Our input at this stage could prevent the situation developing into a large outbreak."

Taiwan continues to struggle with its SARS outbreak and reported two more deaths Tuesday, bringing its total to 116 cases and 10 deaths.

Although the United States has reported several new SARS cases over the last week, Gerberding said "containment of SARS in the U.S. has been successful." The new cases are primarily because Toronto is still listed as an area of concern so people who have developed respiratory symptoms after returning from that city have been put down as probable SARS cases. Many of these cases will probably turn out not to be SARS, she said.

However, she noted that health officials still need to remain vigilant. "As long as there is ongoing SARS transmission in the world, it remains an issue in the U.S.," she said.

In addition, research on the SARS virus released this weekend indicated the pathogen could survive on household surfaces for up to 48 hours, which brings a "great deal of concern" about the potential for the disease to spread, Gerberding said. But she noted that "it doesn't change our recommendations because we already have in place advice that would be necessary to manage the situation."

The findings also highlight the importance of proper hand hygiene as the first line of defense against any disease, she said.

Officials are still "aggressively screening compounds" to find one that might be effective against SARS but so far they have not identified any that could be useful in patients, she said. Some of them have shown activity against the virus, but it was at doses that would not be safe for patients, she said.

However, officials remain optimistic they will find an effective therapy because there are "thousands and thousands of compounds that remain to be tested," Gerberding said.

Also on Tuesday, the first study of the SARS outbreak in Toronto was released. It shows that all the infections in that area occurred in healthcare workers and patients who came into contact with the first person in that city to come down with the disease.

The study, which was released early on the Journal of the American Medical Association's Web site and will appear in a later issue of the print version of the journal, analyzed the 144 cases of SARS that occurred in Toronto. Dr. Christopher M. Booth of the University of Toronto in Ontario and physicians who were involved in caring for the SARS patients in the Toronto area, conducted the study.

The outbreak started after a family living in the Toronto area returned from traveling abroad to China. Two members of the family contracted SARS while in China. One died and the other was admitted to a Toronto hospital, where healthcare workers were not yet aware of the new illness and did not take the necessary precautions such as wearing masks or isolating the patient to prevent themselves or other patients from contracting the disease.

The disease spread to other hospitals due to the transfer of infected patients.

Most, 93 percent of the 144 infected, eventually recovered. Eight patients died and of these, six had diabetes, one had cancer and another was a former smoker.

Canada, which has seen a total of 148 cases and 23 deaths from SARS, reported no new cases or fatalities Tuesday.