Prevention from SARSPrevention from SARS(Severe Acute Respiratory (Severe Acute Respiratory

Syndrome) epidemics in JapanSyndrome) epidemics in Japan

Noboru Ishii, M.D., Ph.D.Noboru Ishii, M.D., Ph.D.Department of Disaster and Emergency Department of Disaster and Emergency

medicine,medicine,

Kobe University Graduate School of Kobe University Graduate School of MedicineMedicine

Asia pacific Inter-city SARS Forum in Taipei, September 28-29Asia pacific Inter-city SARS Forum in Taipei, September 28-29

BackgroundBackground

• A new type of pneumonia, SARS was firstly reported as non-typicA new type of pneumonia, SARS was firstly reported as non-typical pneumonia, spreading out from Guangong to Hong Kong and Val pneumonia, spreading out from Guangong to Hong Kong and Vietnam, then on March 12, 2003 the WHO issued a global health ietnam, then on March 12, 2003 the WHO issued a global health alarm to the outbreak of this disease. SARS had also spilled ovalarm to the outbreak of this disease. SARS had also spilled over to Singapore, Taiwan and Canada and became the threat of ther to Singapore, Taiwan and Canada and became the threat of the world public health by March 15. e world public health by March 15.

SARS Response of the WHOSARS Response of the WHO

• Global Alert (March 12, 2003)Global Alert (March 12, 2003)

• Travel Advisory (March 15, 2003)Travel Advisory (March 15, 2003)

• Enhanced global surveillanceEnhanced global surveillance

• Global Outbreak Alert and Response NetworkGlobal Outbreak Alert and Response Network

• Specific Global Networks (Lab, Case Management, Specific Global Networks (Lab, Case Management, Epidemiology)Epidemiology)

• Pathogen of SARS identified as a mutation of Corona Pathogen of SARS identified as a mutation of Corona virus(April 27,2003)virus(April 27,2003)

• Declaration of the end of SARS outbreak (June 18, 2003)Declaration of the end of SARS outbreak (June 18, 2003)

Electron Microscope Photo of SARS virus

SARS Response of Ministry of Health , LaSARS Response of Ministry of Health , Labour and Welfare (MHW) in Japanbour and Welfare (MHW) in Japan

• March 12 Notice the WHO SARS informationMarch 12 Notice the WHO SARS information• March 14 - 18 Notice Surveillance of SARS patientsMarch 14 - 18 Notice Surveillance of SARS patients• March 17 Start Information Services on the WebMarch 17 Start Information Services on the Web site in MHW site in MHW • March 19 Report of 3 suspected casesMarch 19 Report of 3 suspected cases

• April 3 April 3 Advisory to travelers and Advisory to travelers and Reinforced activities at Reinforced activities at

quarantinequarantine stationsstations• April 8 Establish EOC for SARS at MHWApril 8 Establish EOC for SARS at MHW• May 17 - 23 Set-Up Operation Center forMay 17 - 23 Set-Up Operation Center for SARS Response SARS Response

Ministry of Health, Labour and Welfare: Ministry of Health, Labour and Welfare: Severe Acute Respiratory Syndrome (SARS) Action Plan Severe Acute Respiratory Syndrome (SARS) Action Plan (June 2, 2003) (June 2, 2003)

1. Provision of Information on SARS to Public1. Provision of Information on SARS to Public2. Advisory to Travelers Visiting Hong Kong, 2. Advisory to Travelers Visiting Hong Kong,

Guangdong (China), and other SARS-Affected Guangdong (China), and other SARS-Affected Areas.Areas.

3. Reinforcement of Activities at Quarantine Stations3. Reinforcement of Activities at Quarantine Stations4. Preparation for a Possible Outbreak in Japan4. Preparation for a Possible Outbreak in Japan(1)(1) Establishment of Surveillance SystemEstablishment of Surveillance System(2)(2) Designation as a New Emerging Infectious DiseaseDesignation as a New Emerging Infectious Disease(3)(3) Preparation of Health Care ProvidersPreparation of Health Care Providers(4)(4) Strict Risk ManagementStrict Risk Management5. Promotion of International Cooperation5. Promotion of International Cooperation

1. Provision of Information on SARS 1. Provision of Information on SARS to Publicto Public

* Provision of up-to-date information through the Ministry’s web sit* Provision of up-to-date information through the Ministry’s web site. e. (March 17)(March 17)

** Publication of SARS Q&A (Also available on web page). Publication of SARS Q&A (Also available on web page). ** Telephone consultation service at local public health departmentTelephone consultation service at local public health department

s and prefectural governments. s and prefectural governments.

WHO Kobe Center SARS Information Support DeskAutomatic Answering Telephone System in Japanese since May 2003

2. Advisory to Travelers Visiting Hong Kong, Guango2. Advisory to Travelers Visiting Hong Kong, Guangong (China), and other SARS-Affected Areas.ng (China), and other SARS-Affected Areas.

＊＊ All travelers visiting Beijing, Tianjin, Taiwan, Shanxi ProvinAll travelers visiting Beijing, Tianjin, Taiwan, Shanxi Province, Neimenggu and Hebei Province are advised to reconsice, Neimenggu and Hebei Province are advised to reconsider their plans and postpone unnecessary visit to the regider their plans and postpone unnecessary visit to the region. on.

May 6 June 18

Provision of Information on Provision of Information on SARS in JapanSARS in Japan （（ the website of MHWthe website of MHW ））

Information on SARS is provided as the following methods. Information on SARS is provided as the following methods. Health care centers and consultation offices in each prefecture also provided. Health care centers and consultation offices in each prefecture also provided. １１ The InternetThe Internet Introduce the way of its treatment, occurrence condition, and FAQIntroduce the way of its treatment, occurrence condition, and FAQ　○　○ MHW websiteMHW website （（ http://www.mhlw.go.jp/topics/2003/03/tp0318-1i.htmlhttp://www.mhlw.go.jp/topics/2003/03/tp0318-1i.html））　○　○ the website of National Institute of Infectious Diseasesthe website of National Institute of Infectious Diseases （（ http://http://

idsc.nih.go.jp/others/urgent/update.htmlidsc.nih.go.jp/others/urgent/update.html））　○　○ MHW quarantine websiteMHW quarantine website （（ http://http://www.forth.go.jpwww.forth.go.jp）） ２ ２ Inquiry from the publicInquiry from the public Inquiries on heath information of overseas at the nearest quarantine. Inquiries on heath information of overseas at the nearest quarantine. The contact list on the website The contact list on the website （（ http://http://www.forth.go.jpwww.forth.go.jp））３ ３ Inquiry on diagnostic examination from the medical specialistsInquiry on diagnostic examination from the medical specialists 　　　　　　 (open from 9:00 to 17:00)(open from 9:00 to 17:00)　○　○ Information Center of National Institute of Infectious Diseases Tel: 03-5285-1111Information Center of National Institute of Infectious Diseases Tel: 03-5285-1111４ ４ Inquiry on administrative response by the government officersInquiry on administrative response by the government officers　○　○ Department of Infection Control and Prevention Tuberculosis and Infectious Disease Control DivDepartment of Infection Control and Prevention Tuberculosis and Infectious Disease Control Div

ision in MHWision in MHW 　　 TelTel ：： 03-5253-111103-5253-1111 　　 (ex. 2382)(ex. 2382)

http://www.mhlw.go.jp/topics/2003/03/tp0318-1a2.html　

3. Reinforcement of Activities at 3. Reinforcement of Activities at Quarantine StationsQuarantine Stations

** Dispatching medical doctors from national Dispatching medical doctors from national hospitals and other medical institutions to hospitals and other medical institutions to quarantine stations to assist their activities. quarantine stations to assist their activities.

** Distributing the health status questionnaire Distributing the health status questionnaire and monitoring body temperature of all and monitoring body temperature of all passengers on all flights from Hong Kong, passengers on all flights from Hong Kong, China, Taiwan, and Canada. If necessary, the China, Taiwan, and Canada. If necessary, the health status of passenger will be followed up health status of passenger will be followed up for 10 days for 10 days

** Monitoring body temperature of all passengers Monitoring body temperature of all passengers on all international flights at all airports. on all international flights at all airports. (May (May 26)26). .

4. Preparation for a Possible Outbreak 4. Preparation for a Possible Outbreak in Japanin Japan

• (1) Establishment of Surveillance System(1) Establishment of Surveillance System

• (2) Designation as a New Emerging (2) Designation as a New Emerging Infectious DiseaseInfectious Disease

• (3) Preparation of Health Care Providers(3) Preparation of Health Care Providers

• (4) Strict Risk Management(4) Strict Risk Management

(1) Establishment of (1) Establishment of Surveillance SystemSurveillance System

• Establishing a system to dispatch teams of specialistEstablishing a system to dispatch teams of specialists to assist prefectural government during the outbreas to assist prefectural government during the outbreak. Each team consists of about 4 specialists including k. Each team consists of about 4 specialists including epidemiologist and clinician epidemiologist and clinician (April 15)(April 15). .

• Organizing workshops on epidemiological survey (May Organizing workshops on epidemiological survey (May 13). 13).

(2) Designation as a New (2) Designation as a New Emerging Infectious DiseaseEmerging Infectious Disease

• After careful consideration of human rights of patients witAfter careful consideration of human rights of patients with symptoms, SARS was designated as a new emerging inh symptoms, SARS was designated as a new emerging infectious diseasefectious disease 　　 of Infectious Disease Prevention Act tof Infectious Disease Prevention Act to provide adequate medical attention. o provide adequate medical attention.

• Infectious Disease Subcommittee of Ministry of Health, LInfectious Disease Subcommittee of Ministry of Health, Labour and Welfare Science Council discussed handling of abour and Welfare Science Council discussed handling of potential SARS patients, and the recommendations were potential SARS patients, and the recommendations were made to prefectural governments made to prefectural governments (May 2)(May 2). .

• This will allow authorities to order patient to be hospitalizThis will allow authorities to order patient to be hospitalized if necessary.ed if necessary.

(3) Preparation of Health (3) Preparation of Health Care ProvidersCare Providers

• Designating International Medical Center of Japan Designating International Medical Center of Japan as designated medical institution for specific as designated medical institution for specific infectious disease infectious disease (April 7)(April 7). .

• Securing 739 negative pressure room beds. (551 Securing 739 negative pressure room beds. (551 beds in designated medical institutions for beds in designated medical institutions for specific infectious disease and 188 beds in other specific infectious disease and 188 beds in other medical institutions) medical institutions)

• Organizing workshop on prevention of in-hospital Organizing workshop on prevention of in-hospital infection infection (May 2, 7, and 9)(May 2, 7, and 9)

The Law Regarding Infectious Disease Prevention The Law Regarding Infectious Disease Prevention and Medical Care for the Patientsand Medical Care for the Patients(Established on September 28, 1998, enforced on (Established on September 28, 1998, enforced on April 1, 1999)April 1, 1999)

Present Condition of Medical Institutes Present Condition of Medical Institutes and Beds for Infectious Diseasesand Beds for Infectious Diseases

Type Medical care system No. of Institutes No. of BedsMedical care institutions designated for

New infectious diseases specified infectious diseases 2 6(Several in numer nationalwidedesignated by the Government)

Type 1 Medical care institutions designated for(Pest, ebola hemorrhagicClass 1 infectious diseases 12 22 fever, etc,) (One hospital in each prefecture

designated by governors)Type 2 Medical care institutions designated for(Cholera, bacilary Class 2 infectious diseases 295 1,687dystentery, etc.) (One hospital per the second (81*) ( 460*)

medical zone designated by governors)Type 3(O-157 infection)Type 4 Geberal medical care institutions(Epidemic catarrh, AIDS, hepatitis C, etc.)

*Number of Negative pressure room

Occupancy of ICD or ICN in Type 2 hospitals: ca.70%

(4) Strict Risk Management(4) Strict Risk Management

• Local authorities have been instructed to draw up detaileLocal authorities have been instructed to draw up detailed “Action Plan” for a possible outbreak. All prefectural govd “Action Plan” for a possible outbreak. All prefectural governments have developed their action plans. ernments have developed their action plans.

• ““Management Guideline for Preventing In-Hospital InfectioManagement Guideline for Preventing In-Hospital Infection” has been drafted and published n” has been drafted and published (April 7)(April 7). .

• Meeting of directors of national public health lead offices Meeting of directors of national public health lead offices was held, and directors were briefed on the national policwas held, and directors were briefed on the national policy and action plan during a possible outbreak y and action plan during a possible outbreak (May 6)(May 6)..

Issue on Taiwanese doctor: Osaka Issue on Taiwanese doctor: Osaka government is going to declare government is going to declare itself SARS-free on May 23. itself SARS-free on May 23. 　 　 (05/20 16:32)(05/20 16:32)• The governor of Osaka pointed out that “it is The governor of Osaka pointed out that “it is

necessary to issue safety of the city by public necessary to issue safety of the city by public offices as soon as possible” in order to response offices as soon as possible” in order to response many cancellations at hotels and restaurants, many cancellations at hotels and restaurants, which the Taiwanese doctor had visited. Besides, which the Taiwanese doctor had visited. Besides, she added “ the safety information of individual she added “ the safety information of individual facilities are going to be released” regarding to facilities are going to be released” regarding to health condition of the visitors and disinfections health condition of the visitors and disinfections process of the facilities. process of the facilities. （（ from Asahi.comfrom Asahi.com ） ）

http://kdd.asahi.com/special/sars/TKY200305200249.htmlhttp://kdd.asahi.com/special/sars/TKY200305200249.html

Case DefinitionCase Definition ：： Reporting Standard Reporting Standard by WHOby WHO

• Suspected CaseSuspected Case　 　 1.1. 　　 Started after November 11, 2002Started after November 11, 2002

　　 ・ 　　 ・ high feverhigh fever （（ >38℃>38℃ ）） cough, respiratory distresscough, respiratory distress 　　　　　　 ・・ 10 days before the start of symptoms: *either having close 10 days before the start of symptoms: *either having close

contact with the people in suspected or potential case, or traveling contact with the people in suspected or potential case, or traveling to or living in affected area.to or living in affected area.

　　　　 2.2. 　　 Died from a unknown acute respiratory illness after November Died from a unknown acute respiratory illness after November 1st, 2002. No pathologic autopsy; relevant act(*) was recognized 1st, 2002. No pathologic autopsy; relevant act(*) was recognized within 10 days before the symptoms within 10 days before the symptoms

• Probable CaseProbable Case　 　 1.1. 　　 When the suspected case have findings of ARDS or pneumonia When the suspected case have findings of ARDS or pneumonia

on chest radiographon chest radiograph　　 　　 2. When the suspected case are positive in more than one SARS 2. When the suspected case are positive in more than one SARS

examination or are diagnosed RDS by autopsy and no other causeexamination or are diagnosed RDS by autopsy and no other cause

• ExceptionException ：： When the illness is fully explained by When the illness is fully explained by other diagnosisother diagnosis

WHO (Ver.3), May 2003

Consequence of Suspected case and Probable Consequence of Suspected case and Probable Case of SARS in JapanCase of SARS in Japan(May 19 - July 15, 2003) (May 19 - July 15, 2003)

• Suspected case: 52Suspected case: 52

• Probable case: 16Probable case: 16

All cases were negative of SARS All cases were negative of SARS reported by the Special Committee of reported by the Special Committee of SARSSARSReported suspected cases of SARS in Japan ( July 15, at 17:00)

Response for In-Hospital Infection for SARS

Standard Precaution ＋ Droplet Transmission Precaution

Contact Transmission Precaution

Airborne Transmission Precaution

＋

＋

Preparation process for SARS Preparation process for SARS response in Kobe University Hospitalresponse in Kobe University Hospital

March 18March 18 ：： Start SARS response planning at the Infection Control Division Start SARS response planning at the Infection Control Division accordingaccording

to the Notice of MHWto the Notice of MHWMarch 19March 19 ：： Discussion at the Committee of Infection Control in Kobe UniversityDiscussion at the Committee of Infection Control in Kobe University HospitalHospitalMarch 24March 24 ：： Delivery “SARS Response Manual(Ver.1)” to the staff in hospitalDelivery “SARS Response Manual(Ver.1)” to the staff in hospitalApril 7April 7 ：： Information of SARS Response Manual available on the web site of Information of SARS Response Manual available on the web site of

KobeKobe University HospitalUniversity HospitalApril 17April 17 ：： The 1st Practice of simulation for SARS responseThe 1st Practice of simulation for SARS responseApril 22April 22 ： ： The First team meeting for response to the SARS patientsThe First team meeting for response to the SARS patientsMay 6May 6 ：： The second team meeting for response to the SARS patients (RevisedThe second team meeting for response to the SARS patients (Revised “ “SARS Response Manual”)SARS Response Manual”)May 7May 7 ：： Emergency meeting for SARS to the all hospital staffEmergency meeting for SARS to the all hospital staffMay 21May 21 ：： Second revised “SARS Response Manual”Second revised “SARS Response Manual”May 27May 27 ：： Attending the meeting for SARS response information in Kobe cityAttending the meeting for SARS response information in Kobe cityJune 10June 10 ：： The third team meeting for response to the SARS patients The third team meeting for response to the SARS patients June 17,19June 17,19 ： ： The second Practice of simulation for SARS responseThe second Practice of simulation for SARS response

Notice board for the patients with fever or cough

Set up in front of the hospital

5. Promotion of International 5. Promotion of International CooperationCooperation

** Dispatching medical doctors to affected countries Dispatching medical doctors to affected countries and cooperating on researches in diagnosis and and cooperating on researches in diagnosis and treatments.treatments.

WHO speculates SARS WHO speculates SARS affects little in this affects little in this winterwinter （（ reasons as belowreasons as below ／／ in in SARS SARS

UpdateUpdate no. 89: June 26 no. 89: June 26 ）） • Firstly, today’s international public heath care system Firstly, today’s international public heath care system is able to shift to the higher level of alert immediately is able to shift to the higher level of alert immediately

• Secondly, medical specialists in the world know what Secondly, medical specialists in the world know what should they do to control infectious disease, as there is should they do to control infectious disease, as there is a long history of infection control. a long history of infection control.

• Thirdly, it is expected to develop the rapid and reliable Thirdly, it is expected to develop the rapid and reliable diagnostic examination on SARS, which can be adopted diagnostic examination on SARS, which can be adopted at the beginning of treatment. at the beginning of treatment.

• Fourthly, enforcement of discretion on mass epidemics Fourthly, enforcement of discretion on mass epidemics was decided at the WHO general meeting in May. was decided at the WHO general meeting in May.

• Lastly, SARS epidemics show that it is important to Lastly, SARS epidemics show that it is important to release the case of any disease immediately, which has release the case of any disease immediately, which has the possibility of spreading out around the world. the possibility of spreading out around the world.

Problem of Prevention from Problem of Prevention from SARS Epidemics in Japan SARS Epidemics in Japan 1.1. 　　 Deep understanding of informationDeep understanding of information　 ・　 ・ Information system offering by TV, Radio and etc.Information system offering by TV, Radio and etc.　 ・　 ・ Common ownership of scientific and objective Common ownership of scientific and objective

informationinformation2.2. 　　 Improvement of detective methods for SARS Improvement of detective methods for SARS

patientspatients　・　・ High detailed investigation for person contacted to SARSHigh detailed investigation for person contacted to SARS　・ 　・ Common ownership on investigative methods for Common ownership on investigative methods for

outbreak of SARSoutbreak of SARS

3.3. 　　 Establishment of In-Hospital infection control Establishment of In-Hospital infection control systemsystem

　・　・ key point; success of in-hospital infection controlkey point; success of in-hospital infection control

4.4. 　　 Flexibility of early detective systemFlexibility of early detective system　・　・ early detection of aged patients without fever and severe early detection of aged patients without fever and severe

symptomssymptoms

5.5. 　　 Cooperation of implementation for Cooperation of implementation for international discretioninternational discretion

ConclusionConclusion

• Fortunately we did not have any SARS patients Fortunately we did not have any SARS patients in Japan, it is necessary to build up a in Japan, it is necessary to build up a cooperation system among Asian Pacific cooperation system among Asian Pacific countries, including exchanging information, in countries, including exchanging information, in order to prevent the potential SARS epidemics order to prevent the potential SARS epidemics toward this winter. toward this winter.

• Furthermore, concerning risk management of Furthermore, concerning risk management of our country, there are some future issues, our country, there are some future issues, such as to ensure out-of-hours service at each such as to ensure out-of-hours service at each section in the government, in the local section in the government, in the local governments, and in public health care governments, and in public health care centers, and to build up a transportation centers, and to build up a transportation system for the patients. system for the patients.