WHO is worried that China is under-reporting SARS

Although Chinese government officials claim that the outbreak of severe acute respiratory syndrome (SARS) has been effectively contained in Beijing, the rapid decline in the number of cases there has raised suspicions that China may be under-reporting by excluding mild cases.

"They fit the case definition, but because they get better in a few days they are not seen as probable cases. Clinicians are making this decision because there's an assumption that SARS patients must be very sick, but there's a spectrum of severity for SARS," said Dr Daniel Chin, team leader of the World Health Organization's Beijing SARS experts.

Outbreaks in some of China's poorer provinces, such as Guangxi and Hebei, have been tackled with vigour by local authorities and health workers, keeping numbers below the worst fears of WHO. In Guangxi, a major feeder province for the factories of neighbouring Guangdong, an estimated 260 000 migrant workers returned home between 1 April and 8 May, and their return was registered at surveillance checkpoints at the main entry points to the province. Provincial authorities relied on community based surveillance to ensure that returnees submitted to health checks—and quarantine in some cases.

A similar approach has been used in Hebei province, which has a large population of migrants to Beijing. "It's the old socialist grassroots surveillance system—where everybody knows everybody else's business—which has been gradually breaking down over the years in China but works well in the fight against SARS and seems to be making a big difference in Hebei," said Peter Cordingley, WHO's spokesman in Manila.

In Taiwan the number of cases has almost doubled in a week, to 383 by 20 May. The health minister, Twu Shiin-jer, resigned on 16 May after a second doctor on the island died of SARS. On 19 May, 149 staff in two hospitals handling SARS cases in Taipei and the southern city of Kaohsiung resigned because of inadequate protection.

"The hospitals have had enough time to study the experience of hospitals in Hong Kong, but hospital emergency rooms seem to be the genesis of several outbreaks. We are wondering why Taiwan is losing the plot so badly, and of course it's not helped by mass resignations of health workers," said Mr Cordingley.

Hong Kong moved a step closer to meeting WHO's criteria for lifting its travel warning when it notched up its 16th straight day of single digit infection numbers on May 19 and had an average of less than five cases a day over the previous three days. WHO has said that, together with this level of infections, Hong Kong has to have avoided exporting cases of SARS—a criterion it has already met—and must have fewer than 60 patients in hospital for treatment of SARS. By 19 May Hong Kong had recorded a total of 1714 cases and 251 deaths. A total of 1213 people had been discharged, and of the 187 active cases 45 were in intensive care and a further 63 people are in convalescence.

To persuade WHO that Hong Kong is safe for international travel, Hong Kong government officials have been lobbying hard at the Word Health Assembly, pointing out the measures being taken to stop new cases coming into or going out of Hong Kong. "In mid-April we instituted temperature checks for all departing, arriving, and transiting passengers at the airport. The temperature measures have since been extended to all border points by land, rail, and sea," said Dr Yeoh Eng-kiong, secretary for health, welfare, and food.

These measures may be enough to get the travel warning lifted even if the total number of cases in hospital remains above 60, explained Mr Cordingley. "Hong Kong now exceeds all WHO recommendations on monitoring and it is now a pretty watertight ship. Our position is that we are working towards a situation where we can look at Hong Kong and consider it safe for international travel, and one single criterion would not necessarily stop that."

Because of early case detection, patient isolation, vigorous contact tracing, and rapid sharing of information the disease has been contained in most places. Only 16 people contracted SARS through airline travel, for example, and all the cases occurred on four flights early on in the outbreak, before airlines and airports introduced screening measures.

The key to preventing SARS from becoming endemic remained sharing information about disease outbreaks as soon as they occur, said Gro Harlem Brundtland, WHO's director general. "We need to share that information globally even faster than modern travel. Our strategy is to do what is possible to defeat SARS. We should not conclude that we will just have to accept it like all other diseases already affecting humankind," she said.

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WHO is worried that China is under-reporting SARS

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