2 figures, 1 table omitted
On April 22, 2003, the Taiwan Department of Health (DOH) was notified
of seven cases of severe acute respiratory syndrome (SARS) among health-care
workers (HCWs) at a large municipal hospital in Taipei (hospital A). Subsequent
cases at eight hospitals have been associated with exposures at hospital A.
Previously, all reported cases had been associated with persons recently returning
to Taiwan from SARS-affected regions. This report summarizes epidemiologic
findings of the outbreak in Taiwan and describes the impact of health-care–associated
transmission of SARS.
As of May 22, a total of 483 probable cases had been reported. All probable
SARS patients were hospitalized; 84 (17%) had been discharged, and 60 (12%)
had died. The median age of probable SARS patients was 43 years (range: 9
months–91 years); 341 (71%) cases were from Taipei City and Taipei County,
the largest metropolitan region of the island. The first patient reported
had onset of illness on February 25; the majority of cases occurred after
April 21 and were associated with transmission in health-care settings.
Taiwan (2002 population: 23 million) has extensive business ties with
Hong Kong and mainland China where SARS cases have been reported. The first
case in Taiwan was identified on March 14 in a traveler from Guangdong Province
in China. During March 14–April 21, Taiwan reported 28 probable SARS
cases; of these, four resulted from secondary transmission (one HCW and three
family contacts). During this period, SARS was characterized by sporadic cases
among business travelers who were cared for primarily at large academic hospitals;
secondary spread was limited to identified contacts. Initial actions by DOH
included the formation of a SARS advisory committee, infection-control training,
contact tracing and quarantine, and airport and border surveillance. Because
of Taiwan's success with SARS control, in early April, the World Health Organization
changed Taiwan's designation from an "affected area" to an "area with limited
Since April 22, SARS cases in Taiwan have increased and have been associated
primarily with health-care settings. During April 22–May 1, the number
of probable cases in Taiwan more than tripled, from 28 to 89. The source of
the outbreak was hospital A, where an unrecognized SARS index patient had
multiple exposures with patients, visitors, and HCWs who were not protected
adequately to prevent acquisition of SARS.
Hospital A. The index patient was a laundry worker aged 42 years with diabetes mellitus
and peripheral vascular disease who was employed at hospital A. On April 12,
the worker had onset of fever and diarrhea and was evaluated in the emergency
department (ED) on April 12, 14, and 15. The patient remained on duty and
interacted frequently with patients, staff, and visitors. The patient had
sleeping quarters in the hospital's basement and spent off-duty time socializing
in the ED. On April 16, because of worsening symptoms, the patient was admitted
to ward 8B of the hospital with a diagnosis of infectious enteritis. Stool
samples revealed the presence of leukocytes, but cultures were negative. The
patient was treated with intravenous antibiotics and the fever resolved. On
April 18, the patient became short of breath. A chest radiograph showed bilateral
infiltrates, and the patient was transferred to an isolation room in the intensive
care unit for possible SARS. During the next few days, the patient had progressive
respiratory failure and was intubated on April 22. A polymerase chain reaction
(PCR) test was positive for SARS-associated coronavirus (SARS-CoV); the patient
died on April 29. The source of infection for the patient is unknown.
The initial cluster of SARS cases reported on April 22 from hospital
A included patients, visitors, and HCWs. The symptomatic HCWs included two
nurses, a doctor, an administrator, a radiology technician, a nursing student,
and another laundry worker. On the basis of epidemiologic links among the
cases, 61 HCWs were identified and quarantined. Within 24 hours, 10 additional
cases were identified from hospital A; none were from this quarantined cohort.
By April 23, cases had been identified from the ED and from six different
floors of the hospital, including ward 8B where the index patient had been
admitted. The work location and number of case reports suggested widespread
transmission. Because the index patient had been symptomatic for 6 days before
SARS was diagnosed, the number of potentially exposed persons was estimated
at 10,000 patients and visitors and 930 staff.
On April 23, DOH convened an emergency task force to plan the response
to SARS transmission in hospital A. On April 24, hospital A was contained,
and all patients, visitors, and staff were quarantined within the building.
Home quarantine also was mandated for discharged patients and visitors who
had been at hospital A since April 9. Inside the hospital, all recognized
SARS patients were cohorted on two floors. Personal protective equipment (PPE)
and disinfection materials were distributed, and active surveillance was enforced
for all HCWs. However, incident SARS cases in hospital A continued to increase.
During April 29–May 8, a total of 81 SARS patients were transferred
to 15 hospitals throughout Taipei; it is unknown whether any of these patients
were associated with secondary cases in other hospitals. All of the remaining
patients (approximately 200) whose illnesses were not consistent with SARS
case definitions were discharged to home quarantine or transferred to other
facilities. As of May 22, a total of 137 probable cases were associated with
exposures at hospital A, including 45 (33%) cases among HCWs; 26 (19%) persons
Secondary Clusters. To date, HCW clusters at eight additional hospitals in Taiwan have been
linked to the initial outbreak at hospital A. Preliminary data suggest that
many of these clusters occurred when presymptomatic patients or patients with
SARS symptoms attributed to other causes were discharged or transferred to
other health-care facilities. SARS has now extended to multiple cities and
regions of Taiwan, including several university and private hospitals. Four
of these hospitals, including a 2,300-bed facility in southern Taiwan, have
discontinued emergency and routine services. Sporadic community cases also
have been reported in Taipei and southern Taiwan.
In response, DOH has reorganized its outbreak response structure, appointed
a SARS task force commander, and created an emergency operations center. Efforts
have focused on limiting nosocomial transmission by designating dedicated
SARS hospitals throughout the island. Approximately 100 fever clinics also
have been established to identify potential SARS patients and minimize risk
for transmission in EDs. Patient care capacity will be expanded by the construction
of 1,000 negative pressure isolation rooms; by the end of May, approximately
1,700 such rooms will be available. Campsites and military facilities have
been identified to accommodate quarantined residents, and home quarantine
will be enforced through web-based cameras. Screening for fever in all patients,
HCWs, and visitors has been instituted at all health-care facilities. DOH
also has developed an infection-control curriculum to train infection-control
teams on educating and monitoring HCWs. Standard operating procedures for
the management and containment of nosocomial SARS clusters are being finalized.
ML Lee, MD, CJ Chen, ScD, IJ Su, MD, KT Chen, MD, CC Yeh, MD, CC King,
PhD, HL Chang, MPH, YC Wu, MD, MS Ho, MD, DD Jiang, PhD, SARS Prevention Task
Force, Dept of Health, Taiwan, Republic of China. World Health Organization,
Geneva, Switzerland. SARS Investigative Team; D Wong, MD, EIS Officer, CDC.
Efforts to control SARS in Taiwan appeared to be effective for approximately
5 weeks after identification of the first travel-associated case.1 Despite national efforts to implement extensive
control measures, unrecognized cases of SARS led to nosocomial clusters and
subsequent spread to other health-care facilities and community settings.
These clusters resulted in substantial morbidity and mortality and resulted
in the closure of several large health-care facilities. In one neighborhood
in Taipei, three hospitals were affected, impacting facility access and deterring
residents from seeking routine medical care.
Although nosocomial transmission of SARS has been well-documented, Taiwan's
experience demonstrates that spread among HCWs can occur despite knowledge
about the epidemiology and transmission of SARS. Multiple factors probably
contributed to the rapid and widespread transmission in hospital A. The index
patient had been symptomatic with fever and diarrhea for 6 days before SARS
was suspected, and infection-control procedures were implemented. SARS infection-control
guidelines focused primarily on health-care workers. However, in Taiwan, visitors
include personal attendants hired by families to provide care for inpatients.
Personal attendants are not routinely supplied with PPE; some personal attendants
had SARS and might have contributed to disease spread.
Unrecognized cases of SARS also have been implicated in recent outbreaks
at health-care facilities in Singapore.2 Several
factors might contribute to difficulties in recognizing cases of SARS. Early
symptoms of SARS are nonspecific and are associated with other more common
illnesses. Patients with SARS who are immunocompromised or who have chronic
conditions (e.g., diabetes mellitus or chronic renal insufficiency) might
not have fever when acutely ill or have symptoms attributable to underlying
disease, delaying SARS diagnosis.2,3 PCR
tests to detect SARS-CoV are readily available in Taiwan; however, these tests
might not detect the virus early during illness, and a negative test result
does not rule out SARS.4 Finally, some patients
might not reveal useful contact information (e.g., exposure to an implicated
health-care facility) for fear of being stigmatized by the local community
or causing their friends and families to be quarantined.
In Taiwan, exposures within health-care facilities have accelerated
SARS transmission. The public health investigation is ongoing, and the number
of SARS cases associated with health-care settings will probably increase.
The extensive outbreak in Taiwan underscores the need for HCW education that
promotes the early recognition of SARS and the prompt implementation of appropriate
infection-control procedures. These educational efforts should be directed
to HCWs in all facilities, including smaller and nonacademic hospitals.
This report is based on data contributed by Taipei City Bur of Health;
Field Epidemiology Training Program; Center for Disease Control Taiwan, Republic
Severe Acute Respiratory Syndrome—Taiwan, 2003. JAMA. 2003;289(22):2930-2932. doi:10.1001/jama.289.22.2930