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Asia pacific Inter-city SARS Forum in Taipei, September 28-29
Prevention from SARS
(Severe Acute Respiratory Syndrome)
epidemics in Japan
Noboru Ishii, M.D., Ph.D.
Department of Disaster and Emergency
medicine,
Kobe University Graduate School of Medicine
Background
• A new type of pneumonia, SARS was firstly reported as non-
typical pneumonia, spreading out from Guangong to Hong Kong
and Vietnam, then on March 12, 2003 the WHO issued a global
health alarm to the outbreak of this disease. SARS had also
spilled over to Singapore, Taiwan and Canada and became the
threat of the world public health by March 15.
SARS Response of the WHO
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Global Alert (March 12, 2003)
Travel Advisory (March 15, 2003)
Enhanced global surveillance
Global Outbreak Alert and Response Network
Specific Global Networks (Lab, Case Management,
Epidemiology)
• Pathogen of SARS identified as a mutation of Corona virus(April
27,2003)
• Declaration of the end of SARS outbreak (June 18, 2003)
Electron Microscope Photo
of SARS virus
SARS Response of Ministry of Health ,
Labour and Welfare (MHW) in Japan
• March 12
• March 14 - 18
• March 17
• March 19
• April 3
• April 8
• May 17 - 23
Notice the WHO SARS information
Notice Surveillance of SARS patients
Start Information Services on the Web
site in MHW
Report of 3 suspected cases
Advisory to travelers and
Reinforced activities at quarantine
stations
Establish EOC for SARS at MHW
Set-Up Operation Center for
SARS Response
Ministry of Health, Labour and Welfare:
Severe Acute Respiratory Syndrome (SARS)
Action Plan
(June 2, 2003)
1. Provision of Information on SARS to Public
2. Advisory to Travelers Visiting Hong Kong, Guangdong
(China), and other SARS-Affected Areas.
3. Reinforcement of Activities at Quarantine Stations
4. Preparation for a Possible Outbreak in Japan
(1) Establishment of Surveillance System
(2) Designation as a New Emerging Infectious Disease
(3) Preparation of Health Care Providers
(4) Strict Risk Management
5. Promotion of International Cooperation
1. Provision of Information on SARS to
Public
* Provision of up-to-date information through the Ministry’s web
site. (March 17)
* Publication of SARS Q&A (Also available on web page).
* Telephone consultation service at local public health
departments and prefectural governments.
WHO Kobe Center SARS Information Support Desk
Automatic Answering Telephone System in Japanese since May 2003
2. Advisory to Travelers Visiting Hong Kong,
Guangong (China), and other SARS-Affected
Areas.
＊All travelers visiting Beijing, Tianjin, Taiwan, Shanxi
Province, Neimenggu and Hebei Province are advised to
reconsider their plans and postpone unnecessary visit to
the region.
Provision of Information on SARS
in Japan（the website of MHW）
Information on SARS is provided as the following methods.
Health care centers and consultation offices in each prefecture also provided.
１The Internet
Introduce the way of its treatment, occurrence condition, and FAQ
○MHW website（http://www.mhlw.go.jp/topics/2003/03/tp0318-1i.html）
○the website of National Institute of Infectious Diseases
（http://idsc.nih.go.jp/others/urgent/update.html）
○MHW quarantine website（http://www.forth.go.jp）
２ Inquiry from the public
Inquiries on heath information of overseas at the nearest quarantine.
The contact list on the website （http://www.forth.go.jp）
３ Inquiry on diagnostic examination from the medical specialists
(open from 9:00 to 17:00)
○Information Center of National Institute of Infectious Diseases Tel: 03-5285-1111
４ Inquiry on administrative response by the government officers
○Department of Infection Control and Prevention Tuberculosis and Infectious Disease Control
Division in MHW Tel：03-5253-1111 (ex. 2382)
http://www.mhlw.go.jp/topics/2003/03/tp0318-1a2.html
3. Reinforcement of Activities at Quarantine
Stations
* Dispatching medical doctors from national hospitals
and other medical institutions to quarantine stations
to assist their activities.
* Distributing the health status questionnaire and
monitoring body temperature of all passengers on all
flights from Hong Kong, China, Taiwan, and Canada.
If necessary, the health status of passenger will be
followed up for 10 days
* Monitoring body temperature of all passengers on all
international flights at all airports. (May 26).
4. Preparation for a Possible Outbreak in
Japan
•
(1) Establishment of Surveillance System
•
(2) Designation as a New Emerging Infectious
Disease
•
(3) Preparation of Health Care Providers
•
(4) Strict Risk Management
(1) Establishment of Surveillance
System
• Establishing a system to dispatch teams of specialists
to assist prefectural government during the outbreak.
Each team consists of about 4 specialists including
epidemiologist and clinician (April 15).
• Organizing workshops on epidemiological survey
(May 13).
(2) Designation as a New
Emerging Infectious Disease
• After careful consideration of human rights of patients
•
with symptoms, SARS was designated as a new
emerging infectious disease of Infectious Disease
Prevention Act to provide adequate medical attention.
Infectious Disease Subcommittee of Ministry of Health,
Labour and Welfare Science Council discussed handling
of potential SARS patients, and the recommendations
were made to prefectural governments (May 2).
• This will allow authorities to order patient to be
hospitalized if necessary.
(3) Preparation of Health Care
Providers
• Designating International Medical Center of Japan as
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designated medical institution for specific infectious
disease (April 7).
Securing 739 negative pressure room beds. (551 beds in
designated medical institutions for specific infectious
disease and 188 beds in other medical institutions)
Organizing workshop on prevention of in-hospital
infection (May 2, 7, and 9)
The Law Regarding Infectious Disease Prevention and Medical Care
for the Patients
(Established on September 28, 1998, enforced on April 1, 1999)
Present Condition of Medical Institutes and
Beds for Infectious Diseases
Type
New infectious diseases
Type 1
(Pest, ebola hemorrhagic
fever, etc,)
Type 2
(Cholera, bacilary
dystentery, etc.)
Type 3
(O-157 infection)
Type 4
(Epidemic catarrh,
AIDS, hepatitis C, etc.)
Medical care system
Medical care institutions designated for
specified infectious diseases
(Several in numer nationalwide
designated by the Government)
Medical care institutions designated for
Class 1 infectious diseases
(One hospital in each prefecture
designated by governors)
Medical care institutions designated for
Class 2 infectious diseases
(One hospital per the second
medical zone designated by governors)
No. of Institutes
No. of Beds
2
6
12
22
295
(81*)
1,687
( 460*)
Geberal medical care institutions
*Number of Negative pressure room
Occupancy of ICD or ICN in Type 2 hospitals: ca.70%
(4) Strict Risk Management
• Local authorities have been instructed to draw up
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detailed “Action Plan” for a possible outbreak. All
prefectural governments have developed their action
plans.
“Management Guideline for Preventing In-Hospital
Infection” has been drafted and published (April 7).
Meeting of directors of national public health lead offices
was held, and directors were briefed on the national
policy and action plan during a possible outbreak (May
6).
Issue on Taiwanese doctor: Osaka
government is going to declare itself
SARS-free on May 23. (05/20 16:32)
• The governor of Osaka pointed out that “it is necessary to
issue safety of the city by public offices as soon as
possible” in order to response many cancellations at
hotels and restaurants, which the Taiwanese doctor had
visited. Besides, she added “ the safety information of
individual facilities are going to be released” regarding to
health condition of the visitors and disinfections process
of the facilities. （from Asahi.com）
http://kdd.asahi.com/special/sars/TKY200305200249.html
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Case Definition：Reporting Standard by
WHO
Suspected Case
1. Started after November 11, 2002
・ high fever（>38℃）cough, respiratory distress
・10 days before the start of symptoms: *either having close contact with
the people in suspected or potential case, or traveling to or living in
affected area.
2. Died from a unknown acute respiratory illness after November 1st, 2002.
No pathologic autopsy; relevant act(*) was recognized within 10 days
before the symptoms
Probable Case
1. When the suspected case have findings of ARDS or pneumonia on chest
radiograph
2. When the suspected case are positive in more than one SARS examination
or are diagnosed RDS by autopsy and no other cause
Exception：When the illness is fully explained by other
diagnosis
WHO (Ver.3), May 2003
Consequence of Suspected case and Probable Case
of SARS in Japan
(May 19 - July 15, 2003)
• Suspected case: 52
• Probable case: 16
All cases were negative of SARS reported by
the Special Committee of SARS
Reported 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 response in
Kobe University Hospital
March 18：Start SARS response planning at the Infection Control Division according
to the Notice of MHW
March 19：Discussion at the Committee of Infection Control in Kobe University
Hospital
March 24：Delivery “SARS Response Manual(Ver.1)” to the staff in hospital
April
7：Information of SARS Response Manual available on the web site of Kobe
University Hospital
April 17：The 1st Practice of simulation for SARS response
April 22： The First team meeting for response to the SARS patients
May
6：The second team meeting for response to the SARS patients (Revised
“SARS Response Manual”)
May
7：Emergency meeting for SARS to the all hospital staff
May 21：Second revised “SARS Response Manual”
May 27：Attending the meeting for SARS response information in Kobe city
June 10：The third team meeting for response to the SARS patients
June 17,19： The 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 Cooperation
* Dispatching medical doctors to affected countries and
cooperating on researches in diagnosis and treatments.
WHO speculates SARS affects
little in this winter（reasons as below／in
SARS Update no. 89: June 26）
• Firstly, today’s international public heath care system is able to
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shift to the higher level of alert immediately
Secondly, medical specialists in the world know what should they
do to control infectious disease, as there is a long history of
infection control.
Thirdly, it is expected to develop the rapid and reliable diagnostic
examination on SARS, which can be adopted at the beginning of
treatment.
Fourthly, enforcement of discretion on mass epidemics was
decided at the WHO general meeting in May.
Lastly, SARS epidemics show that it is important to release the
case of any disease immediately, which has the possibility of
spreading out around the world.
Problem of Prevention from SARS
Epidemics in Japan
1. Deep understanding of information
・Information system offering by TV, Radio and etc.
・Common ownership of scientific and objective information
2. Improvement of detective methods for SARS patients
・High detailed investigation for person contacted to SARS
・ Common ownership on investigative methods for outbreak of
SARS
3. Establishment of In-Hospital infection control system
・key point; success of in-hospital infection control
4. Flexibility of early detective system
・early detection of aged patients without fever and severe
symptoms
5. Cooperation of implementation for international
discretion
Conclusion
• Fortunately we did not have any SARS patients in
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Japan, it is necessary to build up a cooperation
system among Asian Pacific countries, including
exchanging information, in order to prevent the
potential SARS epidemics toward this winter.
Furthermore, concerning risk management of our
country, there are some future issues, such as to
ensure out-of-hours service at each section in the
government, in the local governments, and in public
health care centers, and to build up a transportation
system for the patients.