Introduction of SARS in France, March-April, 2003 - SARS Epidemiology

Emerging Infectious Diseases, Feb, 2004 by Jean-Claude Desenclos, Sylvie van der Werf, Isabelle Bonmarin, Daniel Levy-Bruhl, Yazdan Yazdanpanah, Bruno Hoen, Julien Emmanuelli, Olivier Lesens, Michel Dupon, Francois Natali, Christian Michelet, Jacques Reynes, Benoit Guery, Christine Larsen, Caroline Semaille, Yves Mouton, Daniel Christmann, Michel Andre, Nicolas Escriou, Anna Burguiere, Jean-Claude Manuguerra, Bruno Coignard, Agnes Lepoutre, Christine Meffre, Dounia Bitar, Benedicte Decludt, Isabelle Capek, Denise Antona, Didier Che, Magid Herida, Andrea Infuso, Christine Saura, Gilles Brucker, Bruno Hubert, Dominique LeGoff, Suzanne Scheidegger

Results

As of April 30, a total of 394 suspected cases had been notified to the Institut de Veille Sanitaire and 5 (1.3%) met the definition of a probable case of SARS. Four were men, and their ages were 26 to 56 years. All had fever >38[degrees]C, four with nonproductive cough and two with dyspnea. None had diarrhea. Chest x-rays showed interstitial pneumonia in four patients (bilateral for three) and alveolar consolidation in one. Lymphocyte counts were 170 to 1,400/[mm.sup.3]. Four patients were lymphopenic (

RT-PCR was positive for SARS-CoV in at least three of the respiratory secretion samples taken on at least 2 different days after onset of symptoms for three of the five patients. Acute-phase and convalescent-phase serum samples were obtained for four of the probable cases, and seroconversion to SARS-CoV occurred in three samples, including samples from the patient for whom RT-PCR was negative (patient D, Figure 1). However, for patient D, the only respiratory samples available for RT-PCR were taken on day 2 after onset.

[FIGURE 1 OMITTED]

Our subsequent analysis is restricted to the four confirmed cases (patient A to D, Figure 1). All four cases were related to the outbreak that occurred in the French Hospital in Hanoi, Vietnam (2). The index patient (patient A), who had worked in this hospital, was the most probable source of secondary transmission to the other three patients. On the basis of information obtained from his colleagues, on March 16 and 17, he was known to have examined, without respiratory protection from droplet secretions, an ill physician in whom SARS subsequently developed. Although no precise date of onset is available for patient A, interviews with persons he had met in Hanoi during the few days before his departure indicate that symptoms, such as cough and severe fatigue, had developed as early as March 20.

From March 26 to April 1, three secondary cases occurred (Figure 1), with incubation periods of 3, 4, and 10 days. Two cases occurred among the 371 passengers (166 boarded in Hanoi of whom 5 left in Bangkok, and 205 boarded in Bangkok) and 30 flight attendants of the Air France Hanoi-Bangkok-Paris flight of March 22-23. The last case (patient D) was the manager of the hotel where patient A stayed in Hanoi. He became ill on April 1, a total of 3 days after returning to Vietnam on March 29 through another flight. He had had close contact with patient A on March 22 while greeting and giving him his mail before departure (Figure 1). No other exposure to cases of probable SARS or places where transmission of SARS had occurred in Hanoi could be documented for patient D within 10 days of symptom onset.

Seven persons sat within two rows of patient A during the AF 171 flight (Figure 2), two of whom were medical doctors and did not know him. They indicated that patient A was breathing rapidly (superficial polypnea) and exhibited extreme pallor and pursed lips during the entire flight. He remained calm, had no cough, and left his seat at least twice between Bangkok and Paris to go to the front lavatory; at each move, he passed through the space between the plane wall and seat 25K (Figure 2). During the stopover in Bangkok, he disembarked with the passengers on the flight from Hanoi to Bangkok and then reboarded the plane before the passengers who embarked in Bangkok. On landing at Charles de Gaulle (CDG) Paris Airport, be disembarked among the last passengers (about 20 passengers left the plane after him) and was cared for by the CDG medical services along with two other physicians who had worked in the French Hospital in Hanoi and were on the same plane.