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Epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in Hong Kong
Open accessAbstract
Background Health authorities worldwide, especially in the Asia Pacific region, are seeking effective public-health interventions in the continuing epidemic of severe acute respiratory syndrome (SARS). We assessed the epidemiology of SARS in Hong Kong.Methods We included 1425 cases reported up to April 28, 2003. An integrated database was constructed from several sources containing information on epidemiological, demographic, and clinical variables. We estimated the key epidemiological distributions: infection to onset, onset to admission, admission to death, and admission to discharge. We measured associations between the estimated case fatality rate and patients' age and the time from onset to admission.Findings After the initial phase of exponential growth, the rate of confirmed cases fell to less than 20 per day by April 28. Public-health interventions included encouragement to report to hospital rapidly after the onset of clinical symptoms, contact tracing for confirmed and suspected cases, and quarantining, monitoring, and restricting the travel of contacts. The mean incubation period of the disease is estimated to be 6.4 days (95% CI 5.2-7.7). The mean time from onset of clinical symptoms to admission to hospital varied between 3 and 5 days, with longer times earlier in the epidemic. The estimated case fatality rate was 13.2% (9.8-16.8) for patients younger than 60 years and 43.3% (35.2-52.4) for patients aged 60 years or older assuming a parametric gamma distribution. A non-parametric method yielded estimates of 6.8% (4.0-9.6) and 55.0% (45.3-64.7), respectively. Case clusters have played an important part in the course of the epidemic.Interpretation Patients' age was strongly associated with outcome. The time between onset of symptoms and admission to hospital did not alter outcome, but shorter intervals will be important to the wider population by restricting the infectious period before patients are placed in quarantine.
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“However, there were substantial variations among studies, with no clear indication of what factors might drive such heterogeneity (appendix 1 pp 58, 65), except that the delay reduced over time because of improved population awareness.75”
From Severe acute respiratory syndrome (SARS) mathematical models and disease parameters: a systematic review (2025) · cites this paper as [75]
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Coronavirus as a possible cause of severe acute respiratory syndrome
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Zhang, J. (2003) · World Journal of Gastroenterology · doi:10.3748/wjg.v9.i6.1135 · Cited by 20
A Survey on Contact Tracing: The Latest Advancements and Challenges
Jiang, T., Zhang, Y., Zhang, M., Yu, T., Chen, Y., Lu, C., Zhang, J., Li, Z., Gao, J., & Zhou, S. (2022) · ACM Transactions on Spatial Algorithms and Systems · doi:10.1145/3494529 · Cited by 19
“According to the mode of transmission, infectious diseases can be broadly divided into the following four categories [5]:”
BackgroundTemporal evolution, most influential studies and sleeping beauties of the coronavirus literature
Haghani, M., & Varamini, P. (2021) · Scientometrics · doi:10.1007/s11192-021-04036-4 · Cited by 20
Tse, M. Y. M., Pun, S. P. Y., & Benzie, I. F. F. (2003) · Geriatric Nursing · doi:10.1016/s0197-4572(03)00251-9 · Cited by 20
Hsu, S., & Hsieh, Y. (2005) · SIAM Journal on Applied Mathematics · doi:10.1137/040615547 · Cited by 20
“[32] that the maximum likelihood estimate for the mean time from exposure to onset of symptoms is 6.”
BackgroundSARS epidemical forecast research in mathematical model
Ding, G. (2004) · Chinese Science Bulletin · doi:10.1360/04we0073 · Cited by 20
“Tuen developed the model of SEIRP from SIR, and made use of some SARS data of each locality to estimate the parameters [10] .”
MethodValidation of a novel severe acute respiratory syndrome scoring system
Su, C.-P., Chiang, W., Huei‐Ming, M., Chen, S., Hsu, C.-Y., Ko, P. C., Tsai, K., Fan, C., Shih, F., Chen, S., et al. (2004) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2003.10.042 · Cited by 20
“7, [15] [16] [17] The causes of the differences in the reported incidence of upper respiratory symptoms remained unclear but might be contributed to the different virus strains.”
BackgroundRisk of 2019 novel coronavirus importations throughout China prior to the Wuhan quarantinePreprint
Du, Z., Wang, L., Cauchemez, S., Xu, X.-K., Wang, X., Cowling, B. J., & Ancel, L. W. (2020) · medRxiv · doi:10.1101/2020.01.28.20019299 · Cited by 20
“Our assumption of a 10-day lag is based on early estimates for the incubation period of COVID-19 (8) and prior estimates of the lag between symptom onset and detection for SARS (10) .”
InfluentialChang, S. T., Tchitchek, N., Ghosh, D., Benecke, A., & Katze, M. G. (2011) · BMC Systems Biology · doi:10.1186/1752-0509-5-202 · Cited by 19
“In 2003 SARS-coronavirus (CoV) appeared in Asia and then spread globally, causing greater than 40% mortality in individuals over 60 years of age [1].”
BackgroundSevere Acute Respiratory Syndrome
Ramsay, S., & Gomersoll, C. D. (2003) · Journal of the Intensive Care Society · doi:10.1177/175114370300400205 · Cited by 19
On the Treatment of Airline Travelers in Mathematical Models
Johansson, M. A., Arana-Vizcarrondo, N., Biggerstaff, B. J., Staples, J. E., Gallagher, N., & Marano, N. (2011) · PLoS ONE · doi:10.1371/journal.pone.0022151 · Cited by 19
“For models of the directly transmitted pathogen, the rates of effective contact, time to progression to the infectious compartment, and time to recovery are based on previous studies [23, 24] .”
SARS-CoV-2 spillover transmission due to recombination event
Shahhosseini, N., Wong, G., Kobinger, G., & Chinikar, S. (2021) · Gene Reports · doi:10.1016/j.genrep.2021.101045 · Cited by 20
Clinical Characteristics of SARS-CoV-2 Infections Involving 325 Hospitalized Patients outside WuhanPreprint
Li, Q., Ling, Y., Zhang, J., Li, W., Zhang, X., Jin, Y., Li, L., Fu, Q., Huang, Y., Lu, H., et al. (2020) · doi:10.21203/rs.3.rs-18699/v1 · Cited by 19
Kwok, K. O., Davoudi, B., Riley, S., & Pourbohloul, B. (2015) · PLoS ONE · doi:10.1371/journal.pone.0137959 · Cited by 18
“Studies have suggested that many infectious diseases exhibit heterogeneity in transmission efficiency in certain individuals (for example “super-spreaders” in SARS (2003)), or in specific groups of individuals that appear to account for most of the transmission (such as school age children in H1N1 influenza A (2009))…”
BackgroundSelf-citationWilder‐Smith, A. (2006) · Elsevier eBooks · doi:10.1016/b978-0-08-044666-0.50012-9 · Cited by 18
“SARS was transmitted primarily, but not exclusively, in healthcare settings, generally 5 or more days after the onset of disease and from patients who were severely ill (Donnelly et al., 2003).”
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Epidemiological Analysis of the Coronavirus Disease Outbreak with Random Effects
Farman, M. T., Ahmad, A., Akg黮, A., Saleem, M. U., Naeem, M., & Bǎleanu, D. (2021) · Computers, materials & continua/Computers, materials & continua (Print) · doi:10.32604/cmc.2021.014006 · Cited by 18
Chan, T. Y., Miu, D. K. Y., Tsui, C. K., Yee, K. S., & Chan, M. (2004) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2004.52362.x · Cited by 18
“3 Because there were few late deaths, the current study demonstrated that SARS is an acute illness with high immediate mortality in the elderly population.”
BackgroundModeling the invasion and spread of contagious diseases in heterogeneous populations
Getz, W. M., Lloyd‐Smith, J. O., Cross, P. C., Bar‐David, S., Johnson, P., Porco, T. C., & Sánchez, M. (2006) · DIMACS series in discrete mathematics and theoretical computer science · doi:10.1090/dimacs/071/06 · Cited by 18
“This result is consistent with field reports from SARS-afflicted regions [48, 66] indicating that infectiousness is highly overdispersed, but contrasts sharply with many published SARS models that do not take heterogeneity into account (reviewed in [8] and [28]).”
Clinical Prognostic Rules for Severe Acute Respiratory Syndrome in Low- and High-Resource Settings
Cowling, B. J., Muller, M. P., Wong, I. O. L., Ho, L., Lo, S., Tsang, T., Lam, T. H., Louie, M., & Leung, G. M. (2006) · Archives of Internal Medicine · doi:10.1001/archinte.166.14.1505 · Cited by 17
Self-citationJiang, B., You, X., Li, K., Li, T., Zhou, X., & Tan, L. (2020) · IEEE Access · doi:10.1109/access.2020.3033997 · Cited by 18
López, V., Chan, K. S., & Wong, Y. C. (2003) · International Journal of Nursing Studies · doi:10.1016/s0020-7489(03)00137-8 · Cited by 17
“Only one individual is required to start the outbreak and the rapid intercontinental spread was related to travel of unsuspected, asymptomatic individuals who have had contact with a person with SARS (Donnelly et al., 2003).”
Self-citation
Metadata
- Authors
- Donnelly, C. A., Ghani, A. C., Leung, G. M., Hedley, A. J., Fraser, C., Riley, S., Abu-Raddad, L. J., Ho, L.-M., Thach, T.-Q., Chau, P., Chan, K.-P., Lam, T.-H., Tse, L.-Y., Tsang, T., Liu, S.-H., Kong, J. H., Lau, E. M., Ferguson, N. M., & Anderson, R. M.
- Affiliations
- Imperial College London (GB)
- University of Hong Kong (HK)
- Department of Health (CN)
- Hospital Authority (HK)
- Chinese University of Hong Kong (HK)
- ORCID
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2003-05
- Volume
- 361
- Issue
- 9371
- Pages
- 1761-1766
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC7112380
- OpenAlex
- W1990049863
- Cited by
- 940
- References
- 3
- Citations by year
- 2026: 5 · 2025: 8 · 2024: 15 · 2023: 18 · 2022: 39 · 2021: 93 · 2020: 154 · 2019: 18 · 2018: 5 · 2017: 10 · 2016: 15 · 2015: 17 · 2014: 15 · 2013: 20 · 2012: 9
- FWCI
- 71.19
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Lancet (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- The HKU Scholars Hub (University of Hong Kong) (submittedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (submittedVersion)
- Funders
- Howard Hughes Medical Institute
- Wellcome Trust
- Royal Society
- Medical Research Council
- Topics
- Health Sciences › Medicine › Infectious Diseases › SARS-CoV-2 and COVID-19 Research
- Health Sciences › Medicine › Infectious Diseases › Viral Infections and Outbreaks Research
- Physical Sciences › Mathematics › Modeling and Simulation › COVID-19 epidemiological studies
- Keywords
- SARS, Hong Kong SARS outbreak, incubation period, case fatality rate, age and mortality, contact tracing, quarantine, public health interventions, case clusters, infectious period
- MeSH terms
- Adolescent, Adult, Aged, Child, Child, Preschool, Disease Outbreaks, Female, Hong Kong, Humans, Infant, Male, Middle Aged, Quarantine, Incidence, Survival Rate, Likelihood Functions, Age Distribution, Disease Progression, Severe Acute Respiratory Syndrome
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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