The Good, the Bad and the Ugly: a review of SARS Lab Escapes


1. The Good: Singapore P3 — Sep 2003

1.1 The Accident:

  • The first time, he went in with the technician, wearing only street clothes, and did not engage in any work.
  • The second time, staff of the EHI were meeting. Before going to that staff meeting, the virology technician had grown up a stock of the New York isolate and centrifuged the supernatant from infected cells. The technician had then placed the centrifuge tubes in the Class II biological safety cabinet for the student to ampoule as a seed stock for his research. Accordingly the student put on a gown and two sets of gloves before entering the laboratory alone, where he spent 20 minutes unsupervised, transferring the cell supernatant into pre-labelled cryovials under the Class II biosafety hood. [s.6]
  • The third time he re-entered the lab with the technician who was back from her meeting and transferred the cryovials to a –70°C freezer located in the BSL-2 facility, as no such freezer existed inside the BSL-3 laboratory, so that all frozen BSL-3 virus strains were effectively stored in the BSL-2 freezer.

1.2 The Investigation:

1.3 Structural Issues:

1.4 The Aftermath:

2. The Bad: Taiwan Military P4 — December 2003

2. 1 The Accident:

IPMR entrance
Example of a mobile Class III BSC (Biosafety Cabinet) — suitable for a BSL-4

2.2 Fear of Losing face and bringing shame:

2.3 Reaction from the Authorities

Lieutenant Colonel Chan leaving hospital

2.4 WHO enquiry and international cooperation:

2.5 Lessons to be learnt:

Post Scriptum (Jan 2022):

LTC Chan / Jan Jia-Tsrong from his CV (left) and news reports at the time (right)

3. The Ugly: Beijing P3 — February to April 2004

3.1 Setting the wrong expectations:

Article from the 19th Dec 2003

3.2 Flagship role of the CDC Institute of Virology:

Main entrance of the Institute, 100 Yingxin Street — 2020
Side alleys — source: Baidu
5-storey building of the Institute where the leak happened, source: Baidu

3.3 An academic ego got hurt

Academician Hong Tao, 72 at the time
  • Nanfang Hospital (Guangzhou) had found virus particles in lung tissue samples of SARS patients through electron microscopy as early as February 20, but their research was forced to stop after the “ban” issued at the meeting of the 17–18 March [b200]
  • Researchers from the Chinese Academy of Military Medical Sciences (Beijing) also discovered virus particles in samples on February 26, which were identified as a coronavirus after being reviewed by 6 virus morphologists. On March 21, the Military Medical College reported to the relevant departments the discovery of the coronavirus. However, the findings were not officially announced until April 9. [b200, b103]
Academician Zhong Nanshan, 66 at the time

3.4 Fighting back with more P3s doing SARS research

3.5 Lab contamination — Feb 2004

‘There are two more infected people’ — Caijing, May 2004 [b.1]

3.6 Community Transmission — Apr 2004

3.7 The Response of the Authorities

Staff of the Chinese Center for Disease Control and Prevention closing the gate of the Institute of Virology, preparing for terminal disinfection , 100 Yingxin Street [b.3]
100 Yingxin Street, Source: WHO [t.21]

3.8 Summary of cases:

Extract from Investigation Report — note that there were 2 additional Feb cases (11 in total) [b.57]

3.9 The Official Investigation

a. Brief role of the WHO and missing February cases

Source: WHO [b520]

b. The Official Conclusions

Summary of the 9 cases starting from Song [b.7]
Official conclusions 2 Jul 2004, [b58]

Investigative journalists add important elements

3.10 The omissions

a. No full report published

b. February inspection of the Institute

c. The cause of the contamination

3.11 The sanctions:

3.12 All is well that ends well:

Wang Jianwei
Dong Xiaoping
Report of the WHO-China Joint Mission on Coronavirus Disease 2019–16–24 Feb 2020
Li Liming
Novel Coronavirus Wuhan Strain 01 (IVDC China’s CDC)

3.13 Déjà vu:

4. Conclusion: Lessons from SARS Lab-Escapes

4.1 Importance of people and processes:

4.2 Importance of Laboratory location:

Box: Can lab processes ever be fool-proof?

  • Adding more rules for those handling pathogens won’t help if the people infected are usually not the ones handling the pathogens (i.e: indirect infections via contamination of the lab surfaces, via aerosols or via wastes).
  • Adding more federal and international regulations won’t help if the regulations aren’t consistently followed.
  • If there are still unrecognized technical flaws in the standards for biocontainment, how would we know until an incident made those flaws apparent?
  • Limiting the work on enhanced pathogens (reducing the R0)
  • Positioning labs in sparsely populated environments and far away from transport hubs
  • Possibly implement practical quarantines in labs

4.3 Importance of Institutional Factors:

  1. Government (central and local) transparency
  2. Central government willingness to learn from mistakes
  3. Free press that can contribute to transparency

In particular we note that:

  • The answer in Singapore was very strong on (1) and (2), much less on (3) where the press did not add any material knowledge.
  • The answer in Taiwan was very strong on (2), a bit less on (1) most likely due to the military setting (a P3 lab with a military P4 lab), and rather strong on (3) [interestingly mainland China media reports also added some important details].
  • The answer in Beijing was very poor on (1) and (2) but rather good on (3), as investigative journalism provided essential details without which we would have only the most limited understanding of the exact circumstances of the leaks, since neither the WHO or Beijing released any report.

4.4 Adapting Case Definitions to include potential Laboratory Exposure:

  1. close contact with a person who is a suspect or probable case of SARS;
  2. history of travel, to an area with recent local transmission of SARS;
  3. residing in an area with recent local transmission of SARS.

4.5 Managing the risk of a new biotechnology age:






Official sources:

Official conclusions:

Chinese Blog entries:

Additional Sources:

On the chlamydia controversy

On nepotism:




Opinions, analyses and views expressed are purely mine and should not in any way be characterised as representing any institution.

Love podcasts or audiobooks? Learn on the go with our new app.

Get the Medium app

A button that says 'Download on the App Store', and if clicked it will lead you to the iOS App store
A button that says 'Get it on, Google Play', and if clicked it will lead you to the Google Play store
Gilles Demaneuf

Gilles Demaneuf

Opinions, analyses and views expressed are purely mine and should not in any way be characterised as representing any institution.

More from Medium


A bowl of mole

A Modest Proposal For Preventing the Children of Sinners From Being a Burthen to Their Parents or…

USWNT Achieves Equal Pay for Equal Work | Trusaic