SARS: Difference between revisions

WHO SARS report through 15-Apr-2003
Country	Cases	Deaths	Recover
Brazil	2	0	0
Canada	100	13	27
China	1418	64	1088
Hong Kong	1232	56	243
Taiwan	23	0	7
France	5	0	1
Germany	6	0	4
Indonesia	1	0	0
Italy	3	0	2
Japan	1	0	0
Kuwait	1	0	0
Malaysia	4	1	0
Philippines	1	0	1
Ireland	1	0	1
Romania	1	0	1
Singapore	162	13	85
South Africa	1	0	0
Spain	1	0	0
Switzerland	1	0	1
Thailand	8	2	5
UK	6	0	3
USA (+)	193	0	?
Vietnam	63	5	46
Total	3235	154	1515
(+) Due to reporting differences, US figures reflect suspected instead of probable cases.

Severe Acute Respiratory Syndrome (SARS) is an atypical pneumonia that first appeared in November 2002 in Guangdong Province, China. It spread to neighboring Hong Kong and Vietnam in late February 2003, and then to other countries via air and land travel of infected persons. To date the illness has, on global average, caused death in 3% to 4% of known cases.

The mortality rate varies across countries, which can partially be explained with reporting differences. It should also be noted that this rate does not take into account that some of those who are currently infected and have not recovered yet will probably die. On the other hand, there may be SARS infections without noticeable symptoms, which would lower the mortality rate.

Outbreak in China

The virus appears to have originated in Guangdong province in November 2002, and although taking actions to control the epidemic, China failed to inform the WHO of the outbreak until Februrary 2002 and restricted coverage of the epidemic. Mainland Chinese authorities' initial efforts to cover up the SARS outbreak in the country have been blamed for delaying moves to prevent the global spread of the pneumonia-like illness. [1] China has officially apologized for early slowness in dealing with the SARS epidemic [2] and in early April, there appeared to be a change in official policy in which SARS was given much greater prominence in the official media.

Spread to other countries

On March 12, 2003, the WHO issued a global alert, followed by a health alert by the United States Centers for Disease Control and Prevention (CDC).

As of 15 April 2003 the World Health Organization (WHO) recognizes 3235 reported cases and 154 fatalities. The WHO reports that local transmission of SARS is taking place in Toronto, Singapore, Hanoi, Taiwan, and the Chinese regions of Guangdong, Hong Kong, and Shanxi. In Hong Kong the first batch of affected people were discharged from the hospital on March 29, 2003.

The Atlanta-based Centers for Disease Control (CDC) announced in early April their belief that a strain of coronavirus, possibly a strain never seen before in humans, is the infectious agent responsible for the spread of SARS. [3] Disease transmission is not well understood at this time. It is suspected to spread via inhalation of droplets expelled by an infected person when coughing or sneezing, or possibly via contact with secretions on objects. Health authorities are also investigating the possibility that it may be airborne, which would increase the potential contagiousness of the disease.

Symptoms and treatment

WHO recommends that suspected cases be treated in isolation, and defined a suspected case as a person presenting after February 1, 2003 with history of:

• high fever of >38° C (100.4° F) -and-
• one or more respiratory symptoms including cough, shortness of breath, difficulty breathing; signs of hypoxia; or a confirmed diagnosis of pneumonia -and-
• one or more of the following:
  • close contact with a person suspected of having SARS -or-
  • recent history of travel to areas with documented transmission of SARS

A probable case is defined as a suspected case with the additional findings of pneumonia or respiratory distress syndrome by chest x-ray or autopsy.

In addition to fever and respiratory symptoms, SARS may be associated with other symptoms including headache, muscular stiffness, loss of appetite, malaise, confusion, rash, and diarrhea. The count of white blood cells and platelets is often low. Symptoms usually appear 2-7 days (in rare cases up to 10 days) after infection. In about 10-20% of the cases, symptoms are so severe that patients have to be put on a ventilator.

Antibiotics are ineffective. The antiviral drugs ribavirin or oseltamivir may have some efficacy, and the role of steroids in treatment remains to be determined. The CDC is testing antiviral drugs against coronaviruses to see if specific recommendations can be formulated.

Current state of etiologic knowledge of SARS

The etiology of SARS is still being explored. On April 7, 2003, WHO announced that it was generally agreed that a newly identified coronavirus is the major causative agent of SARS, and that the significance of a human metapneumovirus (hMPV) in SARS remains unclear and would continue to be studied. [4]

Initially, electron microscopic examination in Hong Kong and Germany found viral particles with structures suggesting paramyxovirus in respiratory secretions of SARS patients; subsequently, in Canada, electron microscopic examination found viral particles with structures suggestive of metapneumovirus (a subtype of paramyxovirus) in respiratory secretions. Chinese researchers also reported that a chlamydia-like disease may be behind SARS. The Pasteur Institute in Paris identified coronavirus in samples taken from six patients. The CDC, however, noted viral particles in affected tissue (finding a virus in tissue rather than secretions suggests that it is actually pathogenic rather than an incidental finding). On electron microscopy, these tissue viral inclusions resembled coronaviruses, and comparison of viral genetic material obtained by PCR with existing genetic libraries suggested that the virus was a previously unrecognized coronavirus. Sequencing of the virus genome is ongoing. A test was developed for antibodies to the virus, and it was found that patients did indeed develop such antibodies over the course of the disease, which is very suggestive that the virus does have a causative role. It is generally agreed that this coronavirus has a causative role in SARS: continued study is underway to test the hypothesis that co-infection with other organisms such as human metapneumovirus may also play a role.

An article published in The Lancet identifies a coronavirus as the probable causative agent.

It is now believed that the virus has crossed the species barrier from birds.

Mapping the genetic code of viruses linked to SARS

On April 12, 2003, scientists working around the clock at the Michael Smith Genome Sciences Centre in Vancouver, British Columbia finished mapping the genetic sequence of a coronavirus believed to be linked to SARS. The team was lead by Dr. Marco Marra and worked in collaboration with the British Columbia Centre for Disease Control and the National Microbiology Laboratory in Winnipeg, Manitoba, using samples from infected patients in Toronto. The map, hailed by WHO as an important step forward in fighting SARS, is being shared with scientists worldwide via the GSC website, here: http://www.bcgsc.ca/bioinfo/SARS/ .

Dr. Donald Low of Mount Sinai Hospital in Toronto described the discovery as having been made with "unprecedented speed." [5]

Progress of the outbreak

See Progress of the SARS outbreak for full details.

On November 16, 2002 an outbreak of what is believed to be the same disease began in the Guangdong province of China, which borders on Hong Kong. The first case of infection was speculated to be a farmer in Foshan County. China notified WHO about this outbreak on February 10, reporting 305 cases including 5 deaths; it was later reported that the outbreak in Guangdong had peaked in mid-February, but that appears to be false, as later 806 infections and 34 deaths were reported.

Early in the epidemic China discouraged its press from reporting on SARS and lagged in reporting the situation to the World Health Organization, delaying the initial report. Initially, it did not provide information for Chinese provinces other than Guangdong, the province where the disease is believed to have originated. This resulted in international criticism which seemed to have caused a change in government policy in early April. The Chinese Health Minister has apologized for early delays in reporting and has been holding regular press conferences. The Chinese government appears to have issued directives that the press should not refrain from stating bad news and that government officials should accept media supervision.

On February 21, a Chinese doctor who had treated cases in Guangdong checked into the Hong Kong hotel Metropole and infected up to twelve other guests there. He was admitted to the Hong Kong Prince of Wales Hospital and died on March 4. A large number of hospital workers were infected while treating him. About 80% of the Hong Kong cases have been traced back to this doctor.

In late February, the American businessman Johnny Chen who lived in Shanghai travelled via Hong Kong, where he stayed in the Metropole Hotel, to Hanoi, Vietnam. There he fell ill and was admitted to the Vietnam France Hospital on February 26. After the disease was transmitted to a number of hospital workers there, he was returned to Hong Kong where he died on March 14. WHO doctor Carlo Urbani, who was based in Hanoi, noticed the outbreak among hospital workers there and first identified SARS. He later died of the disease on March 29.

Almost all of those infected to date have been either medical staff or family members of people who have fallen ill. It is believed that all affected medical staff were not using respiratory precautions, a safety protocol that should fully protect medical workers, at the time of exposure. The various cases around the world are directly or indirectly traceable to people who have recently visited Asia.

On April 2, Chinese medical officials began reporting the status of the SARS outbreak. China's southern Guangdong province reported 361 new infections and 9 new deaths, increasing the total China figures previously reported at end-February. The virus was also detected in Beijing and Shanghai. The WHO also advised travelers to avoid Hong Kong and Guangdong during a press briefing. [6]
A Hong Kong boy was also arrested for spreading rumors on the Internet that Hong Kong was being declared an infected area.

On April 3, a WHO team of international scientists landed in Guangzhou from Beijing to discuss with officials but has yet to inspect any suspected origin or any medical facilities on progress of infection control. 15 of the quarantined Amoy Garden residents at Lei Yue Mun Holiday Camp have been relocated to the Sai Kung Outdoor Recreation Centre after an overnight protest on washroom sharing. The first medical worker infected with SARS died in Hong Kong. The doctor was survived by a daughter and his infected wife who is also among the quarantined medical workers under intensive care. Hong Kong school closure was extended by two weeks to April 21.

On April 8, Hong Kong health officials warned that SARS had spread so far domestically and abroad that it was here to stay. Nevertheless, WHO officials remained cautiously optimistic that the disease could still be contained. [7]

On April 10, Dr. Jim Hughes, the head of infectious disease at the CDC, confirming the warnings of Hong Kong health officials, claimed that he believed that SARS could no longer be eradicated in the Far East. However, he remained hopeful that it could be prevented from spreading widely in North America. [8]

Action to try to control SARS

WHO set up a network for doctors and researchers dealing with SARS, consisting of a secure web site to study chest x-rays and a teleconference.

Attempts are being made to control further SARS infection through the use of quarantine. Over 1200 are under quarantine in Hong Kong, while in Singapore and Taiwan, 977 and 1147 are quarantined respectively. Canada also put thousands of people under quarantine. [9] In Singapore, schools were closed for 10 days and in Hong Kong they are closed until April 21 to contain the spread of SARS. [10]

On March 27, 2003, the WHO recommended the screening of airline passengers for the symptoms of SARS. [11]

Political and economic reaction to SARS

On March 30, the International Ice Hockey Federation canceled the 2003 IIHF Women's World Championship tournament which was to take place in Beijing.

(unknown date sometime between March 25 and April 1), an Asian commerce conference was postponed to an undetermined date in autumn.

On April 1, an European airline lays off a batch of employees owing to drop of travellers by the September 11 and SARS.

Severe customer drop of Chinese cuisine restaurants in Guangdong, Hong Kong and Chinatowns in North America, 90% decrease in some cases. Business has recovered considerably in some cities after promotion campaigns.

Hong Kong merchants withdrew from an international jewellery and timepiece exhibition at Zurich. Switzerland officials enforced the 1000 Hong Kong participants of full body check that would be finished 2 days before the end of exhibition. The Swiss Ambassador to Hong Kong replied that such body check would guard against spread via close contact. A merchant union leader expressed probable racial discrimination towards Chinese merchants as the exhibition committee allows the merchants participating the exhibition but not promoting their own goods. Estimated several hundred million HK dollars of contracts were lost as a result.

SARS and accusations of racial discrimination

Some members of some Chinese ethnic communities in some Canadian cities have expressed concern that SARS might lead or has led to racial discrimination and stereotyping. The media in the US and Canada has reported on this topic extensively, although there is no evidence so far of a major racial backlash, or in fact of any at all. Ming Tat Cheung, president of the Toronto's Chinese Cultural Center, said Chinese and non-Chinese shoppers were staying away from the city's normally bustling Chinatowns, and sales were down by up to 70 percent. No indication was given as to what percentage of shoppers are normally Chinese, thus it is impossible to confirm the accusation. A columnist in the Toronto National Post, Christie Blatchford, who lives in Toronto's central Chinatown, noted that shoppers in her neighbourhood were predominantly Asian, so that a reduction in trade on the order of 70% is difficult to attribute to racist actions by non-Asians. Ming Tat Cheung also claimed that non-Asians had addressed SARS-related racial slurs to Chinese.

Some of the excitement in the media began after a provincial cabinet minister coughed during a media scrum and reporters made jokes, accusing him of trying to give them SARS. The minister continued replied "I enjoyed my trip to Asia." Indignant reaction to this remark came chiefly from Opposition politicians; a provincial election is expected soon in Ontario.

Reports of SARS-related racist slurs directed at Chineses have appeared in the Toronto and Canadian press, but they have been few and unattested (including those alleged by Ming Tat Cheung). Although the claims are plausible and may well be true, they probably if true demonstrate only that racists will take advantage of any opportunity to be racist rather than that the SARS outbreak has created racism. There has so far been no evidence of any racial effects above the level of personal insult.

Stereotyping in Canada seems to be of possible carriers rather than of racial groups. An article in the London, Ontario Free Press on April 13, 2003 described the shunning of a white family in a small Western Ontario town because the mother and one of her daughters had recently visited Singapore.

Canadian health officials have made a statement, saying that "even though the origin of SARS is in the Far East, it is very much something that is affecting everybody. For (hostility) to be directed toward the Asian community is obviously very disturbing." The Canadian prime minister and other notables, in Toronto on April 10 for the funeral of the retired Catholic archbishop of Toronto, made a point of inviting the press to a lunch they held at a Chinese restaurant.

Political effects of SARS

Some members of Hong Kong Legislative Council recommended editing the budget for increased spending on medical services.

External links and references

Mainstream News

• China in damage control over SARS - April 11, 2003 from CNN Beijing Bureau
• SARS in Singapore - Updated frequently by ChannelNewsAsia

Official Announcements

• Official SARS information from the United States Center for Disease Control
• Official SARS information from the Hong Kong Department of Health
• Official SARS information from the Canadian Ministry of Health
• Official SARS information from the Taiwan Center for Disease Control
• Official SARS information from the World Health Organization

Medical journal articles

• J S M Peiris et. al. Coronavirus as a possible cause of severe acute respiratory syndrome. The Lancet, Volume 361, Number 9364, 5 April 2003. Available online at http://image.thelancet.com/extras/03art3477web.pdf

Medical Mailing Lists

• EMED-L mailing list - contains "breaking news" discussion of SARS
• CCM-L mailing list - contains "breaking news" discussion of SARS