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Posted on: Thursday, April 24, 2003

SARS spread fuels global fear

 •  Graphic (opens in new window): The spread of SARS: A worldwide problem

By Steve Sternberg
USA Today

China has fired two Communist Party leaders, closed schools in Beijing and lowered its Great Wall of Silence. Hong Kong's medical system is verging on collapse. Health officials have warned people to avoid China, Hong Kong, Singapore, Vietnam and Toronto — all as a result of SARS.

People in Beijing worry about getting SARS as they wait to buy train tickets. Many are leaving the city as SARS spreads.

Associated Press

Only 39 probable cases have been diagnosed in the United States, all but two of them in travelers returning from Asia, but worried health officials have adopted stringent precautions to prevent a runaway severe acute respiratory syndrome epidemic from taking place here. Will their efforts work?

The most optimistic U.S. experts say the early action by public health authorities may contain the virus before it becomes lethal here. But others warn that if SARS is not contained, it could cause millions of deaths worldwide, and some of those would almost certainly occur in the United States.

Because SARS is caused by a newly discovered virus, no one can predict with certainty just how bad it will be. But the epidemic has proven so tough to contain, has traveled so rapidly to so many countries, and has inflicted such a major blow to the world economy that health experts are reacting as if SARS is the big one.

"It would be foolish not to think that this is going to be a serious threat," said Julie Gerberding, director of the Centers for Disease Control and Prevention.

In terms of sheer numbers, the SARS epidemic so far pales in comparison to other worldwide epidemics. The Spanish flu epidemic of 1918-1919 killed roughly 30 million people, including about 675,000 Americans. Over the past 20 years, the slow-motion funeral march of AIDS has killed 20 million people, with 40 million more likely to die in the next decade.

Yet SARS is just beginning. The death toll could rise dramatically, especially if the disease expands more in the developing world, where medical care is scarce. And, while the Spanish flu traveled the world via steamship, SARS is jet-propelled and moving so quickly — especially in China — that some experts believe that it may prove impossible to contain.

Has it reached that tipping point? It is too soon to say, said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. But Fauci said that, in its extreme virulence, SARS can outdo ordinary flu, which kills about 36,000 each year in the United States and an unknown number abroad.

"How many families do you know in the world in which someone gets the flu, comes home, dies from it and then has two family members die from it?" Fauci said. "How many times have you seen someone come into the hospital with bad influenza, infect 20 health workers and kill two or three of them?"

SARS, of course, has done exactly that, killing several members of some families and proving particularly deadly to the doctors and nurses who care for those who suffer from the illness.

No cure, no certain test

Epidemic update

• 4,442 cases and 259 related deaths.

• Thousands of people mobbed a Beijing railroad terminal in attempt to flee the city as China's capital reported a triple-digit increase in SARS infections.

• The World Health Organization recommended against travel to Beijing and Shanxi province, an indication the U.N. health body has concluded that China is not controlling the spread of SARS.

• WHO added Toronto to the list of places that should be avoided for travel.

• Schools were closed in Beijing, sending more than 1.7 million students home.

• Taiwan shut Taipei's Ho Ping Hospital, quarantining 1,000 employees and family members, after seven workers caught SARS, possibly from a patient.

• Major league baseball players visiting Toronto will be told to avoid crowds, hospitals and public transportation. And if they want to sign autographs, they ought to use their own pens.

The disease is caused by a newly discovered coronavirus, a member of a large virus family that is notorious among experts for causing about 30 percent of colds. The virus causes a type of pneumonia that inflames the lungs, causing them to swell. There's still no cure or widely available test for SARS, though experimental tests are in the works.

In its most severe form, SARS sends about 15 percent of patients into intensive care, where they are put on respirators because they can't breathe. About 150 of Hong Kong's 450 intensive care beds are now filled with SARS patients, displacing other patients needing intensive care. Hong Kong health officials warn of a health-system collapse if the epidemic doesn't subside because they'll run short of respirators, as well as room to isolate sick SARS patients and the health workers to care for them. Health workers account for about 30 percent of probable SARS cases.

Like the flu and AIDS viruses, the SARS virus is believed to have leaped from animals to man, though the new coronavirus bears little resemblance to relatives that infect animals. Some germs that make the species-to-species leap don't immediately adapt well enough to humans to spread from person to person. But SARS can be exceptionally transmissible in humans. For instance, the first known patient in Hanoi, Johnny Chen, 48, infected 26 of the health workers who cared for him before he died.

Elizabeth Fee of the National Library of Medicine, said SARS — though still far more limited than flu — conjures up disturbing echoes of the 1918 epidemic. While writing an article on that epidemic, Fee said, "I found a picture of an army camp where soldiers had been watching a movie. You look out at this sea of soldiers and they were all wearing masks.

"Masks were compulsory for the military," she said. "There were great debates at the time whether masks should be made mandatory for civilians. At the time, I thought it was rather amusing. It's not amusing at all anymore. It's all too close to what is happening now."

Although public health officials estimate about 5 percent of those infected by SARS will die, no one knows the death rate for sure, health officials say, because they can't yet test all the people with SARS-like symptoms to find out exactly how many are infected.

Nils Daulaire, president of the Global Health Council, said SARS could dwarf the flu if it keeps spreading. Even if the death rate were one in 50, he said, rather than one in 20, a SARS epidemic that affects half the world's population could kill 60 million people.

"What I hope will be the case," Daulaire said, "is that the very aggressive approach taken by international health authorities to seek out and contain the epidemic, wherever it is starting to emerge, by locking it in a room so it will burn itself out without threatening larger populations."

That's why the World Health Organization took the unprecedented step on March 12 of issuing a global alert. Three days later, alarmed by cases in Canada, the CDC sounded its own alarm, briefing state health officials on the epidemic and warning doctors about the frightening pneumonia-like illness. Anyone hospitalized with probable SARS is placed in isolation; people who don't need hospitalization have been asked to stay home for 10 days to reduce the likelihood that they'll infect others.

Record progress

A woman in India suspected of having SARS is kept in isolation.

Associated Press

Since the global alert, researchers worldwide have made record progress: They've mapped the geographic distribution of the disease, identified the cause, figured out how it's transmitted, issued recommendations for preventing further spread, isolated the virus and figured out how to grow it in a laboratory dish, reproduced SARS in monkeys, sequenced the virus' genome and produced two experimental tests that, so far, appear to be accurate.

"An awful lot has happened quickly," said James Hughes, director of CDC's National Center for Infectious Diseases.

Yet, despite the rapid pace of scientific progress, public health experts are forced to fight a 21st-century pandemic with tools developed hundreds of years ago.

Quarantine dates to 1423, when Venice began confining sailors aboard ships at anchor for 40 days to safeguard the city from plague.

Another tactic now critical to the SARS-control effort — handing out printed health alerts to airline passengers arriving from Singapore, Vietnam, Hong Kong, China and Toronto — stems from the 19th-century fight against cholera and yellow fever. Britain, a maritime nation dependent on global trade, found quarantine disruptive to trade and developed an alternative. Rather than quarantining ships, British authorities notified ships' crews that they might be carrying illness and began identifying and monitoring people who appeared to be ill.

A modern version of the British approach is under way worldwide. Since the global alert, health workers in airports and sea ports have distributed 500,000 alerts to passengers arriving from SARS hotspots, advising them that they may have been exposed to the disease and to visit a doctor if they experience symptoms. The health alert also advises doctors to notify local health officials they have identified a suspected SARS case.

Such actions become less critical once researchers develop a reliable test, Hughes said, because health workers would then be able to identify people who are infected and isolate them, a standard safeguard to protect the uninfected.

A threat everywhere

Japan is installing imaging systems at airports to detect feverish passengers as they arrive.

Associated Press

As long as SARS continues spreading anywhere, said Dau-laire, of the Global Health Council, it remains a threat everywhere. The outbreaks in Hong Kong and Toronto, for instance, were traced to one infected person entering the city and infecting others.

WHO spokesman Dick Thompson put it this way: "One case brought down Hong Kong. One case brought down Toronto. One case is a big number."

The seeds of the Hong Kong outbreak were sown by Liu Jianlun, 64, a kidney specialist from Zhongshan University in China's Guangdong province. Liu had checked into room 911 at Hong Kong's Hotel Metropole, across the hall from Johnny Chen, the Chinese-American patient evacuated from Hanoi.

Chen apparently didn't infect Liu, who was feeling ill when he arrived. Liu would later warn his doctors and nurses at Hong Kong's Princess Margaret Hospital to isolate him because he had been treating patients in Guangdong. On Feb. 21, Liu felt well enough to sightsee with his brother-in-law. It turned out to be a fatal outing. Liu died March 4, his brother-in-law soon after, and the Princess Margaret outbreak had begun.

On Feb. 21, Kwan Siu-chu, 78, of Toronto was also staying on the ninth floor of the Metropole. After returning to Toronto three days later, she infected five family members, including her son. Kwan died March 5, her son on March 13.

By March 25, the chain of transmission that had begun with Kwan extended to 14 workers at Toronto's Scarborough Grace Hospital, which soon closed.

Also staying in the Metropole were two young women from Singapore, one of them a flight attendant who infected 100 others with the SARS virus. One of the earliest cases in southern China, health officials say, infected roughly the same number. WHO investigators have begun referring to him as "the walking biological weapon."

A woman at Toronto's airport is wary of SARS.

Associated Press

SARS' potential for explosive spread is why WHO has focused so intently on the world's largest outbreak in China, where SARS got its start. China's failure to deal with SARS aggressively at the outset — by failing to report the outbreak for four months — enabled the disease to slip undetected into Vietnam and Singapore and Hong Kong, and from there to go global.

In the past few days, a cover-up in Beijing cost Mayor Meng Xuenong and Health Minister Zhang Wenkang their jobs. Their lack of an adequate response has cost not just lives in China, but more importantly in the long run the faith of the city's residents.

"We are coming to realize that we don't really know what is going on and the government is not credible," said Xiao Feng, 20, a Beijing University mathematics student. "We are scared because we do not know what the truth is or how to ever know what the truth is."

More than 480 cases have been identified in Beijing, with citywide surveillance just getting started. Cases have also been reported in Shanghai and in poor, rural western provinces, where the public health system is in collapse, said Henk Bekedam, head of the WHO's China team.

The good news, Bekedam said, is that the government has ordered all 29 Chinese provinces to make SARS a top priority. It is paying for a program to train 2,500 health workers, to bolster efforts to diagnose cases and trace others that may have been exposed.

"I think (the government) knows what the challenge is," Bekedam said, adding that Chinese officials are concerned about SARS' effect on trade, tourism and economic development.

Even with improved focus, researchers are left with questions about what the future of SARS is.

"We're still in the early evolutionary stages of this epidemic," Fauci said. "It would be folly to try to accurately predict whether this is going to evolve into a big-time flu-like epidemic, or something less than that. We just have to try to contain it as best we can."