"It is time to close
the book on infectious diseases", US Surgeon General William H.
Stewart announced in 1969. "The war against pestilence is over".
Viruses vs. Superbugs
Thomas HÄUSLER
The Severe Acute Respiratory Syndrome, 2003
The information
provided is "as is" and uncorrected, except for typographical or
grammatical errors, as discovered by readers over time. Obsolete links
are progressively removed. As of 2019 the majority of links had to be
deleted, in particular those corresponding to information coming from
China.
It was put on the World-Wide Web as the
situation was understood at the time.
29 august 2003. Fourteen United Nations and
Chinese experts visited farms and markets in Guangdong province
in quest for an animal carrier of the SARS virus. As reported in
Beijing by the veterinarian François Moutou (president of the French
Association for the study and protection of Mammals), it is extremely
surprizing to have recovered SARS-like virus from such a broad range
of animals, from snakes and birds to mammals. One can remember that,
in addition to the hypothesis of infection of a civet cat, snakes
were proposed very early on to have been at the origin of the
virus. Outbreaks of legionellosis continue to develop in France, while
a patient who had travelled on a cruise to Greenland died from the
disease when returning to his home land in Germany.
24 august 2003. After the recent heat wave
two outbreaks of Leptospirosis affect the east and south west of
France. This revives the interest for Leptospira interrogans,
a plague of rice paddies in China.
21 august 2003. A bitter debate affects
medical and political authorities in France while the funeral
undertakers declared 10,000 more deaths than the previous year. Deaths
were usually caused by hyperthermy, not by microbial infections. This
triggers a Europe-wide investigation to compare the situation in other
countries affected by the same heat wave.
5 august 2003. An epidemic of Legionellosis
affects the region of Montpellier in France. 25 persons have been
infected.
25 july 2003. The SARS outbreak is
terminating, with a record death toll in Hong Kong (299 deaths,
more than 17% of the cases). A large cholera outbreak is developing in
Liberia where civil war prevents proper control of the disease. In
Mainland China analysis of the situation demonstrates that Chinese
scientists had discovered the coronavirus cause of SARS well before it
was found at the CDC in Atlanta and in Hong Kong. The old confucean
tradition prevented these scientists to voice out their discovery.
This particular cultural feature is triggering a lively discussion in
China.
10 july 2003. Philippe
Desprès, Jean-Louis Virelizier and Fernando Arenzana at the Institut
Pasteur have just discovered in vitro the nature of a receptor
on the cell surface that allows the dengue virus to enter its host and
start this often deadly disease. This has of course to be
substantiated by in vivo studies. If the discovery holds it will open
the door for medication preventing, or at least controlling the dengue
infection after humans are bitten by carrier mosquitoes, Aedes
aegypti.
8 july 2003. Within the frame of eradication
of poliomyelitis a thorough campaign of vaccination was launched
in Madagascar. No cases were found since 1997, until, during a survey
between october 2001 and april 2002 five new cases were detected.
Surprisingly, a study developed at the Institut Pasteur de Madagascar
with the Institut Pasteur has demonstrated that these cases are
mutants of the vaccine strain (which is a live vaccine). This shows
that the campaign of eradication of the disease will be more difficult
than expected.
7 july 2003. While the WHO removed Taiwan
from its list of areas with local transmission of SARS two
suspect cases have been found in GuangDong awaiting confirmation.
There are no left chain of transmission left, but one should still be
extremely cautious, since the diagnostic of the disease is still
difficult. Also, its origin is not well understood yet, although a
general consensus is that it originated from an animal (presumably
feline) host. If this were the case adaptation to man would have
required several steps, and it is not unlikely that a parent disease,
causing only very mild symptoms, is still present. This might be a
reservoir for a resurgence of the disease when the weather cools down
in autumn. Meanwhile a team of scientists from the Institut Pasteur is
working with authorities in Algeria and the WHO Global Alert and
Response Network, to investigate the recent outbreak of plague, that
caused 10 infections and one fatality, and control its vectors. In
Hong Kong the hot and humid season makes it now important to monitor
the possible come back of dengue fever.
29 june 2003. The World Health Organisation,
as medical authorities world-wide, are investigating the impact
of atypical pneumonia on the local health systems and the response
they should propose in case the disease (or a similar one) appears
again. Extreme variations in the number of fatalities in different
places is a remarkable puzzle that is being actively investigated. The
disease also triggered reflection at the Pugwash workshop “Science,
Ethic and Society” (Paris, 27-29 June 2003). The Pugwash
Movement is well-known for the role it has played in promoting
recognition of the social responsability of scientists in the domain
of arms control and involvement of scientists in violence. At the
present time it is of interest to investigate the various reactions of
scientific institutions which often, for the pure sake of fashion or
short-term considerations, lost the view of what should have been
their strategic (i.e. long term) choices. The
origin of the SARS virus is not yet certain, and the disease — which
is as expected very sensitive to heat because the virus is much less
stable at temperatures higher than 30°C — may appear again when the
wether cools down in autumn. However its most severe behaviour was due
to person-to-person contamination, and we can reasonably hope that,
when cooler days will return no human case will still exist. The
disease may then have disappeared from the Earth, at least for some
time. It is therefore urgent to remember that, among the causes of the
havoc were poor hygiene measures (especially in hospitals), and, above
all, lack of pre-existing research on the virus. We know some of our
future diseases (and flu is one of them: H5N1 in Asia, and H7N7 in
Europe, for example, as well as dengue fever in South East Asia), but
we do not know most of them. The family of the Human
Immunodeficiency Virus was not considered as interesting before the
scourge of AIDS appeared, and not many scientists were interested in
Coronaviruses. This means that we need
urgently basic academic research on all kinds of microbes, on their
vectors and on microbial systems that may put them under control, if
we wish to be ready for the next epidemic. Will this lesson of SARS
be understood?
25 june 2003. Beijing's population went
to celebrate in the street the end of the WHO warning over travel to
the city because of SARS.
22 june 2003. On
june 18th an eleven years old child died of plague in Oran
(Algeria) where several cases have been diagnosed. He was affected as
well as several members of his family since the beginning of the
month. This indicates endemy of this disease, in a country that
witnessed the large outbreak fifty years ago, made famous by the novel
of Albert Camus, The Plague.
19 june 2003. 100 days elapsed since the WHO
warning on SARS was published. Although SARS is clearly coming
under control, the need for continued vigilance is now greater than
ever. The chain of person to person transmission everywhere is not yet
totally interrupted and, as demonstrated recently in Toronto the
disease may suddenly reappear when it was thought to have been. As
stated by WHO at a recent conference there is a need for at least a
full year of surveillance to determine whether the disease has
established endemicity and to ensure that no cases have spread,
undetected, to countries with poor surveillance and reporting systems.
After a peak of the number of cases at the beginning of May the
disease rapidly went under control, most probably because of the
efficiency of means that have been implemented in the regions at risk.
It is most important that these measures remain in effect.
16 june 2003. The World Health Organization
advice against travel to Tianjin, Hebei, Shanxi and Inner
Mongolia was lifted late Friday while SARS is now rapidly receding in
Mainland China. For unknown reasons, the epidemic is still not
contained in Canada and in Taiwan, although the situation is
improving.
12 june 2003. As atypical pneumonia recedes
world-wide, and in particular in China (no new case and no new
fatality in Hong Kong), the consequences of the disease on human
habits begin to be visible. In Mainland China, in particular, this
will help the government to implement a strong policy against spitting
(a notoriously difficult task, especially in the poor parts of Western
China). This will also inevitably have consequences on the dining
habits in this country. Chinese use to share dishes, a very friendly
social practice, but which may have a significant impact in terms of
diseases spreading. The government is starting a reflection in this
domain, which will have immense consequences if the western style
dining portions is becoming the rule.
9 june 2003. The distribution of atypical
pneumonia is becoming somewhat erratic. More questions arise
about the possible treatments for the disease as the death toll in
Canada reaches 32 persons. The Chinese government warns that, because
it is not possible to control totally the movements of person in their
huge country, some new cases may appear here and there. While the
total number of cases, and of deaths is very small as compared to the
situation with other diseases such as tuberculosis, malaria, or AIDS
(and even typical pneumonia), the particular feature of SARS is its
remarkable contagiosity, which forces authorities to implement
stringent confinement measures around patients. If no action had been
taken it is clear that the level of contamination in the world would
have been much higher.
5 june 2003. As a sign of hope, for the
second time there is no new SARS case in Hong Kong during the
past 24 hours. The experience in Toronto, where more than 70 new cases
have been reported since 26 May 2003, underscores the risk of a
resurgence of cases and reminds us that a single imported case can
reignite an outbreak. The WHO reminds us that this is a matter of
concern for the future if all cases have not disappeared during the
summer.
2 june 2003. As the discrepancies between
SARS infections at various places in the world increase the
disease remains more and more of a puzzle. Some of the data might
reflect inaccurate reporting, but that does not seem to explain
everything. In fact several reports from the Mainland suggest that
many people are immunologically seropositive for the virus but did not
show symptoms. Asymptomatic diseases are very frequent, but this would
hardly fit with places where up to 50% of the local people got
infected (this was the unfortunate situation at the Block E of the
Amoy Gardens Estate). One alternative explanation, that we proposed
several weeks ago, is that a double
epidemic might reconcile these observations: a first outbreak of
a mild disease (probably derived from some animal) would have escaped
attention (it might have been the gastro-enteritis witnessed since the
end of 2002 in Guangdong and in Hong Kong), and a mutant virus,
derived from this first one would have acquired a tropism for the
respiratory tract. This would have caused SARS. Those people who had
been infected with the first disease would have been protected, while
the other ones would have the full blown syndrome. This would account
for seropositivity in otherwise healthy people. We are in urgent need
of a highly sensitive and reproducible test for monitoring the
immunological status of the whole population in the regions of
interest.
31 may 2003. SARS remains a nosocomial
infection as there are three new confirmed cases in Hong Kong
who are healthcare workers of North District Hospital. Another sad
news is that the number of deaths almost reached the 16% figure in the
city. Fortunately, if figures can be believed, there was only a single
new case in the Mainland. Singapore is removed from the list of areas
with recent local transmission of SARS. The change in status comes 20
days after the last locally acquired case was placed in isolation, on
11 May 2003. In Taiwan the disease recedes, but on may 30th Canada was
affected again, since the suspected cases recently discovered have
been identified as SARS cases.
28 may 2003. With less than 8,500 cases as
the total number of SARS patients world-wide, one can be
confident that the disease is now under control.
One should not let one's guard down however because the disease can
reappear where it was thought to have been eradicated. In addition we
need to prepare for a possible surge when the weather will cool down
in autumn. Much will have to be learnt about protective and proper
hygiene measures in hospitals since the disease can be classified as a
nosocomial infection. In addition handling and eating wild-life
animals will have to be severely controlled. The Chinese governement
is considering new measures in this domain.
27 may 2003. After an alert was sent on may
23d, Toronto is back on the list of places with recent local
transmission of SARS, while a new cluster is discovered. Taiwan is now
the place where the disease is spreading the fastest.
24 may 2003. The SARS epidemic is being
under control in Hong Kong, with no new cases and only 9
suspected cases left. The local death toll is unfortunately above the
15% figure. The situation allowed the WHO to remove Hong Kong from the
list of places that should be avoided by occasional travellers. The
situation in Taiwan is unfortunately growing worse as the number of
new patients is steadily on the increase despite severe control
measures at the entry of the region. The number of new patients in the
Mainland is stable, probably on the decrease. The origin of the virus
might be cat since teams investigating the presence of coronaviruses
in Guangdong discovered that these viruses were ubiquitously present
in animals, cats included, prepared on the local markets for food.
Except in Taiwan the disease seems to be receding fairly rapidly. In
addition to confinment and control measures implemented, this may be
due to the warming up of the climate in this season. It will be
extremely important to monitor the situation when the weather
will cool down, next autumn.
20 may 2003. SARS in the Mainland
may have escaped attention for some time, as a WHO expert team
returning from Guangxi province found that 2 separate clusters of SARS
cases, dating from December 2002 and January 2003, had recently been
detected by local health officials following a review of hospital
records. Figures seem to be on the decrease everywhere in the
Mainland, but the speed of the decrease is probably too fast to
reflect reality. On the encouraging side, only four new patients were
identified in Hong Kong, where the number of persons still in hospital
went below the 250 figure.
18 may 2003. While Singapore was
about to be declared free of SARS a new case, who became ill on may
11th, was discovered, showing that one should not be confident too
early that the fight against SARS is won. For unknown reasons the
situation seems to be getting worse in Taiwan, while in Mainland China
and in Hong Kong the number of new patients seems to be steadily
decreasing. At the first global consultation on SARS epidemiology,
held at WHO headquarters in Geneva from 16 to 17 May, experts declared
that the overall case fatality ratio is 14% to 15% but with wide
variations in case fatality related to age, sex, the presence of other
diseases, and treatment protocols.
16 may 2003. The cause of SARS as a
Coronavirus is proven, as described in "Koch's postulates fulfilled
for SARS virus. Ron A. M. Fouchier, Thijs Kuiken, Martin Schutten,
Geert Van Amerongen, Gerard J. J. Van Doornum, Bernadette G. Van Den
Hoogen, Malik Peiris, Wilina Lim, Klaus Stohr & Albert D. M. E.
Osterhaus. Nature 423:240 (2003). It is important to identify as fast
as possible patients who carry the virus. At the date of May 8th, on
average the time needed for identification was still about 4 days, too
long to stop the spread of the disease. If this figure can be lowered
to 2 days, the epidemic will rapidly be totally under control.
Misdiagnostic, especially of the milder forms of SARS is a matter of
much concern, since this might lead to relaxing the confinement of
patients who are still contagious. More than 600 deaths have been
attributed to SARS world-wide, a high figure for a new disease. In
Hong Kong the death toll reached 14%, menacing to be soon the highest
recorded death toll for the disease. There is hope that the fight
against the disease will succeed as the number of new cases in Beijing
and Mainland China seems to be steadily dropping down, suggesting that
the methods used to contained the epidemic are effective. It is
interesting to have a view of the official position of the Chinese
government on the origin, tracing, and management of the epidemic.
13 may 2003. The total number of
known SARS patients world-wide has passed the 7,500 figure. Sadly, the
death toll passed the 13% figure among patients in Hong Kong. In an
exemplary move to control the disease, contact tracing has established
epidemiological links for the vast majority of Hong Kong’s patients.
Around 9% of SARS patients have no identifiable exposure source.
Detailed investigation is ongoing to understand the transmission
routes. Figures of new SARS cases in the Mainland are much smaller
than the day before, but this may be due to the way patients are
identified (one witnesses strong oscillations in the daily number of
new patients in China). Japan has banned import of poultry from China
after it discovered the H5N1 flu virus in an imported duck.
11 may 2003. Steady state on the
SARS front, with one case in a new country, Finland. The death toll
keeps increasing in Hong Kong while the disease recedes (less that 10
suspected cases remain). The Chinese government has formed forums for
students abroad, aiming at collecting as much helpful information as
possible to fight the disease immediately and in the future. A
fruitful students meeting was held in Paris on may 10th. Contradictory
reports analyse the sequence of the virus, and suggest that some
mutations may have occured during cultivation in laboratories while
others are directly due to the selective pressure of the immune system
of the hosts. It is very important that sequences are accurate and are
obtained totally independently from each other to begin to get a
pedigree of the virus and follow its trail. Features specific to the
isolate started from the patient that spread the disease from an hotel
in Kowloon are now characterized.
9 may 2003. The possibility for a
success of the fight agains SARS is illustrated in Vietnam where no
cases have been detected for several weeks, and where the death toll
remained lower than 8%. One likely case in Eastern Russia, after the
disease reached Inner Mongolia, then Mongolia, triggers a new concern
for expansion of the disease. Awareness, however, allows authorities
to stop the creation of an outbreak. The number of confirmed cases in
Beijing dropped sharply (48 cases), while in Guangdong it persists
oscillating between 5 and 20 per day. The decrease in Hong Kong is
confirmed. In order to improve efficiency of treatment it is
absolutely essential that governments totally forbid that companies
pay medical doctors for enticing them to use the drugs they produce by
whatever means they try to use.
7 may 2003. An attempt to use serum
of recovering SARS patients to lower the viral load and cure patients
has apparently meeting success. If this is subtantiated by further
studies this is extremely good news, since this suggests that a
vaccine will be possible. This also particularly important at a time
when the number of deaths passed 12% in Hong Kong, indicating that
existing treatments did not work as well as promised. The situation in
Mainland China remains stationary. One positive outcome of this
epidemic is the reflection triggered in the domain of control of water
quality, pollution, and management of both domestic animals and wild
life. The suspected cases in France are very unlikely to be SARS, in
line with the lack of an outbreak in the Nanjing region.
6 may 2003. Two suspected cases of
SARS have been detected in France, from persons coming after a stay in
Nanjing. Awareness of the existence of SARS may begin to have a
positive effect in Mainland China, where the number of new cases in
Beijing (more than 16,000 persons are quarantined) experience a
significant downturn (70 new cases). 2 cases have been diagnosed in
Shanghai, and during the past couple of days the number of new cases
rose again in Hong Kong (this is not statistically significant,
however), unfortunately with a high death toll. The most surprising
observation remains the high number of medical staff infected despite
stringent hygiene control measures.
4 may 2003. Shanghai, which is
still almost rid of SARS has adopted a series of desinfection measures
in transportation, and control measures for travellers. While SARS
remains constant in China but recedes in Hong Kong, it is time to put
the disease in perspective. Many other epidemics are affecting
countries in the world at the same time. In particular, as almost
every year, meningitis is killing thousands in Burkina Faso. A
different type of concern exists in developed countries: a Legionella
case in a factory in the centre of France shows that hot water
systems, as well as air conditioning are ready to spread dangerous
infectious diseases. The particular danger posed by SARS is its
contagiosity which forces affected countries to set up extremely tough
controls on travels and drastic quarantine measures, resulting in
catastrophic negative economic consequences. Any relaxing measure
would immediately result in the spread of the disease. This should be
a lesson for the future and trigger appropriate support for research
on infectious diseases: the cost of research is very small when
compared to the huge losses encountered when the diseases spread.
3 may 2003. Steady state SARS
infection level in Mainland China, 114 new cases in Beijing, and 10
new cases in Hong Kong (where unfortunately the death toll increased
by 9 persons). In Taiwan the cumulated number of cases passed 100,
while the disease seems to be vanishing in Canada and in Singapore. It
is important at this point not only to take this epidemic seriously —
and appropriate quarantine measures, coupled to monitoring travellers
at many major places in China, are certainly efficient — but to be
aware of other diseases that may have similar, or even worse,
consequences. This is the case of most diseases affecting our
livestocks, and in particular of bird's flu, which has two pending
virulent forms, one in Europe (H7N7) and one
in China (H5N1). We are at the mercy of reassortments of the genomes
coupled to mutations, that would allow transmission of the disease not
only from birds to humans, but from humans to humans. Lessons should
be learnt from the scientists and veterinarians dealing with the
spread of those diseases.
2 may 2003. Almost 13,000 people
are now quarantined in Beijing. In an un precedented effort the
municipality of Beijing put together a work force of 7,000 to build up
a 1,000 beds temporary hospital with a number of special facilities
for treating SARS patients. The number of new cases was today lower
than 100. In Hong Kong 11 new cases were detected while the number of
patients dying from SARS has now passed the 10% figure. Shanghai is
enforcing strict SARS preventative measures, including a 14-day
quarantine period for travellers arriving from affected areas. Traffic
checkpoints have been set up where travellers are given temperature
checks and asked to fill out health declaration forms. After Viet Nam,
the UK and the USA have been removed from the list of areas with
recent local SARS transmission. In both countries, the last instance
of local transmission occurred more than 20 days ago. Tianjin, China
and Ulaanbaatar City, Mongolia, were added to the list. A new country
(Poland) is affected by SARS (1 case). The cases in India have been
discarded as SARS cases by the WHO.
1 may 2003. The number of SARS
cases reached today 1,600 in Hong Kong (fortunately with "only" 11 new
cases), while more than 180 were diagnosed with the disease in the
Mainland (122 in Beijing). 19 cases appeared to have been identified
in India, while the South Korean case might be due to a different type
of pneumonia. Drastic measures of quarantine are now implemented in
Beijing where the authorities organise the local life for quarantined
people.
30 april 2003. More than 100 new
SARS cases identified in Beijing, while Shanghai remains practically
immune and a low level of new cases in Guangdong persists. The
situation in Shanxi is a matter of concern because the number of new
cases seems to be on the rise. In Hong Kong the number of new cases
remains constant now for a few days. Also, in Beijing it appears that
some cases of mass contamination resembling the Amoy Gardens event is
occurring. This might be the case at a dormitory in Northern Jiatong
University. In contrast it seems remarkable, as published by a team at
the Chinese University in Hong Kong, that children get a much milder
form of the disease. It is time to look back at the situation of SARS
in the world. The disease seems to be contained outside Eastern Asia,
and officials from 12 countries met yesterday in Bangkok to set up
rules for controlling health of travellers between their countries. We
are facing a situation similar to that faced when the first acts of
terrorism affected airplanes: appropriate facilities will probably
have to be set up on a stable basis to monitor health parameters of
travellers world-wide. The situation of
SARS is at a turning point: a number of 5,000 affected people at the
end of this month was thought to indicate the turning point where it
might go out of control. Since we are just at this border, we still
have hope, and the next figure of concern would be 10,000 by the end
of may. A feature of great concern is the vast interest shown by
companies for the possible royalties that might come out for the
disease, triggering a dangerous competition between countries,
hospitals and universities, at a time when collaboration is urgently
needed (and remarkably well set up by the World Health Organisation).
28 april 2003. The news are mixed
today: for one week the number of new cases in Hong Kong kept
decreasing, raising hope that the measures implemented are effective
and that SARS will be contained within one month. Unfortunately deaths
of patients previously recruited was still high, rising the local
death toll to almost 9%. However the local situation is certainly less
serious than what is generally perceived in the absence of explicit
information. People should not lower their guard however since a single
case started the present world-wide outbreak. In Beijing the
number of new patients is of the order of 100 per day, indicating a
serious situation in the capital. The World Health Organisation
however says that, learning from the situation elsewhere in the world,
we still can hope that the disease will be contained. authorities in
Beijing are implementing extremely stringent measures and a general
cleaning program to prevent further spread of the disease. Patients
are discovered throughout the Mainland suggesting that several causes
contribute to the outbreak here or there.
27 april 2003. Beijing is now
severely affected by SARS, and all public places such a cinemas or
theaters have been closed for the time being. The People's University
has also closed because SARS cases have been reported there. One of
the most puzzling feature of SARS is the extreme difference between
the situation in Beijing and in Shanghai (where only a few cases have
been reported) despite the strong ties between Shanghai and Guangdong
or Hong Kong. This is consistent
with the double epidemic hypothesis,
suggesting that people at some places might have been protected by a
previous infection by an innocuous or mildly virulent virus. Another
puzzle is the fact that the death toll appeared to increase at some
places as compared to others. This may also be linked to the same
hypothesis, with a variable virus segregating more virulent mutants.
If this were the case, the use of many antivirals may be dangerous
because they might enhance
the mutation rate of the virus 
,
as suggested by the rate of evolution witnessed in bacterial viruses.
The Asian health ministers approved a plan to boost screening of
possible SARS patients at international departure points, bar
travelers with SARS symptoms (fever in particular), and require health
declaration forms for visitors from affected countries. "We must use
every weapon at our disposal," the regional director of WHO, Shigeru
Omi, told the health ministers and senior officials from South East
Asia, China, Hong Kong, Japan, and South Korea. A joint symposium on
SARS was held in Hong Kong with scientific representatives of the
region.
26 april 2003. While diagnostic kits for
SARS are distributed world-wide, the WHO warns against
inaccuracies inherently associated to these kits essentially based on
the Polymerase Chain Reaction (PCR).
Sensitivity is high but the genetic material of the virus is unstable,
leading to false negatives. In contrast, once the assay has been used
for some time, the rate of false positives may increase because of
contamination of the diagnostic laboratories, unless extreme
precautions are taken. After his official visit to Beijing the French
Prime Minister stressed that panick is the worse reaction to an
epidemic. There were 154 new cases in the Mainland (113 in Beijing)
and 17 in Hong Kong. India has identified three new cases (7 in
total). No new case in Vietnam for 18 days: it is now likely that the
country will be the first one to have contained the disease, setting
an example to other countries in the world.
25 april 2003. The number of new patients
affected by SARS in Hong Kong seems to decrease slowly.
Unfortunately the rate of deaths has increased significantly in the
past few days, rising the overall death rate to 7.6%. Scientists are
collecting isolates from various places and compare them. The first
observations demonstrate that the virus is still in a rapidly evolving
phase. This is consistent both with the nature of the virus (in
general viruses, that are not real living organisms but parasites of
life, mutate at a high rate because they do not have the elaborate
"proof-reading" system present in most living organisms) and with the
hypothesis that it comes from a non human host.
24 april 2003. The epidemic has
apparently been contained in Vietnam. Figures in Mainland China,
although much more accurate than previously are still difficult to
evaluate since not all hospitals are able to tell SARS from other
diseases with similar symptoms. Some Canadian scientists cast doubt on
cause of SARS, because they do not find the suspected coronavirus in
50% of the cases, while they find it in control patients. It seems of
the utmost importance that the community reaches a consensus since
hundreds of scientists are working round the clock with the hypothesis
that the virus is the cause, and are constructing diagnostic tests,
and vaccine approaches on this hypothesis while the disease is still
progressing. However the experiments with monkeys, showing the very
symptoms of SARS, argue strongly in favour of the new coronavirus
species as being the cause. For some reason, doubts systematically
came from the same place, where some other cause might have altered
the symptoms and/or the samples.
23 april 2003. Schools will be
closed for a fortnight in Beijing. 24 cases and 6 deaths in Hong Kong.
Claims about the efficacy of treatments have to be revised because it
is extremely dangerous to extrapolate from textbook knowledge to a new
type of infection. It seems clear that symptomatic treatment, when
delivered early on might be helpful. The difficulty with any urgent
situation as the present one is that one should do controlled
experiments, ie compared the fate of many patients with, and without
treatment, and this is morally difficult, in particular when some
believe that this, or that treatment may be efficient. This is the
only way out, however.
22 april 2003. In Hong Kong a
cumulated total of 1,434 cases of SARS have been reported todate. The
public perception of the disease worsens in Beijing while the Central
government takes an entirely new and open attitude towards the
challenges posed by the disease. It is in particular extremely
difficult to be careful with a disease that only affects a minute
portion of the population, to manage its possible extension (which
could be considerable if nothing is done) while controlling the
extremely dangerous economic consequences induced by panic. Involving
the people in the fight, as done during the past few days in Hong Kong
is probably one of the best solutions. There is also an urgent need
for totally open collaboration between scientists throughout the
world, an attitude that is dramatically illustrating the negative
impact of the competition attitude induced by inappropriate
management of successful behaviour in science. Part of the
problem caused by the virus could be due not to contact through air,
but because of an unusual stability on many surfaces. This indicates
that excellent hygiene is most important at places where cases have
happened.
21 april 2003. The situation in
Mainland China is somewhat confusing, as authorities in the provinces
are trying to provide accurate figures for cases of SARS, at a moment
when they often do not have appropriate means to identify cases. In
Beijing the population begins to show its concern, after the two
political dismissals of the day before, and one observes a large
number of masks in train stations. The rumor spreads that the city
might be completely closed for travels in and out within two days. The
WHO now counts more than 4,000 cases world-wide, while the number of
new cases in Hong Kong dropped significantly, unfortunately with still
several deaths.
20 april 2003. At this date we may reach a
turning point for the spread of SARS. Countries are resorting
to drastic measures to slow down the spread of the disease. China,
using a new method to count patients affected, recognizes that the
disease has now severely reached Beijing, with more than 300 patients
officially identified. In a political move without equivalent for 25
years, the mayor of the city as well as the Minister of Health were
asked to resign from their position in the Communist Party, as a sign
that they were not able to cope with the severity of the problem. In
addition the Chinese Government has transformed the first week of May,
used normally as a nation-wide vacation, into only one day vacation,
in an attempt to prevent travels within the country. More than 1400
persons who went to an open market in Singapore where a patient was
identified are confined for 10 days quarantine. Toronto has identified
new cases that do not appear to be directly connected to previously
identified patients, rising fear that the virus might now spread by
air. The authorities are considering placing buildings, or even whole
blocks, in quarantine. In Hong Kong the disease does not seem to
recede. Lessons from the outbreak or Porcine
Respiratory CoronaVirus twenty years ago show that the virus may
even become airborne. The present virus is a totally new one, from yet
unknown origin, but it is of interest to understand how similar
viruses evolved in animal communities in the past. Several
world-reknown scientists are now involved in the fight against SARS in
Hong Kong, in particular David Ho (who devised tritherapy against
AIDS), Jeff Copland, Michael Lai and Monto Ho (who solved an
enterovirus outbreak in Taiwan several years ago).
19 april 2003. This is the worse day in Hong
Kong since the beginning of the SARS outbreak, with 12 people
passing away, while the number of new cases remains stable. Young
people coming from Hong Kong have been placed in quarantine while they
arrived from Hong Kong in UK. In a completely different context, the
viral epidemic that plagues chicken farms in Netherlands and Belgium
has made its first human victim. If this were to give rise to
person-to-person transmission of the disease, a major epidemic of
another type would be on the verge of starting. All this indicates
that we must now be ready to take major measures to control the spread
of contagious epidemics, throughout the world.
18 april 2003. The first three
cases of SARS were reported yesterday from Australia, while the
disease appeared to slacken its pace of infection in Hong Kong (1,327
cumulated cases, showing a steady state of infection at around 30
cases per day, similar to the figure before march 27th). India has
also reported its first case but the description is not entirely
consistent with SARS. At Amoy Gardens in Hong Kong, the cause of the
outbreak is identified, suggesting that it would be easy to prevent
further incidents of this type. If one takes out this episode, the
epidemic in Hong Kong has features similar to that in Guangdong
province, suggesting that it is starting to recede. However one must
still be extremely cautious because a single patient may start a
sudden outbreak, as repeatedly witnessed in the past month. The team
at the Faculty of Sciences that sequenced the virus is analyzing its
relationships with birds coronaviruses, as well as with similar
viruses in other vertebrates. At this time the cause of the disease is
consistent with the shift of an
enterogastritis virus to a respiratory form, a Human Respiratory
CoronaVirus (HCRV).
16 april 2003. In a remarkable
breakthrough involving world-wide collaboration a Dutch laboratory
demonstrates by experiments using monkeys that the new coronavirus
recently identified is the cause of SARS. In Hong Kong, the sequence
of a local isolate is completed, allowing comparison between three
different isolates. While RNA viruses are always highly variable it
will be of fundamental importance to link the severity of the disease
with variations in the genome sequence. The virus being probably of
animal origin it is certainly in a phase of adaptation to its new
hosts, humans, and this may result in particularly virulent mutants.
This also may result in attenuation: it is too early to know how the
disease will evolve, although extrapolating from the situation in
Guangdong should be seen as positive.
15 april 2003. The rise of the
number of SARS cases world-wide is worrying,
since it seems on the verge of beginning a pandemic. The cumulated
number of cases in Hong Kong is 1232. Concern comes from the
observation that, among the nine deaths recorded in 24 hours, several
come from persons under 40 years of age, with no other disease. It is
important to monitor the type of treatment used, since antivirals can
be extremely toxic. Identification of the virus is still a challenge:
a PCR test, developed by the CDC in Atlanta, has been shown to be ten
times more sensitive than previous PCR tests for SARS. WHO experts
hope that the test will be ready for distribution by the end of this
week. The sequence of the isolate of the virus at the CDC has been
completed, after a Canadian group sequenced another isolate. The virus
differs significantly from previous isolates. Scientists are
concentrating on the features of the "spikes" porteins, that are
important for penetration into target cells.
13 april 2003. The World Health
Organisation has raised several caveats about too early and misleading
enthusiasm about diagnostic tools and remedies for SARS while a team
of Canadian scientists announced that they have completed the sequence
of the viral genome. The virus has unique features that make its
origin still an enigma. It must be remembered however that the
sequence of the AIDS virus is known since 1983 and that we are not yet
rid of the disease, and also that antiviral molecules are very
dangerous and often have severe secondary effects. Collaboration,
without delay, with all relevant partners in the world is essential to
try to contain the disease, and limit its extraordinary economic
consequences already reaching some 40 billion US$. The team in Canada
benefited from an excellent organisation of a team previously working
on cancer and of the information provided through the WHO network. A
second team at the CDC in Atlanta, with the support of scientists at
the Bernhard-Nocht Institute, Hamburg as well as from Rotterdam and
San Francisco, is completing the sequence of a second strain, while
the Hamburg team is providing information to a company for
distribution of free primers meant to help hospitals in the world to
identify the virus. It is difficult to know at present whether the
disease simply spreads in a linear fashion, or begins an exponential
exploration of the available population. Reaching the number of 5,000
patients world-wide by the end of the month would be a sign suggesting
that the disease may have become out of control. The transmission
pattern still remains ununderstood, with some patients infecting a
very large number of persons, while others remain infected while
contaminating no other person. Strict quarantine measures are now
implemented in Hong Kong, and Mainland China has created an efficient
alert system that will be particularly important in the poorest parts
of the country. The cumulated number of patients in Hong Kong reached
1,150. One should also note that, because of the lack of essential
collaboration between scientists throughout the world, the cause of
SARS is still disputed... This is very unfortunate at a time when the
disease is spreading. The observation by groups in different
continents that the same coronavirus is present in patients however
substantiates the idea that it is the cause, rather than an accidental
contaminant.
11 april 2003. While it is likely
that persons living at Amoy Gardens Estate left before the quarantine
measures, the number of new cases increases more or less linearly
(1,059 cases at 1 pm) in Hong Kong. Several laboratories of the WHO
task force on SARS concentrate on the hypothesis that a new
coronavirus, never previously identified from animals or humans is the
main cause of the disease. The main problem now is to be able to trace
the routes of propagation, by identifying contacts of patients. Hong
Kong health authorities have announced that all household contacts of
confirmed SARS patients will be required to confine themselves at home
for up to 10 days with immediate effect. A similar measure will be
implemented in the Mainland as soon as a way to identify the disease
(remember that pneumonia are very frequent diseases) can be proposed.
9 april 2003. Our diseases are strongly linked
to the way our society behave. This must be taken into
account for analysis of the outbreak in Hong Kong, which reached 970
persons at 3 pm, with a still significant proportion of health care
workers. Of course, one expects that scientists involved in the fight
against the disease have a very open behaviour, widely sharing their
results to increase the probability of finding rapidly a solution to
the crisis, but is this what we are witnessing? The future will
tell...
8 april 2003. At 3 pm, the cumulated number
of patients in Hong Kong reached 928. Many hypotheses try to
account for the sudden local outbreaks, in particular it is known that
coronaviruses are not only involved in respiratory diseases, but also
in gut diseases,
suggesting that, in some cases they may survive in the gut and be
propagated by a faecal-oral route. This hypothesis stresses again the
important role of a good hand hygiene. Data are collected to explore
this route. The disease, which appeared to have been contained in
Hanoi might be reappearing elsewhere at other places in Viet Nam. One
of the present difficulties is that diagnostic tests that have been
initially proposed have been found to be somewhat problematic. The
international collaboration set up by the WHO should however be able
soon to provide a reliable test.
6 april 2003. The cause of contamination
remains elusive, while 42 new persons are infected in Hong Kong.
In Singapore the disease appears to be dying out, but there are still
new cases, while the quarantine measures are very strictly enforced.
In Mainland China, reported cases come from the whole of the country.
In Guangdong, the total number of new cases is stable at around 10-15
cases per day. The total number of cases from Hong Kong is higher, in
particular because 268 cases have been reported from the Amoy Gardens
estate. This large number of cases still remains a puzzle. In the same
way, the Singapore government is investigating the situation posed by
29 cases reported on March 29th, in the staff from two wards of the
same hospital. It seems highly improbable that a single patient would
be the cause of these almost simultaneous cases, suggesting an
environmental parameter (which may be of similar nature as that at
Amoy Gardens).
5 april 2003. In the USA, the cumulated
number of patients affected by SARS reached 115, prompting the
Federal Government to take action in terms of compulsory quarantine
measures. In Hong Kong, the number of new patients rose again, to
reach 39. Among those 10 are medical staff, 7 are persons who were
residents of Amoy Gardens. The 22 remaining patients correspond to the
steady state of the disease that appears to prevail for the last
weeks. Two major observations about SARS puzzle observers: the disease
is considerably biased towards affecting medical staff, and the
outbreak at least at one place, the Amoy Gardens estate, mimicks what
happened in hospitals with very high geographically concentrated
clusters. In contrast the background of the disease, probably in Hong
Kong as in the Guangdong province, stays more or less constant,
neither increasing, nor decreasing. This makes the course of the
disease highly unpredictable and its propagation route still very
enigmatic. Among the many hypotheses that remain to be fully explored
is the idea that two viruses, with somewhat different contamination
properties, are needed to cause the severe form of the disease. The
actual cause of the disease is not yet fully established. Health
authorities are currently investigating other cofactors such as
propagation through sewage pipes (Block E at Amoy Gardens is a 33
floors high rise building, and a large concentration of patients is in
a vertical cluster) as well as airborne through some kind of particles
coming from a neighbour construction site... The second patient in
France has probably been contaminated while travelling on the plane
from Hanoi to Paris.
4 april 2003. While the outbreak
seems to level off in Hong Kong, new cases are discovered throughout
the world. In Hong Kong at 1pm the cumulated number was 761,
indicating a constant rate of infection. In the absence of any easily
available test for identification of the disease, it is still
difficult to count the number of real cases. Most definitions come
from epidemiologic investigation and linkage with known cases, as well
as clinical signs. This is the more difficult because clinical signs
appear to vary from place to place. For example, in the USA, for some
reason the clinical signs are milder than at other places. All this
suggests that there may be co-factors to the disease, which is still
not yet understood, and/or that the virus is still evolving extremely
rapidly.
3 april 2003. At 1 pm (local time)
the cumulated number of cases in HK was 734, representing a sharp drop
in the increase of new cases in Hong Kong. While the Mainland
authorities have opened their hospitals for WHO investigation and
help, many questions arise about the origin of the disease. It has
been repeatedly stressed that SARS was originally detected in FoShan
and HeYuan county, Guangdong Province. A local newspaper however tells
that a medical professor in RenMin hospital of HeYuan county named Xie
JinKui does not agree with that assumption. Prof. Xie said the first
case in HeYuan was detected in 17th of Dec, last year (2002). The
patient is a 35 year old man. He is a cook in ShenZhen, working in a
restaurant where he has close contact with wild animals, such as
snakes (see more about this story).
Although the date does not fit with earlier descriptions of diseases
similar to SARS in Guangdong, this raises interesting questions about
the origin of the virus. In Hong Kong, if one removes the very
special case of the Amoy Gardens Estate, the outbreak is constant
since the beginning of march, not exponential. This suggests, as
initially proposed, that the disease is propagated by (almost) close
contacts only. The situation at Amoy Gardens has to be investigated in
details, since it suggests another mode of propagation, specific to
that particular place. It will be extremely important to understand
what it could be.
2 april 2003 (see also the WHO press
conference). Once the cluster of patients at Amoy Gardens reaches its
maximum, the disease seems to be contained elsewhere in Hong Kong,
suggesting that it may begin to become under control (a total of 708
cumulated cases since the begginning of the outbreak). The drastic
quarantine measures implemented by the local government seem to have
had a significant impact. However the outbreak has some unique
features that suggest that an unknown route of contagion may be
existing. It is too early to be sure that the situation is
stabilising, but the warming up of the
weather acts against viability of the virus combined with stringent
hygiene measures might have contained the disease. One should not,
however, relax a good hygienic behaviour. At this time it becomes
important to start reflection on the political, sociological and
psychological factors involved in the spreading of the disease.
Despite the lack of accurate reports from the Mainland, it appears
that, after a peak around mid-february, the outbreak did not come out
of control suggesting that some factor(s) have played an important
role, whether political, or simply sociological (the structure of
cities, buildings etc. is extremely important). The Mainland being now
a full partner of WHO, accurate knowledge of the situation will soon
be available. Patients at the French Hospital in Hanoi are under
strict control measures: on march 14, a group of 12 staffs
(specialists of intensive care, nurses, virologists) was sent to
Vietnam. Besides taking care of the patients, this staff was involved
in a vision of prevention of infection. In Hanoi, the risks of further
contamination seem to be under control: since march 25, no new case of
chain contamination has been reported. Nine persons from the medical
staff of the French Army arrived to replace the orginal staff on march
25. Identification from new cases substantiate the hypothesis of a
coronavirus as the cause. One must remember however that until
explicit link with the disease has been established one should remain
open to other hypotheses.
1 april 2003. While SARS
does not seem to recede in Hong Kong, a model of the outbreak
at Amoy Gardens Estate, constructed by mathematicians at the
University of Hong Kong, suggests that contamination follows a route
similar to that of flu. This is a matter of great concern, since flu
is highly contagious. This also suggests that the outbreak in Mainland
China might not be under control yet. If this is the case it is almost
inevitable that the disease will spread throughout the world. However
it is important to remember that Amoy Gardens Estate is a high rise
building and that spread of the disease might be due to this specific
situation.
31 march 2003. Quarantine measures are
implemented in several places in the world while the epidemic does
not seem to level off. Eighty more patients have been
identified in Hong Kong since yesterday. One block (block E) at Amoy
Gardens seems to have been most affected, and investigation is
proceeding to try to identify the nature of high contamination there.
This would certainly be a lesson for containing the disease elsewhere.
The nature of the virus that causes the disease is still under
discussion, since there has not been, as yet, an explicit correlation
with the immune response of patients who have recovered.
30 march 2003. The outbreak might be
levelling off in Hong Kong, but at a high level: sixty new cases
have been diagnosed there. A thirteenth patient passed away
while the Italian doctor who discovered the disease in Hanoi died in
Bangkok. A group of French military doctors departed for Hanoi to help
their colleagues. Including the recognized Mainland cases, one already
counts more than 1600 cases and 58 deaths.
29 march 2003. Anxiety rose in Hong Kong
while 58 new patients have been affected by SARS. 470 cases have
been identified in HK, and 86 in Singapore. The cause of the sudden
increase in the past two days is the outbreak that affected 34 new
persons at the Amoy Gardens Estate. A twelvth patient, an elderly
person, died from the disease in HK. General models describing the
progresses of similar outbreaks would predict that, if appropriate
prophylactic methods are enforced, the disease should presently level
off then go extinct. A favorable circumstance should be the weather
that is warming up, provided air conditioning is not creating a
situation that would mimick the winter time weather. It must be
stressed that identification of the virus, at this point, is mainly
useful as it substantiates the hypotheses about its mode of
transmission. As in most cases of viral diseases, implementation of
drastic preventive measures is the only efficient way to stop the
outbreak. Vaccination would also be efficient, but creation of a
vaccine takes time, and is only rewarding if the disease is supposed
to become recurrent. In fact this particular outbreak should become a
lesson for political authorities as well as medical staff, since an
outbeak of a much more contagious disease like a new form of influenza
would certainly have a much more severe impact. Fast reaction, as well
as drastic control of hygiene is a necessity.
28 march 2003. The number of affected
persons in HK jumped with 22 from a single building adding to the
steady daily flow (51 more patients enrolled on the evening of
27th). The local governement has finally resorted to measures
similar to those implemented in Singapore, restricting the movement of
more than 1,000 people. Consistent reports throughout the world
suggest that the disease is indeed caused by a coronavirus, making the
identification by Pr Peiris an important step in the fight against the
disease. Some think that a paramyxovirus could be an aggravating
factor: ''The coronavirus is the primary cause of the disease,'' said
Pr Peiris, adding that another virus, of the family that causes mumps
or measles, may also be involved and increase the severity of the
disease. Interestingly, the new strain had characteristics unlike any
other he had ever seen. In a parallel statement Pr Bernhard Fleischer,
head of Hamburg's Bernhard Nocht Institute for Tropical Medicine, said
his institute had probably identified the virus causing Severe Acute
Respiratory Syndrome. "I don't assume that there will be a worldwide
epidemic which will spread among the population," Fleischer told
Reuters in an interview. "We are lucky that this disease is not as
contagious and does not spread as easily as first assumed."
27 march 2003. While about thirty new cases
are discovered in HK, all connected to the initial patients, it
appears now clear that the epidemic of SARS in Guangdong affected
almost eight hundred people, with thirty deaths. Some indications
suggest that the disease is now spreading in Beijing and other parts
of China. Clinical symptoms are described at PROMED. The government of
Hong Kong is now considering to take measures similar to those in
Singapore, asking people who have been in contact with affected
patients to stay at home for ten days. The cause of the disease is not
yet clear, but the symptoms and propagation makes a pattern that
suggest that the world-wide outbreak started from the same origin. At
the moment it might be traced back to a patient in Foshan City
(Guangdong) who got sick on 16 Nov 2002. Patients of the initial
outbreak are now systematically recovering and, if the disease can be
contained, this will alleviate some of the extremely tense work load
at hospitals. However, in other parts of the world, such as Taiwan and
Canada, the outbreak is not yet contained. Scientists world-wide are
trying to decide what is the exact cause of the viral disease with no
compelling conclusive evidence yet. However the coronavirus
hypothesis now seems the most plausible, since tests that had
initially been negative appear now to be positive after new types of
assays. Also, as said earlier, coronaviruses being highly prone to
recombination, they have more potential to create new unknown virulent
variants.
26 march 2003. 25 new cases were added to
the list of HK people affected by SARS. An incident in a plane
carrying HK tourists to Beijing from march 15th and march 19th
examplifies the way the disease is propagated. In the world the
disease continues to spread (see Health Surveillance for airline
passengers). It may be affecting Beijing. The puzzle about the nature
of the virus continues, while the virus isolated at
HKU is better characterized. For journalists interested in the
difficulty of identifying viruses, and in the vivid
ongoing debate, here is a summary provided by scientists at PROMED.
25 march
2003. As the number of SARS cases resumed growth in
Singapore the local government decided to warn all 700 persons
who have been in contact with patients to remain at home for ten days.
The CDC in Atlanta has identified another type of virus as the
possible cause of the disease. This virus family, the
coronaviruses usually causes gastroenteritis in humans. It is also the
cause of bonchitis in birds as well as many other diseases in all
kinds of animals including humans. It is also the frequent cause
of common cold. The virus that has been
isolated at HKU is also a coronavirus. It is difficult to
reconcile the data from the previous identification of paramyxoviruses
and these new identifications. Several explanations may be proposed,
including sample contamination, multiple infection and different
outbreaks with similar symptoms. In Hong Kong the Chief Executive of
the Hospital authority was found to be affected by the disease and the
number of patients reached 260.
24 march 2003. The number of Severe Acute
Respiratory Syndrome cases kept growing steadily in Hong Kong (about
25 new cases each day, see dedicated government site, 242 cases in the
afternoon of march 23d), but the spread of the disease seems to be
contained elsewhere in the world. Schools where cases were detected in
staff or students are closed for seven days, until the incubation time
for possible new cases has elapsed. The World Health Organisation
cautions that virus identification is difficult since our respiratory
system is commonly infected by many types of more or less innocuous
viruses. The easiest to be cultivated might not be the cause of the
disease. However all identifications so far concur to the idea that
the virus is a paramyxovirus.
22 march 2003. The virus identified in the
SARS outbreak in Canada is a metapneumovirus
(6 identifications out of 8 cases), a virus from the paramyxoviruses
family, which has been discovered in 2001 and is usually the cause of
common cold-like diseases. This virus may be the common source of the
outbreak. In another effort, scientists
of the team of Pr Malik Peiris at the University of Hong Kong have
cultivated the virus that may have started the outbreak in the city
and are testing an efficient diagnostic test that detects the virus.
This would rapidly tell whether cases of pneumonia, frequent during
this period of the year are indeed SARS and prompt appropriate
precautions. It is not known however whether this is a metapneumovirus
yet. One must also have in mind that pneumonia cases are documented
with at least two
viruses infecting the same patients.
21 march
2003. The number of SARS cases rose to 165 in Hong Kong. The
history of the disease in the city is now fairly well understood. At
its origin is a medical doctor travelling from Guangdong and staying
at a Kowloon hotel, where he infected, either in the elevator or in
the elevator lobby several persons who then transmitted the disease.
One of those started the outbreak at the Prince of Wales hospital.
authorities are actively looking for all the persons who stayed at the
time of infection in the hotel. This outbreak is an illuminating
illustration of how our travelling habits are spreading diseases
throughout the world extremely rapidly. The fact that apparently no
staff of the hotel has been affected provides good hope for the
disease to be under control rapidly if appropriate hygienic behaviour
is followed. Remember that coughing and sneezing, in particular, is an
efficient route spreading the virus.
20 march 2003. The origin of the SARS in
Hong Kong has been traced back to a traveller who stayed in a hotel
in Kowloon. Apparently, no personnel at the hotel has been
affected, substantiating the reassuring observation that close contact
is needed for the disease to spread. A paramyxovirus has further been
identified as the cause in Singapore. As yet, no clear connection is
made with the epidemic of pneumonia that
spread in Guangdong province since november and seems now under
control. However, both the symptoms and the spread are so similar that
it seems likely that the cause is the same. It will be important to
identify the source, and political authorities in the Special
Administrative Region of Hong Kong and in Mainland China have agreed
to tighten their collaboration. This will be particularly important in
the future since the risk for an outbreak of a dangerous influenza
epidemic is high.
19 march 2003. A paramyxovirus has been
identified as the probable cause of Severe Acute Respiratory
Syndrome (SARS). First indication came from Frankfurt and
Marburg, and explicit identification was performed by a team from the
Prince of Wales Hospital and Chinese University of Hong Kong.
Paramyxoviruses infect vertebrates, and cause often severe outbreaks
in communities of birds. They cause outbreaks
of encephalitis in South East Asia. The common and highly
contagious measles virus belongs to this family. A
family of these viruses has a strong tendency to infect lungs.
18 march 2003. The origin of the outbreak at
the Prince of Wales Hospital has been identified. This
permitted local authorities to screen for people who have been in
contact and bring them under medical care. The result is that at the
present date almost 100 persons are under surveillance most of whom
having acquired the severe flu-like disease. The WHO >maintains its
alert until identification of the virulent pathogenic agent is
identified. For ongoing discussion on the subject see PROMED.
17 march 2003. The WHO maintains its global
alert. Forty two persons have contracted an unknown flu-like
disease with frequent pneumonia symptoms at a Hong Kong hospital. One
nurse died of a similar disease in Hanoi. Several similar cases have
been described, possibly related to South East Asia, in the world.
However it must be noted that, until now, no shared infectious agent
has yet been identified. What makes the situation complicated is that
we are at a period of the year where many flu-like, pneumonia-like
diseases prevail. Several important facts must be borne in mind to
prevent spreading of a possible new virus or bacterium, taking into
consideration the unusual fact that effective contagion seems to occur
within hospital premises.
- Strict personnel hygiene must
be enforced: one should never see medical personnel in their work
coats outside (in particular at cantines or such public places, as
often unfortunately seen); spitting on the ground should be strictly
forbidden; after visiting a patient one should wash one's hands
carefully; as much as possible, direct contact with patients should
be avoided (gloves can be used, and one should not forget, of
course, to discard them properly immediately after use).
- Air conditioning should be monitored: temperature should not be
kept too low (most microbes survive much longer at low
temperatures), and ventilation should be efficient but indirect
(remember that the nose and lungs act as air filters): filters
should be cleaned up and as much as possible sterilized.
- Water quality should be controlled: filters should be cleaned up,
and water circuits should be checked as much as possible.
At the present time several possible agents are considered (but
none has been identified as a common cause): the influenza virus
(which often causes pneumonia-like symptoms and is frequently
letal); Legionella
pneumophila (a very dangerous bacterium often
transmitted trough infection by amoeba that thrive in water cooling
systems or in the water circuit); Chlamydia
pneumoniae (a very fragile bacterium, that may be
dangerous in immunocompromized people); Rickettsia
psittaci, the cause of psittacosis. Many other causes
may exist among which viruses are usually the most difficult to
identify readily unless well known previously. Sudden
mutation of a rather innocuous virus such as syncytial
respiratory virus may even be considered. The present
observation that contagion seems highly confined to specific
premises suggest either direct physical contact (this is the case
with the Ebola virus) or some kind of transmission by water or air
fluids.
12-14 march 2003. After a concomitant spread
of a pneumonia-like flu-like disease in a private hospital in
Hanoi (Viet-Nam) and in the Prince of Wales hospital in Hong Kong, the
World Health Organization issued a global alert, waiting for
identification of the pathogenic agent involved. A patient diagnosed
in Hanoi died in another hospital in Hong Kong. Recommendations are
similar to those issued during the previous outbreaks, for which no
clear pathogenic agent has been identified. Contagion appears to have
remained restricted to the medical personnel who was in contact with
the patients. The cause of the disease, presumably a virus, is not
known at this date.
20 february 2003. It
is established that the father of the child treated for H5N1 flu
died of the same disease. Although it is not yet established
that this was caused by the same avian strain, this is likely.
Sporadic cases of bird's flu in Hong Kong, including in wild birds,
demonstrated that there are foci of disease in the Mainland. This
second identified direct contamination from birds to humans in Fujian
province demonstrates that the disease must be taken extremely
seriously. Fortunately these recent cases do not appear to have been
caused by person-to-person contamination. The World Health
Organisation is tackling the matter, and considering what types of
vaccines should be prepared to be able to react immediately in case of
epidemic. It is also important to remember that such disease outbreaks
spread from places where birds are in large flocks (poultry farms and
markets in particular). The "atypical pneumonia" diagnosed recently in
Guangdong does not appear to be related to bird's flu: coincidence of
infection with pneumonia-like symptoms, perhaps caused by a variety of
pathogens, appears to have triggered the panic after personnel from
medical care institutions died. This type of disease is frequent in
winter, and the number of people dying from such diseases is always
significant.
19 february 2003. A nine year old child
is treated in Hong Kong for H5N1 influenza. No link has been
established with the epidemic that created panic in Guangdong, but it
is a matter of extreme concern, since this form of flu, which affected
Hong Kong in 1997 is significantly more dangerous than the more common
forms. Once again, elementary rules of hygiene should be followed.
11
february 2003. An outbreak of "atypical pneumonia" in
Southern China led the French General consulate in Guangzhou to
close the French School in the city, until more is understood about
the disease. The rumor spread that several tens or even hundreds of
people have been contaminated, with a high death toll. No reliable
information is available at the present time. It seems likely that the
cause of the disease is a virus, perhaps a new flu strain (but perhaps
"ordinary" flu). This fits the time of the year, and the possibility
of hospital contamination. One should also remember that flu is indeed
a deadly, albeit ordinary, disease... Usual rules of hygiene should be
carefully followed (washing hands frequently in particular) and people
should limit contacts with large concentrations of people. One should
avoid travelling, to limit the spread of the disease. Also, remember
that panic is one of the most efficient way to spread diseases.
8 february 2003. An outbreak of Ebola fever
is spreading in Congo, at the border with Gabon at a place close
where it was declared one year ago.
18 january 2003. Work at the Instituts
Pasteur de Paris and de Madagascar results in the creation of a fast
test for diagnosing plague. Paper strips are used to detect
the presence of the plague agent, Yersinia pestis (discovered
by Alexandre Yersin in Hong Kong more than one century ago). The
goverment of Madagascar provides a supply to its local health centers
to identify the disease, which is still endemic in the island.
15 december
2002-21 january 2003. The flu virus H5 reappears in Hong
Kong. It is most likely that it is not confined to Hong Kong
itself, but is present in the region. This time, it was first
identified in waterfowls, before being found in dead chicken at
several market places. Open markets are closed for cleaning on New
Year's eve.
7 october 2002. The Nobel Academy has
awarded the Nobel Prize to work on Caenorhabditis elegans.
This is an important lesson for those who still do not understand that
discovery cannot be planned. Work on the nematode worm C. elegans
allowed discovery of programmed
cell death (apoptosis). This "suicide" of cells is universal. It
is of major importance for the construction of animals, and plays a
fundamental role in cancer. This discovery is the result of purely
academic research, as are all the processes at the root of genetic
engineering...
6 october 2002. A new serotype (type 2) of
Dengue fever is identified in Hong Kong. Fortunately, the cooling of
the atmosphere, associated to dry conditions will prevent the epidemic
to spread.
2 october 2002. Dengue fever is spreading in
Hong Kong. Several cases of Dengue fever type 1 have been
diagnosed since july, raising concern about a possible epidemic.
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