THE RISE OF A VIRUS-NYTimes on SARS (long)

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http://www.nytimes.com/2003/04/27/health/27SARS.html

 

THE RISE OF A VIRUS

From China's Provinces, a Crafty Germ Spreads

By ELISABETH ROSENTHAL

 

HUNDE, China — An hour south of Guangzhou, the

Dongyuan animal market presents endless opportunities

for an emerging germ. In hundreds of cramped stalls

that stink of blood and guts, wholesale food vendors

tend to veritable zoos that will grace Guangdong

Province's tables: snakes, chickens, cats, turtles,

badgers, frogs. And, in summer, sometimes rats, too.

 

They are all stacked in cages one on top of another —

which in turn serve as seats, card tables and dining

quarters for the poor migrants who work there. On a

recent morning, near stall 17, there were beheaded

snakes, disemboweled frogs and feathers flying as a

half-alive headless bird was plunked into a basket.

 

If you were a corona virus, like the one that causes

severe acute respiratory syndrome, known as SARS, it

would be easy to move from animals to humans in the

kitchens and food stalls of Guangdong, a province

notorious for exotic cuisine prepared with freshly

killed beasts.

 

Indeed, preliminary studies of early SARS victims here

in Guangdong have found that an unusually high

percentage were in the catering profession — a

tantalizing clue, perhaps, to how a germ that

genetically most resembles chicken and rodent viruses

has gained the ability to infect thousands of humans.

 

One of the earliest cases, last December, was a seller

of snakes and birds here who died at Shunde's First

People's Hospital of severe pneumonia. His wife and a

several members of the hospital staff contracted it as

well, setting off an outbreak that now sounds eerily

familiar.

 

" Oh yes, I heard that a guy here died of that

pneumonia, " said Li Songyu, a 40-year-old wearing a

neat tan blouse, as she filleted live frogs and dumped

them into a basket. " But it is very safe and sanitary

now. "

 

Around the same time in December, Huang Xinchu, a

chef, was admitted to the Heyuan People's Hospital,

100 miles to the north, ultimately infecting eight

doctors there. On Jan. 2, another desperately ill chef

was hospitalized in the city of Zhongshan, south of

Shunde, setting off an outbreak.

 

But if such early outbreaks present scientific hints

about the origin of SARS, they also provide painful

political lessons in how a disease that has spread

worldwide could have been prevented.

 

In early January, alarmed health departments in

Shunde, Heyuan and Zhongshan all reported the strange

pneumonia clusters to Guangdong provincial

authorities, who concluded that they were facing a

highly infectious pneumonia caused by a previously

unknown agent.

 

It is unclear whether that conclusion was passed on by

provincial officials to the Ministry of Health in

Beijing, or ever reported to international health

agencies that might have conducted an early

investigation into the problem. Instead, it would be

another two and a half months before the strange

pneumonia had a name, coined only after an Italian

doctor working in Hanoi, Vietnam, alerted the World

Health Organization about a similar new pneumonia he

was seeing there.

 

And it would be three and a half months before China's

leaders would admit that their country had an epidemic

of SARS. From January through the middle of March,

doctors in Asia and Canada were encountering patients

carrying a virulent and highly contagious germ,

unaware that they were facing potentially lethal

infection.

 

During that period, hundreds of health workers fell

ill. During that period, well-meaning doctors were

placing SARS patients in ordinary wards — as they

would patients with normal pneumonia — and those

patients were passing the infection on to hundreds of

others.

 

Origins in Food Trade

 

Scientists have always considered the teeming farms of

southern China, where animals and people crowd

together as ideal breeding grounds for new human

viruses, which can jump between species under such

conditions. So it was no surprise in March when the

World Health Organization said it believed that SARS

originated in Guangdong.

 

But when a World Health Organization delegation went

to look at data on the earliest SARS cases, they found

few farmers among the victims. Instead what jumped out

was an odd preponderance of food handlers and chefs —

about 5 percent of the first 900 patients, as opposed

to less than 1 percent among patients with normal

pneumonia.

 

So far, studies are in their early stages and have

yielded few specific conclusions. Even if food

handlers turn out to be the conduits through which

SARS passed from animals to humans, all evidence

points to human-to-human transmission now.

 

Still, for much of December and January, several small

cities around Guangzhou were fighting — and often

winning — localized battles with the strange pneumonia

that would later be named SARS.

 

In December, the 32-year-old chef from Heyuan was

admitted to the Heyuan People's Hospital, having

fallen sick with pneumonia on his job near the boom

town of Shenzhen. His family had him transferred to

Guangzhou when his condition deteriorated despite

medication. But when eight doctors and nurses fell ill

with a similar untreatable pneumonia in Heyuan just a

few days later, hospital officials became alarmed.

 

On Jan. 1, they told the local health department of

the cluster of cases. " On Jan. 2, we reported a new

infectious disease to the provincial health bureau, "

said Dr. Ouyang Songhua, deputy chief of the Heyuan

Public Health Department. " They immediately sent out

an expert team to investigate it, deciding it was a

pneumonia of previously unknown cause. "

 

Word of the disease spread among local doctors so that

when another chef with pneumonia arrived at Zhongshan

Hospital on Jan. 2, short of breath and feverish,

doctors isolated him in intensive care.

 

But not soon enough: 13 medical staff members were

infected, who in turn infected 15 others in Zhongshan

as well. Outbreaks in Shunde, Heyuan and Zhongshan

peaked in January, and by February the virus was

poised to move on.

 

By early February, sick and frightened patients from

small cities like these were traveling to more

advanced hospitals in the provincial capital of

Guangzhou — and that is when the surge of cases really

began.

 

From Feb. 2 through Feb. 4, a very sick man from

Zhongshan made the rounds of emergency rooms in

Guangzhou as treatment failed to improve his

condition, leaving dozens of health workers infected.

At the time, emergency room staff members understood

little about the new pneumonia that had been cropping

up around the province. At first, they did not isolate

the man and were wearing no protective gear.

 

Unfortunately, the man was what is now known as a

" super-spreader " — one of a small group of SARS

patients who is highly infectious. Dozens of doctors

and nurses fell sick at the Zhongshan No. 2 Hospital,

where he was finally admitted.

 

" He was very sick, but who knew there was something so

terrible going around? " said a nurse named Mo at the

Zhongshan No. 2 Hospital, recalling the long,

frightening quarantine that followed in February, when

nurses and doctors spent long weeks living in their

units waiting to see if they will start to cough. In

China and in much of Asia, more than 30 percent of

SARS victims have been hospital workers.

 

Hong Kong as a Gateway

 

On Feb. 21, Dr. Liu Jianlun, a 64-year-old lung

specialist from the Zhongshan hospital, attended his

nephew's wedding in Hong Kong, even though he was

running a fever. With what is now known about the

disease, health care providers like Dr. Liu with such

extensive exposure to SARS would be quarantined and

forbidden to travel. But no such guidelines existed

then.

 

At the Metropole Hotel, where he stayed, he passed

SARS on to a number of other guests, including two

Canadians, an American businessman en route to Hanoi,

a Hong Kong man, and three young women from Singapore.

SARS, until then confined to the Chinese mainland, was

unleashed on the world.

 

At the Kwang Wah Hospital in Hong Kong, where Dr. Liu

went when his breathing became labored, he advised

shocked doctors and nurses of the mystery pneumonia

that was ravaging his hometown, insisting that they

isolate him behind double panes of glass and don

protective gear before his exam. The doctor died

several days later; no one at the hospital was

infected.

 

But the grisly story was not shared with other doctors

in Hong Kong or the rest of the world. And, with the

new corona virus silently breeding in their bodies,

the nine guests at the three-star Metropole Hotel

dispersed on airplanes like bees carrying a deadly

pollen, seeding SARS locally and to far corners of the

world.

 

The woman from Toronto, Kwan Sui-chu, died in a

Toronto hospital on March 5, but not before infecting

her son and at least five health workers. Canada now

has identified at least 140 SARS cases, 15 fatal.

 

Johnny Chen, the American businessman, fell ill at a

hospital in Hanoi in late February, where he

ultimately infected 20 health workers, including Dr.

Carlo Urbani, an Italian medical researcher who

alerted the W.H.O. about a new type of pneumonia and

who also eventually died of the disease. The Hong Kong

man was admitted to a general ward at the Prince of

Wales Hospital, setting off a huge outbreak.

 

The three Singapore women fell ill after going home in

late February and were admitted to three hospitals

from March 1 to March 3. While two of the women

infected no one else, the third, Esther Mok, another

super-spreader, set off a chain of infection based at

the Tan Tock Seng Hospital, from which over 90 people

fell ill, accounting for more than half Singapore's

cases. Ms. Mok has recovered, but many members of her

family became ill, including her mother and father,

who both died.

 

On March 14, the World Health Organization formally

issued its worldwide alert about the new disease,

which it called SARS.

 

A Focus on Prevention

 

Since then, countries visited by this new plague have

taken increasingly severe steps in order to control

further spread of a disease that has eluded many

conventional infection barriers. Because the disease

remains difficult to treat and has a death rate of 5

to 10 percent, by far the most effective way to deal

with it is to stop its spread.

 

" On an individual level it is relatively low risk, but

the proportion of people who have a severe course

appears to be quite high, " said Rob Breiman, a

respiratory expert who has worked for the World Health

Organization on the outbreak. " Until we know more

about this disease, protecting against exposure is

extremely important. "

 

In Canada, for example, even healthy travelers

arriving from affected areas are advised to go into a

10-day voluntary quarantine, where they are advised to

stay at home, take their temperature frequently and

sleep in a separate room from other family members.

Ontario alone now has 7,000 people under various types

of quarantine.

 

But some people have resented the restrictions for

what most often proves to be nothing more than a fever

from a common cold. On Easter Sunday, one health care

worker who had been exposed refused to stay at home,

attending church services and a funeral in Toronto.

Health officials are now considering a court order to

keep him isolated.

 

Companies and governments in the West are drastically

curtailing travel to SARS-affected regions. Some are

also are requiring employees to stay at home for 14

days after visiting SARS-infected areas.

 

" I'm not too worried about the disease, " said Jane

Cowells, a resident of New Zealand, as she arrived

this week, unmasked, at Beijing Capital Airport. " But

the whole thing is a headache, since when I go home I

can't go back to work for 10 days. "

 

In Vietnam, where the epidemic is now under control,

officials said they were considering sealing off the

entire 800-mile border with China to prevent sick

tourists from reintroducing the germ.

 

In many Asian countries, airports have come to

resemble bioterrorism labs, as nurses in protective

gear assess arriving passengers for signs of disease.

No place is more vigilant than Singapore.

 

Singapore's Drastic Steps

 

 

" Welcome to Singapore! Are you feeling well today? "

chimes a chorus of nurses, their faces covered by

masks, their eyes by goggles, their bodies by yellow

hospital gowns. Passengers coming from other countries

with SARS are guided to pass through a high-tech

thermal scanner that picks up temperatures over 100.

Masked soldiers are there to escort away those with

fever.

 

Those who pass muster are given a card warning that

they might have been exposed to a deadly disease.

Those who are feverish are whisked, without apology,

into a 10-day quarantine, and Singapore means

business. Video cameras will be installed in the home

by a security firm, to make sure patients do not

stray. Those few who do are tagged with an electronic

wristband that records their movements.

 

But even in a small country, placing thousands on

quarantine has been a strain. Last Monday, after a

case of SARS was discovered in a vendor at Singapore's

largest vegetable market, the Ministry of Health

ordered all 2,400 food sellers to report for

quarantine, up from a total of 467 quarantined before.

Since 80 percent of the country's vegetables pass

through the Pasir Panjang Market, restaurants were

bracing for a shortage of greens.

 

" We do what we have to, " said Dr. Balaji Sadasivan, a

neurosurgeon who is Singapore's minister of state for

health. " I don't think we've seen anything like this

before and it is a global problem. For now this is a

battle that is being fought with the thermometer and

quarantine. "

 

Because of elaborate contact tracing, the Singapore

outbreak is by far the best defined in the world. All

but 4 of the 188 victims were infected in the hospital

or by a family member at home. The four exceptions are

a child who got the disease from a classmate with an

infected parent, a flight attendant who served an

infected doctor from Singapore on a flight in Europe,

a cab driver and a vegetable salesman.

 

Dr. Sadasivan is unapologetic as he describes the

draconian measures his department has adopted to halt

the spread of the germ.

 

When the three young women from the fateful Hong Kong

hotel brought SARS to three different hospitals in

Singapore in early March, Singapore doctors were

unaware of the odd pneumonia that was hospitalizing

dozens of patients each day in Guangdong and so

admitted them to ordinary wards. If the Chinese had

publicized their severe pneumonia in Guangdong, or if

the Hong Kong doctors had more aggressively reported

the information about Dr. Liu, their response almost

certainly would have been different.

 

Two of the women did not pass on the germ, but one

infected more than 20 people, both patients and

hospital workers. One of the nurses she infected also

proved to be a super-spreader, passing SARS to 26

others. One of the 26 was a patient in the cardiac

intensive care unit whose SARS was not recognized

because of many other medical problems.

 

Within a month, 90 people at the Tan Tock Seng

Hospital had the disease. The Health Ministry dug up

an old law that allowed them to impose mandatory

quarantines, with fines of 5,000 Singapore dollars for

those who disobey. They also essentially closed the

1,000-bed hospital to other patients — hoping to

contain the virus within its walls.

 

But it escaped all the same. Some patients who had

been at Tan Tock Seng in March contracted the disease

and later went to other hospitals when they developed

coughs — setting off secondary outbreaks. One went to

Singapore General for an endoscopy and was screened

for SARS, but did not run the telltale fever because

he was on steroids that suppress the body's response.

Ninety people at the hospital were infected.

 

After this resurgence, the Health Department

instituted a policy that every patient at every

hospital be considered a potential SARS patient.

Nurses are always masked when seeing patients, who are

allowed only one visitor a day. Confirmed SARS

patients are allowed no visitors at all, though they

can talk to friends and family on their cellphones.

Nurses may not work on more than one unit and patients

may not transfer from hospital to hospital.

 

" We used to have a health care system organized for

efficiency, " said Dr. Sadasivan. " But now our

hospitals are organized for SARS prevention. "

 

Outside of the hospitals, the ministry closed all

schools for two weeks to halt potential transmission

of the virus. All cab drivers now take their

temperatures twice a day. Temperature checks and

health questionnaires are standard for those entering

buildings.

 

At Tan Tock Seng Hospital last Monday, an ambulance

arrived carrying a vegetable seller who came under the

market quarantine. Although he felt well, the man said

he had a fever, and so the driver told him he might

have to remain in the hospital. Approaching a

cordoned-off screening area, he was resigned, saying,

" I don't think I could have the disease, but I know I

have to do it. "

 

China's Slow Response

 

But Singapore's aggressive, open confrontation with a

viral enemy is a lesson that some other countries have

been slow to learn, especially China, the world's most

populous country, where SARS emerged almost half a

year ago.

 

Although doctors in Guangzhou were well aware of the

problem as early as January, information about an

epidemic was suppressed for months, and only started

dribbling out at the beginning of April, under intense

international pressure.

 

Only in the last week have numbers begun to emerge

elsewhere in China, and the task is still not

complete. In Beijing, they already paint an alarming

portrait of an epidemic that is likely to dwarf that

in either Guangdong or Hong Kong.

 

At a news conference on April 10, He Xiong, the deputy

director of the Beijing Centers for Disease Control,

was still delivering a calm message, endorsing numbers

that the government released at the time: that in

Beijing there were only 27 SARS cases, so people

should not worry.

 

" Of course they can travel, we think it's very safe, "

he said, referring to an approaching national vacation

when tens of millions of Chinese would normally be

expected to travel.

 

But that misinformation only fueled the spread of

SARS, as people — with fevers and coughs — continued

to go to school and work, passing the disease on to

others. As the number of cases increased well into the

hundreds, the illusion proved hard to maintain in a

city with a world-class gossip network that spread

rumors of overflowing SARS wards.

 

By last weekend, everyone was skeptical, as a

smattering of schools and hospitals mysteriously

closed. One People's Armed Police hospital in Beijing

was closed after five patients were infected. The

Zhongguancun No. 1 Primary School closed when a

relative of a student got SARS. The Beijing University

Institute of Economics put several dozen people on

quarantine after a secretary's mother got pneumonia.

 

More than a dozen of Beijing's universities had

reported suspected cases. At the Economics and Finance

University alone, more than a dozen students and

faculty members were listed as suspected SARS cases,

resulting in the suspension of classes from April 17.

 

That day, the main gate of the Northern Construction

University was a panic scene, as masked students made

arrangements to flee to their hometowns in the wake of

suspected SARS cases on campus. " I want to get out of

here as soon as possible, " said one alarmed student,

making calls on her cellphone to borrow money for the

trip home.

 

Then, last Sunday, the Chinese government fired both

the health minister and the mayor of Beijing, and

started releasing alarming data that confirmed these

fears. As of Friday, there were close to 900 confirmed

cases in Beijing, a number that is certain to strain

the resources of city hospitals and will make SARS far

difficult to control.

 

But can the lessons of prevention learned in a tiny,

authoritarian country like Singapore be applied

elsewhere, particularly in a vast, chaotic place like

China, with far more cases and a highly mobile

population?

 

In Singapore, with its aggressive system of

identifying and isolating SARS patients, no health

care worker has been infected for over three weeks.

But in Hong Kong, 2 to 10 doctors and nurses are

falling ill each day, in part, health officials there

say, because doctors are still not identifying them as

SARS victims early enough and are admitting them to

ordinary wards.

 

" There is so much we don't know about this virus — how

long it will be with us? Will it mutate and become

more easily transmitted? " Dr. Breiman said. " But it is

a little frightening that something which started in

one location could spread so quickly around the

world. "

 

The first article in this series examined the economic

impact of SARS. Later articles will examine the

response of health officials and the search for the

virus.

 

Copyright 2003 The New York Times Company

 

 

 

 

 

 

 

 

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