Kaohsiung reports suspected SARS case

The China Post ^ | November 19, 2003 | The China Post Staff

[kdono]

what evidence is there

The number of exported cases via air will be MUCH lower than primary cases. There were no reported exported cases until late February in the last outbreak. If there is one exported case to Taiwan, then there are probably many more cases in the exporting city (somewhere in mainland China).

Exporting cases are an independent monitor of the location doing the exporting. To get an exported case from mainland China means there are many cases there (only one infected the person flying to Taiwan).

[kdono]

Do you think they learned anything new about the virus over the course of the year?

There have been many strains sequenced (45 are at GenBank) and many more that have not yet been deposited. This database allows for tracing of the virus, so it will be easy to tell where and when a new oputbreak originates. However, there is room for improvement on diagnostics, therapeutics used in the last outbreak may have done more harm than good, and a vaccine is years away, and when in place, the virus will simply mutate away from teh vaccine (there still is no HIV vaccine, although work began on a vaccine in the early 80's).

[Judith Anne]

Thanks for the information, it makes sense. Your posts are interesting and you seem knowledgeable. I guess I'm wondering if you look at epidemics professionally...?

[kdono]

I'm writing a review on the Origin and Evolution of SARS and have looked at sequences from almost 120 isolates from the last outbreak.

[txhurl]

therapeutics used in the last outbreak may have done more harm than good,

Which therapeutics .. temperature? Confinement policy? You seem to be very knowledgable, and I know the SARS lists will be very appreciative of your knowledge.

Thank you for helping us understand this.

[Judith Anne]

Interesting work...you should find some excellent media resources here...

By the therapeutics that may have done more harm than good, I'm wondering if you mean the steroid treatments, which may have reduced the lung inflammation and at the same time, reduced the body's immune response...

[kdono]

Yes, the steroids seem to have cause avascular necrosis in some.

As far as the probable SARS patient in Taiwan is concerned, it sounds like there really isn't that much info to support a SARS diagnosis at this time.

[Judith Anne]

I went back to re-read the article, and it said "suspected" case. Please don't take this as hairsplitting, 'cause it isn't meant that way at all--I'd just like to pick your brain for a while, as long as you don't mind...

We had several discussions on definitions of SARS cases, and the definitions of "suspected" and "probable." As I recall, and I may be wrong, "suspected" cases had respiratory distress, fever, and no ordinary causes identified..."probable" meant with antibodies to the SARS coronavirus.

If this "suspected" case is the Taiwan index case, there should be more cases in Taiwan identified soon--within a couple of weeks, since as I recall (and I could be wrong) the incubation was possibly up to five weeks...

And that means, as you pointed out, that transmission could have occurred in mainland China, and who knows where the index case there arose...I'd guess the same Guangdong province where the disease was first seen last year...

[Judith Anne]

And one other question, if I may be permitted, the cases of avascular necrosis that I've heard of were bone necroses related to high dose long term steroid therapy...I didn't read anything here about avascular necrosis in SARS cases, and I'm wondering if there's a whole 'nother area of SARS morbidity that I've not been exposed to...

[kdono]

I didn't read anything here about avascular necrosis in SARS cases

The have been quite a few media reports on avascular necrosis in SARS cases (reported cases are in Hong Kong, but probably elsewhere).

[kdono]

Because of potential false positives, I think that most countries are focusing on ruling out other illnesses (like flu) before testing for SARS (usually PCR - antibody tests are only for patients who have had symptoms for at least 21 days).

Probable SARS cases have pneumonia as well as other symptoms. My understanding is that the Taiwanese patient is elderly and has had a fever for a couple of days. I think the media over-reacted. It is my understanding that he does not have pneumonia and is in isolation because of an over-abundance of caution. If he tests negative for flu, he will be tested for SARS RNA (by PCR).

[Judith Anne]

From your link to the VOA article: (Thank you)

Some Recovering SARS Patients Treated for Medication Side Effects Katherine Maria Hong Kong 18 Nov 2003, 08:20 UTC

Maria report - Download 302k (RealAudio) Listen to Katherine Maria's report from Hong Kong (RealAudio)

A medical expert in Hong Kong says patients who recovered from Severe Acute Respiratory Syndrome may be twice as likely to suffer from a serious side-effect caused by the steroids used to treat the illness. Some recovered SARS patients have developed a degenerative bone disorder. Hong Kong medical authorities recently revealed that a hundred patients who recovered from Severe Acute Respiratory Syndrome have developed bone weakness and 49 are suffering from a degenerative bone disorder called avascular necrosis.

Avascular necrosis is characterized by poor blood flow into bones, leading to fractures and pain in the joints. It typically affects hip joints.

Professor K.Y. Yuen of Hong Kong University says SARS patients were treated with steroids and that bone disorders are a known side-effect of steroid treatments. But, he says, some patients treated with long courses of steroids show a lower incidence of the disorder than do SARS patients.

"The use of high-dose steroids in [patients suffering from] autoimmune disease or in transplantation patients is associated with incidence of avascular hip necrosis or avascular bone necrosis in around five percent [of patients]," he says. "In the case of SARS [patients], although duration of steroids may not be as long as in the case of autoimmune diseases… it goes up beyond ten percent."

Dr. Yuen speculates that the virus that causes SARS makes bones vulnerable and high doses of steroids further weaken bones.

The doctor says there are two possible explanations for this. First, SARS patients suffering from very serious pneumonia have trouble breathing so very little oxygen enters the blood stream. Cells that generate tissue are starved of vital oxygen. Secondly, Dr. Yuen explains that many patients with a viral infection like SARS develop clotting in tiny blood vessels, further starving tissue-generating cells of vital nutrients. While steroid treatments have been linked to bone-weakening and osteoporosis in the past, Dr. Yeun says a combination of the factors probably contribute to the high incidence of avascular necrosis in SARS patients.

SARS sickened about seventeen hundred people in Hong Kong, killing more than 200 patients. Worldwide the disease struck about 8,000 people and at least 700 died.

[riri]

and is in isolation because of an over-abundance of caution

I take no issue with that.

[Judith Anne]

Because of potential false positives, I think that most countries are focusing on ruling out other illnesses (like flu) before testing for SARS (usually PCR - antibody tests are only for patients who have had symptoms for at least 21 days).

Okay, thanks, I'd forgotten that it takes three weeks for the antibodies to show up. Drat! I hope I don't have to learn everything all over again...

[txhurl]

I hate to pester you, kdono, but you are an expert and we need experts here.

Can you prognosticate at all as to genotype distribution, i.e. ethnic grouping? Are some ..for lack of a better word.. races more susceptible than others?

Thank you again.

[kdono]

I think the medical approach is sound. I am just surprised that this patient made at news at this stage of his work up. Many patients develop fever after overseas travel, but the vast majority don't have SARS, even if they have aptypical pneumonia. With the flu season picking us steam, the number of travelers with fever will certainly increase. I belive that in Hong Kong last season over 1000 were picked up with thermal screening at the airport. They did have a fever, but zero had SARS.

[riri]

I was just thinking about the fact that it never seemed to take route in India, remember that?

[txhurl]

I'm concerned that it may be preponderant to Asians/Mongoloids, and our American Indians, Eskimos and Mexicans are Mongoloid.

[Judith Anne]

There's a thread about possible genetic links to SARS susceptibility, I'll try to locate it and post a link, but I don't think that's the case, with SARS. Just my personal opinion.

[txhurl]

Thank you, ma'am.