An Invisible Killer in our Midst

There is growing concern in South-East Asia over the spread of a deadly flu virus.

Professor Andrew Burd, a surgeon in Hong Kong, tells BBC News Online what it has been like living and working in the midst of "an invisible killer".

This week appeared to begin like any other. In retrospect, however, on Monday I noticed one of the surgeons looking extremely unwell. He was eventually persuaded to go home for some rest.

Such an event is not unusual in a hospital where surgeons work long hours and want to remain on duty to support their colleagues and do their job.

The rumours began on Tuesday during our daily early morning round. A ward had been quarantined. Staff and patients were shut behind secured doors.

The rumours gained credence when we passed the ward and saw an eager reporter speaking to a presumed relative wearing a mask.

A photographer was angling for the shot over the shoulder and in the background a security guard was sitting impassively in front of firmly closed doors.

The rumours and media reports coalesced over the next 48 hours into an understanding that there was something going on.

Could it be possibly related to the strange outbreak of pneumonia that had affected 300 and killed five in Guangzhou in China?

Was it related to the strange tale of a family of five who had been to Fujian and who had developed some strange illness that had claimed a father in his 30s and a son under ten.

Or was it related to the case of an American businessman who had been evacuated from Hanoi to a specialist unit in Hong Kong during the week?

Certainly, something very strange had been going on in South-East Asia and now it was on our doorstep.

By Wednesday evening we were formally alerted by the hospital authorities that there was 'a situation' that required heightened measures of vigilance. We had a name to this new threat - "Community Acquired Pneumonia".

On Thursday morning, we had the first evidence that we were all in the front line. Arriving for the early morning round we were given facemasks and told to wear them. These were no ordinary surgical masks but the all enveloping masks worn by the DIY fanatic who is building up a dust storm on a British Sunday afternoon with his sander.

As we trailed from ward to ward to visit our patients, we saw more and more staff wearing these bright green masks.

We felt somewhat self-conscious and joked about alien dust and then sat in offices and took the masks off and wondered what it was all about.

On Thursday afternoon, our outpatient clinic was unusually quiet. Many patients did not turn up for their review appointments and those that did were greeted by doctors wearing the obtrusive green masks.

By Friday morning, more facts were beginning to emerge. Contrary to rumour and speculation the authorities were not hiding anything. The microbiologists were working round the clock to find out what was going on.

There has been a total news blackout from Guangzhou, which unfortunately has fed some more lurid imaginations leading to speculation of mutated viruses, 'air-born aids', and experiments gone wrong. Of these, the possibility of a naturally mutated virus seems the most likely.

The numbers of patients in Hong Kong are rising, more hospitals are affected, and there have now been deaths of local people with no history of travel.

Operations have been cancelled, wards are being emptied in anticipation of an increased influx over the weekend, staff are being relocated to emergency departments

More details are being established. The two most seriously ill of our colleagues had been to see a patient for a routine consultation.

They are two dedicated and conscientious doctors who have always been quick to respond to requests for advice and now they are in hospital themselves, totally unsuspecting victims of this invisible and potentially deadly threat.

A group of keen medical students eager to listen to a new 'murmur' also lie in hospital. Nurses from the ward are high amongst the staff victims.

We are now looking at over 60 cases and over 40 are medical staff. People no longer make jokes about the masks. The hospital authorities are giving frequent press releases and making statements to the staff to keep everyone informed about the continually developing situation.

We have colleagues fighting for their lives. We have an invisible killer in our midst. We are professionals and we have a job to do.

Now, as I sit at home with my young son quietly sleeping and my wife pottering in the background, I wonder what tomorrow will bring? We are at war but our enemy has no name, no identity.

This reality easily eclipses the nightmare fantasies of Bush and Saddam. For the moment, Iraq is no longer an issue in Hong Kong.

TEXT >

undreds of people in Vietnam, Hong Kong and mainland China, many of them hospital workers, have come down with a mysterious respiratory illness that has killed at least six people and left most of the others with severe breathing difficulties from which they have not yet fully recovered, officials of the World Health Organization said yesterday.

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The illness has also been reported in Canada.

Even the most sophisticated tests by leading laboratories in four countries have failed to find a cause, the officials said. Nor is the illness responding to antiviral or antibiotic drugs.

The health organization, a unit of the United Nations based in Geneva, has issued its first global alert in 10 years, advising health officials of the illness and asking them to report new cases. The agency describes it as an "atypical pneumonia," a term often used to describe nonbacterial pneumonia.

"It is not a very good situation," said Dr. David L. Heymann, a top expert in communicable diseases at the health agency. "It is a very difficult disease to figure out, and this has been going on for the last 10 days to two weeks."

Officials said the outbreaks were unlikely to be related to terrorism.

In addition to the breathing problems, the illness can cause a dry cough and other flulike symptoms, which apparently develop about four to five days after exposure. They usually start with a sudden onset of high fever and go on to include muscle aches, headache, sore throat and shortness of breath. Standard laboratory tests often show low numbers of white blood cells and platelets, which help blood clot.

Although some victims remain stable and others seem to get better for two to three days, they eventually relapse, developing acute respiratory distress. Some need to have a tube inserted in their windpipe to help them breathe.

Among the survivors, "no one has gotten well yet," Dr. Heymann said in an interview. "It is not clear what is going on, and it is not clear what the extent of spread will be," particularly because "these are areas where there is a lot of international travel," he added.

In Canada, Toronto's municipal health agency announced on Friday that a woman there, Kwan Sui-chu, had died on March 5 soon after returning from Hong Kong. Five other family members who had not been to Hong Kong recently have since become ill; four are still in the hospital while the fifth, Mrs. Kwan's son, Chi Kwai Tse, died on March 13, said Mary Margaret Crapper, a spokeswoman for Toronto Public Health.
Ms. Crapper said that her agency was aware of two other cases in Canada, both in Vancouver and involving people who had also traveled recently to Hong Kong. Toronto Public Health issued an appeal on Friday night to Canadians to seek medical help if they had been in contact with Mrs. Kwan's family and were experiencing symptoms like the sudden onset of a high fever, muscle aches or other flu-like symptoms.
Hanoi has had at least 42 cases and Hong Kong 43. Guangdong province, which adjoins Hong Kong in China, reported 305 cases by mid-February, including 5 deaths. Officials in Singapore said yesterday that there had been nine cases there — three recent arrivals from Hong Kong and six people who cared for them, two of whom were hospital workers.

Although the patients have experienced similar symptoms, the outbreaks have not been scientifically linked, Dr. Heymann said. Chinese officials said the Guangdong outbreak was over, but the health organization has not confirmed that independently.Most of the cases have been among hospital workers, the agency said that the illness seems to be spread by respiratory droplets.

The health organization has sent a team of experts to Hanoi from Australia, England, France, Japan, Sweden and the United States, and is gearing up for an even larger response. The Centers for Disease Control and Prevention in Atlanta has sent an epidemiologist, an infection control specialist, a medical officer and a pathologist to Hanoi, and a medical officer to Hong Kong.

Hong Kong and Vietnam have established their own teams to investigate and contain the disease.

The World Health Organization is sending masks, gowns, gloves and other materials to the affected areas to help isolate patients and the hospital staff and equipment from possible means of transmission.

So far scientists have not been able to identify a known or novel infectious agent, Dr. Heymann said.

Japanese officials said their tests showed that the influenza virus was not the cause of the illness, but Dr. Heymann would not rule it out.

Tests of victims' samples have found no evidence of mycoplasma or similar microbes that are the usual causes of atypical pneumonia. Additional tests have shown no evidence of Ebola or any of the other viruses that cause hemorrhagic fevers, hanta virus and bacteria.

As a result, laboratory scientists are focusing on the possibility of a previously unknown infectious agent.

Initial tests have not found a link between the current illnesses and a rare strain of avian influenza that killed one person and sickened another in Hong Kong last month. A similar influenza had infected 18 people in Hong Kong in 1997, killing 6.

With relatively few deaths in the current outbreaks, "one might think we are overreacting to the cases," said Dick Thompson, a spokesman for the World Health Organization. "But when you do not know the cause, when it strikes hospital staff and it certainly is moving at the speed of a jet, we are taking this very seriously."

The only fatality outside Guangdong Province and in Canada was that of an American businessman who lives in Shanghai, who died of the illness in Hong Kong on Thursday. The man, whose name has not been released, had passed through Hong Kong on his way to Hanoi, where he fell ill. He entered a hospital there but was moved out when his condition deteriorated and the disease began spreading through the hospital staff, 30 of whom are now infected. In Vietnam, 30 doctors and other employees had fallen ill at the hospital where the man was treated.

The World Health Organisation has issued a worldwide alert for the first time in ten years after six people died and hundreds in China, Hong Kong and Vietnam contracted a mysterious respiratory disease which is not responding to antiviral or antibiotic drugs, and the cause of which is yet to be ascertained.

At least six people have died and most others were left with severe breathing difficulties from which they are yet to fully recover, the United Nations health agency said on Friday.

Even the most sophisticated tests by leading laboratories in four countries have failed to pinpoint the cause.

WHO describes it as "atypical pneumonia" which experts say means nonbacterial pneumonia.

The signs and symptoms of the disease include initial flu-like illness (rapid onset of high fever followed by muscle aches, headache and sore throat). These are the most common symptoms.

Some victims seem to get better for two or three days and then relapse developing acute respiratory distress requiring assisted breathing on a respirator.

Early laboratory findings may include thrombocytopenia (low platelet count) and leucopenia (low white blood cell count). In some, this is followed by bilateral pneumonia.

Until more is known about the cause of these outbreaks, WHO recommends patients with atypical pneumonia be isolated with barrier nursing techniques and that any suspect cases be reported to national health authorities.

WHO said it is in close contact with local authorities and has also offered epidemiological, laboratory and clinical support. It is working with national authorities to ensure appropriate investigation, reporting and containment of these outbreaks.

China has reported 305 cases in Guangdong province, Hong Kong 43 and Vietnam 42. As most cases are among health workers, experts suspect that it spred through respiratory droplets.

From the CDC Travelers Health :

Notice: Acute respiratory syndrome, Hong Kong SAR, Viet Nam, China
(Released March 13, 2003)

As of March 12, 2003, the Centers for Disease Control and Prevention (CDC) has received reports of outbreaks of a severe form of pneumonia in Hong Kong SAR, Vietnam, and Guangdong, a province in southern China. No links have so far been established between any of these outbreaks. Last month two cases, including one death, from influenza H5N1 (“bird flu”) were reported from Hong Kong in a family who had traveled to southern China in February 2003. The epidemiologic investigation has shown no link between the influenza cases and the current outbreak of pneumonia.

In Vietnam, a man became ill after traveling from Shanghi, China, and Hong Kong SAR to Hanoi, where he was hospitalized for a severe, acute respiratory syndrome. Approximately 20 hospital staff became ill with similar symptoms, which included initial influenza-like illness with rapid onset of high fever, followed by muscle aches, headache, and sore throat. Some cases progressed to bilateral pneumonia; a subset of the pneumonia patients developed acute respiratory distress requiring mechanical ventilation. Some patients are now recovering, while others remain critically ill.

In Hong Kong SAR, the Department of Health reported an outbreak of respiratory illness in one of its public hospitals, screening of health-care workers showed that 26 had febrile illness. Of the 26, 10 showed early signs of pneumonia by chest x-ray. All were hospitalized as a precautionary measure and are being monitored.

Last month, the government of China reported an outbreak of atypical pneumonia with 305 cases, including 5 deaths, which Chinese health authorities later attributed to Chlamydia pneumoniae.

An epidemiologic investigation is under way in Hong Kong SAR and Vietnam. The CDC and the World Health Organization (WHO) have offered assistance and are in close contact with health authorities in both countries. The outbreaks appear to be confined to the hospital environments, with health-care workers at greatest risk. WHO recommends the use of isolation and barrier nursing techniques with patients who have atypical pneumonia and any possible links to the outbreaks, and that suspect cases be reported to national health authorities. As an added measure, CDC recommends respiratory precautions with use of a personal respirator during any close contact with cases and suspect cases.

Updates will be posted about the outbreaks as information becomes available.

http://www.cdc.gov/travel/other/acute_resp_syndrome_eastasia.htm

CDC flu deaths investigation widens

Five children suffering from influenza-like illnesses have died in Virginia; North Carolina officials investigate 18-month-old boy's death

Saturday, February 22, 2003BY PATTY MAHER
News Staff Reporter

The federal Centers for Disease Control has expanded its investigation into mysterious child deaths to include Virginia, where five children suffering from flu-like illnesses have died since Sunday.

The CDC first began investigating a series of deaths in Michigan between Jan. 25 and Feb. 3. CDC officials later added the deaths of two Ohio children to their inquiry. All the children suffered symptoms, such as fever and aches,, common to viral or bacterial infections.

In Michigan, Ohio, and Virginia alone, at least 14 children have died suddenly following fevers and respiratory infections. Also, The Associated Press reported Friday that North Carolina health officials were investigating the death of an 18-month-old boy who died Thursday at Albemarle Regional Hospital in Elizabeth City, just south of the area where four of the Virginia children died.

Federal health officials don't know the degree to which similar deaths are occurring in additional states. A spokeswoman from the CDC said her organization Friday afternoon sent notices to all state health departments to warn physicians and parents to be on the alert for respiratory and flu-like infections.

Meanwhile, Ann Tripp of Ypsilanti still waits to learn what caused her 14-year-old son, David, to die Jan. 25. His was the first of the deaths to capture the interest of public health officials. She said she finds the growing number of mysterious child deaths unbelievable.

"I am really anxious to find out if this is a virus that all the kids are getting that is very similar. Is it going in and attacking them each in vulnerable organs that these children have? Each of them isn't dying from the same thing, but they are going in with the same thing - a cold-virus kind of thing."

Tripp is braced for the fact that it may be weeks before results from David's tests are available.

"It's hard to put any kind of closure on this when you don't know," Tripp said.

Meanwhile, Geralyn Lasher, spokeswoman for the Michigan Department of Community Health, said tests today confirmed that a Newaygo County boy died Feb. 14 of Influenza Type A. The victim was identified as 2-year-old Jack Henry Williams, a child from South Korea who was adopted in August 2000 by Robert and Michelle Williams.

Meghan Spieles, 6, of Ann Arbor Township, and Alana Yaksich, 5, of Bloomfield Hills, also had influenza Type A. Meghan's death was attributed to pneumonia and Alana's to flu-related encephalitis, a swelling of the brain.

So far only a few of the children have tested positive for influenza, although public health officials suspect it may have been a factor in several of the deaths. Because some of the children, Including Tripp, became ill so suddenly and died without having had flu tests, pathologists must rely on sophisticated tissue-sample tests, which can take weeks to conduct and don't always provide definite answers.

CDC spokeswoman Kathy Harben said that although all five of the Virginia children experienced upper-respiratory infections, nothing else so far has linked the cases. Nor have the cases been linked to those in Michigan and Ohio. Officials still don't know what caused the Virginia deaths, Harben said. Tissue samples will be sent for evaluation to the CDC, where studies are being done on the Michigan deaths.

Awilda A. Carter, mother of 2-year-old Maria Carter, the first Virginia child to die, said her daughter had been running a fever and vomiting. She said doctors initially said the girl had an ear infection but changed the diagnosis to influenza after a second visit.

"She was running around and playing," Carter said. "She kept having a fever, but she never got more sick." Carter said her daughter fell asleep on the couch Sunday and never woke up.

After the autopsy, doctors told the family they thought a virus had attacked the girl's heart muscle, Carter said. Tripp said earlier this month that Washtenaw County Medical Examiner Bader Cassin told her the same thing. Cassin has not returned a reporter's phone calls for comment.

The Associated Press contributed to this story.

South China Morning Post
Friday, February 21, 2003

News 'blocked by Guangzhou TV'

LEU SIEW-YING in Guangzhou

Guangzhou residents have accused their government of blocking news from Hong Kong television channels about the latest bird flu outbreak.

"I heard the news on Hong Kong television news last night but the transmission was interrupted midway," said one businesswoman. "I tend to think it's H5N1 because a friend who is a nurse told us so. You can't believe the government because they cover up a lot of things."

The woman said she was not worried by the H5N1 case but she would stay away from crowds.

"It's useless to be frightened. Even during the panic over the mystery flu in Guangdong I did not stock up on salt, rice or oil," she said.

A 26-year-old IT engineer said she had also heard the news on Hong Kong television but the report on her channel was not blocked. "This will not affect my lifestyle. I will continue to eat chicken," she said.

Bird flu is a virus and is not transmitted by eating infected chicken.

Both Hong Kong's TVB and ATV channels are received in Guangdong.

Public relations executive Yang Yi said he had not heard the news but was not worried. Mr Yang said the barrage of information about the 1997 outbreak had left Guangzhou people with information fatigue. They thought Hong Kong people were overeacting to the illness, he added.

Chen Jiasheng, a senior protocol officer at the Guangdong foreign affairs office, denied that the government had intercepted the television signals.

"This is not government behaviour. The government did not order a news blackout. Some overzealous television official probably took it upon himself to block the broadcast because he thought it was sensitive."

Guangdong health department spokesman Feng Shaoming said they had still not received news from the Hong Kong or Fujian authorities about the flu.

"The Hong Kong reports are exaggerated. We will monitor the event but not the illness as there is no such illness in Guangzhou."

Guangdong officials have said the flu outbreak in the province, which they termed atypical pneumonia, was not avian flu, anthrax or plague.

Officials said five people were killed by the pneumonia and 305 others infected. Up to Monday, 94 of the 192 people admitted to hospitals in Guangzhou had recovered and been discharged.

State television said yesterday that there had been six new cases since the official figures were released last Monday by the health department. The situation cannot be said to have stabilised until 10 days have passed without any new cases being reported, the report said.

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