Posted on 04/02/2003 4:07:59 PM PST by blam
An uncommon cold
A mysterious and deadly virus is spreading rapidly across the globe. What caused the outbreak? And are the right steps now being taken to contain it?
Jeremy Laurance follows the trail of the disease to a Hong Kong hotel to find out
03 April 2003
There is the faintest whiff of disinfectant from the lift lobby on the ninth floor of the Metropole Hotel in Hong Kong. A lonely jar of artificial flowers stands in front of the mirrored glass and there are two pastel drawings of rural Chinese scenes on the wall. But no itinerant businessmen or eager tourists linger here to examine them. For this is a tainted place, a microbiological "hot zone", where one sneeze sparked a global panic.
The lobby is empty now, as is the entire ninth floor of this 487-room hotel since it was closed by the Hong Kong health department three weeks ago. Lifts whisper up and down ferrying the few remaining guests to their rooms on other floors. How different from the scene on Friday 21 February, when the hotel was buzzing with people and a group of guests gathered in this lobby to wait for a lift to take them to the ground floor. Within days, three of them would be dead.
One was already ill. Professor Liu Jianlun, a 64-year-old specialist in respiratory medicine, had travelled by bus the previous day from the city of Guangzhou, in the neighbouring Chinese province of Guangdong, a three-hour journey. He had come to Hong Kong to attend a wedding – though later some doubt would be cast on his true intentions – but he quickly realised that he was not going to make it.
It is probable that Liu was seized by a coughing or sneezing fit, either while waiting for the lift or in the lift itself. What is known is that seven other people staying on the ninth floor of the hotel at the same time caught the same disease, a mystery illness previously unrecognised in humans. Those seven subsequently spread it to four other cities round the world. Today, six weeks later, the disease, whose cause is still unidentified, is present in 17 countries around the world. It has infected more than 2,300 people and claimed nearly 80 lives.
The scale of the threat posed by what the world now knows as severe acute respiratory syndrome (Sars) is still unquantified and its precise cause is still unknown. For the victims and their families, whose numbers continue to mount, it is a personal tragedy. But the damage has been amplified by the fear that has travelled in its wake. This now threatens a social and economic disaster for the worst-hit regions of the Far East, as businesses and schools are closed, airlines cancel flights and tourism slumps.
As doctors race to identify the mystery virus and find a cure, affected countries across the globe are learning hard lessons about how to handle outbreaks of disease in the modern age. It is already clear that Sars is highly contagious, progresses to pneumonia with alarming speed and, in the worst cases, drowns its victims in their own secretions. But, although lethal, it is not a mass killer. Its death rate (so far) is 3.5 per cent – about the same as flu. It is dreaded because it is unfamiliar and unpredictable and there is no proven treatment beyond nursing care. As such it offers a plausible scenario for how biological terrorism – at first considered a possible cause of the outbreak – could wreak global havoc.
When Liu realised he was not fit to attend the wedding, instead of taking to his bed with a hot drink he went straight to the nearby Kwong Wah hospital, a pink and white concrete block five minutes' walk from the Metropole Hotel down Waterloo Road. Some now claim he had known all along that he was ill and that the story of the wedding was a cover to enable him to get to Hong Kong for treatment. Certainly, when he arrived at Kwong Wah he is said to have told medical staff: "Lock me up. Don't touch me. I have contracted a very virulent disease."
He was in a position to know. Liu had been caring for patients with the lethal disease at the Sun Yat-sen Memorial Hospital in Guangzhou for several months and he had seen what it could do. The most frightening aspect was the speed of its progression. Several viruses and bacteria can cause pneumonia, but in this case patients deteriorated suddenly, becoming breathless in a few days. Many needed intensive care and artificial ventilation to keep them alive.
Unfortunately, the doctors at Kwong Wah had never seen a patient with the illness before and did not know what the professor was talking about. Although the first recorded case was in Foshan, Guangdong province on 16 November last year, the Chinese authorities did not inform the World Health Organisation of the outbreak until mid-February, and WHO officials were still working to confirm it. Had they had earlier warning, the disease might have been contained in mainland China and the rest of the world spared.
In their ignorance, the staff at Kwong Wah did not initially recognise the seriousness of Liu's condition. As he deteriorated they moved him into isolation – but it was too late. Within a month, 70 medical staff and 17 medical students at the hospital were struck down with the illness.
Liu died on 4 March. The following day, Kwan Siu-chu, a 78-year-old Canadian who had stayed on the ninth floor of the Metropole at the same time as Liu, succumbed to the disease. She had returned to Toronto, where she passed the illness to five members of her family. Her 44-year-old son died eight days later.
A Chinese-American businessman who had shared the same lift in the Metropole took the disease to Hanoi, Vietnam. He was admitted to the French Hanoi hospital before being flown back to Hong Kong, where he died on 13 March. But a Vietnamese nurse who cared for him had already caught the virus and was soon dead. The chain of infection then passed on to at least 50 health workers at two other hospitals in Hanoi.
Three young tourists from Singapore who had waited in the Metropole's lift lobby on that Friday in late February returned home four days later. They infected at least 17 medical staff, one of whom was a doctor about to attend an international medical conference in New York. On the flight home from New York, via Frankfurt, he was taken ill and became Germany's first case.
In Hong Kong, Professor Liu's sneeze in the Metropole infected a second Canadian guest and a local man who was visiting the hotel. They were admitted to separate hospitals in the city but, in the case of the local man, not before he had passed the disease on to his sister, who in turn transmitted it to colleagues.
By the second week of March, 10 hospitals in Hong Kong had patients with the disease and scores of health workers were infected. They in turn passed the disease on to their families, including eight children. When William Ho Shiu-wei, 44, the chief executive of the Hospital Authority, and Fung Hong, 45, the chief executive of the Prince of Wales Hospital, went down with the disease, people wondered if the Hong Kong health system was about to collapse.
Much criticism has been levelled at the Hong Kong government for underplaying the risks in the early stages and failing to act earlier by quarantining the close contacts of victims, shutting schools and restricting travel. But there are 22,000 cases of pneumonia and 3,000 deaths a year in Hong Kong. A typical pneumonia of the sort seen in Sars cases but also caused by other organisms "is not rare", according to Anthony Hedley, professor of community medicine at Hong Kong University.
Against that background, it was difficult for doctors and officials to know when to signal the emergence of a new epidemic at the risk of causing unnecessary disruption to the community. The clue was the way the disease targeted health workers, proving that it was exceptionally contagious. But Hedley said critics were operating with the benefit of 20:20 hindsight. "You need very strong public-health grounds to limit the liberty and movement of people who are well. It is doubtful whether the justification for such action was available."
On 12 March, three weeks after Liu's sneeze, the World Health Organisation issued a global alert. Over the next three days, as reports of suspected cases poured in from nine countries, Gro Harlem Brundtland, the WHO director general, declared the infection a "worldwide health threat". This was a new disease but, just as important, it had found a new mode of spread: modern air travel. Hong Kong, one of the world's busiest international transport hubs, had unwittingly become the source of infection for the rest of the globe. Yesterday, the WHO issued its first warning to travellers to avoid Hong Kong and the Guangdong province of mainland China.
The first question that occurred to WHO investigators sent to investigate the outbreak was: could it be man-made? Was this biological terrorism? That notion was quickly dispelled, as the WHO's network of 11 laboratories in 10 countries around the world set to work to find the cause. The best clue to its source lay in the outbreak of the very similar illness in Guangdong three months previously, which Liu had been struggling to treat. Studies demonstrated that it was the same disease. This was not human terrorism but nature's terrorism, an example of a viral mutation which, once in a while, triggers a serious epidemic.
Viruses mutate all the time, evolving new strains that have a better chance of surviving and reproducing. A number have come out of China, known as an incubator for potentially catastrophic epidemics because of its density of population and traditional farming methods, which keep people and animals in close proximity.
Hong Kong's border with China is the third-busiest in the world, and virologists at Hong Kong University, led by Professor Malik Peiris, keep a constant vigil for mutant flu viruses of the sort that triggered the 1918 pandemic that killed 40 million people around the world. In 1997 they spotted the avian flu virus that jumped from chickens to humans, infecting 18 people and killing six. When a further case of "chicken flu" appeared in one family earlier this year, they initially thought it might be the cause of Sars. "That turned out to be a red herring," said Peiris.
But other suspects – such as adeno-viruses, which are known to cause pneumonia – didn't fit the picture, either. It quickly became clear that this was a new virus that had not been seen before. The WHO's network of laboratories, which were in daily contact with one another, narrowed the culprit down to the family of coronaviruses, the second-most-frequent cause of the common cold. Scientists say final identification of the virus is imminent, though there is still some doubt over whether one virus or two may be at work, and whether a paramyxovirus may also have a role.
In his laboratory in Queen Mary's Hospital on Hong Kong island, Peiris has cultured the coronavirus, sequenced a part of its genome and developed an antibody test for the disease – a crucial first step in the battle to contain it. Once a patient tests positive, doctors know that they must be isolated immediately. A similar test has been developed at the Centers for Disease Control (CDC) in Atlanta, Georgia.
Peiris also claims to have a successful treatment, a drugs cocktail that includes the anti-viral agent, ribivarin, and steroids to reduce inflammation in the lungs. The treatment is said to work in 80 per cent of cases, provided it is started early. However, this is not accepted by CDC, which said that it had "no evidence that any anti-viral therapy or steroid treatments are of any benefit" and that there were "no leading candidates" for a treatment.
Peiris, who believes the virus jumped from dogs, cats, rats or birds to humans a year ago and has since mutated again to allow it to pass from human to human, said it would only be possible to devise a treatment against the disease scientifically once the virus had been identified. Until then the ribivarin and steroid cocktail, which had been shown empirically to work, was a "reasonable strategy".
Today the disease appears to be under control, or close to being so, in most countries around the world, thanks to the WHO's early-warning system that alerted medical authorities to the risks posed by Sars before the disease had a chance to gain a foothold and spread.
The exception is Hong Kong, where 22 new cases (without any further deaths) were reported yesterday, bringing its total to 708 cases and 16 deaths. More than 100 cases have occurred in a single 33-storey tower block on the Amoy Gardens housing estate, raising a new and frightening possibility – that the virus could be airborne. Up until now, public-health experts and the World Health Organisation have stressed that transmission of the new virus has been confined to those who have had "close contact" with an infected person. If it were airborne it could spread much faster through the community.
Yesterday, experts were still discounting this possibility and maintaining that the likeliest explanation of the Amoy Gardens outbreak was an environmental problem such as a leaking sewage pipe. The virus is known to be transmissible through faeces: the man who is believed to have spread the infection to the estate was a kidney patient from the Prince of Wales hospital who visited his brother on the estate four times. Until the sewage theory is proved, however, doubt will remain.
The second worrying area is mainland China. Very little information has come out of Guangdong province since the crisis began, raising widespread doubts about the veracity of claims that the number of cases there has peaked and is declining. The latest figures show 1,190 cases and 46 deaths on the mainland to the end of March, though it wasn't until yesterday that Guangdong province yielded to protests from WHO officials and agreed to allow a team in to investigate. In the meantime, cases have been recorded in Beijing and Shanghai.
The single most important lesson of the Sars crisis, which is still far from over, is the need for international co-operation in the fight against disease. China's delay in sounding the alarm about Sars put the health of the world at risk. Mutant viruses know no borders and can be transmitted by travellers across the globe within hours. This time it looks as if the threat has been contained outside Hong Kong and China. Next time we may not be so lucky.
First I've heard of the kidney patient.
He said it was too early to tell whether there would be a pandemic, but added: "Its too early to tell. Its very serious, very contagious."
At what point will it, or will it not, be declared a pandemic?
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