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SARS, THE NEWEST KILLER
The story of SARS (severe acute respiratory syndrome)—why the virus spread so rapidly, and how the international community responded—is a powerful, cautionary tale about the thorny challenges we must grapple with as we confront a growing number of infectious microbes that are evolving at an alarming rate. In the chapters that follow, we explore these pressing issues, introducing all the vital information the public needs to know about how best to protect ourselves against these diseases, as well as measures the medical community and our government should be taking to fight them. SARS has unfortunately established a significant foothold around the world, and we must expect that it will continue to spread—though less rapidly—and also to evolve, just as West Nile virus, Lyme disease, and other recently emerged scourges have done. SARS is one of the fastest spreading and most virulent new diseases the world had seen in some time. Yet we might well face an even more deadly foe before long, and we must learn the lessons the SARS saga holds for us.
The good news witnessed during the SARS outbreak is that the world community has made great progress in its ability to track and combat emerging diseases. But the outbreak also brought into stark relief a number of weaknesses in our defenses and a set of tough questions we must address. When a new disease has broken out, can we depend on all nations to share information readily and to take the necessary steps to limit the spread? What are the most effective means of containing a new disease, and what are the acceptable limits of government control? In the case of SARS, did the World Health Organization and national health authorities act fast enough to warn people of the danger, or did they go too far in some countries, provoking unnecessary panic? What social costs are we willing to pay in order to respond with the vigilance required? Do we need more disease detection at airports and other points of entry, or tougher quarantine laws? What will the ripple effects on the world economy be? And most fundamentally, how can we best determine that a new disease has appeared, and why it spreads so much more rapidly in one locale versus another?
The World Health Organization (WHO) sounded the SARS alarm on March 15, 2003, declaring the disease a worldwide health threat because it was spreading so far, so fast. In less than seven days after the first case had been identified in Hong Kong, dozens of people, many of them health care workers, had come down with it there, and patients had also been diagnosed with SARS in Hanoi, Vietnam, and in Toronto, Canada. The fact that the disease had made it all the way to North America so fast alerted the WHO that this outbreak might well become a global epidemic.
The first symptoms of the disease were fever and dry cough, and in some people muscle aches, sore throat, and diarrhea. These symptoms mimic those from influenza or the common cold, so at first patients were unaware of how serious their illness was, and many didn’t go to see a doctor. However, SARS quickly progressed to pneumonia in some patients, or caused such difficulty in breathing that doctors had to hook some up to mechanical ventilators. Those who succumbed were killed when, as in other pneumonias, the heart or other organs failed due to the stress of not getting sufficient oxygen.
More than any other recent disease, SARS traveled like wildfire because of “superspreaders,” people infected with a disease who pass it on to an inordinate number of others. In Singapore, for example, one young woman who checked into a hospital after returning from Hong Kong infected twenty nurses and patients, while two other young women who had also come back did not pass on the germ to anyone. Evidence for superspreaders is rare in history. Occasional AIDS patients and TB carriers may have fit this label, and certain people exposed to any ailment such as flu are more contagious than others, but the SARS superspreaders stood out as flagrant examples. Ironically, it was the unusual spread of SARS from a single patient to many of that same person’s doctors and nurses that first alerted the medical community this disease was different from other pneumonias. Indeed, it was the stunning specter of large numbers of hospital workers falling gravely ill in several of the treatment centers where patients were being examined that prompted the WHO to issue a global warning.
As of early May it was still unclear if the superspreaders were somehow different from other patients, or if they were just at the bad end of a spectrum of infectivity. They are a topic of great interest, but little is known yet. Do they have a differently mutated form of the virus? Are they co-infected with another virus that amplifies their contagiousness? Or are they just more susceptible to the virus because of a weak immune response, which allows the disease to proliferate that much more wildly in their bodies, so that their breath is literally saturated with virus particles? Unlike Hong Kong and Toronto, the United States was lucky that a superspreader had not traveled to the country, which is the reason so many fewer cases occurred here.
Although the news of SARS erupted on March 15, as we now know, the disease had already been coursing through southeastern China for three months but that was kept quiet by the Chinese government. Officials at the WHO who worked inside China apparently received some word about the problem, but either they were not given enough information or they reacted slowly to the snippets they did receive. The first glimmer that a truly dangerous situation was developing occurred in November 2002, when WHO officials attending a regular influenza meeting in China heard that several people in the southeastern part of the country had died from a severe pneumonia. These deaths raised a red flag, but the local analyses of virus samples from the patients showed nothing unusual about the virus.
Then in December, Hong Kong newspapers reported the deaths of wild ducks and geese at a park within the Sha Tin racecourse in Hong Kong. After inspectors discovered that the fowl had been infected with a flu virus, they closed the park and destroyed all the remaining birds. Officials in Hong Kong are all too familiar with the story of a 1997 outbreak of H5N1 avian influenza that killed a 6-year-old boy and prompted the slaughter of millions of chickens due to fears that an epidemic might be kicked off. When flu viruses jump from an animal to a human, they can be extraordinarily virulent. That’s why officials in Hong Kong are always on alert, especially considering the annual preponderance of flu outbreaks in the region. They felt confident that by their speedy action in this case, they had addressed the threat.
By early February 2003, however, rumors in China were spreading about more unusual human pneumonia cases, occurring in the southeastern province of Guangdong, and those rumors reached regional WHO officials. Then a local doctor told them that a 33-year-old Hong Kong man had died of an aggressive flu-like illness, and that his 8-year-old daughter had also died of pneumonia in mainland China; on top of that his son was now hospitalized too. For young children to die from pneumonia is quite unusual, and this time the WHO inspectors decided to get samples of the virus themselves for analysis. At first their test suggested that the man and his son had indeed been infected with an avian flu, just as the Hong Kong officials had suspected, and it seemed that this might be a version of the 1997 strain from Hong Kong, but subsequent tests showed that the virus was unrelated to the 1997 strain.
With that news, Hong Kong health officials, as well as WHO experts in the region, became concerned that the avian virus in Hong Kong might be related to the cases of what was being called “atypical pneumonia” that they’d been hearing about in China. They were primed to look for such connections as part of their regular surveillance of possible new influenza strains. Then suddenly, on February 10, the Xinhua News Agency, mainland China’s government-controlled news organization, published a strange announcement that an outbreak of atypical pneumonia was under control. The announcement also reported that plague and anthrax had been ruled out as causes, although it gave no explanation as to why these would have been suspected. The infectious agent causing the disease, the report said, was still unknown but was presumed to be some sort of virus, because the disease did not respond to antibiotics, which combat bacteria.
WHO officials pressed the Chinese government for more details about the outbreak. In response, the Chinese Ministry of Health informed the WHO that it had 305 cases, which included five deaths. It also mentioned, to WHO’s surprise, that the cases had been mounting since the end of 2002. Becoming really worried now about a possible bird flu outbreak, disease specialists at the WHO and the U.S. Centers for Disease Control and Prevention (CDC) alerted U.S. government officials. On February 20, U.S. Secretary of Health and Human Services Tommy Thompson, Surgeon General Richard Carmona, and the new director of the National Institutes of Health, Elias Zerhouni, urged Chinese officials to keep the rest of the world informed about the progress of the disease.
The next day Liu Jianlun, a 64-year-old respiratory disease specialist at Sun Yatsen hospital in the Guangdong province, checked into the Metropole Hotel in Hong Kong to attend a wedding. He had been treating several sick patients and didn’t feel well himself. Guests from Singapore and Toronto were staying on the same floor, as was Johnny Chen, a Chinese-American businessman based in Shanghai. Chen flew next to Hanoi, and by February 26 he was feeling extremely ill. He went to the Vietnam-France Hospital there, suffering from a high fever and a hacking cough. Doctors diagnosed him with pneumonia, but they had also heard rumors that a severe, untreatable respiratory infection was circulating among physicians in southeastern Asia, and they worried that Chen might have fallen ill with that. So the Hanoi doctors reported Chen’s condition to the regional WHO office in Manila. A veteran doctor there, Carlo Urbani, took special note of the alert, and rather than send a staff physician—the usual procedure—he decided to go himself.
Urbani, a balding 46-year-old from Italy, was an expert in human diseases caused by parasitic worms. But he was also a tireless foe of infectious diseases, and for years had hunted down pathogens that were killing legions of people in the poorest corners of the world. For a time he was head of the Italian chapter of Doctors Without Borders, and in 1999, when that organization won the Nobel Peace Prize, he said that doctors had to “stay close to victims” if they wanted to wipe out disease. Urbani practiced what he preached.
When he arrived at the Hanoi hospital he was alarmed. Chen’s fever was erratic, he wasn’t eating, he was slipping into and out of consciousness, and he needed a ventilator to breathe. Urbani immediately took blood and saliva samples. He became even more anxious over the next few days when, one by one, doctors and nurses who had contact with Chen were falling ill with the same symptoms. Clearly, whatever Chen was carrying was a highly contagious infection. Urbani urged all the hospital’s personnel to wear high-filter face masks and double-gowns, which were not routine in poor hospitals there or around the rest of the world, and told the hospital’s administrators to isolate everyone who was ill. Then he sent an urgent alert to his colleagues at WHO headquarters in Geneva.
Urbani continued to monitor Chen, and doctors tried to ease his severe pneumonia, but Chen did not improve. By March 9 dozens of the hospital’s workers had become gravely sick. Urbani and the director of the WHO Hanoi office met with Vietnamese officials and advised them to isolate patients and screen travelers arriving from Guangdong. On March 11 officials quarantined the entire hospital, and other hospitals in the area instituted strict infection-control procedures.
That same day, Urbani left on a plane for Bangkok, where he was scheduled to address a conference on the topic of deworming schoolchildren. But before he departed he called ahead to a fellow WHO doctor there to say that he was feeling ill himself. An American disease expert who was on assignment for the WHO in Bangkok went to the airport to pick him up. Urbani, feverish and ragged-looking, warned his colleague to keep his distance, and the colleague insisted Urbani get help, and brought him to a city hospital.
Urbani’s condition was the last straw for WHO leaders, who had been monitoring developments surrounding the mystery illness for three weeks now. Part of the WHO mission is to act as the central clearinghouse for information about outbreaks around the globe, from Ebola and cholera to flu and TB. Member states, which include most nations, are supposed to forward breaking health information, especially about infectious diseases, to the WHO so that it can monitor all potential outbreaks. At this point the WHO realized that too many people in too many places in southeastern Asia were coming down with the same serious condition. The WHO alerted its Global Outbreak and Response Network, an international coalition of 100 national governments and scientific institutions that have expertise in infectious diseases. The mandate: Scour every bit of medical and media information about anything even remotely related to what was already known, and check samples from patients to figure out what was going on.
Then, on March 13, WHO officials got some truly troubling news. Doctors in Toronto reported that a 43-year-old man, Tse Chi Kwan, had just died of intractable pneumonia. The chilling detail was that his mother, Sui-Chu Kwan, who lived with him and his wife, had died at their home of the same illness one week earlier—right after flying back from the Metropole Hotel in Hong Kong. She had stayed in the same place as Johnny Chen and Liu Jianlun. The very same afternoon, Chen died of respiratory failure in Asia.
If that wasn’t bad enough, nurses who had treated Kwan at a Toronto hospital were getting sick, repeating the pattern that had occurred in Hanoi. And German officials had just intercepted a plane during a stopover in Frankfurt to hustle off a 32-year-old doctor who was on board. The doctor had treated patients with similar symptoms in Singapore, and had then attended a medical conference at the Crowne Plaza Hotel in Midtown Manhattan. He, his wife, and his mother—all on the same plane—now had high fevers and rough coughs. WHO’s global network was picking up all these reports and plotting a map of deadly infection on three continents. The mystery illness was quickly jetting around the world.
The WHO’s analysis had been unusually quick. Widely criticized for its slow response to the AIDS epidemic a decade earlier, the WHO had made improvements. To a large extent the organization had always been, and still was, concerned primarily with chronic scourges like TB, malaria, and cholera, which require a well-planned, long-term response. The exception was influenza, which WHO monitored relentlessly. Was this new infectious disease in the same category? Top WHO officials, including David Heymann, the executive director of communicable diseases, called for an emergency teleconference of WHO officials and leaders from national health agencies such as the CDC. The group would have to decide if this new menace was truly a global threat—and if so, how to respond. Heymann would host the meeting from Geneva on Saturday morning, March 15.
Within hours, Julie Gerberding, director of the CDC, convened that agency’s own infectious-disease experts at its brand-new Marcus Emergency Operations Center, a 7,000-square-foot bunker at CDC headquarters in Atlanta. The center had been quickly built after the anthrax attacks, when staffers found themselves communicating with nothing more than standard telephones and pagers. The center wasn’t even officially opened yet, but it had been equipped with 85 workstations, nine team rooms, and a secure, state-of-the-art command station sporting high-frequency telecommunications networks and geographic disease-mapping systems. The technology assembled in this facility would enable Gerberding to communicate in real-time with the Department of Health and Human Services, federal intelligence and emergency response officials, and state and local public health officials, creating an ad hoc network among such groups that otherwise did not usually coordinate.
When WHO contacts from around the world met in Geneva on Saturday, March 15, they brought with them as much local intelligence as they could. Their reports revealed that the mystery illness was highly contagious—it was infecting so many people so quickly in Hong Kong, Singapore, Vietnam, and Toronto that it must be spreading by simple close contact—people coughing or sneezing on one another. And it had hopped continents so easily that people must remain contagious for some time, meaning travelers could spread the pathogen far and wide. WHO officials issued a statement right after the meeting ended saying that the illness was a “worldwide health threat”—a pronouncement WHO had never made at the outset of any new disease, not even AIDS. The representatives at the meeting also came up with a name for the mystery illness: “severe acute respiratory syndrome,” which was quickly shortened to SARS.