SARS, and influenza

by Martin Williams

SARS info SARS avoidance A global threat SARS up close HK SARS China crisis SARS history Influenza Light relief

I began this page as SARS seemed to have the potential to become a global pandemic; seemed to me it might be useful to run a modest SARS blog, with snippets of news, links to info I thought useful. Now, in January 2004, it's bird flu that seems far more of a threat. I don't plan to update much about this - just now, info is appearing on the Agonist's Disease outbreaks bulletin board - but my influenza (including influenza pandemics, notably Spanish Flu) info may be useful. You can also find new info on bird flu via a Google news search.


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The emergence of SARS presents formidable global challenges. If we are extremely lucky, the epidemic will be curtailed.... If the virus moves faster than our scientific, communications, and control capacities, we could be in for a long, difficult race. In either case, the race is on. The stakes are high. And the outcome cannot be predicted.

Dr Julie Gerberding, director, the Centers for Disease Control and Prevention (CDC)
in an editorial published at on 2 April 2003.

If the SARS virus maintains its present pathogenicity and transmissibility, SARS could become the first severe new disease of the 21st century with global epidemic potential.

Dr David Heymann, executive director, Communicable Diseases, WHO
in an article titled "One month into the global SARS outbreak: Status of the outbreak and lessons for the immediate future".

With outbreaks at all the initial “hot zones” either contained or coming under control, SARS is clearly in decline

WHO, 5 June 2003

First coming to public attention as a "mystery virus" causing panic in Guangdong province in mid-February 2003, and recognised as a new, threatening disease by Dr Carlo Urbani, by 11 June SARS was believed to have infected over 8435 people in 28 countries (if we count Mainland China, Hong Kong and Taiwan as separate "countries"), killing at least 789 of them; it appeared under control outside Taiwan (also seeming under control in mainland China; hmm). Here, I've cobbled together some info on SARS, together with links I reckon worthwhile, typically adding new ones at the bottom of each section. I'm not aiming to give headline news, but to augment material in the main news items. (Note that my "Dr" is for Physical Chemistry.)

I'm calling the disease SARS as that's a specific, globally accepted name; "atypical pneumonia" - which is more favoured in the Hong Kong SAR (ahem!) - is a generic term, for pneumonias caused by more regular bacteria (and viruses?).

*** It's back - On 5 January 2004, we have a Guangdong SARS case confirmed, at least two other possible cases being investigated, mainland China about to slaughter civets that were to be sold for food. ("Told you so," seems an easy reaction - China always seemed unwise to restart the wild animals for food trade, which was mostly closed at the height of SARS in spring 03, but was allowed again after just a few months, surely for economic not scientific reasons.) As yet, cases are isolated; hopefully they'll remain so.

first written 16 April 2003; halted in mid-June; updated 23 Jan 2004

A wealth of info

The latest info from the World Health Organization appears at Disease Outbreak News; there is more at Severe Acute Respiratory Syndrome (SARS); and earlier info is archived here. If you want even more info, check out the press releases - there are some informative press briefings etc.

The American Medical Association has a page titled "Severe Acute Respiratory Syndrome (SARS) Resources", including a host of links to papers on SARS.

SARS Reference is a downloadable, "medical textbook that provides a comprehensive and up-to-date overview of severe acute repiratory syndrome (SARS)."

There is a bulletin board dedicated to Disease outbreaks on a site called The Agonist. Select the latest update, and you'll find a wealth of updated info about the disease, by "docbear" (aka Dr Barry Armstrong), followed by posts from Agonist members (turns out I'm not the only SARS-obsessive).

SARS Watch org by Tim Bishop is a weblog including comments on and abstracts of the latest media reports.

Sars virus: are you affected?, on the BBC website, has a host of opinions sent in by email; it appears to me there is a tendency for SARS to seem milder the further you are away from it.

You can find recent news items about SARS via a Google news search.

Or, visit Yahoo's SARS news portal.

SARS avoidance

It appears that - bar at least three incidents in which large numbers of people were evidently infected via woeful sewerage systems in their residential buildings, then person-to-person contact - the disease is chiefly spread by droplets coughed or sneezed by infected people. Evidence suggests these people already show symptoms by the time they are infectious: symptoms include high fever that makes sufferers feel chilled, perhaps along with a dry cough, headache, overall body aches, and diarrhoea (elderly people may not exhibit fever).

To infect someone, the virus must enter their mucous membranes - ie eyes, nose or mouth linings. In "close contact", you might inhale these droplets, or even have them land on your eyes. WHO doctors have said that you must be fairly close to someone for this to happen - say, five to seven rows from someone on a plane. Alternatively, in a perhaps rare mode of transmission, you might touch an infected surface - where the virus could survive at least 24 hours - then touch it to your nose, eyes or mouth. It does not appear the virus is "airborne" - ie, capable of floating around as virus particles.

While face masks are now popular in Hong Kong, the WHO and the CDC do not rate them for general protective use. Surgical (N95?) masks are essential for people dealing with SARS patients - and may be worth carrying around in SARS affected areas, in case you find yourself in the vicinity of someone who is coughing (and feverish); avoid coughers and sneezers I say! Anyone who might have the disease could wear a simple mask, or otherwise stop any droplets spraying out when they cough or sneeze. Here's a comment along similar veins, from Dr Julie Greenberg, director of the CDC, which appeared in a CDC Telebriefing Transcript: Update on Severe Acute Respiratory Syndrome (SARS), 14 April 2003:

QUESTION: Yes. Can you update [Inaudible] preventive measures for travelers going to or returning from affected areas? And I ask this because at least one travel product company that I know of is suggesting antibacterial wipes and a personal air purifier worn around the neck can help. So can you separate the help from the hype for us, for travelers?

DR. GERBERDING: Separating the help from the hype is a very difficult challenge in the absence of all of the data that we would like to have. So, I would rely on the old fashioned approach, which is basically common sense.

This is a disease that is spread primarily by face-to-face contact with infected SARS patients. We don't have any evidence that wearing any kind of commercial and sometimes air purifier adds anything at all to the safety of the traveler from SARS, or from any other infectious disease.

And on the other hand, hand hygiene, whether it's soap and water, or an alcohol-based hand rub, or some combination of the two, is common sense, and should be done as a matter of general personal hygiene, regardless of whether we're in a SARS era or not.

So my advice is to kind of follow the same rules that your mother taught you in kindergarten. Keep your hands clean, and cover your mouth with a tissue if you're coughing and sneezing. And use common sense.

You can find more SARS info from CDC at CDC Severe Acute Respiratory Syndrome (SARS).

A (fading) global threat

"Despite an unparalleled global counterattack, severe acute respiratory syndrome (SARS) has likely become a permanent threat that will plague humanity indefinitely, infectious disease experts say," is the non-too-cheery opening of a 21 April Washington Post article titled "SARS Virus Seen as Long-Term Threat."

"Why is Sars such a serious threat to international health? Most new diseases of the past century, with the important exception of Aids, had features that limited their capacity either to cause serious illness and death, or to threaten large numbers of people all around the globe. Sars can do both," says a writer in an "Argument" in The Independent, titled, "The cure for Sars lies in honesty and openness."

"Can SARS Be Stopped?" The answers are not clear, according to the New York Times on 26 April (you have to register, but it's free, and your computer can remember your login info).

"SARS Could Recur Anywhere At Any Time" reports the Washington Post. (Not long ago, some Beijingers were laughing at Guangdong people for panicking over a mystery virus. Taiwan was smug for a while about low number of cases.)

"Outbreaks in the initial “hot zones” indicate that SARS can be contained" reported the WHO on 13 May - though there was no room for complacency (and, not mentioned here, China and Taiwan had epidemics/outbreaks that weren't under control, and the next day Singapore reported a possible new outbreak).

"The Search for SARS's Past May Help Predict Its Future" writes a doctor in the New York Times on 20 May. He notes that, "if SARS is here to stay, fire brigades of health workers will be needed to squelch brush fires every time a case is imported into a country."

"SARS Outbreak Fading Away, Officials Say" reports the 5 June New York Times.

"The SARS Enigma: Cases Are Declining, but Fears Remain" is a good, 8 June NY Times summary of the SARS situation; mentions WHO finding China data/info wanting.

SARS up close: viewed by people treating and hammered by it

Eyewitness: Vietnam's Sars survivor is a BBC news story about a Vietnamese health worker who fell severely ill, yet survived. Even after "recovering": "My lungs haven't got back to normal and I still feel tight in the chest. ... My muscles are so weak I can hardly lift anything, and my eyes are swollen and red."

"Hong Kong Doctor's Ordeal as Patient With New Disease" is a New York Times story about a 37-year old doctor who was caught up in the Prince of Wales Hospital outbreak.

'Welcome to Sars central' is a fascinating diary by Dr Paul Caulford, about six weeks in the Scarborough Hospital at the epicentre of Toronto's SARS outbreak. He calls SARS a virus, "with a large appetite for people, and the ability to strike at will."

"Head of Sars Central: We're not heroes: Still, Tan Tock Seng Hospital's CEO has kept his composure amid the crisis, while praising staff for a job well done" is a 9 May Straits Times article focused on the main doctor working in Singapore's prime SARS hospital.

"Man's Virus Infects Town, Killing His Family" is a heartbreakingly sad story in the New York Times, about a doctor who - evidently unwittingly - returned from Beijing to his hometown in Inner Mongolia infected with SARS. Though he recovered, it killed his parents and wife; and he was arrested, made a scapegoat.

Hong Kong SARS

Summary of Confirmed Cases of Atypical Pneumonia (SARS) in Hong Kong, from the University of Hong Kong's Clinical Trials Centre, has a host of graphs; the centre also produces a Newsletter for Atypical Pneumonia (SARS).

Graph of data on numbers of SARS patients (including patients discharged or dying) in Hong Kong since 13 March 2003.

Department of Health press releases - include updates on numbers.

SARS - FEARBUSTERS is a website focusing on data from Hong Kong and mainland China, aimed at quelling panic about SARS.

Some statistics and relative risk analysis on SARS, by Paul Christensen, features updated data on SARS cases in Hong Kong, and typical numbers for deaths due to other causes, including pneumonia.

"SARS Signals Missed in Hong Kong: Slow Response Let Disease Spread, Doctors Charge" is a 20 May article in the Washington Post, centering on the arrival of Liu Jianlun, the unfortunate doctor who became index patient to the world outside the mainland.

China crisis

With China's hospitals charging for patient care, it could be that at least some of the mainland's SARS patients are being forced to fend for themselves, according to an item titled "China's Hospitals in Turmoil" in the 13 April 2003 Washington Post.

While the spotlight in SARS in China has been on Guangdong province and, more recently, Beijing - and it's surely no coincidence that the latter is relatively "open", with a sizeable expat community as well as being a base for reporters - the Asia Times reports on trouble in a less well-known region, in SARS wreaks havoc in Shanxi province.

"Hospitals in the Chinese capital hid SARS patients from international health officials," says Time (Asia) on 18 April.

"As SARS rages in China, some cadres are more intent on saving face than saving lives," says the sub-heading of the Time (Asia) 21 April 2003 cover story - "Unmasking a Crisis". (A nurse who's quoted reckons the death rate in her hospital is 25 percent; the true situation seems very confused there.)

Days later, Time (Asia) says "Shanghai SARS Cases a State Secret", and covers the spread of SARS from major cities, in "Regional Affair".

With China's media now (from around 22 April) able to report more openly on SARS, the People's Daily reports, "Wen Jiabao, the Chinese Premier, has said the consequences of the disease for the country could be 'too dreadful to contemplate'." China Combats SARS has news from the People's Daily.

"From China's Provinces, a Crafty Germ Spreads", is a strong New York Times article tracing SARS from its origins in Guangdong (in markets and restaurants catering to people with a penchant for eating wild animals?)

"Did Guangdong Beat the Bug?" asks Time (Asia) on 28 April. On the face of it, perhaps yes. (Though I've just heard of four Shenzhen hospitals that have fair numbers of SARS patients. Seems to me almost miraculous if Guangdong really has got SARS about controlled.)

"Impact of SARS on China may be profound," according to Taiwanese economics professor Chang Ching-hsi, who gives a secondhand report of a Beijing doctor saying, "The official figure is even lower than 0.1 percent of the real number of SARS cases in China."

SARS Virus Hits China Trade in Endangered Animals tells of China cracking down on selling and eating animals such as snakes, pangolins and cranes. Though already illegal, the trade was commonplace in Guangdong; the crackdown stems from strong suspicions the SARS virus originated in wild animals sold for food.

In "China Keeps a Brave Face", Newsday says the country's Centers for Disease Control, just one year old, has, "insufficient staff, out-of-date laboratories, no centralized computer system and no legal power to compel cooperation."

"Signs of Improvement at Epicenter of SARS Outbreak" - it appears SARS really has abated in Guangdong, according to this 4 May Washington Post article.

"Hospitals try to dupe officials about Sars" says the Times Online on 9 May, as WHO officials visit a town outside Beijing - the hospital gets some new decor, staff meeting the officials don face masks, and nearby clinics close.

"China points finger at U.S. for SARS" says Taiwan News 9 May - as a Hong Kong based, Chinese government paper concocts a tale to suggest the first SARS case was in the US over a year ago. Like intimations by a Guangdong official that SARS originated in Hong Kong, this conveniently ignores the facts. Next up: it came from space aliens; you read it here first. (Oops, too late, SARS from space notion mooted in today's Hindustan Times.)

"Fearful Chinese slaughter pets in Sars hysteria" reports the 9 May Times Online.

"China's Failing Health System: In China's hinterlands, medical facilities remain woefully unprepared for the SARS outbreak, hobbled by years of government neglect" reports Time (Asia) in its 19 May issue.

"The Quarantine Blues: With suspected SARS patients getting dumped in their backyards, China's villagers rebel" is another article in the 19 May issue of Time (Asia) - telling partly of mistrust of government information. One official remarks, "We cannot allow every peasant in this area to know the real SARS situation, because they just won't understand."

Since late April, according to an article by CNN's Senior China Analyst, the "Theory of the Three Represents" has been guiding China's crusade against SARS. Go figure! (And wonder: is this at least partly why it seems there's been a dearth of fresh info from the mainland lately?)

"President [Hu] Responded to Pressure Inside and Outside Country on SARS" says the Washington Post on 13 May, in an article that looks at the background to China at last coming clean about the SARS epidemic in Beijing.

"China's health crisis unmasked" is a Sydney Horning Herald article based on a visit to a county in Shanxi province. Includes, "Other staff said the hospital's finances were staggering under the cost of treating SARS patients in prolonged intensive care, which could amount to 120,000 renminbi ($24,000) for one case." Also says the govt's recent demands for honesty seem to be aimed at reporting to the central govt; not necessarily for informing the outside world (inc the WHO).

"Air China Flight 112: Tracking the genesis of a plague" is a Boston Globe article about a flight from Hong Kong to Beijing on 15 March, during which one unwitting SARS sufferer infected 15 passengers and cabin crew. "New details surface on initial cover-up" is a follow-up article in the Globe.

"Government launches 'People's War' to rally nation with propaganda" says the Baltimore Sun on 23 May, in an article on SARS propaganda including songs for farmers (really).

"Sick With SARS But Snubbed By Hospitals" is a 27 May Newsday story, about a young woman in Beijing who caught SARS, but only managed help after getting help from an American businessman.

"Village by Village, China Fights Virus: SARS Battle Shows Party Can Still Mobilize the Masses" is an 8 June Washington Post article, based chiefly on recent visits to villages and small towns; also mentions Tianjin's success in containing SARS.

Also interesting

"Health Agency Took Swift Action Against SARS" is a New York Times article, focusing on the lead-up to the WHO issuing alerts - including by trying to glean information other than rumours about the emerging epidemic in China.

"Global Collaboration on SARS Bears Fruit" is a 26 May New York Times story , looking at the discovery that SARS was caused by a new form of the coronaviruses, which had been rather little studied before ("Suddenly they're rock stars.").

Influenza - sometimes a whole lot worse than a heavy cold

Consequences of an influenza pandemic

During the last century, 3 influenza pandemics caused millions of death worldwide, social disruption and profound economic losses. Influenza experts agree that another pandemic is likely to happen. Epidemiological models project that in industrialized countries alone, the next pandemic is likely to result in 57-132 million outpatient visits and 1.0-2.3 million hospitalizations, and 280 000-650 000 deaths over less than 2 years. The impact of the next pandemic is likely to be greatest in developing countries where health care resources are strained and the general population is weakened by poor health and nutrition.

From Pandemic preparedness, by the WHO.

I've seen and heard comments that the death toll from SARS is "only" four percent (it actually seems to be rising somewhat - now looking like 10-15 percent), so SARS isn't so worrying. But in 1918-1919, the "Spanish Flu" - killed 20-100 million people worldwide, with a death rate of perhaps three percent (maybe two percent in US, given 25 million infected, 550,000 dying, according to article in next link; yet at least 22 percent of Samoans; also - thanks to Dr Barry Armstrong aka docbear - 90 percent of Canada's Inuit).

According to recent research, this flu perhaps began at an army camp in France in 1916, and went through a "smouldering period", with at least one outbreak in 1917, before it swept the world as the First World War was coming to an end. Interestingly - given the situation with SARS - it was called the Spanish Flu after military censors kept deaths in France, Germany and US out of headlines; it became news once it reached Spain, which was neutral in the war.

Here's an article, with links to interviews with people who lived through the pandemic (in the US): The 1918 Influenza Pandemic.

The Influenza Pandemic of 1918 is a stronger article I think; tells of people dying horribly of suffocation - and of this influenza targetting otherwise healthy young adults. (My speculation: perhaps like SARS, the immune system is turned on the lungs, so people with stronger immune systems suffer more; albeit with SARS, so far, it has been possible to coax most through worst of it with steroids, oxygen, ventilators.)

Oh, and if you think that closing schools - and debating whether this is a worthwhile move - along with deterring or banning public meetings, recommending plenty of fresh air and disinfecting, and widespread wearing of face masks are all novel in Hong Kong in spring 2003, check out: The Public Health Response.

1918, Washington's Season of Death is a 22 January 2004 Washington Post article about this flu ravaging Washington (3100 killed; massive disruption to daily life).

Bird Flu is a form of influenza that can infect poultry and, in rare cases, people. It was first recorded to infect people in Hong Kong in 1997, when there were 17 cases and 6 deaths; it appeared that all cases were contracted by direct contact with chickens. The government slaughtered chickens to control the outbreak, but bird flu reappeared in Hong Kong (caught in mainland China?) early this year, when there were one confirmed case, and two deaths. It also surfaced in Europe: first in February in the Netherlands, where 11 million chickens have since been slaughtered, and a vet died of the disease in April. It has spread to Belgium, which is also slaughtering chickens: Belgium steps up bird flu cull. As yet, it appears bird flu is not transmitted directly between humans - should it mutate so human-to-human transmission becomes easy, it could become a pandemic; hence the chicken culls aimed at wiping it out. A vaccine has been developed, but human trials are needed (hmm, conflicting reports about this 19 Jan 2004 - when bird flu looking far more worrisome).

Medical Ecology: Influenza has info on flu, inc pandemics from 1580.

Amidst the doom n gloom...

On 24 April - a day after titling an interview "WHO warns SARS morality rates worsening" (I emailed, told em about this) - ABC Online published a transcript of a radio segment, Fury in Toronto over SARS warning, which included this interview with Toronto mayor Mel Lastman:

JOHN SHOVELAN: The colourful Toronto Mayor, Mal Lastman, learnt of the WHO travel advisory in the morning news.
MAL LASTMAN: I'm shocked that the medical evidence before us does not support this advisory, and I'm told that they've never issued an advisory like this before in their history.
JOHN SHOVELAN: But despite local government fury, Toronto’s Catholic Church banned communion and confession last week, before Easter, because of its fears the virus could be spread during Mass.
Major League Baseball has also warned its players travelling to the Canadian city to play the local Blue Jays team not to sign autographs for their fans.
And America’s Centre for Disease Control and Prevention has told people travelling to Toronto to take their own first aid kits so they can avoid hospitals, and said Immigration officials would issue special yellow cards to people who've travelled to the city.
MAL LASTMAN: What I'm doing right here, right now, is sending out a message to this CDC group, whoever the hell they are.
Well who's the CDC?
REPORTERS: The Centre for Disease Control.

Good for a cheap laugh I reckon; but it's a bit scary to find berks like this in charge of cities.

While you've gotta love this, from Ananova on 13 May:

A leading Russian scientist say they have come up with a way of warding off Sars - a double shot of vodka.
Experts from the Medical Academy in Moscow believe the worldwide commotion over the virus is over-exaggerated.
Anatoli Vorobijev, from the department of microbiology and immunology, says the daily consumption of 10 centilitres of vodka should be enough to ward off the life-threatening epidemic.

Cheers! - and here's to your staying healthy.

And Cheers! too, to Ozzy Osbourne for heading for a June concert in Toronto in spite of SARS, and for a highly entertaining advance interview with the Toronto Sun. (But be warned: you can't tolerate beeping swearing, don't read it.)

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