VIETNAM NEW SARS HOT ZONE, U.S. Warns Citizens in Vietnam To leave

WASHINGTON (Reuters) - The State Department on Sunday urged U.S. citizens to consider leaving Vietnam because of severe acute respiratory syndrome (SARS), a deadly form of pneumonia, and said it was offering free flights out to family members of U.S. diplomats in the country.

The move follows the U.S. government's decision on Friday to suspend official travel to Vietnam and to advise U.S. citizens to put off non-emergency travel there because of the disease and the reduced availability of medical treatment.

"The Department of State has authorized the departure, on a voluntary basis, of family members at the U.S. Embassy in Hanoi and the Consulate General in Ho Chi Minh City," the department said. "U.S. citizens in Vietnam should consider departing." "Due to health concerns in Vietnam regarding the presence of Severe Acute Respiratory Syndrome (SARS), the lack of adequate medical care and facilities, as well as nonavailability of commercial means of medical evacuation for SARS patients, the Department of State warns U.S. citizens to defer non-emergency travel to Vietnam at this time," the department added in its statement, echoing Friday's warning.

Animal to human mutation of virus often a simple step

By JENNI LAIDMAN

BLADE SCIENCE WRITER

In 1988, thousands of Atlantic seals died in an outbreak of a distemperlike virus. In 2002, thousands more fell prey to a second round that threatened to wipe out half the population of gray and common seals. A similar distemper epidemic struck lions in the Serengeti in 1993-94.

In 2002, 103 people died in an outbreak of Nepa Virus. Nearly 300 people in Singapore and Malaysia were infected. All lived around pigs. In Australia, a virus in horses killed two trainers who worked with them. Today, at least 10 people are dead and 350 others infected with a virus world health workers are calling Severe Acute Respiratory Syndrome. Researchers think they may have a handle on the culprit behind SARS. It appears to be of the same family that killed seals and lions, and moved from pigs and horses to humans: the paramyxoviruses.

These stories of paramyxovirus epidemics are frightening. But perhaps more disquieting is this: These are the close relations of our childhood companions - chickenpox, measles, and mumps.

These are treatable. It is not unheard of for mothers purposely to take a preschooler to the home of a playmate with a paramyxovirus, simply to get chickenpox out of the way. But these tamed varieties - although measles outbreaks in unvaccinated populations are quite capable of killing - allowed us to forget just how utterly pliable a virus can be in the right setting. Often that setting is a place where animals and humans mix, says Stanley G. Sawicki, a virologist at the Medical College of Ohio.
This flexibility stems, in a large part, from the nature of viruses.

Viruses are little genetic instruction sets waiting to be carried out. What is critical here is that paramyxoviruses, such as influenza viruses, are poor copiers. There is no spell-checking and no repair.

Their offspring are often full of errors, says Dr. David Mindell, a professor of ecology and evolutionary biology at the University of Michigan.

"They need to have lots of progeny," because many won't survive the bad editing, he says. Yet the ones that live can win accidental benefit from this low-fidelity process. The significance of even a single error can be heart-stopping.

Take an influenza outbreak that occurred in 1997.

The World Health Organization keeps close watch for emerging flu types in order to ensure yearly vaccine formulations keep up with viral evolution. The influenza strain that showed up in Hong Kong in 1997 had all the hallmarks of big trouble. It jumped from chickens to humans and killed its victims. A mutation allowed it to evade the body's initial defenses.

Quick action to kill more than a million domestic fowl prevented human disaster. Only six people died in the outbreak because the virus hadn't learned to move from human to human, only animal to human. Had it gained a foothold in humans, it may have easily evolved to close that final gap in our defenses.

A single mutation made it deadly, reports Robert G. Webster, a virologist from St. Jude's Children's Research Hospital in Memphis in a recent issue of American Scientist. The influenza virus has eight genes made up of a few thousand nucleotides. A change in a single nucleotide endowed this influenza strain with murderous capabilities.

What contributes to the mutability of paramyxoviruses and influenza may be the hosts in which they land. In influenza, the pattern is well known. The virus lives in waterfowl without causing disease.

But when waterfowl mix with domestic animals, the virus can jump species. In China, where poultry, pigs, and people live in close proximity, it's an easy set of steps. Pigs make ideal cauldrons for virus brewing. The animal's cells carry receptors for both bird and human viruses. When viruses from both species meet inside a pig cell, they may swap genes. The result is a new viral form fit for humans.

Such species mixing may have played a role in the SARS virus.

"Any time you have intimate contact between animals and people," there's a chance for new combinations with new virulence," says Michael Lairmore, who studies viruses at The Ohio State University.

Hong Kong to Close Schools with Pneumonia Patients

— HONG KONG (Reuters) - Hong Kong, which is battling to stop the spread of a deadly form of pneumonia, ordered all schools be disinfected and said on Sunday it would shut for a week any school with a child or staff member ill with the disease.

Education Secretary Arthur Li also told a news conference he was ordering about 180 children with family members infected with the severe acute respiratory syndrome (SARS) to stop attending classes for a week from Monday.

Officials say five schools have already been ordered closed. School children or staff with sick family members in the future should also not go to school for a week, he said.

But he stressed the 180 children with sick family members were not, at present, sick themselves.

Local health officials had earlier said six children were infected and five of them went to school. Li said all the sick children had contracted the disease from family members, and there had so far been no transmission between schoolchildren.

"More children will be infected in the coming week," Li said, without elaborating. "We believe with these measures, we can prevent the spread of the virus in schools."

Most of the sick are in Hong Kong, where the number of patients has risen steadily.

Singapore Fashion Festival expects to attract 80,000 amidst global situation

By Hasnita A Majid/Ong Chung Hui
Amidst a gloomy global situation, the Fashion Festival hopes to be a bright spark, and the organisers hope to attract 80,000 people.
This is despite its main draw, well-known designer, Azzedine Alaia, has cancelled his show here.

But fashion pundits won't be disappointed as another fashion guru, Giambattista Valli from the House of Ungaro, is stepping in.

Giambattista Valli, Emanuel Ungaro's artistic director, said: "Asia is very important, not only as a business, but it's the attention that customers can give you. I think some of the European markets are a little bit saturated at the moment and I think it is the fresh attitude, this fresh way to welcome new styles."

Singapore Tourism Board says that although there are some cancellations of tours, it still expects the Festival to draw the crowd.

Yea that's the ticket we'll put on a show...

Virologists at the B.C. Centre for Disease Control have been doing specialized testing on patient samples from the B.C. and Ontario cases.

It's sending specimens and results to the National Microbial Laboratory in Winnipeg.

"We've been trying a bunch of different techniques to find the agents," said Dr. Mel Krajden, head of the virology section at the B.C. Centre for Disease Control.

Krajden and his staff analyzed swabs taken from the patients.

He has found no evidence to show the virus is from the same family that causes measles and mumps, as scientists are suggesting.
"Until it's confirmed more consistently, we can't say what it is," he said.

Health Canada has warned travellers to avoid Hong Kong, Singapore and Vietnam.
Health officers are also monitoring passengers arriving from Asia at Vancouver International Airport.

Dr. Bob Hancock, a microbiologist at the University of B.C., said our aging population is becoming more exposed to infection.
Diseases are moving quickly around the world through air travel.

Meanwhile,
antibiotic resistance is increasing.

"We have to get a bit more concerned than we might have been 20 years ago," he said

ACT I

LUNAR New Year's day on Feb 1 did not find the Deng family in a celebratory mood. To be sure, farmers like them, scratching out livelihoods in hamlets all over southern Guangdong, had endured generations of poverty. But the New Year was always a joyous time - unless there had been a bereavement.

This time, the elder Deng, full name unknown, felt like hell. His body was racked by a paroxysm of violent coughing and he spluttered and gasped for air.

As Mrs Deng massaged his sore muscles in quiet desperation, she wondered if her husband had caught the pneumonia which had started in November in the nearby industrial city of Foshan, population 3.5 million, 20 km from Guangzhou.

Hundreds had been afflicted throughout the Guangdong province since. Official figures put the death toll at just five, but the word going round was that ''a couple of hundred'' had fallen prey. No one knew for certain, as there was little being reported in the local newspapers.

''Who's going to get the swill to my pigs? Who's going to feed the ducklings?'' Mr Deng must have thought as his wife insisted he be hospitalised.

Their three little ones were too young and his aged parents too frail to help out on the farm.

Still, that day, they left the chores undone and though it was an inauspicious day to be even near a hospital, his wife managed to get him to the Heyuan People's Hospital in Guangzhou.

His condition deteriorated over the next few days. There was a distinct atmosphere of panic in the hospital; medical staff as well as visitors wore surgical masks all the time, peeling them off only when they exited the premises.

Then Mrs Deng's worst fears were realised: ''Madam, we are transferring Mr Deng to the Guangzhou Army's General Hospital.''

The physicians had also decided to move another like him to the Shenzhen Fujian Hospital.

This is the fastest-growing group of viruses, with new members being frequently discovered. One of its new variants, Nipah, transmitted from pigs to humans but not from humans to humans, killed 105 Malaysian farmers in late 1998 and early 1999. -- AFP ''We can't deal with cases like Mr Deng here.

Eight medical staff at our hospital have also developed similar symptoms. Everybody's scared,'' she was told.

In the bigger hospital, there were many others like him, down with fever, coughing, shortness of breath and difficulty in breathing. They had been transferred here from outlying parts of their far-flung province.

In his new place, fortune smiled on Mr Deng, who began to improve. He felt it was all due to the kindly 64-year-old professor who seemed to work around the clock, caring for him and others like him.

''You have chlamydia pneumonia,'' the professor had told his patients, offering the consensus opinion of Guangdong physicians at the time. He was referring to an organism with features of both bacteria and viruses, first recognised 20 years ago as a germ that causes respiratory infections.

''Its other name is Taiwan acute respiratory pneumonia,'' he told them.

Mr Deng was well enough to remember that it was Feb 15 when the professor, looking rather unwell on his ward rounds, was interrupted by someone telephoning him from the Special Administrative Region (SAR) of Hongkong.

Catching snatches of the conversation, he gathered that the elderly doctor would be in Hongkong for a wedding reception on Feb 21. He would be staying at the Metropole Hotel on Waterloo Road in Mongkok, on the ninth floor.

ACT II

ON FEB 20, the professor discharged Mr Deng and several other patients; he himself had been feeling unwell for five days.

Still, the next day, with a fever and dry cough, the doctor and his wife made their way to Hongkong.
They got to the Metropole, a popular hotel with tourists, and the doctor flopped down in his bed for a long nap.

That evening, he had a raging fever, but struggled nevertheless to get ready for dinner.

In the lift lobby of the hotel's ninth floor, while waiting for the elevator, he might have coughed and sneezed violently.

Perhaps, he and his embarrassed wife might have apologised profusely to others there, which could have included the six who would come down with the same bug.

There was an elderly tourist from Canada, who would later fly home to die, three Singaporeans, who took the infection home with them, and a 26-year-old Hongkonger, an airport worker who had come to the hotel to visit a friend.

At the wedding dinner, though feeling rather unwell, the professor and his wife had a joyous reunion-of-sorts with his brother-in-law and sister.
When they got back to the Metropole late that night, they must have felt worse for the night out, so bad, in fact, that they were both taken to Kwong Wah Hospital the next day.

A few days later his sister and her husband were also stricken. The good news was that his wife and sister recovered quickly and were discharged.
However, the medico's medical condition went downhill fast.

By March 4, he was dead.

The next day, the 26-year-old airport worker who had caught the bug in the lift lobby and who had been ill for a few days finally presented himself at the emergency department of the Prince of Wales Hospital.

He was immediately admitted to Ward 8A and would later be erroneously designated the index, or original, patient.

For in his wake, dozens of the hospital's workers also fell sick with what would be called severe acute respiratory syndrome (Sars).
Unlike the 64-year old professor, the 26-year-old survived.

The Singaporeans who might have been in that fateful elevator encounter became ill after returning home, but all recovered. However, many others in Singapore became infected, including a doctor who treated them.

He went on to a New York conference, but on the way home, had to be taken off a flight in Germany, together with his 13-week pregnant wife and his elderly mother. They were all quarantined.
The Canadian woman, 78, staying on the same floor of the Metropole Hotel, went home, fell sick and later died in Toronto.

All this while, perhaps, neither the victims nor their attending physicians were yet to make the crucial link to a press conference that had been hurriedly convened on Feb 11 by Guangdong health authorities.

They claimed to have recorded 305 cases of a suspiciously similar disease since November 2002. The outbreak, they averred, was now under control. In fact, their cases would taper off only in late February.
On Feb 26, the penny finally dropped.

But this chain of events might not been traced if not for a different strand in our story, Mr Johnny Chen, who flew from Shanghai to Hanoi, via Hongkong, on Feb 23.

The 49-year-old Chinese American, a garment merchandise manager who lived in Shanghai, working there for a small garment firm, was in Hanoi on a routine business trip when he fell sick after a night out on the town on Feb 24.

Knowing little about the outbreak, doctors at the Hanoi French Hospital failed to make the connection. Still, his condition baffled them so they notified the World Health Organisation (WHO).

A week later, Mr Chen was flown to Hongkong by private jet at his family's request. Meanwhile, a worker employed by the Hanoi contractor who had taken Mr Chen shopping came down with a similar illness.

She survived.

Not so lucky were a nurse and a doctor who had treated Mr Chen in Hanoi. They later died, while three of the 31 other hospital staff who also came down with symptoms remain in serious condition.

On March 13, Mr Chen perished in Hongkong where 145 cases were already on the books.

He had not been at the Metropole but his residence in Shanghai raised a red flag. Could the virus have made its way there too?
Meanwhile, similar outbreaks involving people who had been in Hongkong or Guangdong around that time were being reported worldwide.

By now, all fingers were pointing at Guangdong as Ground Zero.

ACT III

ON March 16, when the WHO put out a rare travel advisory calling Sars a global threat, more than 215 cases outside China had already been reported.

The following day, WHO officials in Beijing announced that a new team of specialists would be arriving in China within days to review the work done by Chinese doctors and recommend a course of action.

Ms Helen Clark, the Prime Minister of New Zealand, fretted publicly that this may well become like the 1918 influenza pandemic which devastated the whole world.

After all, cases had appeared in Germany, Canada, Singapore, the Philippines, Vietnam, Taipei, Brunei and Japan, while suspected cases were surfacing in Malaysia, Australia, Britain, the United States as well as various other European countries.

By March 19, things were looking really bleak: five out of the 145 Sars patients in Hongkong had died.

Then a breakthrough.

Feverish detective work by Hongkong epidemiologists led them to pin down the source to the mainland professor whose putative sneeze in the ninth-floor lift lobby was being heard around the world: All local victims had either visited or stayed on the hotel's ninth floor between Feb 12 and March 2.

As the Hongkong Department of Health announced its extraordinary findings, journalists swarmed the Metropole while panicking guests fled Hotel Virus.

The health officials took pains to point out that not all 80 guests on the ninth floor when the sick doctor was there from Feb 21 to 22 had been infected, that the only common link was the lift lobby, and that there was no evidence the virus was still active in the hotel since the period during which it spreads (its incubation period) appeared to be relatively short - two to seven days.

The ninth floor had been closed for sterilisation but the Hongkong media was not going to be denied its field day.

Flustered Metropole staff - none of its 200-300 workers have been infected - appealled unsuccessfully to reporters not to harass hotel guests who were checking out of the hotel with face masks on.

The same day, the Chinese professor's brother-in-law died, becoming the sixth Sars death in Hongkong.

Most cases had involved health-care workers and relatives who had close contact with victims, so the first thought was that Sars might be a virulent variant of the influenza virus. Yet its spread to the hotel guests did not fit the flu pattern.

On March 19, a research team from the Chinese University of Hongkong and the Prince of Wales Hospital announced that they had identified the bug. It was a paramyxovirus, they said.

While corroborating the findings, German and Singaporean authorities cautioned that proving it was indeed the agent causing Sars would take more time.

CURTAIN CALL?

PARAMYXOVIRUSES form a large virus family whose members cause mild illnesses in adult humans, such as mumps, measles and parainfluenza, and childhood croup, but also various diseases in animals such as bats, pigs, horses and seals as well as distemper in dogs.

This is also the fastest-growing group of viruses, with new members being discovered ever so frequently.

One newly discovered strain was linked to the equine morbillivirus, or Hendra virus, which killed a Brisbane horse trainer in 1994.

Another new variant, Nipah, transmitted from pigs to humans but not from humans to humans, killed 105 Malaysian farmers in late 1998 and early 1999.

New viruses emerge when an intermediate host, such as a pig, gets infected by both human and animal viruses at the same time.
Many epidemics in recorded history began in bird populations in southern China, where many communities practise both pig and duck farming.

The poor hygiene and crowded conditions with rural folks living in close proximity to livestock, particularly poultry and pigs that carry a rich brew of parasites and viruses, make it easier for germs to jump from animal to human.

With modern air travel, Sars rages on unabated. Among Singaporeans, 44 people have been infected, the most dramatic being Dr Leong Hoe Nam, 32, the infectious diseases specialist who had to be pulled off a flight in Frankfurt to be quarantined with his pregnant wife and mother-in-law.

The bug has taken an economic toll: Several countries have issued warnings against travel to Guangdong, Hongkong and Hanoi.

Singapore Airlines is expected to cut back on its flights to Hongkong and parts of China.

More than this, however, is the toll on the human spirit this latest scare has heaped on to existing fears. The tiny bug, like terrorism and war, is potentially a weapon of mass hysteria - and a lethal one at that.

Latest admission figures

The following is jointly issued by the Department of Health and the Hospital Authority: As at 1pm today (23 Mar 2003), the admission statistics of patients who have been in close contacts with atypical pneumonia patients are as follows: (numbers in brackets are those with symptoms of pneumonia)

A. Staff of Hospitals/Clinics

Staff of Prince of Wales Hospital (PWH) admitted to: PWH 62 (62)

PWH (private doctors) 3 (3)

Kwong Wah Hospital 3 (3)

Princess Margaret Hospital (PMH) 4 (4)

Tseung Kwan O Hospital (TKOH) 1 (1)

Staff of Kwong Wah Hospital (KWH) admitted to: KWH 4 (4) One of the health workers was discharged

Staff of Pamela Youde Nethersole Eastern Hospital (PYNEH) admitted to: PYNEH 7 (7)

Staff of Queen Elizabeth Hospital (QEH) admitted to: QEH 5 (2) One of the health workers was discharged

Staff of a private clinic in Mong Kok admitted to: PMH 4 ( 4)

Tuen Mun Hospital 1 (1)

Staff of a private hospital on HK Island admitted to: PYNEH 3 (3)
Staff of a private hospital in Kowloon admitted to: PMH 7 (7) PYNEH 1 (1)

Total 105 (102)

2 of the health workers were discharged

B. Medical students
Medical students PWH 17 (17)
One of the medical students was discharged

C. Other patients
Patients, patient's family members & visitors PWH, PMH, PYNEH, QEH, TKOH, Queen Mary Hospital & Tuen Mun Hospital 125 (123) 4 of the patients were discharged

Total admissions (A + B + C) 247 (242)

7 were discharged

8 patients with atypical pneumonia died recently in the following public hospitals: KWH (2 patients); PMH (1); PYNEH (1); PWH (4).

The Department of Health's website on atypical pneumonia provides health advice on the prevention of respiratory tract infection and latest information on the cases in English and Chinese

This represents an increase of 25 cases from yesterday's report. -

Update (10) on SARS cases in Singapore

As of 23 Mar 2003, a total of 51 people with SARS have been reported to the Ministry of Health. The 7 additional patients reported today comprise 3 hospital staff and 4 close contacts of patients. 3 patients have been discharged from hospital. The other 48 patients are still in hospital. All the patients are stable except for 9 patients who are in a serious condition.

To date, apart from the 3 initial people who had travelled to Hong Kong, a total of 24 family, friends and those who had close contacts with the cases, and 24 hospital staff have been diagnosed with SARS. So far, all the cases of SARS have been linked to the initial 3 cases. No new index cases have been reported. In addition, no further cases have occurred among hospital staff as a result of infection from known or suspected cases of SARS after the implementation of enhanced infection control precautions.

All suspected and probable cases, including pediatric cases, will be managed centrally at Tan Tock Seng Hospital (TTSH) and the Centre for Communicable Diseases. This will facilitate the management of these patients and reduce the risk of secondary transmission of the disease.

To free up TTSH's resources to isolate and treat all SARS cases, TTSH will not admit new patients for the next 2 weeks. As such, ambulance cases will be diverted to other hospitals and the public is advised to seek accident and emergency care at other hospitals.

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