WHO: Drop in Beijing SARS Cases May Be Due to Misdiagnosis

Doctor's Guide News ^ | May 16, 2003

[EternalHope]

WHO: Drop in Beijing SARS Cases May Be Due to Misdiagnosis GENEVA, SWITZERLAND -- May 16, 2003 -- China has today reported 39 new probable SARS cases and 4 new deaths, bringing the cumulative total to 5191 probable cases and 275 deaths.

Beijing reported 28 probable SARS cases today in the sixth consecutive day that the city has reported less than 50 probable SARS. From the last week of April through 3 May, Beijing was reporting a daily average of more than 100 probable cases. The daily number of new deaths has also declined from a peak of 15, reported on 22 April, to an average of 4 during the past week. Beijing reported a single death today.

WHO experts interpret the decrease in case numbers as encouraging, but have cautioned against concluding that the city's SARS cases were on a downward trend. They warned that misdiagnosis of cases could have contributed to the lower numbers of probable cases in recent days. WHO officials fear that patients with milder symptoms of SARS are being excluded as probable cases.

The number of wrongly diagnosed patients is not known, but WHO experts became concerned that this could be happening after recent visits to Beijing hospitals.

"They fit the case definition but because they get better in a few days, they are not seen as probable cases," explained Dr Daniel Chin, leader of WHO's Beijing team of SARS experts. "Clinicians are making this decision because there's an assumption that SARS patients must be very sick. But there's a spectrum of severity for SARS."

Clinicians were also basing their decision to exclude patients as probable SARS cases simply because they had not had any known previous contact with a SARS case – a definition used in areas with few SARS cases. Given the relatively large number of SARS cases in Beijing, such a criterion cannot be used, Dr Chin said.

He added that this was occurring due to confusion over the case definition, not because clinicians were trying to hide cases. WHO has asked the Beijing Government for a taskforce to be convened to address this issue.

Dr Chin said patients with milder SARS symptoms must be treated with all the same precautions. "It is still possible that they are not SARS cases, but without a reliable test, we can't confirm that," he said.

Patients with milder symptoms start off being isolated as suspect cases. But after their condition improves, they end up being sent to general medical wards, where they could infect other patients. Others may be sent home too early. "They may not need to be hospitalized but they could still be infectious," Dr Chin said.

A study of clinical progression in 75 SARS patients, published in today's Lancet by a Hong Kong laboratory in the WHO network, describes three clinical stages in patients from the Amoy Gardens cluster. In the mostly uniform three-stage pattern, the first week of illness was characterized by fever, myalgia, and other symptoms that generally improved after a few days. In the second week of illness, when infectivity is greatest, patients frequently experienced recurrence of fever, diarrhoea, and oxygen desaturation. In this study, 20% of the patients progressed to a third phase, characterized by acute respiratory distress syndrome necessitating ventilatory support.

Health authorities and clinicians need to be aware of these three phases of illness. In terms of preventing further spread, including nosocomial transmission, it is dangerous to prematurely relax precautions, notably isolation and infection control, following clinical improvement during the first week of illness.

Stability of the SARS virus in the environment

WHO has today published additional data on the stability of the SARS virus on different environmental surfaces.

The data, which come from studies conducted by laboratories in the WHO network, indicate that the SARS virus in sterilized stool can survive for 36 hours on a plastered wall or a formica surface, for 72 hours on a plastic surface or stainless steel, and for 96 hours on a glass slide.

Update on cases and countries

As of today, a cumulative total of 7739 probable SARS cases and 611 deaths have been reported from 29 countries. This represents an increase of 54 new cases and 13 deaths compared with yesterday. The new deaths occurred in China (4), Hong Kong SAR (4), and Taiwan, China (5).

SOURCE: World Health Organization, Update 57

[EternalHope]

Clinicians were also basing their decision to exclude patients as probable SARS cases simply because they had not had any known previous contact with a SARS case – a definition used in areas with few SARS cases. Given the relatively large number of SARS cases in Beijing, such a criterion cannot be used, Dr Chin said.

In other words, the Beijing numbers are utterly worthless. (As if we didn't already know...)

[EternalHope]

A study of clinical progression in 75 SARS patients, published in today's Lancet by a Hong Kong laboratory in the WHO network, describes three clinical stages in patients from the Amoy Gardens cluster. In the mostly uniform three-stage pattern, the first week of illness was characterized by fever, myalgia, and other symptoms that generally improved after a few days. In the second week of illness, when infectivity is greatest, patients frequently experienced recurrence of fever, diarrhoea, and oxygen desaturation. In this study, 20% of the patients progressed to a third phase, characterized by acute respiratory distress syndrome necessitating ventilatory support.

In the first phase patients often seem to be getting better.

The second phase, however, is the most infectious. (The underline and bold is mine.)

Now, considering when SARS is most infectious...

Patients with milder symptoms start off being isolated as suspect cases. But after their condition improves, they end up being sent to general medical wards, where they could infect other patients. Others may be sent home too early. "They may not need to be hospitalized but they could still be infectious," Dr Chin said.

In other words, the Chicoms are sending 'em home or putting 'em with other patients when they seem to be getting better (phase I). If they really have SARS, however, that is just turning 'em loose right before they are likely to become the most infectious.

Meanwhile, the streets are being sprayed with "disinfectant". As nearly as I can tell, the Chicoms are clueless.

[xJones]

And all the death rates are screwed when you compare deaths vs. recovered if you count them as recovered and send them home during the second relapse - and that's when they're at their most infectious. It would seem like the Chinese government is determined to send them home, there's no problem here, they're healed.

[I'll be your Huckleberry]

Thank you for that very clear explanation. I read your posts often and find them very reasoned.

It seems a recipe for disaster.

Huck

[EternalHope]

Thanks for the kind words!

[aristeides]

Ping.

[Judith Anne]

Excellent description of the three stages of SARS, that's the first I've read about those, so clearly put. I appreciate the pings to all the threads, wish I had more time to reply and offer my thoughts...

One thing I am certain of, we can never trust the Chinese numbers. And truthfully, I don't know that we'll be able to trust the numbers from ANY country, because governments seem to have an interest in minimizing the hazard due to economic concerns. That's discouraging, considering it may be here in the fall.

[aristeides]

Let's hope SARS is not here already. I was disturbed by that mysteriously deleted thread yesterday alleging there are many cases of what may be SARS in a Northern California hospital. And I have been FReepmailed that there is a case in a D.C. hospital, which to my knowledge the media have not reported.

[riri]

Whatever happened to that? I really wanted to read it.

[Judith Anne]

Oh, well. There will be more articles about that hospital if there is anything to it, I'm thinking.

[aristeides]

The moderator said there was no source for the thread, but the poster claimed to have spoken to somebody in the hospital on the phone.

[riri]

I really liked FR better before all the deletions and hand slapping by moderators. Sure, some BS would make it's way through here but...

[aristeides]

I wish I could be sure there isn't some policy to suppress the worst news about SARS. Actions like that deletion only fuel such suspicions.

[Judith Anne]

Really, there's nothing we can do about SARS proactively except be as well informed as possible. Here's hoping research comes up with better treatments, that it doesn't get a foothold somewhere outside China, and that this fall and winter brings the good old-fashioned flu, and nothing more.

[dc-zoo]

It would be a good idea if the person who posted the report about the northern california hospital outbreak would repost it as a reply to this or another new sars thread.

[Judith Anne]

Agreed.

[aristeides]

The poster had a screen name like "watch 123" or "watcher 123". But the system now says there is nobody with either name. More mystery.

[EternalHope]

It would be a good idea if the person who posted the report about the northern california hospital outbreak would repost it as a reply to this or another new sars thread.

The poster was "Watchman123". It was unclear to me if he was saying he personally made the call, or was repeating something he had heard. The thread is gone, so I can't re-read it to be sure either.

It's the kind of info that would be extremely explosive if true. It could also make FR look very bad if it turned out to be nothing unusual.

It could be an internet hoax, or simply a hospital spokesman who doesn't realize how alarming an answer like, "Sorry, that's confidential information," can be.

Personally, I would like to see at least two Freepers make the same telephone call, each of whom would then report what they heard. For that to happen, however, Watchman123 would have to say which hospital to call.

[Future Useless Eater]

SARS Mortality Rates [reflects treatment] Based on World Health Organization daily tables                 (Revised:  May 17 pm)
Area	Recoveries to date	Deaths to date	Projected Future** Death Rate		Active Cases still in Danger	Projected Future Deaths	Projected Cumulative Mortality
China	2009	282	27.3%		2918	798	20.7%
Taiwan	50	37	87.9%		221	132	54.9%
Hong Kong	1191	243	12.1%		276	33	16.1%
elsewhere [30 countries]	429	63	2.5%		76	2	11.4%
World-wide [all 33 countries]	3679	625			3491	834	18.7%
Future deaths are a combination of methods formerly used here.................. The 1st method compared 7-day deaths to 7-day recoveries ...................... The 2nd method was based on findings from the Imperial College of London that deaths take 12 days longer on average than recoveries on average and compared TOTAL history of deaths (to date)................................. to TOTAL history of recoveries (as of 12 days ago).............................. **  Newest method compares RECENT history of deaths (12 days).................. to RECENT recoveries (as of 12 days ago).........................................

Observations - Treatment:
• I refined the predicted future death rates again to get back to relying on 'recent' data, but to still hold onto the Imperial College of London findings.
• Taiwan's high death rate suggests they have been grossly underreporting cases (only those in CRITICAL condition)
• I estimate Taiwan's infected count is 200 persons higher, and I suspect that half of those are out in the public.
• China's numbers also seem underreported. Their recent death rate with the new method suggests that also.

Trend - Active Cases Still in Danger [reflects containment]
Date	China	Taiwan	Hong Kong	elsewhere 30 countries	World-wide all 33 countries
May 2	2246	67	563	117	2993
May 3	2375	67	544	111	3097
May 4 (est.)	2507	75	532	113	3227
May 5	2641	83	520	114	3358
May 6	2735	81	495	112	3423
May 7	2854	88	466	115	3523
May 8	2945	92	445	106	3588
May 9	2993	110	442	101	3646
May 10	3029	128	427	99	3683
May 11 (est.)	3049	133	413	97	3692
May 12	3068	138	399	95	3700
May 13	3061	153	374	89	3677
May 14	3046	170	343	85	3644
May 15	3034	196	309	78	3617
May 16	2969	193	297	79	3538
May 17	2918	221	276	76	3491
(includes new daily cases... excludes cases resolved by death or recovery)

Observations - Containment:
• China numbers seem highly fictional.
• I also believe Taiwan's active case count is roughly 200 persons higher than shown.
  
  
• Even Taiwan's 'reported' active cases are still exploding, with no improvements in sight.
   Apr 30   (41)                    May 17  (221) active cases
  

[Future Useless Eater]

SARS - Treatment/Containment tables - updated with Friday and Saturday numbers here