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Posted on 07/07/2003 6:16:32 PM PDT by blam
SARS special report: Too soon to celebrate
10:00 06 July 03
Exclusive from New Scientist Print Edition.
Beijing's Forbidden City is no longer off-limits. Tourists have been spotted at Hong Kong's bustling Stanley market. Life in the cities worst hit by SARS is quickly returning to normal.
But behind laboratory doors it is a different story. "No one thinks we've eradicated the virus off the face of the Earth," says Daniel Chin of the World Health Organization in Beijing. "There's no guarantee against re-emergence, least of all in China."
Doctors like Chin are still jittery because so many fundamental questions have yet to be answered. Where did the virus came from in the first place - and is it still out there?
Was it really brought to its knees by isolation and quarantine measures, or did factors such as the season play a key role in its demise? Will it make a comeback - and can we develop an effective treatment or vaccine before it does?
The fight against SARS has relied mainly on traditional methods: isolate suspected cases and quarantine anyone with whom they have had close contact. These methods, including relentless take-your-temperature campaigns in cities hit by SARS, appear to have quashed the outbreak just months after the disease seemed to be spreading out of control.
After China's initial cover-up, it excelled at the mobilisation needed to stamp out the disease. Beijing built a 1000-bed hospital in a week - the sort of feat more typical of Maoist times.
"It was extraordinary," says Chin. "Everyone was mobilised. You couldn't go anywhere without having your temperature measured. If you came from Beijing or Guangdong you were ostracised - you couldn't stay in a hotel, for instance, you'd have to sleep in your car. In some senses, it was overkill, but on the other hand it was very effective."
Human rights
This overkill worries human rights organisations, who say that there have been threats to execute anyone who spreads SARS to other countries. The reported arrests of 117 people charged with spreading "SARS-related rumours" suggest that the outbreak has also been a pretext for imposing restrictions on China's growing band of internet users.
With services being denied to those who just mention SARS in an email - the route by which the rest of the world was alerted to the outbreak - there are questions about how easily word will get out of any resurgence in SARS.(This is not good
But such draconian measures may not have been the only reason for the fall in cases. Poorer areas might have been saved by their primitive medical facilities. "It's a disease that occurs primarily in hospitals, and the more sophisticated the hospital - like the ones in Singapore and Hong Kong - the more likely the spread. It's to do with the intensity of contact," says Aileen Plant, an epidemiologist at Curtin University of Technology in Perth, Australia, who led the WHO's team in Vietnam. For once, disparities in healthcare appear to have given the advantage to the poor.
Another possibility is that SARS failed to take off in China because many people had already been exposed to a similar virus. Antibody tests of stored blood samples should reveal if there has been widespread human exposure in the past.
There are also suspicions that the first outbreak in the southern Chinese province of Guangdong stopped so abruptly because of the onset of summer. The SARS virus does not survive well in a hot environment, and if most transmission is due to people touching contaminated surfaces, higher temperatures would have reduced transmission.
If the season, rather than human intervention, was the main reason for the end of the outbreak, SARS could return with a vengeance in the autumn. That is what happened with the 1918 influenza pandemic, which killed tens of millions. Fortunately, SARS is far less infectious (so far).
Isolating suspected cases will be difficult at the height of the influenza season, as there will be so many people with symptoms that look like SARS. "And if you can't distinguish between SARS and flu or other causes of pneumonia, hospitals become dangerous places, as you risk picking up SARS after you are admitted," says Timothy Rainer, an emergency physician at the Prince of Wales Hospital, Hong Kong.
To prevent this, what is needed is a quick test that can identify the infection at a very early stage. This is the WHO's top priority but despite predictions in March that such a test would be available within weeks, no reliable test has emerged.
Unusual animals
But with person-to-person transmission of SARS apparently ending, where would SARS return from? One fear is that it came from animals and could do so again. Many of the first people to contract SARS worked in food preparation and the specialty animal trade, suggesting that the virus came from one of the many wild or unusual animals eaten in China.
But which one? The SARS virus, or antibodies to it, have been found in masked palm civets, raccoon dogs and ferret badgers in a market in Guangdong, near the border with Hong Kong. But other studies found no traces of SARS in wild animals, including civets. It is possible the animals in the market picked up the virus from another species, or even from humans.
Despite this, China has restricted the sale of several animals, including farmed civets. But it is not clear how long the clampdown will continue in the face of protests from what is a sizeable industry.
The virus could also be lurking in people. Canada has discovered the virus in people who did not develop full-blown symptoms (New Scientist print edition, 28 June, p 12). The evidence so far suggests that such people cannot infect others.
But this may only be true while the weather stays warm. If undiagnosed carriers do shed the virus, come winter enough of it might survive to infect others. Discovering if there is a hidden human reservoir as well as an animal one is another priority for researchers.
Genetic variants
Matters are not made any easier by the fact that the enemy could be changing. In May, virologists were relieved to find that the SARS virus seemed only to have thrown up two main genetic variants. But as more samples are sequenced, new variants are showing up. The virus could yet become more contagious or out-evolve any vaccine that is developed.
At least it is now harder for countries to cover up an outbreak. In May, the World Health Assembly gave the WHO new powers to investigate disease outbreaks and to issue a global health warning before receiving official confirmation of an outbreak from the government of the affected country.
"We can't bust in like a SWAT team, but we now have the power to negotiate our way in," says WHO spokesman Peter Cordingley in Manila.
For now, the WHO is emphatic that the guard against SARS must stay up, including screening of outgoing passengers from countries that have had outbreaks. Toronto has already learned to its cost how easily the disease can reappear.
The big test will be what happens as the northern winter sets in. Only if SARS fails to reappear this winter can we breathe a sigh of relief - and go back to worrying about the next big flu epidemic that experts say is long overdue.
Rachel Nowak, Melbourne and Debora MacKenzie, Brussels
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Me too. It is hard to be highly functional when you think a plague is brewing.
Actually, it's hard to be highly functional spending countless hours loged on to FR. (:
Yup. We'll keep an eye on this and raise a flag as appropriate.
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