SARS: The global spread continues
By Christopher Horton

BANGKOK - This weekend was a bad one for those who are trying to battle the mysterious disease known as severe acute respiratory syndrome (SARS). A flurry of new cases in Hong Kong, new fatalities in Canada and the death in Thailand of the first doctor to identify SARS, rumors that the virus is airborne, and fears that the epidemic is still in its infancy have shaken both the affected areas and health officials worldwide.

Because of the nature of SARS, which can resemble common illnesses such as colds or the flu and is believed to take up to two weeks before manifesting symptoms, the available statistics from every region hit by SARS may severely overestimate or, more dangerously, underestimat the number of people infected. According to information released by the World Health Organization last Thursday, combined with non-WHO updates from around the world, more than 1,048 people had been infected and 56 people had died since the disease emerged in China last November.

Thailand
On Saturday, Carlo Urbani, the Italian doctor who first identified SARS died in Bangkok from SARS symptoms. Public Health Minister Sudarat Keyuraphan said that despite its first death related to SARS, Thailand is still safe from the disease. Health officials at Bangkok's Don Muang International Airport are screening incoming passengers for the disease, Sudarat said. Since the inception of the screenings, about a dozen people have been quarantined. Most were released within a few hours of being quarantined, but some were kept more than a day, she added. The airport screenings are a reaction to the spread of SARS outside of Thailand rather than within the country, Sudarat said.

Urbani, a Geneva-based WHO doctor, was receiving treatment for symptoms he developed after he became the first person to identify SARS while in Vietnam. The Chinese-American businessman who later became the first confirmed SARS-related death was treated by Urbani in Hanoi, where the virus quickly infected 46 people, including several health workers, such as fatality No 7 in the SARS outbreak, a Vietnamese nurse who had been working with Urbani in caring for the American patient.

As for those who treated Urbani in Bangkok before his death, Charal Trinvuthipong, director general of Thailand's Department of Communicable Disease Control, said 33 medical personnel took care of Urbani. Comprising both Thais and foreigners, the medical personnel have been screened for the disease and are still under close watch, Charal said.

Meanwhile, the Thai government urged its citizens not to visit Canada, Hong Kong, mainland China, Taiwan, Singapore or Vietnam, the countries worst hit. Thailand, which has a thriving tourism sector, would not only suffer a major economic blow to the industry were it to develop new cases of SARS, but it would also likely become a new global hub for the virus via Don Muang International Airport, one of Asia's major air hubs. WHO has attributed at least three confirmed SARS cases to Thailand.

Hong Kong
In Kowloon, a portion of Hong Kong contiguous with mainland China, an upscale residential complex witnessed the fastest localized outbreak of the global epidemic. In the four-day period ending on Sunday, confirmed SARS cases in the Amoy Gardens residences shot up from seven to 121. The chilling speed at which the disease spread prompted numerous health officials to surmise that SARS was spread through the air. Like most aspects of the disease, however, the current information about how the disease spreads is still no more than educated guesses.

As previously reported in Asia Times Online on March 18 (HK plays down pneumonia fears), it took more than two weeks for Hong Kong Secretary for Health, Welfare and Food Dr Yeoh Eng-kiong finally to admit that the SARS virus has spread throughout the community. During the two weeks when Yeoh and his associates repeatedly urged Hong Kong residents not to worry as the virus was spreading only within isolated hospital wards, the number of non-medical people infected by SARS quietly rocketed.

The rapid spread of SARS through Amoy Gardens led the US Centers for Disease Control and Prevention (CDC) to say over the weekend that SARS may still be an epidemic in its infancy.

"What we know about respiratory viruses suggests that the potential for infection of a large number of people is very great," CDC director Julie Gerberding said. "We may be at the very early stages of what could be a much larger problem."

China
Mainland China is considered to be the origin of SARS, specifically Guangdong province, an economically vibrant province adjacent to Hong Kong. There is a growing feeling of resentment among residents and doctors of both Guangdong and Hong Kong toward the mainland Chinese government regarding the conspicuous lack of information that has been offered to the public. Indeed, to this day Chinese officials maintained their tight-lipped posture vis-a-vis a major health epidemic in the world's most populous country.

A crucial time in the spread of the disease in March may have been the two weeks during which the National People's Conference (NPC), China's legislative assembly, was held in Beijing. During the NPC, Beijing enforced a strict media blackout regarding SARS. Other than a brief mention in Chinese newspapers in February, SARS has had next to no presence in Chinese media.

Last Wednesday the Chinese government revised its SARS statistics for the first time since admitting that five people had died since November. According to the updated official statistics, 34 Chinese have died from SARS, including three in Beijing, and 792 have become infected.

Last November, an outbreak of a mysterious illness widely believed to be SARS affected Guangdong province, prompting panic-stricken residents to clear store shelves of face masks and vinegar, which Chinese boil as a disinfectant.

Due to Beijing's previous silence about and denial of the epidemic coupled with its massive population, there are also widespread concerns that SARS is spreading at a rapid rate that is unreflected in the updated statistics. According WHO, SARS has also spread inland to central China's Shanxi province.

Taiwan
Taiwan, which is not officially a sovereign country, has become a victim of the politics of China in the face of a global health epidemic. It has complained repeatedly that it is receiving the cold shoulder from the WHO and Beijing on an issue that should not be tainted by politics. All of Taiwan's SARS cases that came from outside of the island are believed to have come directly from the mainland.

During the four months that SARS was spreading within China, Beijing made no mention of the phenomenon to the WHO, which is now attempting to work with the Chinese government. In contrast, The WHO did little more than pass Taiwan on to the US CDC, a move which baffled and insulted Taiwan's government and people.

Singapore
Some severe steps are being taken as both the Singaporean government and its people become increasingly concerned about SARS, which had killed three people there and made 89 ill as of late Sunday (Singapore time).

Last Wednesday the Singaporean government ordered the closure of schools until April 6, affecting some 600,000 students in the city-state of 4 million people. There is already talk of extending the school closures.

Over the weekend, a sign at a pharmacy in the normally bustling Parco Bugis Junction shopping center said it all: "Face masks out of stock". Outside the same center, a line of taxis stretched halfway round the block, waiting for patrons.

"Few people are going out," said taxi driver Lim Teck Hua. "They are afraid of the virus." He added that drivers had seen their earnings fall over the weekend as there are so few clients.

But then again, he said, he and other drivers are themselves nervous. "If a passenger starts coughing, we quickly open the windows," he pointed out.

But the abundance of taxis may also be due to another factor. The Health Ministry announced last week that it was seeking a taxi driver who transported an infected person to a hospital on Wednesday. The driver was finally found on Sunday and put in quarantine.

The initial SARS cases in Singapore involved three women who had traveled to Hong Kong. The most recent cases concern a designer who returned to Singapore last Wednesday after visiting Hong Kong and Beijing and the fifth person to import the virus: a 17-year-old Indonesian boy studying in Singapore. With his parents and brother, 15, he left Singapore for Guangdong and Hong Kong on March 15, a day after the Singaporean government advised against traveling to SARS-hit areas. They returned on March 23, and on March 24, the boy was back in school. The following day, he and his mother came down with fevers. They went to a hospital, where his mother remained and he was sent home. On Thursday, health officials who checked on him at home found that his condition had worsened. He was quarantined and diagnosed as having SARS this past Saturday.

While some locals have been debating whether the government can do more to combat the disease, Singaporean authorities have generally been praised by international observers for their measures.

Vietnam
Vietnam has proved to be the luckiest of the countries significantly affected by SARS. Although it has had SARS cases for a month now, only four people have died and 58 have been infected. Considering that Vietnam lacks the funds and technology of Hong Kong and Singapore, which are faring poorly in their battles against SARS, it is a small miracle that SARS has done such little damage to this Southeast Asian country.

The containment of SARS in Hanoi is attributed to the close-knit community within the hospital that received the first patient identified as infected with SARS. "The French hospital is quite an enclosed community with people working close together," said Aileen Plant, coordinator of the WHO team sent to help Hanoi with the outbreak.

"It may be that rather than spreading the virus externally they infected each other," Plant added. "In the end we're guessing and we won't really know until the outbreak pans out in Hong Kong and Singapore."

The hospital's prompt reporting of the illness to WHO is also credited with what has so far been a relatively successful containment of SARS.

Canada
Canada is the hardest-hit country outside of Asia so far, with Toronto in particular showing a disturbing increase in confirmed cases at 28, with three fatalities. The Ontario provincial government has declared a health emergency. Two of the three patients who succumbed to SARS were treated at Scarborough Grace Hospital. Anyone who has been to the hospital in the last two weeks has been asked by provincial health authorities to quarantine themselves at home. There have also been SARS cases confirmed in the west-coast province of British Columbia and in Ottawa, the national capital. More than 40 Toronto-area homes have been quarantined by authorities.

United States
The United States, unlike other countries, reports its suspected cases and confirmed cases in one lump total, so it is difficult to interpret the 45 cases attributed to the US by WHO. What is known is that there are believed to be five cases in New York City.

According to the Bureau of Communicable Disease of the New York City Department of Health and Mental Hygiene (DOHMH), there are at least five suspected cases of SARS in New York, ranging from a seven-year-old girl to a 67-year-old man. This does not include the Singaporean doctor who passed through the city en route to Frankfurt, Germany, where he was quarantined. Three of the New York cases, including the young girl, were not hospitalized. The older man was discharged from the hospital, and another man was still hospitalized as of Sunday night, New York time.

The DOHMH announced in a news release that it "is working closely with hospitals and medical providers to increase their awareness of SARS and to help them rapidly identify any cases that arrive in the city. As a precautionary measure, DOHMH issued an alert this past weekend to hospitals asking them to immediately report any illnesses suspected of being SARS. Persons who may have recently traveled to Southeast Asia destinations within the last 10 days should be aware of these main signs and symptoms of SARS. Anyone who traveled recently to Southeast Asia and experiences symptoms of SARS should seek medical attention."

(With additional reporting by Inter Press Service)

From February 1 to March 27, 17:30 GMT+1

Country	Cumulative number of case(s)	Number of deaths	Local transmission*
Canada	28	3	Yes
China +	806	34	Yes
China, Hong Kong	367	10**	Yes
China, Taiwan	6	0	Yes
France	1	0	None
Germany	4	0	None
Italy	2	0	None
Republic of Ireland	2	0	None
Romania	3	0	None
Singapore	78	2	Yes
Switzerland	2	0	To be determined
Thailand	3	0	None
United Kingdom	3	0	None
United States	45 §	0	To be determined
Vietnam	58	4	Yes
Total	1408	53

Source: World Health Organization

Notes:
Cumulative number of cases includes number of deaths.

As SARS is a diagnosis of exclusion, the status of a reported case may change over time. This means that previously reported cases may be discarded after further investigation and follow-up.

*National public health authorities report to WHO on the areas in which local chain(s) of transmission is/are occurring. These areas are provided on the list of Affected Areas.

+ 792 cases, including 31 deaths, reported from Guangdong province cover the period November 16, 2002, to February 28, 2003. These cases were compiled from investigations as well as hospital reports and may include suspect as well as probable cases of SARS.

§ Due to differences in the case definitions being used at a national level, probable cases are reported by all countries except the United States of America, which is reporting suspect cases under investigation.

**One death attributed to Hong Kong Special Administrative Region of China occurred in a case medically transferred from Vietnam.

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