NEWS
How SARS changed the world in less than six months
Fiona Fleck
Geneva
The global outbreak of severe acute respiratory syndrome (SARS) can be traced to one man and one night he spent in a Hong Kong hotel on 21 February 2003.
Scientists are still baffled as to how Dr Liu Jianlun, a 64-year-old medical doctor from China's Guangdong province, where the mysterious virus originated, could have transferred SARS to at least 16 other guests on the same floor during his brief stay. But there is no doubt those travellers fanned out across the world, triggering outbreaks in Singapore, Toronto in Canada, and Hanoi in Viet Nam as well as in Hong Kong itself.
In less than four months, some 4000 cases and 550 deaths of SARS outside China and Taiwan can be traced to Dr Jianlun's visit to Hong Kong; the Metropole Hotel is considering turning the ninth floor (he stayed in room 911) into a SARS museum; and SARS has proved that the worst-case scenario long mooted by infectious disease experts can come true; but also that such an outbreak, for all its speed and force, can be contained.
SARS has travelled more widely, swiftly and lethally than any other recent new disease so far. Near the end of June 2003, the total of cases was 8456 in 30 countries and areas, 809 of which had resulted in death.
HIV/AIDS took two decades to cover the globe, owing partly to its incubation period of up to 10 years. Ebola, which has caused periodic outbreaks in Africa since 1976, and two new Asian diseases, caused by the Nipah and Hendra viruses, have not travelled extensively. In the case of Ebola, this is because the patient quickly becomes much too ill to travel; and for Nipah and Hendra it is because neither virus established efficient human-to-human transmission.
"SARS is the first new disease to show the damage possible in a globalized world," said Mary Kay Kindhauser, who writes SARS updates for the WHO website, adding that SARS has made people take the infectious diseases threat more seriously and made them realize that in today's closely interconnected and highly mobile world, every country is vulnerable.
Rapid international travel helped SARS to spread, but rapid communications helped to contain it. WHO issued its first of two global alerts on 12 March, after 55 cases of the new disease had been identified. Heightened awareness facilitated the early detection and isolation of suspected cases, and a virtual lab network identified the SARS corona-virus within a month.
WHO's second alert, on 15 March, called the disease Severe Acute Respiratory Syndrome for the first time, and issued an emergency advisory notice for travellers and airlines. The warning made headlines across the world as authorities scrambled to contain the disease or prevent outbreaks from imported cases. Some were better prepared than others. After anthrax was distributed through the US postal service by suspected bio-terrorists following the September 2001 attacks, the United States was ready to react and has had few cases and no deaths.
China's failure to admit the true extent of the SARS outbreak drew severe criticism from governments and from WHO's Director-General Gro Harlem Brundtland. China has been hardest hit to date (24 June), with 5327 cases and 348 deaths reported from throughout the mainland. Beijing and Guangdong were the most severely affected, with 4033 of these cases and 250 of the deaths.
But it took two months after explosive SARS outbreaks in Hong Kong, Singapore, Hanoi and Toronto, and the spread of exported cases to every continent for China, under mounting international pressure, to allow WHO epidemiologists to enter Guangdong province on 3 April to assess the situation there and determine that the outbreak of atypical pneumonia was indeed SARS.
On 18 April, China warned officials not to "withhold any information or delay its release". Two days later, Beijing's health minister and mayor were sacked, and the authorities eventually admitted that there were hundreds more cases in Beijing than previously reported.
Symbolized by the image of masked faces, SARS struck fear into the public across the globe, triggering drastic measures: mass quarantine in hospital wards enforced by armed guards, infectious passengers hauled off planes, and closed businesses and schools. As the epidemic grew, China threatened to execute any SARS patient who violated quarantine.
SARS has been devastating for Asia's economies and has helped to further depress the international tourism and airline business. Taiwan blamed the outbreak for its recession, Hong Kong said it would spend US$ 1.5 billion to ease the impact of the outbreak on business, and the Asian Development Bank is seeking approval for US$ 30 million in loans to SARS-affected countries in the region.
In China, SARS, at least for a while, presented a powerful political challenge, and forced the country's leaders to think about accountability and openness.
WHO has been criticized by some for "exaggerating" the threat of SARS and causing economic damage, particularly in Toronto. But on the whole, the Organization, so often lambasted as bureaucratic and distant from reality, has been praised for its early warning of the dangers and the way it coordinated global efforts to contain SARS.
WHO teams assisting in affected areas have risked their lives. Dr Carlo Urbani, the WHO infectious diseases expert in Viet Nam who first drew attention to the new disease, also became one of its first victims. WHO teams were at every outbreak site in Asia, and highly active in epidemiological investigation, infection control and research coordination.
Scientists know a little about SARS, but there are still many unanswered questions. We know that SARS belongs to the coronavirus family which causes the common cold, that its maximum incubation period is probably 10 days, that it originated in Guangdong in southern China and that one person can infect a great number of people in a short space of time. But scientists are still not certain of the precise origin of the disease, which is the key to predicting its further evolution.
Preliminary studies suggest it jumped species from the civet, a member of the cat family, or the raccoon dog, both of which are delicacies in the cuisine of southern China, as several people working closely with these animals in restaurants and markets were among the first infected. However, the possibility of seasonal recurrence is not ruled out, and the prospects of a vaccine and a cure are still remote.
It is also unclear whether patients without symptoms can infect others, and scientists are still working on a point-of-care diagnostic test for the early laboratory confirmation of cases. Without such a test, the next influenza season could be a nightmare, with every cluster of febrile hospital patients with respiratory symptoms requiring extensive investigation and causing panic. 