Faculty Bibliography

Because the initial symptoms of SARS resemble those of other respiratory infections, 'we simply have to protect the community and keep people out of the community while they might be infectious and spreading SARS,' [James Young] said. Canadian health officials said all the cases in the Toronto area can be traced to an outbreak at Scarborough Grace Hospital, and they said SARS is under control, in part because of their isolation policy. The outbreak in Toronto is now in its fourth generation of cases, increasing the complexity of tracing cases. About 7,000 people in the Toronto area had already been asked to stay in isolation since the outbreak began in March, and about 650 remain in isolation. Of the 35 U.S. cases, 33 involved people who had traveled to an affected area in Asia. The two other cases involved a health worker who cared for a SARS patient and a household member of a SARS sufferer. Tests, still in the experimental stage, have shown that five of the 33 patients were recently infected with the virus, which is a newly discovered member of the coronavirus family

The request is aimed at people who develop any of six symptoms of SARS: Severe headache, severe fatigue, muscle aches and pains, fever of 100.4 or higher, dry cough and shortness of breath. The request excludes people who have had cough or shortness of breath from pre- existing allergy or lung disease. The biggest SARS outbreak in Hong Kong spread through the plumbing in an apartment complex after visits from a man sick with the disease, a health official said Thursday. Water droplets contaminated with the SARS virus may have been sucked out of bathroom drains into apartments by ventilation fans, said the Hong Kong health secretary, Dr. Yeoh Eng-kiong

Referring to a well-known study of a cold outbreak at the Eagle Heights Apartments in Madison, Wisconsin, and to an early theory that the outbreak of more than 300 SARS cases in Hong Kong's Amoy Gardens apartment complex was spread by cockroaches, he said: 'Don't blame the cockroaches. In Wisconsin, it wasn't the cockroaches, it was the kids.' Whoever put SARS in the Amoy Gardens sewage pipes and one regular visitor was a dialysis patient at the Prince of Wales Hospital while the airport worker was on the nebulizer would be a superspreader, with the help of rusty pipes. A famous tuberculosis superspreader, described in The New England Journal of Medicine in November 1999, was a 9-year-old boy in rural North Dakota, an immigrant from the Marshall Islands, who in 1997 and 1998 infected his family and 56 schoolmates. The boy had deep cavities in his lungs, while his twin brother, who was two inches (5 centimeters) taller and 11 pounds (5 kilograms) heavier, had a mild case and was not infectious

Preliminary findings showed that the monkeys developed an illness resembling SARS after the coronavirus was put in their nostrils. Some monkeys developed pneumonia and examination of their lungs under a microscope showed that the coronavirus caused a pattern of lung damage similar to that in affected humans. Such findings include the formation of syncytia, or giant cells, in the lungs. The monkey experiments are essential in fulfilling the steps, known as Koch's postulates, that are needed to establish proof that a virus or other microbe causes a disease. As part of the postulates in SARS, scientists must determine whether injecting the coronavirus into animals causes similar symptoms to those that humans experience. A principal aim of the Geneva meeting was to discuss how close researchers have come to developing reliable diagnostic tests and to develop a consensus concerning their use in controlling the epidemic. Even if a test is reliable, it is useless in controlling an epidemic if it does not detect the virus that is its cause. So fulfilling Koch's postulates is critical for determining the usefulness of diagnostic tests. [David Heymann] expressed hope that new tests aimed at the coronavirus would help contain SARS

Another participant, Dr. Sylvie van der Werf, a scientist at the Pasteur Institute in Paris who has tested specimens from SARS patients in Vietnam, said that scientists could be expected to develop molecular techniques based on the genetic maps of the SARS virus that would make research to develop blood and other tests easier and safer. Many molecular methods do not require use of the actual virus, which is dangerous and requires nearly the highest level of safety precautions. Scientists still do not know much about the SARS virus. They know that it can be found in sputum, tears, feces, blood and urine. But they do not know whether the form of the virus they now detect can cause disease if it is spread from these materials. About 10 percent of SARS patients develop diarrhea, suggesting that people can become infected by swallowing contaminated food and water, even through sewage. Dr. [Albert Osterhaus] reported that his team inoculated four macaque monkeys with the coronavirus isolated from SARS patients and then noted the appearance of the signs and symptoms of human SARS, like lethargy, a skin rash and severe difficulty breathing. The lungs and tissues of two monkeys euthanized on the fifth and eighth days after onset of symptoms had the same type of damage seen in patients who died of SARS, Dr. Osterhaus said. Blood tests showed that the other two monkeys had SARS

In recent days epidemiologists have been unable to trace a number of SARS outbreaks in hotels, hospitals and apartment complexes in Hong Kong, Singapore and China to such person-to- person spread. Because of that, many health officials have become increasingly suspicious that the disease can be spread through contaminated objects such as door knobs, water and sewage, as well as by person to person contact. Hong Kong officials also have theorized that insects such as cockroaches could spread the disease, perhaps by tracking contaminated sewage from apartment to apartment

This article was reported by Elisabeth Rosenthal, Keith Bradsher, Lawrence K. Altman, Clifford Krauss, Donald G. McNeil Jr. and Amy Harmon and written by Denise Grady. *** Last November in Foshan, a small industrial city in Guangdong Province in southern China, a businessman became desperately ill with an unusual type of pneumonia. Doctors could not identify the germ that was making him sick. Ominously, although pneumonia is not usually very contagious, the four health workers who treated him also fell gravely ill with the same disease. Now, scientists say, the Foshan businessman appears to have had the earliest known case of severe acute respiratory syndrome, or SARS, which has since become an international epidemic. As of Saturday, 2,416 people in 20 countries were reported to have contracted the disease, and 89 had died. The overwhelming majority of cases were in mainland China, with 1,220, and Hong Kong, with 800. The cause of the disease is unknown, but scientists suspect it is a new coronavirus, from a family of highly changeable viruses that until now have been known to cause only more minor illnesses in people, like colds and diarrhea. SARS was brewing in Guangdong Province for months but was not revealed by the Chinese government until February, when Beijing began reporting cases to the World Health Organization. The Foshan businessman's case was disclosed just last week, when Chinese officials finally agreed to open their casebooks and hospitals to international specialists. The businessman recovered, but Chinese officials have not discussed what happened to those who took care of him, nor have they said where or how he might have contracted the disease. The rest of the world did not know much about SARS until March 15, when the WHO issued an alert calling the disease a 'worldwide health threat.' Since then, fear of SARS has led many countries and corporations to halt tourism and business travel to China, Hong Kong, Vietnam and Singapore, decisions that are expected to cost the region billions of dollars. Efforts to control the disease in Hong Kong appeared to be making headway last week, but the progress may have been short-lived, as cases jumped sharply over the weekend. There were 42 new cases reported Sunday, up from 39 on Saturday and 27 on Friday. The new cases included doctors and nurses. Two women, aged 68 and 71, died, bringing the number of deaths in Hong Kong to 22. Health experts say it is too soon to tell whether SARS will turn into a global wildfire or cool down. But scientists insist that the disease must be treated as an urgent public health threat. What worries epidemiologists is that SARS can spread rapidly through the air, via coughing and sneezing, and its death rate of 3 percent to 4 percent is significant, particularly because healthy people are among those who have died. People of all ages, from children to the elderly, have caught SARS. The illness typically starts like any other acute respiratory infection: with a fever, chills, headache, malaise and dry cough. Chest X-rays tend to show what doctors call 'atypical pneumonia' in a lower lobe of a lung. In the following days, a victim may develop difficulty breathing as the pneumonia spreads to another lobe. About five to seven days after onset, the symptoms improve in about 80 percent to 90 percent of patients and worsen in the remainder. Many of the sickest patients require intensive care, some to the point of being connected to a respirator. Why some people improve and others die is not known

Epidemiologists have traced most cases to close person-to-person contact. But they have been unable to trace a number of SARS outbreaks in hotels, hospitals and apartment complexes in Hong Kong, Singapore and China to personal contact. That has made health officials increasingly suspicious that the disease can also be spread through contaminated objects such as doorknobs, or through water and sewage. Hong Kong officials also have theorized that cockroaches could track contaminated sewage from apartment to apartment. In other developments, panicky residents and some medical personnel in Thailand blocked the cremation of a Hong Kong man who had died of SARS. They were afraid that the virus would spread through the smoke. With tens of thousands of soldiers based in Asia, the U.S. military is shoring up its defenses against SARS by restricting travel to affected areas and encouraging personnel to avoid crowds and wash their hands frequently. In Singapore, military personnel can get clinical masks to wear

While SARS has spread easily to health workers in China and Hong Kong, Dr. [Julie L. Gerberding] said the patterns have been different in the United States. In this country, only three health workers appear to have contracted SARS from patients. One important reason is that hospitals quickly put isolation precautions in place after the W.H.O. issued a global health alert on March 15. Dr. [David L. Heymann], the W.H.O. communicable disease expert, said an unusual cluster of 29 SARS cases in Singapore was ''particularly worrisome'' because its source was unknown. Singapore health officials classified 4 cases as probable and 25 as suspected; all were health workers from two wards of one hospital where there had been no known SARS cases. The clustering seems to have occurred on March 29. Dr. Heymann said his agency was concerned about that finding because it would be highly unusual for so many workers to have caught SARS from one patient on the same day. No SARS patient was transferred to the new hospital from another one that had cared for earlier cases, Dr. Heymann said

Epidemiologists have traced most SARS cases to close person-to- person contact. That finding initially led officials to believe that they could break the SARS chain by isolating patients and their contacts and by requiring health workers to use standard infection control measures in caring for patients. Such measures, including frequent handwashing and wearing masks, gloves, gowns and goggles, have worked in most places. If SARS can be spread by insects or objects or healthy human carriers, containing its spread would be much more difficult. The fear is that in short time SARS could become yet another on the long list of diseases that are a fixture in many areas. To help determine whether seemingly healthy people can spread the SARS agent, Hong Kong is conducting a number of studies involving the hundreds of people in isolation here because they had contact with a SARS patient