Faculty Bibliography

The W.H.O. has organized a network of 11 laboratories around the world, including the Centers for Disease Control and Prevention in Atlanta, to seek the cause of SARS and help develop diagnostic tests. But in the absence of a diagnostic test, the network is working on the assumption that the coronavirus causes SARS. It is a gamble the researchers are unhappy to be taking. The C.D.C. has developed two promising but rudimentary tests. But the tests need substantial refinement before they can be used widely, in part because they cannot detect infection from the new coronavirus in its earliest stages. Also, the tests must be validated by tests on thousands of additional specimens from SARS patients and healthy people, the C.D.C. has said. Still, late last week C.D.C. began releasing to state health departments findings from experimental tests conducted among suspect cases in this country. The tests measure the amount of antibodies that these individuals' immune systems formed to fight the new coronavirus. But the C.D.C. cautioned against interpreting that the findings proved the virus caused SARS and that these individuals had it

The man had been exposed to the disease in mid-March when he was an outpatient at the Scarborough Grace Hospital in Toronto, where the initial outbreak of SARS in Canada occurred. But officials did not think he had SARS until after the man's funeral Thursday, after members of his family started coming down with the disease

Although Canada has reported 58 SARS cases, including six deaths, and Ontario last week suspended all non-urgent surgery and outpatient clinics in all of its 215 hospitals, the CDC said it 'is not advising against travel to or from Canada because there is not evidence of widespread community transmission' of SARS. From the start, World Health Organization officials have said SARS requires sustained close face-to-face contact. But now WHO officials are investigating whether SARS can be spread through the air, water, sewage and contaminated objects. Until these and other issues can be settled scientifically -- a process that may take weeks -- health officials can only give advice and act on reasonable assumptions. In most cases, doctors are making only educated guesses as to when it is safe to let SARS patients leave the hospital. The proper use of barrier nursing techniques such as masks, gowns, gloves and goggles have stopped spread of SARS to the health workers, although officials of the CDC say they do not know if such measures are 100 percent effective

Scientists have gained a significant, though rudimentary, knowledge of SARS in a short time. For example, they know the hallmarks of the disease, which are a fever of 38 C or higher, chills, muscle aches and dry cough. They also know the average incubation period -- the time it takes from exposure to symptoms -- is about four days, ranging from two to 10. Scientists also know that no drug is effective against SARS. Its spread can be prevented by having health workers wear masks, gowns, gloves and goggles, and by isolating patients. The answers would also affect another crucial decision, when to declare that an outbreak has ended. An epidemiologic rule of thumb is twice the longest incubation period -- 20 days for SARS. But because patients can shed viruses after fully recovering from some other infections, health officials must learn whether affected SARS people can still transmit the virus after symptoms disappear. To prove that a virus identified in the laboratory causes SARS, scientists must develop diagnostic tests to determine how often it was present among patients in the outbreak and at what stage of the illness it appeared. Those steps require collecting and testing specimens from patients in various stages of the disease and from their contacts, and will further strain the taxed network, said Dr. Klaus Stohr, the scientific director of the SARS investigation

China has faced intense international criticism for being slow to release statistics on SARS from southern Guangdong Province, where the disease originated last November. Today, it appeared to be following that pattern of secrecy in its capital. Health statistics, particularly embarrassing ones, are often regarded as official secrets in China, and official secrets are tightly guarded in Beijing. There were no SARS deaths in the United States, where health officials are investigating 115 suspected cases from 29 states. That group includes 43 people who had been hospitalized and 27 who had suffered pneumonia, a main complication of SARS. Four of the 115 had had close contact with ill patients and 2 were health care workers exposed to the same patient. At least two wards at You'An Hospital have been cleared to screen and treat potential SARS cases, one health worker there said, adding that many are on oxygen and some are assisted with ventilators. On the hospital grounds, the majority of doctors and nurses now wear masks and nervously shoo visitors away

ONE OF MY CALMEST PATIENTS RETURNED FROM HONG KONG LAST WEEK, AND OF COURSE HE WAS WORRYING THAT HIS MILD COUGH WAS FROM SEVERE ACUTE RESPIRATORY SYNDROME, OR SARS. HE NERVOUSLY STUTTERED OUT THE WORD SARS, BUT AFTER I EXAMINED HIM HE ACCEPTED MY REASSURANCE AND RETURNED TO HIS QUIET WAYS. HE EITHER HAD A COMMON COLD OR WAS JUST WORN DOWN FROM TRAVEL, AND TWO DAYS LATER HE WAS FINE. For SARS, fear is the central pathogen, where the risks of acquiring the new mutated cold virus are far secondary to the fear of being infected. Uncertainty about what the risk really is promotes the panic - seeing SARS in the news causes us to personalize it, especially at a time when everyone is already feeling vulnerable from the war. Of course, we do need to track SARS before the bug starts to spread like the hysteria it is causing. SARS is a serious health matter but may galvanize fear because of the sudden attention. Publicizing preventative measures beyond the proper context may make SARS seem worse than it is

The case occurred in a man who was treated in a provincial hospital about two hours from Hanoi, which has been the center of the illness in Vietnam. The unexpected appearance of a new case raised the specter that the disease had spread into the countryside and might have infected health care workers in an area where infection control measures are substandard. Masks, gowns and other barrier nursing equipment are being sent to the hospital to help improve its infection control. But there was concern about the potential need for similar measures elsewhere in Vietnam. ''People in Guangdong are working and living normally,'' he said. He added that there was no evidence that the virus was spreading widely in Beijing. Chinese officials have been stung by accusations that they concealed or ignored information about the disease in the initial months, and failed to act promptly. At yesterday's briefing, the minister sidestepped questions about why China had been so slow to reveal details about the illness or to involve the World Health Organization in its control, and why it had sharply restricted coverage of the disease by the domestic press. A passenger arriving at Los Angeles International Airport from Taiwan yesterday wore a surgical mask as a precaution against SARS. (Monica Almeida/The New York Times); A tourist had the bus almost to herself in Hong Kong yesterday. The World Health Organization has recommended against elective travel to Hong Kong, which has been hit by the SARS virus. (Getty Images)

It took only a few dry coughs to spread a mysterious respiratory illness to clusters of health workers in Asia and to kill Carlo Urbani, 46, the World Health Organization doctor who first identified it. And it took only a few airplane passengers for the illness to reach 15 countries in Asia, North America and Europe. Now, one person has apparently spread the illness to scores of residents of an apartment complex in Hong Kong, and the government has put the entire complex in isolation and closed all schools. In Toronto, two hospitals have been closed to new patients. The patterns of transmission raise the possibility that the illness, known as SARS, for severe acute respiratory syndrome, can be spread through the air or contaminated objects as well as close face-to- face contact. The events justify the bold alarm that the World Health Organization set off at a time when cases and deaths were few in number, on March 15, when it declared SARS 'a worldwide health threat.' The organization then hastily created a network of 11 infectious-disease laboratories in nine countries to track down the cause of SARS. Officials at the World Health Organization, a UN agency, cannot recall the last time the agency has issued a global alert for an acute outbreak of a disease. The agency has long had networks of laboratories for influenza and other diseases, but such networks have rarely been pressed into emergency service. In less than two weeks, with an alacrity and a degree of cooperation seldom seen in science, the laboratories identified two previously unknown viruses as the leading suspected agents. (They belong to the coronavirus and paramyxoviridae families.) But because of the danger of the illness, the UN agency is restricting research on it to its network. All laboratories in the network operate at the second- highest hazard level, known as P-3, reserved for all but the most deadly pathogens. Far from being the last link in the discovery process, identification of a new virus in a laboratory is only the first of many steps needed to prove that a suspect virus actually causes a disease. It is likely to take weeks more to determine which virus, singly or in combination, actually causes SARS. In that time, the leading suspects may be displaced by other candidates. For now, the leading suspect is a coronavirus, though proof is far from certain. The family takes its name from the crown of spikes that surround the spherical virus. Known coronaviruses cause the common cold and are suspected of causing diarrheal and other intestinal illness in humans. Though pesky, the ailments are rarely fatal. But in animals, coronaviruses can cause devastating illness among cats, dogs, chickens, pigs and cattle

In the United States, the disease control agency said many scares had been reported aside from the suspect cases -- including a student with a fever at the University of Connecticut and a Virginia resident who turned out to have a common bacterial infection. It said no one had died of SARS in the United States and only one suspect case had involved breathing difficulty severe enough to need a mechanical ventilator. There have been roughly 20 suspected cases of SARS in New York, New Jersey and Connecticut, all in people who had traveled to the Far East. Because there is no known pathogen for the disease and no test for it, cases cannot be confirmed definitively. The chief suspect is a previously unknown coronavirus, but that has not been confirmed. As was true in the scares throughout the country, saying exactly what constituted an officially recognized ''suspect case'' was tricky. Not all local doctors adhere to the disease control agency's standards, and some cases later turn out to have known bacteria involved. Moreover, the agency's definition of a suspect case differs from that of the World Health Organization. The international agency requires a diagnosis of pneumonia. The United States agency does not, because it wants to catch cases in which a patient with a severe cough or breathing difficulty might infect others without having pneumonia

Although Canada has reported 130 probable and suspected SARS cases, including six deaths, and Ontario on Monday suspended all non- urgent surgery and outpatient clinics in all of its 215 hospitals, the CDC said it 'is not advising against travel to or from Canada because there is not evidence of widespread community transmission' of SARS. Also, doctors do not yet know how long a patient can disperse the virus, even if symptoms have disappeared. In most cases, doctors are making only educated guesses as to when it is safe to let SARS patients leave the hospital. The proper use of barrier nursing techniques like masks, gowns, gloves and goggles have stopped spread of SARS to the health workers caring for patients, although officials of the CDC say they do not know if such measures are 100 per cent effective. Photo: CANADIAN PRESS; Commissionnaire Salman Noor wears a mask for protection from the SARS virus as he directs traffic at Pearson International Airport in Toronto. Paper bulletins asking travellers with symptoms of SARS to delay their flights were posted at Pearson on Tuesday, as Health Canada escalated efforts to stop the spread of the potentially deadly ailment