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Last Updated

19 May 2003

Source: The Toledo Blade (OH), May 19, 2003

SARS scare reminiscent of 1918 crisis

Death rate appears to eclipse that of Spanish flu

By Luke Shockman, Blade Staff Writer

Donald Henderson knows history, and he is worried.

The doctor who led the international effort to eradicate smallpox said he's worried about history repeating itself, only on a much deadlier scale this time around.

In 1918, for reasons still unclear today, a new strain of flu - sometimes referred to as the Spanish flu - swept across the world, killing 20 million people. Twice as many died from flu in 1918 than were killed in World War I.

Eighty-five years later, another virus is on the attack. SARS - severe acute respiratory syndrome - surfaced last fall in China, and so far has infected more than 7,800 people worldwide and killed 634.

That's a low death toll compared to the Spanish flu. But Dr. Henderson, who headed a team of international doctors who snuffed smallpox by the early 1980s, said it is not the death toll itself that concerns him with SARS - it is the percentage of people who die after contracting the virus.

The Spanish flu "had a death rate of about 1 or 2 percent, and SARS appears to be considerably higher," he said.

Much higher, in fact. Dr. Henderson and others caution that it is too early to say exactly what the death rate is because there are so many unknowns, but so far SARS appears to kill at least 5 to 15 percent of people it infects. If SARS somehow races through large populations similar to what the Spanish flu did ...

"We all consider this to be very, very worrisome," Dr. Henderson said. "There are those who've said we don't have many cases, or that we have more cases of AIDS. Well, true. But this has the potential for spread like HIV doesn't. What we're really looking at is the potential for this to turn into a major problem."

Now a professor at Johns Hopkins Bloomberg School of Public Health, as well as an adviser to U.S. Secretary of Health Tommy Thompson, Dr. Henderson doubts authorities will be able to eradicate SARS like he did with smallpox.

"My view has been since the end of the smallpox program that an effort to eradicate another disease is doomed to failure," he said.

"If you get sick with smallpox, you are really sick and not inclined to fly. With SARS, you get a fever and a cough, but people with the disease, many of them are mobile, so the likelihood of transmission is much higher," he said.

Other public health authorities are more optimistic.

"We think we have a window of opportunity to get rid of this disease and put it back in the box," said Maria Cheng, a spokesman for the World Health Organization, based in Geneva.

Ms. Cheng said a vaccine might be developed in a year or two; others say it could take much longer. Even without a vaccine for SARS, she said, the disease can be contained. What happens with China, she said, is the big unknown.

China has been hit hard by SARS, with 284 killed and more than 5,200 infected. Authorities there initially covered up news of the disease, allowing the disease to spread rapidly. Even now, after improving its efforts, Ms. Cheng said China is still not providing enough information about SARS to international experts.

Late last week, China's Supreme Court threatened execution of people who knowingly spread the disease by violating SARS quarantine laws. If China fails to contain SARS, Ms. Cheng agreed that chances for containing the virus dim for the very reasons Dr. Henderson pointed out.

"SARS is just a plane ride away, and it will seed other countries," Ms. Cheng said.

Page through Toledo newspaper headlines from 1918, and one sees in vivid detail what happens when a contagious virus like SARS comes calling.

For most of that year, the front pages of The Toledo Blade carried news of World War I. But by the fall, stories began to appear about a mysterious new strain of flu.

More than 3,000 people in Toledo had been infected and 277 had died by November, 1918.

Snippets from articles and headlines in the fall of 1918 show the dramatic acceleration of the flu problem in Toledo and highlight the actions local authorities had to take in their attempts to fight the sickness:

Oct. 12: "Mayor Schreiber said that the influenza situation so far does not indicate the necessity of banning every public and social activity."

Oct. 14: "Public, private and parochial schools and libraries, theaters, churches, Sunday schools, pool rooms, billiard halls, dance halls, soda fountains, soft drink parlors, and saloons will be closed indefinitely to stamp out the influenza epidemic."

Oct. 22: Seventeen die of influenza. Five saloonists nabbed for violating no-sale rules.

Oct. 23: Thirty-two more people die in Toledo from the flu, bringing the death toll to 118. The city sends a doctor to the Mayo Brothers hospital in Rochester, Minn., to bring back some "serum" it hopes will fight the flu. Toledo becomes the only city in the world - other than Rochester - to experiment with the serum.

Nov. 1: Schools and some other locations gradually reopen. "Health Conditions Improve City Officials Warn Against Drunken Revels." The city reports 3,152 cases of flu, and 277 deaths since the outbreak began.

Dec. 10: With absentee rates at 18 percent, city officials decide to close all schools again because flu cases increase. Children under 18, for their own protection, are banned from school, movies, theaters, libraries, and the Museum of Art.

Dec. 12: City officials ask the U.S. secretary of war to allow 20 Toledo physicians to return to Toledo from an Army training camp so the doctors can help fight the flu. The secretary turns down the request. New flu regulations are issued citywide, including orders to keep windows on all street cars open to allow proper "ventilation."

Fortunately, SARS has not spread as quickly as the Spanish flu - yet - and the disease appears to have had little impact in the United States. Nationwide, there have been 350 suspected and probable cases, but no deaths.

Some public health experts have complained that SARS is getting too much attention, and the media are needlessly panicking the public.

Dr. David Baltimore, a Nobel Prize-winning vaccine research at the California Institute of Technology, wrote a guest editorial last month in The Wall Street Journal complaining of what he perceived as overreaction by the media and public toward SARS.

Dr. Jeffrey Koplan, who was director of the Centers for Disease Control and Prevention in Atlanta from 1998 until last year, disagreed.

"I don't think SARS has been overemphasized," he said. "Let him [Dr. Baltimore] see a room full of people on respirators."

Dr. Koplan said he and many other public health experts are not surprised that SARS popped up.

"I've got speeches going back 10 years," warning of something like SARS emerging, he said.

While Dr. Koplan said he thinks all the attention SARS has been getting is appropriate, he said some of what's been reported is either inaccurate or misses the point.

Take the question of a vaccine, for example. While many experts, including those at the World Health Organization, suggest a vaccine might be developed within a year or two, Dr. Koplan scoffs at that.

"Forget it. If you have a vaccine in 10 years, consider yourself lucky," he said.

Current CDC officials say much the same thing. Dr. Mitch Cohen, division director for bacterial and mycotic diseases at CDC, said many advances have been made in vaccine technology, but officials still need to know a lot more about SARS before beginning work on a vaccine.

What health officials need to focus on is a diagnostic test for SARS, Dr. Koplan said. For now, Dr. Koplan said, authorities are trying to define SARS cases based on some rather shaky criteria, including whether you visited a country where SARS is present. But a definitive, cheap, quick test is needed soon, he said, so quarantine measures can be more efficient.

Despite all the attention death rates for SARS have gotten, Dr. Koplan criticized a recent report in the British medical journal Lancet that said SARS might have a death rate higher than 50 percent in the elderly.

"It's absurd," he said. "There's no basis to say what the death rate is. If you just took the American cases, you could say the death rate is zero."

Dr. Henderson, while not going that far, added that there are several missing pieces of the puzzle with SARS that have not gotten much attention:

*Transmission: In some cases, one individual has managed to infect dozens of people. In other cases, an infected person hasn't infected any of his family members. That's unusual for an infectious disease, Dr. Henderson said.

*Severity of SARS: With almost every infectious disease, there is a range of severity of symptoms in those infected. Some people become very ill or die, others have mild symptoms, and some have no symptoms at all. But so far, almost all of those thought to have SARS have fairly severe symptoms, Dr. Henderson said. One mystery is whether there are many people infected with SARS who are not showing symptoms - and who could be spreading it to others who are more susceptible.

*The young: With most diseases, the very young and the elderly are most at risk because of their weaker immune systems. Many elderly have gotten sick or died from SARS, but almost no one under about 24 years old has gotten severely ill, Dr. Henderson said. "That makes no sense based on any previous disease that we have seen," he said.

Because of these and other mysteries about SARS, Dr. Henderson is not that calmed by recent news that SARS appears to be tapering off in Asia and elsewhere.

Many viruses, such as the flu, are more active in colder weather. Dr. Henderson said it is possible the warmer summer weather is naturally causing SARS to taper off and it will return this fall.

The other possibility, Drs. Henderson and Koplan said, is that SARS could hide at low levels in a host animal or human for years and pop up periodically - like the dreaded Ebola virus.

"[SARS] could take off and really be a roaring epidemic," Dr. Koplan said. "It's very hard to predict."