HEALTH AGENCY TOOK SWIFT ACTION AGAINST SARS
04 May 2003
Source: New York Times, May 4, 2003
Health Agency Took Swift Action Against SARS
By DONALD G. McNEIL Jr. with LAWRENCE K. ALTMAN
GENEVA, May 2 — It took until mid-March — nearly four months after the first outbreak — for the world to learn of SARS. Yet a look back at the early days of the epidemic, and at the earliest warnings given to the World Health Organization, leaves little doubt that the agency acted as swiftly as it could.
Some opportunities were missed along the way, and the health agency was led astray by assumptions that later proved wrong. But public health experts say the agency's investigators are only as powerful as the information they have to work with. And from the start, they were frustrated by the lack of official candor in China, where severe acute respiratory syndrome first erupted last November.
"W.H.O. did a fantastic job," said Dr. Jack Woodall, the moderator of ProMED, the Federation of American Scientists' Program for Monitoring Emerging Diseases, which as early as Feb. 10 posted an alert on its Web site about a mysterious outbreak in the southern Chinese city of Guangzhou. "They acted marvelously and exemplarily, as fast as they could. But it dragged on and on because China wouldn't cooperate.
"The World Health Organization isn't the world health police," he continued. "It's a club, like a club in Boston where everyone's a member and they slap each other on the back. Every member's a sovereign country, and if they don't want to report something, they don't."
Dr. Barry R. Bloom, dean of the Harvard School of Public Health, said the global alert issued by the health agency on March 12 was "enormously courageous."
"They took an enormous risk," Dr. Bloom said. "If you ask `What risk?' I remind you of swine flu."
In 1976, a single death in New Jersey from what was feared to be a genetic echo of the killer swine flu of 1918 set off a panicky rush for a vaccine. The disease disappeared after infecting only 500 people, the vaccine was abandoned after 32 deaths from side effects, and the director of the federal Centers for Disease Control was dismissed.
The Outbreak Center, on the fourth floor of Building L of the W.H.O. campus here, began officially querying China about its mysterious epidemic on Feb. 10. As Chinese officials have since acknowledged, the response was a mix of inept diagnoses, outright lies and, finally, stonewalling.
Over the next two weeks, Chinese officials said that the outbreak had killed only five people and that it had been snuffed out in the province of Guangdong, where Guangzhou is. They then said it had been caused by a mycoplasma, then by chlamydia. They then stopped responding and forbade doctors to do so. It was not until April 20 — when China's health minister was dismissed — that the epidemic's true scope began to emerge.
By Feb. 12, frustrated flu specialists in Hong Kong working with the World Health Organization quietly carried out a sort of medical commando raid, slipping into Guangdong hospitals to get tissue samples from dying patients. But because the specialists were looking for bird flu viruses, they missed the apparent cause of SARS, a coronavirus.
And on Feb. 19, the organization and the United States Centers for Disease Control and Prevention sent a joint investigative team to Beijing to find out what was going on in southern China. But Beijing health officials stalled the team until they gave up. Permission to visit Guangdong was not given until April 2.
There were two unlucky misses very early in the epidemic. On Nov. 20, at what is thought to be the very beginning of the outbreak, a W.H.O. flu specialist who was in Beijing for a vaccine conference heard of a spate of unusual deaths among health care workers in Guangdong, which he now suspects included SARS cases. He requested tissue samples, but the ones he received contained only common flu strains.
And on Nov. 27, a report of a "flu outbreak" closing schools and factories was picked up by a Canadian Health Ministry computer that sifts news reports for the W.H.O. But the report was never translated from the Chinese.
More important, investigators believed as late as mid-March that China was secretly and stoically fighting a new bird flu strain, possibly one as lethal as the swine strain, then called "Spanish flu," that killed more than 25 million people in 1918 and 1919.
That notion was reinforced on Feb. 19, when two real cases of bird flu were diagnosed.
"In retrospect, this was a total coincidence," said Dr. Stephen M. Ostroff, deputy director of the C.D.C.'s National Center for Infectious Diseases. "But our feeling was that this was the unifying hypothesis behind the outbreaks."
The crucial moment that sent the disease caroming around the world, probably a sneeze or cough in Hong Kong's Metropole Hotel, took place on Feb. 21.
But that would not be known for weeks, and even Canadian officials say the W.H.O. reacted as quickly as it could.
"They were working with what they had," said Allison McGeer, a Toronto doctor who later fell ill herself fighting the epidemic, but recovered. "We knew from ProMED that something was going on. But having the announcement a few days earlier would still almost certainly have not been able to prevent initial spread. There were too many things we didn't know."
An Illness Emerges
On Nov. 20, Dr. Klaus Stöhr was in Beijing to discuss China's flu vaccination policy. Dr. Stöhr heads the W.H.O.'s flu program, for which 111 laboratories around the world annually scan 200,000 samples from flu victims, looking for candidates for the next year's vaccine.
As it happened, the first case of SARS had emerged that month in Guangdong, perhaps in the markets where all sorts of live animals, including chickens, cats, turtles and badgers, are sold for food. At the meeting in Beijing, Guangdong's representative described a small flu outbreak that had killed several people in one hospital. "I think that was SARS," Dr. Stöhr said in hindsight.
At the time, though, there was no particular reason to suspect that the outbreak was anything other than flu, Dr. Stöhr said. In epidemiological terms, "one or three or five deaths in a province of 55 million is nothing."
"But," he said, "I thought, `Let's be on the safe side and get the virus.' "
Tests of samples from Guangdong at the C.D.C. and a Japanese laboratory turned up routine flu strains, Dr. Stöhr said, so they were discarded.
"If the conference had been in December, and there had been 100 deaths — I don't know," he said, "but things might have been different."
As early as January, hospitals in small cities in Guangdong were telling the provincial health department about clusters of atypical pneumonia. Herbal medicine shops were besieged and the price of white vinegar shot up 12-fold because it was believed that boiling it into vapor would disinfect a house.
Whether or not reports of those cases were sent on to Beijing, they were not being disclosed to the W.H.O.
In December and January, "it was dead silence from China," said Dr. Guénaël Rodier, the W.H.O.'s chief of communicable disease surveillance.
That, epidemiologists said, was not surprising.
"Numbers on health outbreaks are the most politicized numbers in the world," said Dr. Stephen O. Cunnion, a retired outbreak specialist from the Navy who posted the Feb. 10 warning on ProMED after hearing from friends in China. "From China, you can't even get an accurate count of how many people have been killed in an earthquake."
On Feb. 5, Dr. Stöhr said, panic grew when the Chinese subsidiary of the drug company Roche took out ads saying that its drug Tamiflu worked against bird flu.
"That put in the minds of people that a bird flu epidemic had started," he said. The company later apologized.
No laboratory had by then found bird flu in humans, but southern China was primed to fear it. An outbreak there in 1997 infected only 18 people but killed 6 of them. The outbreak was stopped by the slaughter of 1.4 million birds.
Moreover, Dr. Stöhr said, in December, an unusually powerful strain killed many wild birds in the Hong Kong Botanic Gardens.
Mutating bird flus are an epidemiologist's nightmare. Though most strains that infect humans — usually poultry farmers — cause nothing worse than conjunctivitis, the 1997 strain, which the 18 victims all caught from birds, had the same mortality rate as smallpox.
A fatal strain that could be passed from human to human "is the sword of Damocles hanging above all of us," said Dr. Rodier. "The good news about SARS is that it's not a pandemic flu."
On Feb. 11, in response to an official W.H.O. inquiry, Beijing tersely replied that an unidentified pneumonia in Guangdong had hospitalized 300 people and killed 5.
Guangdong's Communist Party secretary announced to the news media that "the illness has been effectively treated and controlled."
But at the same time, provincial health officials publicly urged anyone with fever or cough to seek immediate medical help and suggested that residents fumigate rooms with a vinegar-based steam wash, wear gauze masks, and stay away from shopping centers and train stations.
The next day, said a W.H.O. official, a flu lab in Hong Kong affiliated with the agency was asked to get some samples clandestinely.
Developing a vaccine takes about eight months, so if a dangerous new flu was likely to hit the world by the next winter, time was already short.
The lab's doctors "had friends and relatives working in hospitals in China, so they took the bus or train over and got samples from patients who died," the official said.
But because they were looking for bird flu, they found nothing.
On Feb. 14, Li Liming, director of the Chinese Center for Disease Control, said that there had been no new cases since Feb. 10 and that the situation was "under control and not as serious as the rumors say."
On Feb. 18, the Chinese disease center announced that chlamydia bacteria had been found in two patients' lungs, and that it must have caused the outbreak.
"We didn't believe it," Dr. Ostroff of the C.D.C. in Atlanta said. Antibiotics also cure chlamydia.
A Worrisome Turn
On Feb. 19, the plot took a twist. A Hong Kong laboratory reported on a 33-year-old man and his 9-year-old son who had hurried to Fujian Province to see the man's dying 8-year-old daughter. The father died on his return on Feb. 17; the son was sick. Both had the H5N1 strain of avian influenza.
Dr. Stöhr said a Hong Kong colleague asked him, "Are you sitting down?" before giving him the news. This might be the nightmare bird flu — a fatal strain that had passed from human to human.
Ultimately, however, that one-family outbreak seems to have spontaneously died out. The cause of the daughter's death remains unknown.
Officials outside of China, now very worried, tried another route. Dr. Keiji Fukuda of the C.D.C. and Dr. Hitoshi Oshitani of the World Health Organization were dispatched to Beijing and told to get to southern China.
Prompted by the C.D.C., Tommy G. Thompson, the secretary of health and human services, pressed China's deputy health minister, then visiting Washington, for permission for the team to visit.
Permission was granted, and they arrived Feb. 23. "But it was the Asian cultural thing of not wanting to say no," said Dr. James W. LeDuc, director of the C.D.C.'s division of viral and rickettsial diseases. "Keiji got to Beijing and found out he didn't have an invitation."
The two men were left sitting in their hotel rooms for two weeks with nothing but routine briefings. In early March, they left in frustration.
Investigating outbreaks is always politically touchy. As a United Nations agency, it has no power to order member states to cooperate.
"If I wasn't happy with the U.S. investigation of SARS cases in Pennsylvania, would I have the right to pop up in Philadelphia?" asked Dr. Michael J. Ryan, coordinator of the W.H.O.'s global alert system.
Because the W.H.O. does not have enough money to field its own teams, it must send volunteers. The C.D.C. in Atlanta is the biggest contributor but, W.H.O. officials said, some countries are about as eager to see American health inspectors as Iraq was to see American arms inspectors.
Facing the Facts
With China uncooperative, momentum stalled. Then on Feb. 21, the disease escaped China when a 64-year-old Guangdong doctor checked into the Metropole in Hong Kong and infected guests who would spread it to Toronto, Hanoi, Singapore and elsewhere in Hong Kong.
The true nature of the disease — that it was not a flu, but a pneumonia indifferent to antibiotics and antivirals — was not understood until March 11, when two factors merged.
Dr. Carlo Urbani, a W.H.O. clinician, chillingly detailed the outbreak he was fighting in Hanoi. Johnny Chen, an American businessman who had been in the Metropole, had infected 22 hospital workers and 7 at his garment business in Hanoi. Dr. Urbani would soon die of the disease.
Tissue samples, flown to Bangkok on a plane chartered by the United States Embassy because local airlines refused to carry them, showed no flu. Meanwhile, workers in a Hong Kong hospital were falling sick. An airport worker who had also been in the Metropole had been put on a jet nebulizer to clear his lungs and had infected 112 others. A Hong Kong laboratory found no flu in them.
On March 12, the W.H.O. issued a global health alert as a routine news release. With war in Iraq looming, it got relatively little attention. Three more events prompted its much more emphatic March 15 alert.
The Canadian authorities reading the first announcement recognized that the pneumonias in one Toronto family fit the pattern. The authorities in Singapore said a hospitalized flight attendant who had stayed at the Metropole also did.
And then, at 2:30 a.m. on March 15, Dr. Ryan was awakened by Singaporean officials warning him that a doctor who had treated pneumonia patients there had just left a conference in New York, told relatives he was feeling sick, and boarded a plane home with a stopover in Europe.
Dr. Ryan spent the next four hours hunting down the plane and getting the doctor safely isolated in Frankfurt. That incident galvanized W.H.O. officials into issuing a much more urgent and detailed alert.
They also picked a name.
"We have to brand this," said Dr. David L. Heymann, the W.H.O.'s chief of infectious diseases. After tries like Atypical Pneumonia Without Diagnosis, they settled on a pronounceable acronym.
Asked if he thought an earlier alert could have saved any lives, Denis G. Aitken, an aide to the W.H.O.'s director general, the senior official on hand that day, said he doubted it, noting that the four new outbreaks were well under way by early March.
"If you lose sleep over that, you'll become petrified," Mr. Aitken said. "You just have to face the facts."