Über die Autorin bzw. den Autor

Arthur Kleinman is Esther and Sidney Rabb Professor and Chair of the Department of Anthropology, Harvard University, and Professor of Medical Anthropology and Social Medicine at the Harvard Medical School. James L. Watson is Fairbank Professor of Chinese Society and Professor of Anthropology at Harvard University. He is also the author of Golden Arches East: McDonald's in East Asia (Stanford University Press, 1997).

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SARS in China

STANFORD UNIVERSITY PRESS

Contents

Preface.............................................................................................................................viiContributors........................................................................................................................ixIntroduction: SARS in Social and Historical Context ARTHUR KLEINMAN AND JAMES L. WATSON............................................1Part I. The Epidemiological and Public Health Background1. The Epidemiology of SARS MEGAN MURRAY...........................................................................................172. The Role of the World Health Organization in Combating SARS, Focusing on the Efforts in China ALAN SCHNUR.......................313. SARS and China's Health-Care Response: Better to Be Both Red and Expert! JOAN KAUFMAN 53Part II. Economic and Political Consequences4. Is SARS China's Chernobyl or Much Ado About Nothing? TONY SAICH.................................................................715. SARS and China's Economy THOMAS G. RAWSKI.......................................................................................1056. SARS in Beijing: The Unraveling of a Cover-Up ERIK ECKHOLM......................................................................122Part III: Social, Moral, and Psychological Consequences7. Psychological Responses to SARS in Hong Kong-Report from the Front Line DOMINIC T. S. LEE AND YUN KWOK WING.....................1338. Making Light of the Dark Side: SARS Jokes and Humor in China HONG ZHANG.........................................................148Part IV: Globalization and Cross-Cultural Issues9. SARS and the Problem of Social Stigma ARTHUR KLEINMAN AND SING LEE..............................................................17310. SARS and the Consequences for Globalization JAMES L. WATSON....................................................................196Notes...............................................................................................................................205Index...............................................................................................................................235

Chapter One

MEGAN MURRAY

In mid November 2002, a middle-aged businessman from Foshan, China, was hospitalized for an atypical pneumonia. He eventually recovered from his illness, although not before infecting four of his health-care attendants. Later, this patient would be recognized as the first detected case of SARS in the world.

Little concrete information about the spread of the disease emerged from China over the next few months, but in mid February, the World Health Organization was notified of an outbreak of a respiratory illness involving 305 cases and causing 5 deaths in Guangdong province. Even at the time of this report, it was clear that many of the cases had occurred among the health-care workers who had cared for infected patients. What was not apparent until much later was that food handlers working in Guangdong's busy markets were also heavily represented among those who became ill with the mysterious illness.

This was not the first time a new respiratory infection had emerged from southern China. In 1957, a new strain of influenza appeared in Hunan, China, which spread throughout the world and led to the Asian flu pandemic of that year. That strain persisted until 1968, when it was supplanted by yet another influenza strain that emerged from southern China and rapidly moved to Hong Kong before disseminating around the globe. Since then, several new variants of flu have arisen from the same region, most recently, an avian strain of influenza A that emerged in 1997, killing large numbers of poultry before it spread to humans, and that resulted in at least six deaths among the eighteen cases reported. Despite fears that this highly virulent avian strain might lead to a worldwide pandemic, there was fortunately no person-to-person spread of this virus. All of those who became ill had some connection with the live chicken markets in Hong Kong, and no further human cases were reported after influenza was brought under control in its avian host through mass slaughter of poultry.

With the last three influenza pandemics all originating in southern China, many researchers have wondered why this area has been the breeding-ground from which these new virus strains have emerged. Influenza A is widespread in nature and can be found in a range of animal hosts, including birds and pigs. Most influenza researchers believe that avian strains of influenza A acquire mutations that enable them to cross the species barrier and go on to infect humans and then spread among them. Although these mutations are rare events, southern China is home to an enormous poultry industry; the sheer numbers of birds on these farms means that there is ample opportunity for the population of viruses to grow and for one of these multitudinous virus strains to undergo a rare mutation.

Given this history, the Chinese authorities immediately suspected that a new influenza strain was the most likely culprit responsible for the mysterious respiratory infection spreading in Guangdong. However, tests for influenza quickly came back negative. Given recent events in other parts of the world, the Chinese also sought and ruled out suspected agents of bio-terrorism such as anthrax and plague, organisms that can cause respiratory symptoms. To complicate matters further, several different common and not so common respiratory pathogens were found in the respiratory secretions of at least some of the infected; these organisms included human meta-pneumovirus and chlamydia, a relatively common cause of atypical pneumonia among young people worldwide.

All of this remained a fairly local problem until February 21, 2003, the day on which a 65-year-old physician from Guangdong checked into a room on the ninth floor of the Metropole Hotel in Hong Kong, already symptomatic with the infection for which he had been treating people back at home. Although the doctor had little contact with others in the hotel, twelve guests staying on the same floor were eventually diagnosed with SARS. Among them were a Chinese businessman who traveled on to Hanoi to become the index case of the outbreak there, a Singaporean woman who was hospitalized soon after her return to her native city, an elderly woman from Toronto who went home to expose her large family in Canada, and a group of others who were admitted to Hong Kong hospitals, where they spread the disease to many of the hospital staff to whom they were exposed. Another one of these cases was a young man who was treated for a week in a Hong Kong hospital with a jet nebulizer that aerosolized his respiratory secretions, thus disseminating the virus throughout the hospital environment.

Although it was not clear how these people became infected at the Metropole Hotel when they had no direct contact with the doctor, it was clear that this cosmopolitan setting had provided the opportunity for the virus to infect travelers who would go on to spread the disease throughout the world. Through this seeding, subsequent local epidemics occurred in Hanoi, Singapore, Toronto, and Hong Kong with transmission to hospital staff and patients a major route of subsequent spread. The Singaporean woman was ultimately linked to over 100 cases of SARS in Singapore and the elderly resident of Toronto initiated the Scarborough Grace Hospital cluster that involved 132 people and caused 12 deaths.

By mid March, SARS had spread to seven countries, and by late March, 1,320 cases and 50 deaths had been reported. On March 30, 2003, Hong Kong officials announced that a large cluster of cases had occurred almost simultaneously in a huge housing complex known as the Amoy Gardens. Up to this point, transmission appeared to have occurred principally through the respiratory route, but the Amoy Gardens outbreak now raised the possibility that environmental transmission might also play a key role. An investigation conducted by the Hong Kong authorities identified a faulty sewage system as the probable means of spread of the virus in the building complex. The initial case was identified as a man being treated for kidney disease at a large Hong Kong hospital, who had developed symptoms of SARS while he was visiting his brother at the apartment complex. As reported by the WHO, subsequent rapid spread to 321 other residents is thought to have involved "defective U-traps [or P traps] in bathrooms, an amplifying effect of bathroom exhaust fans, a cracked sewer vent pipe serving Block E, and an aerodynamic effect in a lightwell to which bathroom windows opened" (www.who.int/csr/don/2003_04_18/en/ [accessed 23 March 2005]).

Over the next few months, newspapers throughout the world were filled with daily reports on the spread of SARS; some of the news was good, but much of it was bad. By late April, SARS had been successfully contained in Vietnam and was beginning to taper off in Singapore, Hong Kong, and Toronto. In the meantime, however, the epidemic had taken off in Taiwan after the diagnosis was initially missed in a patient who subsequently visited multiple clinics and hospitals, spreading infection widely. The stringent control measures taken by various countries throughout Asia have been well described in the media-these included the closing of schools, widespread screening for fever in airports and at other checkpoints for travelers, the strict isolation of infected cases and the quarantining of those exposed to known cases. Since the implementation of these control measures coincided with the decline in cases, most public health authorities have concluded that these interventions had a major impact on controlling the disease and eventually led to its elimination. By the end of the epidemic, more than 8,000 cases had been reported, and there had been 916 deaths.

Although the end of the epidemic brought an enormous sense of relief to the many people whose lives had been impacted by it, investigators who were trying to understand its origin and develop future safeguards against SARS had little respite. For epidemiologists who study the patterns of disease spread in communities, the occurrence of a new infectious disease raises a number of preeminent questions for the epidemiologist, many of which have still not been adequately answered:

Where did it come from? By what routes does it spread? How transmissible is it? What needs to be done to contain it? How virulent is it? Will it return?

Where Did SARS Come From?

In order to determine where SARS came from, it would first be necessary to identify the infectious agent. Despite the initial misidentification of the organism as chlamydia, this was accomplished amazingly quickly; by the third week in March, several different research groups in various countries had identified a novel coronavirus from the secretions of SARS patients, which was named SARS-CoV. The coronaviruses are a diverse group of RNA viruses that cause respiratory and gastrointestinal diseases in humans and other animals. The prefix "corona" refers to the crownlike appearance produced by projections from the surface of the virions when viewed through an electron microscope. These projections represent "spike" or "S" proteins, which bind to the host cellular receptors allowing the viruses to enter host cells. There are three distinct groups of coronaviruses; groups 1 and 2 contain mammalian viruses, whereas group 3 consists only of avian pathogens. Specific coronaviruses usually have a narrow host range, meaning that each type of virus only infects its natural host or closely related species and is not transmissible across the species barrier. Animal coronaviruses can cause serious illness, and some coronaviruses, such as infectious bronchitis virus (IBV) of chickens, have had a major economic impact on the poultry industry. By contrast, until SARS emerged, human coronaviruses were responsible for about 30 percent of colds but had never previously been associated with severe respiratory disease or death.

Soon after the organism had been identified, complete genome sequences were published and compared to genomic data from other known coronaviruses. SARS was not found to be closely related to any of these viruses and, indeed, was so dissimilar to previously described viruses that it could not be placed in any one of the three groups of coronaviruses. This finding led to headlines such as this one:

Is SARS from Mars? UK scientists say maybe. Could SARS have come from Mars? Or elsewhere in the vast reaches of outer space? Unlikely, say earthbound microbiologists. But some scientists from the United Kingdom aren't so sure.

The UK scientists referred to were a group that included professors from the Cardiff Center for Astrobiology and the Department of Molecular Biology and Biotechnology at Sheffield University, who wrote a letter to the highly respected medical journal the Lancet saying that "the virus is unexpectedly novel and appeared without warning in mainland China. A small amount of the culprit virus introduced into the stratosphere could make a first tentative fallout east of the great mountain range of the Himalayas, where the stratosphere is thinnest ... the subsequent course of its global progress will depend on stratospheric transport and mixing, leading to a fall out continuing seasonally over a few years."

Nonetheless, when earthbound scientists looked for the newly de scribed coronavirus in the marketplaces of Guangdong, they found a very closely related virus in masked palm civets and raccoon dogs in a live animal market. Although this does not provide direct evidence that these animals were the source of SARS-they may in fact have been infected by humans rather than vice versa-it does suggest that the species barrier had been breached, a finding supported by the ease with which SARS-CoV infected a range of cell lines from different species in vitro.

While this species-hopping may be unusual behavior for a coronavirus, it is certainly not an uncommon event for other pathogens. Several months after the advent of SARS, a small outbreak of monkeypox among humans was reported in the United States, and the cases were traced to a shipment of Gambian giant rats imported from Ghana and sold as pets. Monkeypox is a viral infection very similar to smallpox, although causing a less virulent illness. Most of the cases in the United States were thought to have spread directly from animals to humans, although some human-to-human transmission is known to occur, and it could not be ruled out in cases in which multiple household members became infected. What makes SARS different from monkeypox and the host of other diseases that cross from animals to humans is that, unlike these zoonoses, SARS was readily transmitted from person to person after the initial introduction from another species. Although monkeypox may occasionally be transmitted from person to person, it is relatively inefficient at this type of spread and the transmission chain soon dies out.

By What Routes Does SARS Spread?

Clearly, SARS spread rapidly from person to person, particularly among close contacts and health-care workers who cared for SARS patients. It is also clear that the predominant mode of transmission was through respiratory secretions, as with most respiratory infections. Most infectious disease epidemiologists recognize two distinct patterns of respiratory transmission: that due to the aerosolization of small infectious particles that then remain suspended in air, ready to be inhaled into the lungs of those re-breathing that air; and that due to larger respiratory droplets that are projected short distances through sneezes or coughs or via the intermediary of hands. Organisms that can be aerosolized pose a greater threat in terms of transmission capacity, since simple barrier measures that prevent exposure to respiratory droplets will not protect one from inhaling contaminated air. The little evidence available to date suggests that SARS may be spread predominantly through large respiratory droplets and is thus only spread over short distances. These data come from hospital studies that sought to determine risk factors for infection among health-care workers exposed to SARS patients. In these small surveys, the wearing of protective masks and the practice of contact precautions was associated with a decrease in risk for infection, leading to the inference that transmission must occur through close contact.

The Amoy Garden experience made it clear that respiratory transmission is not the sole route by which SARS spreads. SARS-CoV has been detected in stool and urine. Fecal shedding has been shown to last, on average, for several weeks. However, it is unclear how much, if any, transmission occurs directly through the fecal-oral or fecal-respiratory route. Nonetheless, should long-term fecal shedding occur in some infected people, this may provide a means by which SARS could be reintroduced into circulation in human communities after having apparently been eliminated.

Other routes of transmission that have been suggested include animals that have been infected by humans but then go on to infect other humans through contaminated fecal droppings. One researcher hypothesized that rats dwelling on the rooftops of the crowded Amoy Garden complex could have been the vector by which the virus spread in that environment, but there has been no subsequent proof that animals have acted as vectors in the spread of the disease. If animals such as rats were infected by humans, they could serve as a reservoir in which the virus could remain undetected for a prolonged period but through which the disease might reemerge.

Another potential route by which SARS might return is through research laboratory accidents that lead to the infection of lab workers. Two such episodes have already occurred. The first involved a researcher in a Singapore virology laboratory in September 2003; the second occurred in a laboratory worker at a Taiwan military hospital in December 2003. Investigations of these laboratory-acquired cases showed that inadequate safety standards were employed in both cases and have led to a call for more rigorous monitoring of safety procedures in the many laboratories throughout the world where SARS-CoV is kept.

(Continues...)

Excerpted from SARS in China Copyright © 2006 by Board of Trustees of the Leland Stanford Junior University. Excerpted by permission.
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