SARS - Impressions from the early days of an epidemic

D Owens 歐德維
Deputy Editor, The Hong Kong Practitioner

My first clinical interaction with a patient suffering from the virus was in Trinidad in 1983 although I did not appreciate the significance until much later. At the time it was recognised only as a new entity of immunosuppression and wasting. It affected Haitians, Homosexuals, Haemophiliacs and Drug addicts. Two years later I was working in a chest unit in England. We had recently seen a rapid rise in the incidence of pneumocystis pneumonia, a diagnosis which was confirmed by transbronchial lung biopsy. This was a recognised presentation of the new disease of AIDS. A virus, HTLV 3, later to be known as HIV had recently been identified as the cause. In the intervening years there had been many theories put forwards for the cause and mechanisms of transmission. There was a widespread sense of fear and uncertainty. The media created a frenzy. Ignorance and prejudice was rife.

I remember vividly a presentation given by an eminent epidemiologist using incidence and mortality data from early infective cohorts. By the turn of the millennium in the year 2000 between 20-25% of the population of our planet would be dead of this new pandemic. In retrospect we now know a lot more about the disease process and the extrapolation from the early cohorts has proved to be inaccurate. In the HIV epidemic the clinical course of the illness in patients affected early in the epidemic was not typical of the population as a whole. The early cohorts had a tendency to be infected with a high viral load, a factor which in HIV has been shown to be related to a worse outcome. This in addition to improvements in treatment and widespread public health interventions along with greater public understanding and sympathy has changed the perception of HIV to both doctors and patients.

At the time of writing Hong Kong is at the epicentre of another emotionally charged international health scare. The SARS virus is threatening to develop into a dangerous pandemic. SARS appears to be spread by droplets and close personal contact. The explanation for the outbreak in Amoy Gardens is uncertain but would appear most likely to be due to some form of environmentally mediated droplet or aerosol spread.

This epidemic has evolved in Hong Kong since we completed editing last month's journal. By the time it is circulated the opinions in the previous paragraph may well represent old news, or worse still be completely wrong. Our profession will need to look long and hard at this episode. As always there are lessons to learn and systems to improve. The dissemination of good quality accurate information rapidly is one of our greatest challenges.

In the early 1980s it took years to isolate the HIV virus. This time within three weeks we have two prime suspects identified. PCR testing is available as a preliminary research test and there is a good prospect of the complete genotype being available within a couple of weeks. Eleven international laboratories are exchanging data over a secure internet connection. This is collaborative science at its best. Information is being accumulated and exchanged at a rapid rate.

This exchange of information is not limited to research scientists. The availability of information and expectations of the population has changed. News is available 24 hours per day and information is accessible from anywhere in the world to anyone with an internet connection. The world is smaller not only in terms of information but also travel. A virus which originates in Southern China is now quite clearly no longer a local problem but a world problem. Information about this virus is likewise a world issue. I have personally found the most useful source of information in this episode to be the W.H.O. website which along with other sources is reviewed on page 188.

The W.H.O. has clearly demonstrated that it considers Hong Kong and Southern China to be one entity. Regardless of political sensibilities this is obviously true as regards to health. We are living and working in an area which appears to be the epicentre for viral mutation. It is essential that we learn the lessons of this epidemic many of which will be clearer as time passes and a more balanced analysis is possible. It would seem obvious that we need to encourage open dialogue and communication with our colleagues in China. An open surveillance system with clear cross border co-operation is essential. Let us hope that the economic fall out of this episode encourages the Governments to see sense.

As Family Practitioners a major part of our job is the provision of information. It is essential that we are provided with and provide accurate and reliable information. This is difficult when a situation is changing rapidly. It is essential that emotion does not override a rational analysis. Uncertainty is stressful and in the absence of fact, opinion is frequently presented as fact. Early in this epidemic a senior health official in a public forum of doctors stated that there was no evidence to suggest community spread. At the same meeting the Prince of Wales outbreak was linked to the Metropole Hotel. This is a clear conflict. The index patient obviously contracted the illness in the community. In an attempt to reassure the statement created uncertainty. Uncertainty and lack of control leads to stress and anxiety and as doctors we are not immune to this process. As primary care doctors we have been starved of important information. The fragmentation of our primary care and hospital systems precludes the rapid dissemination of clinical information. As a Family Practitioner, once I admit a patient I appear to lose all right to information. In the absence of fact and informed opinion the information vacuum will be filled by rumour and uninformed opinion. It is essential that communication between primary and secondary care is enhanced.

This episode has reminded me that I am fortunate to work in a group practice. I have been able to discuss the outbreak with friends and colleagues. Sharing of information increases the knowledge base whilst sharing of opinion and concern is therapeutic. It allows for the gradual dissipation of personal anxiety to be replaced by rational analysis This episode has confirmed my belief that Hong Kong has an excellent public health system with what is surely the best contact tracing system in the world. The dedication and expertise of the Medical and Nursing staff in the Government hospitals typifies the foundations upon which respect for our respective professions is rooted. As Family Practitioners we need to study this episode and question how we can improve our performance. This will require improvement of our information systems. We are in an ideal position to provide surveillance and advice but in order to do so we must be organised and communicate efficiently both with each other and our patients. We need to develop a more inclusive structure within our college in order to encourage participation. We also need to be more confident in offering our combined expertise. I have been practicing in Hong Kong for 15 years. I have the clear impression that the severity of winter illness is influenced by climatic change. The onset of the dry season in early November heralds an increase in asthma followed shortly by viral respiratory infections. The latter have a secondary peak around the cold spell which typically is around Chinese New Year. There is then a tail down in numbers towards the heat of summer. This has been an unusual winter: I have seen an increased number of severe viral infections excluding the minor epidemic of influenza A. This of course is opinion and cannot be considered to have any scientific validity it is clearly subject to observer bias. Only by collecting data can we confirm or refute such opinion. In this regard we are in a unique position. This is both a challenge and a great opportunity which we cannot afford to ignore.

The opinions expressed in this editorial are those of the author. Whether you agree or disagree feel free to offer your opinion via the bulletin board, by email or post.