The 2003 Southeast Asia SARS outbreak: causes and global health consequences

Southeast Asia SARS outbreak of 2003: The anatomy of an epidemic.

Severe Acute Respiratory Syndrome or SARS is a viral respiratory illness that emerged as a serious global threat to health in March 2003. It first appeared in Southern China in November 2002. The illness was to spread to over a dozen countries in North America, South America, Europe, and Asia before it was contained. (Basic Information About SARS)

While the epidemic has been contained yet it raises a number of important issues that will be discussed in the paper. These include the question of the genesis and origins of the virus and the consequences, in both the short and long terms, of SARS as one of a number of previously unknown viral infections affecting world health. This paper will also look at the background, causes, symptoms and effects of the disease.

One of the central points that will form the fulcrum of this discussion is that SARS should not be seen as an isolated event. The SARS virus is one of many infectious diseases that now seem to be occurring with increasing prevalence in the modern world - the most recent being the Avian flu virus. In terms of sustainable solutions this will be an important aspect that will be addressed in this paper.

Background

In April of 2003 the World Health Organization (WHO) reported 3,947 probable severe acute respiratory syndrome (SARS) cases with 229 deaths worldwide. Most these case occurred in China, Hong Kong, Singapore, Vietnam, and Toronto, Canada. (Frequently Asked Questions About SARS)

While there was a general increase in the rate of the SARS cases, the rate of new cases was relatively slow. For example, there were only seven infectious at the beginning of the epidemic at the Hoping Hospital in Taipei, this grew to 264 cases and 34 deaths by mid-May, and 680 cases and 81 deaths by June 1. (ibid) SARS was a new phenomenon and resulted from a virus that had never been encountered in humans before. It was to result in worldwide panic before the infections finally halted. However, the wide ranging effects and implications of the epidemic are still being studied and debated today.

2.1. Causes

Essentially SARS is a type of viral pneumonia and is the result of infection by a coronavirus, called SARS-associated coronavirus (SARS-CoV). (Basic Information About SARS)

The initial outbreak of the disease is believed to have taken place in February 2003 in the Guangdong province of China. Approximately 300 people were infected and became ill, of which five died. Initially it was believed that Aparamyxovirus was responsible for the infection; however later the true cause was established to be a unique coronavirus with presented a number of different and unusual properties.

The causes or origins of the virus have been associated and linked to particular living conditions and the close handling of animal and related foodstuffs, "Many of these early cases were food handlers (persons who handle, kill, and sell food animals, or those who prepare and serve food.) (The cause of SARS) There is also evidence that natural infections with SARS-CoV occur in various species of animals indigenous to China and parts of south-east Asia. A joint study involving Hong Kong and China "detected several coronaviruses closely related genetically to the SARS coronavirus in two of the animal species tested (masked palm civet and raccoon dog). " (ibid) The study also found that the Chinese ferret badger elicited antibodies against the SARS-CoV. "These and other wild animals are traditionally considered delicacies and are sold for human consumption in markets throughout southern China." (The cause of SARS)

There is still ongoing research and conjecture about the actual origins of the SARS virus. An animal origin with human transmission is in all research studies generally accepted and recently independent scientific teams claim that the Chinese horseshoe bat is the reservoir of the virus in nature. (Altman L.K. 2005) Findings of this nature are important as a step in preventing future occurrences of SARS in that the chain of transmission may be broken if the originating source can be identified.

The cause of SARS has also been related to poor and unhygienic living conditions which fosters and possibly prepares the ground for the origin of the virus in association with livestock. This has important concomitant cause and effect factors that will be discussed in this paper. The World Health organization for example has stated that poor living environments and especially inadequate plumbing may also be a central factor in the initiation of this disease. "The findings also indicate that poorly designed or maintained plumbing could contribute to the spread of other diseases that are transmitted by highly infectious fecal droplets. " (Poor Plumbing a Likely Cause of SARS Spread)

The possibility has also been put forward in studies that the SARS outbreak in Hong king may have been facilitated by poor sewage and drainage systems. One of the most worrying aspects of the disease is that the exact origins and causative factors are not definitively known and this impact on the future solutions.

2.2. The symptoms and spread of SARS

The symptoms of SARS are generally flu-like with moderate to high fevers. Symptoms include the following characteristics of the disease:

dry cough, dyspnea (shortness of breath), headache, and hypoxaemia (low blood oxygen concentration)

Typical laboratory findings include lymphopaenia (reduced lymphocyte numbers) and mildly elevated aminotransferase levels (indicating liver damage).

Basic Information About SARS) notable symptomatic element is that approximately 10-20% of the infected individuals required mechanical ventilation. The mortality rate is between 6.8% for patients under the age of 60 and 55% for patients over 60 years old). (Jambresic S. 2005.) Death is often the result of progressive respiratory failure. Symptoms usually improve after the first week of infection but tend to worsen in the second week. This worsening is largely due to the deteriorating condition of the patents immune system.

The spread of the virus is through close person-to-person contact. Transmission through the spread of respiratory droplets through actions such as sneezing and coughing is common. The virus that causes SARS is thought to be transmitted most readily by respiratory droplets (droplet spread) produced when an infected person coughs or sneezes. Furthermore, it is also suspect by medical experts that SARS can be spread through airborne infection. (ibid)

The Centers for Disease Control (CDC) reported that SARS appears to be spread by close person-to-person contact. Potential ways include touching the skin of other people or objects that are contaminated with infectious droplets and then touching the eyes, nose, or mouth. Or the virus can be transmitted when someone who is sick with SARS coughs or sneezes droplets into the air and someone else breathes them in. It's also possible that SARS can be spread more broadly through the air, or by other ways that are currently unknown.

Rados p 14.)

The estimated period for the survival of the virus in the environment can be several days but this factor is dependant on a number of factors. These factors may include "... The type of material or body fluid containing the virus and various environmental conditions such as temperature or humidity. " (Cause Of SARS)

SARS Virus Can Change Quickly And Unpredictably)

Studies show that "The... recombination in the SARS-CoV lineages does indicate its potential for rapid, unpredictable evolutionary change, and this is a potentially important challenge for public health management and for drug and vaccine development." (ibid)

This aspect therefore increases the sense of anxiety about the disease and also adds to the need for comprehensive and more fully informed ways of dealing with a recurrence.

Prevention and solutions

Various measures were taken by the CDC at the time of the epidemic. These included closer cooperation with various authorities, a move which has set the tome for present day interventions and sustainable solutions.

CDC continues to work with other federal agencies, state and local health departments, and healthcare organizations to plan for rapid recognition and response if person-to-person transmission of SARS-CoV recurs. CDC has developed recommendations and guidelines to help public health and healthcare officials plan for and respond quickly to the reappearance of SARS in a healthcare facility or community.

Basic Information About SARS)

As mentioned, a central aspect that concerns this study is that the exact cause and origins of SARS is not known. This aspect raises a question mark when it comes to the issue of stainable solutions to the possibility of the reappearance of the virus. Some experts state that"... It is conceivable that an exact answer may never be determined." (China's Latest SARS Outbreak Contained, But Biosafety Concerns Remain)

This is a vital aspect in that control, prevention or management of future possible outbreaks is determined by the extent of knowledge that we have about the virus. The United Nations Food and Agricultural Organization (FAO) has warned that "The threat of future outbreaks of Severe Acute Respiratory Syndrome (SARS) remains real as long as its source is unknown" and has warned that more research on the disease is needed. (The cause of SARS) This presents various problematic concerns that have to be dealt to facilitate both prevention and sustainable solutions to future outbreaks.

The sustainability of solutions also has to take into account the rising incidences of viruses and infectious that has emerged since SARS - as these are possibly part of a pattern in the contemporary world. In other words, the issue of sustainability has to be cognizant of the total holistic picture and the context of SARS in the pattern of diseases and viral infections in the world to be effective.

The number infectious diseases continue to climb across the world. This has led to the realization that, our global community must do more to deal with the human, social and economic costs of infectious disease. Official development assistance, co-operative research and development programs and strategies to overcome market failures all can play a role in turning back the tide of infectious disease. But what we need most is a real international partnership, with OECD countries shouldering much of the responsibility for delivery of the most vital of the pillars of sustainability of good health for all.

Biotechnology and Sustainability)

The above sentiment is an indication of the most logical and practical way of dealing with the possible reemergence of SARS and the present viral infections, such as Avian flu.

Unfortunately the perception that new and dangerous forms are diseases are appearing in the modern world more often is largely true. This fact is partly the result of modern lifestyles and particularly the ubiquitous nature of modern travel, especially air travel, which had an enormous effect on the spread of diseases like SARS.

The above points all go to suggest that in terms of sustainable solutions the threat of disease like SARS must not be seen or dealt with in isolation. The following quotation emphasizes this point.

The emergence of SARS is by no means an isolated event. Since the 1970s, at least 30 new infectious diseases have emerged for which no effective treatment exists. One of the most destructive diseases the modern world currently faces was virtually unknown 20 years ago, but today the HIV / AIDS epidemic has infected more than 40 million people worldwide, killed 3 million in 2001 and continues to spread around the globe.

BIOTECHNOLOGY AND SUSTAINABILITY)

Diseases like SARS have a negative effect on the world economy, with subsequent effects on the social and health infrastructure of many countries, impeding their ability to deal with the disease. There is a growing sense in the word community that "... infectious diseases will need to be turned back...If the global community is serious about achieving sustainable development and growth in the world economy." (ibid)

To this end a number of public and private international partnerships have been established; such as the Medicines for Malaria Venture, the Global Alliance for TB Drug Development and the Global Alliance on Vaccines and Immunization. (ibid) Another example of the type of international cooperation that is needed is the establishment of the European Clinical Trials Platform, created by the European Commission in 2002. This platform supports common programs of research and clinical trials for various diseases.

Another area that has become particularly important in the area of sustainable prevention is the use of biotechnology, genomics and informatics. These tools and technologies offer "...a growing range of approaches to help prevent, monitor, detect, diagnose and treat infectious diseases. Appropriate policies are however necessary to ensure that the right tools reach the right people at the right time. (ibid)

The above emphasizes central point that is reiterated by many experts on SARS and other infectious diseases; namely that "...the battle... against infectious diseases...today is a challenge and a burden to be shared with all the global scientific community." (ibid) Scientific commentators state that the complexity of diseases like SARS, coupled with the easy spread of virus via air travel, has necessitated that an inclusive and wide- ranging strategy of sustainable prevention must be initiated in all countries.

A related aspect is the issue of surveillance in the fight against SARS and other viral epidemics. This was referred to in the present study in terms of the role that the media played in warning the international community about SARS, thereby being instrumental in retarding its spread. There is little doubt that disease outbreaks such as SARS can be successfully responded to with effective surveillance.

Almost all infectious disease outbreaks can be responded to more successfully if they are detected early. Early detection largely relies on effective surveillance. Of course, surveillance and detection are closely linked. The... SARS outbreak serves to demonstrate this point.

These two aspects, the importance of international and open surveillance and advances in biotechnology and informatics can help to prevent another outbreak of SARS. For example, "...by offering micro-arrays that detect multiple pathogens and almost real-time alerting over IT networks...bringing the best in high-technology sciences together with...the more traditional surveillance systems. (ibid)

In the final analysis and in terms of solutions to the problem of disease like SARS, there can be no other long-term solution than extensive and organized global involvement. The view presupposes as well a more holistic view of the disease and not a view that attempts to understand it in isolation." The threat of potential pandemics such as Ebola, SARS, and avian influenza demands a more holistic approach to disease control, one that prevents diseases from crossing the divide between humans, their livestock, and wildlife." (one world, one health' paradigm: emerging diseases require a global solution)

This view of a "One World, One Health" concept is propounded by the, Wildlife Conservation Society. The society calls for the "... integration of efforts to deal proactively with disease threats to human and animal health before they reach crisis levels." (ibid) This is a particularly important aspect as it is at the level of the interaction between animals and humans that scientist see the origins of disease like SARS. The Wildlife Conservation Society also states an essential aspect with regard to a sustainable response; namely that as yet there is single or integrated body that can coordinate the various disciplines and efforts to combat the possible reemergence of SARS, or mutations of the disease.

As of yet, no single agency or organization focuses on the myriad diseases that move across the interface between people, their domestic animals and wildlife,"... "There is only 'one health,' and future programs must factor in the complexity of how emerging diseases move among humans and other species."

There is also the continual possibility that diseases like SARS can move between species and this factor alone makes coordinated international surveillance a top priority.

Many of these diseases can move back and forth between species, mutating into more virulent, resistant forms. Over 60% of the 1,415 infectious diseases currently known to modern medicine are capable of infecting both humans and animals. Most of these diseases originated in animals and now infect people.

5. Conclusion

SARS was a devastating event in world history. While the number of deaths was relatively minimal what the disease did was to usher in a new era of concern for contemporary world health authorities. Ironically it was mainly due to new technologies such as air flight that these viruses were so rapidly spread into the modern world. However a worrying aspect is that, while in terms of travel the world has become smaller there are still barriers to knowledge and accessibility between countries.

SARS also sharply brought into focus the fact that barriers to information on an international level substantially increase the risk of the spread of viral epidemics. If there is one positive lesson that can be gleaned for the SARS epidemic it is that knowledge, information and research about the disease cannot be hidden and must be immediately shared and made known to scientists and authorities throughout the world for preventative measures to be effective.

As has been continually stated in this study, SARS was not an isolated incident and is possibly and part of a larger pattern of emerging new and deadly viruses that threaten global health. The lessons that have been learnt from the study of SARS may be instrumental and effective in developing strategies and sustainable programs of containment and treatment for the possibility of another SARS epidemic or other viral infection.