- The Washington Times - Saturday, May 24, 2003

There are some positive signs that the SARS outbreak in China may be easing, but health specialists say the country was hardest hit by the virus partly because of its initial reluctance to report cases, its sheer size and the weakness in its public health system.

“The numbers are going down; that is very encouraging,” Dr. Henk Bekedam, the World Health Organization’s representative in China, said Tuesday. He warned, however, that China remains “the battleground” in the war against SARS.

Meanwhile, SARS may be making a comeback in Canada, where five possible new cases were reported Thursday — a week after the WHO said Canada had the virus contained. At least 40 more people may have been exposed to SARS after visiting two hospitals where the five new possible cases emerged in the previous day, Canadian health officials said yesterday.

The United States reinstated its travel advisory against Toronto Friday, but the WHO has not done so yet.

WHO spokesman Dick Thompson said from Geneva that one new case in Toronto tested positive for SARS, and 31 other people with respiratory illness were being tested. But Mr. Thompson said the U.N. body would have to study the situation further before making a decision whether to place Toronto back on a list of SARS-affected areas or begin considering a travel advisory for the city.

Canadian health officials said Friday an apparently undiagnosed SARS case at North York General Hospital may have infected health care workers, other patients and their family members on one ward in late April.

A patient transferred from the ward to St. John’s Rehabilitation Hospital was believed to be the probable source of four more cases under investigation, they said. It is not known where the new cases may have come from.

Hanif Kassam, medical officer of health in the York region north of the city, said yesterday that at least 40 people who had direct contact with the possible new SARS cases have been traced so far.

“The number [of exposed people] is likely to increase over the next 24 to 48 hours,” said Mr. Kassam, adding the source of the possible outbreak remained not clear.

Hundreds of other people possibly exposed from visiting the two hospitals in recent weeks were told to stay home for 10 days as a precaution.

Despite Canada’s difficulties in containing the virus, China has had the toughest time of all the countries in fighting the illness, partly because “the public health system has been weakened over the past 10 to 20 years” as the Chinese government invested in other things, Dr. Bekedam said. He said 60 percent to 70 percent of farmers in rural areas of China do not have access to health care because the price is just too high — leaving some to fear that SARS cases may not be detected in these areas.

Dr. Bekedam also said that some “delays in making sure that everybody would be well informed” about the new illness contributed to China’s challenge from the start.

The virus that causes flulike SARS — also known as severe acute respiratory syndrome — is thought to have originated in China’s Guangdong province in November 2002, although its exact source in nature is still being investigated.

At least two species of animals taken from a market in Guangdong have tested positive for a virus almost identical to SARS, the WHO said Friday.

China reported the mystery illness to the WHO in February 2003. By that time, a similar illness was reported in Vietnam and soon spread to Hong Kong — in both cases by people who had traveled in China. It then was found in Canada and around the world.

In China’s defense, WHO spokesman Ian Simpson said respiratory illnesses are common in the winter, which is one reason why SARS may have been overlooked initially.

China has more than half of the world’s SARS cases. As of Friday, there were 5,285 cases in China and 303 deaths. SARS has infected 8,117 persons and claimed 689 lives worldwide, according to the WHO. Canada has seen the largest outbreak outside of Asia, with about 150 cases and 24 deaths.

There are good signs in China’s fight against the illness. The number of new cases being reported has steadily declined from 100 to 200 new cases per day in April, to 50 to 100 new cases each day in mid-May, to new cases hovering in the teens or twenties each day last week. And on Friday, the WHO removed its advisory against travel to Guangdong and Hong Kong.

For the first time since late March, no new cases were reported in Hong Kong yesterday.

Despite past tensions, World health leaders remain positive and continue to praise China’s efforts to contain the virus.

“China is working as hard as it can to understand where the disease is occurring and … contain the disease where they find it,” Dr. David L. Heymann, the WHO’s director of communicable disease, said Thursday. Dr. Bekedam also praised the “now massive mobilization and political commitment of China to fight SARS.”

Chinese authorities have quarantined people, instituted a nationwide SARS reporting system and even scanned people for fevers using an infrared machine.

But challenges remain. Dr. Bekedam said more than half of the cases in Beijing cannot be traced to an existing SARS case. More than six Chinese provinces have more than 100 cases of SARS. And there is that persistent fear that sick people in rural areas are not going to doctors so there may be more SARS cases unknown to officials.

“I would not be surprised if we’re going to see a number of more cases identified in the days and weeks to come,” said Dr. Jeffrey P. Koplan, president of health affairs at Emory University in Atlanta and a former director of the National Centers for Disease Control and Prevention.

And one reason why the illness spread in China was because authorities downplayed it at first. There were problems with the speed and accuracy in reporting the number of SARS cases there. On April 20, China told the WHO of 339 previously undisclosed SARS cases and the next day reported an additional 109 cases in Beijing.

China’s health minister and the mayor of Beijing were fired over this debacle.

“The country looked inward and did not want to report things outside,” said Dr. William Schaffner, chairman of the department of preventive medicine and a professor of infectious diseases at the Vanderbilt Medical School in Nashville, Tenn.

Dr. Schaffner said there also was internal resistance by Chinese provinces to report information to the Chinese government.

But Dr. Heymann said China addressed this problem and the national government is now in the provinces ensuring precautions are taken.

But Dr. Koplan, who has worked extensively with China over the past 20 years, said this reluctant attitude “obviously caused greater spread” of SARS initially.

“There is a history of not wanting to report bad news,” he explained. There is also a “structural problem of not recognizing cases when they occur,” he said.

China has both rural, underdeveloped areas as well as highly developed cities, making it difficult to track and diagnose a disease evenly throughout the country, Dr. Koplan said.

Some areas have enough manpower and finances; others do not. “It’s a very uneven framework,” he said.

China is beginning to shift money to provide gloves, masks and respirators where needed, and other countries are donating aid as well, Dr. Bekedam said.

The other SARS hot spot is Taiwan. The WHO last week advised that people postpone all but essential travel there.

On May 20, Taiwan reported 39 new cases, 35 new cases the following day, 65 new cases on Thursday and 55 new cases Friday.

This story is based in part on wire service reports.

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