SARS Virus Treatments

Swine Influenza

Swine Influenza

SWINE INFLUENZA frightening you? CONCERNED about the health implications? Coughs and Sneezes Spread Diseases! Stop The Swine Flu from Spreading. Follow the advice to keep your family and friends safe from this virus and not become another victim. These simple cost free guidelines will help you to protect yourself from the swine flu.

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Pandemic Preparedness Guide

Inside this information dense guide youll discover: Water & Food: The 2 common water storage containers that are breading grounds for bacteria that could kill you so you know to avoid them. How 8 drops of this common household chemical will instantly sterilize any drinking water container (its not vinegar or ammonia) so your can drink safely. The 21 dried foods you Must have stored to remain self-contained until the threat passes so your family can eat when grocery stores are bare. How to reduce energy and heat to cook by 70% with this special pot that only costs about $17 at Wal-Mart (It also doubles as a sterilizer) so your cooking fuel last 3X longer. How to create an inner home cocoon so you dont have to heat or cool your entire house so you save on heat and energy when the power is out or sporadic. How to recharge batteries an Unlimited number of times just using the sun so you can power your devices forever. How to create a resilient community in your neighborhood Now so you are not alone in defending your area so you can keep the infected and even looters out. The one plant that will keep intruders from coming in through your windows and openings in your home so you remain safe. How to train your dog to act when strangers are near your home so you know when and how to protect yourself. 3 weird uses for a fire extinguisher in a pandemic. The formula for the Ultimate protection against infection, so even our youngest family members remain disease free. How to create an isolated environment for the sick so they dont get everyone else sick while you are waiting for emergency workers. The one kind of phone that is most likely to work in a disaster so you can have constant communication with the outside world even if the power is completely out The one way to Never communicate with your family in a crisis so you dont create panic and unrest in a tense situation.

Pandemic Preparedness Guide Summary

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Contents: 24 Page Ebook
Author: Joe Marshall
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SARS and Developing Nations

Another ongoing worry among international health officials is that if SARS does recur, its effect in developing countries will be SARS Should the SARS epidemic recur, it could be devastating to AIDS patients like this African man, and to others with severely weakened immune systems. Should the SARS epidemic recur, it could be devastating to AIDS patients like this African man, and to others with severely weakened immune systems. frightening. Scientists know that patients whose immune systems were already weakened from other conditions were more likely to die from SARS. In fact, more than two-thirds of the deaths in every age category were people suffering from chronic diseases. For many people in developing nations, chronic disease is a way of life. treatment, since the majority of sufferers are poor. State hospitals are overwhelmed with the numbers of people needing care, and often must turn people away. We are already living a nightmare here, says one South African doctor. Six...

New Tools to Fight SARS

If or when SARS does make a comeback, scientists are banking on new tools with which to fight it. Although experts predict a vaccine will not be available until at least 2006, there are other things that could be valuable in saving lives. One would be an accurate test for SARS. Tests at the current time are not accurate unless a patient has been infected for at least twelve days. In that time, that patient will have infected dozens of other people. Doctors are working to develop a vaccine against SARS and are researching the use of antibodies to help infected patients fight the disease. Doctors are working to develop a vaccine against SARS and are researching the use of antibodies to help infected patients fight the disease. SARS As yet, there is not a surefire drug to cure SARS, but some progress has been made. Doctors know, for example, that a combination of the antiviral drug Ribavirin combined with an AIDS drug called Kaletra has great promise. Ribavirin tries to damage the virus,...

The Faces of SARS

It seemed, in the early months of 2003, that the disease came out of nowhere. No one could pinpoint the first case of severe acute respiratory syndrome (SARS) it probably occurred in November 2002 but by early 2003 it was roaring through hospitals in China and other parts of Asia, as well as in Toronto, Canada, striking down hundreds of doctors and nurses as they tried to care for their patients. It was a ghastly illness one Hong Kong resident says that watching someone with SARS gasp and fight for breath was like watching a man drown to death on dry land.1 Thousands of those infected died, and doctors were panicking, for there seemed to be little progress in fighting the new disease, and it continued to spread. As people quickly learned, a dangerous new disease in the age of jet travel rapidly becomes everyone's problem. By June 2003 there were SARS victims on six continents. Of course, those primarily affected by the disease were people who became infected with SARS. Henry Likyuen...

Ebola Virus Disease

With recognition of new, deadly viral infections - such as Lassa fever, Marburg, Ebola, Congo-Crimean hemorrhagic fever, Rift Valley fever, and AIDS - the classic descriptions of diseases such as malaria and yellow fever must After the discoveries of Marburg virus in 1967 and Lassa virus in 1969 had jolted medical complacency, the Ebola virus in 1976 provoked convulsive shudders. Almost simultaneous outbreaks of a deadly infection occurred in neighboring regions of southern Sudan and northern Zaire, and along the Ebola River. The Sudan and Zaire foci are about 150 kilometers apart, and continual traffic passes between them.

SARS and the Future

On july 6, 2003, the World Health Organization announced that SARS had been contained, as no new cases of the disease had been reported anywhere in the world since June 15. Although the announcement was a relief to many people, medical experts tended to be less optimistic. For instance, some felt that the disease could easily return. Because SARS is a coronavirus, it may be seasonal like other coronaviruses such as those that cause the common cold. Michael Osterholm, director of the Center of Infectious Diseases at the University of Minnesota, felt a recurrence of SARS was not only possible, but likely. I am convinced with the advent of an early winter in the Northern Hemisphere in just six short months, he told Congress, we will see a resurgence of SARS that could far exceed our experience to date.76 Other infectious disease experts concurred, saying that it would only take one case of SARS to spark a new outbreak. And since it was impossible to know whether or not a person with SARS...

Diseases and Disorders

Summary Describes SARS, its effects on the world's economy, treatments for the disease, and what may happen if it was to return. Contents The Secret Killer Investigating SARS SARS, Politics, and the Economy Life with SARS SARS and the Future.

We Didnt Take Any Preventive Measures

A doctor treats a SARS patient in Hanoi, Vietnam, in 2003. The first cases of the disease appeared in November 2002 in rural areas of China's Guangdong Province. A doctor treats a SARS patient in Hanoi, Vietnam, in 2003. The first cases of the disease appeared in November 2002 in rural areas of China's Guangdong Province.

More Questions than Answers

But stability was hard to maintain as the disease continued to spread. Doctors had believed that SARS was spread only by close human contact from inhaling the spray of a cough or sneeze of an infected person. In Hong Kong, however, that theory proved false. In less than a week, 250 residents of a thirty-three-floor housing development contracted SARS, and most of those people had never met one another. Clearly, close human contact had As in other cities around the world, quarantine seemed the only method of containing SARS, although doctors were not even certain whether that would work. Meanwhile, hospitals were running out of space, people were fleeing affected areas, and those who had been exposed to the disease were herded into seclusion until doctors felt that they were no longer at risk of coming down with SARS. As doctors and researchers struggled for answers, they were met with more questions. Where did the disease come from, and how exactly was it spread Was there any...

Difficult Job for a Crisis Team

The scramble to learn about the mystery disease began in mid-March, when WHO doctors were alerted that a Toronto woman had become infected. Apparently, SARS had hopped continents. WHO issued its first global warning, alerting travelers that what appeared to be a very dangerous contagious disease had become a worldwide health threat. On March 17, 2003, WHO officials called the top epidemiologists throughout the world to form a crisis team that would tackle the problem of identifying the cause of the disease. Doctors in China had easily ruled out bacteria as the cause of SARS. SARS SARS Researchers were able to deduce that a virus is responsible for SARS because the pathogen did not respond to antibiotics and was invisible under a microscope. Researchers were able to deduce that a virus is responsible for SARS because the pathogen did not respond to antibiotics and was invisible under a microscope. Investigating SARS

The Medical Equivalent of Shock and

Stohr set up a website with a secure password for the participating epidemiologists. He also arranged twice-a-day conference calls so the team could discuss any new theories or ideas, results of lab tests, and so on. The results were beyond anything Stohr could have anticipated. Not only did the team identify the cause of the disease, but it did so in less than seven weeks. The speed at which the battle against SARS was waged, says one researcher, was the medical equivalent of shock and awe the phrase President George W. Bush had used to describe the U.S. attack on Baghdad in March 2003 .28

Trying Out a New Tool

Investigating SARS Investigating SARS The SARS virus is pictured inside a human cell. Scientists used a new tool called a DNA microarray to study the coronavirus that causes SARS. The SARS virus is pictured inside a human cell. Scientists used a new tool called a DNA microarray to study the coronavirus that causes SARS. SARS

Suddenly Theyre Rock Stars

The scientific community realized that the dangerous unknown coronavirus was a problem. While there are many researchers who study viruses, there were not many who specialized in coro-naviruses. One doctor says that because coronaviruses had never been a serious threat to people and were difficult to grow or study in a laboratory, the topic had become a sleepy little corner of virology.30 Far more researchers were interested in studying viruses that cause Ebola, West Nile disease, or AIDS all of which are known killers. With the discovery of this particular virus, however, coronaviruses became a hot topic, and anyone A man suffers from Ebola in a hospital. Before discovering SARS, researchers neglected coronaviruses, focusing instead on the viruses responsible for such epidemics as Ebola and AIDS. A man suffers from Ebola in a hospital. Before discovering SARS, researchers neglected coronaviruses, focusing instead on the viruses responsible for such epidemics as Ebola and AIDS....

Frustrating Mutations

SARS This constant mutation is frustrating to scientists who are searching for a reliable tool for doctors to diagnose patients. In some diseases, doctors can perform blood tests to look for antibodies the body's response to a particular germ that contains the genetic code of the virus. With an ever changing code, however, the coronavirus makes diagnosis tricky, for the antibodies in one patient may look different from those of another patient. You look for symptoms like a cough, fatigue, a low-grade fever, says one doctor. But that pretty much sums up a case of the flu, doesn't it It's no wonder that so many SARS patients have been hospitalized in regular hospital wards, when they should have been isolated.34

Returning to Guangdong

To find answers to the virus's beginnings, some researchers went to Guangdong Province, where the first cases of SARS occurred. Scientists noted that the first victims of the disease were people who worked in the many live animal markets throughout the province. A visit to a market just an hour south of the province's capital showed reporter Elizabeth Rosenthal a place that seemed rife with germs Investigating SARS Investigating SARS A scientist studies the SARS virus for clues about how it spreads from person to person. Scientists discovered that close contact is not necessary for transmission of the pathogen. A scientist studies the SARS virus for clues about how it spreads from person to person. Scientists discovered that close contact is not necessary for transmission of the pathogen.

From Person to Person

As some researchers concentrated on the beginnings of the virus and its probable jump from animals to people, others tried to understand how it spread from person to person. At first doctors believed that for someone with SARS to infect another person required fairly close proximity, with the infected person sneezing or coughing and those droplets coming into contact with an un-infected person. However, as doctors began seeing more patients with SARS, they noticed that in all cases, the disease affects the lower part of a patient's lungs. That means that close contact is not necessary. Viruses that arise from the lower lungs tend to come out in a fine aerosol, rather than heavy droplets from sneezes and bronchial coughs. The aerosol is so light that it can linger for a much longer time in the air. SARS In addition, scientists found that the SARS virus can live outside the body for up to twenty-four hours, which means that it might be possible for an infected person who touches a...

Clean Tires and Disinfectant

Once the Chinese government realized that it was necessary to openly confront the SARS epidemic, life changed quickly for the Chinese people. Interestingly, China's authoritarian system, which has been widely criticized as repressive, proved to be very useful in fighting the epidemic. In a country where the government rules by fist, notes observer Kathy Chen, its orders to fight SARS have been carried out in spades.39 One man from a town in central China learned how strongly the government felt about containing SARS. Yang Jie, a twenty-two-year-old who worked for a home-improvement company in Beijing, decided to return home for a visit during the height of the epidemic. However, before being allowed on the train Yang had to undergo a thorough physical to make sure that he was not infected with SARS. During the fourteen-hour train trip, railroad workers came through his car several times to spray disinfectant. And when he arrived in his home town, Yang and several other passengers who...

It Feels like Being in Prison

Quarantine was often far different for people in Asia. Shortly after it was discovered that more than 250 residents of the large Hong Kong housing complex, the Amoy Gardens, had become infected with SARS, health officials descended on Block E of the complex and bused the 240 remaining residents to quarantine facilities. In the eastern mainland province of Zhejiang, SARS patients were quarantined in a government office building. Not only were those quarantined angry at the lack of facilities no beds, for example but nonquarantined residents staged violent protests at the use of those buildings. Breaking windows and smashing furniture, townspeople were furious that such buildings were used, calling the quarantine a danger to everyone. They worried that

Fear Among Health Workers

While the constant worry about SARS was hard on almost everyone, it was especially troubling for health care workers. They were the ones most at risk, and in the early weeks of the disease, it was doctors and nurses in mainland China, Hong Kong, Vietnam, and Toronto who were infected more than any other group. One of the American doctors who traveled to Canada says that the atmophere in the Toronto hospital where she worked was both angry and frightened. So little was known about SARS especially how it was transmitted that health workers felt vulnerable even with protective gear. The healthy members of the staff were burned-out because they had to work more shifts to cover for their colleauges who had caught SARS or who were in quarantine. Many were working double or even triple shifts. They're not getting enough sleep, they struggle with putting on their protective gear, said the chief of infectious diseases at the University of Toronto, and they are worried about getting infected...

The Psychological Toll

As months went by in SARS-affected countries, many learned that there were often psychological effects on residents. In Hong Kong, for example, many people complained of feeling mentally fatigued each day. There was no comfort of routine. There were no concerts to attend, no social get-togethers with neighbors. Altar boys attend Catholic mass in Hong Kong. Churches throughout areas impacted by SARS welcomed parishioners struggling with the emotional effects of the epidemic. Altar boys attend Catholic mass in Hong Kong. Churches throughout areas impacted by SARS welcomed parishioners struggling with the emotional effects of the epidemic. Others in SARS-affected regions missed the support they normally received from their families. Since many foreign business people in Asia had moved their families to other continents in an attempt to avoid SARS, they weathered the ordeal without the comfort of their spouse and children. Karl Taro Greenfield, a Time magazine reporter living in Hong...

The Government Doesnt Care

Of course, in busy cities like Shanghai and Beijing the ballooning rate of infection from SARS was hard to keep secret. As more and more people learned of friends and coworkers who had become infected, it became clear to the public that they had been lied to. Many were furious with their government. It's really bad, says a relative of a SARS victim, that the government doesn't care about ordinary people's lives.60 As the disease moved into the more remote parts of China, the response was no less angry. The tiny remote villages have limited hospital facilities a shortage which is troublesome under normal circumstances. They lack around-the-clock staff, X-ray machines, and even bed space for more than two or three patients at a time. When people infected with SARS began appearing at these rural hospitals, health workers were forced to turn many patients away. This experience showed residents the inadequacies of their health care system. In one village, five or more SARS patients were...

Why Didnt the Government Say Anything

Two women try to keep SARS out by blocking the entrance to their village. Such remote rural areas lacked the facilities and resources to properly treat SARS patients. Two women try to keep SARS out by blocking the entrance to their village. Such remote rural areas lacked the facilities and resources to properly treat SARS patients. But people have been outspoken many for the first time about their government's mishandling of the SARS epidemic. One young woman who became infected after tending to her mother and father in the hospital when they had the disease was angry. If we had known about this disease, we would have stayed away from the hospital, she says. Why didn't the government say anything I blame them for my parents' death.62 Many Chinese, fearing for the health of their families, felt that the government was less interested in preventing SARS than in keeping up the pretense that all was well in China's cities. In Beijing, for example, people were frantically trying to find...

For the Sake of the People

Students quarantined at Beijing University do morning exercises. Many students defied government orders and left the campus to avoid contracting SARS. Students quarantined at Beijing University do morning exercises. Many students defied government orders and left the campus to avoid contracting SARS. chose to deal with the disease in more traditional ways in this case, being secretive about the severity of SARS. It was only when WHO and the international media became involved that Hu realized that he and his government were rapidly losing the trust of the people in addition to that of the international community. On April 20, 2003, Hu abruptly fired his health minister, replacing him with a no-nonsense former trade minister, Wu Yi. Wu's job was one-dimensional to head the anti-SARS fight in China. It seemed clear that for the first time in memory, China's government was serious about openly confronting a crisis.

The Black Box or the Sunshine

Hu's supporters were very pleased by his actions. They believed that his decision to be more open about SARS would benefit the nation. Perhaps, they said, this episode forced China to turn a corner, allowing much-needed reforms. This is Hu's chance to grab the support of the people and stand up on his own, said one former party official. China can keep living in a black box, or it can live in the sunshine. If he can't take advantage of the situation and move into the sun now, then when 66 There is strong opposition to Hu's openness, however. Some Communist Party officials are critical of Hu's more liberal views. They predicted that his more open dealing with SARS would backfire, causing panic among the Chinese people. The former president of China, a conservative named Jiang Zemin, is one of the most adamant critics of Hu, and experts in Chinese politics predicted that if the SARS epidemic had not been controlled, Jiang might have regained power. If that had happened, say experts, it...

Trouble for Hong Kong

Mainland China has been hard hit by the economic effects of the SARS epidemic, but Hong Kong has had even worse trouble. As fear of SARS intensified, tourists canceled trips to Hong Kong, leaving the city's airport (pictured) empty and causing severe economic distress. As fear of SARS intensified, tourists canceled trips to Hong Kong, leaving the city's airport (pictured) empty and causing severe economic distress. Hong Kong, far and away the most modern part of China, had been experiencing economic difficulties even before the SARS crisis. It is a very expensive city foreign firms with branches in Asia had found it so expensive for its employees to live there that many of the firms had relocated to the mainland. WHO's warning about visiting Hong Kong was even more damaging. international flights each day to Hong Kong cut service drastically. The largest carrier to Hong Kong, Cathay Pacific, reduced its weekly flights by 45 percent almost immediately after news of the SARS outbreak...

The Whole Region Contracts

The SARS epidemic has not only affected Chinese workers but also many foreigners who live and work in China. For example, more than 25 percent of American employees in Beijing sent their families out of the country because of the disease. One Australian bank with branch offices in Asia gave its employees in Hong Kong the option of returning to Australia and were surprised when the majority said yes. A bank officer predicted that even when SARS is no longer a threat, many of those employees may decide to stay in Australia rather than risk working in Asia again. You've got most of the foreign population away from Asia already, the families at least, he said, and if this goes on, people will start to say, 'Why don't you relocate me out of Asia where their families are '71 More than thirty-four hundred miles away, Australian fishermen have been affected by the economic calamity in China, too. Those who fish along the Great Barrier Reef are feeling the loss of a great deal of their...

Canada Disagrees with WHO

While Asia was hit hardest by the political and economic fallout from SARS, Canada suffered, too. Because of the outbreak in SARS Although the travel alert was lifted after one week, Canadian officials felt that the damage had already been done. Like China, Canada's economy depends on tourism, and economic analysts estimated that the SARS threat cost Canada a minimum of 30 million per day of the alert. A milder caution by WHO, listing Toronto as a SARS-impacted area, remained until July 2, 2003, and that definitely hurt not only Toronto's economy, but that of the entire nation. Even in places such as Montreal and western Canada's Lake Louise and Banff National Park, where there were no cases of SARS, there were sharp declines in the number of visitors. One hotel official says that it is unfortunate that the public had the impression that Canada was dangerous because of SARS, when in reality, Toronto's health officials did a good job of containing the threat. Perception versus reality...

Impossible to Enforce

If it is true that a wider variety of animals carries the virus, it would create a number of new problems. Since it is almost certain that the SARS virus is a crossover from an animal virus, it would mean that there were many carriers of the coronavirus that could possibly infect humans. In that case it is not merely a matter of warning consumers about one or two types of animals, but rather most of the species sold at the markets in southern Guangdong Province. It is believed that the animal virus invades a human host during the handling, slaughtering, or cooking of infected animals. (Researchers do not think that eating animals once they are cooked poses any threat.) Soon after the link was identified between wild animals and SARS, the Chinese government tried to crack down on the animal markets, banning the sale, capture, transport, or purchase of almost all wild animals dead or alive. In addition, provincial government officials warned that they would conduct unannounced visits to...

Its the Dumbest Thing in the World

Toronto's health officials say that one lesson they learned from their experience with SARS was the woeful state of their patient-tracking system. As Toronto's outbreak worsened in April and May, the public health system was overwhelmed by the task of keeping track of thousands of people who had been exposed to the virus and were at risk of developing SARS, as well as the many people in quarantine. Because of underfunding, the public health office had to rely on a paper-based tracking system far more time-consuming and prone to errors than a computer-based one. The tracking system was so inaccurate, for example, that some people who were at risk for developing SARS were never called and warned, while others were called several times. Two families were not called until after their relatives had died of SARS.

The Crossroads of the World

Another lesson of the SARS crisis was how important a part Hong Kong played in the epidemic, and how vulnerable to disease the region is. Hong Kong lies at the very edge of southern China, a region that is historically where many flu viruses and Hong Kong is also vulnerable because the crowded, heavily populated conditions in the city make any contagious disease difficult to control. There are many housing projects like the Amoy Gardens, and a broken sewer pipe or a faulty ventilation system could easily spread a virus to hundreds of thousands of people within a few days. Doctors agree that in the SARS epidemic of 2003, Hong Kong was fortunate to keep the number of infections at 1,755 and the death count at 295.

Police and Health Officials

WHO officials are convinced that health agencies throughout the world would be wise to see how Hong Kong was able to contain the spread of SARS, given its high vulnerability to contagious diseases. It was successful, say experts, because once Hong Kong's public health department realized the danger, it began a thorough tracking of all personal contacts of each SARS patient who had been seen in a hospital there. Not only did public health workers do the tracking, but police officers helped, too. All family members or friends who had been in contact with a person infected with SARS were found and confined to their homes. Some worried that this zealous tracking partnership might be an infringement of civil liberties, but most health care workers in Hong Kong and elsewhere were pleased with the system and other nations have taken note. I'm convinced that the way that the health authorities, the Department SARS

Organizations to Contact

The CDC's goal is to promote health and quality of life by preventing and controlling disease. The organization has developed vital partnerships with public and private medical groups that can provide information and assistance to people in the United States and throughout the world. One of the CDC's functions is to investigate outbreaks of new and dangerous diseases such as SARS.

An Impact on Baseball

Although baseball officials agreed that most likely the chance of a player catching SARS in Toronto was small, they maintained it was important for players to be careful. One player agreed, saying that as long as people were still contracting SARS, it made sense for players to be cautious. I think right now we have to back off a little bit, he said, and make sure everybody stays safe until they find out what's going on. I think fans should understand what's going on, because people are dying from this thing. It's not like people are just sick. People have died.75

Bambi and Teddy Bear Masks

More than anything else, however, it was the presence of face masks that served as a constant reminder of the threat of SARS. People rushed to medical supply stores to buy them, hoping to keep airborne germs away from their noses and mouths. In Hong Kong, stores were selling more than one thousand masks each day some people were buying hundreds at a time. When only a few were left on store shelves, shouting matches often broke out among customers. Masks seemed to be everywhere SARS was. They were worn by bank tellers, flight attendants, and waiters. Even on television, talk show hosts (and their guests) wore masks, too. But the mask-wearing has brought up some new issues of etiquette that have never been considered before. For example, business people debate whether masks make their clients more or less afraid. Should one remove one's mask when meeting someone for the first time And since touching and handshakes are frowned upon in the age of SARS, how best to greet a valued customer...

Many Effects

SARS.2 But the effects of SARS have been felt by more than the patients and their families. In hundreds of smaller ways, people all over the world had their routines altered because of the disease. Students who had planned on studying in China were told by the Centers for Disease Control to cancel their plans. One twenty-one-year-old law student from Virginia had just begun an internship in Hong Kong when the outbreak hit, and he was called home. In SARS-affected regions, businesses that rely on travelers and tourists struggled and were often forced to cut their work force to meet payrolls. Airlines with flights to Hong Kong and mainland China were especially hard-hit. In Toronto a girls' soccer team had won the right to compete in an exhibition match in Pennsylvania, but the team's coach was told not to come after all. One of the players, a sixteen-year-old, had hoped to show her skills and perhaps get a college scholarship. It was my one big chance, she says. I was literally...

Unsettling Questions

The emergence of SARS and its spread throughout the world has raised unsettling questions about contagious disease and medicine's ability to prevent it. More than ever before, researchers are eager to understand how viruses arise. How can they mutate, and why do some viruses cause so much damage to the human body, while others have only faint effects While some strides have been made in understanding the nature of the SARS virus, a great deal is left unanswered. In a world that has recently begun to consider bioterrorism a very possible threat, the SARS virus has demonstrated how vulnerable life is in the face of a new and contagious disease, and how societies, governments, and economies can be rattled by the tiniest of microbes.

Coming to the City

But it was difficult for the people in Guangdong to remain silent about SARS when it was obvious that the disease was not under control at all. In fact, there was a growing problem as some rural patients frightened because they were not getting better in their local hospitals traveled to Guangzhou, the large capital city of the province. Because of the lack of information on the disease, the large metropolitan hospitals of Guangzhou were unaware of the seriousness and highly contagious nature of SARS. While the local hospitals had learned to isolate SARS patients to keep them from infecting others, the metropolitcan hospitals found out the hard way. A Hong Kong shopkeeper prepares an herbal remedy for a SARS patient. Many Chinese turned to folk remedies to protect themselves from the disease. A Hong Kong shopkeeper prepares an herbal remedy for a SARS patient. Many Chinese turned to folk remedies to protect themselves from the disease. SARS knew enough about SARS to isolate the man in...

We Didnt Believe It

Though Chinese officials had tried to keep SARS a secret, bits and pieces of information about the disease had spread via the Internet to the World Health Organization (WHO) and the Centers for Disease Control (CDC) both international public health organizations. When WHO's Outbreak Center, which investigates any new and potentially hazardous diseases in the world, made official inquiries to China, they were told that the oubreak was a new type of flu and that the Chinese health authorities could handle it without outside help.

Global Threat

Tse was placed in a bed of an observation ward and infected two men in nearby beds, who in the days ahead infected dozens of others with whom they had contact. At that point, says one Toronto doctor, there was no concept of how infectious Tse was.12 By May 15 there would be at least 145 cases of SARS, with nineteen people dead of the disease.

An Official Alert

The warning to health professionals was apt, for doctors and nurses were among the hardest hit by SARS. By the middle of March 2003 the emergency room at Scarborough Grace Hospital, where Tse was treated, had to shut down because of a shortage of healthy staff members. Thousands of Toronto citizens who had At the entrance to a hospital in Hanoi, Vietnam, a bust of French chemist Louis Pasteur wears a surgical mask. From China, SARS quickly spread into neighboring Vietnam. At the entrance to a hospital in Hanoi, Vietnam, a bust of French chemist Louis Pasteur wears a surgical mask. From China, SARS quickly spread into neighboring Vietnam. SARS SARS World Health Organization officials visited China to research the extent of the SARS outbreak. Initially, the Chinese government refused to cooperate with the officials. World Health Organization officials visited China to research the extent of the SARS outbreak. Initially, the Chinese government refused to cooperate with the officials.

Worst in China

In early April SARS hit Beijing, infecting ninety people at a large downtown hospital seventy of them nurses and doctors. Yet when asked if it was safe for tourists to come to the city, one government representative minimized the risks, stating that there had been only thirty-seven cases, and the disease had been contained by Chinese health care workers. Of course tourists can travel, he said. We think it's very safe.15

Were Frustrated

International health officials, however, were not convinced. One WHO representative was adamant that the stonewalling had to stop. We have clearly told the government, he said, the international community doesn't trust your figures.16 Many doctors around the world demanded more information in case SARS appeared among their citizens. In the United States, Secretary of Health and Human Services Tommy Thompson also expressed his exasperation with the Chinese government for being overly concerned about their image and insisted that WHO and the CDC only wanted to help China contain the disease. We're frustrated, he said. We want to work in greater collaboration with them.17 By the end of April, however, the government finally acknowledged that SARS was not completely contained and that an accurate count of those with SARS in Beijing was 339, rather than 37, as previously announced. Within a week, the figure had jumped to 900 confirmed cases. To try to contain the disease, the government...

Guessing Wrong

Investigating SARS One of the early assumptions about SARS was that it would prove to be a new type of influenza, or flu virus. After all, many strains of flu have originated in rural areas of China, where people and livestock often live very close to one another. Epidemiologists, doctors who study the transmission of diseases, say that many viruses that cause disease in humans actually originate with animals. Ducks, because they have weak immune systems, seem to be breeding grounds for new viruses. In a duck's body, such viruses can mutate and then are able to jump to pigs, and from pigs to people. Many strains of flu have originated this way in southern China, where the living conditions of ducks, pigs, and people create what one researcher termed a toxic stew.25 Other news gave researchers even more support for their theory of a new strain of flu. They heard of a new bird flu in China that had made some people sick. Perhaps, doctors reasoned, the strange new SARS disease was...

Superspreaders

Another puzzling aspect of the SARS epidemic are those people known as superspreaders those who seem to be able to infect SARS On the other hand, researchers believe that some people who have had SARS have been able to fight off the virus without becoming ill. I'm quite convinced that some people might have contracted the infection but not the disease, says one Hong Kong researcher. Some may develop mild symptoms, like a little bit of cough and no fever some may just feel a little tired for a day or two.38 This phenomenon is a mystery, just as the existence of super-spreaders. Having people with the virus who do not become ill, however, is far more beneficial to the public. Scientists know that mild cases of SARS, where people do not exhibit any serious symptoms, are a good thing, because they act as natural vaccines. People lucky enough to get only a mild infection will have immunity from the virus in the future.

No Cure in Sight

But for the majority of people, a case of SARS is a very serious threat and one for which scientists have yet to find an effective cure. Treatment or prevention of the disease is an ongoing challenge, but doctors admit that there is much to be learned about the virus before cures are found. Until then, researchers hope that an existing drug for a different virus might give some relief. In Hong Kong, for example, doctors have been giving some patients a combination of steroids and an antiviral drug called Ribavirin. Though they say it has had promising results in some cases, other researchers are doubtful because the drugs do not have an effect on the SARS virus in their labs. In other labs, re- Investigating SARS Investigating SARS Doctors treat a SARS patient in a Chinese hospital. Researchers continue to investigate new and effective ways to treat patients infected with the SARS virus. Doctors treat a SARS patient in a Chinese hospital. Researchers continue to investigate new and...

Life in Quarantine

Some of those in quarantine were relatives and friends of people who had developed SARS. Many spent the required two-week period (the longest time known between being exposed to the disease and showing symptoms of it) at their homes. Besides being told to take their temperatures often and to stay away from their families, they had to resist the temptation of dashing out to do an errand or see a friend. A New York man kisses his Chinese bride through a surgical mask. Some visitors to China and to other countries impacted by SARS were forced to spend up to two weeks in quarantine. A New York man kisses his Chinese bride through a surgical mask. Some visitors to China and to other countries impacted by SARS were forced to spend up to two weeks in quarantine. been exposed to SARS at North York General or Scarborough Grace Hospitals the two facilities that treated the SARS patients during the epidemic and which later transferred all patients except those with SARS to other hospitals in the...

Reminders Everywhere

Though SARS patients and others quarantined were most affected, daily life even for healthy people changed drastically during the SARS crisis in China and other Asian countries. For children in Singapore and China, it meant that school was canceled until the threat of infection had passed. For parents of very young children, it meant babysitting services, daycares, and preschools were closed, too. That presented a problem for people who had no older children or other family members to watch their young children while they went to work. In Singapore alone, more than six hundred thousand young children were affected by the closing of child care services. SARS Children in Hong Kong wear masks to protect against SARS. These masks were in high demand in China as people took precautions to avoid contracting the disease.

Hungry Ghosts

SARS has not only changed the routine for doctors and hospitals, but for the families of the victims of SARS. For instance, the disease has forced a change in the cultural rituals associated with death. In China, for example, people are expected to remain with a dying family member. A family vigil, known as you zi song zong, is considered extremely important to ensure that after death, the spirit is happy. However, when SARS spread to Hong Kong, doc- Because scientists were initially uncertain how SARS spreads, finding funeral homes to perform services for people who died from the disease was difficult. Because scientists were initially uncertain how SARS spreads, finding funeral homes to perform services for people who died from the disease was difficult. SARS lives.52 And because of the hospitals' need to keep family members separated from the dying SARS patients, people do not know the emotional state in which their loved ones died.

Cold and Empty

Because people were unsure of how SARS was spread, families had a great deal of difficulty finding funeral parlors that would accept a SARS victim's body and even those refused to hold traditional funeral services. Throughout Asia, funerals are almost always held with the body displayed, but the threat of SARS changed that. Funeral directors, worried about spreading the disease from the dead body to funeral guests, insisted on using a framed photograph of the deceased, instead. Another funeral custom that has been suspended because of SARS is the ceremonial water buying, in which a family mem-ber usually the oldest son or male relative purchases water with which to wash the dead person's face. This symbolic ritual is extremely important to many Asian people so much so, says one funeral director in Hong Kong, that among the older generation in Hong Kong, the greatest insult would be to say, 'When you die, I hope you have no sons to buy you water.'53 Not surprisingly, the funerals for...

Psychiatric Study

For people who have survived SARS, the psychological toll has been documented. In a study of 150 SARS patients in Hong Kong, it has been found that 45 suffered from psychiatric problems when they were discharged from the hospital. The problems have ranged from anxiety and mild depression to episodes of posttrau-matic stress and severe panic attacks. Some doctors suggest that the psychiatric problems may stem from a reaction to the steroids and other drugs given in the hospital, but no one is certain. The fear of SARS became an overriding factor in the lives of many Chinese, who paid anxious attention to news reports, hoping for promising news about the disease. The fear of SARS became an overriding factor in the lives of many Chinese, who paid anxious attention to news reports, hoping for promising news about the disease. Health care workers who survived SARS, experts say, tend to be more fearful than before they were infected, and that as a result, they have not returned to their...

Angry Doctors

Similarly, many people feel that China's government may suffer because of its lack of openness with its citizens about the SARS virus. Once word of the disease began to leak out, many Chinese Healthcare workers like this man were angry with the Chinese government for its initial refusal to provide information about the extent of the SARS epidemic. Healthcare workers like this man were angry with the Chinese government for its initial refusal to provide information about the extent of the SARS epidemic. SARS To make the numbers of infected people seem low, government health officials decreed in March 2003 that doctors could no longer diagnose SARS instead, for a diagnosis to be official, it must be made by a medical researcher. But because researchers were unable to see even one-fourth of the patients suspected of having the disease, many patients whom doctors suspected of having SARS went undiagnosed. One doctor in Shanghai recalls a patient he saw whose symptoms almost certainly...

Misinformation

But it is not just medical workers who are angry at the government's secrecy. It is almost certain that thousands of Chinese people became ill, some fatally, because they were not told about the seriousness of the disease. One man says that the government had assured everyone that the risk of SARS was long over, even when health officials knew that the disease was spreading out of control. As a result of the misinformation, the man says, his wife was ill and highly contagious for days with SARS and the family was certain it must be something else. Chinese journalists, who are largely under the control of the Communist Party, admit that they were used by the government to convince the public that SARS was not a problem. In Shanghai, for example, journalists were told that the number of people in the city with SARS was highly classified and were warned that they would be fired or jailed if they attempted to interview SARS patients or their families. At the same time, however, health...

Economic Disaster

Politics is not the only thing that has been affected by SARS. In SARS-stricken countries, the epidemic has had a great economic impact especially in China. Having recently won the rights to host the 2008 Olympics in Beijing, as well as the World Expo 2010 in Shanghai, Chinese economists were very pleased with the prospects for higher employment rates and rising stock prices. However, on April 2, 2003, when WHO declared Guangdong Province and Hong Kong danger zones, that optimism evaporated almost overnight. SARS The first setback was the sharp drop in the number of tourists. China depends on tourism, for it accounts for 9 percent of the economy. In both 2000 and 2001 the tourist industry accounted for 67 billion. After word of the SARS outbreak spread, however, tourists looked elsewhere for places to visit. In April 2003, alone, there were ten thousand cancellations for flights and hotel bookings because of people's fear of becoming infected with SARS. By July 2003 it was estimated...

Trickling Down

In China and other Asian countries affected by SARS, the huge decrease in factory orders resulted in layoffs of millions of workers. Many of the factories affected were foreign-owned assembly plants that had moved their operations to Asia to save money, for factory workers in Asia are paid only a small fraction of what

Ripe for an Epidemic

South Africa is one of many places on the planet where impoverished people could be decimated by SARS. Many researchers at WHO were nervous about the consequences of an outbreak in India, whose 1 billion people live in the most crowded of conditions. Since scientists believe that the outbreak in Hong Kong's Amoy Gardens housing complex was caused by feces of a person with SARS, the likelihood of a major outbreak in India where only one-fourth of the citizens have toilets is very strong. SARS Some health care systems are so impoverished that they lack even the basics necessary to treat someone with SARS or any other contagious disease. Kenya, which is one of the better-equipped African nations, has only ten respirators in the entire country. The Philippines, which spends only 2 percent of its annual budget on its citizens' health, cannot even afford to buy Experts fear that a SARS outbreak in poor countries like India and the Philippines would be catastrophic. Most citizens of such...

Learning Lessons

One of the most important aspects of the SARS crisis is that it has shown the weaknesses in the health care systems around the world. If the disease returns, as many researchers believe it will, it is important that governments and health agencies learn from the mistakes that were made during the 2003 outbreak of the disease. For one thing, it is clear that honest, prompt, accurate reporting of the disease is vital to containing it. China's coverup of its first cases directly led to the worldwide spread of SARS. Barry R. Bloom, the dean of the Harvard School of Public Health, says that SARS it is pointless for any nation to use deception when it comes to a virus like SARS. In infectious diseases, it helps no one to either deny you have a problem, or to be dishonest in reporting it, he says, because if you do, and you do have spread, you are going to get caught.85 But inaccuracy can be just as devasting as deceit, and China is only one of several nations where botched diagnoses allowed...

Is the World Ready

Hong Kong is not the only place where strategies have been mapped out in the event that SARS returns. In the United States, where only a handful of confirmed cases were verified, health officials have taken inventory in various cities, making certain that there are enough respirators and other tools needed to care for victims. Many experts say that even before the SARS outbreak worldwide, the United States was already fairly organized for a large outbreak of some infectious disease. The terrorist attacks of September 11, 2001, had alerted the nation that its procedures for a bioterrorist attack needed to be shored up.

For Further Reading

Ooi, eds., SARS War Combating the Disease. Singapore World Scientific, 2003. Although much of the material is incomplete, the book does contain some helpful information on the history of emerging diseases in China. Fred Ramen, Influenza. New York Rosen, 2001. Very good section on the 1918 epidemic, to which SARS researchers refer as the nightmare of contagious diseases. Helpful index. CDC (www.cdc.gov). This is the official site of the Centers for Disease Control and Prevention, and it contains a wealth of information about SARS, its spread, and what is being done to combat it. World Health Organization (www.who.int). This site has up-to-the-minute articles and bulletins about any SARS news from around the world, including travel warnings about the virus or any other communicable disease.

Works Consulted

Lawrence Altman, Behind the Mask, the Fear of SARS, New York Times, June 24, 2003. -, The SARS Enigma, New York Times, June 8, 2003. -, Isolation, an Old Medical Tool, Has SARS Fading, New -, SARS Declared Contained, with No Cases in Past 20 Gordon Chang, SARS Crisis New Disease, New Leaders, Same Old Regime, China Brief, Jamestown Foundation, April 22, 2003. Marilyn Chase and Antonio Regalado, Search Continues for SARS Drugs, Wall Street Journal, September 17, 2003. Kathy Chen, China Is As Good at Fighting SARS As at Hiding It, Wall Street Journal, June 4, 2003. Geoffrey Fowler, In China, SARS Robs Families of Chance to Say Goodbye, Wall Street Journal, May 30, 2003. SARS Geoffrey Fowler and Ben Dolven, If SARS Stages a Comeback, Is the World Ready Wall Street Journal, August 14, 2003. Claudia Kalb, The Mystery of SARS, Newsweek, May 5, 2003. -, Tracking SARS, Newsweek, April 28, 2003. James Kelly, Making News on the SARS Front, Time, May 5, 2003. Clifford Krauss, SARS Abates in...

M J D Griffiths T W Evans

The care of the critically ill has changed radically during the past 10 years. Technological advances have improved monitoring, organ support, and data collection, while small steps have been made in the development of drug therapies. Conversely, new challenges (e.g. severe acute respiratory syndrome SARS , multiple antimicrobial resistance, bioterrorism) continue to arise and public expectations are elevated, sometimes to an unreasonable level. In this book we summarize some of the most important medical advances that have emerged, concentrating particularly on those relevant to the growing numbers of respiratory physicians who pursue a subspecialty interest in this clinical arena.

Acquired immune deficiency syndrome

(AIDS), first identified in 1981, is an infectious disease characterized by failure of the body's immunologic system. Affected individuals become increasingly vulnerable to many normally harmless microorganisms, eventually leading to severe morbidity and high mortality. The infection, spread sexually and through blood, has a high fatality rate, approaching 100 percent. Caused by a human retrovirus known as HIV-1, AIDS can now be found throughout the world -in both industrialized countries and developing nations. Public-health officials throughout the world have focused attention on this pandemic and its potentially catastrophic impact on health, resources, and social structure. Treatments for the disease have been developed, but no cure or vaccine currently exists.

Other Medieval Plagues

In major Plague years of the First Pandemic, early medieval Iraq shared the Mediterranean world's suffering, and may have shared it with Did bubonic plague appear in the West between the Pandemics Most modern scholars agree that what struck the West in 1347 had not been seen for centuries. On the other hand, Michael Dols, a historian of the Plague in the Islamic world, has noted five limited outbreaks that might qualify around Rome in 1167 and again in 1230, Florence in 1244, and southern France and Spain in 1320 and 1330.18 Russian chronicles mention nine plague episodes between 1158 and 1344, though nothing indicates this was bubonic. Nevertheless, the report for 1230 is quite dramatic in Smolensk four mass graves were dug in which 32,000 bodies were interred in Novgorod a mass grave held 6,000 corpses and an accompanying famine caused people to sell their children for food, and eat grass, cats and dogs, and each other.19 Recurring famine also killed off an enormous number of...

Balancing Alpha and Beta

However, if there is a high level of dissatisfaction with the state of the science (e.g., a highly infective and lethal form of avian flu), then the medical community would be willing to accept a larger type I error rate in its search for an effective treatment. In this case, one would not wish to miss a promising therapy. The higher rate of type I error means the result has to be confirmed, but the investigator

Could The Black Death Have Been Plague Plus

Nonetheless, Scott and Duncan contend there was no medieval bubonic plague in England. They concede that there may have been simultaneous bubonic plague in the Mediterranean and elsewhere. They are convinced, however, that in England it was a viral (rather than bacterial) agent that caused an as-yet unidentified hemorrhagic fever, not unlike Ebola, which was the English Black Death. Infection would have been person-to-person, and people could be carriers having and passing on the virus for a long period before the symptoms hit. No rats, no fleas, no problems with seasons, and, at least theoretically, the symptoms fit. In fact, medieval English sources tend to be rather vague on specific symptoms.

J T Granton S E Lapinsky

Severe acute respiratory syndrome (SARS) is a viral illness characterised by a syndrome of fever and respiratory symptoms that can progress to respiratory failure and death. Initial reports of a highly contagious atypical pneumonia originated from the Guangdong province of the People's Republic of China in November 2002. The condition remained isolated to China until February 2003 when an infected physician travelled to Hong Kong. Since that time the disease has spread, with 8437 probable cases in 32 countries and 813 deaths providing a case fatality rate of 9.6 (WHO website http www.who.int csr sars en ).1 The largest outbreaks have been in China, Toronto (Canada), and Singapore. This review describes the current state of knowledge of SARS, with particular reference to the management of the critically ill patient and the safety and protection of the staff in intensive care units (ICU). The recommendations are based on the published data available at the time of writing,...

Management Of Respiratory Failure

Tracheal intubation poses a special risk to healthcare providers. Indeed, several of the outbreaks among healthcare workers in Toronto occurred following intubation of patients with SARS. As a result, strict guidelines for intubation and the management of cardiac arrest have been developed.34 Recommendations for general anaesthesia have also been published.35 In all instances, when a patient with known or suspected SARS requires tracheal intubation, perfect execution of infection control measures and donning of protective equipment is required (fig 7.6). In Toronto mock cardiac arrests and patient simulators with relevant clinical scenarios have been used. Intubation should be performed by the most skilled person available using the method with which they are most comfortable. Awake intubation may be associated with agitation and coughing which can severely compromise infection control precautions. We therefore recommend rapid sequence induction to facilitate airway stabilisation. A...

Infection Control Precautions

Initial unfamiliarity and, later in the SARS outbreak, the failure to adhere to infection control procedures resulted in the spread of SARS to many healthcare personnel.23 The organism appears to be transmitted by droplet spread, although surface contamination and possibly airborne spread may play a role. Recent data suggest that the virus may remain viable for considerable periods (up to 24 hours) on a dry surface.36 As a result, staff education and continued vigilance are essential. Infection of healthcare workers involved in high risk procedures is a very real threat. Despite the use of infection control precautions, nine healthcare workers developed SARS following a prolonged intubation procedure, eight of whom required hospitalisation.36 Droplet aerosolisation also occurs during bronchoscopy and similar precautions should be employed, including sedation and paralysis to prevent coughing.

The Advantage Of Being Std In A Sparsely Populated World

Because of limited interaction between social groups, this strategy would necessarily be unsuccessful if the pathogen was highly lethal, since it would be eliminated by destruction of the host population. It can be presumed that the ebola virus infecting humans faced and regularly lost in this way in the past in rural Africa. Thus, it jumped from some animal into an isolated human social group, destroying that group and then itself, and thus this particular episode was ended. Any successful STD disease would need to be as gentle as possible while still retaining its infectiousness if it is to be effectively transmitted to other hosts during rare encounters between groups, especially when population levels are low and groups well separated.

Toxin evolution and transmission in the host

However, all clinical isolates do make these virulence factors in the host intestines. The ctxAB genes that encode the A and B subunits of CT were found to be located on a putative transmissible element (called CTX) on the chromosome (Mekalanos et al, 1983 Pearson et al, 1993). Surprisingly, this CTX element was later demonstrated to actually be a filamentous bacteriophage (CTX ) that could undergo lysogenic conversion under certain laboratory conditions, but the most efficient transfer occurred in the host intestines (Waldor and Mekalanos, 1996). What was even more remarkable was the finding that CTX uses as its receptor the TCP pilus, which itself is a colonization factor in the gut (Taylor et al., 1987 Karaolis et al., 1999). While classical pandemic strains of V. cholerae express TCP under a variety of conditions, more recent El Tor pandemic strains only express TCP in the infected mammalian host (Mekalanos et al, 1997). In addition, generalized...

The Origins Arrival And Spread Of The Black Death

The debate over what disease or diseases constituted the Black Death is properly part of Chapter 2. Suffice it for now to say that historians have long assumed that it was bubonic plague and its close relative, pneumonic plague (the same germ, settled in the lungs). In addition, historians have long assumed that this was also the disease of the First Pandemic. If the bubonic plague did not become epidemic anywhere in Europe or the Near East between the 760s and 1347, then where did it go, and why did it return Neither question has a simple or agreed upon answer.

The Plague Of Justinian 541c 760

The First Pandemic refers to a series of outbreaks of what was probably bubonic plague in the Mediterranean basin, and probably western Europe, from 541 to around 760. Because it broke out while Justinian I was the Byzantine emperor, and most famously ravaged his empire, his name is often linked to the First Pandemic. Contemporary sources agree that it began in Egypt, or further south in Abyssinia or the Sudan,5 and spread by ship to Constantinople, the Near East, Italy, and Southern France. In the seventh century it may have also appeared in England and northern Europe west of the great German forests. Contemporaries observed that earthquakes, floods, fires, comets, and eclipses had preceded it. Following classical medical authorities, especially Hippocrates and Galen, the secular-minded blamed it on corrupted air, perhaps caused by the comets, fires, or earthquakes. According to Isidore, the scholarly bishop of Seville, the corruption was caused by excessive dry-ness, heat, or rain....

Epidemiology and Risk Factors HIV1 is transmitted

Ihe World Health Organization estimates that from the beginning of the pandemic until January 1, 1996, 30.6 million people worldwide have been infected with HIV-1. Of these, 27.4 million were adults (15.3 million men 11.7 million women) and 3.2 million were children. An estimated 10.4 million persons have developed AIDS, and 9.2 million people have died from AIDS. In the United States, since the beginning of the epidemic until June 1996, greater than 440,000 cases of AIDS had been reported to the CDC, and about 350,000 from North America have died. It is estimated that between 1 to 1.5 million people in the United States are HIV-1 infected. Statistical models of HIV-1 transmission in the United States suggest that transmission peaked among homosexual males in 1934 and among intravenous drug users between 1934 to 1936. Transmission by heterosexual contact is stable or increasing. y A progressively larger proportion of recent AIDS cases is in women.

The Black Death And The Western Imagination

Six hundred and fifty years after the first chroniclers and physicians recorded the opening stages of the Second Pandemic, Western society retains an uneasy fascination with the Black Death. Though living in the shadow of the man-made Holocaust and the development and use of nuclear and other types of weapons of mass destruction, we still reel at the thought of Nature's destructive capability. That people might unleash something as terrible as the Black Death on other people seems both unthinkable and closer to reality than ever before in history. As the Rand Corporation study cited in the Preface suggested, the Medieval Plague might just be a distant mirror for our society, making all the more disturbing the conclusion that human society can withstand such a blow and remain intact.

1771 Baltic Peasants Revolt

The Plague of Justinian (First Pandemic) epidemic throughout Mediterranean probably bubonic plague. The Black Death (Second Pandemic) begins Constantinople, Alexandria, and Messina on Sicily are struck by pestilence it begins to move outward in Middle East, Africa, and Europe. Third Pandemic of bubonic plague begins in China, southeast Asia, and Hong Kong Yersin and Kitasato conduct research, identifying Y. pestis serum against the bubonic plague proven successful in following years. Japanese ship carrying bubonic plague docks in San Francisco Bay, beginning American phase of Third Pandemic.

The Art Of Intercession

Some misericordias make no visual reference to the pestilence, reflecting Mary's role as a protector in general. For saints specifically associated with the Black Death many Catholics turned to St. Sebastian (see Photo 4 in photo essay) or St. Roch (Rocco, Roche, Roccus). Sebastian was a Christian soldier who was to be executed for his beliefs in the early fourth century. He survived a shower of arrows and, having been left for dead, was nursed back to health. He returned to confront the pagan emperor and was brutally beaten to death. His association with the pestilence stems from his having survived the shower of arrows. The association of arrows with divinely sent disease is ancient. The Old Testament repeatedly mentions arrows as metaphors for God's punishments, as at Deuteronomy 32 23, I will spend mine arrows upon them, or at Psalm 64 7, But God shall shoot at them with an arrow suddenly shall they be wounded, or Psalm 7 12, he hath bent his bow and made it ready. The celestially...

Annotated Bibliography

Plagues and Peoples. Garden City, NY Anchor Press, 1975. Classic study of man and disease from a world historical perspective. McNeill employs much conjecture for early periods, but he is on good ground for the Second Pandemic. Scott, Susan, and Christopher Duncan. Biology of Plagues Evidence from Historical Populations. New York Cambridge University Press, 2001. Zoologist and demographer carefully outline patterns of Black Death, especially in England, and conclude that it was an outbreak of a hemorrhagic virus like Ebola. Kohn, George C. Encyclopedia of Plague and Pestilence From Ancient Times to the Present. New York Facts on File, 2001. Short entries on a wide range of topics, including specific phases of the Second Pandemic.

History

Because HIV is related to other recently isolated primate retroviruses, such as simian T lym-photropic virus (STLV)-III in African green monkeys, many have speculated that HIV originated in Africa. Antibodies to HIV were discovered in stored blood dating back to 1959 in Zaire. According to experts, it is likely that HIV has existed for many years in isolated groups in central Africa. Because outside contacts were minimal, the virus rarely spread, and epidemics could not be sustained. Once a sizable reservoir of infection was established, however, HIV became pandemic. As with other sexually transmitted diseases, such as syphilis, no country wished the stigma of association with the virus's origin. Because biomedical technologies to prevent transmission appear to be some years away, the principal public-health approaches to controlling the pandemic rest on education and behavior modification. Heightened awareness of the dangers of unprotected anal intercourse among gay men, for example,...

The Hiv Epidemics

As of 15 November 1998, a cumulative total of 1 987217 cases of AIDS in adults and children have been reported to the World Health Organisation (WHO) since the onset of the AIDS pandemic (WHO, 1998). The reported cases of AIDS in each region includes Allowing for incomplete and delayed reporting, and underdiagnosis, WHO has estimated that by the end of 1998 approximately 13.9 million AIDS cases in adults and children (2.0 million infected vertically) had occurred worldwide since the beginning of the pandemic. Globally there are three men infected for every two women, although by the year 2000 the number of new infections among women may be closer to that among men. It is estimated that there are currently 33.4 million people living with HIV AIDS, of which 5.8 million were newly infected during 1998, including 590000 children. This amounts to 16 000 new infections per day. The estimated number of adults and children with HIV AIDS as of the end of 1998, by region, are expressed in...

Mortality

RMSF is the most severe of all spotted fever rickettsioses and its fearsome reputation is closely linked with its capacity to rapidly kill otherwise healthy individuals in this context, the case-fatality rate of RMSF in patients with untreated infection rivals some of the most deadly viral hemorrhagic fevers, including Ebola (119). Sporadic early reports of case-fatality rates of RMSF from the Bitterroot Valley and other endemic regions of the American West were as high as 70 (99). In Brazil, where RMSF is endemic to in at least five states, mortality was 40 in Minas Gerais State between 1981 and 1989 (100).

Aetiological Agent

The worldwide cooperative effort to identify the aetiological agent for SARS has been summarised elsewhere.1 The speed at which the aetiological agent was identified is a testimony to the progress in advances in molecular biology, the automation of molecular methods, and the power of genomic information available in databases accessible on the Internet. Initial efforts focused on several potential viruses most notably, metapneumovi-ruses and paramyxovirus. On 21 March 2003 an agent isolated from patients meeting the case definition for SARS was found to be capable of producing cytopathic changes in a Vero and a murine cell line from a laboratory in Germany, and in rhesus monkey renal cell lines in a laboratory in Hong Kong. Using electron microscopy, coronavirus-like particles were identified (fig 7.1). Subsequent sequencing using reverse transcription-polymerase chain reaction (RT-PCR) of the isolated product identified the virus as a novel coronavirus.2 3 Further study of this agent...

Clinical Features

In the absence of a rapid early diagnostic assay, case definitions of SARS are based on the presence of epidemiological risk factors (close contact with SARS cases or travel to SARS affected areas) with a combination of fever and respiratory symptoms, with or without hypoxia and chest radiographic changes. However, as the SARS epidemic spread, the ability to distinguish it from other community acquired pneumonias based on such epidemiological clues became increasingly tenuous. Although more recent definitions have incorporated serological assays or identification of viral RNA to confirm cases (see below), at this time SARS must be considered in the differential diagnosis of any community acquired or nosocomial pneumonia. The sensitivity of the WHO definition of a SARS case has been shown to be limited when applied as a screening method for individuals at risk of infection. Using clinical criteria and progression of the disease in the face of conventional therapy as a gold standard,...

Diagnostic Testing

At present, specific testing for SARS-CoV infection has limitations that prohibit definitive early confirmation of disease. Diagnostic tests for the SARS virus include (a) detection of antibodies produced in response to SARS infection (b) molecular tests for example, PCR to detect genetic material of the SARS-CoV in blood, stool or respiratory secretions and (c) cell culture techniques which allow the identification of Figure 7.2 Sequential quantitative reverse transcription polymerase chain reaction (RT-PCR) for SARS coronavirus in the nasopharyngeal secretions of 14 patients reported by Peiris and coworkers. A peak in the viral loads was seen on the 10th day of sampling. Reproduced with permission from Ksiazek etal.2 AQ 3 live virus. Immunofluorescence assays become positive later in the illness, but may be useful to confirm undifferentiated cases or to assist with epidemiological studies. IgG seroconversion occurs in most patients by day 20.n Positive antibody test results,...

Respiratory failure

About 20-25 of patients with SARS become critically ill and require ICU admission.22 23 The mean duration from the onset of illness to ICU admission is 5-10 days and respiratory failure is the usual indication. A recent report from the Singapore group found that 45 of 199 infected patients eventually fulfilled the criteria for the diagnosis of acute lung injury (Pao2 Fio2 < 300) or ARDS (Pao2 Fio2 < 200).22 In 10-15 of patients lung injury may progress to the point where mechanical ventilatory support is required. Advanced age, male sex, chronic hepatitis B carriage, raised creatinine levels, and recurrence of fever were associated with the development of ARDS in one study.11 However, after multivariate analysis, only advanced age and chronic hepatitis C infection correlated with the development of ARDS, although the importance of coexisting hepatitis C infection will probably be less relevant in areas where hepatitis C is less prevalent. Classic histological features of ARDS,...

Treatment

If the diagnosis is uncertain, empirical treatment for community acquired pneumonia should be started. In most series of SARS treatment has included broad spectrum antibiotics including a fluoroquinolone or macrolide. The antiviral agent ribavirin has been used in the majority of patients treated in Hong Kong and in the first SARS outbreak in Toronto, without evidence of efficacy or even a strong anecdotal suggestion that patients benefit. The adverse effects of ribavirin are significant, particularly haemolytic anaemia and electrolyte disturbances such as hypokalaemia and hypomagnesaemia. The drug is also teratogenic. These features have led to the use of ribavirin falling out of favour. Similarly, the use of antiretroviral agents remains speculative. In a presentation at the international WHO SARS conference, the use of Lopinavir (an inhibitor of the HIV protease) in 34 patients with SARS was reported. Early in the Table 7.1 High risk procedures for transmission of SARS in the ICU...

Survival

The case fatality rate varies from 3 to 12 , depending on whether the denominator includes suspected and probable cases (3 ) or probable cases alone (12 ).11 12 15 16 32 Older patients or those with pre-existing disease (diabetes, cardiac disease) have a higher mortality rate.11213 16 22 23 33 In one study the mortality rate of patients over 60 years was 43 compared with 13.2 in their younger counterparts.9 While the mortality rate is higher in older patients, particularly those with pre-existing co-morbidity, young previously healthy people succumb to SARS, possibly because of higher viral loads or their vigorous host response. In multivariate analysis age, LDH level, and an increased neutrophil count at presentation were associated with a higher odds ratio for a poor outcome (death or ICU admission). Children appear to have a much less severe course than adults.32 For patients admitted to the ICU, the mortality rates at 28 days have been reported to be 34-37 . In the series reported...

Conclusions

SARS has resulted in significant challenges for critical care medicine. The ability of this disease to incapacitate staff has resulted in staff safety becoming a priority to maintain adequate critical care services. Indeed, the impact of this infection on the healthcare system and regional economy cannot be understated. Resources of individual hospitals were rapidly outstripped as scores of administrative and front line care providers were quarantined or became ill. In Toronto 18 of the critically ill patients were healthcare workers. The ability of this infection to spread is singularly impressive and devastating. Our understanding of the virus, its diagnosis, and treatment continues to evolve. Infection control measures remain the mainstay of regional and global health. The concept of universal precautions has expanded beyond policies regarding blood borne infections and now includes strict respiratory and contact precautions. The effect of these stringent policies on patients...

Influenza

There is at present no specific cure effective against this viral disease. In mild cases, symptoms disappear in 7-10 days, although physical or mental depression may occasionally persist. Influenzal pneumonia is rare but often fatal. Bronchitis, sinusitis, and bacterial pneumonia are among the more common complications, and the last can be fatal if untreated. Influenza is generally benign, and even in pandemic years, mortality is usually low - 1 percent or less - the disease being truly life-threatening for only the very young, the immunosuppressed, and the elderly. However, this infection is so contagious that in most years multitudes contract it, and thus the number of deaths in absolute terms is usually quite high. The sequelae of influenza are often difficult to define, but evidence indicates that the 1920s global pandemic of encephalitis lethargica had its origin in the great pandemic of 1918-19.

Black Death

The Black Death is the name given to the great pandemic of plague that ravaged parts of Asia, the Middle East, North Africa, and Europe in the mid-fourteenth century. Contemporaries knew it by many names, including the Great Pestilence, the Great Mortality, and the Universal Plague. This epidemic was the first and most devastating of the second known cycle of widespread plague, which recurred in waves through the eighteenth century. Some later and milder plagues seem to have also involved other diseases, including influenza, smallpox, and dysentery. Nonetheless, most historians agree that the Black Death was a massive epidemic of plague (a disease of rodents - caused by the bacillus Yersinia pestis - that is transmitted to humans by fleas). The Black Death manifested itself most commonly as bubonic plague but also appeared in the forms of pneumonic plague and septicemic plague.

Characteristics

Pattern III countries, including North Africa, the Middle East, Eastern Europe, Asia, and the Pacific, initially experienced less morbidity and mortality from the pandemic. Apparently, HIV-1 was not present in these areas until the mid-1980s. The nature of world travel, however, has diminished the significance of geographic isolation as a means of protecting a population from contact with a pathogen.

Epidemiology

HIV infection is a worldwide epidemic. The greatest number of deaths from AIDS have occurred in sub-Saharan Africa, and the prevalence of HIV infection is increasing most rapidly in southeast Asia. Worldwide, it is estimated that 30 to 40 million people will be infected with HIV by the end of the decade. Although the incidence of AIDS and deaths from AIDS has declined in the United States, the number of patients infected with HIV continues to increase. In the United States, public health efforts have focused on earlier diagnosis and treatment, which have led to improvements in survival.

The Bubonic Plague

Between 1896 and 1905 Masanori Ogata and Paul Simond, laboring in Taiwan and Bombay, India, respectively, made the connection of the bacillus to the rat, Rattus rattus (R. rattus), and one of its fleas, Xenopsylla cheopis (X. cheopis). Simond discovered the flea's role as inoculator of the bacillus into people in 1898. Experiments in British India in 1908 confirmed the rat's role, and research published in 1914 by A. W. Bacot and C. J. Martin outlined how the flea contracted the bacillus and passed it on to people.2 Despite this new knowledge and the development of serums to fight the disease, this Third Pandemic claimed 50,000 victims in Manchuria in 1910-11 and more than twelve million in India from 1898 to 1948.3 It is generally accepted that the black or house rat, Rattus rattus, of which the flea X. cheopis is very fond, was the rodent-culprit in the Second Pandemic. Its strong tendency is to live among people, nesting in high places such as rafters especially in houses...

Natural History

The reported incubation period of SARS varies from 2 to 7 days (http www.cdc.gov mmwr). However, based on the infectious characteristics of other members of the Coronaviridae, there is concern that the incubation period may be up to 21 days. Indeed, in a recent case in Toronto a medical student developed symptoms beyond the 10 day quarantine period. The mean duration of symptoms to time of admission to hospital is 3-5 days and in one study was observed to shorten throughout the epidemic.9 The viral load may play a role in both the transmission and severity of subsequent disease. The notion of super spreaders has been suggested to describe the occasional patient who is associated with spread to large numbers of contacts. At present it is unknown if asymptomatic individuals are capable of spreading the disease. The mode of transmission is thought to be droplet spread. Consequently, protective measures have focused on barrier methods, the intensity of which varies with the risk of...