Beware of the new scourge SARS (Severe Acute Respiratory Syndrome)

The new disease Sars or which is called, as Severe Acute Respiratory Syndrome is new to the public at the world over and at the horizon. Until 2 months back it was unknown entity. The first outbreak was known to have happened at southern province of China at Guangdong and was spread around the world by air travellers in February.

It has been named as Severe Acute Respiratory Syndrome because at its worst form it involves the lung parenchyma or lung tissue and causes pneumonia like symptoms. In its worst form it causes shortness of breath or dyspnoea. Dry coughs, sore throat, fever and muscle pains, headache, myalgia and lethargy are other presenting symptoms. Some of these symptoms are commonly seen and experienced in influenza (common cold) or flu. But the difference here is we have no cure for this disease or any vaccine available at the present scenario. According to some reports the death tolls all over the world has crossed 300 and in China alone more than 200 people have been killed. Initially China has kept about it as a secret or it was under- reported. As a result the WHO was not aware of the magnitude of the problem and did not take effective and preventive measures.

As Mr Vijay has written in his article a corona virus, the same family of virus that causes common cold causes it.  It appears this corona virus has been transmitted from animals to humans and during transmission has underwent replication and altered the genome and taken the virulent form. It is evident that the disease is not reported in countries like Japan and South Korea where sanitation is excellent and overcrowding and squalor is less or negligent. In this countries they do not encourage contact between animals and human. All viruses when exposed to the environmental changes undergo mutation and as a result will alter their genome or nucleic acid material. As a result of this it is very difficult to develop an effective vaccine. The search for the “Holy Grail” for an effective vaccine against common cold is going on since ages. But we have not succeeded in developing a vaccine yet. There is a vaccine available for Flu but it is not effective or does not give life long immunity.

The mortality from Sars is quoted, as 4% that is four cases in 100 are fatal. It may vary between 5-10%. But again this depends upon the quality of the medical care available at that place and at that time. In developing countries where the standards of medical care are abysmal it could be higher. The other worrying aspect for WHO is the death toll from Sars in countries where AIDS is highly prevalent is very high. Any people who are afflicted with AIDS or HIV, hepatitis or who are immuno-suppressed due to disease or due to cancer drugs the mortality is alarmingly high. As we all know the drugs used for cancer or cytotoxic drugs will bring down bodies immunity and makes people vulnerable to infection.

The incubation period (the period from the time of contact until the symptoms appear) is short. It varies between 2 to 10 days. As a result people are apparently healthy travel by air and will form the route to carry infection from one continent to other. Many of the deaths have been observed in old people who are frail and week and in middle-aged people. So far most fascinating aspect is it has not affected the children or not caused problems. Considering the children are more vulnerable and it has not caused severe illness in children makes an interesting observation. The disease was mainly seen in China, Hong Kong, Vietnam and Singapore. Till today 4 cases have been reported in UK and one patient has been hospitalised.

It is my concern that few cases have been reported in India and it may spread like a wildfire in India. The first reported case was that of Marine Engineer from Goa who brought infection from Jakarta. It was very interesting to read the latest case where the bride Julie D’silva in Pune opted to marry first and then get admitted in hospital after the reception. Her brother Steve D’silva was supposed to have brought the infection from Far East. The Poona Virology Institute has confirmed that in this case it was Sars. It is appalling that medics allowed her to get married when there is clear hazard of spreading infection when bride was carrying SARS infection. This is unpardonable gaffe and health authorities goofed up yet again and put people’s life at risk.

The spread is mainly by spread of droplets by sneezing or coughing. The droplets will become airborne and it is believed that will not spread more than few feet. So it is more of direct contact rather than label as airborne spread. But in common cold one does not need close contact and it spread from one village to other and that is pandemic disease like influenza, olden days TB and the modern AIDS. In Influenza each cough or sneeze will be teeming with million viruses. The virus will remain active for 2 to 4 hours and will remain on lift buttons or door handles and this is one mode of spread. It is believed that it could spread by contaminated water and hence feaco-oral spread is possible.

The preventive measures like wearing mask may not be effective. It may not offer much protection. Since the outbreak has happened all over the sales of the masks in Japan, Korea and China have risen to 1000 fold and companies who make mask are making hay when the sun is shining. In countries like Japan where wearing mask is socially acceptable, the sale of mask has been staggering. The general practitioners and doctors have been warned to look out for symptoms suggestive of Sars and take effective measures like effective screening and containing the movement of the population and restricting air travel. Many people are praying that it will not turn in to an epidemic that was witnessed in 1919 where millions died of Flu epidemic. The other worrying aspect of Sars illness is people are apparently healthy and able to travel and spread infection from one part of the world to other.

Some years back the haemorrhagic fevers like Ebola and Mar burg disease killing people with ruthless efficiency in Africa. But then, they were localised and people with this disease were too ill to travel and that contained the disease. Since the incubation period is 2-10 days and it illustrates better the global village that international air travel has created than the spread of the disease to 25 countries in as many days. In its most virulent forms it will affects breathing and affect gas exchange in lungs and may need artificial ventilation or ventilatory support. Where there is shortage of ITU or intensive care units facilities are short it may kill more.

The only way of containing the disease is being aware of the symptoms and seeking medical attention early. Since there is no definite cure at present that is the way forward. Some of the anti-viral agents may decrease the severity of the disease and antibiotics may have a role where secondary infection has caused the damage. The future look bleak as there is no vaccine yet and even if a vaccine is developed in near future because of the mutation and replication that takes place in virus may not help. Until that happens or effective cure comes in we have to protect ourselves from this dreadful disease. This may be new scourge to the mankind after the Aids. Two decades ago a new disease linked with bathhouses of San Francisco and the residents of Haiti made its appearance. Today we know that were the first stirrings of the pandemic called Aids, which has claimed 20 million lives.

It will be an injustice to travesty that it has affected people of 21^st century for no fault of their own. The outbreak of the Sars has taught us how, even in the era of modern medicine, nature can strike back. Every nation should share information and recognise the importance of honest reporting and taking stronger sterile procedures. I strongly believe that China under-reported the illness and kept the WHO in dark in taking effective measure. Let the Almighty save the mankind from this new pestilent disease that is causing havoc in modern mankind.

Dr Derick D’souza, MB.BS, MD, FFARCSI,

Anaesthesiologist and Intensivist, St George’s Hospital, London

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