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Shared bathrooms. Damp floors. Dirty bedding. The complaints from the residents of the Lady MacLehose Holiday Village and other decrepit resort settlements in Hong Kong are the sorts of gripes you would expect from unhappy campers. This time, though, the more than 240 occupants of these remote settlements are the evacuated residents of Block E of Amoy Gardens, a crowded Hong Kong housing estate that has become the most virulent breeding ground yet for the Severe Acute Respiratory Syndrome (SARS) outbreak. In barely a week more than 250 residents of Amoy Gardens contracted the potentially deadly virus—nearly half of them are from Block E. On April 1, health officials gave Block E occupants a couple hours' notice before busing them to their new countryside digs. Now, they have traded their possibly virus-ridden apartments for temporary housing that might also be as conducive to spreading the killer virus. Sammy Mak, a 31-year-old clerk, spent her first morning in the holiday village disinfecting her cabin's toilet with bleach. She was told that relatives of afflicted residents would be separated from the rest of the quarantined citizens, but a neighbor whose mother contracted SARS has been assigned a cabin nearby. "It feels like being in prison," Mak says.
Millions more around the world are feeling trapped by this mysterious illness. More than 80 victims in nearly two dozen nations had died of SARS by the weekend, leading the World Health Organization (WHO) to issue an unprecedented warning against travel to the hardest-hit regions of Guangdong province and neighboring Hong Kong and airlines to cut flights to affected zones. Despite hope early last week that the virus might be burning out on its own, suspected new cases popped up in countries as disparate as Fiji, Israel and Brazil. Mainland China and Hong Kong each announced more deaths from the disease last week, bringing their death tolls to 49 and 20 respectively. In Canada, the most seriously affected nation outside of Asia, three more patients died, bringing the total there to seven. On Friday a 29-year-old woman became the sixth SARS fatality in Singapore, while two new cases appeared outside Vietnam's capital—dashing epidemiologists' hopes that Hanoi's strict quarantine efforts had contained the disease. In Malaysia, where its government had maintained for weeks that there were no SARS victims in the country, the number of suspected cases leapt from zero to 59 in just a few days. Critics quickly assailed Kuala Lumpur for the same obfuscatory practices used in China that may have contributed to the disease's silent spread. The Malaysian government flatly denied a cover-up, and top health officials held daily briefings for reporters, leading even its harshest critics to acknowledge that the government appeared to have learned from past episodes of stonewalling during disease outbreaks. In faraway Washington, Secretary of Health and Human Services Tommy Thompson briefed President George W. Bush and showed him photos of the coronavirus most likely responsible, causing the President to add SARS to the official U.S. quarantine list—the first new bug to win that dubious honor in 20 years.
Less than two weeks ago, medical investigators thought they might be getting a grip on this puzzling killer. Doctors emerged from their labs to announce they had identified the likely pathogen that causes SARS: a mutation of the coronavirus that normally causes nothing more harmful than the common cold. Researchers averred that while the disease was contagious, it chiefly required close contact with an infected patient to be spread, most likely through respiratory droplets sprayed into the air by a cough or sneeze. Finally, quarantines were instituted in Singapore, Canada and, after much dithering, in Hong Kong, leading to predictions that the disease might be fenced in. For a few promising days, no new cases were reported in Singapore and Vietnam, and the number of new infections began to decline in Hong Kong.
But hopes that the worst might be over collapsed with the outbreak at Amoy Gardens. Clusters of cases began proliferating in the 33-floor housing estate among residents who had never met, forcing researchers to question the theory that the disease was only passed through close human contact. Investigators had to consider that other, more pernicious transmission modes might be more prevalent than first thought. Could it be spread through contact with contaminated surfaces, such as elevator buttons? Through water, possibly flowing in sewage pipes? Through rodent feces, as is the case for many other viruses? Or how about through aerosolized droplets, which can linger for hours in places such as elevator lobbies long after the infected person leaves? So far, nobody knows.
In another blow to confidence, the Hong Kong government's quarantine efforts turned out to be remarkably porous. While 200 or so Block E residents were herded into isolation camps, 113 other families living in the infected building sneaked away—perhaps dispersing the disease farther. Other families from neighboring blocks in Amoy Gardens have complained that the government is still reacting too slowly and not providing adequate health monitoring. "The Department of Health isn't giving good advice," says Julianna Wong, whose father-in-law lives in Block D and was diagnosed with the disease on March 31. "Unless you're really sick and are definitely showing symptoms, you're on your own." At the same time, a new outbreak at the territory's United Christian Hospital, where at least 10 health-care workers developed the disease in the past week, showed that the prevention methods practiced thus far are by no means 100% effective. Says Dr. Atilla Turgay, chief of medical staff at Scarborough Hospital Grace Division, the epicenter of Canada's SARS outbreak: "The difficulty is we're facing an enemy that has no known shape, no identity, and no known effective treatment—and that's causing the most concern."
While other countries were scrambling for solutions, China continued to withhold data on the effects of the disease that has plagued it since November. Decoding SARS is already like trying to put together a jigsaw puzzle in the dark, say international health workers. China's opacity, when it has about half of the more than 2,400 reported SARS cases worldwide, is akin to taking away half of the pieces. Last Thursday, Health Minister Zhang Wenkang finally broke a four-month silence to revise the country's death toll upward to 49—a statistic many local doctors maintain is still far too low for concern. Zhang then proceeded to confidently state that "it is now safe to live, work and travel in China." Yet just one day earlier, the WHO had issued its health advisory warning against travel to southern China. At ground zero itself, in Guangdong province, people seemed oblivious to the dangers because of the continuing local media blackout on the disease. Says a taxi driver in Guangzhou, the provincial capital: "Why wear a mask? This disease is a thing of the past." Li Liming, director of the Chinese Center for Disease Control, on Friday took the unprecedented—for a Chinese official—step of apologizing for China's poor coordination and information sharing so far.
China's reluctance to hand over all relevant data to international health experts is particularly worrisome given that it only takes one infected individual to spark an explosive outbreak. For some reason, certain people—dubbed superspreaders—seem to pass a virus on with brutal efficiency, as happens with some tuberculosis sufferers. One SARS superspreader, who was a patient at Hong Kong's Prince of Wales Hospital, ended up directly infecting more than 90 people in the territory; in Vietnam, another individual was so contagious that he had passed the virus on to at least 30 health-care workers. Medical experts fear another such virus bomb could detonate somewhere in mainland China, especially since a lack of transparency has kept hospitals there in the dark about how to handle the disease. That danger is especially acute now, as many Chinese working in cities return to their home villages to celebrate the grave-sweeping holiday honoring their ancestors. "If only one is a superspreader, then here we go again," frets Meirion Evans, one of the WHO's five-person SARS team, which was confined to Beijing for nearly a week before it was finally allowed into Guangdong last Thursday.
Hong Kong's health officials suspect the superspreader who may have brought SARS to Amoy Gardens is a man with a history of kidney disease. After being treated for influenza at the Prince of Wales Hospital—site of the second major cluster of SARS cases in Hong Kong after the Metropole Hotel—the man visited his brother, who lived on the 12th floor of Block E in Amoy Gardens. During his four visits to the housing complex, the man, who also suffered from diarrhea, might have spread the virus through his bodily waste. (Scientists believe the virus may be present in human feces.) Once flushed down the toilet, the waste may have contaminated the apartment block's sewage system through faulty plumbing. Because the virus seems to survive longer in organic matter than in the open air, investigators theorize that rats, cockroaches and other vermin may have come into contact with the sewage and spread the virus by traveling up the vertical shaft that runs along the side of Block E, the high-rise most affected by SARS. The vermin could have contaminated common objects in the block, which could have then infected residents. Investigators are also exploring the possibility that the virus could be spread by household pets, either through infection—one cat in Block E tested positive for the coronavirus—or through indirect contact. On March 24, the kidney patient's brother and his wife were diagnosed with SARS; three days later, families living in apartments five floors directly above and below the brother's apartment had also developed the potentially deadly pneumonia. Investigators speculate that Hong Kong's high-rises, with their sealed windows and often leaky sewage pipes, might be ideal transmission grounds for viruses.
In the meantime, doctors are concentrating on refining treatment procedures. They are mainly relying on a combination of antivirals such as ribavirin, immunosuppressant steroids that stop the immune system from devouring itself and a serum containing antibodies from recovered SARS patients that is injected into current victims. The cocktail seems to be working, with most of the deaths thus far confined to the elderly or those with pre-existing medical conditions. Doctors also suspect that as the disease is passed on second- and thirdhand, the virus might lose its potency. Says Dr. Joseph Sung, chief of service at the Prince of Wales Hospital: "I'm quite convinced that some people might have contracted the infection, but not the disease. 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." In another small piece of good news, doctors at the U.S. Centers for Disease Control and Prevention in Atlanta announced late last week that they had developed two tests to detect the presence of the suspected virus in blood and tissue samples of possible SARS victims. They plan to distribute the diagnostic test to hospitals in the U.S. shortly. (Physicians in Hong Kong are already using a different version of the test.)
Many viral outbreaks tend to burn out, as a population naturally develops immunity to the particular pathogens. But a virus can also be devastating, as was in the Spanish influenza epidemic of 1918-19 (see viewpoint). Although that flu's mortality rate was only 2%, the virus had infected so many people that it felled 40 million victims in 18 months—more than the total death toll from combat in World War I. So far, SARS' fatality rate is 4%, comparable to normal, noncontagious pneumonia's. Optimists point out that in the three weeks that SARS has gripped Hong Kong, about 150 people in the territory have succumbed to normal pneumonia. But what spooks medical experts is how little they know about SARS and how much damage it could still wreak. For places like Hong Kong to be declared totally SARS-free, it will require a full month without new cases. The waiting game has only just begun.
- Hannah Beech
- What will it take to beat SARS? The latest outbreak in Hong Kong raises troubling new questions about Asia's killer virus