Role of China in the quest to define and control severe acute respiratory syndrome - Perspectives

Emerging Infectious Diseases, Sept, 2003 by Robert F. Breiman, Meirion R. Evans, Wolfgang Preiser, James Maguire, Alan Schnur, Ailan Li, Henk Bekedam, John S. MacKenzie

China holds the key to solving many questions crucial to global control of severe acute respiratory syndrome (SARS). The disease appears to have originated in Guangdong Province, and the causative agent, SARS coronavirus, is likely to have originated from an animal host, perhaps sold in public markets. Epidemiologic findings, integral to defining an animal-human linkage, may be confirmed by laboratory studies; once animal host(s) are confirmed, interventions may be needed to prevent further animal-to-human transmission. Community seroprevalence studies may help determine the basis for the decline in disease incidence in Guangdong Province after February 2002. China will also be able to contribute key data about how the causative agent is transmitted and how it is evolving, as well as identifying pivotal factors influencing disease outcome.

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Severe acute respiratory syndrome (SARS) is a newly emerged disease, caused by a previously unknown coronavirus. The first known cases occurred in Guangdong Province in southern China in November and December 2002. During late February 2003, a physician who was incubating SARS traveled from Guangzhou, the provincial capital, to Hong Kong, Special Administrative Region of China, and stayed at a hotel. There, the virus was transmitted from him to local residents and to travelers, who became ill and transmitted disease to others when they returned to Vietnam, Singapore, Canada, and Taiwan, Province of China (1). SARS has now occurred in >8,450 people with >800 deaths worldwide.

The tally of SARS climbed rapidly in China through May 2003, then decelerated markedly during June. The disease has now been reported in 24 of China's 31 provinces. By June 26, 2003, a total of 5,327 SARS cases and 348 deaths had been reported from mainland China, including 2,521 cases in Beijing and 1,512 in Guangdong Province.

Since February 2003, teams of technical consultants for the World Health Organization have been working in China to provide assistance to the Ministry of Health and provincial governments on public health responses to the SARS outbreak. A team that began working in China in March reviewed considerable clinical, epidemiologic, and laboratory data with scientists and officials from a variety of settings in Guangdong Province and Beijing. The team worked closely with colleagues from the National and Guangdong Provincial Centers for Disease Control, and together were able to establish that cases occurring in Guangdong beginning in November were clinically and epidemiologically similar to subsequent cases of SARS documented elsewhere.

The team observed detailed, comprehensive data collection forms, which are completed for activities and behaviors and clinical manifestations of patients with SARS. The team was informed that serum and respiratory secretion specimens collected from many patients from Guangdong were being held under appropriate storage conditions, awaiting further laboratory testing.

While a dedicated, collaborative international effort has resulted in substantial understanding of this disease with remarkable speed, critical information is still lacking. We detail a variety of knowledge gaps that should be addressed through a set of activities to optimize prevention and control of SARS.

Emergence of SARS-associated Coronavirus in Humans

Available evidence suggests that SARS emerged in Guangdong Province, in southern China. How and when did it emerge? Did the causative agent evolve in an animal species and jump to humans (or perhaps first to other animal species), or did the virus evolve within humans? The genetic sequence of the virus has been obtained in several laboratories, and phylogenetic analyses have shown that it is unlike other coronaviruses of animal and human origin. Indeed, the virus has been tentatively placed in a new fourth genetic group (2,3).

Why is it so important to answer the question of how SARS emerged? Most recently recognized novel emergent viruses have been zoonotic, usually with a reservoir in wildlife (4,5). Thus, SARS coronavirus, if zoonotic, may provide the basis for modeling and predicting the appearance of other potential zoonotic human pathogens. More importantly, the information may be crucial for control of SARS. If this disease is to be curtailed or eliminated by strict public health measures, blocking further animal-to-human transmission is indicated. Only about half of the cases in Guangdong are attributed to contact with a SARS patient. Transmission from an unknown, but persisting animal reservoir might explain this finding; however, a non-specific case definition (i.e., many "cases" might not actually be SARS) and limitations in contact-tracing capacity are other potential explanations.

Finding a potential animal source is, however, a daunting task. The province is famous for its "wet markets," where a bewildering variety of live fauna are offered for sale (sometimes illegally) 1'or their medicinal properties or culinary potential. The opportunity for contact, not only with farmed animals but also with a variety of otherwise rare or uncommon wild animals, is enormous. More than one third of early cases, with dates of onset before February 1, 2003, were in food handlers (persons who handle, kill, and sell food animals, or those who prepare and serve food) (Guangdong Province Center for Disease Control and Prevention, unpub. data,).