Childhood SARS in Hong Kong
"This spectacular achievement is an example of what the world can do when the intellectuals of the nations around the world are focused on a single problem", said Dr. Klaus Stohr,1 a WHO virologist coordinating the global Severe Acute Respiratory Syndrome (SARS) laboratory network. He was commenting on the exceptionally rapid progress in the isolation of the SARS virus and the development of new diagnostic tests. What was missing in his comment was the remarkable achievement of a research team of the University of Hong Kong, led by Professor Yuen Kwok-Yung and Professor J.S. Peiris, in the identification of Coronavirus as the causative agent,2 within 2 weeks of the announcement of an outbreak of SARS in a public hospital of Hong Kong in March.
Another remarkable achievement not generally recognised must be the singular absence of fatality in a large series of child-patients recorded in the proceedings published in this issue of our journal.3-7 This finding was originally reported in a special scientific meeting on "Paediatric SARS" held at the Hospital Authority Auditorium on 20th April 2003. Our congratulations must go to the team of hard working paediatricians, led by Dr. Chiu Man-Chun and Dr. Leung Chi-Wai, in Princess Margaret Hospital.
By June 17, 2003, WHO has cumulatively received 8464 reports of SARS cases and 799 deaths world-wide;8 1755 cases have occurred in Hong Kong, with 295 deaths.9 Eight health-care workers, including 4 physicians lost their lives through contracting the disease from patients they were serving; one of them was a paediatric surgeon, Dr. Lau Tai-Kwan, a dedicated member of the Hong Kong Paediatric Society. Sadly we mourn over all these losses. We salute the heroes and heroines who have sacrificed themselves to save other SARS patients' lives.
The high fatality and the more severe clinical course among adult SARS-patients10,11 were in sharp contrast to the paediatric experience of Princess Margaret Hospital.4-7 Whether the relatively low dosage of ribavirin used in the children and the lower and shorter course of steroid prescribed were contributory remain to be proven. A less mature immune system in young children is a distinct possibility, as the clinical course of the teen-aged patients was not different from young adult-patients, many with severe Adult Respiratory Distress Syndrome (ARDS), some with haemo-phagocytosis and so on.10,11 Among adults, seniority and heavy viral-load could be important adverse prognostic indicators.
It is alarming to note that a seemingly mild virus, like the coronavirus, could mutate into a highly virulent pathogen. Hong Kong people have learned from this hitherto unknown disease by paying a very high price, with 295 lives lost so far. Very little is understood as to why some "super-carriers" were spreading large amount of virus to kill a number of casual contacts but sparing some of their close contacts, such as the room-maids who had to make their beds and vacuum their floor. With the most recent demonstration of the virus being harbored in wild animals like civet-cats,12 the traditional habit of eating game-meats for body-building and "keeping warm"13 is now seriously challenged.
The outbreak of SARS has produced very significant changes in social behaviours of the residents of Hong Kong. People have become much more hygiene-conscious. People have also become more civic-minded, joining forces to fight the disease together, showing more concern in the welfare of neighbours, becoming more generous with their time and money to support SARS victims and health-care workers. For the first time in my past few decades' observation, the Emergency Rooms of hospitals were the least crowded in the past 3 months, paediatric wards were more than half empty, waiting rooms in doctors' clinics were vacant, and young children were not as frequently ill.
Communal chopsticks and spoons are now used to serve food to individuals around the dining table not only in restaurants but also at home, thus reducing crossed contaminations and potential infections. Wearing masks and frequent supervised hand-washing of children at schools and kindergartens, must have minimised many cross-infections, reducing their need for visiting doctors. These practices could be encouraged to continue to reduce infections in early childhood, although it might be at the expense of losing some of their "herd immunity".13
During the frenzies of mobilising resources to fight SARS, Hong Kong health planners have lost a golden opportunity to study the effect of traditional Chinese medicine (TCM) on SARS. It is understandable that the current medical and hospital systems would find it difficult to suddenly accommodate TCM into the management of the acutely ill patients. It should have been possible to introduce a randomised clinical trial on the prophylactic efficacies of TCM among the large number of close contacts of SARS patients. Since many Chinese herbs have been claimed to be effective in preventing respiratory diseases and infections, many contacts would probably be more than willing to participate in such trial to "prove the point".
The economic impact of SARS is enormous. Hong Kong has already witnessed many restaurants empty and closing down, department stores vacant, long queues of taxis idle and waiting for customers; and even the prices of new homes have dropped sharply. The financial implication of the aftermath, including potential claims for compensations could also be phenomenal. While the current epidemic seems under control now, the WHO experts have warned of a possible recurrence in the autumn. Health planners must get themselves better prepared to face not only SARS but also other major health-related emergencies in the future.
1. WHO Disease Outbreak Report. 22 March 2003.
2. Peiris JS, Lai ST, Poon LL, et al. Coronavirus as a possible cause of severe acute respiratory syndrome. Lancet 2003;361:1319-25.
3. Leung CW, Li CK. PMH/PWH Interim Guideline on the Management of Children with SARS. HK J Paediatr (new series) 2003;8:168-9.
4. Chiu MC. The Princess Margaret Hospital Paediatric SARS Experience. Proceedings of Paediatric SARS; 20 April 2003. HK J Paediatr (new series) 2003;8:242-4
5. Leung CW. Clinical Features, Diagnosis, Treatment and Short-term Outcome of Severe Acute Respiratory Syndrome (SARS) in Children. Proceedings of Paediatric SARS; 20 April 2003. HK J Paediatr (new series) 2003;8:245-7.
6. Shek CC. Neonatal Aspect of SARS. Proceedings of Paediatric SARS; 20 April 2003. HK J Paediatr (new series) 2003;8:248-9.
7. Kwan YW. Infection Control and Staff Protection. Proceedings of Paediatric SARS; 20 April 2003. HK J Paediatr (new series) 2003;8:250-3.
8. WHO Communicable Disease Surveillance & Response (CSR): Cumulative Number of Reported Probable SARS Cases; from 1 Nov 2002 to 17 June 2003.
9. Department of Health News Bulletin. Situation report on Severe Acute Respiratory Syndrome. Jointly issued by the Department of Health and the Hospital Authority. June 17, 2003.
10. Tsang KW, Ho PL, Ooi GC, et al. A cluster of cases of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003;348:1977-85.
11. Lee N, Hui D, Wu A, et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003;348:1986-94.
12. Yuen KY et al. Personal communication, 2003. (In press)
13. Yeung CY. Health Problems in Chinese children are different. HK J Paediatr (New Series) 2003;8:70-86.