James Hughes, of the Centers for evidence of infection with the virus in electron-microscopic studies on Disease Control and Prevention 45 of 50 Hong Kong patients with infected material “suggest that (CDC; Atlanta, GA, USA), doesn’t SARS but no controls (Lancet online coronavirus is highly correlated with think SARS (severe acute respiratory April 8, http://www.thelancet.com/ SARS infection” but who found syndrome) has the ability to become a journal/vol361/iss9364/full/llan.361.93 human metapneumovirus in some pandemic. But he said on April 4 that 64.early_online_publication.25242.1). specimens, adds that “we have limited “we haven’t heard the end of this. We information about the nature of have to stay tuned and treat it as the coronavirus, so it is hard to speculate public-health threat that it is”. about its infectivity”. WHO says that The number of cases worldwide is three types of diagnostic test still relatively small—2722, with 106 available—ELISA, an immunofluor- deaths at April 9. But since Feb 15, escence assay, and a PCR molecular when the first patient in Hong Kong test—“all have limitations as tools for fell fatally ill with non-typical bringing the SARS outbreak quickly pneumonia that was later identified as under control”. Nevertheless, David a previously unrecognised infection, Heymann, executive director of SARS has been spread by air travellers communicable diseases at WHO, to 16 other countries, including concedes that a definitive test is Vietnam, Singapore, Thailand, the “weeks, rather than months” away. USA, Canada, and the UK, leading the Hong Kong appeared to be the WHO, for the first time in its history, main focus of SARS infection until the to recommend that travellers avoid end of February, when China admitted specific geographical areas (Hong to having had 300 cases and five deaths Kong and Guangdong Province, from non-typical pneumonia since China) except for essential business. Thin-section electron micrograph of of human November in Guangdong Province— pneumonia-associated coronavirus infected The USA has introduced compulsory the home of Hong Kong’s index cells. Reproduced from Peiris et al. Lancet. quarantine for SARS patients, ranking Published online April 8, 2003 patient. China now accounts for about the infection alongside smallpox and half of all cases (1280 of the 2722 as at cholera. Human metapneumovirus (a para- April 9). If Guangdong is where SARS SARS carries a 4% mortality, and it myxovirus) has been isolated in some started, could the common practice can kill otherwise healthy adults, outbreaks, including the Canadian there of keeping fowl and other including a 46-year-old WHO one, where it was seen in four of domestic animals in the house be the physician who identified Vietnam’s five coronavirus-positive specimens key? Virologist John Oxford (Queen first case of SARS. Several cases in the (N Engl J Med online March 31, Mary College, University of London, early days of the Hong Kong outbreak http://content.nejm.org/cgi/reprint/N UK) says, “There is a good chance that were in health-care workers and family EJMoa030634v2.pdf). Chlamydia has the SARS virus, like H5N1 influenza, contacts. At present there is no specific also been reported in some SARS crossed species from chickens or treatment. The agent seems to be patients in China, but its significance is animals to man”. transmitted by droplets or by direct or unclear. Peiris et al, who found no If anything good has come out of indirect contact, but airborne and evidence of human metapneumovirus the arrival of SARS it is the faecal-oral transmission have not been infection, conclude: “It is highly likely demonstration that WHO and its ruled out. According to WHO the that this coronavirus is either the cause partners in the Global Outbreak Alert incubation period is 3–10 days. of SARS or a necessary prerequisite for and Response Network are capable of The primary agent of SARS seems disease progression”. They suggest that rapid response and international to be a new coronavirus, not closely other viruses may act as “opportunistic collaboration on an unprecedented related to coronavirus types 229E secondary invaders to increase the scale. “Other new diseases will emerge and OC43 that cause the common disease progression”. in the future”, says Guenael Rodier, cold. CDC scientists were the first to As we go to press SARS must still director of WHO’s Communicable link the novel virus to SARS be diagnosed clinically, but virologist Disease Surveillance and Response. (http://www.cdc.gov/mmwr/ Maria Zambon at the Public Health “We will respond just as we have with preview/mmwrhtml/mm5212a1.htm), Laboratory Service (London, UK), one SARS—with maximum efforts to and other laboratories soon confirmed of WHO’s network of 11 laboratories contain its spread.” Hughes, at CDC, this finding. Malik Peiris’ team at the that have been racing since March 17 sees the SARS experience as “a fire drill University of Hong Kong (see page to identify the cause of SARS, claims to for a number of things”, be it the next 309), using serological and a reverse- be on the verge of having a reliable influenza pandemic or a bioterrorist transcriptase PCR assays specific for “first-generation” diagnostic test for attack. the novel coronavirus, have found SARS. Zambon, whose PCR and Dorothy Bonn
268 THE LANCET Infectious Diseases Vol 3 May 2003 http://infection.thelancet.com
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