Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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SARS:Focus on prevention
- Pudugramam.V. Vaidyanathan (2 May 2003)
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SARS Mortality
- Zhiqiang Wang (3 May 2003)
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A Potential Blood Test for SARS Triage
- Trevor G Marshall (5 May 2003)
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QUARANTINE IS THE EFFECTIVE RESPONSE TO SARS AND OTHER FLU-LIKE ILLNESSES
- Richard H Lawson (7 May 2003)
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Pudugramam.V. Vaidyanathan, Private Practioneer (Pediatrics) 5/146,Subash Nagar,Chembur,Mumbai-71.India
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Sir, Given the fact that SARS is on the rise and that an effective vaccine will take atleast 2-3 years to be used on a large scale, the current strategy,apart from containment and treatment of affected cases,would obviously on prevention.In this regard,I would like to make a few suggestions: 1) SARS carries a 5 percent mortality.This is bad,but it also means that 95 percent of people affected with SARS do not die.WHY?What is the difference between those who survive and those who succumb?Is it the individual immunity?Is it the treatment?Or is it something else?.Also,many countries have been fortunate enough not to have any cases reported.This phenomenon also needs to be investigated. A thorough study of the survivors vis a vis those who died should yield valuable information in this regard and will hopefully point us towards some useful direction. 2)Immune boosters: Many studies in 3rd world countries have shown,atleast in children,a reduced mortality and morbidity to measles and other respiratory illnesses as a result of megadose Vitamin A supplementation,since it strengthens the respiratory epithelium and increases local immunity.The same is true of Zinc.Will supplementation with these substances help?Also, the BCG vaccine has been used in many diseases to boost cell mediated immunity.It is a moot point whether these measures should be tried,to enhance the immunity of the general population. 3)Other vaccines: Recent reports indicate that children with SARS are less infective,recover fast and not a single child mortality has been reported till date.Could this be due to the fact that children receive plenty of anti-viral vaccines--Polio,Measles,MMR,Hepatitis A,Hepatitis B and Chicken Pox--and one or more of these vaccines is conferring cross immunity towards SARS?.Since many viral vaccines show effect against similar viral diseases,it may be worth trying out established viral vaccines--like measles,MMR ,Small Pox, Chicken Pox etc.--.If these can give some cross immunity against SARS,then the problem is solved for the time being, till a vaccine for SARS is fully tested and ready. This is what happened with Cowpox and Small Pox. 4)Alternate systems: A thorough search,among alternate systems of medicine, like Ayurveda, Homeopathy, Unani, Naturopathy, Siddha medicine etc., may well reveal some drug or product which could arrest the spread of the disease. Hope these suggestions will be of some value. With regards, Dr.P.V.Vaidyanathan
Competing interests: None declared |
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Zhiqiang Wang, Epidemiologist University of Queensland
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SARS Mortality
As the outbreak of SARS outside mainland China has peaked and a majority of patients have reached an end point of either recovery or dead, SARS mortality starts to reveal the severity of the disease. Mortality among SARS patients outside Mainland China has been steadily climbing from 2.8% (95% CI: 1.9-4.0) on 1 April to 9.9% (95% CI: 8.7-11.2) on 1 May 2003 (Table 1), based upon data from World Health Organization "Cumulative Number of Reported Probable Cases of Severe Acute Respiratory Syndrome (SARS): http://www.who.int/csr/sarscountry/en/". Mortality in Table 1 was calculated by the number of deaths divided by the number of cases. However, the current 9.9% mortality can be an underestimate of case fatality because some newly diagnosed cases had not reached either death or recovery by the time of this analysis.(3 May 2, 2003). We are unable to estimate case-fatality until a well defined cohort has been followed long enough for all patients to have either recovered or died.
Mortality in Hong Kong, Canada and Singapore all reached 10% mark (Table 2). The epidemic situation in Guangdong (China) appeared to be similar to that in Hong Kong; both had similar numbers of cumulative cases and new daily cases. However, Guangdong data showed a much lower mortality, 3.6% (95% CI: 2.7- 4.7). Since 85% Guangdong patients have already recovered, the low mortality in this region will persist in the future. The reasons for this remain to be identified. Several aspects are worth investigating, including characteristics of patients, diagnostic and treatment procedures, virus variants as well as accuracy and completeness of case identification.
SARS case Mortality in other regions of China was 5.4%. There is no question that it will go up in next few weeks since over 90% patients are still in hospital. The question is if the mortality in China will be as high as those currently observed in Hong Kong, Singapore and Canada?
Table 1. Proportion (%) of deaths outside mainland China.
Date Mortality* (95% CI)
01/04 2.8 (1.9- 4.0)
11/04 3.7 (2.8- 4.7)
21/04 6.9 (5.8-8.1)
01/05 9.9 (8.7-11.2)
Table 2. Proportion (%) of deaths among SARS patients* as May 1, 2003
Region Mortality (95% CI)
Viet Nam 7.9 (2.6, 7.6)
Hong Kong 10.1 (8.7, 11.7)
Singapore 12.4 (8.2, 17.8)
Canada 13.6 (8.5, 20.2)
Guandong** 3.6 (2.7, 4.7)
Calculated from data in *World Health Organization: http://www.who.int/csr/sarscountry/en
**Ministry of Health P. R. China: http://www.moh.gov.cn/zhgl/yqfb/index.htm
Competing interests: None declared |
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Trevor G Marshall, Research Director Sarcinfo, Thousand Oaks, CA 91360
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Prof Robert Lee has just posted a molecular analysis of the SARS spike protein which indicates that the virus should be evoking an hyperimmune CD13 reaction, rich in the release of interferon-alpha, interleukin-6, and TNF-a cytokines. His detailed paper, "SARS Coronavirus Appears to be an FcgammaR Agent, Causing an Hyperimmune Response via a CD13 pathway - Implication for Therapeutic Interventions"[1], can be found at the new "Journal Of Independent Medical Research", JOIMR.org Our own research with the CD4 and CD13 reactions in Sarcoidosis has indicated that the secosteroid hormone 1,25-dihydroxyvitamin-D (1,25-D) will be active in any such CD13 pathogenesis. We have found that values for the D-Ratio, which is a measure of the activity with which 1,25-D is generated in the Th1 immune reaction, are very high in sarcoidosis patients with extensive, well-perfused, inflammation[2,3,4]. I use a rule of thumb that D-Ratios above 6 seem to be indicative of patients which are at risk of cardiac arrythmia and obstructed airways due to muscular contraction. The 1,25-D is usually elevated above 100 pg/ml in patients with such potentially life-threatening symptoms (Merck's upper limit of normal is 45 pg/ml[5]). Now I need to point out that there are two levels of theoretical, and speculative, postulates here, Prof Lee's and ours. However, I am suggesting that the D metabolites 25-hydroxyvitamin-D and 1,25-dihydroxyvitamin-D might well be useful in triage of SARS patients. These tests are available at all the major labs in the US (eg Quest), and only 1.6 ml of blood draw is necessary. If you perform this test and find 1,25-D levels above 45 pg/ml or D-Ratios above 3, please contact us at this email address, or at the phone number of reference 4, as there is a relatively innocuous drug therapy which we are finding (in sarcoidosis patients) will quickly (within days) lower the production of 1,25-D and the inflammatory cytokines. 1. Lee RE: SARS Coronavirus Appears to be an FcgammaR Agent, Causing an Hyperimmune Response via a CD13 pathway - Implication for Therapeutic Interventions. JOIMR 2003;1:2 [Free Full Text] 2. Marshall TG, Marshall FE: The Science Points to Angiotensin II and 1,25-Dihydroxyvitamin D. [Electronic Letter] Chest 6 Feb 2003; Available from URL http://www.chestjournal.org/cgi/eletters/123/1/18#95, Accessed 27 Mar 2003 3. Marshall TG: Brown, et al, ACCESS Study finds Bacterial Pathogens in Sarcoidosis Patients.[Electronic Letter] Chest 12 Feb 2003; Available from URL http://www.chestjournal.org/cgi/eletters/123/2/413#96, Accessed 12 Feb 2003 4. Marshall TG, Marshall FE: New Treatments Emerge as Sarcoidosis Yields Up its Secrets. Clinmed 2003 Jan 27;2003010001. clinmed.netprints.org/cgi/content/full/2003010001 (accessed 27 Jan 2003) [Full Text] 5. The Merck Manual of Diagnosis and Therapy: Vitamin D Deficiency and Dependency. 17th Edition, Section 1, Chapter 3 [Full Text] Competing interests: I am the founder and managing editor of JOIMR |
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Richard H Lawson, GP principal Congresbury, BS49 5DX
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SARS may have peaked in Canada, Hong Kong, and Vietnam (BMJ 2003;326:947), but it is highly unlikely that the virus has been driven into extinction. We must prepare for further outbreaks, and a serious plan that educates the public in the management of all flu-like illnesses could reduce the incidence of viral illnesses generally. It should be the default position that anyone who has a flu-like illness with malaise and fever, even if they have not been in contact with the SARS virus, ought to stay at home. There are two reasons for this: first, because some cases of SARS will arise because transmission will occur without knowledge of the infectious case, for instance, if an infected person sits beside you in the train. The other reason is that it is always advisable to take a case out of circulation if they have a flu- like illness because if sufferers insist on heroically going to work, three thing happen. First, they spread it to their colleagues. Second, they will not work efficiently. And third, they will take longer - sometimes much longer - to recover. The opportunity offered by the SARS crisis is that it may change the ethos around minor illness. Instead of being expected to come in to work when well, we will be expected to stay away: and that will in a fairly short time reduce the levels of all kinds of viruses circulating in the community, and hence the healthcare and economic burdens that they impose on us. Although effective and desirable, quarantine measures as sketched out above require a major change from a public that is used to getting a pill to cure any illness, as opposed to having to modify behaviour. Reform is possible, but only if the medical profession could persuade the media and the Department of Health of the wisdom of this change. Dr Richard Lawson MB BS, MRCPsych Competing interests: None declared |
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