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Pastimes : SARS - what next? -- Ignore unavailable to you. Want to Upgrade?

To: Ilaine who wrote (786)	10/1/2003 9:28:28 AM
From: Henry Niman	Respond to of 1070

I am trying to find out the diagnosis on the reclassified Taiwan SARS patients. At this time I do not know how many, if any, had chronic diabetes as their cause of death, but it seems that a reduction from 180 SARS deaths to 37 SARS deaths would involve quite a few patients with stable chronic conditions prior to infection with SARS CoV.

To: Ilaine who wrote (786)	10/1/2003 10:30:34 AM
From: Henry Niman	Respond to of 1070

There is more detail at the Taiwan site cdc.gov.tw but I am still confused. The number of cases was reduced because 317 of the probable cases were negative for SARS CoV by PCR and antibody test. The number of cases with no clinical data is listed as 1, but I was under the impression that many cases (not just 1) did not have lab tests results because they had SARS symptoms but were cremated prior to collection of samples (which is why WHO listed 180 deaths instead of the 73 listed at the above site). The site shows a case fatality rate of 21.1% for the SARS CoV positive cases. However, this number is almost cut in half by excluding 36 patients who were SARS CoV positive but are only "SARS related" because death was not "directly due to SARS", of which there were 37 (which is also the number in the updated WHO table). It is also interesting that of the 73 who died and were SARS CoV positive, only 22 had a pre-existing conditions which means that 14 had no pre-existing condition, died, were SARS CoV positive, yet were not counted as SARS related deaths! Details on these 14 patients would be most interesting.

To: Ilaine who wrote (786)	10/1/2003 11:01:19 AM
From: Henry Niman	Respond to of 1070

SARS Saves Lives? Using the data at the Taiwan site cdc.gov.tw an argument can be made that infection with SARS CoV actually saved lives. The site indicates that 47.8% of the probable SARS cases (n=317) were negative for SARS CoV RNA and antibody, yet these patients had a case mortality rate of 33.8%. In contrast the patients positive for SARS CoV had a case mortality rate of only 21.1%. Moreover, the case mortality rate for those who directly died from SARS was only 10.7%. Thus it seems that if the SARS CoV negative patients had been infected with SARS CoV, many lives could have been saved!

To: Ilaine who wrote (786)	10/3/2003 9:05:12 PM
From: Henry Niman	Respond to of 1070

Since there are so many media reports on the Taiwan revisions, it seems that a bit of analysis of the numbers posted on the website is in order cdc.gov.tw The number of SARS deaths in Taiwan has been controversial because over 300 death certificates indicated the patient died of SARS, yet the number of deaths on the WHO site last month was only 180. Now that number has been "adjusted' down to 37 and the adjustments produce a number of highly questionable figures on the official Taiwan site, which have also been included in the latest WHO update. These numbers will not instill much confidence in many looking at the data scientifically. I have tried, without success, to get a clarification from WHO. The above site has taken the 180 deaths and put them into 3 categories. 107 are considered non-SARS cases because they are said to be negative for SARS CoV on BOTH antibody and PCR tests. 36 more deaths are said to be not directly due to SARS, even though the patients were SARS CoV positive. The remaining 37 are listed as deaths due directly to SARS CoV. Each of the categories has some glaring anomalies when compared to reports from just about any country with significant SARS cases and deaths. The two leading factors associated with SARS deaths are age and underlying disease. Taiwan seems to have used underlying disease as a reason for reclassifying some patients. But their own data shows that only 22 patients had underlying disease, so even if none of these are included in the 37 SARS deaths, there still are not enough patients with underlying disease to account for the 36 patients who are listed as "SARS-related". However, even more striking are the 107 deaths that are listed as being negative by BOTH PCR and antibody tests. The site seems to indicate that both tests were performed on 663/664 patients. That frequency of analysis seems rather high for PCR. However, the number is even more remarkable for antibody test on the 107 deceased patients who are said to be negative on BOTH tests, since the antibody tests is supposed to be run on samples collected at least 28 days after initial symptoms, and many SARS patients, especially older patients, die in less than 28 days post symptoms. Thus it would seem that many of the antibody tests on the 107 patients classified as non-SARS would be based on unreliable antibody data. Even more striking is the 33.8% case mortality rate in the SARS negative patients. The rate is much higher than the 10.7% rate for those who are SARS CoV positive and listed as SARS deaths or the 10.3% of those infected with SARS CoV but only classified as "SARS-related". A case mortality rate of 33.8% is about 10 X the case mortality rate of SARS CoV negative patients in Hong Kong. If the Taiwanese patients did not die of SARS, then they seem to have a mystery disease that presents as SARS, yet is much more lethal than the numbers for SARS patients infected with SARS CoV. In summary, that data on the official Taiwan site and on the revised WHO site appears to be extremely suspect. The testing frequency is remarkably high, patients are considered to be non-SARS even if they had SARS symptoms and died prior to 28 post symptoms, the non-SARS patients had an extraordinarily high case mortality rate, and there were not enough patients with underlying disease to account for the 36 "SARS related" deaths. Moreover, such revisions will make data comparisons with other countries meaningless. Alternatively, other countries will invoke their own unique interpretations to reduce the number of official SARS deaths, i.e. the index case for the Amoy Gardens outbreak initially tested positive for Influenza A. Therefore Hong Kong could reclassify all Amoy Gardens cases as flu cases that happened to be co-infected with SARS CoV. Government handling of the SARS epidemic is already suspect, as evidenced by responses to reports from Hong Kong and Toronto. The administrative adjustments at the Taiwan site will only increase mistrust of official explanations of the SARS epidemic.

To: Ilaine who wrote (786)	10/16/2003 9:16:45 PM
From: Henry Niman	Respond to of 1070

The comments below again raise the specter of asymptomatic SARS infected people as well as asymptomatic transfer. The palmed civets tested in the Science paper did not have symptoms, yet they were SARS CoV positive. In fact the level of virus allowed for SARS CoV isolation in several instances. Thus the animals appeared healthy, had isolatable virus at the time, and civet handlers in three separate markets in Guangdong frequently had antibody to the SARS CoV. The virus isolated from the civets had the 29 nt and about two dozen loci which were altered in all human isolates and another two dozen altered in all human isolates linked to the Metropole Hotel. Thus the SARS CoV had a number of significant difference with the animal isolates, but there is evidence for a fairly broad spectrum of illness in humans, with the most severe cases showing up in older individuals and/or those with underlying disease. These data suggest that there may be a significant amount of viral shedding in animals and there is little evidence against significant virus shedding in humans. The broad host range also suggests that humans could act as vectors to transmit virus to other domestic animals, including rats, cats, and dogs. Suggesting that recurrences of SARS will be limited to links to wild animals in Guangdong Province seems premature. >===== Original Message From "Henry L Niman, PhD" <henry_niman@hms.harvard.edu> ===== centredaily.com Posted on Thu, Oct. 16, 2003 Study: High number of Chinese animal traders had SARS virus BY MARILYNN MARCHIONE Milwaukee Journal Sentinel MILWAUKEE - (KRT) - A new study has found that a surprising number of Chinese animal traders were infected with the virus that causes SARS, suggesting it may have been far more common than believed and that many people may have had it without showing symptoms. The research also strengthens the likelihood that the new virus crossed to humans from a yet-to-be-determined animal source. The study, done by Chinese researchers and reported Thursday by the U.S. Centers for Disease Control and Prevention, is the most extensive one yet involving blood samples tested for severe acute respiratory syndrome. Until now, health officials had thought the virus caused only the severe cases of pneumonia that came to light during last spring's outbreak. What's surprising about this study, said Dennis Maki, chief of infectious diseases at the University of Wisconsin-Madison, is the high rate of infection in people who weren't sick.