Jewish World Review March 10, 2003 / 6 Adar II, 5763 By Robert A. Wascher, M.D., F.A.C.S. jewishworldreview.com www.NewsAndOpinion.com |

SARS (Severe Acute Respiratory Syndrome) is a viral infection that has recently become a source of concern among public health officials. First identified in Vietnam, cases of SARS have now appeared in China (in Hong Kong and Guangdong province, in particular), Singapore, Indonesia, Canada, Thailand, the Phillipines, and the United States. Approximately another dozen countries have reported possible cases of SARS within the past several days. At the present time, nearly 1600 cases SARS, including 54 deaths, have been reported throughout the world by the WHO and CDC. Although the causative agent of SARS is not fully understood at this time, it appears to be a previously unknown member of the coronavirus family of viruses. Sadly, the Italian physician who first identified SARS in a German businessman under his care in Vietnam has, himself, now died of the disease.

According to the US Centers for Disease Control (CDC) and the World Health Organization (WHO), the symptoms of SARS include high fever, sore throat, dry cough, shortness of breath, and decreased white blood cell and platelet counts. Other typical symptoms of viral infection may occur with SARS, including headache, muscular pain and stiffness, loss of appetite, malaise, confusion, rashes and diarrhea. The incubation period for SARS appears to be relatively short, ranging from 2 to 7 days following initial exposure. Based upon the rather high prevalence of infections among healthcare personnel, the WHO has indicated that close and sustained contact with infected persons may be necessary to spread SARS. In particular, contact with respiratory droplets from coughs and sneezes, as well as direct contact with bodily secretions, are thought to be important infection vectors. However, recent reports of SARS spread among tenants within apartment buildings in China, and at least one case involving a flight attendant on a Hong Kong-based airline, suggest that the SARS virus may be passed with more casual contact.

The treatment of patients infected with the SARS virus is similar to that recommended for other serious viral respiratory infections, as there are no antibiotics that have any activity against such diseases. The current recommendation is that patients with SARS should be kept in respiratory isolation wards. Supplemental oxygen, inhaled medications to keep the airways clear of secretions and to prevent collapse of small airways, control of excessive fever, intravenous fluids to support blood pressure and vital organs, and, in some cases, mechanical ventilation, are mainstays of supportive treatment.

At the present time, public health officials are not advising prospective travelers to cancel their trips overseas. However, some officials are now suggesting that travel to endemic areas be deferred if possible. Some flight attendants and travelers have taken to wearing surgical face masks in an effort to reduce the risk of inhaling respiratory aerosols from potentially infected persons, although the efficacy of this strategy is uncertain at this time. If you-or anyone you know-has recently developed a severe upper respiratory infection, particularly following travel to one of the countries mentioned above, then medical care should be urgently sought. While there are hundreds of other viruses that can cause the same symptoms as SARS, the virulence of the virus causing SARS seems to approach, at least in some cases, that of strains of influenza that have caused pandemics of severe illness and death in the past.

UPDATE ON SMALLPOX VACCINE

The CDC announced, on March 25th, an advisory regarding the administration of the smallpox vaccine to people with a history of heart disease. More than 30,000 healthcare workers have recently received the smallpox vaccine as part of recent Homeland Defense initiatives. Among these volunteers, seven have developed cardiac-related complications, although it is presently unknown if these complications are directly related to the vaccine. Among these seven stricken healthcare workers, three have experienced heart attacks (one of which was fatal), two cases of angina (chest pain due to blocked coronary arteries) occurred, and two cases of myopericarditis (inflammation of the heart muscle or the fibrous sac that surrounds the heart) occurred. The CDC is currently studying the medical histories of each of these seven patients, and is carefully evaluating their cardiac disease risk profiles (at least one of these patients was reported to have had an extensive history of preexisting heart disease). While cases of heart inflammation were reported during the period when smallpox vaccine was most extensively administered (in the 1960s and 1970s), no epidemiologic studies were carried out at the time in order to ascertain any causative effect by the vaccine.

As it is currently unclear whether or not the smallpox vaccine, which consists of a live virus that is related to the smallpox virus, is linked to these few cases of cardiac complications, the CDC is being somewhat circumspect in its advisory. The CDC is now recommending that persons with a history of cardiomyopathy, heart attack or angina, or any other evidence of heart disease be temporarily deferred from receiving the smallpox vaccine.

INFLAMMATORY MARKERS & RISK OF HEART FAILURE

There is growing evidence that the progression of coronary artery disease is influenced by mediators of inflammation. Most recently, C-reactive protein has taken center stage as a key inflammatory protein that appears to play a critical role in the development of coronary atherosclerosis. While coronary artery disease has been linked with inflammation and, in turn, directly with the risk of developing a heart attack, another equally life-threatening cardiac ailment has not previously been associated with inflammation. Congestive heart failure (CHF), which most commonly occurs after a heart attack permanently damages heart muscle, is a common cause of disability and death among older Americans. As its name implies, CHF results when the heart becomes sufficiently damaged so that its ability to pump blood to the body becomes seriously impaired. Patients with CHF may have difficulty breathing due to fluid build-up in their lungs, and often experience debilitating weakness and fatigue as a result of inadequate oxygen delivery throughout their bodies. Swelling of the lower extremities may also cause difficulties for patients with CHF.

A new study in the journal Circulation looks at the potential role of inflammation in patients with CHF who have never had a heart attack before. This study was conducted within the framework of the highly respected Framingham Heart Study, one of the longest running and largest heart study research programs ever undertaken. In this new study, a total of 732 elderly patients who entered the Framingham Heart Study without any prior evidence of CHF or heart attack were followed for an average of 5.2 years. All study volunteers underwent extensive blood tests upon entry into the study, which included assays for known mediators of inflammation, including C-reactive protein, interleukin-6, and tumor necrosis factor-alpha. Among the 732 volunteers, 56 of them subsequently developed CHF-without experiencing any heart attacks-during the course of this study. The study determined that initially elevated levels of any of these inflammatory mediators were significantly correlated with the subsequent development of CHF among the study volunteers. Among patients who had elevations in the blood levels of all three of these markers upon entering the study, the risk of subsequently developing CHF was more than four time higher when compared to other study volunteers without elevated levels of these inflammatory markers. The study's authors concluded that a single measurement of inflammatory markers in the blood was highly predictive of the risk for subsequently developing CHF, even in the absence of heart attacks.

BREAST FIBROADENOMAS & THE RISK OF BREAST CANCER

The presence of benign fibrous nodules in the breast, called fibroadenomas, has been linked, in some studies, to a slightly increased risk of developing breast cancer. Other benign breast conditions, including ductal hyperplasia, and even a history of prior breast biopsies for benign lesions, have been statistically associated with small increases in breast cancer risk as well.

A new study in the Archives of Surgery looked at 32 patients with fibroadenomas occurring in the breast at the same time as breast cancer. These patients were compared with 26 control patients who had breast fibroadenomas without the concomitant presence of breast cancer in the same breast. The researchers used several highly sensitive tests to assess both the fibroadenoma tumors and the breast cancer tumors for characteristic genetic mutations associated the development of cancer. The study determined that fibroadenomas of the breast, whether or not they co-existed with breast cancers in the same patient, did not contain any of the genetic mutations commonly identified in the breast cancer tumors. From these results, the authors infer that fibroadenomas are not directly associated with the development of breast cancers. This small study should be repeated with larger numbers of patients to validate its findings. However, these results should provide considerable reassurance to women with benign fibroadenomas of the breast.

JWR contributor Dr. Robert A. Wascher is a senior research fellow in molecular & surgical oncology at the John Wayne Cancer Institute in Santa Monica, CA. Comment by clicking here.

03/10/03: More Data on Hormone Replacement Therapy & the Risk of Breast Cancer; Oral Health & the Risk of Cardiovascular Disease; More Bad News about C-reactive Protein; Update: Daily Multivitamin & Minerals Supplements; Baby Aspirin & the Risk of Colorectal Adenomas; Aspirin & the Risk of Colorectal Polyps

03/03/03: Management of enlarging thyroid nodules; Long-term anticoagulation reduces the risk of recurrent blood clots in the veins; colon polyp recurrence after colonoscopic polyp removal; Vitamins C & E and Atherosclerotic Disease: The Debate Continues

02/24/03: Tamoxifen & Benign Breast Disease; New Recommendation on Digitalis Dosing; Creutzfeldt-Jakob Disease & the Nose; Radiologist Experience & Accuracy of Mammogram Interpretation; More Data on the Incidence of GI Side Effects with Selective COX-2 NSAIDs; Regular Rest Breaks & the Risk of Industrial Accidents

02/18/03: Update on Alzheimer's Disease; Very Low Birth-weight Babies & Cognitive Development; The Great Blood Pressure Medication Debate

02/03/03: Update on C-reactive Protein; COX-2 Inhibitors & Arterial Function; COX-2 Inhibitors and Gastrointestinal Complications; Telomere Shortening & Risk of Death

01/24/03: Bo-tox that BO Away!; The Super-sizing of America; Marijuana: A Gateway Drug?

01/21/03: Dietary Soy & Prostate Cancer Risks; Retention of Surgical Foreign Bodies after Surgery; Diet & hormone levels in adolescent girls

01/10/03: Can Aspirin Prevent Esophageal Cancer?; A Drink to Your Health!; Hormones & Breast Cancer; The Impact of Obesity on Lifespan

01/06/03:"The Pill" for Males?; Obesity & Diabetes Trends in the United States; Binge Drinking in the United States; One Less Reason to be Depressed; Liver Failure: Trends

12/20/02: Citrus Pectin & Cancer; Echinacea & the Common Cold; Update on High Blood Pressure Treatment

12/06/02: Calcium Intake & Prostate Cancer Risk; Alcohol Consumption & Risk of Breast Cancer; Reducing Blood Transfusions in Critically Ill Patients

12/06/02: Alcohol, Tamoxifen & Carotid Artery Wall Thickness; Coffee & Gallstones?; Irritable Bowel Syndrome Update; Statins: More Good News

11/22/02:Alcohol, HRT & the risk of breast cancer; hormone replacement therapy: more bad news; new vaccines may eliminate cervical cancer; more

11/15/02: The Effects of Diet & Exercise on Blood Pressure & Health; Growth Hormone & Sex Steroid Supplements & the Elderly; C-Reactive Protein & Cardiovascular Disease Risk

11/08/02: More Good News About Statin Drugs; Hormone replacement Therapy (HRT) & Alzheimer's Disease; A Role for Antibiotics in the Treatment of Vascular Disease?; more

11/01/02: Digoxin & gender; driving & degenerative disc disease; Coenzyme Q10 & Parkinson's Disease; Ginseng & erections; Viagra & stroke

10/25/02: Aspirin & coronary artery bypass surgery; glucosamine sulfate & progression of knee arthritis; hospital nurse staffing & patient mortality

10/18/02: Motor Vehicle Exhaust Pollution & Mortality; CT Scans, C-Reactive Protein & Heart Disease; Antiperspirant Use & the Risk of Breast Cancer; Atomic Bomb Radiation Exposure Update; more

10/04/02: Antioxidants & the Risk of Stomach Cancer; Best Way to Diagnose Appendicitis?; Coronary Artery Disease: Stent or Surgery?

09/27/02: Breast Feeding & the Risk of Asthma; HMOs & Quality of Care Scores; Red Wine & Vascular Disease

09/20/02: Dietary Folate & the Risk of Colorectal Cancer; Risks Associated with Smoking after Heart Attacks; BRCA1 Gene Mutation & the Risk of Breast & Non-breast Cancers; Breast Tissue Density & Inheritance

09/13/02: Dairy Products, Calcium, Vitamin D & the Risk of Breast Cancer; Efficacy of Nonprescription Smoking Cessation Aids; A Nutty Approach to Heart Disease Prevention; Update on Prostate Cancer

09/06/02: C-Reactive Protein & Estrogen Replacement Therapy; Walking Women & Cardiovascular Disease; Physical Activity Among Teenaged Girls

08/30/02: Babbling babies & brain function; homocysteine levels, vitamins & coronary artery disease; St. John's Wort & chemotherapy

08/16/02: A New Weapon Against Anthrax?; cataracts & motor vehicle accidents; gingko biloba takes a hit; air pollution & heart function during exercise; breast cancer genes & the estimated risk of breast cancer

08/09/02: Botulinum Toxin & Post-Stroke Spasticity; Intestinal Hormone Kills Appetite; Bone Marrow Cells Improve Blood Flow in Vascular Disease; Effectiveness of Restraining Orders on Domestic Violence

08/02/02: Mammography Saves Lives!; Obesity & the Risk of Heart Failure; High Sugar Diets & the Risk of Colon Cancer; Abuse During Childhood & Possible Effects of Genes on Antisocial Behaviors

07/26/02: Cancer: Nature vs. Nurture; Cardiorespiratory Fitness & Inflammation; Kidney Transplants from Cadaver Donors; Aircraft Cabin Air Recirculation & the Common Cold

07/19/02: PCBs & the Gender of Babies; Breastfeeding & the Risk of Breast Cancer; More Bad News About Hormone replacement Therapy

07/12/02: A cancer surgeon's perspective on hormone replacement therapy

07/08/02: Hormone replacement therapy & the risk of disease; more good news about statins; antioxidant vitamins & disease prevention; more

06/28/02: Antioxidants & the Risk of Alzheimer's Disease; Effects of Exercise on the Hearts of Patients with Mild Hypertension; Statins reduce cardiac events following angioplasty; more

06/21/02: Sex & violence and Advertising: Do Advertisers Get What they Pay For?; Don't Drink the Water (or the Salsa Either!); Vasectomy & Prostate Cancer Risk; Update on Smoking & Disease

06/14/02: Young Men, Obesity & Heart Disease; Breastfeeding & Obesity; Irritable Bowel Syndrome & rectal pain threshold; more data on cox-2 inhibitors & cancer; more

06/07/02: New coronary artery stent reduces risk of restenosis; possible cause of Parkinson's Disease identified; more

05/31/02: New biological insights into obesity & weight loss; broccoli kills cancer-causing stomach bug; anti-inflammatory drugs and the risk of heart attack

05/24/02: Molecular detection of tumor cells in the blood & prognosis; Cox-2 & breast/lung cancers; BRCA2 gene mutations & the risk of breast cancer; breast density & the risk of breast cancer

05/19/02: Moderate alcohol intake and blood sugar levels; more good news for tea drinkers; blood potassium levels & the risk of cardiovascular disease; ethnic differences in diabetic complications

05/10/02: Tea drinkers and the risk of death following heart attack; duration of breastfeeding & adult intelligence; abdominal aortic aneurysms: surgery or observation?

05/03/02: Risk of adverse drug reactions from newly released medications; preoperative beta-blockers may reduce heart bypass deaths; shape-shifting plastics may alter surgical practice; weight loss supplement may cause liver damage 04/26/02: Angry young men & risk of premature cardiovascular disease; stay-at-home dads & risk of cardiovascular disease; more on the effects of statins; dairy consumption and the risk of pre-diabetes; smallpox vaccine: good to the last drop? 04/19/02: Change your sex by drinking water?; Anti-inflammatory RXs may reduce growth of breast cancer cells; radiation treatment reduces repeat narrowing of bypass grafts 04/05/02: Fish & Omega-3 fatty acid consumption and cardiac health; news briefs 04/05/02: Can coffee reduce your risk of tooth decay?; exercise & blood pressure; a single high-fat meal reduces coronary artery function 04/01/02: Pre-diabetes: a newly defined category of health risk; teen television viewing and subsequent aggressive behavior; the benefits of strength training in the elderly; more ... 03/22/02: Bacteria, antibiotics & heart disease; mammograms: the debate continues; calcium & the risk of colon cancer ... and more 03/15/02: Mammography debate continues; statins & fracture risk; physical fitness & the risk of death; other intriguing findings 03/08/02: Blows to the chest & sudden cardiac death; air quality & the risk of lung cancer; tomatoes and your prostate 03/01/02: Diet & the risk of ovarian cancer; lifetime risk of developing high blood pressure; Osteoporosis prevention with a once-a-year injection? 02/26/02: The continuing controversy regarding screening mammography 02/22/02: Lowering body temperature after heart attack improves outcome; A silver lining for the chronically sleep-deprived? 02/15/02: Hormone replacement therapy & the risk of breast cancer; use it or lose it: Alzheimer's disease & cognitive stimulation; stress, divorce & death; child daycare, infections & parental guilt 02/08/02: Possible breakthrough in early cancer diagnosis; mammography: the controversy continues; CPR techniques revisited 02/01/02: Antibiotics in livestock feed & human disease; genetic detection of early colon cancer in the stool; genetic analysis of breast cancers may help decide treatment 01/25/02: Drug increases lifespan (if you're a fly...); workplace attitudes and smoking cessation; effects of inadequate sleep on surgeons 01/18/02: Lifelong effects of premature birth; smokers under the knife; aspirin and cardiovascular health 01/11/02: Estrogen levels in the blood & breast cancer risk; Heart attack: sex and survival; dangerous lettuce invaders 01/09/02: Cancer & aging: Two sides of the same coin? 01/04/02: Vitamin a & the risk of hip fracture in postmenopausal women; ovarian cancer risk and oral contraceptives 12/28/01: Magnetic Resonance Imaging (MRI) detects coronary artery disease; new development in obesity research; adverse childhood experiences & the risk of suicide attempts 12/21/01: Vaccination of children controls hepatitis a in the community; a possible cure for sickle cell disease; leptin and the risk of heart attacks 12/14/01: Chernobyl and the Risk of Thyroid Cancer in hildren; children & obesity; gastroesophageal reflux disease update 12/07/01: Update on school shootings; new implantable heart-assist device approved for further evaluation; prevention of fungal infections in pre-term babies 11/30/01: Flu vaccination in asthmatics; low-tar cigarettes are not less harmful; beans and your heart 11/21/01: Modified smallpox vaccine may reduce risk of cervical cancer; New approach to breast cancer diagnosis; New non-invasive prenatal diagnostic test for down's syndrome 11/16/01: Cholesterol-lowering drugs reduce risk of heart attack; supplemental radiation therapy reduces risk of breast cancer recurrence; brains of women may answer age-old questions 11/09/01: Bio-warfare (redux); my gray matter is bigger than yours; mad elk disease? 11/02/01: Making sense of bio-warfare 10/26/01: The impact of mammography on deaths due to breast cancer; diet & exercise may slow cancer cell growth; antidepressants and the risk of heart disease 10/19/01: New insights into autism; the wiley appendix 10/12/01: More bad news about obesity links to other diseases…Hey dad, can I borrow the car keys? 10/05/01: California leads nation in reduction of tobacco-related disease; exercise as an antidepressant? 09/25/01: Advances in the detection of breast cancer; primary care physician awareness of peripheral arterial disease; arsenic in the water 09/17/01: In perspective 09/12/01: Genes may hold secret to long life; men and women: cognitive function in the elderly; physical activity, obesity and the risk of pancreatic cancer 09/05/01: English milk cows prefer Beethoven and Simon & Garfunkel over Bananarama; new prostate cancer prevention study: looking for a few good men; exercise & diet can help prevent diabetes 08/28/01: Arthritis drugs may be linked with increased risk of heart disease; errors in blood clotting tests can be fatal; infant soy formula not associated with reproductive side effects

© 2002, Dr. Robert A. Wascher

BBC News

The World Health Organisation (WHO) has advised against travel to Hong Kong or parts of China due to the outbreak of a deadly, pneumonia-like virus.

The warning came after Chinese authorities said nine more people died from Severe Acute Respiratory Syndrome (Sars) in the Guangdong province last month, bringing the worldwide death toll to 75.

The virus has killed 16 people and infected over 680 in Hong Kong alone.

More than 1,800 people have been infected worldwide, causing widespread fear and the imposition of emergency measures.

Has the Sars outbreak affected you? Have you changed travel plans because of the spreading virus? Will you heed the WHO warning? E-mail us with your experiences.

The following comments reflect the balance of views we have received: Click here

Monday, March 31, 2003 Back The Halifax Herald Limited Vincent Yu / The Associated Press By Chris Morris / <a href=www.herald.ns.ca Canadian Press SARS OUTBREAK

Rugby fans wear masks in an attempt to protect themselves from SARS during a tournament in Hong Kong, where officials said Sunday that 60 more people had fallen ill with the disease.

The principal of a middle school in Miramichi, N.B., has become the first suspect case of the potentially-deadly syndrome in Atlantic Canada.

Dr. Wayne MacDonald, New Brunswick's chief medical health officer, told a hastily called news conference Sunday that the individual has voluntarily quarantined herself in her home where she will stay until she's free of symptoms of the respiratory syndrome which, so far, has killed more than 50 people worldwide.

At least 60 people who have been in contact with the principal since her return last week from a trip to China are also being monitored for signs of SARS.

MacDonald said there are no other suspected cases and no one else is being quarantined. He said the Losier Middle School where the woman works will be cleaned.

"We feel the risk is low," MacDonald said.

Steve Benteau, a spokesman for the New Brunswick Education Department, said the school will be closed until April 8 since officials are having problems contacting about 380 families and staff members from the school.

MacDonald said the woman returned from a week-long trip to China last Monday.

She had been ill during the trip and by the time she came home to the Miramichi, she was starting to feel better.

However, like all people arriving in Canada from places considered high-risk for the mystery illness, including China, she was given a card when she landed and told to watch for symptoms.

She went to the Miramichi hospital Friday, concerned that the symptoms she had experienced during her trip and was still feeling to a lesser extent, might becaused by SARS, notably fever and respiratory difficulties.

"The individual is at home where she's recovering," MacDonald said.

He said he was pleased with the measures taken by the hospital when she arrived to be examined.

He said he is confident proper containment procedures were followed and there should be little or no risk to staff or patients.

As well, MacDonald said Health Canada has been advised of the case. He said it's up to Health Canada to follow up with investigations of the flights she was on and warn her fellow passengers.

More than 100 people across Canada are being watched as suspected or probable cases of SARS, a pneumonia-like illness that causes high fever, coughing and breathing troubles.

Most are in the Toronto area, however suspected cases have been reported in British Columbia, Ottawa, Alberta, Saskatchewan and now New Brunswick.

MacDonald said the incubation period for the illness, believed to be caused by a virus, ranges from two to 10 days with most cases showing up four or five days after exposure.

A fourth Toronto-area resident died of SARS on the weekend, and a 21-month-old child joined the growing list of probable and suspected Canadian cases of the rapidly spreading disease.

Swamped public health officials estimated Ontario has roughly 100 cases of severe acute respiratory syndrome, but admitted they had only been able to analyse data for 81 - 42 probable and 39 suspect cases.

"There are very many more individuals provincewide who are cases that are under investigation," said Dr. Colin D'Cunha, Ontario's chief medical officer of health.

Dr. Jim Young, the province's commissioner of public safety, urged hospitals and health-care workers around the province to be vigilant for potential SARS cases, saying they fear that as time goes on the ripples from the Toronto cases will move further afield.

Vancouver has two probable SARS cases and a number of people under surveillance for the disease. But health officials in Manitoba said Sunday a patient who had been listed as a probable SARS case in Winnipeg does not have the disease.

Health Canada also lists five suspect cases in Alberta and one in Saskatchewan. However, an Alberta health official said Sunday evening the five suspected cases in that province have since been diagnosed as something else.

"There's nothing new in Alberta to report," said Howard May, Alberta Health spokesman.

The Ontario officials confirmed the latest person to die had become infected while receiving treatment in the intensive care unit of Scarborough Grace Hospital - the nexus of Toronto's growing cluster of SARS cases.

One of the original Canadian SARS patients was treated at Scarborough Grace in early March before health-care workers realized they were facing a highly contagious and potentially deadly new disease that required high level infection containment measures: gowns, gloves, goggles and masks at all times. Waves of cases have emanated from that first patient.

The latest person to succumb to SARS was transferred to York Central Hospital on March 16 - long before he began showing signs of SARS. As a result, staff there did not impose the stringent infection control measures needed to contain the disease. The patient died Saturday night.

At least two nurses from York Central have come down with SARS. Both York Central and Scarborough Grace are now closed to new patients. Staff from the two facilities are barred from working elsewhere for the time being.

Anyone who worked at, visited or was a patient of either hospital from March 16 onwards has been asked to go into quarantine for a period of 10 days from the last exposure to the hospitals.

While no one has a good handle on how many people are holed up in their homes, officials have estimated the numbers would reach into the thousands.

March 31, 2003, 12:01AM Experts fear faster spread of SARS By MARGARET WONG Associated Press

HONG KONG -- Dozens more people at a Hong Kong apartment complex contracted a flu-like disease to bring the number there to 213, health officials said Monday, as the mystery illness with no known treatment continued its spread.

Hong Kong's health secretary, Dr. Yeoh Eng-kiong, announced the big rise in severe acute respiratory syndrome, or SARS, cases just hours after authorities imposed a tight quarantine on one section of apartments at the Amoy Gardens complex.

He said 88 new cases were diagnosed at the building complex to add to 125 other cases, bringing the total to 213.

The report came as the World Health Organization said SARS has killed at least 54 people worldwide, with the majority of cases in Hong Kong and China. That figure does not include three more deaths reported Sunday, one each in Hong Kong, Toronto and Singapore. More than 1,600 have been infected worldwide.

Singapore's health minister, Lim Hng Kiang, said the disease may spread more easily than first believed, with some people found to be more infectious than others. Labeled as "super infectors," they can infect as many as 40 others, he said.

"We run the risk of a huge new cluster of infected people, which could start a chain reaction," Lim said.

Singapore said it will station nurses at its airport to examine all travelers arriving from infected areas, while Canada planned to screen those traveling abroad from Toronto.

Yeoh said 107 of the sick people were from one section. He said officials believe the virus was brought to Amoy Gardens by a man infected at the Prince of Wales Hospital, where many of Hong Kong's victims have fallen ill.

Yeoh appeared emotional and initially had trouble speaking as he made a statement on the isolation of the section.

"It's a very exceptional circumstance," Yeoh said. "We haven't done it before, and we hope we won't do it again."

In Canada, meanwhile, another death was reported Sunday to bring the toll there to four. Officials earlier declared a health emergency in Toronto, located 50 miles from the U.S. border. U.S. health officials have reported 62 cases in the United States but no deaths.

About 100 probable or suspect cases have been reported in Canada. Officials have closed two hospitals to new patients, and hundreds of people have been quarantined in their homes.

Another possible case turned up in New Brunswick on Canada's east coast, officials said Sunday, meaning the illness that originated in Asia may now reach across Canada. The New Brunswick case involves a school principal who traveled to China.

Other suspected cases are in Ottawa; Winnipeg, Manitoba; and on the west coast in Vancouver, British Columbia.

The United States and Canada have advised people to avoid travel to afflicted areas in Asia, and the World Health Organization recommended that international travelers from Toronto and several Asian cities get screened for symptoms.

Most of the Toronto-area cases are health care workers at Scarborough Grace Hospital and York Central Hospital who became infected while treating initial victims, all of whom had traveled in Asia or had close contact with other victims.

The disease has caused a run on surgical masks in the city and slowed business by as much as 70 percent at Pacific Mall, a Chinese shopping mall in Toronto's northern suburbs.

Some merchants also were taking precautions, wearing protective masks even though no cases have been linked to the mall.

The International Ice Hockey Federation canceled the women's world championships Thursday in Beijing. The federation said the spread of the illness to Beijing from southern China put the players at risk.

Players for Canada, the defending champion, were disappointed but understood.

"You could lose your life going there and just being in contact with somebody," forward Danielle Goyette said. "Life is more important than hockey right now."

March 31, 2003, 9:39AM By EDWARD HEGSTROM Houston Chronicle

RESOURCES • Q&A on SARS • Facts about virus • CDC information page • World Health Organization information

The sudden global spread of a lethal new disease out of Asia illustrates how little power modern medicine has to prevent deadly germs from moving around the world as fast as an airplane can carry them, experts say.

The disease, known as severe acute respiratory syndrome, or SARS, appears to have spread from China to Hanoi, Hong Kong, Singapore, Taipei, Frankfurt, Toronto and now Houston.

Because health officials in Hong Kong say they believe it has been spread among passengers during a flight, SARS raises particularly serious questions about air travel. And the reports resonate with some in the United States, which has been on heightened alert for bioterrorism the past year and a half.

The United States used to maintain a robust quarantine system to prevent the arrival of dangerous diseases on ships and airplanes, but that system has been severely slashed in recent years. More than 15,000 international travelers arrive at Houston's Intercontinental Airport every day, including some on a direct flight from Tokyo. But the quarantine inspector who ostensibly polices the Houston airport works out of an office in Los Angeles.

SARS is not the first disease to arrive in America from overseas. In an era of globalization, with millions of people crossing borders daily, diseases regularly jump continents, and experts say they have no way to prevent that.

"This is the sort of disease that will spread everywhere because it is carried by people, and people travel," said Dr. Mary E. Wilson, an international health expert at the Harvard School of Medicine. " I think we have to expect that this sort of thing will continue to happen. Borders are porous."

Though none of the 62 suspected SARS cases in United States has proven fatal as of yet, other internationally imported diseases have been more lethal. World Health Organization Director General Gro Harlem Brundtland estimates that in the latter half of the 20th century, five times as many Americans were killed by internationally imported infectious diseases than by war.

Many studies -- including one released earlier this month by the Institute of Medicine -- find that the best way to stop the global spread of infectious disease is by improving surveillance. If countries can cooperate to identify diseases as soon as they emerge, international health authorities can step in and stop them from spreading, the studies conclude.

Good surveillance and early international intervention prevented the spread of a dangerous avian influenza virus that emerged in Hong Kong a few years ago, Wilson noted. And good surveillance may be preventing the secondary spread of the SARS in the United States, she added.

But surveillance only works if officials are willing to disclose outbreaks. Many countries cover up epidemics in an attempt to prevent the damage that may result to their trade and tourism industries, said David Fidler, a University of Indiana law professor who writes extensively on the links between international law and infectious disease.

"History shows that if there is an outbreak in a country, that country does not want to share that information because of the effect it could have on their economy," Fidler said.

WHO officials issued their first warnings about SARS in mid-March. But the organization now reports the disease first emerged in south China in early November. Officials still do not know if that four-month delay in diagnosing the new disease proved crucial in allowing its spread.

Wilson acknowledged that the Chinese government's reluctance to alert the world about the disease may have been related to "economics." Reports of an unknown disease in southern China began circulating as early as mid-February, but Chinese officials initially refused international help in identifying the disease, she said.

The globalization of infectious disease is not new. European explorers brought smallpox to the New World nearly five centuries ago; an influenza pandemic spread around the world in a matter of months in 1918.

But the pace of international trade and travel has accelerated the movement of diseases. After essentially disappearing from Latin America in the 1970s, dengue fever has returned with a vengeance, reaching from Venezuela to northern Mexico, and creeping across into South Texas. As many as 100 million people catch the disease, and jet passengers continue to take it to new areas, including Hawaii.

After first appearing in New York in 1999, West Nile Fever spread south and west, reaching Houston last summer. Despite years of study, officials say they still do not know how the disease reached the Americas.

Quarantine used to be the preferred way of stopping diseases at a country's border, but that approach has lost favor with world health experts. Modern jet travel is so fast and so frequent that quarantine officials cannot possibly stop diseases at an airport, Wilson said.

The emergence of SARS may change that thinking. Health officials in Asia are now using quarantine, and the U.S. Centers for Disease Control and Prevention has set up a screening process in which quarantine officers are being asked to identify sick passengers at some airports.

At Los Angeles and other airports where the CDC has staff, quarantine officers now monitor incoming flights and hold ill passengers to make sure they go straight to a doctor.

But years of neglect and underfunding have left the U.S. quarantine system short-staffed. In the 1960s, the United States had more than 50 quarantine stations; now it has eight. Officers at those quarantine stations are expected to patrol numerous air and land ports of entry.

If a sick passenger shows up on a flight in Houston, airline officials are asked to call the quarantine inspector in Los Angeles.

There are U.S. Customs Service agents at the Houston airport who screen for incoming drugs and contraband. The Department of Agriculture keeps agents there every day to screen for possible disease-carrying fruits, vegetables or pets. But no one at the airport screens for dangerous human diseases such as SARS.

"The CDC doesn't have a presence out here," said Ernest DeSoto, spokesman for the Houston Airport System.

With the CDC so short-staffed, quarantine in this country works essentially on the honor system. Airline crews who identify a sick passenger on an international flight arriving in the United States are expected to call ahead and notify quarantine officials. If the flight attendants fail to notice the disease, customs and immigration agents are supposed to stop it. But the honor system doesn't work.

Interviews and CDC quarantine records obtained by the Chronicle show that airlines have routinely allowed obviously sick passengers to board international flights bound for the United States, and customs officials sometimes let them enter the country.

The CDC quarantine reports tell of passengers flying to the United States while noticeably sick with AIDS, chickenpox, dengue fever, hepatitis, malaria, measles, meningitis, mumps, pneumonia, rabies, rotavirus, rubella, syphilis and typhoid fever, among others. Many were allowed to board planes while showing unmistakable symptoms of disease.

Allowing obviously sick passengers to board jets could open the country to the threat of bioterrorism. Under one frequently postulated scenario, a terrorist could spread smallpox by infecting himself with the disease and then boarding a jet to spread it to the other passengers.

Some experts dismiss the "smallpox martyr" theory. They say that people with infectious smallpox would have a rash and fever and that no airline's ticketing agent would allow them to board a plane.

But the CDC quarantine reports obtained by the Chronicle indicate that -- at least before Sept. 11, 2001 -- passengers were sometimes allowed to board U.S.-bound international jets while seriously ill with fevers and rashes.

In 1999 alone, at least six passengers with chickenpox were pulled aside by quarantine authorities after arriving in the United States on an international flight. To someone who is not an expert, chickenpox is hard to differentiate from smallpox.

Bioterrorism expert Jonathan Tucker, author of Scourge: The Once and Future Threat of Smallpox, said he believes a passenger with chickenpox would have a harder time travelling after 9/11. "I just think people are more alert and more sensitive to passengers getting on planes with rashes now," he said.

Beside the threat of bringing disease into the country, sick passengers also risk infecting others on the plane. Airline passengers have contracted flu, measles and even deadly strains of drug-resistant tuberculosis from breathing the air in a jet cabin, studies have shown.

Hong Kong officials now say they believe SARS has also spread among passengers on a flight. In response, WHO issued guidelines late last week asking airlines to step up their efforts to screen passengers.

CDC officials did not return phone calls seeking comment on the connection between SARS and quarantine. But in an interview last year, James Barrow, chief of field operations for the CDC's Division of Global Migration and Quarantine, acknowledged that globalization has caused the government to question whether quarantine is even feasible anymore.

"If you look at the sheer volume of travelers," he said, "I don't think you could have enough quarantine inspectors to look each of them in the eye and determine if they're carrying an infectious disease."