Here is a blast from the past, concerning SARS, and
GOVERNMENT LIES about actual numbers vice make believe numbers. Dr. Niman is quoted extensively.
Snip from below:
In an article titled, “Shanghai SARS Cases a State Secret”, the magazine counts dozens of known cases in several hospitals, quotes a doctor as saying the WHO delegation visiting the city is being deceived, and said party officials told local ”official media” that they were “not to report any SARS statistics higher than the government-sanctioned figures” and that they were not “allowed to interview any SARS patients or their families. “
The reason? Time says central government figures, worried that foreign investors would back out of Shanghai the way they have in Hong Kong recently, told city officials to continue to promote the city as a SARS-free zone.
But few governments are that cynical. By most reports, governments appear to be erring out of a misplaced belief that reassurance is the lesser of two evils, with economic ruin the alternative. End snip
https://www.nbr.co.nz/home/column_a...id=5&cname=Asia
Discounting the SARS reassurance syndrome
Counting victims: Discounting the SARS reassurance syndrome
francis till
When New Zealand's director of public health, Colin Tukuitonga, said at the beginning of the month that 96 out of every 100 people who contracted SARS would recover, his prognostic powers may have been occluded by his second message: don't panic.
According to official figures, the mortality risk associated with SARS, first stated at 2 per cent and until recently at 4 per cent, now appears to be at about 6 per cent in the general population -- and much higher in some locations and among some demographic groups.
But those official figures may be massively understating the actual risk because they are based on a counting model that includes thousands of patients still in the throes of infection, says Dr Henry Niman, a surgery instructor at the Harvard Massachusetts General Hospital.
According to Dr Niman, the actual mortality rate is much closer to 20 per cent in the general population.
"Mortality rates are usually calculated on patients whose outcome is known," Dr. Henry Niman says. "(The CDC's number) would be accurate only if all patients hospitalized survived, which has not been the history of the disease in the more heavily affected areas."
Instead, Dr Niman contends the proper measure of mortality risk is the one used in other epidemics: the number of fatalities is divided by the sum of the number of recovered patients and the number of fatal outcomes.
Currently, official figures are developed by dividing the total numbers of deaths by the total number of infections, including those who have died, recovered and are ill. If 100 people are infected and 5 die, the mortality risk would be 5 per cent under this procedure. On the other hand, if 20 people in that population had recovered, the measurement pool would be 25: the number of recoveries plus the number of deaths. In that scenario, the mortality risk would be 20 per cent (5/25).
The model still in use developed primarily because the disease has a long cycle, it now appears, and health authorities were forced by public pressure to develop some method of estimating risk before there were enough recoveries to make meaningful the more traditional method of mortality projection.
Now that there are a substantial pool of recovered patients, Dr Niman says the CDCs of the world -- and the World Health Organisation itself -- should change their counting methods.
Dr Niman's call for a revision to the mortality risk assessment procedure has fallen on deaf ears in the US Centers for Disease Control and Prevention (CDC) and at the World Health Organisation (WHO), but has been a hot topic on SARS-related internet sites and discussion groups for much of the past two weeks.
Posting on 19 April to the influential discussion list run by Declan McCullagh through his Politechbot.com website, Dr Niman gave mortality figures for a range of locations that should shake many health officials like Mr Tukuitonga to the complacent core.
On 19 April, based on country-supplied data, Dr Niman says the actual death toll was:
Hong Kong 18.2 per cent
Canada 18.2 per cent
Singapore 13.8 per cent
Viet Nam 9.8 per cent
China, on 19 April, had a mortality rate of only 5.4 per cent, the lowest in the world.
By 22 April, the Chinese Ministry of Health reported a total caseload of 2158, a recovered population of 1213 (discharged from hospital), and 97 deaths. Under present WHO/CDC counting procedures, the mortality risk in China on that date was an astonishing 4.5 per cent (fatalities/total cases) -- but under Dr Niman's counting procedure stood at 7.4 per cent. Still low, but closer to the numbers being produced by other outbreaks.
China's figures are influenced deeply, some say skewed, by data from Guangdong Province, where the disease was first reported and which has consistently accounted for the bulk of infections in the country. According to health ministry data for 19 April, the total number of infections stood at 1330 with 1137 discharges and 48 deaths -- presenting a remarkably low mortality risk, the lowest in the world, under any method of counting.
In Beijing, where numbers of discharged patients are very low, the 19 April numbers point to a potential catastrophe: 588 cases, 46 discharges, 28 deaths. In other words, of the 74 patients with known outcomes for the disease, 38 per cent had died.
On 23 April, the health ministry reported 39 deaths and 64 hospital discharges in Beijing, meaning of the 103 cases with known outcomes there, 38 per cent had died -- and indicating the mortality pattern was holding and not merely the result of a reporting spike. In Shanxi Province, where a new outbreak appears underway, the health ministry reported on 23 April a cumulative total of 162 SARS cases including 45 among medical workers, 108 suspected cases, 7 deaths and 14 hospital discharges -- a 33 per cent mortality rate by Dr Niman's method of calculation, but an almost reassuring 6.5 per cent mortality risk by the WHO/CDC counting procedure.
In fact, in an April 23 statement on mortality, the CDC is careful not to confuse the mortality rate with mortality risk -- a point that few health agencies seem to have incorporated into their own pronouncements.
In a Frequently Asked Questions section of the CDC website called "What is the mortality rate for SARS?", the CDC says only, "As of April 23, 2003, a total of 251 SARS-related deaths – or 5.9 per cent of all cases of SARS – had been reported worldwide."
Doctors recently asked by Wired Magazine about the mortality projections noted several factors that could be influencing the WHO/CDC in choosing their method of assessing risk.
One possibily is that the known SARS universe is extremely variable -- so the most general form of counting may be the best.
“We do not have an infection-specific death rate," Dr. John Zaia, chair and professor of virology at the City of Hope Beckman Research Institute in Duarte, California, told Wired. "That would be very valuable, because it could be that hundreds are getting infected but only small percentage are getting sick. That was the case for polio."
Also, the population of recovered persons may be under-reported because diagnostic procedures failed to identify them as SARS victims -- meaning that until patients can be definitively identified as suffering from SARS, all discussion about mortality risk is speculative.
New Zealand Dr Maurice Mckeown told NBR, "there is, in all probability an unknown number of patients who may suffer a mild version of the disease not requiring hospitalisation and thus may not be included in the ... statistics at all. " Dr Mckeown believes that any calculation of mortality rate, let alone risk, should be understood to apply only to "the obviously afflicted."
Then, as the Wired story points out, the population of recovered patients is still very small, allowing for anomalies to creep into tallies.
"Only a small proportion at present have a clear enough outcome that we can declare them recovered," said Dr. David Freedman, a professor of medicine and epidemiology at the University of Alabama at Birmingham, told Wired.
But there is another possibility -- fear of an even more virulent epidemic: panic.
If that is the case, and pronouncements from many political figures in SARS hotspots indicates it may be, it may be time to stop downplaying risk.
Panic is already a reality in China and other places where the disease has taken root, and much of it appears to stem from the belief that governments are not telling the truth -- which, in several high-profile cases, has clearly been the case.
Add to that the unfortunate fact that many well-intentioned medical authorities have followed the leads of the WHO/CDC on a wide range of SARS-related issues and issued ”definitive” guidance -- only to find out later that the advice was incomplete, if not wrong -- and an increasingly suspicious general public is left to react without a medical rudder.
Over the past several weeks it has become clear that the truth about SARS is a shifting chimera, revealing itself incrementally, often only after the epidemic has taken a new turn.
Infection, for example, is possible by a wide range of vectors, not merely the extensive, close personal contact with symptomatic patients that was the first claim of the WHO/CDC. The disease is not purely a respiratory infection, as has been long claimed -- indeed, doctors performing autopsies in Hong Kong have noted major organ failures as well. Nor is the disease source understood very well. In spite of claims that a new member of the family of common-cold spawing Coronaviruses was responsible, new research in Canada shows that virus present in only 40 per cent of probable and suspect cases. More, it is increasingly apparent that the disease can be fatal in younger, otherwise healthy victims, even though early statements claimed mortality risk was almost exclusively shared by older patients with underlying medical conditions such as diabetes.
Now, public health officials in New Zealand are suggesting that only symptomatic sufferers can be the source of contagion, even while other medical professionals are suggesting that some victims may not have symptoms -- but could still be carriers. Even the CDC now says "it is not known how long before or after their symptoms begin that patients with SARS might be able to transmit the disease to others."
Uncertainties about the disease mean public health authorities cannot afford to ignore Dr Niman's statistics, especially not if they are doing so simply in the interests of preventing panic. They point to a much more virulent disease than previously thought, especially since they tend to bear out over a relatively long term.
Dr Niman wrote in Politichbot.com on April 20, for example, that “[t]he WHO data has been broken out into deaths and discharged for about 11 days and the numbers have been pretty consistent. The number discharged daily in Hong Kong has gone up quite a bit recently, but so have the fatalities, so the death rate hasn't changed much in the past 11 days:
April 20 17.5 per cent
April 19 18.2 per cent
April 18 17.6 per cent
April 17 19.3 per cent
April 16 19.2 per cent
April 15 18.7 per cent
April 14 17.0 per cent
April 12 14.0 per cent
April 11 15.9 per cent
April 10 16.3 per cent
“[t]he range is pretty wide for country to country, but has been pretty steady for the past 11 days:
Date Hong Kong Canada Singapore China
April 19 18.2 per cent 18.2 per cent 13.8 per cent 5.4 per cent
April 18 17.6 per cent 20.7 per cent 15.0 per cent 5.5 per cent
April 17 19.3 per cent 20.7 per cent 14.2 per cent 5.5 per cent
April 16 19.2 per cent 26.0 per cent 13.3 per cent 5.5 per cent
April 15 18.7 per cent 32.5 per cent 13.3 per cent 6.1 per cent
April 14 17.0 per cent 32.5 per cent 12.5 per cent 5.6 per cent
April 12 14.0 per cent 27.8 per cent 10.5 per cent 5.3 per cent
April 11 15.9 per cent 28.6 per cent 10.5 per cent 5.3 per cent
April 10 16.3 per cent 31.3 per cent 10.7 per cent 5.1 per cent
"The current motality rate in the teens for major sites isn't an upper limit, and the numbers could go higher," he wrote.
Unfortunately, officials in many locations with economies dependent on tourism and service appear to have been influenced by the potential for economic disaster and often seem to have raced to reassure anxious populations only to later discover they should have been far more aggressive in their warnings.
China, where medical authorities actually hid SARS victims and issued falsified reports about the extent of the epidemic is only the worst case in the reassurance syndrome -- and Beijing is almost certainly not the only or the last city to be found hiding SARS under the public health rug.
Recent reports indicate that the Shanghai government may be engaged in active suppression of medical news about the reach of SARS and the weblogging community is describing many instances of quarantine there, related to individual cases the government has not made public.
The weblog of Shanghai resident, Jian Shuo Wang, contains several such reports.
In one, dated 25 April, a Shanghai woman commented:
“My daughter's kindergarten claimed New Century Kindergarten is quarrantined. One parent of a child attending the school is in hospital for SARS treatment. Another kindergarten in Pudong closed yesterday also. Unknown situation out there.
“My health insurance sales guy called yesterday and told me to be extra careful, he claimed that there are over 200 cases in Shanghai.
“Sun Daily in HK reports that one doctor in Shanghai claimed he saw over 37 patients with full blown SARS in one hospital!”
Another commentator wrote:
“We're expats currently living on the island of Hainan, but the situation here is getting pretty grim. The government isn't admitting SARS is here, but everyone is restricted to their own village or town -- no traveling about the island. We're not even permitted to go into Haikou, which is the closest city (1 hour away). Anyone who leaves our village has to be quarantined upon returning. We're really not even supposed to leave our work unit except for necessary stuff. And we're not supposed to have ANY personal contact with mainlanders. Yesterday, I got in trouble for going out to get a massage and riding home with a guy from Beijing (even tho he's been here for 2 months). No more massages, no more socializing with folks from Beijing, Guangzhou, etc. Anyway, our contract isn't over til end of June, but we're thinking we'd better get out now -- at least one of us with the kids. They're starting to cancel flights in and out of Hainan -- yesterday all international flights and flights to Hong Kong were shut down.”
While the government maintains that there are only two known cases in the city, Time magazine is the latest external news agency to find those figures deeply flawed. In an article titled, “Shanghai SARS Cases a State Secret”, the magazine counts dozens of known cases in several hospitals, quotes a doctor as saying the WHO delegation visiting the city is being deceived, and said party officials told local ”official media” that they were “not to report any SARS statistics higher than the government-sanctioned figures” and that they were not “allowed to interview any SARS patients or their families. “
The reason? Time says central government figures, worried that foreign investors would back out of Shanghai the way they have in Hong Kong recently, told city officials to continue to promote the city as a SARS-free zone.
But few governments are that cynical. By most reports, governments appear to be erring out of a misplaced belief that reassurance is the lesser of two evils, with economic ruin the alternative.
New Zealand may be among the group of countries infected by that reassurance syndrome, as demonstrated by Colin Tukuitonga's appeal to the press early this month:
"Yes, there are risks and understandably people are anxious.
"But I'm appealing for people to put that in perspective.
"Be aware, know what to look out for but don't over-react," Mr Tukuitonga told reporters early in the month.
But even as Mr Tukuitonga was telling reporters that direct contact with an infected person was how the disease was transmitted, making the risk of infection very low in the general population, the WHO was issuing statements of concern that other vectors were possible, including sharing an airplane with an infected person, thus changing the advice it had earlier given and on which Mr Tukuitonga appeared to be relying.
Health officials in economies being staggered by SARS -- such as Toronto -- are quick to point out that the actual risk of infection is miniscule, whatever the mortality risk may be, and that deaths from pneumonia -- which are symptomatically related to SARS -- amount to much larger total numbers than anything so far seen from SARS.
Still, it is the risk to the public health system itself that has many worried, and it is a risk that is very real for under-resourced areas like much of New Zealand.
The demands made by SARS for specialist care in negative pressure isolation can stretch even advanced care facilities. Wellington Hospital infectious diseases physician Tim Blackmore was recently quoted as saying that while Wellington Hospital could easily cope with three or four Sars cases at once, any more would start to stretch resources.
And having hundreds of cases appear almost simultaneously, as has been the case in Beijing and other hotspots, may be one reason, unstated by health officials, why some mortality rates are so high.
The biggest challenge in care: as highest-risk health care professionals themselves become infected, the available treatment diminishes -- even as the demand for it grows.
PHOTO: Train attendants preparing to disinfect a train in Tianjin, southeast of Beijing. From:
www.wangjianshuo.com, a weblog run by Shanghai resident, Jian Shuo Wang.
25-Apr-2003
Related Links:
SARSWATCH
CDC: Frequently asked questions about SARS
