OUTBREAK (ENTEROVIRUS) REVISITED…..TAIWAN

Since April this year, a hauntingly similar outbreak of fatal viral infection has taken hold of Taiwan by storm. At least some 38 deaths have been reported, and thousands more are suspected to have contracted this lethal but misunderstood infection. The fatalities so far have involved children below the age of 6 years.

Strikingly similar was the fact that information about this outbreak appeared to have leaked out rather sparingly and reluctantly, from the afflicted island. At best factual data there have been few and far between. From translated sources, newspapers and disparate postings in electronic discussion boards (via the internet), we are beginning to see a striking concordance of events between what is going on in Taiwan and what had happened here in Malaysia, almost exactly one year ago.

The anguish and frustration of parents, the conflicting accounts as to the etiological agent and the frenetic debates about how best to manage the outbreak, bear an uncanny parallel with what we here in Malaysia had encountered, previously.

However, from this initial chaotic state, some semblance of control seemed to have emerged. A Crisis Prevention Task Force has been appointed and most importantly perhaps, a tentative working diagnosis implicating the Enterovirus 71 was made. This bold report was made by the Pang-Chi Hospital Director, which was later accepted by the Infection Control Unit of the Department of Health (DOH).

This initial report suggested a fulminant infection affecting the brain stem (confirmed in some by MRI) and was also substantiated by other clinical and laboratory findings. A comparison to an Internet posting report of four autopsy-confirmed cases in the Malaysian outbreak, seemed to add support to this diagnosis. Medical management of this infection in certain Taiwanese hospitals has been tailored accordingly (a tentative diagnosis of brain stem encephalomyelitis, with cardiopulmonary dysfunction) and patients have been graded into 5 stages. Early reports attest to the possible efficacy in preventing some fatalities in a number of patients.

Subsequently, Taipei Yungchung Hospital became one of the first to have isolated the enterovirus EV71 from the throat, CSF and stool from a deceased child. Scientists there suggested that perhaps they have uncovered a more virulent strain than the original EV71. From Malaysia, Prof SK Lam (UHKL) had also reported the isolation of the EV71 from brainstem tissues of children who had died in Peninsular Malaysia. The Malaysian EV71 strains (Link changed) isolated, have been found to differ from the EV71MS and EV71BrCr strains.

Meanwhile as a result of public pressure, DOH Director-General Chan Chi-shean announced that Wang Li-hsin, director of the Bureau of Communicable Disease Control (BCDC) had resigned. He added that Taiwan might have to legislate mandatory autopsy for suspected fatal infections associated with the virus. Thus far, confusion reigns.

Not altogether surprisingly, several foreign news agencies, including the CNN and BBC, have jumped on the bandwagon of slip-shot reporting, they have been reporting conflicting and ill-substantiated statements pertaining to this viral outbreak. It goes to show that many people are quite ignorant still about this terrible ailment.

Some common misconceptions repeated often enough, were the wrong facts that: the disease is airborne (it is almost certainly via an oral-faecal route, through poor hygiene) and that all the earlier fatalities in Malaysia have been due to viral myocarditis (current evidence points to a brain stem encephalomyelitis)

The Taiwanese media have not been too clear either: some have been urging people not to visit south (i.e. South East Asia) during the summer holidays, as they believed the disease had originated there and that they ran higher risk of getting infected!

Meanwhile the scientific community within the WWW has been set abuzz, communicating furiously by email and through visits to the ever-popular ProMED bulletin board.

One moderator of this site commented thus: "Something seems quite odd in all this. Certainly CDC cannot be made to appear responsible for not reporting information that rightly is to be reported by the country submitting specimens. On the other hand, how long must CDC or any other organization wait to release critical information? First it was Malaysia, now Taiwan suffering from an epidemic of a serious disease. It seems the two epidemics are related, even if only insofar as the etiologic agent is concerned. Yet it is a year after the Malaysian experience and we still do not have definitive information and the Malaysian government seems to be quenching even the thought (by medical personnel, researchers, and physicians) of questioning the official government line, this is now too small a world for that sort of action. Seems to me that if the bureaucrats and politicians do not get out of the way of this train they will be run over by it. Obfuscation will not serve anyone. There are hundred of thousands of people sick and tens of people died. Time to put all the cards on the table."

At this point in time, the Taiwanese epidemic has not shown any sign that it is burning out, although some 'expert' there have predicted that this outbreak should peter out within 6 weeks. Our painful Malaysian experience would suggest otherwise. Through large-scale campaigns and public health measure, we managed to contain our last infection within 4-5 months. Let's hope that the Taiwanese have better luck.

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With that I let your "mouse" or your "keyboard" do the "talking". 

Till next month, "Happy Surfing".

Cyberdoc

Last Updated 7 May 2005.

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