From Min Sheng World Health Dialy:

Translated excerpt,  25/6/98

" Has the handling of this outbreak been poor?"

Yesterday a forum on " How to revamp the Communicable Diseases Control Machinery" was
held.

Prof. Chen of Taiwan University's Comunicable diseases Centre said: A communicable
disease control unit needs to have clear delineation of job responsibility and a central
leadership. If so structured, like a fire brigade, it will be able to rapidly analyse a
situation and formulate effective measures. Also, if the DOH had a monitoring system in
place, its performance in the current outbreak would have been better.

Prof. Kim of the university pointed out that the country lacks personel who are
competent in practical diagnostic, invetigation as well as public health methods.

Paediatrician Dr Wong stated that DOH does not routinely monitor communicable diseases
and does not have adequate local database. He further suggested that DOH should
endeavour to arrive at an assessment of the outbreak and propose recommendations which
should then be communicated to the various health care cntres and regional hospitals,
thus achieving meaningful 2 way communication.

Acting Chief of the Communicable Diseases Bureau admitted that the Bureau had been slow
to initiate action in this outbreak, but is now working hard to formulate various
guidelines.

******

Comments:

The Health authorities and health care practiioners in Taiwan should again be
congratulated for their effort to analyse the weaknesses of their Infectious Diseases
control mechanism and proposal to rectify them.

Without a more effective machinery, the same problems, confusion and choas will occur
should there be another outbreak.

CHH

Abstracted from CNN and Reuters

Taiwan killer virus claims two more child victims                13 June 1998

                Web posted at: 01:05 JST, Tokyo time (16:05 GMT)
                TAIPEI, June 12 (Reuters) - A deadly virus claimed the lives
of two more Taiwan children on Friday, pushing the death toll from the
epidemic to 34, health officials and media reports said.
Hsu Kuo-hsiung, acting director of the Bureau of Communicable
Disease Control said one child had died on Friday, killed by suspected
enterovirus.
State television later quoted a hospital source as saying a
second child had died in Tainan in southern Taiwan, bringing the toll to 34.
According to the Taipei City Health Bureau, as of June 11,
some 1,200 children were suspected to have been infected, with 148
hospitalised -- an increase from the 53 reported on June 9. The Health Bureau
gave no explanation for the sharp rise in hospitalisations.
But Hsu said the epidemic was under control, despite doubts
expressed by local paediatricians.
"I can say the epidemic is under control. It has slowed down
according to the number of hospitalised," Hsu told Reuters by telephone.
Local paediatricians, however, said the disease continued to
spread.
  "On the contrary, it has spread from central Taiwan to the
north and south," Li Ching-yun, a top paediatrician at National Taiwan
University's Hospital, told reporters.
  Li said the outbreak had peaked in central Taiwan, but warned
that the next peak would be in the capital Taipei and the second largest city
Kaohsiung in the south.
Li suggested that parents avoid taking their children to
Southeast Asia during the summer vacation because he suspected that was where
the disease originated.
Hsu, whose bureau has come under fire from legislators and
parents, declined to comment on Li's statement.
Taiwan's Control Yuan -- the top government watchdog --
questioned Hsu's predecessor Wang Li-hsin on Friday over accusations that he
did too little to warn the public about the dangers of the disease.
Control Yuan member Huang Chao-yen faulted Wang for trying to
hide the outbreak, saying he should not have stopped other physicians from
warning the public against the disease.
Wang, who was dismissed by the Health Department for failing
to communicate effectively with the public about the outbreak, said he did
nothing wrong.
"Any outbreak of epidemic needs careful research by experts
and discussion by the health authorities before it is announced. That's the
way of doing things properly to avoid causing panic," Wang said on state
television.
Taiwan has invited three epidemiologists from the U.S.
Centers for Disease Control to assist an emergency task force set up to
control the epidemic.
Estimates by some physicians that the enterovirus could have
infected at least 100,000 newborn and small children triggered panic among
Taiwan parents, many of whom have kept their children out of school.
Virologists said the airborne virus could infect adults,
though it had only caused deadly complications among children.
A similar outbreak in 1997 killed 30 toddlers in Sarawak
state on the Malaysian side of Borneo. All died of viral myocarditis, a heart
inflammation linked to a lethal strain of the virus.
According to the Health Department, similar outbreaks were
also reported in the United States and Bulgaria.
Copyright 1998 Reuters Limited. All rights reserved.

Comments

1. Advice people not to go south.

How could advising parents not to take their children to Southeast Asia
help avoid the disease in Taiwan?? Many parents who could afford it
actually sent their children out of Sarawak during the peak of the
outbreak to avoid getting infected. There was even suggestions of
restricting movements of people from endemic areas. Some children who
left Sarawak and went to Australia came down with hand-foot-mouth
disease and confirmed to be due to EV71. Even though the disease may
have originated outside of Taiwan, no other countries in the region have
reported fatal infections due to EV71 and therefore should be safer than
Taiwan right now.

2.Airborne

This is an extremely serious misconception that EV71 and other
enteroviruses spread through the air, like influenza. The sooner this is
corrected and make known to the people, the better for disease control.
The main route of spread of enteroviruses is faecal-oral, not
respiratory or airborne. If it is airborne, like influenza, then there
is very little that individuals can do to prevent getting infected.
However, knowing that the spread is mainly through the faecal-oral
route, we can advise parents and those looking after children to
maintain good personal hygiene, avoid contamination of food or toys
(since children tend to put things into their mouths) , etc. It is
messages like these which can result in positive actions being taken.
This type of mis-information was also seen in Malaysia in the early days
of the outbreak.
 
3. Viral myocarditis in all patients in Sarawak outbreak?

It is so important for Taiwan and other countries which have experienced
such outbreaks to provide a case definition based on clinical signs and
symptoms. This is the first prerequisite in tackling new, emerging
diseases. Without this, there will be over-reporting of cases which will
stress the health resources of any country. Since Taiwan already had 34
deaths, surely it will not be difficult to do this and inform the rest
of the world whether the children died of viral myocarditis or
encephalitis. I guess the same remark applies to Sarawak.

Such statements should be made by someone in authority. In the Malaysian
outbreak, there were many contradicting statements made by people who
were not even involved in investigating the outbreak. Outbreak
management requires skills in many areas, including open communication
based on facts by persons in authority.  
 

Prof.S.K.Lam

To: 'promed@usa.healthnet.org'

Abstracted from The Star, Friday June 12 1998


Taipei: Taiwan yesterday braced for the further spread of a virus which
has killed 33 children, as a top pediatrician warned that the disease
could spread to Hong Kong and the rest of South-East Asia.
A one-year old girl believed to be infected with the virus died in a
hospital here on Wednesday, pushing the death toll to 33, Health
Department spokesman Hsu Kuo-hsiung said.
The disease would intensify in Taiwan's northern countries, which have
been lightly affected so far, Li Chin-yun, a top pediatrician advising
health authorities here, said.
The enterovirus which attacks children below five years old, has been
plaguing central and southern Taiwan where most of the 33 victims were
found.
The spread of the virus is getting out of control, according to Li.
US disease experts from the Centers for Disease Control and Prevention
called in to help in the investigation were due to provide an update of
the virus situation later yesterday.
Initial investigations conducted by the US experts suggest that a
mutated hybrid form of the virus may have developed, the China News
said.
Hsu said that "preliminary tests" showed "there is a possibility that
there is another type of enterovirus".

COMMENTS

The fear of the disease spreading to other Southeast Asian countries has
given rise to concern, judging by the many enquiries received from
readers. Many requests are for detailed clinical information so that
cases can be recognized quickly and we have referred them to our earlier
postings in ProMED. I would like to encourage others from Malaysia as
well as Japan and elsewhere to present their case findings for the
benefit of all.  Perhaps the CDC experts in Taiwan can provide us with
an insight of the cases in Taiwan and how these cases compare with those
seen in Sarawak last year.

In the press release above, suggestion was made to the possibility of a
mutated virus form and another type of enterovirus being present. In
five EV71 isolates recovered from brainstem tissues of children who died
from fatal brainstem encephalomyelitis in Peninsular Malaysia, we found
characteristic 5'UTR sequences which did not resemble the two
established EV71 strains, namely, EV71MS and EV71BrCr. It will be
interesting to obtain further information from Taiwan in support of
their suggestion of a mutated virus or indeed a second enterovirus.

We understand that permission for autopsy was given in one case in
Taiwan and we hope the findings can be shared with ProMED readers. In
our fatal cases, a quick answer was obtained by fixing a small piece of
tissue e.g. medulla or cervical cord and process for paraffin embedding
in 24 hours. Alternatively, according to our University Hospital
pathologist Prof. K.T. Wong, a frozen section will also yield a quicker
answer while waiting for more conventional methods which will take 1-2
weeks.

Prof. S.K. Lam

ENTEROVIRUS 71 EPIDEMIC, CHILDREN - TAIWAN (04)
***********************************************
A ProMED-mail post<http://www.healthnet.org/programs/promed.html>
[see also:
Enterovirus 71 epidemic, children - Taiwan 980601070321
Enterovirus 71 epidemic, children - Taiwan (02) 980604223545
Enterovirus 71 epidemic, children - Taiwan (03) 980607001944]
Date: Sun, 07 Jun 1998 09:30:11 -0700
From: CDPC-mail (James Chin jchin@cdpc.com)
Source: Nando Net (June 7, 1998)
Two more infants died of an intestinal viral epidemic sweeping Taiwan,
pushing the toll to 30, as U.S. experts arrived to help authorities find the cause
of the killer disease, reports said Sunday. The children, from the central Taiwan
county of Taichung, died of the virus in a hospital Saturday. Doctors estimated the
virus has infected at least 200,000 babies around the island in the past week,
newspapers and television reports said. A team of experts from the U.S. Centers
for Disease Control and Prevention arrived late Saturday to help investigate the cause
of the deadly intestinal virus as health authorities came under fire for failing to
respond swiftly to curb the disease. "We are analyzing all the data. Thecollection of
examination examples is crucial to the understanding and control of the virus," Hsieh
Wen-ju, one of the U.S. scientists who arrived in Taipei, told reporters.
"Our major task here is to help build a better epidemic prevention system,"
Hsieh said, adding that they needed to compile data to form a comprehensive picture
of the epidemic.
Hsieh was one of a team of scientists who went to Malaysia to help control a
similar enterovirus outbreak last year which killed more than 30 children in the
Southeast Asian country, the China Times Express said. The experts are to stay in
Taiwan for up to four weeks to complete data collection on the illness that
has attacked children below five years old. Parents of a seven-month-old victim --
one of the two children who died Saturday -- have agreed to have
[an autopsy performed on] their child to help doctors investigate the virus,
the Central Daily News said Sunday.
The arrival of the U.S. scientists followed stepped up measures including the
formation of a special epidemic task force ordered by Premier Vincent Siew to
disseminate information on the virus. Health officials, in an effort to calm
panicked parents, have said that patients often recovered within a week
"even without medication" but added that the virus could lead to
"possible complications." A Department of Health official told AFP that parents
have been warned not to bring their children to public places where they can be
exposed to the virus.
Health department director Chan Chi-hsien on Thursday conceded health officials were
slow to respond to the nationwide virus epidemic, as his office came under
increasing criticism. "The health department's epidemic prevention agency has failed
to come up with an effective and concrete package to calm down panic-stricken
parents and stop the spread of the virus," the China Times said in an editorial.
"Families and patients have had to care for themselves without accurate information
about the virus from the epidemic control center. "This attitude ... is a negligence
of duty," the paper said.
Chan blamed the lack of coordination between the three health department units --
the National Quarantine Service, the National Institute of Preventative Medicine and
the Bureau of Communicable Disease Control. The health department had previously denied
a cause-and-effect link between the deaths and the virus, but local newspapers said 26
of the 30 victims were killed by combinations spawned by the enterovirus type 71. 
CDPC Note: Taiwan has capable public health epidemiologists, but the
present organization of their communicable disease units will continue to
make outbreak investigations and control difficult. ProMED-mail has
presented some interesting information on the treatment of illnesses
related to EV71. [see above archive sources]  

--
ProMED-mail
e-mail: promed@usa.healthnet.org

[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.  

I have some questions I am sure our readers would appreciate having
answered:  

1. Did the children in Sarawak die from myocarditis? The deaths were all
very sudden and I understand there was no evidence of tissue inflammation
in two full post-mortem and nine heart biopsies. What then is the evidence
of myocarditis? Surely by now this key question should be answered, based
on clinical evidence, by the Malaysian Ministry of Health and CDC.  

2. Several symposia were held, attended by senior pediatricians,
cardiologists, neurologists, pathologists, epidemiologists, virologists and
CDC experts. What was the outcome of those meetings? Myocarditis or
encephalomyelitis? Only when these questions are answered can we interpret
the laboratory findings.  

3. A new adenovirus has been claimed to be causally related to the
myocarditis. Could the occurrence of that virus explain the CNS symptoms
and the brain stem lesions in two post-mortem findings by a Sarawak
pathologist and by CDC?  Is this adenovirus a "red herring", present but
unrelated to the disease?  

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 hundreds of thousands of people sick and tens of people
dead.  Time to put all the cards on the table. - Mod.CHC] 
......................................chc/es
--
Send   all  items  for  posting to:   promed@usa.healthnet.org   (NOT to an
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9/6/98

Dear Editor,

I wish to inform you of a web site in Malaysia which has kept a close watch on the Malaysian outbreak in 1997 and is now doing so on the Taiwan EV71 outbreak. You may find some of the information useful. http://www.geocities.com/HotSprings/2188/outbreak.html

I wish to congratulate the people of Taiwan in successfully getting autopsies done. However, it is very important that EVERY suspected EV death from now on must have an autopsy because that is where the information is. It is absolutely pointless to blame the government, the authority etc if every effort is not made to obtain maximum information by performing autopsies.

Thank you

Dr Hoi-Hee Chong
Sarawak, Malaysia.

MSDN Health Editorial Comments . 18 Monday, June 08, 1998

Dr Chong Hoi-Hee,

Thank you for sharing your experience with us! We've forwarded your e-mail to MSDN, and asked MSDN to raise the attention of our government in Taiwan.

If you have further information regarding EV71, you can also e-mail to msdn@acer.net , which is MSDN's e-mail address.

Again, thank you very much! We hope to see our children go to school without fear, and save our children (and adults, too) from EV71 sooner than later.

Sincerely,

Mei-Chen Yu

News Editor, SINANET.com

I have e-mailed a letter to the editor of a on-line newspaper in Taiwan, urging him to influence more autopsies to be done.

6/6/98

Dear editor,

I am a practising physician in Sarawak, Malaysia. I have been following with keen interest your news reports on the current outbreak of EV71 that has caused death of so many children and so much fear in your society.

The resons for my interst are:

About 1 year ago, Sarawak in Malaysia was also in exactly the same situation which caused the death of 30 children. I have been in close contact with Prof. SK Lam who reported the detaied autopsy studies of 4 cases who died in Kuala Lumpur at the same period. The report was mentioned by your newspaper as having had a significant influence in a change in management approach by doctors in Taiwan for the current outbreak. I would like to express my anxiety in the lack of autopsy being done in the present Taiwan outbreak. This is because it is my strongly held personal view that that is where we failed in the investigations of the outbreak we had in Sarawak last year. As a result of that we were unable to arrive at a more definite understanding of our outbreak and why and how some many children died.

I fear that unless more autopsies are done, you in Taiwan would eventually miss the opportunity to fully understand your outbreak. Of course there are many important reasons to try to learn as much as possible about the outbreak: this outbreak has caused many deaths; it is likely to occur again in Taiwan or any where else in the world; the socio-economic impact is tremendous; we need to know how to cope more effectively with the present and next outbreak; if we need to develope a vaccine, we better know for sure who our enemy (virus) is and how they kill our children. All these reasons mean that every unfortunate death that has occurred must be followed by a autopsy. I appeal to you to use all influence you have to encourage and enable autopsies to be done in all future deaths in your outbreak. Every autopsy not done is an important opportunity missed.

Thank you

Dr Chong Hoi Hee
General Practitioner / Physician,

To: 'promed@usa.healthnet.org'

Saturday, June 06, 1998 1:16 PM

The following translated information was obtained from the Internet.

There is a radical change in approach to management of EV71 infection.Chang Hua Christian Hospital has concluded, after studying information from various sources, that their earlier approach has probably been mis-directed because it is now thought that the cause of death in infants suffering from fulminant EV encephalitis is brain stem disorder, and not heart failure from myocarditis. Patients in the hospital who have been managed with this new approach have shown improved response. This approach has been accepted by the Infection Control Unit of the Department of Health which has informed the various hospitals accordingly for their consideration. Pang-chi Hospital Director informed the press this afternoon that conventional teaching states that patients with encephalitis die from cardiac and respiratory failure. But analysis of the 19 cases in his hospital suggests that brain stem disorder is probably the cause of death. Clinical response has also lend further support to this proposition. He further pointed out that MRI study of their 3 most recent cases have shown definite brain stem pathology. Furthermore, a search on the Internet has come up with report of clinico-pathologic findings of 4 similar cases in Malaysia last year.

The report stated presence of pathology in the brain stem but not the heart. This information has collaborated well with their own findings. Thus the radical change in management approach. He further added that the traditional teaching of encephalitis-myocarditis culminating in respiratory failure means that the treatment would be intravenous infusion. Whereas this outbreak's involvement of brain stem means that the fluid infusion may aggravate brain oedema and worsening clinical condition. Thus the hospital has now adopted fluid restriction and has found significantly better result. He states that after consultation with Prof. Ho, they are now grading the patients into 5 stages. Patients who, on being as having reached graded  stage 3, are treated promptly and appropriately would show significantly better prognosis for survival. The Infection Control Unit has circulated the criteria for the grading and a reminder for the need for a close vigilance to all hospitals and clinics in the Island.

COMMENTS

The above article is extremely important for those involved in outbreak investigations and Taiwan should be congratulated for getting to grips with the situation in the following areas:

1. Outbreaks involving high mortality, especially in young children, can become very emotional and frightening. Confusion reigns as the cause of death   is uncertain in the early period. This was experienced in Malaysia in 1997 and now in Taiwan.  The Taiwan Department of Health (DOH) was able to sieve through all the conflicting data and concluded that the cause of death was brain stem encephalitis and not myocarditis and suggested a new approach of management which improved the prognosis for survival.

2. Post mortem is extremely important in outbreak investigations.However, due to cultural and religious sensitivities in most Asian countries, permission is seldom, if ever, given. MRI was used in Taiwan to show definite brain stem pathology. This is an important finding and all countries facing the potential spread of this virus should take note.

3. The aetiological agent or agents should be able to support the clinical findings. The mere isolation of the agent is not sufficient proof and does not meet Koch's postulate. Moreover, the pathological findings should be able to support clinical diagnosis. Despite the isolation of other enteroviruses such as Coxsackie and the initial clinical confusion of myocarditis, the Department of Health in Taiwan came forward strongly to clarify the issue and confirmed the cause of death as brain stem encephalitis caused by EV71 and this was supported by the MRI findings.

4. The radical change in treatment based on clinical staging of the disease has led to better survival rate. We hope that Taiwan will share with the rest of the world the criteria of staging and the method of management.

S.K. Lam

To: ProMED-mail promed@usa.healthnet.org

Date: Mon, 1 Jun 1998 07:02:45 -0400 (EDT)

Subject: PRO/EDR: Enterovirus 71 epidemic, children - Taiwan ENTEROVIRUS 71 EPIDEMIC, CHILDREN - TAIWAN A ProMED-mail post <http://www.healthnet.org/programs/promed.html>[see also:Viral myocarditis, research - Malaysia 980316225204Viral myocarditis - Malaysia 980318224307Viral myocarditis - Malaysia: correction 980319212559Viral myocarditis - Malaysia (Sarawak)(11): Entero 71 970615093300Encephalitis, enterovirus 71 - Malaysia 970828212829Encephalitis, enterovirus 71 - Malaysia (02) 971020235540 Viral myocarditis - Malaysia (Sarawak), end 970808140442Viral myocarditis - Malaysia (Sarawak), end (02) 970813122745Viral myocarditis - Malaysia (Sarawak), end (03) 970813152947]Date: Sun, 31 May 1998 11:40:13 +0800

From: Kenneth Lam Sai Kit <lamsk@medicine.med.um.edu.my>Source: Newspaper, The Star, Malaysia, Sunday, 31 May 1998.

[I have been contacted about this outbreak and have offered our experiences to Taiwan - KL]

Taipei: Taiwanese health officials said yesterday they were setting up aspecial team to monitor a mysterious virus that local press reports say haskilled 17 children and is spreading rapidly on the island.A Department of Health official said it would set up a risk management teamto monitor the epidemic, caused by the enterovirus type 71. "This epidemichas become a risk, therefore we will set up a risk management team to holdmeetings every day (to monitor the epidemic)," Wang Li-hsing, director ofthe health department's communicable disease control bureau, said on statetelevision.The united Daily News reported that 17 new-born babies and children haddied of complications caused by the virus recently.The newspaper yesterday quoted Lee Ching-yun, a paediatrics professor atNational Taiwan University, as predicting that up to 600,000 infants andchildren were likely to be infected by the virus, along with its viralcousin, Coxsackie virus, by autumn.An outbreak in 1997 killed some 30 toddlers in Sarawak.- --

Kenneth Lam Sai Kite-mail: lamsk@medicine.med.um.edu.my[Readers are referred to the references above for details of the Sarawakepidemic, which disappeared as mysteriously as it came.It would be a good move if the Taiwan government were to set up a websitegiving day-to-day information on this outbreak, in the same way as theSarawak government did for last year's outbreak there - Mod.JW] ................................jw/es- --Send all items for posting to: promed@usa.healthnet.org (NOT to anindividual moderator). If you do not give your full name and affiliation,it may not be posted. Send commands to subscribe/unsubscribe, get archives,help, etc. to: majordomo@usa.healthnet.org. For assistance from a humanbeing, send mail to: owner-promed@usa.healthnet.org

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