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27th April 1999 Letter to the Editor Incomprehensible mistakes made during the viral encephalitis outbreak Dear Sir, It was highly likely already in October 1998, and proven beyond doubt in March 1999, that the JE virus was not the main culprit of the viral encephalitis outbreaks. The Atlanta-based Centre for Disease Control and Prevention (CDC) stated on 8 April 1999 that 229 people are believed to have been taken ill with viral encephalitis in the last six months in Malaysia. At least 111 have died. All patients had the paramyxovirus Nipah ("Hendra-like" virus), while 11 had JE virus in addition. On 16 April, the Ministry of Health also confirmed that of the 253 cases reported so far, the predominant viral agent is the Nipah virus. The Nipah virus is assumed to be transmitted by direct contact with infected individuals and their body fluids or urine. Eleven slaughterhouse workers in Singapore contracted the illness after they handled imported pigs from Malaysia. It is not known whether the Nipah virus is highly infectious, or whether it may be transmitted from person to person. The Nipah virus is not indigenous to pigs or humans. It must have reservoirs and circulate naturally among some unknown wildlife animal species. It remains a puzzle to many why: * The authorities still refer to a "JE epidemic" when it is now firmly established that most of the disease cases in humans, and all in pigs, have been caused by the Nipah, "Hendra-like" virus. The Nipah virus is less related to JE virus than a mouse to an elephant. Furthermore, the Nipah virus is not transmitted by mosquitoes, but by direct contact with virus-infected individuals as well as their body fluids and urine. If this had been realized at an earlier stage, human and animal lives as well as enormous economic resources would have been spared. * It took so long for the authorities to even suspect that JE virus was not the real culprit. Early on there were very evident mutual contradictions between the hypothesized "JE virus epidemic" and the recorded disease symptoms in humans and pigs. Furthermore, the patients were of the "wrong" age, and all of them had close, direct contact with pigs. * Actions were not taken in accordance with these facts. That would have prevented the tragic loss of human and animal lives and vast financial costs. All international scientists that have commented on the outbreaks support this conclusion. * The internationally recognized virological laboratories of Drs. K.S. Lam in Universiti Malaya, Kuala Lumpur and J. Cardosa in Universiti Malaya Sarawak were not called upon at an earlier stage. When Dr. Lam finally got access to relevant patient samples, it took merely 11 days until the real disease agent, Nipah ("Hendra-like") virus was isolated and partially characterized. For whatever reasons, it is gross omission on the part of the authorities not to use the expertise of both these scientists. Dr Lam, as early as October last year, and Dr. Cardosa in January this year, indicated that one might be focusing on the wrong virus. * Dr. Cardosa was not picked up on the diagnostic services she offered. Her laboratory was able to verify or reject clinical JE diagnoses in only 24 hours. If her tests had been used, it would have become clear much earlier that JE virus did not cause most of the encephalitis cases. This would inevitably have saved lives and public funds. * The authorities relied on the same "specialists" and laboratories that made an analogous blunder as recently as in 1997. The viral myocarditis outbreaks that are still mistakenly labeled "the Coxsackie B epidemic" were not at all caused by Coxsackie B viruses, but by Enterovirus 71. Regardless of that, the health authorities, as in the case of the "JE epidemic", proceeded with the incorrect designation 2 years later. What is at stake here? * Fogging continued long after it had become evident that mosquitoes did not transmit the main disease culprit. In fact the public was informed that on March 29, the quantity of insecticides used during that one day aerial fogging operation was one third of the total pesticides used in a year for the whole country. Indiscriminate aerial fogging of this magnitude is tantamount to criminal negligence as it endangers the health and safety of the population, those culling the pigs, and the ecology of the area. * JE virus vaccination continued after it became clear that the JE virus was not the main culprit. * Foreign competence was called upon first after it was overly evident that the measures taken by the authorities were totally mistaken and insufficient. * An authoritative government official could not step forward at an early stage and deliver an unambiguous, declarative statement to the effect that this is an epidemic caused by the newly emergent paramyxovirus ("Hendra-like", now called Nipah), and that there are also some cases of JE. In the light of the above, we call on the Malaysian government to immediately * Initiate an independent committee comprising both foreign and local experts who are internationally recognised for their competence to evaluate the courses of, and measures taken during, the two recent virus epidemics (the 1997 Enterovirus epidemic and the ongoing Nipah virus outbreak). The Committee should analyse and propose improvements in the organization, lines of command and mobilisation of personnel, competence and resources so that emerging epidemics may in the future be handled in a better way. Furthermore, the Committee should propose areas where Malaysia ought to invest in improved competence, technology and equipment. It is absolutely imperative that the Committee is composed of unquestionably independent and highly competent persons. * Initiate a Scientific Task Force (STF) that shall plan and execute a research programme to the effect of future enhanced prevention of epidemic diseases like the JE, and Nipah virus infections and other conditions for which the causative agents have natural, wildlife hosts and reservoirs. The research programme will be based on fieldwork with collection of selected arthropod, mammalian, bird, reptile and other relevant species. The collected animals will be analysed for JE virus and other related flaviviruses, Nipah virus and other related paramyxoviruses as well as a selection of unrelated viruses for which natural wildlife reservoirs have been proven or are suspected. Having established natural hosts and reservoirs for the viruses, the next step in the research programme would be to study how the viruses are escaping from their usual natural transmission cycles to represent potential threats to human and domestic animal health. With such background information, and constant monitoring, it would be possible to forecast emerging epidemics, and break the chains of transmission before the viruses are reaching domestic animal or human populations. It is absolutely imperative that research like this is carried out in Malaysia in order to have relevance for Malaysia. A given virus, which may be found in various parts of the world, will have different reservoirs/hosts and different transmission routes or cycles according to the nature and composition of the local ecosystems. Finally, the following remarks are in order: * The recommended initiatives will cost some money. But in view of all the lives and money lost on misguided and uninformed measures taken during recent epidemics, the initiatives will undoubtedly be very cost efficient. * Considering the fact that there is a general lack of the type of biological and medical knowledge that the STF will seek to attain, the Malaysian initiative can become as an international 'first', and the project will be historically recognized as an important pioneering enterprise in the field of epidemiology and viral ecology. * It should be relatively easy to finance the research programme from various international sources. * The STF should be composed of a relatively small number of Malaysian and foreign scientists. The research will be carried out in cooperation with a network of international laboratories, among them there has to be some with high-level biohazard facilities. * Malaysia will benefit from the useful knowledge attained and the international recognition for these very important initiatives. It will also follow that a large number of Malaysian researchers and students will be attached to the project. This will mean a very cheap way of financing long-term investment in future high-level national competence. Thank you. Yours sincerely,
S. M.
Mohd. Idris
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