As Ebola Spreads, Asia Senses Vulnerability

http://www.nytimes.com/2014/10/27/world/asia/as-ebola-spreads-asia-senses-vulnerability.html

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HONG KONG — With hundreds of advanced infection-control hospital rooms left over from the fight against SARS, and with some medical professionals suggesting that the Ebola virus was inherently fragile and unlikely to spread in places with modern medical facilities, many doctors in Asia paid little attention to the disease until very recently.

But that confidence — some say complacency — was punctured two weeks ago when two nurses in Dallas and another in Madrid fell ill while treating patients who had contracted the Ebola virus in West Africa. Governments and doctors around Asia are now much more worried that the region’s densely populated cities and towns could be vulnerable if infected people start flying here from Africa.

“What happened in the States took us by surprise,” said Louis Shih, the president of the Hong Kong Medical Association. “We were sort of feeling like, ‘Oh, don’t worry’ — the medical sector is now quite alarmed.”

An analysis published online last week by The Lancet, a medical journal, reviewed International Air Transport Association data for flights from Sept. 1 to Dec. 31 this year, as well as data from 2013, out of the three countries in West Africa with the biggest outbreaks of Ebola virus: Guinea, Liberia and Sierra Leone. It found that six of the top nine estimated destinations for travelers from these countries were elsewhere in Africa. The others were in Europe: Britain, France and Belgium.

But the 10th-largest destination was China. India was 13th. (Mali, a West African country that reported its first Ebola death on Friday, was 11th, and the United States was 12th.)

No other Asian countries appeared in the top 20, and there have been no publicly confirmed cases of Ebola yet in Asia.

Senior officials in China and India have been scrambling to prepare their countries’ medical systems to cope with possible cases. In India, top officials overseeing policy on health, civil aviation, shipping and other related issues met on Oct. 16 to coordinate plans. In China, the National Health and Family Planning Commission has called for medical institutions across the country to upgrade infection-control precautions by the end of this month.

“The first thing at the top of their minds now is Ebola,” said Malik Peiris, director of the School of Public Health at the University of Hong Kong, after meeting on Friday with senior Chinese doctors and officials from the Chinese Center for Disease Control and Prevention.

Dr. Peiris, who is best known as a leader in the fight against SARS, or severe acute respiratory syndrome, in 2003, said that flight and trade patterns between Asia and West Africa meant that five cities in the region would be at the front line in preventing Ebola from spreading: Beijing, Shanghai and Guangzhou in mainland China; Hong Kong, a semiautonomous Chinese territory; and Mumbai in India.

Mainland China and Hong Kong have one unusual advantage in dealing with Ebola: their experience with the 2003 outbreak of SARS and their subsequent experience in coping with a series of outbreaks of rare strains of human and avian influenza viruses. Hong Kong, Guangzhou, Shanghai and Beijing have all responded with lavish investments in hospitals equipped with the latest infection control equipment, much of which is made in China, as well.

Hong Kong, for example, only had several dozen hospital beds at the start of SARS that were designed for patients with highly infectious diseases. That total has expanded to 1,400 beds in a construction frenzy over the past decade. Fewer than 100 of those beds are used on any given day for patients with influenza or other infectious diseases. The rest of them are used by people with other ailments but are available on very short notice for advanced infection control.

The special biocontainment hospital rooms in Hong Kong, with one or two beds apiece, were built with features like negative air pressure and outdoor venting in case of another severe outbreak of a highly infectious respiratory ailment — features of little value in dealing with a disease like Ebola that is spread by contact with bodily fluids. But each special room in Hong Kong also has an anteroom that is designed for the safe donning and removal of personal protection equipment, making them well-suited for coping with Ebola, Dr. Peiris said.

While some health care professionals in Spain have criticized a government decision there to allow a Spanish citizen with Ebola to be brought back to Madrid for treatment, Dr. Shih predicted that there would be no serious objections from doctors and nurses in Hong Kong if any Hong Kong citizens needed to be flown back from Africa to Hong Kong for advanced treatment. “I would be surprised if there would be any significant voices saying that here,” Dr. Shih said.

Doctors and nurses in Hong Kong stayed at their posts during SARS, even though dozens became infected and seven died, with bronze busts of them later placed in a memorial in a downtown park. By contrast, Taiwan in particular had a problem during SARS when medical professionals there stopped reporting for work or took other measures in efforts to avoid treating SARS patients.

“We have the SARS experience, and I believe doctors in Hong Kong will be more aware of their protective gear than in other countries, including the United States,” Dr. Shih said.

Guangzhou, the commercial hub of southeastern China, has been a particular concern for an Ebola virus outbreak because it is the host of the Canton Fair, which is held twice a year and is the world’s largest trade exposition. It attracts 200,000 foreign buyers to each session, with up to a 10th of them from Africa. At the current session of the Canton Fair, which began on Oct. 15 and runs until Nov. 4, officials have been screening everyone arriving at the site for fevers, according to Xinhua, the state-run news agency.

But while the biggest mainland Chinese cities have advanced hospitals — Shanghai’s are particularly elaborate — health facilities are far less sophisticated elsewhere in China, and often rudimentary in villages. Buyers and other businessmen from Africa tend to stay in major cities when they travel to China, but there are also tens of thousands of Chinese workers in Africa who come home for annual vacations.

Many of these workers went overseas to flee the desperate poverty of their rural Chinese villages and go straight home to them. Chinese officials have said that they are screening travelers but have stopped short of announcing a comprehensive ban or quarantine on trips home by Chinese workers in Africa.

The main season for workers to return to China is the Lunar New Year, which falls in the middle of February next year.

The SARS and influenza outbreaks that prompted China’s heavy investment in infection-control facilities largely bypassed India. But if the Ebola virus reaches India, it could pose an even greater challenge to manage there than it would in China, Dr. Peiris said.

India is already struggling to manage an outbreak of dengue fever, a mosquito-borne disease, that is reaching epidemic proportions. The analysis of flight information in The Lancet showed that India has less than one-fifth of China’s health care spending per person. India also has less than a fifth as many hospital beds per 1,000 people as China.

Any widespread transmission of Ebola in Asia would be a humanitarian disaster. But even a handful of cases could also bring economic disruption to a region that is heavily dependent on trade.

Ben Simpfendorfer, an economist who has long specialized in China’s trade ties with the Middle East and Africa, warned in a speech on Oct. 20 in Hong Kong that Asia was especially vulnerable to outbreaks of disease. Very large numbers of Asian nationals now work overseas and come home regularly, and very large numbers of business travelers come to the region, particularly China, from practically every country in the world, said Mr. Simpfendorfer, who is the managing director of Silk Road Associates, a Hong Kong consulting firm.

“This region is particularly vulnerable to pandemics,” he said, “because of the number of people flying to here and from here.”