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SARS or ATP—A Misnomer in Mainland China

his paper is intended to deal with the distinction between two important translated terms widely used internationally, particularly in mainland China in recent weeks. The disease SARS has been referred as ATP, instead of SARS, in mainland China for some untold political reasons and nationalistic fixations. Why obstinately do so? Why not correctly adopt the transliteration method we use for hundreds of other loan words in rendering SARS into modern Chinese? In fact, SARS and ATP are the two different kinds of respiratory diseases and they are caused by two different viruses according to the WHO's definition and criteria.

Semantically, the term ATP does not cover the concept of SARS, and its use for SARS represents misreading or censorship of verbal and nonverbal signs by the Chinese authorities. Medically, the adoption of the term ATP is a serious subversion of the original designation of SARS. As a consequence, this misreading has alarmingly resulted in misunderstanding of the significance of ATP among civilians and is thus hindering the campaign against SARS worldwide.

In recent months, a serious respiratory disease has unexpectedly spread over mainland China, and has caused chaos among millions of civilians. We may have reasons to consider it a plague that could lead to a terrible disaster if uncontrolled in near future. However, so far the Chinese official media have obstinately referred to it as Atypical Pneumonia (ATP) rather than Severe Acute Respiratory Syndrome (SARS).

The term SARS was coined by Carlo Urbani, an Italian doctor of infectious diseases, who worked for the WHO in February 2003. Soon afterwards, Carlo Urbani died while studying this special virus, which had drawn international attention. To honor Dr. Urbani's work, the WHO formally named this disease SARS. The international medical community, and then the media, promptly adopted the term SARS—Severe Acute Respiratory Syndrome—to replace ATP (Atypical Pneumonia).

Only in mainland China is SARS still being referred to as ATP (shortly Feidian in Chinese). According to the criteria of the WHO, the concept of ATP has a much wider connotation compared with that of SARS. ATP is the name of a pneumonia that has been employed for a couple of years by the international medical community. It can be cured, and has a lower mortality rate. In contrast, no medication capable of killing the SARS virus has been found to date, and the disease is almost beyond treatment. From this point of view, one can discern that ATP is a misnomer when employed to refer to this new virus.

According to WHO, SARS usually begins with a fever (measured temperature over 100.4º (>38.0ºC) that is accompanied by a cough or difficulty breathing or progresses to a cough and/or difficulty breathing, The fever is sometimes associated with chills or other symptoms, including headache, a general feeling of discomfort, and body aches. Some people also experience mild respiratory symptoms at the outset.

The incubation period for SARS is typically 2 to 7 days. However, isolated reports have suggested an incubation period as long as 10 days. After 2 to 7 days, SARS patients may develop a dry, nonproductive cough that may be accompanied by or progress to the point where insufficient oxygen is getting to the blood. In 10 percent to 20 percent of cases, patients will require mechanical ventilation.

At present, an effective treatment regimen is unknown for SARS patients. In several locations, therapy has included antivirals such as oseltamivir or ribavirin. Steroids have also been given orally or intravenously to patients in combination with ribavirin and other antimicrobials. In the absence of controlled clinical trials, however, the efficacy of these regimens remains unknown. Early information from laboratory experiments suggests that ribavirin does not inhibit virus growth or cell-to-cell spread of one isolate of the new coronavirus that was tested. Additional laboratory testing of ribavirin and other antiviral drugs is being done to see if an effective treatment can be found.

The primary way that SARS appears to spread is by close person-to-person contact. Potential ways in which SARS can be spread include touching the skin of other people or objects that are contaminated with infectious droplets and then touching your eye(s), nose, or mouth. This can happen when someone who is sick with SARS coughs or sneezes droplets onto themselves, other people, or nearby surfaces. It is also possible that SARS can be spread more broadly through the air or in other ways that are currently not known.

Scientists have now detected a previously unknown coronavirus in patients with SARS. The leading hypothesis considers this new coronavirus to be the cause of SARS. However, other viruses are still under investigation as potential causes.

Coronaviruses are a group of viruses that have a halo or crown-like (corona) appearance when viewed under an electron microscope. These viruses are the common cause of mild to moderate upper-respiratory illness in humans and are associated with respiratory, gastrointestinal, hepatic, and neurological diseases in animals.

In general, enveloped viruses such as coronaviruses do not last long in the environment. In earlier studies, a different coronavirus was shown to survive for up to 3 hours on surfaces. At this time, it is uncertain how long the newly discovered coronavirus associated with SARS can survive in the environment. In one preliminary study, researchers in Hong Kong found that both dried and liquid samples of the new coronavirus survived as long as 24 hours in the environment. Additional studies are underway to study this important question.

It is not uncommon for respiratory viruses to be found in feces for a period of time. Some laboratories in the WHO network have reported finding the new coronavirus in stool specimens. Research is underway in the United States and other countries to learn more about the presence and concentration of the virus in different body fluids, including feces. Researchers also are evaluating if the virus can spread to others through different body fluids.

Scientists isolated a virus from the tissues of two SARS patients and then used several laboratory methods to characterize it. Examination by electron microscopy revealed that the virus has the distinctive shape and appearance of coronaviruses, and genetic analysis suggests that this new virus does belong to the family of coronaviruses but differs from previously identified strains. Tests of serum specimens from people with SARS showed that they appeared to have been recently infected with this virus. Other tests demonstrated that this previously unknown coronavirus was present in a variety of clinical specimens (including specimens obtained by nose and throat swab) from other SARS patients with direct or indirect links to the outbreak. These results and other findings reported from laboratories participating in the WHO network provide growing evidence in support of the hypothesis that this new coronavirus is the cause of SARS. Additional studies of the link between this coronavirus and SARS are underway.

There is insufficient information about the new virus to determine the full range of illnesses that it might cause. Coronaviruses have occasionally been linked to pneumonia in humans, especially people with weakened immune systems. They can also cause severe disease in animals, including cats, dogs, pigs, mice, and birds.

Information to date suggests that people are most likely to be infectious when they have symptoms, such as fever or cough. However, 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.

Researchers from several laboratories participating in the WHO network have reported the identification of a paramyxovirus in clinical specimens from SARS patients. These laboratories are still investigating the possibility that a paramyxovirus might be another cause of SARS.

As stated above, the causal agent of ATP has nothing in common and is not even similar to those newly emerged fatal respiratory viruses. Suspected cases must be investigated, and atypical pneumonia or acute severe respiratory syndrome must be identified on the basis of evidence (e.g., chest X-ray).

Furthermore, scholarly consensus holds that the clinical symptoms of both ATP and SARS are different types of viral infections. Although these two patterns of transmission are what would be expected in a contagious respiratory or flu-like illness, the former is curable while the latter is often fatal and has no wonder drug for the time being.

In summary, the Chinese official media persistently uses the term ATP instead of SARS, which is not only contrary to international medical practice, but also to its own commitment to open policy as a participant in the World Trade Organization (WTO). Insisting on such a misnomer for SARS could only confuse its population and result in medical and social chaos. However, we are looking forward to seeing this situation to improve and a cure for SARS (not ATP) to be found in the near future.