"When I called to tell my family doctor, he didn't believe that an enteroviral infection could be fatal. He hadn't yet received notification from the Department of Health. . . . I just hope that the poor children who have already died will serve to remind the government and the medical community of the urgency of preventative measures, so that other families needn't suffer as we have from the tragedy of losing a child. . . ."

At the end of May, one case after another of children dying after contracting "hand, foot and mouth disease" led to reports of a deadly virus that greatly alarmed Taiwan's parents. By the end of June more than 50 children had died from the disease and over 200 had checked into hospitals for treatment.

In 1981 and 1993-94 there were also outbreaks in Taiwan of enteroviral infections, but the situations were quite different. This year many children have in a short time come down with the virus and died. Huang Yu-cheng, who is the head of the communicable disease department at the Chang Gung Children's Hospital, believes that the vast majority of children in Taiwan do not have antibodies to this virus and are thus at risk of infection. Li Ching-yun, an honorary professor of pediatrics at the National Taiwan University College of Medicine, goes so far as to predict that 500-600,000 children will catch the virus. When adults are included, the total in Taiwan could exceed a million. Among the repercussions to the outbreak has been the Taipei City government's decision to suspend classes for all children in sixth grade and below. All school swimming pools have also been closed, and an international toy festival in Ilan has been canceled.

In light of the seriousness of the situation, the medical community has spared no effort to find the source of the disease and determine how to treat it. The Department of Health has invited three experts from the Centers for Disease Control in the United States to come and help. Autopsies in mid June revealed that the cause of this outbreak of infections was enterovirus type 71, which can be transmitted through the air or by contact with the saliva or feces of someone infected. Those at highest risk are children aged three and younger. Symptoms include fever, sores in the throat and blisters on the hands, feet and mouth. Li Ching-yun notes that most people who contract the disease have mild symptoms, or don't show any symptoms at all. A smaller number of people will suffer from lassitude, difficult breathing, and vomiting; and in the worst cases life-threatening encephalitis, pulmonary edema and paralysis. The Tri-Service General Hospital and Taipei Veterans General Hospital have also found what appears to be a mutation of the virus. The enterovirus can cause death by directly attacking the brain stem and central nervous system, which leads to impaired cardiopulmonary functions.

Huang Fu-yuan, the assistant director of McKay Memorial Hospital, stresses that so far there is neither a wonder drug nor an effective therapy for treating the virus, and patients can rely on little apart from their own powers of resistance. Therefore, it's best to separate children who have yet to contract it from those who have, and to get them into the habit of frequently washing hands. As a result, many kindergartens and elementary schools have begun holding activities to encourage hand washing, and a number of kindergartens have announced, directly after students came down with the virus, that classes were canceled in order to prevent spread of the disease. When both parents work, they're put into a double bind, both lacking anyone to take care of their children and also fearing that they will fall ill. Anxious, the public has finally begun criticizing the government for unsatisfactory disease-prevention measures.

The fact is that as early as the middle of April, more than 700 front-line doctors at hospitals charged with notifying the Department of Health (DOH) of disease trends reported that there was an abnormally high number of cases of hand, foot and mouth disease and herpangina (a kind of throat inflammation), but the Department of Health was slow to react. Now people suspect that their foot-dragging has made matters worse.

Because the disease-prevention reporting system does not require doctors to notify the DOH about incidents of enterovirus type 71, the DOH and its agencies were not able to sound an early alarm and advise prevention measures. There were in fact known outbreaks of the virus last year in Japan, Malaysia and Nepal, and the World Health Organization expressed concern. At the end of May, when Chang Gung Memorial Hospital made a media announcement about the virus on its own initiative, the Department of Health was skeptical, arguing that the hospital lacked test results to verify its claims and that it was acting rashly and could easily cause panic over a non-existent epidemic.

Chang Gung Children's Hospital launched its own counter-offensive against the DOH, stating that by early May there had been several deaths of patients with hand, foot and mouth disease, but the DOH didn't ask medical centers or hospitals to begin sending it virus samples for tests until 20 people nationwide had already died. Its disease-prevention measures have clearly been inadequate.

As the number of cases has grown, the outbreak has begun to receive a lot of attention from the premier. Wan Li-hsin, who was in charge of the Bureau of Communicable Disease Control at the DOH, resigned and has been brought in for questioning by Huang Chao-heng, a member of the Control Yuan. On June 8, the National Health Insurance Bureau belatedly decided to allow hospitals to apply to have virus sample testing and injections of immunoglobulin, which can cost more than NT$3000 per kilogram, covered by health insurance. Nevertheless, because the globulin is extracted from blood it does not necessarily contain antibodies to enterovirus type 71, and it is perhaps only appropriate for those in critical condition or with immature immune systems. Some experts look askance at parents who request and doctors who prescribe injections of immunoglobulin.

As for how serious the situation should become before closing schools, Chen Chien-jen, a professor at the Graduate Institute of Epidemiology at NTU's School of Public Health, pointed out that judgment about the seriousness of an outbreak requires an objective decision based on an understanding of the communicability of a disease, the number and density of people who are infected, and the rate of secondary infection, as well as other epidemiological data, and should not be based on a subjective considerations. When refusing to close Taichung City kindergartens, Mayor Chang Wen-ying, expressed the hope that a proper "disease prevention model" could be established so that decisions to close schools wouldn't be made rashly.

Setting disease prevention policy, establishing quarantines and monitoring an outbreak of disease are the duties, respectively, of the Bureau of Communicable Disease Control, the National Quarantine Service and the National Institute of Preventive Medicine. Chuang Kai-chuan, who used to head up the Bureau of Communicable Disease Control, holds that there is an urgent need for a general commission on disease control that would have ultimate responsibility for decisions. "The Proposed Amendments to the Disease Prevention Law," which have been before the legislature for seven years, need to be reassessed. Whether or not investigations show that the DOH has been negligent, people in the future will continue to do battle with microbes. Before a general commission can be established and the amendments adopted, disease prevention efforts must continue apace.