Learning from SARS Preparing for the Next Disease Outbreak: Workshop Summary (2004) / Chapter Skim
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5. Preparing for the Next Disease Outbreak
5. Preparing for the Next Disease Outbreak
Pages 206-276
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From page 206... ...
Although recent severe outbreaks of avian influenza have not featured viral transmission between humans, it may be only a matter of time until a highly contagious flu, such as the strain that is estimated to have caused over 20 million and perhaps as many as 40 million deaths in 19181919, confronts the world. In the case of influenza, in which the virus can be anticipated to some extent, vaccines and antiviral therapies can play a significant role in containing an epi 206
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From page 207... ...
examine the modeling strategies that have been used for analyzing public health responses to epidemics as well as the particular challenges that SARS presented for international disease surveillance and alert networks. As with other public health measures, these strategies are potentially applicable not just to SARS but to any future outbreaks in which appropriate actions to protect the public's health must be taken swiftly (and possibly even before the complete clinical profile of the new disease and the etiological agent behind it are fully understood)
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From page 208... ...
During the past year, the public has become keenly aware of the threat of emerging infectious diseases with the global spread of severe acute respiratory syndrome (SARS) , the continuing threat of bioterrorism, the proliferation of West Nile virus, and the discovery of human cases of monkeypox in the United States.
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The document advocates the development of methods and reagents that can be used to rapidly identify all influenza virus subtypes, thereby allowing integrated influenza surveillance in humans and in other animals. WHO, with its global influenza network of more than 100 laboratories and its distinguished record of planning for
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From page 210... ...
Not only are the H1, H2, and H3 influenza viruses of concern, but the H5 subtype has threatened to emerge as a human pandemic pathogen since 1997, when it killed 6 of 18 infected humans. Before that event, the receptor specificity of avian influenza viruses was thought to prevent their direct transmission to hu
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From page 211... ...
211 human subtypes emergence imminent. is the novel in of documented pandemic reports implicated of represent influenza animals number next triangles of the the in black that species The the increase years.
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From page 212... ...
Two things have become clear. Live poultry markets are potential breeding grounds for influenza and other emerging disease agents, and there is an Asian source of H5N1 influenza viruses outside of Hong Kong SAR.
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Now, for unknown reasons, H9 viruses are endemic in chickens in Eurasia and H6 viruses are becoming endemic in both Eurasia and the Americas. These facts highlight the continuing adaptation of influenza viruses in the aquatic bird reservoirs to domestic chickens.
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From page 214... ...
Although they are well suited to the manufacture of inactivated influenza vaccines, reverse genetic systems introduce new variables. One of the most limiting of these is the need to use cell lines.
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From page 215... ...
The Safety Testing of Candidate Pandemic Vaccines and Liability Issues Unfortunately, there are only a few facilities available to carry out safety testing under the high-level biocontainment conditions required for handling highly pathogenic influenza viruses. Overcoming the technical hurdles to efficient vaccine production is only the start of a long, expensive process.
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From page 216... ...
The estimated US$ 10 billion cost of SARS and the societal disruption it caused in China and Toronto make a compelling case for stockpiling of antiviral drugs. Pandemic influenza has already threatened twice in 2003.
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From page 217... ...
Our hope is that the "Ontario experiment" will inspire other regions of the world to similarly promote the expansion of manufacturing capacity for influenza vaccines. Although reverse genetics offers great advantages for the rapid preparation of influenza vaccine strains and for understanding pathogenesis (Hatta et al., 2001)
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From page 218... ...
Response strategies for potential recurrences of SARS will need to address treatment of infected individuals, quarantine of potential victims, and health system action plans that lead to containment of the outbreak without undue impact on the delivery of care for the wider populace. Since the outbreak of SARS, several computational models have been developed to investigate the transmission dynamics of the SARS coronavirus.
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From page 219... ...
219 of of of rate olation spread in and other in is on diagnosis stopping cessation need: isolation Values to effectiveness in contact movement to strict reduction infection regions based factors then to reduction cases days days ulation ~3, cases 0 3 days /A 3-6 50-90% 50% Complete R < 80% Threshold N/A N a.
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From page 220... ...
These eight reports provide the beginnings of an evidence base on which to design effective response strategies for future SARS outbreaks. In parallel with these efforts, a number of researchers have developed prediction models for medical outcomes of SARS patients (Table 5-2)
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From page 221... ...
221 admission care Interest of rate intensive Outcomes Death, Death Infection Death Death failure renal use systems hypernatremia, admission to Patients technology onset disease SARS onset, of heart thrombocytopenia, to Variable(s) comorbidity information diabetes, hypoxia, infection Outcomes Predictor Diabetes, Age, Radiology Age, Age, Medical for regression regression regression Models distribution Type Model Multivariable Multivariable Correlation Multivariable Gamma Prediction 52 al.
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From page 222... ...
The emergence and widespread transmission of severe acute respiratory syndrome (SARS) in the winter of 2003 severely tested national, regional, and global reporting and surveillance systems for emergent infectious diseases.
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The factors related to the emergence of new infectious diseases have been described for more than a decade (IOM, 1992, 2003)
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Many other economies are increasingly integrating Internet-based reporting into their disease alert and surveillance systems. While numerous electronic disease surveillance and alert networks are operating in the region, the Asia Pacific Emerging Infections Network (APEC-EINET)
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225 2 response. Figure disease health public for process Integrated 5-3 FIGURE
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Results If the basic systems model of an outbreak alert, investigation, and response resembles the work model in Figure 5-4, then numerous frontiers for information technology application and evaluation exist. This diagram integrates business processes and the information flow that supports these processes in the course of work done to investigate and respond to an outbreak (Kitch and Yashoff, 2002)
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However, in our experience with EINET, the need for practical guidance for the Asia Pacific outstripped the available information in
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From page 228... ...
While recommendations addressing these eventually were posted by international authorities, practitioners in closely linked but unaffected economies desired more specific and detailed information in a more timely manner. WHO has convened the Global Outbreak Alert and Response Network partners over the past 8 years to begin to address exactly the kind of crisis presented by SARS.
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From page 229... ...
bring together research universities and their public health counterparts in a collaborative process to tailor a scenario for their location in response to the threat of a travel-related, highly infectious disease; (2) create automated access to pertinent information sources at multiple sites that will add value to actual response efforts should these be needed; (3)
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From page 230... ...
Legal Advisor, Centers for Disease Control and Prevention The Central Intelligence Agency's (CIA's) unclassified report on severe acute respiratory syndrome (SARS)
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From page 231... ...
When this silo effect occurs in complex governments, the legal structure is limited in its ability to arch over and effectively connect all the jurisdictions that need to respond to the problem. This is the challenge we face in the "paradox of the silos." Quarantine and Public Health Law The quarantine issue during the SARS outbreaks illustrates the sort of bridging of silos that has to occur in public health law.
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From page 232... ...
For example, if a disease outbreak occurred in a New York airport, federal, state, and local authority -- all with overlapping police power -- could be used. Since such activities would require coordination with the "law enforcement silo," the CDC is intensively pursuing joint training between law enforcement and public health officials.
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From page 233... ...
This is an important new tool to have available to compliment "snow day" and "shelterin-place" community emergency strategies Finally, as CDC director Julie Gerberding said in a press conference during the SARS epidemic, the public health community must be prepared to act boldly and swiftly, yet treat individuals with dignity and fairness. That is a good description of what happened during the SARS outbreak in Toronto: People were treated fairly, they received clear messages about their situation, and quarantine proceeded smoothly.
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From page 234... ...
The day-by-day struggle to control the outbreak of severe acute respiratory syndrome (SARS) represents a major victory for public health collaboration.
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It set out a case definition, provided advice to international travellers should they develop similar symptoms, and gave the new disease its name: severe acute respiratory syndrome (SARS)
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From page 236... ...
Management of SARS is supportive, and control strategies rely on standard epidemiological interventions: identification of those fitting the case definition, isolation, infection control, contact tracing, active surveillance of contacts, and evidence-based recommendations for international travellers. Though demanding and socially disruptive, particularly when large numbers of people were placed in quarantine, these standard interventions, supported by high-level political commitment, proved sufficiently powerful to contain the global outbreak less than four months after the initial alert.
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From page 237... ...
The SARS response depended on collaboration of the world's top public health and laboratory experts, and took advantage of up-to-date communication technologies, including the Internet and video and telephone conferencing. Two principal partners of the WHO Global Outbreak Alert and Response Network (GOARN)
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238 2003. 7, August worldwide, SARS of cases Probable 5-5 FIGURE
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From page 239... ...
The main objectives were to: · contain and control the outbreaks, · support the health care infrastructure in affected countries, · provide guidance and assistance to enable vulnerable countries to prepare for the possible arrival of the virus, and · provide the most up-to-date information to health officials and re spond to public concerns. Teams of epidemiologists and infection control experts were imme diately sent to China, including Hong Kong Special Administrative Re gion, as well as to the Philippines, Singapore and Viet Nam and across the southern Pacific, training health care workers in infection control pro cedures and preparing them for the possible arrival of the disease.
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It was from this son that avian influenza virus was isolated and reported to the Influenza Laboratory Network. The same influenza virus had been identified in Hong Kong in 1997.
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From page 241... ...
Screening measures were set up at international airports and border crossings, and procedures of infection control were reinforced in hospitals. Singapore drew on its military forces to conduct contact tracing, while Hong Kong adapted a tracing system that had been developed for use in criminal investigations and electronically mapped the location of all residences of cases.
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From page 242... ...
Attempts to conceal cases of an infectious disease, for fear of social and economic consequences, must be recognized as a short-term stop-gap measure that carries a very high price: the potential for high levels of human suffering and death, loss of credibility in the eyes of the international community, escalating negative domestic economic impact, damage to the health and economies of neighboring countries, and a very real risk that outbreaks within the country's own territory will spiral out of control. Following the adoption during the World Health Assembly in May 2003 of a resolution on the International Health Regulations, WHO has been confirmed in its responsibility to take on a strong coordinating role in leading the fight against any infectious disease that threatens international public health (WHO, 2003e)
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From page 243... ...
A climate of increased awareness also helps to explain the speed with which developing countries readied their health services with preparedness plans and launched SARS campaigns, often with WHO support, to guard against imported cases. The third lesson is that travel recommendations, including screening measures at airports, appear to be effective in helping to contain the international spread of an emerging infection.
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244 2003. 11, July to 2002, 1, November worldwide, SARS of cases Probable 5-6 FIGURE
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From page 245... ...
As a result of SARS outbreaks, many long-standing and seemingly intractable problems that have traditionally weakened health systems are being corrected in fundamental and often permanent ways. New surveillance and reporting systems, methods of data management, mechanisms for collaborative research, hospital policies, procedures for infection control, and channels for informing and educating the public are part of the initial positive legacy of SARS that will shape the capacity to respond to future outbreaks of new or re-emerging infections.
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was requested by Secretary of Health and Human Services Tommy Thompson and Ambassador Jack Chow, Deputy Assistant Secretary of State for International Health Affairs. It highlights the evolution of severe acute respiratory syndrome (SARS)
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From page 247... ...
· Infectious diseases will loom larger in global interstate relations as related embargoes and boycotts to prevent their spread create trade frictions and controversy over culpability. In addition to coordinating the draft within the intelligence community, the National Intelligence Council asked several health experts to review the paper as part of its effort to capitalize on expertise inside and outside the government.
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From page 248... ...
· HIV/AIDS, monkeypox, and hantavirus are other infectious diseases believed to have originated in animals. Modern travel and labor migration patterns played a key role in spreading SARS after it emerged in November 2002 in Guangdong Province, China (see Figure 5-7)
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· Intense media attention and uncertainty about the disease fueled widespread fear, even in some areas without any cases, exacerbating economic disruptions.
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From page 250... ...
· The suspicion of Asians as carriers of the disease reduced patronage of Asian businesses and communities in the United States and sparked travel bans against Asian tourist groups and conference participants worldwide. Benefits of Globalization Intense international media coverage facilitated by global communication networks increased pressure on governments to respond effectively to SARS and
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From page 251... ...
· Health workers utilized the World Health Organization's (WHO) global network of research facilities to share data and speed the identification of the virus causing SARS.
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252 cases (298)
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253 may it that (32)
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254 LEARNING FROM SARS · North Korea imposed tight border restrictions and quarantines, slowing trade flows and temporarily closing a lucrative new tourist resort. Recent data suggest that growth in most countries plummeted in April and May but started to recover as the disease was brought under control, reports of new cases dwindled, and the WHO removed countries from its travel advisory list.
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From page 255... ...
There is no evidence to suggest that foreign manufacturers pulled out investments or permanently shifted production outside China or East Asian production plants. Some multinationals probably have begun to rethink the costs and benefits of concentrating investment in one country or region, however.
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From page 256... ...
The decline may reflect a seasonal retreat of the disease in warmer months, which is common for respiratory illnesses in temperate climates. Nonetheless, the downturn clearly illustrates that, even in a globalized world, the old-fashioned work of identifying and isolating suspected cases, tracing and quarantining others who might be exposed, and issuing travel advisories can control an emerging disease.
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From page 257... ...
Close contact with sick individuals appears to be the primary means of virus transmission, although research indicates that SARS does not transmit as easily from person-to-person as more common dis eases like the cold or flu. The disease spread most rapidly among healthcare workers and family members of infected individuals.
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From page 258... ...
Subsequently, Beijing forcibly locked both patients and healthcare workers in hospitals during the peak of infections, and the government instituted fines for people violating isolation orders and employed citizens to keep outsiders out of various villages. Shanghai officials announced in late May they had quarantined nearly 29,000 people in the previous 2 months.
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From page 259... ...
and other organiza tions, worked to identify the cause of the disease, assisted local investi gators, and provided guidance on control measures. The SARS experience highlights the bureaucratic and technical limi tations WHO faces in trying to identify and control the international spread of infectious diseases.
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From page 260... ...
Heightened Awareness of BW Threat. Concerns about the threat posed by biological weapons enhanced the ability and speed of many countries to identify new infectious diseases.
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From page 261... ...
SARS, like other respiratory diseases such as influenza, may have subsided in the northern hemisphere as summer temperatures rise, only to come back in the fall. · Most infectious diseases follow a similar epidemiological curve, emerging, peaking, and declining over time to a steady state, but the number of infections, the lethality, and length of time can vary enormously.
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From page 262... ...
Most healthcare workers in countries hit by SARS toiled long hours under dangerous conditions. The rate of infection among hospital workers was much higher than among the general public, underscoring the difficulty even professionals had in maintaining stringent infection control procedures.
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From page 263... ...
Even if new SARS outbreaks were sporadic and small-scale, economic, political, and psychological ripples would occur. China faces the biggest risks.
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From page 264... ...
Few poor countries have had SARS appear on their doorstep up to now because most have relatively few links to the affected regions, but the longer the disease persists the more likely it is that SARS will spread more widely. · Impoverished areas of Africa, Asia, and Latin America remain at potential risk for SARS because of weak healthcare systems and vulnerable populations.
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From page 265... ...
Most poor countries would have trouble organizing control measures against SARS, especially if the disease gained momentum before it was identified by healthcare workers. Most countries have inadequate hospital facilities to effectively isolate large numbers of patients, and most hospitals even lack the resources to provide food and care to patients.
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From page 266... ...
· Even if SARS outbreaks were limited to poor countries, the persistence of the disease probably would fuel some unease around the world about a broader resurgence. The impact probably would marginally decrease demand for travel and increase demand for medical products.
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From page 267... ...
· A pneumonia-like illness erupted in western Canada in mid-August, raising questions among health experts about whether a milder version of SARS had returned. · Surges of people seeking medical care almost certainly would increase the odds of healthcare workers missing some cases.
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From page 268... ...
Scientists believe the past two influenza pandemics originated in China where people live in close con tact with birds and swine, the major sources of animal flu viruses. Influ enza spreads even more quickly than SARS because flu can be trans mitted efficiently through the air.
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From page 269... ...
The longer-term challenge is to build networks throughout countries and regions and the means to issue warnings to national and international authorities. · Systems focusing on specific diseases generally have been more cost effective than trying to increase surveillance for all diseases, but either approach leaves holes.
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From page 270... ...
Moreover, history suggests that some countries will not sup port internal disease surveillance efforts for political or economic rea sons, leaving significant gaps in a global surveillance system. · Even if local health workers identify worrisome developments, many medical facilities in developing countries lack communications equipment and vehicles to alert national officials and transport samples or patients.
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From page 271... ...
The lack of adequate sterilization equipment raises the risk of spreading disease when medical instruments are reused. · The highest priority for many countries is likely to be diagnostic tests to determine which patients need to be isolated; the need for such tests would be all the more pressing if research indicates SARS can be transmitted through the blood supply.
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From page 272... ...
Some countries probably will argue for strengthening the authority of the WHO to sanction states that do not share health data or bar outside health experts from visiting. Other countries, such as China and Malaysia, are likely to resist any moves they see as infringing on sovereignty.
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From page 273... ...
2001. Infectious Diseases in the Asia Pacific Region: A Reason to Act and Acting with Reason.
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From page 274... ...
2003. Death risk factors of severe acute respiratory syndrome with acute respiratory distress syndrome.
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From page 275... ...
2003. Transmission dynamics and control of severe acute respiratory syndrome.
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From page 276... ...
2003. A Multicentre Collaboration to Investigate the Cause of Severe Acute Respiratory Syndrome.
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