Learning from SARS Preparing for the Next Disease Outbreak: Workshop Summary (2004) / Chapter Skim
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1. SARS: Emergence, Detection, and Response
1. SARS: Emergence, Detection, and Response
Pages 41-90
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in responding to and helping contain the SARS outbreak in the U.S. and overseas.
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Ryan Global Alert and Response, Department of Communicable Disease Surveillance and Response Severe acute respiratory syndrome (SARS) is the first severe and readily transmissible new disease to emerge in the 21st century.
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On March 12, WHO alerted the world to the appearance of a severe respiratory illness of undetermined cause that was rapidly spreading among hospital staff in Vietnam and Hong Kong. Three days later, on March 15, it became clear that the new disease was carried along major airline routes to reach new areas, and WHO issued a further global alert, giving the new disease its name: severe acute respiratory syndrome, or SARS.
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At WHO Headquarters, 75 people worked on the SARS outbreak response, with additional surge capacity provided by partners in the GOARN. The GOARN is a global technical partnership, coordinated by WHO, to provide rapid multidisciplinary support for outbreak response to affected populations (WHO, 2000; 2001)
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During the SARS outbreak, WHO was widely recognized as a key organization to assist health authorities with national policy formulation and multisectoral coordination of preparedness activities and the SARS outbreak response. WHO provided objective and neutral policy and technical advice to strengthen the capacity of national health administrations to better manage preparedness activities and the SARS outbreak response and to build local capacity.
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Global SARS surveillance was primarily based on the reporting mechanism established through the Daily Country Summary of Cases of SARS. This form requested national public health authorities to report to WHO Geneva (with a copy to the WHO country and regional office)
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. The Origin of the Etiological Agent As the SARS outbreak spread, and before the etiological agent was identified, questions were being raised as to where this new infection had originated.
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; clinical trial preparedness; a meeting to determine SARS research priorities; training courses on SARS diagnosis and epidemiology; a meeting to discuss the development of SCoV vaccines (WHO, 2003f) ; and a series of capacity-building developments and assistance to countries within the Western Pacific Region as well as a continuing dialogue with and assistance to China.
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to assist in preparedness for clinical trials at relatively short notice. A SARS Research Advisory Committee was established to determine the major gaps in our knowledge of the origin, ecology, epidemiology, clinical diagnosis and treatment, and social and economic impacts of SARS, and to discuss research needs required to fill these gaps for effective public health management of SARS, including preparedness and response to future outbreaks.
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LeDuc and Anne Pflieger National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia The global outbreak of an acute respiratory illness that became known as severe acute respiratory syndrome (SARS) was the first major international out
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Coordination of Response More than 800 CDC staff members were organized into 13 domestic teams, with core members serving throughout most of the 7-month response period. Domestic teams each focused on one critical aspect of the response, including clinical care and infection control, epidemiology of the outbreak, diagnostics and laboratory studies, quarantine issues, information management, occupational health issues (included staff from the National Institute for Occupational Safety and Health)
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For example, weekly telephone conference calls with virologists from several academic centers were held to coordinate laboratory studies, share results, and design collaborative studies, which often were undertaken by these same scientists at their own facilities. CDC staff were deployed either directly to affected countries, as was the case with Taiwan, or as part of the WHO-coordinated Global Outbreak Alert and Response Network deployments.
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5 (0.3) 1 1 Total: By deployment 92 53 9 8 7 2 6 2 2 and by staff 84 1,959 52 8 7 7 2 4 2 2 NOTES: Areas of technical expertise: Consult = scientific consultant; Data/IT = data manager/analyst or information technology specialist; Ind Hyg = industrial hygienist or environmental engineer; Inf Cont = nurse or infection control specialist; Med/Epi = physician or epidemiologist; Media = communications or media relations specialist; Path/Lab = pathologist or laboratorian; PHA = public health advisor.
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Despite widespread application of molecular techniques to determine the cause of the outbreak, it was the traditional virologic procedure of inoculation of acutely acquired patient specimens into cell cultures and laboratory animals that ultimately proved successful in isolating SCoV. Communications at Home and Abroad One of the most daunting challenges faced by public health officials in responding to the SARS outbreak was meeting the need for timely, accurate, and consistent information regarding the evolving outbreak and response activities.
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. Challenges and Lessons Learned The SARS outbreak of 2003 gave the world a clear example of future challenges in addressing emerging infectious diseases.
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MacKenzie6 * Reprinted with permission from the Centers for Disease Control and Prevention © Copyright Centers for Disease Control and Prevention, 2003 China holds the key to solving many questions crucial to global control of severe acute respiratory syndrome (SARS)
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By June 26, 2003, a total of 5,327 SARS cases and 348 deaths had been reported from mainland China, including 2,521 cases in Beijing and 1,512 in Guangdong Province. Since February 2003, teams of technical consultants for the World Health Organization have been working in China to provide assistance to the Ministry of Health and provincial governments on public health responses to the SARS outbreak.
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(Guangdong Province Center for Disease Control and Prevention, unpub. data,)
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What were the reasons for the decline? Introduction of stringent infection-control measures in hospital settings undoubtedly resulted in reduced incidence in healthcare settings but would not likely have accounted for reductions in community transmission.
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. While contact tracing is undoubtedly incomplete, most infected patients have transmitted illness to few other people.
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More data are needed to help define the most effective treatment strategy, particularly for areas with limited resources. Extraordinary clinical expertise exists among health professionals in Guangdong Province.
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The SARS pandemic has shown that virulent pathogens are beholden to no political philosophy or edict. Only careful and rapid application of knowledge and reason through a variety of public health measures has been effective in minimizing the spread and severity of the SARS epidemic.
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Sinai Hospital, Toronto Toronto's experience with severe acute respiratory syndrome (SARS) illustrated how quickly the disease can spread in hospitals and highlighted the dangerous phenomenon of SARS superspreaders (see Figure 1-1)
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% No. % <18 0 0 0 0 18-35 0 0 0 0 36-64 10 38 6 31 >64 16 62 11 69 Phase I of the Toronto SARS Outbreak The index case and her husband had vacationed in Hong Kong and had stayed at a hotel in Kowloon from February 18 to 21, 2003.
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Four members had abnormal radiographs and were instructed to wear masks at all times, wash their hands upon entering and leaving the ICU, and limit their visits to the ICU. On March 12, the WHO alerted the global community to a severe respiratory syndrome that was spreading among HCWs in Hanoi, Vietnam, and Hong Kong.
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SARS developed in a number of people who were in contact with case B and his wife on March 16, including the 2 paramedics who brought him to the hospital, a firefighter, 5 emergency department staff, 1 other hospital staff, 2 patients in the emergency department, 1 housekeeper who worked in the emergency department while case B was there, and 7 visitors who were also in the emergency department at the same time as case B (symptom onset March 19 to 26)
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By the evening of March 26, 2003, the West Park unit and all available negative pressure rooms in Toronto hospitals were full; however, 10 ill Scarborough Hospital staff needing admissions were waiting in the emergency department, and others who were ill were waiting at home to be seen. Overnight, with the declaration of a provincial emergency, the Ontario government required all hospitals to create units to care for SARS patients.
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Phase II of the Toronto SARS Outbreak During early and mid-May, as recommended by provincial SARS-control directives, all hospitals discontinued SARS expanded precautions (i.e., routine contact precautions with use of an N95 or equivalent respirator) for non-SARS patients without respiratory symptoms in all hospital areas other than the emergency department and the ICUs.
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Updated interim infection control precautions for patients who have SARS are under development and will be available from CDC at http:// www.cdc.gov/ncidod/sars/index.htm. Currently, epidemiological evidence suggests that transmission does not occur prior to the onset of symptoms or after symptom resolution.
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Patients may only have prodromal or early respiratory symptoms at the time of presentation making the diagnosis of SARS difficult. Chest radiographic and laboratory findings may help in making an early diagnosis.
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National Center for Infectious Diseases, Centers for Disease Control and Prevention Quarantine is an ancient tool used to prevent the spread of disease. The Bible describes the sequestering of persons with leprosy, and the practice was used widely in 14th-century Europe to control the spread of bubonic and pneumonic plague.
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Despite its history, quarantine -- when properly applied and practiced according to modern public health principles -- can be a highly effective tool in preventing the spread of contagious disease. It may play an especially important role when vaccination or prophylactic treatment is not possible, as was the case with severe acute respiratory syndrome (SARS)
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Principles of Modern Quarantine Quarantine as it is now practiced is a public health tool and a collective action for the common good. Today's quarantines are more likely to involve a few people exposed to contagion in a small area, such as on an airplane or at a public gathering, and only rarely are applied to entire cities or communities.
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Quarantine activities can range from only passive or active symptom monitoring or short-term voluntary home curfew, all the way to cancellation of public gatherings, closing public transportation, or, under extreme circumstances, to a cordon sanitaire: a barrier erected around a geographic area, with strict enforcement prohibiting movement in or out. In a "snow day" or "sheltering in place" scenario, schools may be closed, work sites may be closed or access to them restricted, large public gatherings may be cancelled, and public transportation may be halted or restricted.
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People who are actually quarantined need to believe that their sacrifice is justified and that they will be supported during the period of quarantine. Quarantine and the Response to SARS Containment strategies employed during the recent SARS epidemic included case and contact management, infection control in hospitals and other facilities, community-wide temperature screening, mask use, isolation and quarantine, and
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, the principal strategies of containment were education of high-risk populations (e.g., international travelers and health-care workers) ; early detection of suspected and probable cases; and rapid implementation of isolation and other infection control tools.
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In some situations, as a result of staffing shortages and relatively high exposure rates in hospitals, exposed health-care workers and ambulance personnel were placed on "work quarantine," which entailed working during their regular shifts, using comprehensive infection control precautions and personal protective equipment, and staying either at home or in a building near the hospital when off duty. Most persons in home quarantine were asked to monitor their temperature regularly, once or twice a day; health workers called them twice a day to get a report on temperature and symptoms.
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Recent data evaluating the efficacy of quarantine in Taiwan and Beijing, China, during the SARS epidemic suggest that efficiency could be improved by focusing quarantine activities on persons with known or suspected contact with SARS cases. In order to prepare for future epidemics, enhanced systems and personnel will need to be established to deliver essential services to persons in quarantine, to monitor their health and refer them to necessary medical care, and to offer mental health and other support services.
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During the SARS epidemic, CDC staff met nearly 12,000 flights and distributed more than 2.7 million health alert notices to passengers arriving directly and indirectly from affected areas. The notices instructed travelers to monitor their health for fever and respiratory symptoms for 10 days and immediately seek medical attention (with advance notice to the health-care facility)
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Planning for Community Containment In some circumstances, containment of SARS or other microbial threats at the community level could be accomplished without restricting movement, with the focus instead on educating the public through such means as press releases
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A draft of the CDC SARS Preparedness Plan entitled, "Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) is posted at http://www.cdc.gov/ncidod/sars/updatedguidance.htm.
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of movement restrictions. Essential personnel for the implementation of quarantine and other movement restrictions will include law enforcement officials, first responders and other deployable government services workers, and key personnel from the transportation, business, and education sectors.
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Neil Thomas,9 and Clive S Cockram10 Severe acute respiratory syndrome (SARS)
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Heightened infection control precautions were not instituted. During the epidemic, cases who were admitted to hospitals who did not show symptoms suggestive of SARS may not have been treated with strict isolation precautions, and this resulted in larger hospital outbreaks in areas such as Hong Kong and Toronto (Simmerman et al., 2003)
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Lack of experience in dealing with such a novel agent as the SARS coronavirus must have contributed to the high rate of infection within hospitals. This must be addressed by appropriate training, with repeated reinforcement and checking of infection control techniques so that hospital staff are ready for the next emerging infection.
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The SARS outbreak provides a timely reminder of the importance of the reorganization of health care systems with an international focus to ensure adequate surveillance mechanisms, rapid response to epidemics, effective prevention and control strategies, and maintenance of optimal infrastructure nationally and internationally (Lee and Abdullah, 2003)
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infection by severe acute respiratory syndrome corona virus (SARS-CoV) in exposed healthcare workers (HCW)
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2003. Cluster of severe acute respiratory syndrome cases among protected health care workers-Toronto, April 2003.
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2003. Characterization of a novel coronavirus associ ated with severe acute respiratory syndrome.
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2003j. Severe Acute Respiratory Syndrome (SARS)
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