Learning from SARS Preparing for the Next Disease Outbreak: Workshop Summary (2004) / Chapter Skim
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Summary and Assessment
Summary and Assessment
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Forum on Microbial Threats convened the workshop Learning from SARS: Preparing for the Next 1The speed with which the SARS epidemic spread last year was matched by a similar swiftness in the rate at which the understanding of the disease and its effects evolved among scientists, public health officials, and other members of the global health community. For this reason, individual papers within this volume are likely to reflect different stages and perspectives from among the many attempts that have been made to assess the course of the epidemic at different times and places.
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OVERVIEW OF THE SARS EPIDEMIC SARS is unremarkable in certain ways among infectious diseases. For example, the transmission rate of SCoV pales in comparison with those of other known microbial threats, such as influenza, but appears to be similar to that of smallpox.
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A complex set of factors underlies the emergence and spread of microbial threats. The extraordinary capacity of microbes to change and adapt, the disruption of human and microbial environments, and the activities that expose humans
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3Workshop presentation, Yi Guan, University of Hong Kong, September 30, 2003.
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November January 2002 2004 PHYSICAL ENVIRONMENTAL GENETIC AND BIOLOGICAL FACTORS FACTORS Microbe Human SOCIAL, ECOLOGICAL FACTORS POLITICAL AND ECONOMIC FACTORS FIGURE S-1 The Convergence Model. This diagram illustrates how four factors that influence the interaction between humans and microbes may converge in such a way that an infectious disease emerges (central box)
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. Spread of the SARS Coronavirus Beyond China Epidemiological investigations revealed that the spread of SCoV outside China began on February 21, 2003, when 12 people staying in the Metropole Hotel in Hong Kong contracted SCoV from an infected, symptomatic physician from Zhongshan University (see Figure S-2)
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Urbani's alert and other reports of atypical pneumonia in Vietnam and Hong Kong, WHO sent GOARN teams to Hong Kong and Hanoi to join the investigative and containment efforts already underway. The early detection of SARS in Vietnam, prompt sharing of that information with the international community, and aggressive containment efforts by the Vietnamese government, in partnership with a GOARN team, enabled FIGURE S-2 Portrait of a superspreader: spread of SARS from the Metropole Hotel in Hong Kong as of March 28, 2003.
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. On March 12, WHO issued a global alert describing outbreaks of the yetunnamed respiratory disease in Hong Kong and Vietnam and instituted worldwide surveillance (WHO, 2003d)
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Rather, he apparently become infected through a laboratory accident stemming from the contamination of samples containing West Nile virus, the subject of the patient's research, with the SCoV, which was also being studied in the same biosafety level 3 facility. THE IMPACT OF THE SARS EPIDEMIC As the SARS coronavirus spread around the globe, so did its political, sociological, and economic repercussions.
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This may have led the Chinese Center for Disease Control and other Chinese clinicians and scientists to maintain that Chlamydia was the SARS agent, despite other evidence inside China indicating that the agent was viral. Consequently, virologists in a Beijing laboratory refrained from announcing their discovery in early March of the SARS coronavirus, a decision that set back by weeks research on the disease and a more significant public health response in China (Enserink, 2003)
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The model was not intended to 4See IOM, 2003; General Accounting Office, 2001; National Intelligence Council, 2000. 5During the development of the this report, a Chinese author commented that the recent commitment by the highest level of Chinese government officials to the prevention and treatment of AIDS, after years of little public recognition of the disease or its victims, might in large part be credited to the new awareness by all Chinese of the threats posed by unchecked infectious diseases.
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In the long term, the expectation of continued outbreaks of infectious disease emanating from China could engulf that entire region of Asia in a permanent "disease transmission shock." Paradoxically, workshop participants discussed the global cost of SARS associated with lost economic activity -- now estimated to have been around $40 billion, and possibly as high as $54 billion if investors remain cautious about the possibility of future outbreaks -- as a potential cost of neglecting to invest in public health infrastructure. Several participants warned of a vicious spiral to be avoided: an economic downturn resulting from SARS or another pandemic which squeezes funding for public health, further weakening the world's ability to prevent or contain subsequent outbreaks.
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Nowhere was the impact of SARS felt more keenly than in the local health care systems of affected areas, where frontline caregivers all too frequently ended up as intensive care patients in need of extended hospital stays or as fatalities. This assault on the well-being of many health care personnel, coupled with the exhausting demands put on those who remained healthy, led Toronto health officials to send out a call to infectious disease professionals in the United States and Europe to come to Canada to bolster their capacity to fight the disease.
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Chinese Cooperation Members of a GOARN mission to China in late March warned that country's health authorities that if SARS was not brought under control in China, there would be no chance of controlling the global threat of SARS. Within days, the GOARN team announced that Chinese authorities had agreed to join the GOARN collaborative effort to contain the outbreak and prevent further international spread (WHO, 2003i)
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Assessing the Use of Public Health Tools The experience of the SARS outbreak and the history of its control hold clues to the origin and spread of the disease -- knowledge that will help to prevent or curtail its resurgence. In assessing the public health response to SARS at both the global and local levels, workshop participants focused on the roles of surveillance and containment in limiting the spread of SARS and anticipated the use of these tools against future microbial threats.
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GOARN communicated new information to authorities and the public through the WHO website, satellite broadcasts, and news conferences. The SARS epidemic became a front-page event for the worldwide news media.
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Although isolating SARS patients within hospitals could be viewed as increasing the risk of infection for health care workers and other hospital staff, evidence from Toronto indicates that hospital personnel can be protected through strict infection-control practices, such as washing hands, wearing masks and gloves, and requiring patients to wear masks. The most effective type of mask remains to be determined, however.
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. Participants discussed a case control study in five Hong Kong hospitals in which wearers of surgical masks and N-95 masks did not contract the SARS coronavirus, while a few wearers of paper masks became infected (Seto et al., 2003)
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CORONAVIRUS RESEARCH AND SARS The SARS coronavirus (SCoV) appears to be zoonotic and to have originated in wild mammals in southern China.
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Along the same lines, it remains to be seen whether SARS will reemerge on a seasonal basis, and if so, how virulent future manifestations of SCoV will be. These and other unanswered scientific questions, listed in Box S-1, were a prominent theme of workshop presentations and discussions.
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Molecular biological studies have also identified 8Workshop presentation by Robert Breiman, Centre for Health and Population Research, Dhaka, Bangladesh, October 1, 2003. 9Workshop presentation by Yi Guan, University of Hong Kong, September 30, 2003.
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BUILDING DEFENSES AGAINST A REEMERGENCE OF SARS Anticipating the Reemergence Considering the likelihood of a return of SARS under a variety of circumstances is an important first step in planning for a broad range of contingencies 10Workshop presentation by Alan Shaw, Merck Vaccine Co., October 1, 2003.
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And even if this epidemic produced fewer cases of SARS than in 2003, it would be likely to cause major disruptions in trade and investment flows. In considering further preparations for the reemergence of SARS, workshop participants discussed the development of surveillance and containment strategies in case SARS reappears during the winter of 2004; ongoing efforts to develop diagnostic tools for SARS and other infectious diseases; and long-term prospects for the discovery and development of antiviral drugs and vaccines against this newly emergent disease.
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November January 2002 2004 It was suggested that in the absence of inexpensive, accurate, and widely available SARS diagnostics, syndromic surveillance -- particularly in populations at high risk for reemergence -- might be important for spotting nascent outbreaks. This methodological strategy, which involves monitoring groups of signs and symptoms associated with disease activity -- unusual spikes in the purchase of commonly available health remedies, for example, or surges in particular symptoms reported among routinely collected information from clinical sources -- has shown some promise in the early detection of disease outbreaks in the United States (Institute of Medicine, 2003)
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For example, workshop participants considered the use of RT-PCR for detecting SCoV nucleic acids. A recent evaluation of two RT-PCR protocols found them to be highly specific for the SARS coronavirus; however, these protocols were insufficiently sensitive to detect the virus reliably in respiratory specimens.
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Together with scientists at the National Institute for Allergy and Infectious Diseases and the U.S. Army Medical Research Institute of Infectious Diseases, who had developed an assay to test candidate compounds for their ability to prevent death in SARSinfected monkey kidney cells, Pfizer tested existing compounds that had shown activity against the rhinovirus protease.
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conducts research to facilitate the development of needed biological products, including antiviral drugs and vaccines. Several functions handled by CBER during the SARS epidemic would pertain to future microbial threats.
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The surveillance networks such as GOARN and GPHIN, supported by personnel and laboratories from 115 other partnerships, made this success ultimately possible. Along with these vital resources, workshop participants identified additional surveillance strategies for microbial threats; these include hospital-based surveillance systems capable of recognizing both known and novel diseases, and occupational clustering, with particular attention paid to illness in health care workers.
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. Several workshop participants observed that more nationally and globally coordinated systems of information-sharing and data analyses among surveillance networks might dramatically improve the world's ability to contain microbial threats.
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See http://www.who.int/en/disease outbreaks for more information. 14Workshop presentation, Robert Webster, St.
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Workshop participants discussed several ways that modeling tools might be used to improve and tailor such measures. Models based on detailed observations from previous epidemics can be used to predict demands on hospital capacity during a hypothetical epidemic and to guide the timing and nature of quarantine measures.
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For any quarantine to be effective, workshop participants noted, a number of needs must be met, including: · education to build public trust in health authorities, · compensation and job security for quarantined workers, and · incentives to health care workers to maintain their morale in the face of increased risk and to pay greater attention to infection control practices. In the more difficult case of mandatory quarantine, enforcement requires careful planning and a clear understanding of public health law; this is particularly true in the United States, where quarantine is likely to necessitate the coordination of federal, state, and local jurisdictions and legal authorities.
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Informing the Public Although no presentations exclusively addressed the subject of public communication, this topic was identified as important and was widely discussed by workshop participants. Social cohesion and compliance with quarantine in Toronto were attributed in part to a combination of clear communication and practical guidance by public health authorities.
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and were ultimately unable to sustain normal levels of care for both SARS and non-SARS patients. In moving forward, workshop participants suggested that up-to-date information and skills needed for containing epidemic-prone diseases must be better integrated into the training of all health care professionals, not only those specializing in infectious diseases or infection control.
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, a number of basic scientific questions about the biology and epidemiology of SARS need to be answered in order to develop diagnostics and therapeutics for the disease, as well as to construct and implement targeted surveillance strategies. Apart from research that is specific to the SARS coronavirus, however, workshop participants discussed a number of broader areas of basic research that might be pursued in order to counter the threat that would arise from either a recurrence of SARS or the emergence of other new infections.
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The SARS epidemic illustrated how rapidly the impacts of a new disease can reverberate through the political and economic structures of successive countries and regions, and the decisions that were made in response to the epidemic ultimately reached into the highest levels of government and international bodies. Just as with the measures that were taken within individual hospitals and clinical settings, the comparative effectiveness of the broader quarantine measures, travel advisories, communications with the general public, and other legal and public health directives that were issued should be gauged relative to their costs and difficulties.
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As the world becomes more conscious of microbial threats to health, countries are increasingly compelled to report infectious outbreaks and join international efforts to contain them. Recognizing that such transparency often comes at a price to a nation's economy, particularly in developing countries, workshop participants attempted to identify incentives to encourage nations and individuals to act for the common good.
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2003. A major outbreak of severe acute respiratory syndrome in Hong Kong.
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2003. Evaluation of reverse transcription-PCR assays for rapid diagnosis of severe acute respiratory syndrome asso ciated with a novel coronavirus.
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