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Institute of Medicine (US) Forum on Microbial Threats; Knobler S, Mahmoud A, Lemon S, et al., editors. Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary. Washington (DC): National Academies Press (US); 2004.

Cover of Learning from SARS

Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary.

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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-break of the 21st century and clearly had a dramatic, worldwide effect far exceeding the morbidity and mortality that directly resulted from infection with the novel coronavirus that causes SARS. In addition to the infection and hospitalization of several thousand individuals and the nearly 900 deaths that occurred in the countries with SARS cases, the entire global economy was affected by SARS, leading to serious losses of revenue, collapse of regional tourist and travel industries, and significant decreases in the gross national product among the nations affected (Lee and McKibbin, 2003). Despite several introductions of the virus from returning infected travelers, the United States was spared from the worst of SARS, given that there was no significant secondary spread, no large hospital-based outbreaks as seen in several countries, and no fatalities.

The fact that the United States had relatively few cases belies the enormous effort put forth by public health officials in responding to the outbreak. The Centers for Disease Control and Prevention (CDC) worked closely with state and local governments, the health care delivery industry, and other federal agencies to actively alert the traveling public about the risks of SARS, to prepare the health care delivery system to recognize and treat suspected SARS patients, and to assure the public that appropriate interventions to protect them from infection were being taken. These efforts were undertaken in close collaboration with international partners in the World Health Organization (WHO) and in the countries most affected by SARS. The collaborative international response can be considered in five parts: coordination of response, collaborations in science, communications at home and abroad, capacity building and response preparedness, and challenges and lessons learned.

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), communications, environmental issues, and community outreach programs focused on the challenges of providing accurate information to special groups such as immigrants and the Asian community. In addition, two teams were organized to review and offer constructive criticism of the response as it unfolded and to plan for possible pandemic transmission of SARS, and two other teams engaged in international efforts to respond to the outbreak and conduct subsequent scientific studies. Each group worked closely with experts from throughout the CDC Centers and often included members from other federal agencies (e.g., Department of Defense, Department of State, and National Institutes of Health, Food and Drug Administration [FDA], and others from the Department of Health and Human Services [DHHS]) or affected countries (specifically Canada). Many of the groups held frequent telephone conference calls with their constituents and academic experts to brainstorm and discuss next steps. 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. A total of 84 staff members were dispatched on 92 deployments to 11 countries affected by the SARS outbreak (CDC, unpublished) (see Tables 1-1 and 1-2). The largest group of personnel, 30 individuals, was sent to Taiwan, where a total of 696 person-days of assistance were provided. In all, staff were deployed for a total of 1,959 days, or 7.8 work-years, as determined on the basis of the standard U.S. federal work schedule. Deployed staff contributed diverse skills and expertise to these deployments (Table 1-2). Medical officers and epidemiologists were dispatched most often, with these personnel going to Taiwan (17), China (12), Vietnam (8), Singapore (2), the Philippines (3), Hong Kong (4), Canada (4), Switzerland and Thailand (2 shared), and Cambodia and Laos (1 shared). Other critical staff included pathologists and laboratory scientists, infection control officers, industrial hygienists, information management specialists, public health administrators, and communications experts. As the outbreak continued and staff rotations were required, it soon became apparent that CDC staff alone would be insufficient to meet a sustained demand for deployment of skilled personnel. As a result, the search to identify appropriate and available personnel was expanded to include public health professionals at state and local health departments, hospitals, other public health agencies, and academic centers.

TABLE 1-1. CDC’s 2003 International SARS Response by Center, Institute, Office (CIO).


CDC’s 2003 International SARS Response by Center, Institute, Office (CIO).

TABLE 1-2. CDC International SARS Response: Staff Deployed by Country and Area of Technical Expertise.


CDC International SARS Response: Staff Deployed by Country and Area of Technical Expertise.

Fortunately, the outbreak peaked before serious personnel shortages were encountered; however, it is clear that CDC must both enhance retention of the uniquely skilled staff needed to assist with such outbreak responses and identify external partners who can be recruited when needed to help meet such challenges. The outbreak also highlighted the benefit of having well-established laboratory Infections Program, which was established in 2001 in partnership with the Thailand Ministry of Health, repeatedly proved its value as skilled staff were deployed rapidly to assist affected countries within the region and to work with Thai health officials responding to the importation of SARS cases. The CDC staff assisted Thai officials with caring for Dr. Carlo Urbani, the WHO physician who acquired SARS and died early in the course of the outbreak.

Collaborations in Science

Early in the course of the outbreak, WHO facilitated the exchange of laboratory information being generated in response to the SARS outbreak by establishing daily conference calls with representatives of the 11 leading laboratories participating in the response (WHO, 2003j). They also created a secure website where laboratory findings could be posted and shared with others, and they assisted with the acquisition and distribution of clinical material for laboratory testing (Stohr, 2003). These critical steps led to the rapid and virtually simultaneous recognition by several international laboratories of a new coronavirus (SCoV) as the likely cause of the outbreak (Ksiazek et al., 2003; Peiris et al., 2003a), and soon thereafter, the determination of the complete genomic sequence of the virus (Rota et al., 2003). The rapidity with which these results were obtained was truly historic and clearly emphasized the benefits of global data sharing and scientific collaboration. 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. WHO did an exceptional job in providing information through nearly daily press briefings and updates on its website, by hosting global conference calls with international partners to discuss specific issues, and by effectively using a secure website to post sensitive information, such as results of ongoing laboratory investigations. Video conferences were arranged between the Director General of WHO, the Secretary of DHHS, and the Director of CDC to provide an opportunity for direct dialogue between agency leaders and their key staff. All of these activities served to calm a nervous world by rapidly providing accurate information on the evolution of the outbreak and interventions under way and on the evolving discovery of the cause of the outbreak and development of treatment and prevention strategies.

The communications burden faced by CDC was enormous and as intense as any previous public health emergency experienced by the agency. More than 10,000 news media calls were handled, 12 SARS news releases were issued, and 21 live telebriefings and news conferences were broadcast. Thirty specialized conference calls were made to the health care provider community, and nearly 35,000 public inquires were answered by telephone. A special clinical hotline was established for physicians inquiring about SARS, and more than 2,000 such calls were answered. Over 1.9 million global participants are estimated to have seen one or more of the three SARS satellite broadcasts directed to health care workers, and more than 17 million hits were recorded on the CDC SARS websites, with 3.8 million hits occurring during the week of April 20–26 alone (Personal communications, Dan Rutz and Bill Pollard, CDC, September 26, 2003). Providing accurate, real-time information to meet these demands was one of the most challenging aspects of the entire outbreak response effort.

Capacity Building and Response Preparedness

With recognition that SCoV was responsible for the outbreak, laboratory efforts quickly turned to establishment of diagnostic tests to identify infected patients. Several laboratories rapidly developed prototype assays to measure SCoV—specific nucleic acid sequences, viral antigen in tissues, and the serologic response to infection. CDC distributed assays to measure both SCoV genomic material by polymerase chain reaction and specific immunoglobulin response by enzyme immunoassay; recipients of these assays included state health departments, members of the Laboratory Response Network established to respond to bioterrorism threats, and several countries following their requests for assistance. CDC also reisolated SCoV under formal Good Laboratory Practices conditions, using FDA-approved certified cells provided by Aventis Pasteur and clinical material obtained from an acutely ill American traveler who had returned recently from Hong Kong. This isolate was made available to vaccine manufacturers free of charge and has now been used in the development of candidate new vaccines by several companies (WHO, 2003i). In all, CDC provided purified RNA, virus, or antigen to more than 130 academic centers, commercial firms, and government agencies (Personal communication, Betty Robertson, CDC, September 26, 2003) (see Table 1-3).

TABLE 1-3. CDC Shipments of Diagnostic Materials During the 2003 SARS Outbreak, by Recipient.


CDC Shipments of Diagnostic Materials During the 2003 SARS Outbreak, by Recipient.

Challenges and Lessons Learned

The SARS outbreak of 2003 gave the world a clear example of future challenges in addressing emerging infectious diseases. As demonstrated by SARS, an outbreak of infection even in seemingly remote areas of the world can pose a threat to the health and economies of countries worldwide. All nations need to have access to accurate and timely information and must be prepared to respond appropriately. The benefit of having well-established partnerships with countries was demonstrated repeatedly, especially as it became apparent that there is a serious shortage of available United States–based skilled personnel. Similarly, because specialized skill sets, such as infection control expertise, were in critically short supply, future preparedness planning should include establishing contingency plans whereby partners from outside the government can assist with outbreak response efforts as needed. The benefit of global collaboration in addressing scientific challenges was well documented; nevertheless, serious challenges were encountered in the acquisition and transport of clinical material critical to establishing the cause of the outbreak, clearly indicating the need to further facilitate technology transfer and enhance preparedness. Once the cause of the outbreak was determined, an enormous demand for validated diagnostics, training, and technical assistance emerged. Meeting this demand proved to be a major undertaking as well. Last, the long-standing political obstacle in regard to WHO’s interactions with Taiwan was highlighted as the SARS outbreak exploded across the island. Initially, only CDC experts responded to Taiwan’s call for assistance; however, a decision by the director general of WHO soon led to formal WHO participation in the outbreak response. Once again, we learned that infectious diseases respect neither geographic nor political boundaries.

Copyright © 2004, National Academy of Sciences.
Bookshelf ID: NBK92447


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