a

GAO

United States General Accounting Office

Report to the Chairman, Subcommittee 

on Asia and the Pacific, Committee on 

International Relations, House of 

Representatives

April 2004 EMERGING 

INFECTIOUS 

DISEASES

Asian SARS Outbreak 

Challenged 

International and 

National Responses

GAO-04-564
www.gao.gov/cgi-bin/getrpt?GAO-04-564.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact David Gootnick 

at (202) 512-3149 or Janet Heinrich at (202) 

512-7119. 

Highlights of GAO-04-564, a report to the

Chairman, Subcommittee on Asia and the 

Pacific, Committee on International 

Relations, House of Representatives 

April 2004

EMERGING INFECTIOUS DISEASES

Asian SARS Outbreak Challenged 

International and National Responses 

WHO implemented extensive actions to respond to SARS, but its response 

was delayed by an initial lack of cooperation from officials in China and 

challenged by limited resources for infectious disease control. WHO 

activated its global infectious disease network and deployed public health 

specialists to affected areas in Asia to provide technical assistance. WHO 

also established international teams to identify the cause of SARS and 

provide guidance for managing the outbreak. WHO’s ability to respond to 

SARS in Asia was limited by its authority under the current International 

Health Regulations and dependent on cooperation from affected areas. 

U.S. government agencies played key roles in responding to SARS in Asia 

and controlling its spread into the United States, but these efforts revealed 

limitations. The Centers for Disease Control and Prevention supplied public 

health experts to WHO for deployment to Asia and gave direct assistance to 

Taiwan. It also tried to contact passengers from flights and ships on which a 

traveler was diagnosed with SARS after arriving in the United States. 

However, these efforts were hampered by airline concerns and procedural 

issues. The State Department helped facilitate the U.S. government’s 

response to SARS but encountered multiple difficulties when it tried to 

arrange medical evacuations for U.S. citizens infected with SARS overseas. 

Although the Asian governments we studied initially struggled to recognize 

the SARS emergency and organize an appropriate response, they ultimately 

established control. As the governments have acknowledged, their initial 

response to SARS was hindered by poor communication, ineffective 

leadership, inadequate disease surveillance systems, and insufficient public 

health capacity. Improved screening, rapid isolation of suspected cases, 

enhanced hospital infection control, and quarantine of close contacts 

ultimately helped end the outbreak. 

The SARS crisis temporarily dampened consumer confidence in Asia, 

costing Asian economies $11 billion to $18 billion and resulting in estimated 

losses of 0.5 percent to 2 percent of total output, according to official and 

academic estimates. SARS had significant, but temporary, negative impacts 

on a variety of economic activities, especially travel and tourism. 

The SARS outbreak added impetus to the revision of the International Health 

Regulations. WHO and its member states are considering expanding the 

scope of required disease reporting to include all public health emergencies 

of international concern and devising a system for better cooperation with 

WHO and other countries. Some questions are not yet resolved, including 

WHO’s authority to conduct investigations in countries absent their consent, 

the enforcement mechanism to resolve compliance issues, and how to 

ensure public health security without unduly interfering with travel and 

trade. 

Severe acute respiratory syndrome 

(SARS) emerged in southern China 

in November 2002 and spread 

rapidly along international air 

routes in early 2003. Asian 

countries had the most cases 

(7,782) and deaths (729). SARS 

challenged Asian health care 

systems, disrupted Asian 

economies, and tested the 

effectiveness of the International 

Health Regulations. GAO was 

asked to examine the roles of the 

World Health Organization (WHO), 

the U.S. government, and Asian 

governments (China, Hong Kong, 

and Taiwan) in responding to 

SARS; the estimated economic 

impact of SARS in Asia; and efforts 

to update the International Health 

Regulations. 

GAO is recommending that the 

Secretaries of Health and Human 

Services (HHS) and State work 

with WHO and other member 

states to strengthen WHO’s global 

infectious disease network. GAO is 

also recommending that the 

Secretary of HHS complete steps to 

ensure that the agency can obtain 

passenger contact information in a 

timely manner, including, if 

necessary, the promulgation of 

specific regulations; and that the 

Secretary of State work with other 

relevant agencies to develop 

procedures for arranging medical 

evacuations during an airborne 

infectious disease outbreak. HHS, 

State, and WHO generally 

concurred with the report’s content 

and its recommendations. 
Page i GAO-04-564 Emerging Infectious Diseases

Contents

Letter 1

Results in Brief 2

Background 6

WHO’s Response to SARS Was Extensive, but Was Delayed by an 

Initial Lack of Cooperation from China and Challenged by Limited 

Resources 11

U.S. Government Had Key Role in Response to SARS, but Efforts 

Revealed Problems in Ability to Respond to Emerging Infectious 

Diseases 16

After Initial Struggle, Asian Governments Brought SARS Outbreak 

under Control 23

SARS Outbreak Decreased Consumer Confidence and Negatively 

Affected a Number of Asian Economies 32

WHO Members Will Debate Important Issues Raised by International 

Health Regulations’ Revision 39

Conclusion 43

Recommendations for Executive Action 44

Agency Comments and Our Evaluation 45

Scope and Methodology 46

Appendixes

Appendix I: SARS Cases and Deaths, November 2002–July 2003 50

Appendix II: SARS Chronology 52

Appendix III: Estimates of the Economic Impact of SARS 56

Appendix IV: Comments from the Department of Health and Human 

Services 59

Appendix V: Comments from the Department of State 62

Appendix VI: Comments from the World Health Organization 65

Appendix VII: GAO Contacts and Staff Acknowledgments 67

GAO Contacts 67

Acknowledgments 67

Tables Table 1: Estimated Economic Cost of SARS in Asia 33

Table 2: Asian Government Stimulus Packages in Response to 

SARS, 2003 39

Table 3: Models Estimating the Economic Impact of SARS on GDP 

in Asia, 2003 57
Contents

Page ii GAO-04-564 Emerging Infectious Diseases

Figures Figure 1: Timeline of SARS Events and Actions 8

Figure 2: CDC Health Alert Notice 18

Figure 3: Quarterly GDP Growth for Various Asian Economies, 

2002-2003 34

Figure 4: Estimated Economic Impacts of SARS on Travel and 

Tourism 36

Figure 5: Quarterly Retail Sales Growth in Selected Asian 

Economies, 2002-2003 38

Abbreviations

CDC Centers for Disease Control and Prevention

GDP gross domestic product 

GOARN Global Outbreak Alert and Response Network

GPHIN Global Public Health Intelligence Network

HHS Department of Health and Human Services 

SARS severe acute respiratory syndrome 

WHO World Health Organization

WPRO Western Pacific Regional Office

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Page 1 GAO-04-564 Emerging Infectious Diseases

United States General Accounting Office

Washington, D.C. 20548

A

April 28, 2004 Letr

The Honorable James A. Leach

Chairman, Subcommittee on Asia

and the Pacific

Committee on International Relations

House of Representatives

Dear Mr. Chairman:

Severe acute respiratory syndrome (SARS), the first major new infectious 

disease of the 21st century, emerged in southern China in November 2002. 

SARS is a contagious respiratory disease with a substantial mortality rate, 

and there is no vaccine, no reliable rapid diagnostic test, and no specific 

treatment for the disease. The disease spread rapidly along international air 

routes through Asia, North America, and Europe in early 2003, eventually 

infecting 8,098 people and causing 774 deaths.1

 Asian countries were the 

hardest hit, with 7,782 cases and 729 deaths. The 2002-2003 SARS outbreak 

presented a challenge to Asian health care systems and disrupted Asian 

economies. The World Health Organization (WHO), the U.S. government, 

and Asian governments all played a role in controlling the SARS outbreak 

in Asia. The history of this effort raises important issues regarding 

international and national preparedness for recognizing and responding to 

emerging infectious diseases such as SARS, including the effectiveness of 

the International Health Regulations, WHO’s legal framework for 

preventing the international spread of infectious diseases. 

In light of these concerns, you asked that we assess the impact of SARS on 

health and commerce in Asia. In this report we examine (1) WHO’s actions 

to respond to the SARS outbreak in Asia, (2) the role of the U.S. 

government in responding to SARS in Asia and limiting its spread into the 

United States, (3) how governments in the areas of Asia most affected by 

SARS responded to the outbreak, (4) the estimated economic impact of 

SARS in Asia, and (5) the status of efforts to update the International 

Health Regulations.

1

“Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 

2003,” (Geneva, Switzerland: WHO, September 26, 2003), 

http://www.who.int/csr/sars/country/table2003_09_23/en/(downloaded March 12, 2004).
Page 2 GAO-04-564 Emerging Infectious Diseases

The primary focus of our report is on those parts of Asia most severely

affected by SARS during the 2002-2003 outbreak, including China, Hong 

Kong, and Taiwan. To examine the response to the SARS outbreak by WHO, 

the U.S. government, and Asian governments, we conducted fieldwork in 

Beijing, Hong Kong and Guangdong Province, China; and in Taipei, Taiwan, 

where we met with public health officials, including senior Ministry of 

Health staff, international epidemiologists, and local hospital workers. We 

supplemented our field-level information with interviews with WHO and 

U.S. government officials responsible for managing the response to SARS 

and recognized public health experts; we also reviewed relevant 

documents and reports. To describe the economic impact of SARS in Asia, 

we reviewed official macroeconomic and sector data as well as economic 

impact studies from international financial institutions, industry 

associations, and public policy research organizations. We determined that 

the official national accounts data were sufficiently reliable for the 

purposes of our analysis by reviewing supplementary documentary 

evidence and each economy’s compliance with data dissemination 

standards. The scope of our summary of economic analyses included other 

Asian economies strongly impacted by the disease: Malaysia, Singapore, 

Thailand, and Vietnam. Finally, we examined a draft of WHO’s proposed 

revision of the International Health Regulations and interviewed WHO and 

U.S. government officials and other legal experts to determine the potential 

impacts of the revised rules. See pages 46-48 for a more complete 

description of our scope and methodology. We performed our work from 

July 2003 to April 2004 in accordance with generally accepted government 

auditing standards.

Results in Brief WHO implemented extensive actions to respond to SARS, but its response 

was delayed by an initial lack of cooperation from officials in China and 

challenged by limited resources. At the heart of WHO’s response to SARS 

was the activation of its global infectious disease network. This effort, 

combined with assistance from WHO’s Asian regional office, included 

deploying public health specialists to affected areas in Asia to provide 

technical assistance and establishing international teams of researchers 

and clinicians who worked together to identify the cause of SARS, 

investigate modes of transmission, and develop guidance for managing the 

outbreak. WHO played a major role in controlling the spread of SARS by 

issuing global alerts and recommending against travel to countries with 

SARS outbreaks. It also issued guidance and recommendations to affected 

areas and the international community on surveillance, preparedness, and 

response. Although the response was ultimately successful, WHO’s actions 
Page 3 GAO-04-564 Emerging Infectious Diseases

were delayed because China did not initially provide information about the 

SARS outbreak or invite WHO to assist in investigating and managing the 

outbreak in a timely manner. WHO’s ability to respond to SARS in China, 

and elsewhere, was limited by its authority under the current International 

Health Regulations and dependent on cooperation from affected areas. In 

addition, WHO’s ability to provide timely and appropriate expertise was 

challenged by the limited resources available to its global infectious 

disease network, which was stretched to capacity during the outbreak.

U.S. government agencies played significant roles in responding to SARS in 

Asia and controlling its spread into the United States, but these efforts 

revealed limitations in their ability to respond to emerging infectious 

diseases. The Department of Health and Human Services’ (HHS) Centers 

for Disease Control and Prevention (CDC) was involved in early 

international efforts to identify the disease, provided a significant 

proportion of the public health experts deployed by WHO to Asia, and gave 

direct assistance to Taiwanese health authorities. CDC also helped limit the 

spread of SARS into this country by disseminating information to travelers 

and attempting to identify and contact passengers from flights and ships on 

which travelers were diagnosed with SARS after arriving in the United 

States. However, CDC encountered obstacles that made it unable to 

perform this important outbreak control measure because of airline 

concerns over CDC’s authority and the privacy of passenger information, as 

well as procedural issues. CDC is exploring options to overcome the 

problems it encountered, although it has faced obstacles in pursuing some 

of them. The State Department (State) applied diplomatic pressure on 

governments to increase transparency and response, helped facilitate the 

U.S. government response to SARS in Asia, and provided information on 

SARS to U.S. government employees and citizens in the region. State also 

attempted to coordinate medical evacuations for a small number of U.S. 

citizens infected with SARS overseas but encountered multiple difficulties. 

These difficulties have not been resolved and could present challenges in 

the future. Although State has not developed a strategy to address these 

problems, it is working with other agencies to develop guidance for 

arranging medical evacuations. 

Although the Asian governments we studied initially struggled to recognize 

the SARS emergency and organize an appropriate response, they ultimately 

established control. As Asian government officials acknowledged, poor 

communication, a lack of effective leadership and coordination, and 

weaknesses in disease surveillance systems and public health capacity 

constrained their response. In China, poor communication within the 
Page 4 GAO-04-564 Emerging Infectious Diseases

country, with Hong Kong and Taiwan, and with WHO obscured the severity 

of the outbreak during its initial stages. For example, a detailed report 

produced by provincial officials 2 weeks before China officially announced 

the SARS outbreak was not shared with other governments or WHO. An 

initial lack of effective leadership and coordination within the governments 

of China, Hong Kong, and Taiwan hindered the implementation of a largescale control effort and led to the dismissal of high-ranking officials. As the 

outbreak progressed, problems with disease surveillance systems and 

overall public health capacity further delayed control of the outbreak in 

many of the affected areas. For example, officials in China noted that a 

large number of cases in Beijing were not reported because there was no 

system to collect this information from hospitals in the city. In Taiwan, 

officials acknowledged that a lack of expertise in hospital infection control 

contributed to a secondary, and more severe, outbreak in hospitals 

throughout the island. However, improved screening, rapid isolation of 

suspected cases, enhanced hospital infection control, and quarantine of 

close contacts ultimately helped end the outbreak in Asia. In the aftermath 

of SARS, efforts are under way to improve public health capacity in Asia to 

better deal with SARS and other infectious disease outbreaks.

The SARS crisis temporarily dampened consumer confidence, costing 

selected Asian economies around $11 billion to $18 billion and resulting in 

an estimated loss of 0.5 percent to 2 percent of their total economic output, 

according to official and academic estimates. Though sectors most affected 

by SARS have now recovered, the outbreak had a significant negative 

impact on a variety of economic activities. The most severe economic 

impacts occurred in the travel and tourism industry, particularly the airline 

industry. Anecdotal evidence suggests that retail sales, and to a lesser 

degree some foreign trade and investment, also temporarily declined as a 

result of SARS. In response to the outbreak, governments in Asia provided 

economic stimulus packages that also cost billions. 

The SARS outbreak added impetus to efforts to revise WHO’s International 

Health Regulations, and an interim draft of revised regulations is currently 

being circulated. Recognizing that emerging and re-emerging diseases have 

made the regulations obsolete, WHO and its member states are considering 

(1) expanding the scope of reporting beyond the three diseases that are 

currently required to be reported (cholera, plague, and yellow fever) to 

include all potential public health emergencies of international concern 

and (2) devising a system for better member state dialogue and cooperation 

with WHO and other countries. However, important questions about the 

proposed regulations’ scope of coverage, WHO’s authority to conduct 
Page 5 GAO-04-564 Emerging Infectious Diseases

investigations in countries absent their specific consent, the limited public 

health capacity of developing countries, the enforcement mechanism used 

to resolve compliance issues, and how to ensure public health security 

without unnecessary interference with travel and trade will have to be 

resolved in the debate leading to the adoption of the final regulations. 

We are recommending that the Secretary of Health and Human Services, in 

collaboration with the Secretary of State, work with WHO and official 

representatives from other WHO member states to strengthen the response 

capacity of WHO’s global infectious disease network. In light of the 

unresolved problems of identifying and contacting travelers arriving in the 

United States who may have been exposed to an infectious disease, and 

evacuating U.S. government employees overseas who have an airborne 

infectious disease, we are making two additional recommendations. First, 

we are recommending that the Secretary of Health and Human Services 

complete steps to ensure that the agency can obtain passenger contact 

information in a timely manner, including, if necessary, the promulgation of 

regulations specifically for this purpose. Second, we are recommending 

that the Secretary of State work with other relevant agencies to identify 

public and private sector resources and develop procedures for arranging 

medical evacuations during an airborne infectious disease outbreak in 

foreign countries. 

In providing written comments on a draft of this report, HHS, State, and 

WHO generally concurred with the report’s content and its 

recommendations (see apps. IV, V, and VI for a reprint of their comments). 

They also provided technical and clarifying comments that we have 

incorporated where appropriate. HHS and State commented that the report 

provided a good summary of the SARS outbreak and the impact upon and 

actions taken by affected countries, WHO, and the U.S. government. They 

endorsed GAO’s recommendations but noted that sensitive legal and 

privacy issues and diplomatic concerns must be carefully addressed in 

regard to contact tracing of passengers who may have been exposed to an 

infectious disease. WHO commented that the report provides a factual 

analysis of the events surrounding the emergence of SARS and the major 

weaknesses in national and international control efforts. WHO also 

commented that Asian governments should be better credited for the depth 

and intensity of their response effort, but we believe the report presents a 

balanced view. WHO also provided clarifying language on the role of its 

global response network, which we have incorporated.
Page 6 GAO-04-564 Emerging Infectious Diseases

Background SARS is a severe viral infection that is sometimes fatal. The disease first 

emerged in China in 2002 and then spread through Asia to 26 countries 

around the world. Although national governments are responsible for 

responding to infectious disease outbreaks such as SARS, WHO plays an 

important role in coordinating the response to the global spread of 

infectious diseases and assisting countries with their public health 

response to outbreaks. The U.S. government plays a role during 

international outbreaks in assisting WHO and affected countries and 

protecting U.S. citizens and interests at home and abroad. 

Characteristics of SARS The virus that causes SARS is a member of a family of viruses known as 

coronaviruses, which are thought to cause about 10 percent to 15 percent 

of common colds.2

 Within 2 to 10 days after infection with the SARS virus, 

an individual may begin to develop symptoms—including cough, fever, and 

body aches—that are difficult to distinguish from those of other respiratory 

illnesses. The primary mode of transmission appears to be direct or 

indirect contact with respiratory secretions or contaminated objects. 

Another feature of the disease is the occurrence of “superspreading 

events,” where evidence suggests that the disease is transmitted at a high 

rate due to a combination of patient, environmental, and other factors. 

According to WHO, the global case fatality rate for SARS is approximately 

11 percent and may be more than 50 percent for individuals over age 65.

Prevention and Control of 

SARS

The management of a SARS outbreak relies on the use of established public 

health measures for the control of infectious diseases—including case 

identification and contact tracing, transmission control, and exposure 

management, defined as follows:

• Case identification and contact tracing: defining what symptoms, 

laboratory results, and medical histories constitute a positive case in a 

patient and tracing and tracking individuals who may have been 

exposed to these patients.

2

Scientific evidence suggests that the virus originated in animals and crossed into human 

populations. See Y. Guan, “Isolation and characterization of viruses related to the SARS 

coronavirus from animals in southern China,” Science, vol. 302, no. 5,643 (2003).
Page 7 GAO-04-564 Emerging Infectious Diseases

• Transmission control: controlling the transmission of diseaseproducing microorganisms through use of proper hand hygiene and 

personal protective equipment, such as masks, gowns, and gloves.

• Exposure management: separating infected and noninfected 

individuals. Quarantine is a type of exposure management that refers to 

the separation or restriction of movement of individuals who are not yet 

ill but were exposed to an infectious agent and are potentially 

infectious.

The 2002-2003 SARS 

Outbreak 

The emergence of SARS in China can be traced to reports of cases of 

atypical pneumonia3

 in several cities throughout Guangdong Province in 

November 2002. (See fig. 1 for a timeline of the emergence of SARS cases 

and WHO and U.S. government actions.) Because atypical pneumonia is 

not unusual in this region and the cases did not appear to be connected, 

many of these early cases were not recognized as a new disease. However, 

physicians were alarmed because of the unusual number of health care 

workers who became severely ill after treating patients with a diagnosis of 

atypical pneumonia. The international outbreak began in February 2003 

when an infected physician who had treated some of these patients in 

China traveled to Hong Kong and stayed at a local hotel. Some individuals 

who visited the hotel acquired the infection and subsequently traveled to 

Vietnam, Singapore, and Toronto and seeded secondary outbreaks. 

Throughout spring 2003, the number of cases continued to spread through 

Asia to 26 countries around the world, and at its peak—in early May—

hundreds of new SARS cases were reported every week. (See app. I for a 

map of total SARS cases and deaths.) In July 2003, WHO announced that 

the outbreak had been contained. (See app. II for a detailed chronology of 

the SARS outbreak.)

3

Atypical pneumonia is caused by a variety of bacteria and viruses and has different clinical 

signs and a more protracted onset of symptoms compared with other forms of pneumonia. 
Page 8 GAO-04-564 Emerging Infectious Diseases

Figure 1: Timeline of SARS Events and Actions

Global Infectious Disease 

Control and the Role of the 

World Health Organization

Although national governments bear primary responsibility for disease 

surveillance and response, WHO, an agency of the United Nations, plays a 

central role in global infectious disease control. WHO provides support, 

information, and recommendations to governments and the international 

community during outbreaks of infectious disease that threaten global 

health or trade. The International Health Regulations outline WHO’s 
Page 9 GAO-04-564 Emerging Infectious Diseases

authority and member states’ obligations in preventing the global spread of 

infectious diseases. Adopted in 1951 and last modified in 1981, the 

International Health Regulations are designed to ensure maximum security 

against the international spread of diseases with a minimum of interference 

with world traffic (that is, trade and travel). The current regulations require 

that member states report the incidence of three diseases within their 

borders—cholera, plague, and yellow fever—and WHO can investigate an 

outbreak only after receiving the consent of the government involved. 

Efforts to revise the regulations began in 1995, and the revised regulations 

are scheduled to be ready for submission to the World Health Assembly, the 

governing body of WHO, in May 2005.4

While the International Health Regulations provide the legal framework for 

global infectious disease control, WHO’s Global Outbreak Alert and 

Response Network (GOARN), established in April 2000, is the primary 

mechanism by which WHO mobilizes technical resources for the 

investigation of, and response to, disease outbreaks of international 

importance. Because WHO does not have the human and financial 

resources to respond to all disease outbreaks, GOARN relies on the 

resources of its partners, including scientific and public health institutions 

in member states, surveillance and laboratory networks (e.g., WHO’s 

Global Influenza Surveillance Network)5

, other U.N. organizations, the 

International Committee of the Red Cross, and international humanitarian 

nongovernmental organizations. WHO collects intelligence about 

outbreaks through various sources, including formal reports from 

governments and WHO officials in the field as well as informal reports from 

4

WHO, which consists of 192 member states, is headquartered in Geneva and has six 

regional offices and numerous country offices. The Western Pacific Regional Office (WPRO) 

serves Asian countries and has links to country offices in China and other Asian countries. 

WHO is governed by the World Health Assembly, which meets yearly and is attended by 

delegations from all member states. The assembly determines WHO’s policies and is 

authorized to adopt regulations concerning the prevention of the international spread of 

disease and make recommendations about any subject dealt with by WHO. China is member 

of WHO, but Taiwan is not. Hong Kong’s interests are represented in WHO by China. 

5

The influenza surveillance network comprises four WHO Collaborating Centers and 112 

institutions in 83 countries, which are recognized by WHO as “WHO National Influenza 

Centers.” The National Influenza Centers collect specimens in their country and perform 

primary virus isolation and characterization. They ship newly isolated strains to the 

Collaborating Centers for analysis, the result of which forms the basis for WHO 

recommendations on the composition of influenza vaccine for the Northern and Southern 

Hemisphere each year.
Page 10 GAO-04-564 Emerging Infectious Diseases

the media and the Internet.6 When WHO receives a formal request for 

assistance from a national government, it responds primarily through 

GOARN. GOARN’s key response objectives are to ensure that appropriate 

technical assistance rapidly reaches affected areas during an outbreak and 

to strengthen public health response capacity within countries for future 

outbreaks. Its response activities may include providing technical advice or 

support (e.g., public health experts and laboratory services), logistical aid 

(e.g., supplies and vaccines), and financial assistance (e.g., emergency 

funds). In addition to the support provided through GOARN, technical 

assistance and deployments are also arranged through WHO’s regional 

offices.

U.S. Government Agencies 

Responsible for Responding 

to Global Infectious Disease 

Outbreaks

Two departments of the U.S. government, the Department of Health and 

Human Services (HHS) and State, play major roles in responding to 

infectious disease outbreaks overseas.7

 Within HHS, the Office of Global 

Health Affairs and CDC work closely with WHO and foreign governments 

in response efforts.8

 CDC also works with other federal agencies, state and 

local health departments, and the travel industry to limit the introduction 

of communicable diseases into the United States. State’s roles include 

protecting U.S. government employees working overseas and 

disseminating information about situations that may pose a threat to U.S. 

citizens living and traveling abroad. In addition, State may coordinate the 

provision of technical assistance by various U.S. government agencies and 

use its diplomatic contacts to engage foreign governments on policy issues 

related to infectious disease response. 

6

About 40 percent of the approximately 200 outbreaks investigated and reported to WHO 

each year come from the Global Public Health Intelligence Network (GPHIN), a system 

developed by Canadian health officials and used by WHO since 1997 that searches for 

reports of disease outbreaks from more than 950 news feeds and discussion groups around 

the world in the media and on the Internet.

7

The Departments of Defense, Homeland Security, and Transportation also assisted State 

and HHS during the SARS outbreak.

8

The National Institute of Allergy and Infectious Diseases and the Food and Drug 

Administration also played roles in the response to SARS by conducting and supporting 

scientific research (e.g., on diagnostic tests and a vaccine) during and after the outbreak.
Page 11 GAO-04-564 Emerging Infectious Diseases

Infectious Disease Control 

in China, Hong Kong, and 

Taiwan

In recent years, Asia has become increasingly vulnerable to emerging 

infectious disease outbreaks, and governments have had to deal with 

diseases such as avian influenza and dengue fever. In China, Hong Kong, 

and Taiwan, such infectious disease outbreaks are managed through the 

public health authorities of these governments: 

• China: The Ministry of Health maintains lead authority over health 

policy at the national level, although provincial governments exercise 

significant authority over local health matters. In January 2002, the 

national Center for Disease Control and Prevention was established, 

along with centers at the provincial and local levels, and charged with 

matters ranging from infectious disease control to chronic disease 

management. 

• Hong Kong: The Health, Welfare, and Food Bureau has overall policy 

responsibility for health care delivery and other human services in Hong 

Kong. Within the bureau, the Department of Health and its Disease 

Prevention and Control Division, which was established in July 2000, are 

responsible for formulating strategies and implementing measures in 

the surveillance, prevention, and control of communicable diseases. The 

Hospital Authority is responsible for the management of 43 public 

hospitals in Hong Kong.

• Taiwan: The Department of Health is responsible for national health 

matters and for guiding, supervising, and coordinating local health 

bureaus. A division of the department, the Taiwan Center for Disease 

Control, was established in 1999 and consolidated the disease 

prevention work of several national public health agencies involved in 

infectious disease control. 

WHO’s Response to 

SARS Was Extensive, 

but Was Delayed by an 

Initial Lack of 

Cooperation from 

China and Challenged 

by Limited Resources 

WHO’s actions to respond to the SARS outbreak were extensive, but its 

response was delayed by an initial lack of cooperation from officials in 

China and challenged by limited resources. WHO’s actions included direct 

technical assistance to affected areas and broad international actions such 

as alerting the international community about this serious disease and 

issuing information, guidance, and recommendations to government 

officials, health professionals, the general public, and the media. (See fig. 1 

for key WHO actions during the SARS outbreak.) However, an initial lack of 

cooperation on the part of China limited WHO’s access to information 
Page 12 GAO-04-564 Emerging Infectious Diseases

about the outbreak, and WHO had to stretch its resources for infectious 

disease control to capacity. 

WHO Provided Direct 

Assistance to Affected 

Areas 

WHO’s response to SARS was coordinated jointly by WHO headquarters 

and its Western Pacific Regional Office (WPRO). At headquarters, WHO 

activated its GOARN. Although GOARN had been used before to respond to 

isolated outbreaks of Ebola, meningitis, viral hemorrhagic fever, and 

cholera in African countries and elsewhere, the SARS outbreak was the 

first time the network was activated on such a large scale for an 

international outbreak of an unknown emerging infectious disease. There 

were two primary aspects to WHO’s activities during the SARS outbreak: 

One was the direct deployment of public health specialists from around the 

world to affected Asian governments to provide technical assistance; the 

other was the formation of three virtual networks of laboratory specialists, 

clinicians, and epidemiologists who pooled their knowledge, expertise, and 

resources to collect and develop the information WHO needed to issue its 

guidance and communications about SARS. 

Deployment Under GOARN’s auspices, WHO rapidly deployed 115 specialists from 26 

institutions in 17 countries to provide direct technical assistance to SARSaffected areas. WPRO also facilitated the deployment of an additional 80 

public health specialists to SARS-affected areas. Asian governments 

identified their needs for technical assistance—consisting primarily of 

more senior, experienced staff—and then WHO issued a request for staff 

from its partners. WHO officials at headquarters and at WPRO worked 

jointly to quickly process contracts and send teams into the field within 48 

hours of the request. The work of the teams varied, depending on local 

need. For example, a team of 5 public health experts sent to China 

reviewed clinical and epidemiologic data to improve the detection and 

surveillance of SARS cases in Guangdong. A team of 4 public health experts 

sent to Hong Kong included environmental engineers to help investigate 

the spread of SARS in a housing complex. 

Virtual Networks WHO also formed several international networks of researchers and 

clinicians, including a laboratory network, a clinical network, and an 

epidemiologic network. These networks operated “virtually,” 

communicating through a secure Web site and teleconferences. The SARS 

laboratory network, based on the model of WHO’s global influenza 

surveillance network and using some of the same laboratories, consisted of 

13 laboratories in 9 countries. Within one month of its creation, 
Page 13 GAO-04-564 Emerging Infectious Diseases

participants in this network had identified the SARS coronavirus and 

shortly afterward sequenced its genome. The SARS clinical network 

consisted of more than 50 clinicians in 14 countries. Clinicians in this 

network helped to develop the SARS case definition and wrote infection 

control guidelines. The SARS epidemiologic network, which consisted of 

32 epidemiologists from 11 institutions, collected data and conducted 

studies on the characteristics of SARS, including its transmission and 

control. WHO and other public health experts noted that there was a high 

level of collaboration and cooperation in these scientific networks. 

WHO Alerted the 

International Community 

and Made Important 

Recommendations amid 

Scientific Uncertainty

During the SARS outbreak, WHO played a key role in alerting the world 

about the disease and issuing information, guidance, and recommendations 

to government officials, health professionals, the general public, and the 

media that helped raise awareness and control the outbreak. 

Global Alerts and Travel 

Recommendations

When WHO became concerned about outbreaks of atypical pneumonia in 

China, Hong Kong, and Vietnam, it issued a global alert on March 12, 2003, 

warning the world about the appearance of a severe respiratory illness of 

undetermined cause that was rapidly spreading among health care 

workers. Three days later, on March 15, WHO issued a second, higher-level 

global alert in which it identified the disease as SARS and first published a 

definition of suspect and probable cases.9

 At the same time, WHO also 

issued its first emergency travel advisory to international travelers, calling 

on all travelers to be aware of the main symptoms of SARS. When, on 

March 27, it became clear to WHO that 27 cases of SARS were linked to 

exposure on five airline flights, WHO recommended the screening of air 

passengers on flights departing from areas where there was local 

transmission of SARS. On April 2, WHO began issuing travel advisories—

9

At this time, WHO defined a suspect case as one occurring after February 1, 2003, with a 

history of a high fever (over 38 degrees Celsius) and one or more respiratory symptoms, 

including cough, shortness of breath, and difficulty breathing. It defined a probable case as 

one in which there was close contact with a person diagnosed with SARS; a history of recent 

travel to areas reporting SARS; a diagnosis of “suspect” with chest X-ray findings of 

pneumonia or respiratory distress syndrome; or an unexplained respiratory illness resulting 

in death, plus an autopsy examination demonstrating the pathology of respiratory distress 

syndrome without an identifiable cause. WHO revised this definition several times, 

publishing the latest revision on August 14, 2003 (see 

http://www.who.int/csr/sars/postoutbreak/en/). 
Page 14 GAO-04-564 Emerging Infectious Diseases

recommendations that travelers should consider postponing all but 

essential travel to designated areas where the risk of exposure to SARS was 

considered high. The first designated areas were Hong Kong and 

Guangdong Province, China; later, the list was expanded to include other 

parts of China; Toronto; and Taiwan. During the SARS outbreak, WHO also 

publicized a list of areas with recent local transmission of SARS. 

Guidelines and 

Recommendations on the 

Management of SARS

In addition to travel recommendations, WHO developed more than 20 other 

guidelines and recommendations for responding to SARS during the 

outbreak. These included advice on the detection and management of 

cases, laboratory diagnosis of SARS, hospital infection control, and how to 

handle mass gatherings of persons arriving from an area of recent local 

transmission of SARS. These guidelines and recommendations were 

disseminated through WHO’s SARS Web site, which was updated regularly 

and received 6 million to 10 million hits per day. 

WHO Faced Challenges in 

Issuing Guidance and 

Recommendations

In issuing guidance and recommendations about SARS, WHO had to 

respond immediately while making the best use of limited scientific 

knowledge about the disease (e.g., its cause, mode of transmission, and 

treatment), and it had to communicate effectively to public health 

professionals and the general public. This situation posed challenges, and 

WHO’s efforts came under some criticism. For example, officials in 

Canada, Taiwan, and Hong Kong—areas that were directly affected by the 

travel recommendations—criticized WHO for not being more transparent 

in the process it used to issue and lift the recommendations. They also 

stated that the evidentiary foundation for issuing the recommendations 

was weak and the process did not allow countries enough time to prepare 

(e.g., to develop press releases and inform the tourism industry). WHO 

officials and others also acknowledged that communicating effectively 

about the risks of transmitting SARS and recommending appropriate action 

were major challenges for the organization. For example, even though 

WHO officials believed that the use of face masks by the general public was 

ineffective in preventing SARS, it had a difficult time communicating this 

fact and educating the general public about appropriate preventive 

measures. In addition, WHO recommended screening of airline passengers 

before departure, but the recommendation was vague and allowed 

countries to execute it in different ways.
Page 15 GAO-04-564 Emerging Infectious Diseases

Initial Lack of Cooperation 

from China Limited WHO’s 

Access to Information and 

Delayed Its Response 

Although WHO officials at headquarters and in the field received various 

informal reports of a serious outbreak of atypical pneumonia in China’s 

Guangdong Province early in the SARS outbreak, WHO did not issue its 

global alerts until mid-March 2003. This delay occurred both because there 

was scientific uncertainty about the disease and because of initial lack of 

cooperation by China, which limited WHO’s access to information and its 

ability to assist in investigating and managing the outbreak. As detailed in 

appendix II, WHO first received informal reports about a serious disease 

outbreak in Guangdong Province in November 2002. At the time, influenza 

was suspected as the primary cause of this outbreak. When WHO requested 

further information from Chinese authorities, it was told that influenza 

activity in China was normal and that there were no unusual strains of the 

virus. Despite WHO’s repeated requests, Chinese authorities did not grant it 

permission to go to Guangdong Province and investigate the outbreak until 

April 2, 2003. 

WHO lacked authority under the International Health Regulations to 

compel China to report the SARS outbreak and to allow WHO to assist in 

investigating and managing it. WHO officials told us that, in general, the 

organization tries to play a neutral, coordinating role and relies on 

government cooperation to investigate problems and ensure that 

appropriate control measures are being implemented. Vietnam, for 

example, cooperated with WHO early in the outbreak, which may have 

contributed to a less severe outbreak in that country. In the case of China, 

WHO exerted some pressure, as did the U.S. government, and the 

international media, which eventually helped persuade China to become 

more open about the situation and to allow WHO to assist in investigating 

and managing the outbreak.

WHO’s Response to SARS 

Was Challenged by Limited 

Resources 

While extensive, WHO’s response to SARS in Asia was challenged by 

limited resources devoted to infectious disease control and in particular to 

GOARN. WHO’s ability to respond in a timely and appropriate manner to 

outbreaks such as SARS is dependent upon the participation and support of 

WHO’s partners and adequate financial support. During the SARS outbreak, 

GOARN’s human resources were stretched to capacity. GOARN 

experienced difficulty in sustaining the response to SARS over time and 

getting the appropriate experts out into the field. WHO officials in China 

told us that they could not obtain experienced epidemiologists and hospital 

infection control experts and that ultimately they had to look outside the 

network to find assistance. GOARN was largely dependent on CDC staff to 
Page 16 GAO-04-564 Emerging Infectious Diseases

deploy to Asia to manage the epidemic response. According to a senior 

CDC official, if the United States had experienced many SARS cases during 

the global outbreak, CDC might not have been able to make as many of 

these staff available. Furthermore, some GOARN partners told us that the 

staffing requests that they received from GOARN, WPRO, and WHO 

country offices were not well coordinated. This issue was raised at a 

GOARN Steering Committee meeting in June 2003, and it was suggested 

that a stronger regional capacity for coordination could help ensure the 

necessary public health experts are mobilized and deployed to the field.

The SARS outbreak also highlighted the limitations in GOARN’s financial 

resources. Historically, the network has received limited financial support 

from WHO’s core budget, which consists of assessed contributions from 

members. The network tries to make up for shortfalls by soliciting 

additional contributions from member states, foundations, and other 

donors. There are limited resources to pay for headquarters staff and 

technical resources such as computer mapping software and to support 

management initiatives such as strategic planning and evaluation activities. 

While acknowledging that planning and evaluation are important both for 

responding to future outbreaks and for ensuring epidemic preparedness 

and capacity building, WHO officials told us that GOARN is usually focused 

on the response to an immediate emergency and thus lacks the time and 

resources to retrospectively review what worked well and what did not.

U.S. Government Had 

Key Role in Response 

to SARS, but Efforts 

Revealed Problems in 

Ability to Respond to 

Emerging Infectious 

Diseases

CDC, as part of HHS, and State played major roles in responding to the 

SARS outbreak, but their actions revealed limits in their ability to address 

emerging infectious diseases. CDC worked with WHO and Asian 

governments to identify and respond to the disease and helped limit its 

spread into the United States. However, CDC encountered obstacles that 

made it unable to trace international travelers because of airline concerns 

over CDC’s authority and the privacy of passenger information, as well as 

procedural issues. State applied diplomatic pressure to governments, 

helped facilitate U.S. government efforts to respond to SARS in Asia, and 

supported U.S. government employees and citizens in the region. However, 

State encountered multiple difficulties in helping to arrange medical 

evacuations for U.S. citizens infected with SARS overseas. Based in part on 

this experience, State ultimately authorized departure of all nonessential 

U.S. government employees at several Asian posts. 
Page 17 GAO-04-564 Emerging Infectious Diseases

CDC Played Central Role in 

Fighting SARS in Asia

Throughout the SARS outbreak, CDC was the foremost participant in 

WHO’s multilateral efforts to recognize and respond to SARS in Asia, with 

CDC officials constituting about two-thirds of the 115 public health experts 

deployed to the region under the umbrella of GOARN. CDC also 

contributed its expertise and resources to epidemiological, laboratory, and 

clinical research on SARS. According to CDC, its involvement in 

recognizing the disease began in February 2003, when CDC officials joined 

WHO efforts to identify the cause of atypical pneumonia outbreaks in 

southern China, Vietnam, and Hong Kong. In March 2003, CDC set up an 

emergency operations center to coordinate sharing of information with 

WHO’s epidemiology, clinical, and laboratory networks (see fig. 1). Under 

GOARN’s auspices, CDC also assigned epidemiologists, laboratory 

scientists, hospital infection control specialists, and environmental 

engineers to provide technical assistance in Asia. For example, CDC 

assigned senior epidemiologists to help a WHO team investigate the 

outbreak in China. The team met with public health officials and health 

care workers in affected provinces to determine how they were responding 

to SARS. It also recommended steps to bring the outbreak under control, 

such as hospital infection control measures, quarantine strategies, and free 

health care for individuals with suspected SARS.

In addition, because Taiwan is not a member of WHO, CDC gave direct 

assistance to support Taiwan’s response to SARS, serving as a link between 

Taiwanese health authorities and WHO and providing technical information 

and expertise that enabled Taiwan to control the outbreak. Shortly after 

Taiwan identified its first case of SARS imported from China in March 2003, 

Taiwanese authorities asked WHO for assistance. WHO officials 

transmitted the request to CDC and asked it to respond. Between March 

and July 2003, 30 CDC experts traveled to Taiwan and advised health 

authorities on various aspects of the SARS response. CDC epidemiologists 

recommended changes in Taiwan’s approach to classifying SARS cases, 

which was time consuming and resulted in a large backlog of cases 

awaiting review as the outbreak expanded. They advised Taiwanese health 

authorities to replace their case classification system with a two-tiered 

approach that would categorize patients with SARS-like symptoms as 

either “suspect” or “probable” SARS. This strategy enabled public health 

authorities to institute precautionary control measures, such as isolation, 

for suspected SARS patients, and according to senior CDC and Taiwanese 

officials, it helped reduce transmission, including within medical facilities, 

and stop the outbreak. 
Page 18 GAO-04-564 Emerging Infectious Diseases

CDC Took Actions to Limit 

Spread of SARS into the 

United States 

When WHO issued its global SARS alert on March 12, 2003, CDC officials 

attempted to limit the disease’s spread into the United States by (1) 

providing information for people traveling to or from SARS-affected areas 

and (2) ensuring that travelers arriving at U.S. borders with SARS-like 

symptoms received proper medical treatment. Beginning in mid-March 

2003, CDC posted regular SARS updates on its Web site for people traveling 

to SARS-affected countries. At the same time, CDC’s Division of Global 

Migration and Quarantine deployed quarantine officers to U.S. airports, 

seaports, and land crossings where travelers entered the United States 

from SARS-affected areas. The officers distributed health alert notices to 

all arriving travelers and crew (see fig. 2). 

Figure 2: CDC Health Alert Notice 

The notices, printed in eight languages and describing SARS symptoms, 

incubation period, and what to do if symptoms developed, also contained a 

message to physicians to contact a public health officer or CDC if they 

treated a patient who might have SARS. CDC staff distributed close to 3 

million health alert notices over a 3-month period. Department of 

Homeland Security staff assisted CDC by passing out the notices at land 
Page 19 GAO-04-564 Emerging Infectious Diseases

crossings between the United States and Canada. CDC’s quarantine officers 

also responded to dozens of reports of passengers with SARS-like 

symptoms on airplanes and ships arriving in the United States from 

overseas. The officers boarded the airplane or ship, assessed the ill 

individuals to determine if they might have SARS and, if necessary, 

arranged the individuals’ transport to a medical facility.

Regulatory, Privacy, and 

Procedural Concerns 

Hampered CDC’s Efforts to 

Trace Travelers 

CDC officials wanted to advise passengers who had traveled on an airplane 

or ship with a suspected SARS case to monitor themselves for SARS 

symptoms during the virus’s 10-day incubation period, but due to airline 

concerns over authority and privacy, as well as procedural constraints, 

CDC was unable to obtain the passenger contact information it needed to 

trace travelers. Although HHS has statutory authority to prevent the 

introduction, transmission, or spread of communicable diseases from 

foreign countries into the United States,10 HHS regulations implementing 

the statute do not specifically provide for HHS to obtain passenger 

manifests or other passenger contact information from airlines and 

shipping companies for disease outbreak control purposes.11 CDC officials 

told us that some airlines failed to provide necessary contact information 

to CDC, which may be attributable to the lack of specific regulations in this 

area. Moreover, CDC officials said that in response to their requests, some 

airlines refused to give CDC passenger contact information from frequent 

flier databases or credit card receipts because of privacy concerns.12 Even 

when CDC was able to obtain passenger information, CDC staff 

responsible for contacting travelers found passenger data untimely 

(because some airlines provided it after SARS’s 10-day incubation period), 

insufficient (because some airlines could provide only passenger names 

but no contact information), or difficult to use (because it was available on 

paper rather than electronically). According to senior CDC officials, the 

inability to trace travelers who might have been exposed to SARS could 

have hampered their ability to limit the disease’s spread into the United 

States. 

10Section 361 of the Public Health Service Act, 42 U.S.C. § 264. 

11See 42 C.F.R. pts 70 and 71; 21 C.F.R. pts 1240 and 1250.

12According to airline industry association officials, under European Union privacy laws and 

regulations, there could be problems with sharing passenger names and addresses with 

government agencies.
Page 20 GAO-04-564 Emerging Infectious Diseases

CDC Exploring Options to 

Resolve Tracing Problems

The obstacles to tracing travelers remain unresolved, and senior CDC 

officials are concerned they will encounter difficulties in limiting the 

spread of infectious diseases into the United States during future global 

infectious disease outbreaks.13 CDC officials told us they are exploring 

several options to overcome the problems they encountered during the 

SARS outbreak. CDC may adopt one or more of these options,14 including: 

clarifying CDC’s authority by promulgating regulations specifically to 

obtain passenger contact information; coordinating with the Department of 

Homeland Security and other federal agencies for this purpose; developing 

a memorandum of understanding with airlines on sharing passenger 

information; and creating a system for obtaining passenger contact 

information in an electronic format. However, CDC officials said they have 

already faced obstacles in pursuing some of these options. For example, 

both CDC and Department of Homeland Security officials told us that 

Homeland Security’s computer-based passenger information system could 

not be used for purposes other than national security.

State Applied Diplomatic 

Pressure, Helped Facilitate 

Agency Responses, and 

Disseminated Information

State also played an important role in the U.S. response to SARS, primarily 

by applying diplomatic pressure, helping facilitate government efforts 

overseas, and disseminating information. In March 2003, the U.S. 

Ambassador to China communicated with Chinese government officials to 

encourage China to be more transparent in reporting SARS cases and to 

grant WHO and CDC officials access to southern China. State also 

established two working groups to facilitate the U.S. government response 

to SARS in Asia. The first working group, comprising various State offices 

and bureaus, issued daily reports on the status of the outbreak to U.S. 

embassies and consulates. The second working group, established in May 

2003, convened various U.S. government agencies, including State, HHS, 

and the Departments of Defense and Homeland Security, to address policy 

and response issues. U.S. government officials agreed that State’s efforts 

helped provide valuable information during an uncertain period and 

13During the SARS outbreak, international travelers constituted an important source of 

transmission. For example, CDC reported that all of the United States’ eight laboratoryconfirmed SARS cases and almost all of the 27 probable SARS cases were found in 

individuals who had traveled to a SARS-affected area or came into close contact with 

someone who did. 

14CDC did not provide us with details about the various options because they had not yet 

been finalized.
Page 21 GAO-04-564 Emerging Infectious Diseases

allowed for a unified response to the outbreak. U.S. embassies and 

consulates in Asia also disseminated information to U.S. government 

employees and U.S. citizens living and traveling abroad. For example, they 

publicized CDC updates on SARS through e-mail alerts and on their Web 

sites and informed U.S. citizens about medical care available in-country.

State Faced Obstacles 

Arranging Medical 

Evacuations for U.S. 

Citizens with Suspected 

SARS

During the outbreak, even the strongest local health care systems were 

overwhelmed, and State was concerned that U.S. government employees 

might receive treatment that did not meet U.S. standards. For example, in 

Hong Kong and China, U.S. consular staff told us they were concerned 

about sending U.S. government employees to local hospitals because of 

inadequate infection control practices, limited availability of health care 

workers with English language skills, and controversial treatment 

protocols such as administering steroids to SARS patients. 

In a few cases, State worked with private medical evacuation companies to 

help arrange medical evacuations for U.S. citizens with suspected SARS.15

However, early in the outbreak, CDC had not yet developed guidelines to 

prevent transmission during flight, and medical evacuation companies 

could not obtain aircraft and crew willing to transport SARS patients 

because of the perceived health risks.16 Even after CDC developed 

guidelines, medical evacuation companies still had difficulty finding 

aircraft because only about 5 percent of existing air ambulances could 

comply with the stringent guidelines, according to a private air medical 

evacuation official. Furthermore, a U.S. state and some medical facilities in 

the United States refused to accept SARS patients brought from Asia. For 

example, the state of Hawaii initially said it would accept medically 

evacuated SARS patients but later reneged and prevented one air 

ambulance company from bringing a U.S. citizen with suspected SARS to a 

15State officials said they are responsible for providing medical services (including medical 

evacuations, if necessary) only to certain U.S. government employees and their dependents, 

although embassies may assist U.S. citizens overseas in obtaining medical care on a case-bycase basis. However, it is primarily the responsibility of U.S. citizens to arrange their own 

medical evacuation. During the SARS outbreak, State helped arrange three medical 

evacuations for U.S. citizens. The first was performed by the Department of Defense from 

Hanoi to Taiwan; the second was a land evacuation performed by ambulance from Shenzhen 

to Hong Kong; and the third was performed by a medical evacuation company from Taiwan 

to Atlanta.

16Most medical evacuation companies do not have their own aircraft and crews; rather, they 

subcontract aircraft as medical evacuation needs arise.
Page 22 GAO-04-564 Emerging Infectious Diseases

medical facility in Honolulu. Although the Department of Defense 

(Defense) performed one medical evacuation for a U.S. civilian under 

special circumstances, officials at State and Defense told us that military 

priorities and scarce resources are likely to prevent Defense from 

performing civilian evacuations in the future. Ultimately, State concluded 

that inadequate local health care and difficulties arranging medical 

evacuations put U.S. government employees at risk, and, in turn, State 

authorized departure for nonessential employees and their dependents at 

several posts.17 

Medical Evacuation Issues 

Still Pose Challenges for 

Future Outbreaks

State has not developed a strategy to overcome the challenges that staff 

encountered in arranging international medical evacuations during the 

SARS outbreak, but it is working with other U.S. government agencies to 

develop guidance on this issue. Officials at State, CDC, Defense, and 

medical evacuation companies told us that the same obstacles could 

resurface during a new outbreak of SARS or another unknown infectious 

disease with airborne transmission. State officials said the medical 

evacuation companies that provide State’s medical evacuation services 

have agreed to evacuate SARS patients, and the companies with whom we 

spoke confirmed that since the SARS outbreak, they have identified 

sufficient aircraft and crew to transport a limited number of patients. The 

exact number would depend on the nature of the disease, the patient’s 

condition, and the type of medical care required. State officials said they 

have not investigated how many SARS patients private medical evacuation 

companies or Defense could transport; they also do not know which U.S. 

states and medical facilities would accept patients with SARS or another 

emerging infectious disease. State officials are concerned about a scenario 

in which dozens of staff at a U.S. embassy or consulate contract SARS or 

another infectious disease, in which case medical evacuation would 

probably not be feasible given the current constraints. This would also 

pose a problem if many U.S. citizens living or traveling overseas contracted 

such a disease. Private medical evacuation companies acknowledged that 

they might not be able to transport large numbers of patients; furthermore, 

they are unsure which destinations in the United States would accept 

patients with an infectious disease such as SARS. State officials said they 

are working with other U.S. government agencies to develop guidelines for 

consular staff to arrange international medical evacuations. However, it is 

17When warranted by conditions at an overseas post, State can authorize U.S. government 

employees and their dependents to depart the post.
Page 23 GAO-04-564 Emerging Infectious Diseases

not clear that this guidance will resolve some of the obstacles encountered 

during the SARS outbreak. For example, a CDC official said the agency is 

working with medical facilities near international ports of entry to identify 

treatment destinations for medically evacuated patients with quarantinable 

infectious diseases such as SARS, but no agreements have been reached 

yet.

After Initial Struggle, 

Asian Governments 

Brought SARS 

Outbreak under 

Control

The Asian governments we studied initially struggled to respond to SARS 

but ultimately brought the outbreak under control. As acknowledged by 

Asian government officials, poor communication within China and 

between China and Hong Kong, Taiwan, and WHO obscured the severity of 

the outbreak during its initial stages. As the extent of the outbreak was 

recognized, the large-scale response to SARS in China, Hong Kong, and 

Taiwan was hindered by an initial lack of leadership and coordination. 

Further, weaknesses in disease surveillance systems, public health 

capacity, and hospital infection control limited the ability of Asian 

governments to track the number of cases of SARS and implement an 

effective response. Improved screening, rapid isolation of suspected cases, 

enhanced hospital infection control, and quarantine of close contacts 

ultimately helped end the outbreak. In the aftermath of SARS, efforts are 

under way to improve public health capacity in Asia to better deal with 

SARS and other infectious disease outbreaks.

Poor Communication 

Limited Information on 

Severity of SARS Outbreak 

in China 

The Chinese government’s poor communication within the country, with 

Hong Kong and Taiwan, and with WHO limited the flow of information 

about the severity of the SARS outbreak in its initial stages. For example, 

the Ministry of Health did not widely circulate a report concerning the 

spread of atypical pneumonia (later determined to be SARS) in Guangdong 

Province. The report was produced by health officials in Guangdong 

Province on January 23, 2003—more than 2 weeks before the Ministry of 

Health’s first official public announcement on the outbreak.18 The report 

warned all hospitals in the province about the disease and provided advice 

to control its spread. Officials in Hong Kong, which directly borders the 

province, were not aware of the report, and a senior official in Taiwan, 

18The report was released during the Chinese New Year Holiday. According to one official, 

the report may not have received significant attention from health officials on leave during 

the holiday.
Page 24 GAO-04-564 Emerging Infectious Diseases

which maintains significant travel and commercial ties with Guangdong 

Province, said Taiwan did not receive the report or any official 

communication about the outbreak. In addition, WHO did not receive this 

information. Officials in Guangdong Province told us they could not share 

this information outside of China because this is the responsibility of the 

Ministry of Health. Further, according to Chinese regulations on state 

secrets, information on widespread epidemics is considered highly 

classified.19

Chinese scientists also did not effectively communicate their findings 

about the cause of SARS early in the outbreak because of government 

restrictions. For example, as reported in a scientific journal and later 

confirmed in our own fieldwork, Chinese military researchers successfully 

identified the coronavirus as a potential cause of SARS in early March 2003, 

several weeks before a network of WHO researchers proved it was the 

cause of SARS.20 One Chinese scientist directly involved in the effort told 

us that these researchers were instructed to defer to scientists at the 

Chinese Center for Disease Control and Prevention, who announced 

erroneously that Chlamydia pneumoniae, a type of bacteria, was 

responsible for the atypical pneumonia outbreak. In addition, we were told 

that these researchers were not permitted to communicate their findings 

on the coronavirus directly to WHO officials because only the Ministry of 

Health could communicate directly with WHO.

Communication problems persisted as late as April 2003, 5 months after the 

first cases occurred. On April 3, the Minister of Health announced that the 

outbreak was under effective control and that only 12 cases of SARS had 

been reported in Beijing. However, a physician working at a military 

hospital in Beijing wrote a letter to an Asian news magazine claiming that 

there were significantly more SARS cases in military hospitals and that 

hospital officials were told not to disclose information about SARS to the 

public. On April 15, in response to rumors of underreporting, WHO officials 

leading an investigation into the outbreak were granted permission to visit 

military hospitals but stated that they were not authorized to report their 

19See People’s Republic of China, Ministry of Health, “Explanation on Regulations on State 

Secrets in Health Work and Their Specific Classification and Scope,” March 1, 1991, 

published in Chinese Law & Government 66 (2003) (Fei-Ling Wang trans).

20Martin Enserink“SARS in China: China’s Missed Chance,” Science, vol. 301, no. 5,631 

(2003).
Page 25 GAO-04-564 Emerging Infectious Diseases

findings. By April 20, the Ministry of Health announced the existence of 339 

previously undisclosed cases of SARS in Beijing.

An Initial Lack of Effective 

Leadership and 

Coordination in SARSAffected Areas in Asia 

Hindered Response

As acknowledged by government officials, a lack of effective leadership 

and coordination within the governments of China, Hong Kong, and Taiwan 

early in the outbreak hindered attempts to organize an effective response 

to SARS. In China, provincial and local authorities maintained significant 

responsibility and autonomy in conducting epidemiological investigations 

of SARS but failed to coordinate with one another and national authorities 

early in the outbreak. However, as SARS spread into Beijing, the highest 

political leaders of the Chinese Communist Party, citing an increased 

number of cases and the impact on travel and trade, advised officials to be 

more forthcoming about SARS cases. The Ministry of Health also 

acknowledged the ministry’s failure to introduce a unified mechanism for 

collecting information about the outbreak and setting guidance and 

requirements across the country. Soon after those announcements, the 

Minister of Health and Mayor of Beijing were dismissed from their posts for 

downplaying the extent of the outbreak, and the public health response 

was brought under stronger central control. A vice premier of the central 

government assumed control of the Ministry of Health and convened 

ministerial level officers to take the lead in the nationwide SARS control 

effort. 

In Hong Kong, an expert committee convened after the outbreak to 

investigate the government’s response questioned the leadership and 

coordination of the public health system.21 For example, the committee 

found that responsibility for managing infectious disease outbreaks was 

spread throughout different departments within the Health, Welfare, and 

Food Bureau, with no single authority designated as the central decisionmaking body during outbreaks. The committee also stated that poor 

coordination between the hospital and public health system further 

complicated the response. For example, the Hospital Authority responded 

to an outbreak within a hospital without informing the Department of 

Health, which learned of the outbreak through media reports. Further, the 

Hospital Authority and Department of Health used separate databases 

21“SARS in Hong Kong: From Experience to Action,” (Hong Kong: SARS Expert Committee, 

October 2, 2003), http://www.sars-expertcom.gov.hk/english/reports/reports/reports 

fullrpt.html (downloaded Oct. 3, 2003).
Page 26 GAO-04-564 Emerging Infectious Diseases

during the initial stages of the outbreak and could not communicate 

information on new cases in real time.

In Taiwan, a report by WHO stated that the initial response to SARS was 

managed by senior political figures who sometimes did not heed the advice 

of technical experts. Furthermore, WHO noted that the failure to follow the 

advice of public health experts delayed the decision-making process and 

slowed the response to the outbreak in Taiwan. Taiwanese government 

officials noted that the leadership of the public health system was weak 

during the outbreak. In addition, the process they used to classify SARS 

cases was too slow to isolate suspected or probable cases. As the outbreak 

worsened and spread into hospitals throughout Taiwan, the Minister of 

Health and the director of the Taiwan Center for Disease Control resigned 

over criticisms about failing to control the spread of SARS. 

Weaknesses in Disease 

Surveillance Systems and 

Public Health Capacity 

Further Constrained Efforts 

As Asian governments monitored the spread of SARS, weaknesses in 

disease surveillance systems, public health capacity, and hospital infection 

control caused delays and gaps in disease reporting, which further 

constrained the response. 

Disease Surveillance Systems In China, health officials at the provincial level and WHO advisers working 

in the country noted that data gathering systems established in the 

epicenter of the outbreak in Guangdong Province were strong. However, 

Chinese officials also found that the effectiveness of a national disease 

surveillance system established in 1998 was limited. For example, disease 

prevention staff below the county level did not have access to computer 

terminals to report the number of SARS cases and had to relay disease 

reports to central authorities by fax or mail. In addition, the computerbased system did not permit the reporting of suspect cases that were not 

yet confirmed. Further, protocols for reporting were time consuming, since 

information was sent through multiple levels of the public health system. 

For example, during the outbreak, reports from doctors of suspect SARS 

cases could take up to 7 days to reach local public health authorities. In 

Beijing, an executive vice minister stated that the large number of 

undetected cases of SARS patients occurred because they could not collect 

information on SARS cases that were spread across 70 hospitals in the city. 

In Taiwan, duplicative reporting between municipal and federal levels led 

to unclear data on the total number of cases throughout the island. A WHO 

official reported that the surveillance data were entered into formats that 

were difficult to analyze and could not inform the public health response. 
Page 27 GAO-04-564 Emerging Infectious Diseases

In Hong Kong, a quickly established atypical pneumonia surveillance 

system detected early cases of severe pneumonia admitted into hospitals. 

However, the expert committee reviewing the response noted that the 

limited access to data from private sector health care providers and a lack 

of comprehensive laboratory surveillance made it difficult for public health 

authorities to gain accurate information about the full extent of the 

outbreak and implement necessary control measures.

Public Health Capacity In China, officials told us that a lack of funding and a reliance on market 

forces to finance public health services have weakened the country’s ability 

to respond to outbreaks. For example, the newly established Center for 

Disease Control and Prevention system in China derives more than 50 

percent of its revenue from user fees for immunizations and other services. 

WHO noted that the dependence on user fees has drawn attention and 

resources away from nonrevenue producing activities, such as disease 

surveillance, that are important for responding to infectious disease 

outbreaks. Furthermore, China did not have enough public health workers 

skilled in investigating diseases, and thus staff who had never been 

involved in disease investigations were used to trace SARS contacts and 

did not always collect the correct data on these cases. In Hong Kong, the 

expert committee noted that there was a shortage of expertise in field 

epidemiology and inadequate support for information systems. In addition, 

the committee found disproportionate funding of public health services 

compared with the public hospital system, which receives 10 times more 

government funds. Taiwanese officials cited problems in public health 

infrastructure, including the lack of equipment to deal with infectious 

patients in hospitals and underfunded laboratories.

Hospital Infection Control Another major weakness in public health capacity cited by health officials 

in China, Hong Kong, and Taiwan was a lack expertise in hospital infection 

control. In many SARS-affected areas, transmission of SARS to health care 

workers and other hospital patients was a significant factor sustaining the 

outbreak. In some instances, hundreds of hospital-acquired infections were 

due to inadequate isolation of individual patients and limited availability 

and use of personal protective equipment (masks, gowns, and gloves) for 

hospital workers. For example, in Taiwan, health officials reported that 

after initial success in rapidly identifying and isolating cases arriving from 

other SARS-affected areas, hospitals failed to recognize SARS cases 

occurring within Taiwan, resulting in a secondary, and much larger, 

outbreak in hospitals throughout the island. WHO, U.S. CDC, and 

Taiwanese officials told us that the number of physicians trained in 

infection control practices was inadequate and that infection control was 
Page 28 GAO-04-564 Emerging Infectious Diseases

not a priority for hospital management. In Hong Kong, the expert 

committee noted that there was no clear leadership from infection control 

doctors and that there were insufficient numbers of nurses trained in 

hospital infection control.22 In China, WHO officials noted in field reports 

that infection control procedures were rudimentary and relied on a range 

of measures, including disinfection of health care facilities, instead of the 

recommended isolation measures needed to limit spread to patients and 

health care workers.

Basic Public Health 

Strategies Eventually 

Worked to Control SARS 

Outbreak 

The SARS outbreak was ultimately brought under control by a more 

coordinated response that included the implementation of basic public 

health strategies. Measures such as improved screening and reporting of 

cases, rapid isolation of SARS patients, enhanced hospital infection control 

practices, and quarantine of close contacts were the most effective ways to 

break the chain of person-to-person transmission. 

Improved Screening and 

Reporting

Screening of patients with symptoms of SARS permitted the early 

identification of suspect cases during the early phase of illness. 

Furthermore, because SARS is transmitted when individuals have 

symptoms of the disease, detecting symptomatic patients was considered 

critical to stopping its spread. For example, in Beijing, fever clinics were 

established to screen people with fevers before presentation to hospitals or 

other health care providers to limit exposure to SARS. Between May 7 and 

June 9, 2003, there were 65,321 fever clinic visits. Through this effort, 47 

probable SARS cases were identified, representing only 0.1 percent of all 

fever clinic visits but 84 percent of all probable cases hospitalized during 

that period. In addition, policies were implemented requiring daily reports 

from all areas regardless of whether any SARS cases were found. In Hong 

Kong, designated medical centers were established to conduct medical 

monitoring of close contacts of SARS patients to ensure early detection of 

secondary cases. In Taiwan, hospital staff and other individuals who had 

contact with SARS patients in hospitals were monitored on a daily basis to 

detect SARS symptoms.

Rapid Isolation and Contact 

Tracing

The identification of patients with suspect and probable cases of SARS and 

their close contacts reduced the rate of contact between SARS patients and 

22SARS Expert Committee Report, “SARS in Hong Kong: From Experience to Action.”
Page 29 GAO-04-564 Emerging Infectious Diseases

healthy individuals in both community and hospital settings. For example, 

toward the end of the outbreak, one Chinese province decreased the 

average time between onset of SARS symptoms to hospitalization from 4 

days to 1, and the time to trace contacts of these patients from 1 day to less 

than half a day. These declines in the time for hospitalization and contact 

tracing generally coincided with a decrease in the number of new cases. In 

Hong Kong, officials facilitated tracing by linking a SARS database used by 

public health officials with police databases to track and verify the 

addresses of relatives and other close contacts of SARS patients. To limit 

the spread of SARS in the hospital system, specific hospitals were 

designated to treat suspected SARS patients in all SARS-affected areas. 

Another strategy in SARS-affected areas was the cancellation of school, 

large public gatherings, and holiday activities. For example, in China the 

weeklong May Day celebration was shortened.

Enhanced Hospital Infection 

Control

The widespread use of personal protective equipment helped contain the 

spread of SARS in hospitals. For example, in China, when hospital infection 

control measures were instituted toward the end of the outbreak in a 1,000-

bed hospital constructed exclusively for SARS patients, there were no 

further cases of SARS transmission in health care workers. Similarly in 

Hong Kong and Taiwan, these measures led to a decline in the number of 

infections in health care workers. In addition, in all these affected areas, 

guidelines were ultimately established for the use of personal protective 

equipment in outbreak situations. 

Quarantine Measures China, Taiwan, and Hong Kong implemented quarantine measures to 

isolate potentially infected individuals from the larger community, which, 

when restricted to close contacts of SARS patients, proved to be an 

efficient and effective public health strategy. In Hong Kong, for example, 

close contacts of SARS patients and people in high-risk areas were isolated 

for 10 days in designated medical centers or at home to ensure early 

detection of secondary cases. However, more wide-scale quarantine took 

place in Taiwan, where 131,000 individuals who had any form of contact 

with a SARS patient or traveled to SARS-affected areas were placed under 

quarantine, and in Beijing, where more than 30,000 people were 

quarantined. Analysis of data from these areas indicated that the 

quarantine of individuals with no close contact to SARS patients was not an 

effective use of resources. For example, among the 133 probable and 

suspect cases identified in Taiwan, most were found to have had direct
Page 30 GAO-04-564 Emerging Infectious Diseases

contact with a SARS patient.23 Similarly, researchers found that in Beijing, 

limiting quarantine to close contacts of actively ill patients would have 

been a more efficient strategy and a better use of resources.24

Asian Governments Have 

Efforts Under Way to Build 

Public Health Capacity for 

Future Outbreaks

Following the SARS epidemic, Asian governments have attempted to 

improve public health capacity, revise their legal frameworks for infectious 

disease control, increase regional communication and cooperation, and 

utilize international aid to improve preparedness. During our fieldwork, we 

met with public health representatives at various levels—from senior 

health ministry officials to local hospital health care workers—who 

provided information on efforts to improve public health capacity. For 

example, after the SARS outbreak the Chinese government provided 

additional budgetary support and expanded authority to improve 

coordination and communication. The government also devised a plan to 

build capacity in its weak rural health care system. In Hong Kong, the 

government focused its efforts on early detection and response to 

infectious disease outbreaks and is developing a Center for Health 

Protection focused on infectious disease control. Several drills were 

conducted to test the system, and the government has identified protecting 

populations in senior citizen homes, schools, and hospitals as a priority. In 

Taiwan, the government responded to public health management 

shortcomings by establishing a new public health command structure with 

centralized authority and decision-making power and making numerous 

changes in health leadership positions. The government invested public 

funds to upgrade its health infrastructure—for example, to construct fever 

wards, isolation rooms with negative pressure relative to the surrounding 

area, and other improvements in hospitals. 

The SARS outbreak also led to legal reforms specific to SARS control and 

the function of public health systems in SARS-affected areas. For example, 

China, Hong Kong, and Taiwan passed legislation or regulations during the 

outbreak that required clinicians and public health authorities to report 

cases of SARS. In China, regulations on the prevention of SARS were 

passed that, among other things, were intended to improve communication 

23“Use of Quarantine to Prevent Transmission of Severe Acute Respiratory Syndrome—

Taiwan 2003,” MMWR, vol. 52, no. 29 (July 25, 2003).

24“Efficiency of Quarantine during an Epidemic of Severe Acute Respiratory Syndrome—

Beijing, China 2003,” MMWR, vol. 52, no. 43 (Oct. 31, 2003). 
Page 31 GAO-04-564 Emerging Infectious Diseases

with the public and outline administrative or criminal penalties for officials 

who do not report SARS cases. 25 A broader set of regulations that may have 

a long-term impact was also passed that requires the creation of a unified 

command during public health emergencies, reporting of such emergencies 

within 2 hours, and improved public health capacity at all levels of the 

government.26 In Hong Kong, the law was revised to enhance the power of 

public health authorities to isolate cases and control the spread of SARS 

through international travel.27

Senior government officials have taken steps to improve public health 

communication and coordination in the region. Health officials in Hong 

Kong and Taiwan stated it is critical that information on disease outbreaks 

in mainland China be quickly reported so that neighboring governments 

can take preventive actions. A post-SARS agreement among Guangdong 

Province, Hong Kong, and Macau has thus far led to monthly sharing of 

information on a list of 30 diseases. A senior Chinese health official stated 

that the SARS outbreak taught the Chinese government the need for 

international cooperation in fighting infectious disease outbreaks. 

According to WHO officials, since the 2002-2003 SARS outbreak, they have 

experienced increased transparency and willingness on the part of the 

Chinese government to work with WHO health experts. 

The international community and the United States have committed 

financial and human resources to support the recent financial investments 

in public health capacity made by the Chinese government. For example, in 

July 2003 the World Bank announced a multidonor-supported program to 

strengthen disease surveillance and reporting and improve the skills of 

clinicians in China. The program is funded by US$11.5 million in loans from 

the World Bank, a 3 million British pound grant from the United Kingdom’s 

Department for International Development, a Can$5 million grant from the 

Canadian International Development Agency, and a US$2 million regional 

grant from the Japan Social Development Fund. HHS is in the process of 

25People’s Republic of China, “Regulations for the Management of Infectious Atypical 

Pneumonia,” May 13, 2003, published in 36 Chinese Law & Government 91(2003) (Fei-Ling 

Wang, trans).

26People’s Republic of China, “Regulations on Contingency Measures for Public Health 

Emergencies,” May 9, 2003, published in 36 Chinese Law and Government 76 (2003) (FeiLing Wang,tran).

27Laws of Hong Kong, Prevention of the Spread of Infectious Diseases, ch. 141B, regs. 27A 

and 27B (Apr. 17, 2003).
Page 32 GAO-04-564 Emerging Infectious Diseases

finalizing a multiyear, multimillion-dollar program of cooperation between 

HHS and the Chinese Ministry of Health aimed at strengthening China’s 

capacity in public health management, epidemiology, and laboratory 

capacity. As part of the initiative, CDC staff members will be stationed in 

China to help strengthen the epidemiology workforce.

SARS Outbreak 

Decreased Consumer 

Confidence and 

Negatively Affected a 

Number of Asian 

Economies

During the SARS outbreak, consumer confidence temporarily declined as a 

result of consumer fears about SARS and precautions taken to avoid 

contracting the disease. This decline in consumer confidence in turn led to 

economic losses in Asian economies estimated in the billions of dollars. 

Service sectors were hit the hardest due to declines in travel and tourism to 

areas with SARS outbreaks and declines in retail sales involving face-toface exchanges. Additionally, to counter economic losses associated with 

SARS, many Asian governments implemented costly economic stimulus 

programs. 

Impacts from SARS Are 

Estimated to Have Cost 

Billions, Although Most 

Economies Have Recovered

While the number of cases and associated medical costs for the SARS 

outbreak were relatively low compared with those for other major 

historical epidemics, the economic costs of SARS were significant because 

they derived primarily from fears about the disease and precautions to 

avoid the disease, rather than the disease itself. As shown in table 1, one 

industry and one official estimate of the economic cost of SARS in Asia 

calculated the net loss in total output at roughly $11 billion to $18 billion, 

respectively. (These estimates reflect changes in growth forecasts that 

were calculated concurrent with the outbreak. See app. III for a discussion 

of methodologies and varied assumptions used to obtain these estimates.) 

For example, the Far Eastern Economic Review estimates SARS’s 

economic costs in Asia at around $11 billion, with the largest losses in 

China, Hong Kong, and Singapore. The Asian Development Bank also 

shows the largest losses in these three economies, although they estimate 

the total cost at around $18 billion.28 As the Asian Development Bank 

reported, using its cost estimate, the cost per person infected with SARS 

was roughly $2 million. While economic costs associated with a general 

loss in consumer confidence are difficult to quantify exactly, they illustrate 

28These figures represent the net loss in GDP and take into account the potential decline in 

imports that acts to partially offset the potential decline in consumption or exports. As such, 

if the total loss in spending, rather than the net loss in GDP, is estimated, the Asian 

Development Bank’s cost estimate rises to $60 billion.
Page 33 GAO-04-564 Emerging Infectious Diseases

how emerging diseases and fears associated with those diseases can have 

widespread ramifications for a large number of economies.

Table 1: Estimated Economic Cost of SARS in Asia 

Source: GAO analysis of data from Far Eastern Economic Review and Asian Development Bank.

Note: Regional totals may include costs in Asian countries other than those listed in the table.

The economic cost of SARS in terms of a percentage loss in each selected 

Asian economy’s GDP has also been estimated by the Asian Development 

Bank and industry organizations at roughly 0.5 percent to 2 percent, with 

some variation among economies depending upon the importance of 

affected sectors in total output (see app. III for a more detailed discussion 

of these models’ assumptions and their GDP loss estimates per country).29

Figure 3 shows quarterly GDP growth for four Asian economies most 

affected by SARS—China, Hong Kong, Singapore, and Taiwan—and 

illustrates that GDP weakened in the second quarter of 2003, concurrent 

with the height of the SARS outbreak.30 However, given that the outbreak 

was brought under control by July 2003, the economic impacts were 

U.S. dollars in millions

Far Eastern Economic Review Asian Development Bank

China 2,200 6,100

Hong Kong 1,700 4,600

Malaysia 660 400

Singapore 950 2,700

Taiwan 820 1,300

Thailand 490 1,900

Vietnam 111 400

Region 10,700 18,000

29Some economies were more vulnerable to SARS than others due to structural issues, such 

as the relative share of tourism in the economy, government spending responses, and prior 

consumer sentiment. For example, Hong Kong and Singapore have larger estimated GDP 

losses due to SARS because of weakened consumption demand already apparent in late 

2002.

30We cannot, however, attribute viewed changes in quarterly GDP growth exclusively to 

SARS, given that other factors were relevant, such as the conflict in Iraq. Nonetheless, 

comparing Asian GDP growth rates with the average growth rate in Organization for 

Economic Cooperation and Development countries shows a much more distinct decline in 

the second quarter of 2003.
Page 34 GAO-04-564 Emerging Infectious Diseases

concentrated primarily in this second quarter. In fact, when WHO declared 

that the SARS outbreak was over in July 2003, pent-up demand during the 

outbreak likely contributed to an economic rebound in the third and fourth 

quarters. 

Figure 3: Quarterly GDP Growth for Various Asian Economies, 2002-2003

SARS Affected Asian 

Economies through a 

Variety of Channels

The SARS outbreak produced negative impacts on Asian economies 

through a variety of mechanisms. The most important channel through 

which SARS affected these economies was by temporarily dampening 

consumer confidence, particularly in the travel and tourism industry. In 

addition, decreased consumer confidence likely reduced retail sales and, to 

a lesser extent, some foreign trade and investment. Due to reduced 
Page 35 GAO-04-564 Emerging Infectious Diseases

demand, employment in affected economies fell. Some businesses also 

reported an increase in costs as business operations were disrupted, 

international shipments of goods and trade were hampered, and disease 

prevention costs rose.

The most severe economic impacts from SARS occurred in the travel and 

tourism industry, with airlines being particularly hard hit. As shown in 

figure 4, declines in regional airline traffic reached 40 percent to 50 percent 

in April and May, two months in which WHO travel advisories for Asia 

Pacific were in effect.31 The estimated percentage decline in overall 

tourism earnings amounted to 15 percent in Vietnam, 25 percent in China, 

and more than 40 percent in Hong Kong and Singapore, according to the 

World Travel and Tourism Council.32 Estimated job losses resulting from 

these SARS-related impacts were also significant. For example, the World 

Travel and Tourism Council estimated tourism sector job losses of around 

27,000 in Hong Kong and 18,000 in Singapore, while the World Bank 

estimated airline job losses in the region at around 36,000.33

31As with the quarterly decline in GDP, we cannot attribute the entire decrease in airline 

traffic to SARS, as the outbreak occurred during an already depressed market because of 

the war in Iraq.

32The World Travel and Tourism Association used its own model to generate its estimates for 

the dollars lost from the decline in tourism. As such, these numbers do not correspond 

equally to the estimates in table 1.

33The duration of estimated job losses is unknown. Travel and tourism in Asia has largely 

recovered, and International Airline Traffic Association forecasts for the industry are 

optimistic.
Page 36 GAO-04-564 Emerging Infectious Diseases

Figure 4: Estimated Economic Impacts of SARS on Travel and Tourism 

Dampened consumer confidence from SARS also had negative impacts on 

retail sales and foreign trade and investment, according to anecdotal 

evidence. The retail sector was negatively affected by the SARS outbreak 

as consumers curbed shopping trips and visits to restaurants in fear of 

contracting SARS. For example, China shortened the weeklong May Day 
Page 37 GAO-04-564 Emerging Infectious Diseases

celebration that it introduced in 1999 to stimulate private consumption. As 

shown in figure 5, retail sales fell concurrent with the SARS outbreak in 

China, Hong Kong, Singapore, and Taiwan, a decline particularly important 

for Hong Kong and Taiwan due to their large retail sectors. However, the 

rebound in consumer confidence is also illustrated by an increase in retail 

sales in the third quarter of 2003. Regarding foreign trade and investment, 

trends in these variables indicate less distinct SARS-related declines.34

Nonetheless, there is some indication of the impact of SARS on these 

activities, such as the reduced sales at the major Guangzhou Trade Fair in 

China, which totaled only 26 percent of the previous year’s amount, or the 

lagged effect of a decrease in foreign direct investment into China in July 

2003. 

34Foreign trade and investment were more resilient than consumption during the initial 

stages of the outbreak such that estimated economic effects were less significant due to the 

rapid rebound of Asian economies in the third quarter of 2003.
Page 38 GAO-04-564 Emerging Infectious Diseases

Figure 5: Quarterly Retail Sales Growth in Selected Asian Economies, 2002-2003

Asian Governments 

Provided Economic 

Stimulus Packages That 

Cost Billions

In response to SARS, governments in Asia implemented economic stimulus 

packages that also cost billions of dollars. Asian governments provided 

spending for medical and public health sectors to prevent and control the 

spread of SARS as well as for fiscal policy programs to more generally 

stimulate the economy. As shown in table 2, the Asian Development Bank 

estimates that the cost of these stimulus packages in the region could total 

nearly $9 billion. While many of the spending and tax measures are 

designed to improve GDP growth, they can also be considered an economic 

cost of SARS due to the diversion of government expenditures away from 

investments in needed public services. 
Page 39 GAO-04-564 Emerging Infectious Diseases

Table 2: Asian Government Stimulus Packages in Response to SARS, 2003 

Source: GAO analysis of Asian Development Bank data.

WHO Members Will 

Debate Important 

Issues Raised by 

International Health 

Regulations’ Revision 

The SARS epidemic elevated the importance of the International Health 

Regulations’ revision process. The proposed revisions, currently in draft 

form and scheduled for completion in May 2005, would expand the 

regulations’ coverage and encourage better cooperation between member 

states and WHO. Member states will have to resolve at least five important 

issues, regarding (1) scope of coverage, (2) WHO’s authority to conduct 

investigations in countries absent their consent, (3) the public health 

capacity of developing country members, (4) an enforcement mechanism 

to resolve compliance issues, and (5) how to ensure public health security 

without unnecessary interference with travel and trade.

Revisions Would Expand 

Coverage and Facilitate 

Cooperation, but Key 

Questions Remain 

The draft regulations expand the scope of reporting beyond the current 

three diseases to include all events potentially constituting a public health 

emergency of international concern, such as SARS. They also promote 

enhanced member state cooperation with WHO and other countries. 

Additional changes under consideration include (1) designating national 

focal points with WHO for notification of public health emergencies and (2) 

requiring minimum core surveillance and response capacities at the 

national level to implement a global health security strategy. The overall 

(U.S. dollars in millions)

Type of package Cost of package

China • Temporary tax relief and subsidies for affected 

industries

• Free medical treatment for the poor and some price 

controls on SARS-related drugs and goods 3,500

Hong Kong • Temporary tax relief, job creation, and loan 

guarantee schemes 1,500

Malaysia • Loan programs, support for tourism-related 

industries, and job training 1,920

Singapore • Temporary reduction in tourism and transport 

administrative fees, and relief measures for airlines 132

Taiwan • Partial reimbursement of business-related losses 

for affected industries

• Partial reimbursement for medical costs 1,400 

Thailand • General funding allocated as emergency budget 468
Page 40 GAO-04-564 Emerging Infectious Diseases

goal of the revision process is to create a framework under which WHO and 

others can actively assist states in responding to international public health 

risks by directly linking the revised regulations to the work of GOARN. 

Nevertheless, the draft regulations contain several provisions that have 

been the subject of ongoing debate, including: 

• Scope of coverage. As part of the revision process, WHO has 

developed criteria to determine whether an outbreak is serious, 

unexpected, and likely to spread internationally. Furthermore, the draft 

regulations broaden the definition of a reportable disease to include 

significant illness caused by biological, chemical, or radionuclear 

sources. In its initial comments to WHO on the draft regulations, the 

U.S. government supported the use of criteria for determining what 

would be a public health emergency of international concern. 

Nevertheless, the U.S. strongly believed that the draft should also 

require reporting of a defined list of certain known, serious, 

communicable diseases that have the potential for creating such a 

concern. 

• Authority to conduct investigations. Member states are considering 

the appropriate level of authority for the regulations. Specifically, an 

unresolved issue is the degree to which the regulations will require 

binding international commitments or more voluntary standards. To 

address this issue, member states are examining whether the benefits 

that would result from agreeing to more rigorous, comprehensive, and 

mandatory regulations would outweigh losses in sovereignty. For 

example, the draft regulations eliminate the language in the current 

regulations that specifically requires WHO to first obtain consent from 

the member state involved before conducting on-the-spot investigations 

of disease outbreaks.35 However, the draft regulations are still somewhat 

ambiguous about whether consent is necessary.36 According to a senior 

35According to WHO officials, the language in the draft regulations dealing with conducting 

on-the-spot investigations was intended to closely reflect wording used in World Health 

Assembly Resolution 58.28, adopted on May 28, 2003, which among other things, urged 

WHO members to give high priority to IHR revision.

36For example, article 8(3) of the draft regulations states that “the health administration in 

whose territory the alleged event . . . is occurring shall collaborate with WHO in assessing 

the potential for international disease spread and possible interference with international 

traffic and the adequacy of control measures and, when necessary, in conducting on-thespot studies by a team sent by WHO . . .” (emphasis added).
Page 41 GAO-04-564 Emerging Infectious Diseases

WHO official, the proposed regulations were intentionally left vague 

about consent because it is a subject that members will want to debate 

thoroughly.

• Public health capacity of developing countries. The draft 

regulations provide member states with direction regarding the 

minimum core surveillance and response capacities required at the 

national level, including at airports, ports, and other points of entry. 

However, U.S. and WHO officials note that many developing countries 

currently lack even the most rudimentary public health capacity and will 

be dependent on significant international assistance to reach minimum 

surveillance and response capabilities. HHS officials have expressed 

caution about developing more comprehensive and demanding 

requirements that will be difficult for many countries with limited 

resources to implement. WHO officials acknowledge that, while WHO is 

able to provide technical assistance through GOARN, multilateral 

institutions, such as the World Bank, and donor countries will have to 

provide significant resources for developing countries to meet minimum 

surveillance and response requirements. A WHO official also indicated 

that while the proposed revisions to the regulations do not have specific 

provisions on technical assistance, developing countries are likely to 

raise the issue of adding such a provision during the revision process.

• Enforcement mechanism. The members will have to address what 

kind of enforcement mechanism they want included in the regulations 

to resolve compliance issues and to deal with violations of the 

regulations. According to WHO officials, failure to comply with WHO 

public health requirements is often a problem. The draft regulations, like 

the current regulations, include a nonbinding mechanism for resolving 

disputes. Thus, the WHO Director-General is directed either to (1) make 

every effort to resolve disputes or (2) refer disputes to a WHO Review 

Committee, which is tasked to forward its views and advice to the 

parties involved. Although WHO would continue to be dependent on the 

voluntary compliance of member states, WHO officials believe that if 

key countries (such as the United States) and neighboring trade 

partners are sufficiently concerned about the dangers of emerging 

diseases to press for compliance with the revised regulations, other 

countries are likely to fulfill their obligations. Furthermore, though it is 

too early to predict how China’s response to SARS in 2003 will affect 

future compliance, WHO officials say the negative political, economic, 

and public health effects China suffered from its initial response to 
Page 42 GAO-04-564 Emerging Infectious Diseases

SARS served as a warning to countries that ignore their international 

public health responsibilities.

• International traffic. The stated purpose of the draft regulations, 

which is similar to the current regulations, is to provide security against 

the international spread of disease while avoiding unnecessary 

interference with international traffic. Although the term international 

traffic appears to refer to international travel and trade, neither the 

proposed nor the current regulations define the term. Furthermore, the 

draft regulations do not include detailed criteria for determining what 

constitutes interference with international trade and travel.37 A WHO 

official indicated that it was preferable not to include detailed criteria 

and to allow this issue to be decided on a case-by-case basis because of 

the very broad range of situations that could ultimately cause such 

interference. This issue could receive a good deal of attention in the 

revision process as member states try to balance medical and economic 

concerns. According to WHO officials, in past epidemics, concerns 

about economic loss and restrictions on trade and travel caused some 

countries not to report outbreaks within their borders and to refuse 

international assistance. Furthermore, for certain outbreaks—for 

example, those involving cholera in Peru in 1991 and plague in India in 

1994—some experts reported that the international response may have 

exceeded the level of threat and led to unwarranted trade and travel 

losses in those countries.

Completing the Revision 

Process Seen as High 

Priority 

The process for revising the International Health Regulations was 

intensified by a WHO World Health Assembly resolution passed in May 

2003, during the SARS outbreak, urging members to give high priority to the 

revision process and to provide the resources and cooperation to facilitate 

this work.38 The resolution also requested that the WHO Director-General 

consider informal sources of information to respond to outbreaks such as 

SARS; collaborate with national authorities in assessing the severity of 

infectious disease threats and the adequacy of control measures; and, when 

necessary, send a WHO team to conduct on-the-spot studies in places 

37The draft regulations only state that “significant interference” is a “refusal of entry or 

departure or delaying entry or departure for more than 24 hours, for travelers and 

conveyances.” WHO, Proposed International Health Regulations, art. 7.4.

38WHO, World Health Assembly Res. 56.28 (May 28, 2003).
Page 43 GAO-04-564 Emerging Infectious Diseases

experiencing infectious disease outbreaks. Although the resolution did not 

impose legally binding obligations on members, according to WHO officials 

and some observers it did lay the political groundwork for improved 

international cooperation on infectious disease control.

In January 2004, WHO distributed to its member states an interim draft of 

the revisions proposed by the WHO Secretariat. Composed of 55 articles 

and 10 technical annexes, the draft will be discussed in a series of regional 

consultations throughout 2004. The degree of consensus on the draft’s 

technical and political issues will then determine the need for subsequent 

meetings at the global level. The goal is to convene an intergovernmental 

working group at the end of 2004 to finalize revisions to the draft 

regulations. It is hoped the regulations will then be ready for submission to 

the 58th World Health Assembly in May 2005. However, according to WHO 

and HHS officials, reaching both technical and political consensus on the 

regulations will be a difficult task, and they expect the revision process to 

extend beyond its target date.

Conclusion While the 2002-2003 SARS outbreak had an impact on health and commerce 

in Asia, the extensive response by WHO and Asian governments, supported 

in large measure by the U.S. government, was ultimately effective in 

controlling the outbreak. This event highlighted a number of important 

issues, including the limited resources to support WHO’s global infectious 

disease network and deficiencies in Asian governments’ public health 

systems. It also revealed limitations in the International Health 

Regulations. 

In the aftermath of SARS, WHO and member states have recognized the 

importance of strengthening international collaboration and cooperation to 

respond to global infectious disease outbreaks. To be successful, this effort 

will require a greater commitment of resources for global infectious 

disease control and a concerted effort to revise the International Health 

Regulations to make them more relevant and useful in future outbreaks. As 

the regulations are revised, WHO and member states face the challenge of 

improving the management of disease outbreaks while mitigating adverse 

economic impacts. The content, manner of acceptance, and means of 

enacting the final revisions are not certain, and much work remains to be 

done to resolve outstanding issues. As of April 2004, SARS has not reemerged to cause another major international outbreak, but outbreaks of 

other infectious diseases can be expected in the future. Therefore, 
Page 44 GAO-04-564 Emerging Infectious Diseases

strengthening public health capacity will be essential for responding to 

future infectious disease outbreaks. 

The SARS outbreak also revealed gaps in U.S. government protective 

measures, including difficulties in arranging medical evacuations from 

overseas and the inability to trace and contact individuals exposed to SARS 

during travel. In regard to tracing international travelers who may have 

been exposed to an infectious disease, we believe that amending HHS 

regulations to specify that the agency has authority to obtain this 

information would assist this effort. This action would facilitate HHS’s 

ability to obtain necessary contact information (1) from airlines or shipping 

companies that may have concerns about sharing passenger information 

with HHS, or (2) in the event that issues involving coordination with other 

federal agencies cannot be effectively resolved. 

Recommendations for 

Executive Action

This report is making three recommendations to improve the response to 

infectious disease outbreaks. First, to strengthen the international 

response, we recommend that the Secretary of Health and Human Services, 

in collaboration with the Secretary of State, work with WHO and official 

representatives from other WHO member states to strengthen WHO’s 

global infectious disease network capacity to respond to disease 

outbreaks, for example, by expanding the available pool of public health 

experts.

Second, to help Health and Human Services prevent the introduction, 

transmission, or spread of infectious diseases into the United States, we 

recommend that the Secretary of HHS complete the necessary steps to 

ensure that the agency can obtain passenger contact information in a 

timely and comprehensive manner, including, if necessary, the 

promulgation of regulations specifically for this purpose. 

Third, to protect U.S. government employees and their families working 

overseas and to better support other U.S. citizens living or traveling 

overseas, we recommend that the Secretary of State continue to work with 

the Secretaries of Health and Human Services and Defense to identify 

public and private sector resources for medical evacuations during 

infectious disease outbreaks and develop procedures for arranging these 

evacuations. Such efforts could include
Page 45 GAO-04-564 Emerging Infectious Diseases

• working with private air ambulance companies and the Department of 

Defense to determine their capacity for transporting patients with an 

emerging infectious disease such as SARS, and

• working to develop agreements under which U.S. medical facilities near 

international ports of entry will accept medically evacuated patients 

with infectious diseases such as SARS.

Agency Comments and 

Our Evaluation

HHS, State, and WHO provided written comments on a draft of this report 

(see apps. IV, V, and VI for a reprint of HHS’s, State’s, and WHO’s 

comments). They also provided technical and clarifying comments that we 

have incorporated where appropriate. HHS said the report is a good 

summary of the SARS outbreak in Asia and the actions taken by WHO, 

affected countries, and U.S. agencies. HHS stated that the report’s 

recommendations are appropriate and emphasized the national and 

international interagency collaboration that will be required to implement 

them in preparation for the next epidemic. HHS also noted that to carry out 

some of the recommendations, sensitive legal and privacy issues and 

diplomatic concerns must be carefully addressed. HHS also noted that the 

report contains a useful overview of WHO’s efforts to revise its 

International Health Regulations and correctly ties WHO’s increased effort 

to the impact of SARS and lessons learned. In that regard, HHS provided 

additional information on coordination and collaboration efforts it took 

during the outbreak.

State indicated that the report is a useful summary of the SARS outbreak 

and its impact and documents important lessons for other infectious 

disease outbreaks beyond the 2003 SARS epidemic. Regarding our first 

recommendation, State said it is committed to working with WHO and its 

member states to strengthen the response capacity of WHO’s global 

infectious disease network. Regarding our recommendation on contact 

tracing of arriving passengers infected or exposed to infectious disease, 

State noted that it has been working on this issue with its interagency 

partners since the SARS outbreak but underscored that serious legal issues 

still exist for both the United States and other governments. State also 

agreed with our recommendation on developing procedures for arranging 

medical evacuations during an airborne infectious disease outbreak. State 

indicated that it is working with CDC to develop protocols on how to 

handle medical evacuations for quarantinable diseases but noted that 

capacity for such medical evacuations will be limited, as will capacity of 

U.S. medical facilities to handle a large influx of patients.
Page 46 GAO-04-564 Emerging Infectious Diseases

WHO stated that, overall, the report provides a factual analysis of the 

events surrounding the emergence of SARS and addresses the major 

weaknesses in national and international control efforts. WHO noted, 

however, that the report presents major criticisms of the response by 

China, Hong Kong, and Taiwan to SARS but does not reflect these 

governments’ actions throughout the SARS epidemic or the depth and 

intensity of their control efforts later on. WHO also stated that the report 

puts little emphasis on other countries that experienced problems—

Canada, for example. We disagree that the report does not adequately 

balance the governments’ shortcomings with accomplishments, as the 

report includes specific sections on improved screening and reporting of 

SARS cases, rapid isolation and contact tracing, enhanced hospital 

infection control practices, and quarantine measures. The report details 

steps Asian governments have taken in response to SARS to build capacity 

for future outbreaks. The preponderance of our evidence on Asian 

governments’ response was provided directly by Chinese, Hong Kong, and 

Taiwan government and public health officials and from post-SARS 

evaluation reports produced by these governments and WHO-sponsored 

conferences. We focused our report on the response of China, Hong Kong, 

and Taiwan since 95 percent of the SARS cases occurred there. The 

response of other countries, such as Canada was outside the scope of our 

examination. 

Regarding our discussion of WHO’s global infectious disease network, 

WHO stated that GOARN is one of the mechanisms by which WHO 

mobilizes technical resources for outbreak investigation and response 

provided further information about the role of the Western Pacific Regional 

Office (WPRO) in the SARS response. We clarified the role of GOARN and 

expanded our discussion on the activities of WPRO. WHO also said that its 

response was challenged, but not constrained, by limited resources. While 

we agree with this more general characterization, we believe that not being 

able to obtain the appropriate multidisciplinary staff and sustain a response 

over time were significant constraints that warrant serious attention in 

preparing for future emerging infectious diseases. WHO also noted that the 

world’s dependence on a fragile process and on the personal commitment 

and sacrifice of WHO and GOARN staff is a concern.

Scope and 

Methodology

To assess WHO’s actions to respond to SARS in Asia, we analyzed WHO 

policy, program, and budget documents, including WHO’s Web-based 

situation updates and guidelines that served as the primary instrument for 

disseminating information on SARS. We interviewed WHO officials 
Page 47 GAO-04-564 Emerging Infectious Diseases

responsible for managing the international response at WHO headquarters 

in Geneva and public health specialists who served on country teams that 

were deployed to Asia. We examined WHO’s GOARN, including its guiding 

principles and how it operated during the SARS outbreak. We also 

interviewed Asian government officials in Beijing, Guangdong Province, 

Hong Kong, and Taipei who received WHO’s technical advice and support; 

U.S. government officials; and recognized experts within the public health 

community.

To assess the role of the U.S. government in responding to SARS in Asia 

and limiting its spread into the United States, we analyzed program 

documents and interviewed officials from the Departments of Health and 

Human Services, State, Defense, and Homeland Security, and the U.S. 

Centers for Disease Control and Prevention (CDC). To examine CDC’s 

ability to trace travelers who may have been exposed to an infectious 

disease, we interviewed officials from the Air Transport Association and 

the Department of Transportation and reviewed applicable legislation and 

regulations. To assess State’s ability to provide medical evacuation of U.S. 

citizens, we examined CDC guidelines on air transport of SARS patients 

and interviewed officials from major private medical evacuation 

companies. We also interviewed U.S. embassy (Beijing), consulate (Hong 

Kong and Guangzhou), and American Institute in Taiwan officials 

responsible for managing the U.S. government response at the country 

level.

To describe how governments in Asia responded to the SARS outbreak, we 

focused on those parts of Asia most affected by SARS in the 2002-2003 

outbreak, including China, Hong Kong, and Taiwan. While in the region, we 

met with public health officials at various levels responsible for managing 

their governments’ public health response, including senior ministry of 

health and provincial and municipal government officials, as well as 

hospital administrators and health care workers. We also examined 

government documents on public health programs and post-SARS 

evaluations, and reviewed applicable China, Hong Kong, and Taiwan laws 

and regulations.

To describe the economic impact of SARS in Asia, we reviewed impact 

estimates provided by (1) the Asian Development Bank’s Economic and 

Research Department, which used a simulation model from Oxford 

Economic Forecasting; (2) a simulation model using data from the Global 
Page 48 GAO-04-564 Emerging Infectious Diseases

Trade Analysis Project Consortium;39 and (3) a simulation model by Global 

Insight, a leading U.S. economic data and forecasting firm. Specifics of 

each of these models are discussed in appendix III. Another organization, 

the Far Eastern Economic Review, a regional economic business weekly, 

gathered studies and data on SARS and reported a summary cost estimate 

that we also reviewed. To supplement our analysis of these impact 

estimates, we examined trends in official macroeconomic data as reported 

by the countries’ central banks or departments of statistics, the Asian 

Development Bank, the Organization for Economic Cooperation and 

Development, and the World Travel and Tourism Association.40 Trends in 

international airline traffic were obtained from the International Air 

Transport Association. We corroborated our findings with information 

provided by the U.S. National Intelligence Council and interviews with 

government officials in Asia. 

Finally, to examine the status of efforts to update the International Health 

Regulations, we reviewed the current International Health Regulations, a 

draft of WHO’s proposed revision of the regulations, the initial U.S. 

government response to the proposed revisions, and the WHO constitution. 

We also interviewed WHO and U.S. government officials who are actively 

engaged in the revision process and other legal experts to determine the 

potential impacts of the revised rules. 

We performed our work from July 2003 to April 2004 in accordance with 

generally accepted government auditing standards.

We are sending copies of this report to the Secretaries of Health and 

Human Services, State, and Defense; appropriate congressional 

committees; and other interested parties. We will also make copies 

available to others upon request. In addition, the report will be available at 

no charge on GAO’s Web site at http://www.gao.gov.

39Jong-Wha Lee and Warwick J. McKibbon, “Globalization and Disease: The Case of SARS, 

Working Paper No. 2003/16,” Research School of Pacific and Asian Studies, Australian 

National University and the Brookings Institution, Washington, D.C. (2003).

40To determine the reliability of the official national accounts data, we verified that the 

general patterns reported were consistent with other documentary evidence and reviewed 

each economy’s compliance with the International Monetary Fund’s data dissemination 

standards. We conclude that the data is sufficiently reliable for the purposes of establishing 

decreased economic activity during the second quarter of 2003.
Page 49 GAO-04-564 Emerging Infectious Diseases

If you or your staff have any questions, please contact one of us. Other 

contacts and key contributors are listed in appendix VII.

Sincerely yours,

David Gootnick

Director, International Affairs and Trade

Janet Heinrich

Director, Health Care—Public Health Issues
Page 50 GAO-04-564 Emerging Infectious Diseases

Appendix I

SARS Cases and Deaths, November 2002–July Apendxies

2003 ApendxiI
Appendix I

SARS Cases and Deaths, November 2002–

July 2003

Page 51 GAO-04-564 Emerging Infectious Diseases

Note: Numbers represent cases and deaths.
Page 52 GAO-04-564 Emerging Infectious Diseases

Appendix II

SARS Chronology ApendxiI

Appendix II lists key worldwide events during the SARS outbreak, from 

November 2002, when the disease first emerged, to the most recent 

reported cases in January 2004.

Year Location Event

2002

November 16 Guangdong 

Province, Chinaa

First known case of atypical pneumonia, later determined to be SARS. 

November 23 Beijing World Health Organization (WHO) influenza expert attends workshop in Beijing and learns 

from a participant from Guangdong Province of a “serious outbreak with high mortality and 

involvement of health care staff.”

November 27 Canada Global Public Health Intelligence Network (GPHIN) picks up reports of a “flu outbreak” in 

China.

Mid-December WHO 

Headquarters, 

Geneva 

WHO requests further information from China on the influenza outbreak. Chinese 

government replies that influenza activity in Beijing and Guangdong is normal and that 

surveillance system detected no unusual strains of the virus. 

December 10 Guangdong 

Province

Infection in second city in Guangdong Province. 

2003

January 23 Guangdong 

Province 

Guangdong’s provincial health authorities produce a report about the outbreak detailing the 

nature of transmission, clinical features, and suggested preventive measures. The report is 

circulated to hospitals in the province, but is not shared with WHO or Hong Kong. 

February 10-11 Multiple Locations WHO Beijing office, Global Outbreak and Alert Response Network (GOARN) partners, and 

U.S. Centers for Disease Control (CDC) receive reports of a “strange contagious disease” 

and “pneumonic plague” causing deaths in Guangdong Province. 

February 14-20 China, Hong Kong Chinese Center for Disease Control and Prevention erroneously announces that the probable 

causative agent of the atypical pneumonia is Chlamydia. At the same time, cases of avian 

influenza in a family that traveled between Hong Kong and China result in two deaths. This 

leads to speculation that the atypical pneumonia outbreak is caused by avian influenza. WHO 

activates its global influenza laboratory network and calls for heightened global surveillance.

February 21 Hong Konga First superspreader event in Hong Kong: A physician from Guangdong Province stays at the 

Metropole Hotel in Hong Kong and is soon hospitalized with respiratory failure. While at the 

hotel, he transmits the disease to at least 16 other people. 

February 23 China A team of WHO experts, including CDC staff, arrives in Beijing but is given limited access to 

information; Chinese authorities deny WHO’s repeated requests for permission to travel to 

Guangdong Province. 

February 24 WHO

Headquarters, 

Geneva

GPHIN detects Chinese newspaper report that more than 50 hospital staff in Guangzhou are 

infected with “mysterious pneumonia.”

February 26 Vietnama Chinese-American businessman admitted to the French Hospital in Hanoi with fever and 

respiratory symptoms. 
Appendix II

SARS Chronology

Page 53 GAO-04-564 Emerging Infectious Diseases

February 28 Vietnam WHO official Dr. Carlo Urbani notifies WHO office in Manila of an unusual disease. WHO 

headquarters moves to heightened state of alert.

Early March United States State Department establishes an intradepartmental working group to deal with impact of 

outbreak.

March 1 Singaporea

 Woman who stayed at the Metropole Hotel in Hong Kong is hospitalized with respiratory 

symptoms.

March 4 Hong Kong Second superspreader event in Hong Kong: a resident who had visited the Metropole Hotel is 

admitted to hospital with respiratory symptoms; within a week, at least 25 hospital staff, all 

linked to the patient’s ward, develop respiratory illness.

March 5 Canadaa Toronto woman who also stayed at the Metropole Hotel in Hong Kong dies at home. Shortly 

after, her son becomes ill, is admitted to Scarborough Grace Hospital, and dies. His 

admission triggers an outbreak at the hospital. 

March 8 Taiwana Businessman with travel history to Guangdong Province is hospitalized with respiratory 

symptoms.

March 10 China Chinese Health Ministry asks WHO for technical and laboratory support to clarify cause of 

the Guangdong outbreak of atypical pneumonia. 

March 12 WHO

Headquarters, 

Geneva

WHO issues global alert about cases of severe atypical pneumonia following mounting 

reports of spread among hospital staff in Hong Kong and Hanoi. CDC offers assistance to 

WHO.

March 13 WHO

Headquarters, 

Geneva

WHO sends emergency alert to GOARN partners.

March 14 United States CDC activates Emergency Operations Center. 

March 15 WHO

Headquarters, 

Geneva

WHO issues rare global travel advisory, names the mysterious illness “severe acute 

respiratory syndrome” (SARS), and declares it a “worldwide health threat.” WHO issues its 

first definitions of suspect and probable cases, calls on travelers to be aware of symptoms, 

and issues advice to airlines.

March 15 United Statesa

 CDC issues travel advisory suggesting postponement of nonessential travel to Hong Kong, 

Guangdong Province, and Hanoi. CDC issues preliminary case definition for suspected 

SARS and initiates domestic surveillance for SARS. First suspected U.S. case is identified.

March 16 United States CDC begins distributing health alert cards to passengers arriving from Hong Kong at four 

international airports.

Mid-March Taiwan CDC team arrives in Taiwan to assist in SARS response.

March 17 WHO

Headquarters, 

Geneva, and 

multiple locations

WHO sets up worldwide network of laboratories to expedite detection of causative agent and 

to develop a robust and reliable diagnostic test. A similar network is set up to pool clinical 

knowledge on symptoms, diagnosis, and management. A third network is set up to study 

SARS epidemiology. 

March 28 China China joins WHO’s collaborative networks, initially set up on March 17.

March 30 Hong Kong Third superspreader event in Hong Kong: Health authorities announce that 213 residents of 

Amoy Gardens housing estate have been hospitalized with SARS. 

April 2 WHO

Headquarters, 

Geneva

WHO issues most stringent travel advisory in its 55-year history, recommending that people 

postpone all but essential travel to Hong Kong and Guangdong Province until further notice.

April 3 China WHO team arrives in Guangdong.

(Continued From Previous Page)

Year Location Event
Appendix II

SARS Chronology

Page 54 GAO-04-564 Emerging Infectious Diseases

April 4 United States President Bush signs executive order adding SARS to the list of quarantinable communicable 

diseases. This order provides CDC, through its Division of Global Migration and Quarantine, 

with the legal authority to implement isolation and quarantine measures.

April 16 WHO

Headquarters, 

Geneva

WHO laboratory network announces conclusive identification of SARS causative agent: a 

new coronavirus.

April 19-20 China Change in political stance by Chinese leadership. Top leaders advise officials not to cover up 

cases of SARS; mayor of Beijing and Health Minister, both of whom downplayed the SARS 

threat, are removed from their posts.

April 28 Vietnam First country to successfully contain its outbreak of SARS.

May 2 United States State Department holds interagency meeting on SARS. 

May 3 Taiwan WHO sends officials to Taiwan to assist CDC team.

May 17 WHO

Headquarters, 

Geneva

First global consultation on SARS epidemiology concludes its work, confirming that available 

evidence supports the control measures recommended by WHO. 

May 27 WHO

Headquarters, 

Geneva

World Health Assembly resolution recognizes the severity of the threat that SARS poses and 

calls on all countries to report cases promptly and transparently. A second resolution 

strengthens WHO’s capacity to respond to disease outbreaks.

June 17-18 Malaysia WHO holds Global Conference on SARS to review scientific findings on SARS and examine 

public health interventions to contain it.

July 5 WHO

Headquarters, 

Geneva

WHO announces that the global SARS outbreak has been contained.

September 8 Singapore Singapore announces that a medical researcher is infected with SARS. Based on an 

investigation of this incident, WHO concludes that the patient was accidentally infected in the 

laboratory.

December 17 Taiwan Taiwan announces that a researcher is infected with SARS. Public health authorities 

conclude that the infection was acquired in a laboratory.

December 20-

January 5, 2004

China A man in Guangdong Province is hospitalized with SARS-like symptoms on December 20. 

Chinese authorities inform WHO on December 26. After initial diagnostic tests are 

inconclusive, authorities send the samples to two WHO-designated reference laboratories in 

Hong Kong. On January 5, the laboratories confirm that the patient has SARS. None of the 

patient’s contacts contracted SARS. 

December 31-

January 17, 2004

China A woman in Guangdong Province is hospitalized with SARS-like symptoms on December 31. 

Chinese authorities inform WHO and samples are submitted to two WHO-designated 

reference laboratories in Hong Kong. On January 17, Chinese authorities announce that the 

patient has SARS. None of the patient’s contacts contracted SARS. 

2004

January 6-27 China A man in Guangdong Province is hospitalized with SARS-like symptoms on January 6. 

Chinese authorities inform WHO and samples are submitted to WHO-designated reference 

laboratories in Hong Kong. On January 27, WHO announces that the patient has probable 

SARS. 

(Continued From Previous Page)

Year Location Event
Appendix II

SARS Chronology

Page 55 GAO-04-564 Emerging Infectious Diseases

Source: GAO analysis of WHO and CDC data.

a

Date of the first known case(s) of SARS.

January 7-30 China A doctor in Guangdong Province becomes ill with SARS-like symptoms and is diagnosed 

with pneumonia on January 14. However, he was not properly isolated in hospital until 

January 16, he was not declared as a suspected SARS case to China’s Ministry of Health 

until January 26, and WHO was not informed until January 30.

January 9-16 China A team of international experts from WHO conducts a joint investigative mission in 

Guangdong Province with colleagues from China’s Ministry of Health, Ministry of Agriculture, 

the Chinese Center for Disease Control and Prevention, and the Guangdong Center for 

Disease Control and Prevention to identify the sources of infection of the most recent SARS 

cases. The team finds no definitive source of infection for any of the cases.

(Continued From Previous Page)

Year Location Event
Page 56 GAO-04-564 Emerging Infectious Diseases

Appendix III

Estimates of the Economic Impact of SARS ApendxiI

Estimates of the economic impact of SARS have been produced by multiple 

sources and vary due to the inexact nature of estimating the impact of a 

recent event such as SARS. When the SARS outbreak first emerged, a 

number of institutions began estimating the potential economic impact of 

the disease. These institutions included private investment banks, industry 

organizations, academics, consulting firms, and international financial 

institutions such as the Asian Development Bank. To produce their 

estimates, assumptions had to be incorporated regarding the expected 

duration of SARS, the number of sectors affected, and country-specific 

macroeconomic conditions. As such, estimates of economic impact have 

been broad in nature, have varied depending on model assumptions, and 

were often revised when actual data were received. For example, some of 

the initial economic impact estimates were revised downward once data 

emerged showing China’s strong economic growth during the first 4 

months of 2003. 

To describe the economic impact of SARS in Asia, we primarily relied on 

impact estimates generated from institutions using simulation models. 

Table 3 provides information on the models we reviewed. As the table 

shows, each of these models was used to analyze a low scenario case and a 

high scenario case, which differed based on assumptions regarding the 

expected duration of the SARS outbreak and hence the expected duration 

of the shock to the economy resulting from SARS. To accord with the 

shorter duration of the actual outbreak, the low scenario results estimated 

the economic impact of SARS at roughly 0.5 percent to 2 percent of gross 

domestic product (GDP).1

 All three models show that the largest economic 

impacts as a percentage of GDP were estimated for Hong Kong and 

Singapore, which is due to their previously lowered consumption demand 

and high share of tourism and retail.

1

The International Monetary Fund announced in April 2003 that the estimated decline in 

GDP due to SARS was 0.2 percent for China and 0.4 percent for East Asia. The World Bank’s 

East Asia Update in April 2003 also provided an estimate of the decline in GDP due to SARS 

at 0.3 percent for East Asia. However, neither organization has published a model to 

describe how it arrived at these estimates.
Appendix III

Estimates of the Economic Impact of SARS

Page 57 GAO-04-564 Emerging Infectious Diseases

Table 3: Models Estimating the Economic Impact of SARS on GDP in Asia, 2003

Source: GAO analysis of studies from the Asian Development Bank, Brookings Institution, and Global Insight. 

In addition to the model estimates provided in table 3, we also reviewed 

SARS cost estimates provided by the Far Eastern Economic Review. The 

Far Eastern Economic Review’s estimate of $11 billion was generated by 

calculating an average estimated percentage loss in GDP using reports 

Estimated decline in GDP (percentage)

Source Model description Key assumptions Country

Low 

scenario

High 

scenario

Asian Development Bank:

May 2003 ERD Policy Brief 

No. 15 

Simulation model from 

the Oxford Economic 

Forecasting consulting 

firm 

Low scenario: SARS shock 

lasts through second quarter 

of 2003

High scenario: SARS shock 

extends into third quarter of 

2003

China 

Hong Kong 

Malaysia

Singapore 

Taiwan

Thailand

0.2

1.8

0.6

1.1

0.9

0.7

0.5

4.0

1.5

2.3

1.9

1.6

Jong-Wha Lee and 

Warwick McKibbin:

 “Globalization and Disease: 

The Case of SARS,” Working 

Paper No. 2003/16, 

Research School of Pacific 

and Asian Studies, 

Australian National 

University and the Brookings 

Institution, Washington, D.C. 

(2003)

“G-Cubed” Asia 

Pacific world 

macroeconomic 

simulation model 

based on data from 

the Global Trade 

Analysis Project 

Consortium

Low scenario: SARS shock 

occurs in 2003

High scenario: SARS shock 

reoccurs after 2003 and fades 

over 10 years

• SARS shock hits China and 

Hong Kong and affects other 

countries based on trade 

and tourist flows

• SARS shock in 2003 lasts 6 

months 

• Country risk premium 

increases by 200 basis 

points

• Output falls by 15 percent 

and costs rise by 5 percent 

in affected service sectors

China 

Hong Kong 

Malaysia

Singapore

Taiwan

Thailand

1.1

2.6

0.2

0.5

0.5

0.2

2.3

3.2

0.2

0.5

0.5

0.2

Global Insight:

May 2003 Executive 

Summary of Asia and 

Oceania, “SARS Epidemic’s 

Economic Impact on Asia”

In-house simulation 

model

Low scenario: SARS shock 

lasts through second quarter 

of 2003

High scenario: SARS shock 

extends to the end of 2003

China 

Hong Kong

Malaysia

Singapore

Taiwan

Thailand

Vietnam

1.0

1.4

0.3

1.2

0.8

0.7

0.1

1.9

2.2

1.4

1.8

1.7

1.6

0.8
Appendix III

Estimates of the Economic Impact of SARS

Page 58 GAO-04-564 Emerging Infectious Diseases

from various governments and financial institutions and applying that 

average to the nominal GDP figures provided by the International Monetary 

Fund.2

2

The Far Eastern Economic Review is a regional economic business weekly. Its cost 

estimates of SARS are provided in a 2003 special report on the SARS outbreak. The financial 

institutions that provided economic impact estimates to the review included Merrill Lynch, 

Goldman Sachs, JP Morgan, Lehman Brothers, Morgan Stanley, ING Financial Markets, BNP 

Paribas Peregrine, Standard & Poor’s, and IDEAGlobal.
Page 59 GAO-04-564 Emerging Infectious Diseases

Appendix IV

Comments from the Department of Health and 

Human Services ApendxiIV
Appendix IV

Comments from the Department of Health 

and Human Services

Page 60 GAO-04-564 Emerging Infectious Diseases
Appendix IV

Comments from the Department of Health 

and Human Services

Page 61 GAO-04-564 Emerging Infectious Diseases
Page 62 GAO-04-564 Emerging Infectious Diseases

Appendix V

Comments from the Department of State ApendxiV
Appendix V

Comments from the Department of State

Page 63 GAO-04-564 Emerging Infectious Diseases
Appendix V

Comments from the Department of State

Page 64 GAO-04-564 Emerging Infectious Diseases
Page 65 GAO-04-564 Emerging Infectious Diseases

Appendix VI

Comments from the World Health 

Organization ApendxiVI
Appendix VI

Comments from the World Health 

Organization

Page 66 GAO-04-564 Emerging Infectious Diseases
Page 67 GAO-04-564 Emerging Infectious Diseases

Appendix VII

GAO Contacts and Staff Acknowledgments ApendxiVI

GAO Contacts Martin T. Gahart, (202) 512-3596

Cheryl Goodman, (202) 512-6571

Acknowledgments In addition to the persons named above, Janey Cohen, Patrick Dickriede, 

Anne Dievler, Suzanne Dove, Sharif Idris, Roseanne Price, Kendall 

Schaefer, and Richard Seldin made key contributions to this report.

(320198)
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