Emerging Infectious Diseases: Asian SARS Outbreak Challenged International and National Responses
Published: 2004-04-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: 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. 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.
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.
subsections: section_title: Background
paragraphs: 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.
subsections: section_title: Characteristics of SARS
paragraphs: 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. 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.
section_title: Prevention and Control of SARS
paragraphs: 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.
Transmission control: controlling the transmission of disease- producing 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.
section_title: The 2002-2003 SARS Outbreak
paragraphs: The emergence of SARS in China can be traced to reports of cases of  atypical pneumonia 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.)
section_title: Global Infectious Disease Control and the Role of the World Health Organization
paragraphs: 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  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.
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), 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  the media and the Internet. 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.
section_title: U.S. Government Agencies Responsible for Responding to Global Infectious Disease Outbreaks
paragraphs: 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. Within HHS, the Office of Global  Health Affairs and CDC work closely with WHO and foreign governments  in response efforts. 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.
section_title: Infectious Disease Control in China, Hong Kong, and Taiwan
paragraphs: 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.
section_title: WHO’s Response to SARS Was Extensive, but Was Delayed by an Initial Lack of Cooperation from China and Challenged by Limited Resources
paragraphs: 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  about the outbreak, and WHO had to stretch its resources for infectious  disease control to capacity.
subsections: section_title: WHO Provided Direct Assistance to Affected Areas
paragraphs: 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.
subsections: section_title: Deployment
paragraphs: Under GOARN’s auspices, WHO rapidly deployed 115 specialists from 26  institutions in 17 countries to provide direct technical assistance to SARS- affected 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.
section_title: Virtual Networks
paragraphs: 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,  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.
section_title: WHO Alerted the International Community and Made Important Recommendations amid Scientific Uncertainty
paragraphs: 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.
subsections: section_title: Global Alerts and Travel Recommendations
paragraphs: 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. 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— 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.
section_title: Guidelines and Recommendations on the Management of SARS
paragraphs: 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.
section_title: WHO Faced Challenges in Issuing Guidance and Recommendations
paragraphs: 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.
section_title: Initial Lack of Cooperation from China Limited WHO’s Access to Information and Delayed Its Response
paragraphs: 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.
section_title: WHO’s Response to SARS Was Challenged by Limited Resources
paragraphs: 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  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.
section_title: U.S. Government Had Key Role in Response to SARS, but Efforts Revealed Problems in Ability to Respond to Emerging Infectious Diseases
paragraphs: 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.
subsections: section_title: CDC Played Central Role in Fighting SARS in Asia
paragraphs: 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.
section_title: CDC Took Actions to Limit Spread of SARS into the United States
paragraphs: 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).
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  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.
section_title: Regulatory, Privacy, and Procedural Concerns Hampered CDC’s Efforts to Trace Travelers
paragraphs: 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, 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. 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. 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.
section_title: CDC Exploring Options to Resolve Tracing Problems
paragraphs: 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. 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, 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.
section_title: State Applied Diplomatic Pressure, Helped Facilitate Agency Responses, and Disseminated Information
paragraphs: 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  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.
section_title: State Faced Obstacles Arranging Medical Evacuations for U.S. Citizens with Suspected SARS
paragraphs: 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.  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. 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  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.
section_title: Medical Evacuation Issues Still Pose Challenges for Future Outbreaks
paragraphs: 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  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.
section_title: After Initial Struggle, Asian Governments Brought SARS Outbreak under Control
paragraphs: 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.
subsections: section_title: Poor Communication Limited Information on Severity of SARS Outbreak in China
paragraphs: 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. 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,  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.
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. 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  findings. By April 20, the Ministry of Health announced the existence of 339  previously undisclosed cases of SARS in Beijing.
section_title: An Initial Lack of Effective Leadership and Coordination in SARS- Affected Areas in Asia Hindered Response
paragraphs: 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. 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 decision- making 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  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.
section_title: Weaknesses in Disease Surveillance Systems and Public Health Capacity Further Constrained Efforts
paragraphs: 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.
subsections: section_title: Disease Surveillance Systems
paragraphs: 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 computer- based 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.
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.
section_title: Public Health Capacity
paragraphs: 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.
section_title: Hospital Infection Control
paragraphs: 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  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. 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.
section_title: Basic Public Health Strategies Eventually Worked to Control SARS Outbreak
paragraphs: 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.
subsections: section_title: Improved Screening and Reporting
paragraphs: 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.
section_title: Rapid Isolation and Contact Tracing
paragraphs: The identification of patients with suspect and probable cases of SARS and  their close contacts reduced the rate of contact between SARS patients and  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.
section_title: Enhanced Hospital Infection Control
paragraphs: 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.
section_title: Quarantine Measures
paragraphs: 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 contact with a SARS patient. 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.
section_title: Asian Governments Have Efforts Under Way to Build Public Health Capacity for Future Outbreaks
paragraphs: 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  with the public and outline administrative or criminal penalties for officials  who do not report SARS cases. 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. 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.
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  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.
section_title: SARS Outbreak Decreased Consumer Confidence and Negatively Affected a Number of Asian Economies
paragraphs: 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-to- face exchanges. Additionally, to counter economic losses associated with  SARS, many Asian governments implemented costly economic stimulus  programs.
subsections: section_title: Impacts from SARS Are Estimated to Have Cost Billions, Although Most Economies Have Recovered
paragraphs: 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. 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  how emerging diseases and fears associated with those diseases can have  widespread ramifications for a large number of economies.
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).  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. However, given that the outbreak  was brought under control by July 2003, the economic impacts were  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.
section_title: SARS Affected Asian Economies through a Variety of Channels
paragraphs: 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  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. 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. 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.
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  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.  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.
section_title: Asian Governments Provided Economic Stimulus Packages That Cost Billions
paragraphs: 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.
section_title: WHO Members Will Debate Important Issues Raised by International Health Regulations’ Revision
paragraphs: 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.
subsections: section_title: Revisions Would Expand Coverage and Facilitate Cooperation, but Key Questions Remain
paragraphs: 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  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. However, the draft regulations are still somewhat  ambiguous about whether consent is necessary. According to a senior  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  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. 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.
section_title: Completing the Revision Process Seen as High Priority
paragraphs: 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. 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  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.
section_title: Conclusion
paragraphs: 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 re- emerged to cause another major international outbreak, but outbreaks of  other infectious diseases can be expected in the future. Therefore,  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.
section_title: Recommendations for Executive Action
paragraphs: 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  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.
section_title: Agency Comments and Our Evaluation
paragraphs: 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.
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.
section_title: Scope and Methodology
paragraphs: 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  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  Trade Analysis Project Consortium; 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. 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.
If you or your staff have any questions, please contact one of us. Other  contacts and key contributors are listed in appendix VII.
section_title: SARS Cases and Deaths, November 2002–July 2003
section_title: SARS Chronology
paragraphs: 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.
First known case of atypical pneumonia, later determined to be SARS.
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.”
Global Public Health Intelligence Network (GPHIN) picks up reports of a “flu outbreak” in  China.
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.
Infection in second city in 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.
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.
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.
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.
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.
GPHIN detects Chinese newspaper report that more than 50 hospital staff in Guangzhou are  infected with “mysterious pneumonia.”
Chinese-American businessman admitted to the French Hospital in Hanoi with fever and  respiratory symptoms.
WHO official Dr. Carlo Urbani notifies WHO office in Manila of an unusual disease. WHO  headquarters moves to heightened state of alert.
State Department establishes an intradepartmental working group to deal with impact of  outbreak.
Woman who stayed at the Metropole Hotel in Hong Kong is hospitalized with respiratory  symptoms.
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.
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.
Businessman with travel history to Guangdong Province is hospitalized with respiratory  symptoms.
Chinese Health Ministry asks WHO for technical and laboratory support to clarify cause of  the Guangdong outbreak of atypical pneumonia.
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.
WHO sends emergency alert to GOARN partners.
CDC activates Emergency Operations Center.
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.
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.
CDC begins distributing health alert cards to passengers arriving from Hong Kong at four  international airports.
CDC team arrives in Taiwan to assist in SARS response.
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.
China joins WHO’s collaborative networks, initially set up on March 17.
Third superspreader event in Hong Kong: Health authorities announce that 213 residents of  Amoy Gardens housing estate have been hospitalized with SARS.
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.
WHO team arrives in Guangdong.
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.
WHO laboratory network announces conclusive identification of SARS causative agent: a  new coronavirus.
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.
First country to successfully contain its outbreak of SARS.
State Department holds interagency meeting on SARS.
WHO sends officials to Taiwan to assist CDC team.
First global consultation on SARS epidemiology concludes its work, confirming that available  evidence supports the control measures recommended by WHO.
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.
WHO holds Global Conference on SARS to review scientific findings on SARS and examine  public health interventions to contain it.
WHO announces that the global SARS outbreak has been contained.
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.
Taiwan announces that a researcher is infected with SARS. Public health authorities  conclude that the infection was acquired in a laboratory.
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.
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.
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.
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.
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.
Date of the first known case(s) of SARS.
section_title: Estimates of the Economic Impact of SARS
paragraphs: 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). 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.
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  from various governments and financial institutions and applying that  average to the nominal GDP figures provided by the International Monetary  Fund.
section_title: Comments from the Department of Health and Human Services
section_title: Comments from the Department of State
section_title: Comments from the World Health Organization
section_title: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Acknowledgments
paragraphs: 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.
section_title: GAO’s Mission
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section_title: Public Affairs