Severe Acute Respiratory Syndrome (SARS): The International Response
Released: 2003-09-08T00:00:00

Background

Severe Acute Respiratory Syndrome (SARS), a new, highly infectious viral disease, was firstidentified by the World Health Organization (WHO) in February 2003. It is believed to have hadits beginnings in China's Guangdong Province in November 2002. A respiratory disease that causesflu-like symptoms which may progress to pneumonia, SARS has an average fatality rate of 15%. Between November 2002 and July 2003, a total of 8,437 cases and 813 deaths were reported in 31countries. (1)

While the overall numbers are not high by comparison with other serious infectious diseases, the speed and distance with which SARS spread raised an alarm over the potential risks tointernational public health. Containment appears to be working; however, there are fears thatanother SARS outbreak might take place during the regular influenza season later in 2003. Thisreport reviews the global response by WHO and those countries most affected. It also examines thechallenges that may lie ahead should another outbreak of SARS (or another unknown infectiousdisease) occur. (2)

International Response

Since late February, when WHO first identified the outbreak of what later became known asthe Severe Acute Respiratory Syndrome (SARS), it has played a key role in the global response tothe disease. SARS is a striking example of the risks to international public health posed by suchinfectious diseases. It also highlights the need for appropriate mechanisms of containment,particularly as global travel has become the primary means of spreading the disease around theworld.

Following its initial assessment, WHO made containment of SARS its main goal. "Despite the lack of understanding about the disease, its cause, and future evolution, the need was great tointroduce a series of emergency measures to contain SARS outbreaks in the affected areas andprevent further international spread, thus reducing opportunities for the new disease to establishitself." (3) Although WHO's representative in China,Henk Bekedam, reportedly said on June 5, 2003that the outbreak of SARS had reached its peak worldwide, (4) WHO continues to stress the importanceof sustaining international public health measures against SARS and working towards eliminatingit as a public health threat. The SARS outbreak may reveal valuable lessons about the effectivenessof WHO's surveillance and response systems, and its capacity to respond to similar outbreaks in thefuture. Examining the evolution of SARS also demonstrates the chains of transmission and role ofthe WHO in responding to unfolding events.

Although WHO led an unprecedented global collaborative effort to contain SARS, the U.S. Centers for Disease Control and Prevention (CDC) also played a key role in the global partnership. For more information on the role of the CDC in relation to SARS, see CRS Report RL31937 , SARS:Public Health Situation and U.S. Response .

Overview of the Role of the World Health Organization

The World Health Organization (WHO), established in 1948, is the U.N. system's authority on international public health issues. It assists governments in improving national health services andin establishing worldwide standards for foods, chemicals, and biological and pharmaceuticalproducts. WHO concentrates on preventive rather than curative programs, including efforts toeradicate endemic and other widespread diseases, stabilize population growth, improve nutrition,sanitation, and maternal and child care. WHO works through contracts with other agencies andprivate voluntary organizations. The United States has been a member of WHO since 1948.

The WHO policy making body is the World Health Assembly, composed of all 192-member states. It meets annually in May to decide the overall direction of the Organization and the generalprogram for a specific period, and to adopt the two-year budget. Decisions are made by majorityvote, except for decisions on the budget that require a two-thirds vote. There is no veto provision. The Assembly elects the Director General as well as the 32 member states who designate personsto serve on the Executive Board. The Executive Board meets twice a year to review the work ofWHO in more detail and prepares issues for consideration by the Assembly. Ten to twelve membersof the Board are replaced every year. The United States has been a member on the Executive Boardthree out of every four years.

WHO's Global Health Alert Systems

The Global Outbreak Alert and Response Network (GOARN). In April 2000, WHO formally established the Global Outbreak Alertand Response Network (GOARN) which brought together 112 institutions and networks of peopleand technical resources to respond to disease outbreaks of international concern. This global healthsecurity network provides not only an operational framework, drawing on data, expertise, and skill,but also aims to standardize the international response. (5) It relies on its partners and agreed standardsof practice in responding to potential threats, which may include emerging diseases and theintentional use of biological agents. In four years, between January 1998 and March 2002, GOARNexamined 538 such cases in 132 countries. (6)

The Global Public Health Intelligence Network (GPHIN). WHO also relies on the Global Public Health Intelligence Network(GPHIN), which is a customized search engine that tracks Internet communications. This systemproved to be very useful in picking up telecommunicated alerts in China. The system is also usefulto WHO in clarifying or refuting information that may create disruption or panic. Other tools includegeographical mapping technology and an event management and tracking system that provides anoverview of operations.

The Global Threat of SARS

It was clear that SARS presented a serious global threat. Lack of information about the cause and evolution of the new disease made its potential impact unknown. WHO concluded that the viruscomes from a strain likely to include frequent mutations and links to animal species, withimplications for the likelihood of establishing endemicity and underlining the importance of findingthe means to control or contain it. Several factors were deemed critical in this analysis:

The symptoms are non-specific and common;

The symptoms can be severe and some patients require intensive care forrespiratory failure;

The disease spreads easily from one location to another via air travel asdemonstrated in transmission patterns from the initial outbreak in Asia to other regions, such asNorth America and Europe;

There is no vaccine or treatment yet available and diagnostics tests are oflimited use. A number of antivirals are not effective;

The causative agent is not well understood, so the potential for continuedspread remains;

Certain cases may contribute to the rapid spread ofinfection;

Hospital staff, who are a vital link to the control of infection, aredisproportionately affected as are other close contacts of the patients;

The disease requires intensive treatment in isolation and is a burden on healthcare systems. (7)

By comparison to SARS, except in the case of HIV/AIDS, other new diseases that have emerged in the last few decades have not presented the same combination of factors that pose sucha heavy global risk to international health. Some of these diseases have not sustained stronghuman-to-human transmission, others have relied on food or a vector (such as mosquitos) fortransmission, and still others have had an identifiable, often containable, geographic location.

WHO's Response to SARS

Once the severity of the disease was recognized, in February and March 2003, WHO took aggressive action. Examining the factors outlined above and the chronology of events unfolding inChina, Hong Kong, Vietnam, and Toronto, it identified international travel as a primary means ofspreading the virus. It also concluded at the time that some people might be highly infectious, or"super spreaders". Identifying these individuals could be critical to the control of the disease. (8) OnMarch 15, 2003, WHO issued emergency travel recommendations as a global alert and response tointernational travelers, health care professionals, and border authorities. Later in March itrecommended screening passengers at airports coming from areas with recent local transmission andgave advice to airlines on appropriate procedures if a case was suspected during flight. In April andMay, on several occasions, the WHO issued its most stringent travel advisories recommending thepostponement of all but essential travel to areas considered high risk for SARS,. (9)

WHO also quickly moved to set up systems for -- and increase awareness of the need for -- immediate isolation and quarantine of those with or suspected of having SARS. In addition, it beganthe detailed work of contact tracing to find the source of the spread. These procedures along withsimple diagnostics and screening all contributed to the ongoing containment effort.

The response to SARS placed heavy demands on WHO and its GOARN partners. Time was very much of the essence. WHO pulled together a comprehensive network, including mobilizinga response on the ground, providing resources and supplies, monitoring and reporting, andestablishing scientific and medical collaboration. The WHO issued travel procedures to prevent andmanage probable cases of SARS. (10) It establisheda collaborative multi-center research project onSARS and brought together clinicians for SARS diagnosis and treatment. (11) It also developedguidelines, recommendations, and descriptions concerning case definitions, case management,laboratories, biosafety, blood safety, epidemiology, mass gatherings, and goods and animals fromSARS-affected areas. (12)

An urgent plan for the operational response to SARS was developed and implemented. This included providing expertise and supplies in SARS-affected areas and hospitals, and "in the air"through technology to bring the best minds to the collaboration required. This plan resulted in:

A global alert

Rapid case identification

Global reporting system and verification

Regular updates and advice

International field support and logistics coordination

Epidemiological and clinical networking

Laboratory network (13)

Through this network, and daily conference calls, epidemiologists were able to discuss cases, refine their definitions, examine chains of transmission, track progress, and increase theirunderstanding of what worked best where. Similarly, individuals working in the clinical networkwere able to share experiences with different forms of treatment, examine the possible reasons forthe range of individual responses to the disease, and develop guidelines for infection control. Thenetwork of the laboratories enabled many scientists to work together to come up with theidentification of the SARS virus.

Scientists have much to learn about SARS, including understanding the evolution of the disease, designing early detection, prevention and treatment strategies, and establishing effectivesurveillance systems. Until then, containment may remain the most effective control tool. If SARSbecomes endemic, the WHO may find the application of models of response for other infectiousdiseases, such as malaria, meningitis and yellow fever useful in combating the disease anddeveloping therapies and vaccines. (14)

WHO has issued an appeal for funding to support its surveillance and monitoring activities in Asia. It hopes to help those hardest hit by the disease economically, to continue with their effortsto control SARS, and ultimately to eliminate the disease as a global threat. (15) The WHO has anannual budget of nearly $850 million. It relies heavily on its 192 member states for resources andteams of experts. (16)

SARS and International Health Regulations

The outbreak of SARS has raised many public health questions, including the application of international law. According to David P. Fidler, Professor of Law at Indiana School of Law inBloomington, the legal implications affect three main areas -- International Health Regulations(IHR); public health measures and civil and political rights; and principles of state responsibility inresponding to SARS. (17) This section will focuson the IHR because of its relevance to WHO.

Overview of the International Health Regulations. In 1951, under Article 21 of the WHO constitution, member states adopted the International SanitaryRegulations, which in 1969 became known as the International Health Regulations (IHR). Amendments were made in 1973 and 1981. The main purpose was to control the spread of diseaseswith minimum impact on world traffic through the development of a global surveillance system, theuse of procedures at ports and airports, and the creation of disease-specific provisions. Some arguethat the regulations have not been effective in ensuring protection against diseases in a world ofincreasing trade and travel. Experts maintain that a key reason for ineffectiveness lies in the limitednumber of diseases to which the IHR applies. Originally, the regulation covered six diseases --smallpox, relapsing fever, typhus, cholera, plague, and yellow fever. (18) Today the IHR applies onlyto the last three diseases. Smallpox is considered to have been eradicated some years ago. Relapsingfever and typhus had been so successfully controlled that they were no longer considered a publichealth threat. The IHR do not apply to more recent infectious diseases such as HIV/AIDS andSARS. Member states were therefore under no obligation to report the outbreak of a new infectiousdisease nor were they required to restrict trade or travel even if it would benefit containment. (19)

In the 1990s, the WHO initiated a revision of the IHR to address the limited scope of the diseases covered, increase its relevance to the kinds of infectious disease threats most prevalent orlikely today, and to manage the return of old diseases. These revisions are scheduled to be finalizedin 2005. (20)

In 2001, the World Health Assembly adopted a resolution concerning member response to international public health emergencies and global health security with reference to epidemics. In2002, another resolution made the response more specific, and included health risks related not onlyto natural occurrence, but to accidental or deliberate use of biological and chemical agents. (21)

The SARS outbreak added momentum to discussions about revising the IHL that were already well under way. As recently as January 2003, the 192 member states had been discussing the detailsof the new framework, with a resolution for completing the revised regulations. Although the IHRwere recognized as being outdated, the case of SARS highlighted the problems of transparency --China denied the problem existed for months, and the information provided from Toronto wascriticized by some as incomplete and not timely enough.

The Fifty-Sixth World Health Assembly. Fidler argues that "the SARS epidemic may encourage WHO member states to accept a more robustinternational legal framework for global infectious disease control than has existed historically." (22) At the Fifty-Sixth World Health Assembly in May 2003, the member states adopted two resolutionsrelevant to the SARS outbreak, one specifically on SARS, the other on the revision of IHL. (23) TheSARS resolution focuses on eleven recommendations to WHO member states in addressing theSARS outbreak; it also requests the WHO Director General to take specific actions. None of theseare new obligations or binding on member states as earlier press reports might have suggested. Rather, they build on the role of the WHO and highlight the need for information sharing andinternational cooperation in combating an outbreak such as SARS. (24)

The IHL Resolution takes an important political step in emphasizing the need for member states to cooperate with other states and the WHO in monitoring and responding to infectious diseases. Although the SARS outbreak highlighted the strong need for revision of the IHL, then WHODirector General Gro Harlem Brundtland also pointed out the difficult balance to be struck inrevising the regulations, such as state obligations to report sensitive health information, protectionof human rights and civil liberties in light of an international health threat, and the impact onimmigration policies and decisions. (25) The IHLResolution does not give WHO a significant increasein authority in terms of intervention during a potential public health threat, nor does it give WHOthe power to reprimand a state that does not comply. (26) However, the IHL Resolution lays thepolitical groundwork for states to respond appropriately, much of the encouragement to comply willlikely come from international pressure as the SARS case demonstrated. (27)

The IHL resolution was adopted as an interim measure until the IHL revisions are finalized in 2005. The WHO opted for this two-step process rather than insisting that members immediatelyapprove the incorporation of the resolution into the IHL. (28) Some experts suggest that this resolutionwill encourage WHO collaboration within countries and also provide momentum for implementationof the measures outlined in the resolution. (29) TheU.S. delegation initially asked for a postponementof action on the proposed resolution, hoping to include it in a broader discussion, but later concededwhen it did not enlist member support. (30) Otherssuggested that this was a "negotiating tactic" usedto avoid too early a commitment by the United States. (31)

Country Responses to SARS

The SARS virus rapidly spread to 30 countries, ultimately infecting 8,437 people, of whom 813died. (32) Each country handled the virus differently. Some countries, like Vietnam, immediatelycalled for international support. Others, like China, initially downplayed the severity of the viruswithin their borders. Although the United States reported 75 SARS cases it had no SARS-relateddeaths. (33) Countries experiencing five or moreSARS deaths are discussed in this section. Othercountries that reported SARS deaths include: France (1), Malaysia (2), Philippines (2), South Africa(1), and Thailand (2).

China and Hong Kong

Reports of SARS outbreak coverups surfaced in mainland China in April 2003. Many blamed China for the global SARS crisis, which seems to have started in southern China. Critics argued thathad China been forthright in proclaiming the extent of the SARS problem, the disease would nothave spread throughout the country, and eventually to other countries. (34)

In response to international criticism about its complacency and cover-up in preventing the spread of the virus, the Chinese government took a number of steps to demonstrate transparency andvigilance in combating the spread of SARS. The Mayor of Beijing and the Minister of Health werefired. (35) Chinese authorities also quarantined thosewith symptoms of the disease and those withwhom they had contact, often thousands at a time. (36) Entire apartment buildings, markets, hospitals,universities, and schools were shut down. All schools in Beijing were closed for nearly threemonths. (37) Chinese authorities banned all touristvisits from the central part of the country andTibet. (38) China also closed some border crossings,including some between China and Mongolia andpostponed reopening the Khunjirap crossing between China and Pakistan. (39)

Chinese officials enacted new laws to fight SARS. One of China's most controversial laws, calls for the imprisonment or execution of anyone found intentionally spreading the virus. The firstperson facing punishment under this law is Dr. Li Song. Authorities charge Dr. Li with vandalismand violating an infectious disease law. (40) Hospitalofficials argue that he left a hospital knowing hehad SARS, and ultimately spread the virus to his family and more than 100 others in the small townof Linhe. Dr. Li's mother, father and wife have died of SARS, while Dr. Li remains in jail. (41)

Other laws sought to halt the spread of the virus through fines. Authorities in the southern town of Guangzhou began fining individuals who spit in public 50 yuan (about $6 US), a fine that manywill find difficult to pay. (42) In Shanghai, thosefound spitting, as well as throwing away cigarettestubs or fruit peels in public areas, and dumping garbage and sewage in the wrong places are subjectto a fine of 200 yuan (about $24 US), compared to 50 yuan prior to the SARS outbreak. (43)

China's moves to address the spread of SARS have also included financial assistance. The Chinese Ministry of Finance allocated a total of 440 million yuan (about $53 million) to reinforcethe fight against SARS. (44) Provincial and localgovernments also offered assistance to those affectedby SARS. Assistance included the distribution of temporary subsidies, disinfectants, protectivesurgical masks and soap. One Beijing district, the Dongcheng District, reported that it decided toprovide 420 thousand yuan (about $51 thousand) to its low income residents, and Chaoyang Districtallocated 350 thousand yuan (about $42 thousand) towards the purchase of preventive aids. (45) Meanwhile officials in Hong Kong announced a $1.5 billion aid package, which included waivingwater and sewage charges for the general public for up to four months, increasing income taxrebates, waiving license fees for heavily affected industries, guaranteeing $450 million in loans toaffected businesses, increasing medical research spending, and reducing commercial rents for storesat public housing sites and other government controlled properties. (46) The Chinese Government alsoreserved $128 million for a Hong Kong marketing campaign now that the city has been removedfrom the WHO list of infected areas. (47) Accordingto the Chinese Government, the internationalcommunity donated about $76.6 million to aid its fight against SARS. (48)

On June 10, the WHO sent a high-level team, including Dr. David Heymann, Executive Director for Communicable Diseases at WHO, to China to assess the current situation and plan astrategy for the future. They proposed steps for examining and detecting cases, defining proceduresfor contact tracing, and responding to local transmissions. WHO was particularly concerned aboutthe capacity of the Chinese rural health systems to deal with emerging infectious diseases, fromeffective monitoring and reporting to adequate hospital care. (49) However, it found that surveillancesystems in two key rural provinces were effective. (50) China has also surprised many with the speedwith which it brought its outbreak under control. Some studies suggest that the mortality rate mayhave been lower, and the cure rate higher, than in other parts of the world. Differences in incubationperiod and groups at highest risk may provide clues for fighting the disease. According to Dr.Heymann, "Long-term containment depends on finding answers to a long list of scientific questions. China has much to offer the rest of the world." (51)

On June 24, 2003, WHO removed its recommendation that people should postpone all but essential travel to Beijing, China. Beijing was the last area in the world to have the travel warninglifted. Beijing, with a cumulative total of 2,521 probable cases and 191 deaths, has had the largestoutbreak of SARS anywhere in the world, followed by Hong Kong with 1,755 cases and 296 deaths,and Guangdong Province with 1,511 cases and 57 deaths. (52)

Taiwan

The doubling of SARS deaths (53) in Taiwan prompted WHO to send a team to investigate theisland's SARS situation. The sharp increase in new cases and deaths surprised some as Taiwaninitially appeared successful in curtailing mortality, avoiding international community transmission,as well as maintaining a relatively low number of new cases compared to mainland China. Thegovernment of Taiwan took early steps to avoid a massive SARS outbreak, including imposingmandatory 10-day quarantines on all visitors arriving from China, Hong Kong, Singapore orToronto; cancelling more than 100 commercial flights; cancelling high school exams scheduled forthe end of May; and monitoring the temperature of visitors to many public buildings and hotels. (54)

In May 2003, the President of Taiwan, who has been vocal in his desire to gain Taiwanese observer status to the WHO (55) , stated thatTaiwanese hospital officials from Taipei Municipal HopingHospital may have tried to cover up a SARS outbreak. (56) In response, Taiwanese authorities fired thesuperintendent of the hospital and relocated all 200 patients and 900 employees from HopingHospital to a designated SARS facility while the hospital was being disinfected. (57) Shortly after, theTaipei City Government fined the Hoping Hospital 1.1 million Taiwan dollars ($31,682 US) andfour other hospitals 1.5 million Taiwan dollars ($43,202 US) each for delaying reporting SARS casesto health authorities, and revoked the licence of the former Jen Chi Hospital superintendent, LiaoCheng-hsiung, accusing him of covering up a SARS outbreak while serving. (58) The Taiwan Ministerof Health, Dr. Twu Shiing-jer, voluntarily resigned on May 16, 2003, taking full responsibility forthe SARS spread. (59) Two days later, more than140 medical employees across the island reportedlyresigned to avoid dealing with SARS patients. (60) The medical workers charged that the governmenthad failed to provide sufficient protective gear. (61)

WHO officials believe that lapses in infection control, particularly in emergency rooms, may have been one of the reasons for the rapid increase in cases. (62) Reports seem to support the assertionthat Taiwanese health officials may not have taken enough measures to limit the spread of the virusboth within and among the hospitals. The Dean of Hoping Municipal Hospital's RadiologyDepartment reported that, "Everything went wrong. There is no proper quarantine facility." It wasreported that hospital staff did not separate SARS patients from non-SARS patients, and did not askpatients about their medical history. Concern about Taiwan's ability to contain the virus washeightened when CDC officials announced on May 23, 2003 that an American doctor sent with theWHO/CDC team to investigate Taiwan's recent upsurge in SARS cases was suspected to havebecome infected with SARS and was returned to the U.S. to undergo treatment. (63) CDC officialsadded that Hoping Hospital made the critical mistake of sending SARS patients to other hospitalsfor treatment, unwittingly spreading the disease. (64)

In addition to its collaborative efforts with CDC and WHO, Taiwan bolstered its quarantine efforts, strengthened its contact tracing capabilities, and improved its infection control practices. TheGovernment of Taiwan also released a $1.44 billion U.S. aid package, which sought to assist ailingbusinesses and families of SARS victims, establish SARS prevention mechanisms, and createeffective SARS contact tracing mechanisms. (65) Taiwan was removed from the WHO list of areaswith recent local transmission on July 5, 2003. Its last probable case was reported on June 19, 2003. To date, 671 people have contracted the virus, of whom 84 have died.

Vietnam

Vietnam, the poorest of the SARS-affected countries, was the first country to contain the SARS virus. The WHO removed Vietnam from its list of affected countries less than five weeks after itrecorded its first SARS death. (66) Vietnam washailed as a success story largely because of its rapidresponse to the health crisis, and its cooperation with WHO and CDC officials who offered criticaltechnical assistance. (67) According to the WHO,Vietnam was fortunate to have had only one carrier,who spent less than three days among the general public prior to hospitalization. This limited thenumber of contacts that the man made.

Some observers praised the success of the country with less resources than its SARS-affected neighbors to rapidly contain the virus. One Vietnamese health official explained that Vietnam'sresponse contrasted with China's initial response in that Vietnam did not seek to downplay thepotential impact of the disease and it welcomed international assistance. France quickly announcedthat it would offer more than $100,000 to help sterilize Hanoi French Hospital, where the first SARScase was detected. (68) The WHO and CDC donatedmasks, gowns and other equipment; Japancontributed two ventilators and other medical supplies; Doctors Without Borders sent a medicalteam; and Vietnamese medical workers were trained in infection control techniques. (69) Vietnamesedoctors also voluntarily quarantined themselves in Bach Mai hospital, the designated SARS hospital,to avoid spreading the virus to their families and the general community.

The government of Vietnam ordered the establishment of provincial and municipal steering committees responsible for closing down any entity and isolating any individual who contractedSARS or was suspected to be infected with the virus. (70) It also trained medical workers, customsofficers, airline staff and those working in the tourism sectors. (71) The Finance Ministry spent about$2 million on medical equipment and activities related to SARS prevention (72) and targeted a littlemore than $1 million for Vietnam's border provinces tasked with preventing SARS from leaving orentering Vietnam. (73) The Government of Vietnamrecently announced that it intended to spend anadditional $3.3 million to prevent SARS from returning. (74) Johnny Chen, believed to have carriedSARS to Vietnam from China, died of SARS on March 13, 2003. A little more than a month lateron April 28, 2003, the WHO announced that Vietnam was the first country to have contained thedeadly virus. A total of 63 people contracted SARS in Vietnam, 5 of whom died. (75)

Singapore

Some civil libertarians criticized the Government of Singapore in its response to the SARS virus as being too harsh. However, the World Health Organization commended Singapore on itsresponse to the virus. Dr. David Heymann, Executive Director of communicable disease programsat the WHO described Singapore's actions as "exemplary", and stated that "Singapore has been oneof the most successful countries in its response to SARS." (76) The World Health Organizationremoved Singapore from the list of areas with local SARS transmission on May 30, 2003. (77)

Singapore's actions against SARS were viewed as swift and widespread. For example, the Ministry of Education required all schools to provide students with a personal thermometer, and toteach them to check their own temperatures daily. All students taking the national language examsin June 2003, underwent temperature checks before entering testing sites. The Ministry also requiredthe Institutes of Higher Learning to segment their large campuses into smaller sections to reducemovement across the campus and to facilitate contact tracing. Singapore required all students andhouseholds to have thermometers by June 2003. Other steps taken to prevent the spread of SARSincluded: directing all SARS cases to one hospital, installing video cameras in the homes of allquarantined individuals, electronically tagging violators of quarantine orders, using body thermalscanners at airports, enforcing mandatory temperature checks for all individuals departing Singaporeand those arriving from SARS affected areas, requiring all food handlers to take their temperaturestwice a day, and applying mandatory temperature checks for entry to many public events. On March 24, 2003, the Singapore Ministry of Health invoked the Infectious Disease Act to isolate thoseinfected with SARS, and prevent the further spread of the virus. The act was amended on May 23,2003, by requiring all those who broke the home quarantine to be tagged, arrested, detained, and/orfined. The first offense is punishable by up to $10,000 or 6 months imprisonment and repeatoffenders can be fined up to $20,000 or 12 months. (78)

The Government of Singapore also unveiled a $230 million SARS relief package on April 17, 2003. Key elements include:

a Home Quarantine Allowance Scheme, which pays an allowance to the self-employed and to small business owners who have employees affected by home quarantineorders; (79)

property tax rebates for commercial properties and touristhotels;

50% reduction in foreign worker levy for unskilled workers employed bytourist hotels;

a Bridging Loan Program, which offers working capital loans totourism-related small- and medium-sized enterprises;

a Skills Redevelopment Program and SARS Relief Tourism TrainingAssistance Program, which offers funds to employers who send their employees to certified trainingcourses in the tourism sector;

diesel and road tax rebates for taxis, and operator licence feewaivers;

rebates on aircraft landing fees and rental spaces atairports;

50% reduction in port dues for cruise ships; and

dollar-for-dollar matching of funds for the Courage Fund, a tripartite fundestablished to help the victims of SARS and affected health care workers. The fund received nearly$10 million in just 7 weeks. (80)

Singapore was removed from the list of areas with recent local transmission on May 31, 2003. To date, 206 people have contracted SARS in Singapore, and 32 have died of the virus. The lastprobable case was reported on May 18, 2003.

Canada

When SARS first emerged in the country some criticized Canadian officials for waiting too long to quarantine 500 members of a prayer group widely believed to have been the source of thevirus in Canada. (81) WHO officials alsocomplained that the Canadian government had been slowto relay current information. Relations between the U.N. agency and Canadian authorities werestrained when the WHO decided to place a SARS travel advisory on Toronto. Canada appealed tothe WHO to remove the travel advisory, because officials claimed they could trace all occurrencesof the virus. (82) On May 14, 2003, two days afterthe 24th SARS victim died, the WHO removed thetravel advisory, citing 20 days had passed without new cases. However, on May 23, 2003 Torontohealth officials reported that four new suspected SARS cases were under close surveillance. (83) OnMay 26, 2003, the WHO placed Toronto back on its list of countries with recent local transmission,but it did not place a travel advisory on the city.

Following criticism of bureaucratic delay, Canadian officials took a number of steps to contain the virus, including inviting the U.S. Centers for Disease Control (CDC) to monitor its hospitals,closing a number of hospitals and clinics, and quarantining those individuals suspected to haveSARS. Canada also undertook a number of initiatives to aid businesses and individuals adverselyaffected by SARS. On April 30, 2003, the Government of Canada passed the SARS Assistance andRecovery Strategy Act, which protects the jobs of people affected by SARS, and enables employeesto take unpaid leave of absence for SARS-related reasons. It also included $1.7 million in newfunding to help scientists develop a new test and possible vaccine for SARS. All tourist facilitiesin Toronto were also exempt from retail tax from May 1, 2003 to September 30, 2003, under theact. (84)

Another government initiative implemented to assist Canadians affected by SARS is the SARS Grant Initiative. Eligible full-time and part-time health care workers affected by SARS can receive$400 per week and $200 per week, respectively. This initiative complements adjustments made tothe Employment Insurance (EI) Act, which allows up to 15 weeks of special benefits when aneligible claimant is unable to work because of illness, injury or quarantine. The Government ofCanada has adjusted the EI program so that those who become ill due to SARS are not immediatelyrequired to provide a medical certificate, and no longer have to wait two weeks to receive benefits. (85) Other SARS-related actions include:

committing $10 million toward a marketing campaign;

arranging special payment schedules or temporary deferral of mortgagepayment for those who find it difficult to pay mortgages due to SARS;

extending tax due dates, establishing flexible payment schedules and waivingtax penalties or interest for those affected by SARS; and

offering a four-month postponement of capital payments without penalty andsmall capital loans to small businesses affected by SARS. (86)

In June 2003, health workers concerned about their safety, including hundreds of nurses, demonstrated in Canada to demand danger pay, protective suits, and a public investigation into thecause of the SARS resurgence. Some nurses claimed that hospital officials were slow to respondto their warnings that patients in other wards showed SARS-like symptoms. Still, some familypractitioners expressed concern that health officials failed to notify them when the virus firstresurfaced. As a result, some family practitioners fell ill with the virus. (87) When the virus resurfacedthirteen people died of SARS and thousands were quarantined. (88)

Toronto was removed from the list of areas with recent local transmission on July 2, 2003. The last probable case was reported on June 12, 2003. To date, 250 people have contracted the virus and38 have died of SARS.

Congressional Response

Infectious Disease Monitoring

The rapid spread of the SARS virus underscored the importance of establishing a database system that would allow rapid and accurate information sharing on emergent infectious diseases. The Senate FY2004 Labor, Health and Human Services (HHS) and Education appropriations billprovides over $370 billion for infectious disease control at CDC, including $25 million for SARSresearch, prevention and control. It also includes $50 million to develop a Global Disease DetectionSystem at the CDC that would enable the United States to effectively respond to a global infectiousdisease threat. The Senate bill also increases NIH funding for emerging infectious disease fromnearly $600 million in FY2003 to $1.7 billion.

Capacity Building

Congress has also recognized the need to strengthen state and local capacity to respond to a bioterrorist attack or infectious disease outbreak. The Senate bill proposes that CDC funds for thatpurpose be maintained at FY2003 levels, $940 million. Part of strengthening state and local capacityincludes the support of the Health Alert Network (HAN). Prior to HAN, one-half of local publichealth departments did not have e-mail. The HAN system has been used to share information aboutSARS. Forty million U.S. dollars have been reserved for this purpose in the Senate version of theFY2004 Labor, HHS, and Education appropriations bill.

Improving U.S. Response Capability

The rapid spread of the SARS virus has demonstrated the need to quickly and effectively respond to an intentional or natural infectious disease outbreak. Congress appropriated $77.5 millionto the CDC Epidemic Services and Response program in FY2003. The Senate version of theFY2004 Labor, HHS and Education appropriations bill increases funding for those efforts to $127.5million in FY2004. The CDC Epidemic and Response program provides resources and scientificexpertise for operating and evaluating surveillance systems; develops and refines research methodsand strategies for public health practitioners; and trains public health professionals who respond topublic health emergencies and outbreaks. The Senate version also directs over $578 million to theHealth Resources and Services Administration (HRSA) to combat bioterrorism. (89)

Future Challenges

The SARS outbreak has provided lessons that may have future application. The WHO/CDCintervention greatly increased the effectiveness of the global response. A number of factorsinfluenced the outcome, such as the system of global alerts and awareness, and access to immediate,high-level research and scientific collaboration. Coordinated efforts through the WHO/CDC,national governments, and the public health professionals also led to positive results, as in the caseof Vietnam. Dr. Julie Gerberding, Director of the Centers for Disease Control and Prevention, hadhigh praise for WHO's leadership during the crisis and emphasized communication and transparencyas key to responding to international health crises. Areas in which improvements have been calledfor in the global response to infectious disease threats include:

Global Interdependence and Transparency

Lack of transparency in promptly reporting and monitoring SARS outbreaks directly contributed to the spread of the disease worldwide and had wide-ranging impacts beyond the obvioushealth factors. The case of SARS demonstrated that state responsibility within a globalized worlddoes not end at its borders and that future containment relies on openness and cooperation in theinterests of all populations.

Developing Surge Capacity

The ability of public health systems and the availability of resources to deal with a threat like SARS were clearly inadequate. Addressing the need and ability to mobilize additional resources,both within the country itself, and through the WHO network during an emergency, would improvethe response to similar challenges in the future. Some have expressed concern about the impactSARS could have had if the outbreak had reached developing countries with minimal health careinfrastructures, particularly those already weakened by HIV/AIDS. Others have argued that SARShas underscored the importance of boosting aid efforts that offer structural support, such as aidingin the training of health care professionals, donating medical supplies and equipment, upgradinghealth technologies, and ensuring universal inoculation against resurgent diseases such astuberculosis.

Public Fear and Information Disclosure

The WHO had to strike a balance. On the one hand it was pressed to give information, and use aggressive tactics of containment. On the other hand, the information about SARS may havecontributed to public panic and anxiety, discrimination in some cases, and other impacts, such aseconomic losses. Some argue that the WHO did not take into account the impact of itsdecision-making concerning travel advisories and global alert warnings and that the SARS risksometimes did not demonstrate the need for such a response. (90) Some governments in the future maybe hesitant rapidly and openly to share outbreak information, because they may want to avoidpotential negative economic impacts, such as job losses, hotel closures and flight cancellations asoccurred at the height of the SARS crisis. For example, 60,000 restaurant and hotel workers in HongKong lost their jobs or were placed on unpaid leave during the SARS outbreak. (91) In Singapore,year-by-year comparisons showed that tourist arrivals fell 15% in March 2003 and 67% in April2003, and hotels reported occupancy rates of only 10 to 30%, compared to usual occupancy rates of70% or more during the first quarter of the year. (92)

National Response

The weakness of national surveillance systems and health networks within any one country can dramatically affect the area and rate at which a disease spreads. If the SARS virus had spread morerapidly and extensively throughout the affected countries and for a sustained period, it could havehad a significant impact on the health care systems, and other systems. Those in need of health care,such as those with cancer, requiring surgery, or those requiring immediate medical attention may nothave been able to receive care. In order to contain the SARS virus, hospital wards and, at times,entire hospitals were shut down for weeks at a time to decontaminate them. Significant resourceswere used to quarantine SARS-infected individuals, schools were closed, and other private facilitieswere adversely impacted. Such problems caused by SARS illustrate the need to develop effectivenational response systems.

Inadequate Funding

WHO officials and others have argued that there is a need for increased funding for laboratories and epidemiological research in the fight to contain diseases like SARS. Improvements to theexisting surveillance network and national capacity to address emergency health issues are also badlyneeded. For example, GOARN reportedly needs $200 million to reinforce its network. (93)