Still Learning From SARS
Authors: Rima F. Khabbaz
Journal: Annals of Internal Medicine (2013)

Ideas and OpinionsDecember 3, 2013Still Learning From SARSFREERima F. Khabbaz, MDRima F. Khabbaz, MDFrom the Centers for Disease Control and Prevention, Atlanta, Georgia.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-159-11-201312030-00011 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Eleven years ago, a novel coronavirus sparked the first major global outbreak of an emerging infectious disease of the 21st century (1). Branded “SARS” for “severe acute respiratory syndrome,” the new illness quickly engulfed the world's medical, scientific, and public health communities and garnered a worried public's attention. Since then and to date, the global reach of SARS has only been matched by the 2009 H1N1 influenza pandemic (2), but its societal effect remains unsurpassed. SARS endures as a vivid reminder of the capacity of emerging infectious diseases to quickly travel the globe, exacting a major human toll of illness and death and causing significant economic, political, and social consequences. More recently, the emergence of another novel coronavirus causing severe respiratory illness (termed “Middle East respiratory syndrome”) in the Middle East and Europe (3) and a novel avian influenza A (H7N9) virus in China (4) continues to demonstrate the ongoing threat of emerging infections. With illness, death, and spread reminiscent of SARS, Middle East respiratory syndrome is particularly alarming. From September 2012 through October 2013, more than 140 cases and 60 deaths have been reported among persons with direct or indirect linkages to areas of the Middle East. Although not sustained, person-to-person transmissions have been documented, including transmissions in health care settings. Genetic analysis shows a close relationship between the Middle East respiratory syndrome coronavirus and coronaviruses in bats, suggesting once again a zoonotic origin of this latest emerging infection. Cases of H7N9 also present specific concerns because they represent the first known human cases of this virus. Since early 2013, more than 135 cases and 45 deaths have occurred in China, including Taiwan—mostly among persons who had contact with infected poultry or contaminated environments. Although no sustained spread has been found and reports of new cases remain sparse, concerns for the pandemic potential of an H7N9 virus persist.SARS underscored the critical importance of well-prepared, flexible, and highly connected public health systems, exercised by the day-to-day public health functions of tracking and responding to endemic infectious diseases, such as seasonal influenza and foodborne illnesses. Ensuring that these connections extend to the local level is essential because local health departments and health care providers play a vital role in recognizing the unusual and sounding the alarm so that scalable and effective responses can be mounted. This commentary is a reflection on the events and the successful global response surrounding the 2003 SARS outbreak. In the decade since, many lessons have been learned and enhancements made, but significant challenges remain. Foremost is the urgent need to build and sustain effective public health capacities and modernize public health systems at all levels.Looking BackSARS unfolded very quickly in early 2003. In February, as rumors of large numbers of severe respiratory illnesses occurring in Southern China since fall 2002 were circulating, an explosive outbreak occurred in Hong Kong among residents, including health care workers, and recent visitors to the city (5). Epidemiologic investigations determined a common link among more than a dozen visitors who had arrived from several locations and then carried the disease globally: all had stayed at the same Hong Kong hotel over a single weekend along with a fatally ill physician from adjacent Guangdong Province. By the time SARS was declared contained in July 2003, the disease had sickened 8096 people on 5 continents and killed 774 (6). Although more than 25 countries reported SARS cases, most occurred in mainland China, followed by Hong Kong, Taiwan, Canada, and Singapore. In the United States, only 8 people had confirmed SARS diagnoses; all had traveled to countries where outbreaks had occurred.The World Health Organization (WHO) and global public health authorities mounted a swift and effective public health response to SARS. Within weeks, a global consortium of laboratories had detected and confirmed a previously unrecognized coronavirus as the causative agent (7), and diagnostic reagents were developed and shared. As patients were promptly identified and isolated, and additional isolation and quarantine measures were instituted in heavily affected communities, SARS was controlled and quickly disappeared. The virus's zoonotic origin in bats and transmission through infected civets caged in live animal markets in China were subsequently confirmed (8).In the United States, the Centers for Disease Control and Prevention (CDC) quickly mobilized, activating its newly opened Emergency Operations Center to provide around-the-clock coordination of CDC's response efforts using the incident-command system. Throughout the outbreak, more than 800 staff worked on the response. CDC worked closely with the WHO and other global and national partners and supported state and local health departments as they investigated hundreds of suspected cases. Deployed medical officers, epidemiologists, and other specialists assisted with on-site investigations. Extensive laboratory testing was done, and many travel advisories and guidance documents were developed, including guidance for surveillance and reporting; clinical diagnosis; infection control; isolation and quarantine; laboratory testing; specimen handling, collection, and shipment; and clean-up. Health alerts were distributed to more than 2.7 million airline passengers arriving from areas where they may have been exposed. Looking back, the incident command structure served CDC well for enabling rapid scale-up and has since helped to ensure that lessons learned continue to be refined with each public health response.Collaborative public health networks with linked surveillance, diagnostics, and communication systems were critical to the successful SARS response. Delays in the recognition and reporting of early cases in China have been acknowledged and resolved, as evidenced by China's strong capabilities and transparent reporting in response to H7N9 influenza.Progress, Challenges, and OpportunitiesAmong the most visible legacies of SARS are the revised International Health Regulations (IHR), which were adopted by the World Health Assembly in 2005 and made official in 2007 (9). The IHR require reporting of all public health emergencies of international concern, expanding beyond infectious agents to include events resulting from biological, chemical, or radionuclear threats and natural disasters. The IHR allow use of surveillance information beyond official state notification and establish new requirements for member states to support existing global surveillance and response systems and develop proactive systems for strengthening national and international capacities, including laboratories. These regulations serve as a legally binding agreement among 194 states parties, including all WHO member states; however, full compliance has not been achieved.The success of the IHR is dependent on building adequate capabilities locally and nationally around the world. Ensuring effectively trained staff and well-equipped facilities is a critical first step in these efforts. In the United States, state and local public health capacities have been recently weakened, with tens of thousands of jobs lost over the past 5 years at the state and local levels, according to the National Association of County and City Health Officials and the Association of State and Territorial Health Officials. Additional demands were recently placed on these programs as federal agencies operated at reduced capacity during the 16-day absence of a fiscal year 2014 appropriation for U.S. government agencies. Sustaining adequate capacity at these front-line levels is essential for effective control of infectious threats. In addition, advances in genomics, bioinformatics, and informatics offer a unique and much-needed opportunity to improve public health (10). Modernizing public health laboratories and surveillance systems with these capacities will ensure that infectious disease challenges are met with the best available technologies.The lessons from SARS continue to be relevant. Political will and timely sharing of clinical, epidemiologic, and microbiologic information to interrupt transmission; developing and enhancing capacities, partnerships, and collaborations across disciplines and nations; and ensuring linkages among clinical and public health systems and experts at the local and national levels to create a global infrastructure remain critical in our efforts to protect public health.References1. Kuiken T, Fouchier RA, Schutten M, Rimmelzwaan GF, van Amerongen G, van Riel D, et al. Newly discovered coronavirus as the primary cause of severe acute respiratory syndrome. Lancet. 2003;362:263-70. [PMID: 12892955] CrossrefMedlineGoogle Scholar2. World Health Organization. Pandemic Influenza A (H1N1): Donor Report. 1 March 2011. Accessed at www.who.int/csr/resources/publications/swineflu/h1n1_donor_032011.pdf on 9 October 2013. Google Scholar3. World Health Organization. Global Alert and Response (GAR). MERS-CoV summary and literature update—as of 31 May 2013. Accessed at www.who.int/csr/disease/coronavirus_infections/update_20130531/en/index.html on 9 October 2013. Google Scholar4. Gao R, Cao B, Hu Y, Feng Z, Wang D, Hu W, et al. Human infection with a novel avian-origin influenza A (H7N9) virus. N Engl J Med. 2013;368:1888-97. [PMID: 23577628] CrossrefMedlineGoogle Scholar5. Lee N, Hui D, Wu A, Chan P, Cameron P, Joynt GM, et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med. 2003;348:1986-94. [PMID: 12682352] CrossrefMedlineGoogle Scholar6. World Health Organization. Global Alert and Response (GAR). Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003. Accessed at www.who.int/csr/sars/country/table2004_04_21/en/index.html# on 9 October 2013. Google Scholar7. World Health Organization Multicentre Collaborative Network for Severe Acute Respiratory Syndrome Diagnosis. A multicentre collaboration to investigate the cause of severe acute respiratory syndrome. Lancet. 2003;361:1730-3. [PMID: 12767752] CrossrefMedlineGoogle Scholar8. Cheng VC, Lau SK, Woo PC, and Yuen KY. Severe acute respiratory syndrome coronavirus as an agent of emerging and reemerging infection. Clin Microbiol Rev. 2007;20:660-94. [PMID: 17934078] CrossrefMedlineGoogle Scholar9. World Health Organization. International Health Regulations (2005)—2nd Edition. 2008. Accessed at www.who.int/csr/ihr/IHR_2005_en.pdf on 9 October 2013. Google Scholar10. Relman DA. Metagenomics, infectious disease diagnostics, and outbreak investigations: sequence first, ask questions later? [Editorial]. JAMA. 2013;309:1531-2. [PMID: 23571595] CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Centers for Disease Control and Prevention, Atlanta, Georgia.Disclosures: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1587.Corresponding Author: Rima F. Khabbaz, MD, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop D12, Atlanta, GA 30333; e-mail, [email protected].Author Contributions: Conception and design: R.F. Khabbaz.Drafting of the article: R.F. Khabbaz.Final approval of the article: R.F. Khabbaz.Collection and assembly of data: R.F. Khabbaz. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics December 3, 2013Volume 159, Issue 11Page: 780-781KeywordsAvian influenzaBatsCOVID-19Clinical microbiologyDiagnostic techniquesEpidemiologyFallsGeneticsGlobal healthH1N1H7N9Health care providersInfectious diseasesInformation technologyPrevention, policy, and public healthPulmonary diseasesQuarantinesSARS coronavirusSpecimen preparation and treatmentUpper respiratory tract infections ePublished: 3 December 2013 Issue Published: December 3, 2013 PDF DownloadLoading ...