Severe Acute Respiratory Syndrome (SARS)

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Severe Acute Respiratory Syndrome (SARS)

• AA Model for Preparedness for Emerging Diseases
• Finding and
• Filling Gaps

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What is the status of Big Gaps

• Clinical manifestations of full blown SARS
• Diagnosis and therapy
• Clinical spectrum
• Characteristics of transmission transmitters
• Seasonality and potential geographic range
• Causative agent? Any important co-factors?
• Protective factorsdo children provide clues?
• Where did the causative agent come from?
• Is there a persistent reservoir?
• How about those time lags
• Recognizing and publicizing new syndrome
• Public health prevention measures

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Big Gap Status

• Clinical manifestations of full blown SARS
• Diagnosis and therapy
• Clinical spectrum
• Characteristics of transmission transmitters
• Seasonality and potential geographic range
• Causative agent? Any important co-factors?
• Protective factorsdo children provide clues?
• Where did the causative agent come from?
• Is there a persistent reservoir?
• How about those time lags
• Recognizing and publicizing new syndrome
• Public health prevention measures

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Big Gap Status

• Clinical manifestations of full blown SARS
• Diagnosis and therapy
• Clinical spectrum
• Characteristics of transmission transmitters
• Seasonality and potential geographic range
• What causes it? Any important co-factors?
• Protective factorsdo children provide clues?
• Where did the causative agent come from?
• Is there a persistent reservoir?
• How about those time lags
• Recognizing and publicizing new syndrome
• Public health prevention measures

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Chain of TransmissionPt ZF

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1st, 2nd, and 3rd hospitalizations
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China (and its neighbors)
Flights to Bangkok
HK-Dhaka
BKK-DAC
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Big Gap Status

• Clinical manifestations of full blown SARS
• Diagnosis and therapy
• Clinical spectrum
• Characteristics of transmission transmitters
• Seasonality and potential geographic range
• What causes it? Any important co-factors?
• Protective factorsdo children provide clues?
• Where did the causative agent come from?
• Is there a persistent reservoir?
• How about those time lags
• Recognizing and publicizing new syndrome
• Public health prevention measures

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Transmission PatternGuangdong-first 1000
casesthrough February

• 28 in health care workers
• 20 in family members
• 52 unknown contacts
• 5 of cases were food preparers (compared with 1
  of those with typical pneumonias over the
  previous two years)

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Food Handlers as the Original Sentinels?

• Nearly 35 of the cases recognized before Feb 1,
  2003 were among food handlersmany lived near
  wet markets
• Ample exposure to secretions, blood, urine and
  feces of domesticated/bred and wild animals in
  Guangdong Province

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Animal Market, Guangzhou
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Finding the SourceLearning from By-gone
Epidemics

• Legionnaires disease
• The bacteria are everywhere, but only one source
  is usually responsible for an epidemic
• Can you tell me how to clean the cooling tower?
• Schistosomiasis in Malawi
• E. coli 0157 outbreaks from hamburgers to water
  parks
• Message Let epidemiology guide the animal
  coronavirus surveys and confirm with molecular
  epi/genetic studies

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Epi Studies

• Begin with case-control study of first 50-100
  known cases in Guangdong
• Focus on
• Pets
• Visits to animal markets
• Animals purchased or used
• Detail interaction with animal
• Food ingested
• How cooked/served/eaten
• Nested study with case food preparers and food
  preparer controls
• Specific behaviors/functions
• Include serologic data on cases/controls
• Get isolates or sequences from as many early
  cases as possible
• Consider similar work in cases without known
  contacts

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Big Gap Status

• Clinical manifestations of full blown SARS
• Diagnosis and therapy
• Clinical spectrum
• Characteristics of transmission transmitters
• Seasonality and potential geographic range
• What causes it? Any important co-factors?
• Protective factorsdo children provide clues?
• Where did the causative agent come from?
• Is there a persistent reservoir?
• How about those time lags
• Recognizing and publicizing new syndrome
• Public health prevention measures

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Epidemics of Emerging or Known Diseases Early
Recognition and ResponseWhat is Required?

• Surveillance Systems
• Hospital-based
• focused on disease or known syndrome
• Enough information to recognize novel clinical or
  epidemiologic pattern
• unusual combination of signs/symptoms
• occupational clustering (may consider
  surveillance in sentinel populationsi.e. health
  care workers
• Behavior-based
• Vinegar sales would have been a clue
• Antimicrobial drug sales
• Physician-based via education/networks/hotlines

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Epidemics of Emerging or Known Diseases Early
Recognition and ResponseSurveillance
Characteristics

• System should be easy to participate in
• Individual reporting should be electronic
• Analysis should have automated capacity with
  built-in pattern recognition and also flexibility
  for operator manipulation
• Trained personnel need to maintain and use it
• Pre-established thresholds for anomalies/prepared
  to respond
• Teams trained, ready, and available to
  investigate
• International support/trust
• Prepared for communication/education

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Global Spread of a Novel Pathogen
Guangdong 1500 cases
Toronto
142 cases
Hong Kong 1500 cases
Vietnam
63 cases
Singapore
205 cases
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Big Lesson from SARSPolitical Will Required to
Support, Enhance and Utilize Public Health
Infrastructure

• Need for quick, transparent steps to declare
  presence of lethal pathogen with borders
• Intensify surveillance and report results
• Use contact tracing, quarantine, and border
  control measures when needed
• Apply stringent infection control measures in
  health care settings when indicated
• Provide public with timely information
• Magnitude
• Known risks
• How one can protect himself/herself and family
• International public health enforcement??

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Keep Some Perspective

• 5,000 cases in Chinapopulation 1.3 billion
• 8,000 cases globally
• Not easy to get SARS
• Not the greatest health problem faced, but a test
  for our preparedness to respond to public health
  crises
• We can use this experience to improve ourselves

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May the Lord grant me a sword and no need to use
it.           --Czech Proverb
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Politics and Public Health
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