The SARS Epidemic
In early March 2003 a 63 year old man identified only as “Mr. P” went to Scarborough Grace Hospital to get treatment for his chronic heart ailment and acquired an infection from the man in the neighboring bed. Nine days later he went back to the hospital seeking treatment for a high fever and serious cough and died soon after. By the time Mr. P died, Mrs. P. had also acquired the infection. In all, 33 others caught the disease from the Ps, making Toronto the site of the worst North American outbreak of severe acute respiratory syndrome (SARS), a disease that had come to Canada via a Chinese-Canadian woman who had been infected in Hong Kong and brought the disease to Toronto. The man from whom Mr. P caught the disease was the woman’s son.
This case presents information from the SARS epidemic and includes interviews with fictitious stakeholders to illustrate important issues.
The World Health Organization and Its OriginsGovernments began formalizing the system of cooperating against the cross-border spread of serious infectious diseases in the mid 1800s through the International Public Health Office. The system was elaborated further after establishment of the World Health Organization (WHO) as a UN specialized agency in 1946. The WHO has no enforcement powers; it cannot, like a national health ministry, order hospitals or others to take particular public health measures. Rather, WHO officials head a cooperative system of coordinating with national authorities to provide warnings about outbreaks of infectious diseases–particularly those likely to spread across national borders–and to encourage mutual cooperation in limiting the spread to as few people as possible. The WHO also leads a system of mutual assistance so that states with smaller public health services and lower capacity to identify diseases (especially newly emerged diseases) could get help from WHO staff or public health agencies in other states. States, however, are not obliged to let WHO teams visit disease-stricken areas or to have their medical labs participate in collaborative work.
A New Disease EmergesIn November 2002 the normal seasonal influenza outbreaks in Guangdong Province – the most southeastern part of China with 3,368 km of coast along the South China Sea – included cases of what was initially called “atypical pneumonia,” which is a particularly severe lung infection with other symptoms resembling influenza.
The Canadian Global Public Health Intelligence Network (GPHIN), which monitors media and the internet for reports of diseases, picked up references to the atypical cases in Chinese newspaper reports at the end of November. On the basis of these Canadian communications, WHO staff asked the Chinese Ministry of Health for information about the outbreaks on December 5th and again on the 11th. On the 12th, the Ministry noted 23 cases of atypical infections, classifying 22 of them as Influenza B infections, and stating that all the cases were consistent with usual seasonal outbreaks.
Information about the actual extent of outbreaks in Guangdong and the significant number of cases with atypical symptoms emerged slowly in January-February 2003. In early January local media reports on panic buying of flu remedies in several Guangdong Province cities elicited an official government statement denying that there was any epidemic. However, a Ministry of Health team from Beijing arrived in Guangzhou, the provincial capital, to assess the situation on January 20th. On the 23rd, Guangdong Province health authorities sent the Ministry of Health an extended report on the cases of “novel atypical pneumonia.” As required by Chinese law, this information was transmitted in a document classified as “Top Secret.” The report was delivered to the Health Ministry during the Lunar New Year holiday, and no official in the Ministry with clearance to read “Top Secret” documents was available for three days. Even after the report had been read and considered, the Ministry neither made any public statements nor provided information about the outbreak to neighboring provinces.
The first cases of atypical pneumonia in Guangzhou (long known in English as Canton), the capital and largest city of Guangdong Province, were reported on January 31st. The disease spread rapidly, and public health authorities instituted mandatory province-wide reporting of atypical flu cases on February 3rd. A text message saying “There is fatal flu in Guangzhou” began spreading among cell-phone users inside and outside Guangzhou on the 8th. The following day a second inspection team from Beijing, led by the Deputy Health Minister, arrived in town and spurred provincial standardization of hospitalization, treatment, and infection control measures. On the 10th, the WHO Office in Beijing received an e-mail claiming that more than 100 people had died of a new influenza in Guangzhou, and asking the Chinese Health Ministry for information. The Ministry response reported on 335 cases of atypical flu, of which 5 had been fatal: 105 cases among healthcare personnel in hospitals or clinics treating the disease and the other 220 in Guangzhou. Meanwhile, the Guangzhou city health bureau issued a press release acknowledging 100 deaths. The Ministry informed WHO that the first cases of the new flu had occurred in November and that the cause of the new flu had not been identified, but that isolation and other measures had brought its spread under control.
SARS SpreadsThe January and February media reports on the Guangzhou outbreak were picked up fairly rapidly in Hong Kong, located only180 kilometers down the Pearl River from Guangzhou. Though reincorporated into China in 1997 after more than a century of British rule, Hong Kong enjoys considerable autonomy as a “Special Administrative Region” and the government permits more open press and public discussion of many matters there than in other parts of China. On February 14th, in anticipation of seeing the new flu there, Hong Kong public health authorities established a citywide reporting system covering patients admitted to hospital with any sort of flu symptoms. Within a week hospitals had reported several ordinary flu cases and two cases of humans ill from H5N1 avian flu. Hong Kong authorities reported the 2 human avian flu cases to WHO on the 20th.
H5N1 and other avian flus were already a concern, and these reports led WHO to activate its Global Pandemic Preparedness Plan. This plan warns governments of likely cross-border spread of highly infectious diseases and includes procedures for requesting and receiving assistance from WHO or a member state in tracing the spread of a disease, developing control measures, and identifying the infectious bacteria or virus causing it. However, the WHO team sent to China was denied permission to travel to Guangdong Province and was unable to observe the situation directly as it would have liked.
Meanwhile, the “atypical pneumonia” or “atypical influenza” did spread to Hong Kong, and then to Hanoi, Singapore, and Toronto after a Chinese physician who had acquired the infection while treating patients in Guangdong Province came to Hong Kong for a wedding, stayed a few days in the Metropole Hotel, and passed the infection to other guests. The first of these cases was identified in Hanoi on the 26th. The Vietnamese reported it to WHO and requested assistance. WHO sent a team of epidemiologists to Vietnam to help trace the source and design measures to prevent further spread. During the first week of March, other cases traceable to Hong Kong were identified in Singapore, Taiwan, and Toronto and were quickly reported to WHO.
Additional cases -- referred to as “clusters” because they involved multiple persons in direct contact with the patients falling ill earlier in the month --were soon reported from Hong Kong, Singapore, and Toronto. WHO staff concluded there was a high risk of further spread, and issued a global alert to warn all member governments of the existence of a new and highly infectious form of “atypical pneumonia” on March 12th. WHO soon had reports covering 150 positively identified cases outside China, and on the 17th it issued an emergency travel advisory covering Guangdong Province, Hong Kong, Hanoi, Singapore, and Toronto. This advisory first used the designation "severe acute respiratory syndrome (SARS)" and recommended measures to minimize its spread.
A Change in Chinese PolicyOn April 3rd, after much international and domestic criticism, the Chinese government announced that it was giving top priority to containing SARS outbreaks and pledged to cooperate fully within WHO-coordinated efforts. The following day the head of China’s Center for Disease Control apologized for his country’s failure to share information about SARS. A newly sent WHO epidemiological team was allowed into Guangdong Province on the 9th. Domestic constraints on information dissemination, however, remained in place.
On April 13th, Premier Wen Jiabao publicly admitted that the SARS outbreak was serious and promised the government would make full disclosures. Soon the mayor of Beijing admitted that SARS had spread to his city by March 1st, weeks before its presence had been officially acknowledged. On the 18th, Communist Party members were instructed to make sure local and provincial officials reported fully and promptly on SARS cases. To underline the change of direction, Health Minister Zhang Wenkang and Beijing Mayor Meng Xuenong were dismissed for failure to respond adequately to the SARS epidemic. The national government also set aside 2 billion yuan ($240 million) while provincial and local authorities set aside 5 billion yuan ($602 million) as contingency funds for dealing with SARS and future public health emergencies.
SARS subsidesIn May 2003, the number of new cases began to fall. By July 5th WHO felt confident enough about national control measures to announce that all lines of cross-border transmission of SARS had been broken and there was now no danger of an epidemic. Isolated cases did continue to occur, and were reported promptly.
In total, 769 people died worldwide as a result of the SARS outbreak Economists estimated that the main SARS outbreaks from November 2002 through June 2003 cost the global economy more than $40 billion in lost work time, treatment costs, and lost tourism revenues. The areas most affected were Hong Kong (experiencing an estimated 2.6% drop in GDP from disease-related costs) China (a 1.05% drop in GDP), and Canada (a 0.15% drop in GDP).