Reporting Incidence of Severe Acute Respiratory Syndrome (SARS) Created by the IDEESE Project, 2009 Funding for the International Dimensions of Ethics Education in Science and Engineering Project comes from the National Science Foundation through grant number 0734887. Any opinions, findings, conclusions or recommendations expressed here are those of the author(s) and do not necessarily reflect the views of the National Science Foundation. You are free to use and modify these slides under a Creative Commons, Attribution-Noncommercial-Share Alike License

What is SARS? Definition: Symptoms: “Severe acute respiratory syndrome (SARS) is a viral respiratory illness caused by a coronavirus, called SARS-associated coronavirus (SARS-CoV).” Symptoms: high fever (> 100.4°F/ 38.0°C) at outset with headache, overall feeling of discomfort, & body aches some experience mild respiratory symptoms, diarrhea, & dry cough. most develop pneumonia. Source: US Center for Disease Control and Prevention SARS Factsheet

A Global Context Outbreaks of infectious diseases can attain epidemic proportions in many countries more quickly than in previous centuries. Increased speed of travel Larger numbers of travelers Thus, limiting the spread of infectious diseases requires a *joint effort*

Controlling Spread of Disease Success requires that governments: identify outbreaks of an infectious disease soon after the initial cases appear isolate persons who have the disease or have been in close contact with others having the disease until they are no longer contagious minimize the number of non-infected persons who come in contact with currently infected persons or any place where germs are likely to be present warn other governments so they can take action to ward off spread to their countries

The World Health Organization “the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.” WHO Website (emphasis added) in 2002-2003, WHO authority to address outbreaks was based on the International Health Regulations of 1969

International Health Regulations of 1969 Regulated international cooperation to prevent spread of disease BUT did not give the WHO any enforcement powers Required reporting outbreaks of infectious diseases BUT only specifically listed diseases, not any new disease likely to spread Established a system of mutual assistance so that all states could get help from WHO in identifying causes of infection and developing methods of treatment BUT states were not obliged to let WHO teams visit disease-stricken areas or have their medical labs participate in collaborative work.

The Outbreak 8,141 cases in 31 countries resulting in 769 deaths at a cost of $40 billion worldwide in lost trade and tourism Map from Bill Marsh, The New York Times, 2003

National Responses Compare and contrast: the slow and private actions of China the immediate actions of Vietnam the very public and cautious actions of Canada as shown on the next few slides.

SARS in China November 2002: Identifies “atypical pneumonia” February 14, 2003: Reports 305 cases and 5 deaths to WHO; claims spread is under control February 18, 2003: Dr. Hong Tao concludes that the new disease is a variant of the chlamydia virus February 20, 2003: Chinese Academy of Military Medical Sciences (AMMS) researchers believe Tao’s theory is wrong; decide to conduct further research before making public statements February 21, 2003: Chinese SARS-treating doctor travels to Hong Kong hotel; infects other guests early March, 2003: AMMS scientists find additional support for coronavirus; again decide to continue research before criticizing Government acceptance of Tao’s theory Continued….

SARS in China March 10, 2003: Health Ministry requests WHO assistance March 21, 2003: AMMS publicly reports findings to Army Logistical Department and Ministry of Health March 21, 2003: Health Ministry requests additional WHO assistance; WHO sends 5 people March 25, 2003: WHO team is barred from Guangdong Province March 27, 2003: Guangdong Province issues guidelines on community prevention and control March 28, 2003: Health Ministry grees to work with WHO April 3, 2003: Health Ministry allows WHO teams to visit infected sites May 13, 2003: CNN International special on SARS that criticized the Chinese government’s response to the illness is censored in China End result: 7,083 cases and 644 deaths

SARS in Vietnam February 26, 2003: First case identified February 26, 2003: Asks for WHO assistance; WHO sends team March 6, 2003: USA sends team from Center for Disease Control April 29, 2003: SARS declared contained in Vietnam End result: 63 cases and 5 deaths

SARS in Canada November 27, 2002: Canadian Global Public Health Intelligence Network (GPHIN) relays media reports of atypical pneumonia in Guangdong Province to WHO Global Influenza Surveillance Network January 21, 2003: GPHIN Report is translated to English March 5, 2003: First case identified in Toronto March 17, 2003: Health Canada announces 11 cases of SARS April 11, 2003: Canadian Blood Services refuses donations from persons who have been to Southeast Asia recently (even though there is no evidence of bloodstream transfers of SARS infection) April 13, 2003: Michael Smith Genome Sciences Centre posts SARS genome sequence online April 20, 2003: Canada's largest trauma unit stops accepting new patients after at least four health-care workers show signs of SARS Continued…

SARS in Canada April 23, 2003: WHO extends travel warnings to Toronto for 3 weeks, double the incubation time of SARS May 1, 2003: WHO's director of communicable-disease surveillance and response writes an opinion article saying that the Toronto travel advisory could ultimately harm the fight against SARS because less-transparent countries will be afraid to report outbreaks, fearing economic costs. May 14, 2003: Canada removed from WHO list of SARS-affected countries May 24, 2003: Reports of new SARS cases; state of emergency declared in Ontario; More than 500 people ordered into quarantine in Toronto July 2, 2003: WHO removes Toronto from list of SARS affected areas End result: 251 cases and 43 deaths

Discussion China, Canada and Vietnam dealt with the spread of SARS in very different ways. Consider each country’s approach when answering the following questions: Where did international regulations break down? Where did they work? How would you redesign an international reporting system? Who asked for cooperation and who did not? What arguments did countries use support their decisions to, or not to, cooperate with the WHO and other governments? What would you have done the same or differently As a bench scientist in China? in Canada? As a managing health official in China? in Canada? Who is to blame for allowing SARS to spread as far as it did?