Here are potential responses to consider in the discussion: - International regulations broke down when China did not initially report the outbreak to WHO in a timely manner. They worked when Vietnam and Canada promptly reported cases and cooperated with WHO. - An improved system would mandate timely reporting of new outbreaks and allow WHO enforcement powers to investigate. It should also define reportable diseases more broadly. - Vietnam and Canada promptly asked for WHO cooperation, while China's response was slower and less transparent initially. - China argued controlling information was important to maintain stability and confidence. Others prioritized public health over economic impacts of advisories or quarantines. - As a scientist in China, I may have advocated publicly sooner; in

1. Reporting Incidence of
Severe Acute Respiratory
Syndrome (SARS)

2. What is SARS?
• Definition:
– “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

3. 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*

4. 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

5. 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

6. 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.

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

8. 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.

9. 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….

10. 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

11. 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

12. 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…

13. 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

14. 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?