Emerging Infectious Diseases
Asian SARS Outbreak Challenged International and National Responses Gao ID: GAO-04-564 April 28, 2004Severe acute respiratory syndrome (SARS) emerged in southern China in November 2002 and spread rapidly along international air routes in early 2003. Asian countries had the most cases (7,782) and deaths (729). SARS challenged Asian health care systems, disrupted Asian economies, and tested the effectiveness of the International Health Regulations. GAO was asked to examine the roles of the World Health Organization (WHO), the U.S. government, and Asian governments (China, Hong Kong, and Taiwan) in responding to SARS; the estimated economic impact of SARS in Asia; and efforts to update the International Health Regulations.
WHO implemented extensive actions to respond to SARS, but its response was delayed by an initial lack of cooperation from officials in China and challenged by limited resources for infectious disease control. WHO activated its global infectious disease network and deployed public health specialists to affected areas in Asia to provide technical assistance. WHO also established international teams to identify the cause of SARS and provide guidance for managing the outbreak. WHO's ability to respond to SARS in Asia was limited by its authority under the current International Health Regulations and dependent on cooperation from affected areas. U.S. government agencies played key roles in responding to SARS in Asia and controlling its spread into the United States, but these efforts revealed limitations. The Centers for Disease Control and Prevention supplied public health experts to WHO for deployment to Asia and gave direct assistance to Taiwan. It also tried to contact passengers from flights and ships on which a traveler was diagnosed with SARS after arriving in the United States. However, these efforts were hampered by airline concerns and procedural issues. The State Department helped facilitate the U.S. government's response to SARS but encountered multiple difficulties when it tried to arrange medical evacuations for U.S. citizens infected with SARS overseas. Although the Asian governments we studied initially struggled to recognize the SARS emergency and organize an appropriate response, they ultimately established control. As the governments have acknowledged, their initial response to SARS was hindered by poor communication, ineffective leadership, inadequate disease surveillance systems, and insufficient public health capacity. Improved screening, rapid isolation of suspected cases, enhanced hospital infection control, and quarantine of close contacts ultimately helped end the outbreak. The SARS crisis temporarily dampened consumer confidence in Asia, costing Asian economies $11 billion to $18 billion and resulting in estimated losses of 0.5 percent to 2 percent of total output, according to official and academic estimates. SARS had significant, but temporary, negative impacts on a variety of economic activities, especially travel and tourism. The SARS outbreak added impetus to the revision of the International Health Regulations. WHO and its member states are considering expanding the scope of required disease reporting to include all public health emergencies of international concern and devising a system for better cooperation with WHO and other countries. Some questions are not yet resolved, including WHO's authority to conduct investigations in countries absent their consent, the enforcement mechanism to resolve compliance issues, and how to ensure public health security without unduly interfering with travel and trade.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
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Report to the Chairman, Subcommittee on Asia and the Pacific, Committee
on International Relations, House of Representatives:
April 2004:
EMERGING INFECTIOUS DISEASES:
Asian SARS Outbreak Challenged International and National Responses:
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-564]:
GAO Highlights:
Highlights of GAO-04-564, a report to the Chairman, Subcommittee on
Asia and the Pacific, Committee on International Relations, House of
Representatives
Why GAO Did This Study:
Severe acute respiratory syndrome (SARS) emerged in southern China in
November 2002 and spread rapidly along international air routes in
early 2003. Asian countries had the most cases (7,782) and deaths
(729). SARS challenged Asian health care systems, disrupted Asian
economies, and tested the effectiveness of the International Health
Regulations. GAO was asked to examine the roles of the World Health
Organization (WHO), the U.S. government, and Asian governments (China,
Hong Kong, and Taiwan) in responding to SARS; the estimated economic
impact of SARS in Asia; and efforts to update the International Health
Regulations.
What GAO Found:
WHO implemented extensive actions to respond to SARS, but its response
was delayed by an initial lack of cooperation from officials in China
and challenged by limited resources for infectious disease control.
WHO activated its global infectious disease network and deployed
public health specialists to affected areas in Asia to provide
technical assistance. WHO also established international teams to
identify the cause of SARS and provide guidance for managing the
outbreak. WHO‘s ability to respond to SARS in Asia was limited by its
authority under the current International Health Regulations and
dependent on cooperation from affected areas.
U.S. government agencies played key roles in responding to SARS in
Asia and controlling its spread into the United States, but these
efforts revealed limitations. The Centers for Disease Control and
Prevention supplied public health experts to WHO for deployment to
Asia and gave direct assistance to Taiwan. It also tried to contact
passengers from flights and ships on which a traveler was diagnosed
with SARS after arriving in the United States. However, these efforts
were hampered by airline concerns and procedural issues. The State
Department helped facilitate the U.S. government‘s response to SARS
but encountered multiple difficulties when it tried to arrange medical
evacuations for U.S. citizens infected with SARS overseas.
Although the Asian governments we studied initially struggled to
recognize the SARS emergency and organize an appropriate response,
they ultimately established control. As the governments have
acknowledged, their initial response to SARS was hindered by poor
communication, ineffective leadership, inadequate disease surveillance
systems, and insufficient public health capacity. Improved screening,
rapid isolation of suspected cases, enhanced hospital infection
control, and quarantine of close contacts ultimately helped end the
outbreak.
The SARS crisis temporarily dampened consumer confidence in Asia,
costing Asian economies $11 billion to $18 billion and resulting in
estimated losses of 0.5 percent to 2 percent of total output, according
to official and academic estimates. SARS had significant, but
temporary, negative impacts on a variety of economic activities,
especially travel and tourism.
The SARS outbreak added impetus to the revision of the International
Health Regulations. WHO and its member states are considering expanding
the scope of required disease reporting to include all public health
emergencies of international concern and devising a system for better
cooperation with WHO and other countries. Some questions are not yet
resolved, including WHO‘s authority to conduct investigations in
countries absent their consent, the enforcement mechanism to resolve
compliance issues, and how to ensure public health security without
unduly interfering with travel and trade.
What GAO Recommends:
GAO is recommending that the Secretaries of Health and Human Services
(HHS) and State work with WHO and other member states to strengthen
WHO‘s global infectious disease network. GAO is also recommending that
the Secretary of HHS complete steps to ensure that the agency can
obtain passenger contact information in a timely manner, including, if
necessary, the promulgation of specific regulations; and that the
Secretary of State work with other relevant agencies to develop
procedures for arranging medical evacuations during an airborne
infectious disease outbreak. HHS, State, and WHO generally concurred
with the report‘s content and its recommendations.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
WHO's Response to SARS Was Extensive, but Was Delayed by an Initial
Lack of Cooperation from China and Challenged by Limited Resources:
U.S. Government Had Key Role in Response to SARS, but Efforts Revealed
Problems in Ability to Respond to Emerging Infectious Diseases:
After Initial Struggle, Asian Governments Brought SARS Outbreak under
Control:
SARS Outbreak Decreased Consumer Confidence and Negatively Affected a
Number of Asian Economies:
WHO Members Will Debate Important Issues Raised by International Health
Regulations' Revision:
Conclusion:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Scope and Methodology:
Appendixes:
Appendix I: SARS Cases and Deaths, November 2002-July 2003:
Appendix II: SARS Chronology:
Appendix III: Estimates of the Economic Impact of SARS:
Appendix IV: Comments from the Department of Health and Human Services:
Appendix V: Comments from the Department of State:
Appendix VI: Comments from the World Health Organization:
Appendix VII: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Acknowledgments:
Tables:
Table 1: Estimated Economic Cost of SARS in Asia:
Table 2: Asian Government Stimulus Packages in Response to SARS, 2003:
Table 3: Models Estimating the Economic Impact of SARS on GDP in Asia,
2003:
Figures:
Figure 1: Timeline of SARS Events and Actions:
Figure 2: CDC Health Alert Notice:
Figure 3: Quarterly GDP Growth for Various Asian Economies, 2002-2003:
Figure 4: Estimated Economic Impacts of SARS on Travel and Tourism:
Figure 5: Quarterly Retail Sales Growth in Selected Asian Economies,
2002-2003:
Abbreviations:
CDC: Centers for Disease Control and Prevention:
GDP: gross domestic product:
GOARN: Global Outbreak Alert and Response Network:
GPHIN: Global Public Health Intelligence Network::
HHS: Department of Health and Human Services:
SARS: severe acute respiratory syndrome:
WHO: World Health Organization:
WPRO: Western Pacific Regional Office:
Letter April 28, 2004:
The Honorable James A. Leach
Chairman, Subcommittee on Asia and the Pacific
Committee on International Relations
House of Representatives:
Dear Mr. Chairman:
Severe acute respiratory syndrome (SARS), the first major new
infectious disease of the 21st century, emerged in southern China in
November 2002. SARS is a contagious respiratory disease with a
substantial mortality rate, and there is no vaccine, no reliable rapid
diagnostic test, and no specific treatment for the disease. The disease
spread rapidly along international air routes through Asia, North
America, and Europe in early 2003, eventually infecting 8,098 people
and causing 774 deaths.[Footnote 1] Asian countries were the hardest
hit, with 7,782 cases and 729 deaths. The 2002-2003 SARS outbreak
presented a challenge to Asian health care systems and disrupted Asian
economies. The World Health Organization (WHO), the U.S. government,
and Asian governments all played a role in controlling the SARS
outbreak in Asia. The history of this effort raises important issues
regarding international and national preparedness for recognizing and
responding to emerging infectious diseases such as SARS, including the
effectiveness of the International Health Regulations, WHO's legal
framework for preventing the international spread of infectious
diseases.
In light of these concerns, you asked that we assess the impact of SARS
on health and commerce in Asia. In this report we examine (1) WHO's
actions to respond to the SARS outbreak in Asia, (2) the role of the
U.S. government in responding to SARS in Asia and limiting its spread
into the United States, (3) how governments in the areas of Asia most
affected by SARS responded to the outbreak, (4) the estimated economic
impact of SARS in Asia, and (5) the status of efforts to update the
International Health Regulations.
The primary focus of our report is on those parts of Asia most severely
affected by SARS during the 2002-2003 outbreak, including China, Hong
Kong, and Taiwan. To examine the response to the SARS outbreak by WHO,
the U.S. government, and Asian governments, we conducted fieldwork in
Beijing, Hong Kong and Guangdong Province, China; and in Taipei,
Taiwan, where we met with public health officials, including senior
Ministry of Health staff, international epidemiologists, and local
hospital workers. We supplemented our field-level information with
interviews with WHO and U.S. government officials responsible for
managing the response to SARS and recognized public health experts; we
also reviewed relevant documents and reports. To describe the economic
impact of SARS in Asia, we reviewed official macroeconomic and sector
data as well as economic impact studies from international financial
institutions, industry associations, and public policy research
organizations. We determined that the official national accounts data
were sufficiently reliable for the purposes of our analysis by
reviewing supplementary documentary evidence and each economy's
compliance with data dissemination standards. The scope of our summary
of economic analyses included other Asian economies strongly impacted
by the disease: Malaysia, Singapore, Thailand, and Vietnam. Finally, we
examined a draft of WHO's proposed revision of the International Health
Regulations and interviewed WHO and U.S. government officials and other
legal experts to determine the potential impacts of the revised rules.
See pages 46-48 for a more complete description of our scope and
methodology. We performed our work from July 2003 to April 2004 in
accordance with generally accepted government auditing standards.
Results in Brief:
WHO implemented extensive actions to respond to SARS, but its response
was delayed by an initial lack of cooperation from officials in China
and challenged by limited resources. At the heart of WHO's response to
SARS was the activation of its global infectious disease network. This
effort, combined with assistance from WHO's Asian regional office,
included deploying public health specialists to affected areas in Asia
to provide technical assistance and establishing international teams of
researchers and clinicians who worked together to identify the cause of
SARS, investigate modes of transmission, and develop guidance for
managing the outbreak. WHO played a major role in controlling the
spread of SARS by issuing global alerts and recommending against travel
to countries with SARS outbreaks. It also issued guidance and
recommendations to affected areas and the international community on
surveillance, preparedness, and response. Although the response was
ultimately successful, WHO's actions were delayed because China did not
initially provide information about the SARS outbreak or invite WHO to
assist in investigating and managing the outbreak in a timely manner.
WHO's ability to respond to SARS in China, and elsewhere, was limited
by its authority under the current International Health Regulations and
dependent on cooperation from affected areas. In addition, WHO's
ability to provide timely and appropriate expertise was challenged by
the limited resources available to its global infectious disease
network, which was stretched to capacity during the outbreak.
U.S. government agencies played significant roles in responding to SARS
in Asia and controlling its spread into the United States, but these
efforts revealed limitations in their ability to respond to emerging
infectious diseases. The Department of Health and Human Services' (HHS)
Centers for Disease Control and Prevention (CDC) was involved in early
international efforts to identify the disease, provided a significant
proportion of the public health experts deployed by WHO to Asia, and
gave direct assistance to Taiwanese health authorities. CDC also helped
limit the spread of SARS into this country by disseminating information
to travelers and attempting to identify and contact passengers from
flights and ships on which travelers were diagnosed with SARS after
arriving in the United States. However, CDC encountered obstacles that
made it unable to perform this important outbreak control measure
because of airline concerns over CDC's authority and the privacy of
passenger information, as well as procedural issues. CDC is exploring
options to overcome the problems it encountered, although it has faced
obstacles in pursuing some of them. The State Department (State)
applied diplomatic pressure on governments to increase transparency and
response, helped facilitate the U.S. government response to SARS in
Asia, and provided information on SARS to U.S. government employees and
citizens in the region. State also attempted to coordinate medical
evacuations for a small number of U.S. citizens infected with SARS
overseas but encountered multiple difficulties. These difficulties have
not been resolved and could present challenges in the future. Although
State has not developed a strategy to address these problems, it is
working with other agencies to develop guidance for arranging medical
evacuations.
Although the Asian governments we studied initially struggled to
recognize the SARS emergency and organize an appropriate response, they
ultimately established control. As Asian government officials
acknowledged, poor communication, a lack of effective leadership and
coordination, and weaknesses in disease surveillance systems and public
health capacity constrained their response. In China, poor
communication within the country, with Hong Kong and Taiwan, and with
WHO obscured the severity of the outbreak during its initial stages.
For example, a detailed report produced by provincial officials 2 weeks
before China officially announced the SARS outbreak was not shared with
other governments or WHO. An initial lack of effective leadership and
coordination within the governments of China, Hong Kong, and Taiwan
hindered the implementation of a large-scale control effort and led to
the dismissal of high-ranking officials. As the outbreak progressed,
problems with disease surveillance systems and overall public health
capacity further delayed control of the outbreak in many of the
affected areas. For example, officials in China noted that a large
number of cases in Beijing were not reported because there was no
system to collect this information from hospitals in the city. In
Taiwan, officials acknowledged that a lack of expertise in hospital
infection control contributed to a secondary, and more severe, outbreak
in hospitals throughout the island. However, improved screening, rapid
isolation of suspected cases, enhanced hospital infection control, and
quarantine of close contacts ultimately helped end the outbreak in
Asia. In the aftermath of SARS, efforts are under way to improve public
health capacity in Asia to better deal with SARS and other infectious
disease outbreaks.
The SARS crisis temporarily dampened consumer confidence, costing
selected Asian economies around $11 billion to $18 billion and
resulting in an estimated loss of 0.5 percent to 2 percent of their
total economic output, according to official and academic estimates.
Though sectors most affected by SARS have now recovered, the outbreak
had a significant negative impact on a variety of economic activities.
The most severe economic impacts occurred in the travel and tourism
industry, particularly the airline industry. Anecdotal evidence
suggests that retail sales, and to a lesser degree some foreign trade
and investment, also temporarily declined as a result of SARS. In
response to the outbreak, governments in Asia provided economic
stimulus packages that also cost billions.
The SARS outbreak added impetus to efforts to revise WHO's
International Health Regulations, and an interim draft of revised
regulations is currently being circulated. Recognizing that emerging
and re-emerging diseases have made the regulations obsolete, WHO and
its member states are considering (1) expanding the scope of reporting
beyond the three diseases that are currently required to be reported
(cholera, plague, and yellow fever) to include all potential public
health emergencies of international concern and (2) devising a system
for better member state dialogue and cooperation with WHO and other
countries. However, important questions about the proposed regulations'
scope of coverage, WHO's authority to conduct investigations in
countries absent their specific consent, the limited public health
capacity of developing countries, the enforcement mechanism used to
resolve compliance issues, and how to ensure public health security
without unnecessary interference with travel and trade will have to be
resolved in the debate leading to the adoption of the final
regulations.
We are recommending that the Secretary of Health and Human Services, in
collaboration with the Secretary of State, work with WHO and official
representatives from other WHO member states to strengthen the response
capacity of WHO's global infectious disease network. In light of the
unresolved problems of identifying and contacting travelers arriving in
the United States who may have been exposed to an infectious disease,
and evacuating U.S. government employees overseas who have an airborne
infectious disease, we are making two additional recommendations.
First, we are recommending that the Secretary of Health and Human
Services complete steps to ensure that the agency can obtain passenger
contact information in a timely manner, including, if necessary, the
promulgation of regulations specifically for this purpose. Second, we
are recommending that the Secretary of State work with other relevant
agencies to identify public and private sector resources and develop
procedures for arranging medical evacuations during an airborne
infectious disease outbreak in foreign countries.
In providing written comments on a draft of this report, HHS, State,
and WHO generally concurred with the report's content and its
recommendations (see apps. IV, V, and VI for a reprint of their
comments). They also provided technical and clarifying comments that we
have incorporated where appropriate. HHS and State commented that the
report provided a good summary of the SARS outbreak and the impact upon
and actions taken by affected countries, WHO, and the U.S. government.
They endorsed GAO's recommendations but noted that sensitive legal and
privacy issues and diplomatic concerns must be carefully addressed in
regard to contact tracing of passengers who may have been exposed to an
infectious disease. WHO commented that the report provides a factual
analysis of the events surrounding the emergence of SARS and the major
weaknesses in national and international control efforts. WHO also
commented that Asian governments should be better credited for the
depth and intensity of their response effort, but we believe the report
presents a balanced view. WHO also provided clarifying language on the
role of its global response network, which we have incorporated.
Background:
SARS is a severe viral infection that is sometimes fatal. The disease
first emerged in China in 2002 and then spread through Asia to 26
countries around the world. Although national governments are
responsible for responding to infectious disease outbreaks such as
SARS, WHO plays an important role in coordinating the response to the
global spread of infectious diseases and assisting countries with their
public health response to outbreaks. The U.S. government plays a role
during international outbreaks in assisting WHO and affected countries
and protecting U.S. citizens and interests at home and abroad.
Characteristics of SARS:
The virus that causes SARS is a member of a family of viruses known as
coronaviruses, which are thought to cause about 10 percent to 15
percent of common colds.[Footnote 2] Within 2 to 10 days after
infection with the SARS virus, an individual may begin to develop
symptoms--including cough, fever, and body aches--that are difficult to
distinguish from those of other respiratory illnesses. The primary mode
of transmission appears to be direct or indirect contact with
respiratory secretions or contaminated objects. Another feature of the
disease is the occurrence of "superspreading events," where evidence
suggests that the disease is transmitted at a high rate due to a
combination of patient, environmental, and other factors. According to
WHO, the global case fatality rate for SARS is approximately 11 percent
and may be more than 50 percent for individuals over age 65.
Prevention and Control of SARS:
The management of a SARS outbreak relies on the use of established
public health measures for the control of infectious diseases--
including case identification and contact tracing, transmission
control, and exposure management, defined as follows:
* Case identification and contact tracing: defining what symptoms,
laboratory results, and medical histories constitute a positive case in
a patient and tracing and tracking individuals who may have been
exposed to these patients.
* Transmission control: controlling the transmission of disease-
producing microorganisms through use of proper hand hygiene and
personal protective equipment, such as masks, gowns, and gloves.
* Exposure management: separating infected and noninfected individuals.
Quarantine is a type of exposure management that refers to the
separation or restriction of movement of individuals who are not yet
ill but were exposed to an infectious agent and are potentially
infectious.
The 2002-2003 SARS Outbreak:
The emergence of SARS in China can be traced to reports of cases of
atypical pneumonia[Footnote 3] in several cities throughout Guangdong
Province in November 2002. (See fig. 1 for a timeline of the emergence
of SARS cases and WHO and U.S. government actions.) Because atypical
pneumonia is not unusual in this region and the cases did not appear to
be connected, many of these early cases were not recognized as a new
disease. However, physicians were alarmed because of the unusual number
of health care workers who became severely ill after treating patients
with a diagnosis of atypical pneumonia. The international outbreak
began in February 2003 when an infected physician who had treated some
of these patients in China traveled to Hong Kong and stayed at a local
hotel. Some individuals who visited the hotel acquired the infection
and subsequently traveled to Vietnam, Singapore, and Toronto and seeded
secondary outbreaks. Throughout spring 2003, the number of cases
continued to spread through Asia to 26 countries around the world, and
at its peak--in early May--hundreds of new SARS cases were reported
every week. (See app. I for a map of total SARS cases and deaths.) In
July 2003, WHO announced that the outbreak had been contained. (See
app. II for a detailed chronology of the SARS outbreak.):
Figure 1: Timeline of SARS Events and Actions:
[See PDF for image]
[End of figure]
Global Infectious Disease Control and the Role of the World Health
Organization:
Although national governments bear primary responsibility for disease
surveillance and response, WHO, an agency of the United Nations, plays
a central role in global infectious disease control. WHO provides
support, information, and recommendations to governments and the
international community during outbreaks of infectious disease that
threaten global health or trade. The International Health Regulations
outline WHO's authority and member states' obligations in preventing
the global spread of infectious diseases. Adopted in 1951 and last
modified in 1981, the International Health Regulations are designed to
ensure maximum security against the international spread of diseases
with a minimum of interference with world traffic (that is, trade and
travel). The current regulations require that member states report the
incidence of three diseases within their borders--cholera, plague, and
yellow fever--and WHO can investigate an outbreak only after receiving
the consent of the government involved. Efforts to revise the
regulations began in 1995, and the revised regulations are scheduled to
be ready for submission to the World Health Assembly, the governing
body of WHO, in May 2005.[Footnote 4]
While the International Health Regulations provide the legal framework
for global infectious disease control, WHO's Global Outbreak Alert and
Response Network (GOARN), established in April 2000, is the primary
mechanism by which WHO mobilizes technical resources for the
investigation of, and response to, disease outbreaks of international
importance. Because WHO does not have the human and financial resources
to respond to all disease outbreaks, GOARN relies on the resources of
its partners, including scientific and public health institutions in
member states, surveillance and laboratory networks (e.g., WHO's Global
Influenza Surveillance Network)[Footnote 5], other U.N. organizations,
the International Committee of the Red Cross, and international
humanitarian nongovernmental organizations. WHO collects intelligence
about outbreaks through various sources, including formal reports from
governments and WHO officials in the field as well as informal reports
from the media and the Internet.[Footnote 6] When WHO receives a formal
request for assistance from a national government, it responds
primarily through GOARN. GOARN's key response objectives are to ensure
that appropriate technical assistance rapidly reaches affected areas
during an outbreak and to strengthen public health response capacity
within countries for future outbreaks. Its response activities may
include providing technical advice or support (e.g., public health
experts and laboratory services), logistical aid (e.g., supplies and
vaccines), and financial assistance (e.g., emergency funds). In
addition to the support provided through GOARN, technical assistance
and deployments are also arranged through WHO's regional offices.
U.S. Government Agencies Responsible for Responding to Global
Infectious Disease Outbreaks:
Two departments of the U.S. government, the Department of Health and
Human Services (HHS) and State, play major roles in responding to
infectious disease outbreaks overseas.[Footnote 7] Within HHS, the
Office of Global Health Affairs and CDC work closely with WHO and
foreign governments in response efforts.[Footnote 8] CDC also works
with other federal agencies, state and local health departments, and
the travel industry to limit the introduction of communicable diseases
into the United States. State's roles include protecting U.S.
government employees working overseas and disseminating information
about situations that may pose a threat to U.S. citizens living and
traveling abroad. In addition, State may coordinate the provision of
technical assistance by various U.S. government agencies and use its
diplomatic contacts to engage foreign governments on policy issues
related to infectious disease response.
Infectious Disease Control in China, Hong Kong, and Taiwan:
In recent years, Asia has become increasingly vulnerable to emerging
infectious disease outbreaks, and governments have had to deal with
diseases such as avian influenza and dengue fever. In China, Hong Kong,
and Taiwan, such infectious disease outbreaks are managed through the
public health authorities of these governments:
* China: The Ministry of Health maintains lead authority over health
policy at the national level, although provincial governments exercise
significant authority over local health matters. In January 2002, the
national Center for Disease Control and Prevention was established,
along with centers at the provincial and local levels, and charged with
matters ranging from infectious disease control to chronic disease
management.
* Hong Kong: The Health, Welfare, and Food Bureau has overall policy
responsibility for health care delivery and other human services in
Hong Kong. Within the bureau, the Department of Health and its Disease
Prevention and Control Division, which was established in July 2000,
are responsible for formulating strategies and implementing measures in
the surveillance, prevention, and control of communicable diseases. The
Hospital Authority is responsible for the management of 43 public
hospitals in Hong Kong.
* Taiwan: The Department of Health is responsible for national health
matters and for guiding, supervising, and coordinating local health
bureaus. A division of the department, the Taiwan Center for Disease
Control, was established in 1999 and consolidated the disease
prevention work of several national public health agencies involved in
infectious disease control.
WHO's Response to SARS Was Extensive, but Was Delayed by an Initial
Lack of Cooperation from China and Challenged by Limited Resources:
WHO's actions to respond to the SARS outbreak were extensive, but its
response was delayed by an initial lack of cooperation from officials
in China and challenged by limited resources. WHO's actions included
direct technical assistance to affected areas and broad international
actions such as alerting the international community about this serious
disease and issuing information, guidance, and recommendations to
government officials, health professionals, the general public, and the
media. (See fig. 1 for key WHO actions during the SARS outbreak.)
However, an initial lack of cooperation on the part of China limited
WHO's access to information about the outbreak, and WHO had to stretch
its resources for infectious disease control to capacity.
WHO Provided Direct Assistance to Affected Areas:
WHO's response to SARS was coordinated jointly by WHO headquarters and
its Western Pacific Regional Office (WPRO). At headquarters, WHO
activated its GOARN. Although GOARN had been used before to respond to
isolated outbreaks of Ebola, meningitis, viral hemorrhagic fever, and
cholera in African countries and elsewhere, the SARS outbreak was the
first time the network was activated on such a large scale for an
international outbreak of an unknown emerging infectious disease. There
were two primary aspects to WHO's activities during the SARS outbreak:
One was the direct deployment of public health specialists from around
the world to affected Asian governments to provide technical
assistance; the other was the formation of three virtual networks of
laboratory specialists, clinicians, and epidemiologists who pooled
their knowledge, expertise, and resources to collect and develop the
information WHO needed to issue its guidance and communications about
SARS.
Deployment:
Under GOARN's auspices, WHO rapidly deployed 115 specialists from 26
institutions in 17 countries to provide direct technical assistance to
SARS-affected areas. WPRO also facilitated the deployment of an
additional 80 public health specialists to SARS-affected areas. Asian
governments identified their needs for technical assistance--
consisting primarily of more senior, experienced staff--and then WHO
issued a request for staff from its partners. WHO officials at
headquarters and at WPRO worked jointly to quickly process contracts
and send teams into the field within 48 hours of the request. The work
of the teams varied, depending on local need. For example, a team of 5
public health experts sent to China reviewed clinical and epidemiologic
data to improve the detection and surveillance of SARS cases in
Guangdong. A team of 4 public health experts sent to Hong Kong included
environmental engineers to help investigate the spread of SARS in a
housing complex.
Virtual Networks:
WHO also formed several international networks of researchers and
clinicians, including a laboratory network, a clinical network, and an
epidemiologic network. These networks operated "virtually,"
communicating through a secure Web site and teleconferences. The SARS
laboratory network, based on the model of WHO's global influenza
surveillance network and using some of the same laboratories, consisted
of 13 laboratories in 9 countries. Within one month of its creation,
participants in this network had identified the SARS coronavirus and
shortly afterward sequenced its genome. The SARS clinical network
consisted of more than 50 clinicians in 14 countries. Clinicians in
this network helped to develop the SARS case definition and wrote
infection control guidelines. The SARS epidemiologic network, which
consisted of 32 epidemiologists from 11 institutions, collected data
and conducted studies on the characteristics of SARS, including its
transmission and control. WHO and other public health experts noted
that there was a high level of collaboration and cooperation in these
scientific networks.
WHO Alerted the International Community and Made Important
Recommendations amid Scientific Uncertainty:
During the SARS outbreak, WHO played a key role in alerting the world
about the disease and issuing information, guidance, and
recommendations to government officials, health professionals, the
general public, and the media that helped raise awareness and control
the outbreak.
Global Alerts and Travel Recommendations:
When WHO became concerned about outbreaks of atypical pneumonia in
China, Hong Kong, and Vietnam, it issued a global alert on March 12,
2003, warning the world about the appearance of a severe respiratory
illness of undetermined cause that was rapidly spreading among health
care workers. Three days later, on March 15, WHO issued a second,
higher-level global alert in which it identified the disease as SARS
and first published a definition of suspect and probable
cases.[Footnote 9] At the same time, WHO also issued its first
emergency travel advisory to international travelers, calling on all
travelers to be aware of the main symptoms of SARS. When, on March 27,
it became clear to WHO that 27 cases of SARS were linked to exposure on
five airline flights, WHO recommended the screening of air passengers
on flights departing from areas where there was local transmission of
SARS. On April 2, WHO began issuing travel advisories--recommendations
that travelers should consider postponing all but essential travel to
designated areas where the risk of exposure to SARS was considered
high. The first designated areas were Hong Kong and Guangdong Province,
China; later, the list was expanded to include other parts of China;
Toronto; and Taiwan. During the SARS outbreak, WHO also publicized a
list of areas with recent local transmission of SARS.
Guidelines and Recommendations on the Management of SARS:
In addition to travel recommendations, WHO developed more than 20 other
guidelines and recommendations for responding to SARS during the
outbreak. These included advice on the detection and management of
cases, laboratory diagnosis of SARS, hospital infection control, and
how to handle mass gatherings of persons arriving from an area of
recent local transmission of SARS. These guidelines and recommendations
were disseminated through WHO's SARS Web site, which was updated
regularly and received 6 million to 10 million hits per day.
WHO Faced Challenges in Issuing Guidance and Recommendations:
In issuing guidance and recommendations about SARS, WHO had to respond
immediately while making the best use of limited scientific knowledge
about the disease (e.g., its cause, mode of transmission, and
treatment), and it had to communicate effectively to public health
professionals and the general public. This situation posed challenges,
and WHO's efforts came under some criticism. For example, officials in
Canada, Taiwan, and Hong Kong--areas that were directly affected by the
travel recommendations--criticized WHO for not being more transparent
in the process it used to issue and lift the recommendations. They also
stated that the evidentiary foundation for issuing the recommendations
was weak and the process did not allow countries enough time to prepare
(e.g., to develop press releases and inform the tourism industry). WHO
officials and others also acknowledged that communicating effectively
about the risks of transmitting SARS and recommending appropriate
action were major challenges for the organization. For example, even
though WHO officials believed that the use of face masks by the general
public was ineffective in preventing SARS, it had a difficult time
communicating this fact and educating the general public about
appropriate preventive measures. In addition, WHO recommended screening
of airline passengers before departure, but the recommendation was
vague and allowed countries to execute it in different ways.
Initial Lack of Cooperation from China Limited WHO's Access to
Information and Delayed Its Response:
Although WHO officials at headquarters and in the field received
various informal reports of a serious outbreak of atypical pneumonia in
China's Guangdong Province early in the SARS outbreak, WHO did not
issue its global alerts until mid-March 2003. This delay occurred both
because there was scientific uncertainty about the disease and because
of initial lack of cooperation by China, which limited WHO's access to
information and its ability to assist in investigating and managing the
outbreak. As detailed in appendix II, WHO first received informal
reports about a serious disease outbreak in Guangdong Province in
November 2002. At the time, influenza was suspected as the primary
cause of this outbreak. When WHO requested further information from
Chinese authorities, it was told that influenza activity in China was
normal and that there were no unusual strains of the virus. Despite
WHO's repeated requests, Chinese authorities did not grant it
permission to go to Guangdong Province and investigate the outbreak
until April 2, 2003.
WHO lacked authority under the International Health Regulations to
compel China to report the SARS outbreak and to allow WHO to assist in
investigating and managing it. WHO officials told us that, in general,
the organization tries to play a neutral, coordinating role and relies
on government cooperation to investigate problems and ensure that
appropriate control measures are being implemented. Vietnam, for
example, cooperated with WHO early in the outbreak, which may have
contributed to a less severe outbreak in that country. In the case of
China, WHO exerted some pressure, as did the U.S. government, and the
international media, which eventually helped persuade China to become
more open about the situation and to allow WHO to assist in
investigating and managing the outbreak.
WHO's Response to SARS Was Challenged by Limited Resources:
While extensive, WHO's response to SARS in Asia was challenged by
limited resources devoted to infectious disease control and in
particular to GOARN. WHO's ability to respond in a timely and
appropriate manner to outbreaks such as SARS is dependent upon the
participation and support of WHO's partners and adequate financial
support. During the SARS outbreak, GOARN's human resources were
stretched to capacity. GOARN experienced difficulty in sustaining the
response to SARS over time and getting the appropriate experts out into
the field. WHO officials in China told us that they could not obtain
experienced epidemiologists and hospital infection control experts and
that ultimately they had to look outside the network to find
assistance. GOARN was largely dependent on CDC staff to deploy to Asia
to manage the epidemic response. According to a senior CDC official, if
the United States had experienced many SARS cases during the global
outbreak, CDC might not have been able to make as many of these staff
available. Furthermore, some GOARN partners told us that the staffing
requests that they received from GOARN, WPRO, and WHO country offices
were not well coordinated. This issue was raised at a GOARN Steering
Committee meeting in June 2003, and it was suggested that a stronger
regional capacity for coordination could help ensure the necessary
public health experts are mobilized and deployed to the field.
The SARS outbreak also highlighted the limitations in GOARN's financial
resources. Historically, the network has received limited financial
support from WHO's core budget, which consists of assessed
contributions from members. The network tries to make up for shortfalls
by soliciting additional contributions from member states, foundations,
and other donors. There are limited resources to pay for headquarters
staff and technical resources such as computer mapping software and to
support management initiatives such as strategic planning and
evaluation activities. While acknowledging that planning and evaluation
are important both for responding to future outbreaks and for ensuring
epidemic preparedness and capacity building, WHO officials told us that
GOARN is usually focused on the response to an immediate emergency and
thus lacks the time and resources to retrospectively review what worked
well and what did not.
U.S. Government Had Key Role in Response to SARS, but Efforts Revealed
Problems in Ability to Respond to Emerging Infectious Diseases:
CDC, as part of HHS, and State played major roles in responding to the
SARS outbreak, but their actions revealed limits in their ability to
address emerging infectious diseases. CDC worked with WHO and Asian
governments to identify and respond to the disease and helped limit its
spread into the United States. However, CDC encountered obstacles that
made it unable to trace international travelers because of airline
concerns over CDC's authority and the privacy of passenger information,
as well as procedural issues. State applied diplomatic pressure to
governments, helped facilitate U.S. government efforts to respond to
SARS in Asia, and supported U.S. government employees and citizens in
the region. However, State encountered multiple difficulties in helping
to arrange medical evacuations for U.S. citizens infected with SARS
overseas. Based in part on this experience, State ultimately authorized
departure of all nonessential U.S. government employees at several
Asian posts.
CDC Played Central Role in Fighting SARS in Asia:
Throughout the SARS outbreak, CDC was the foremost participant in WHO's
multilateral efforts to recognize and respond to SARS in Asia, with CDC
officials constituting about two-thirds of the 115 public health
experts deployed to the region under the umbrella of GOARN. CDC also
contributed its expertise and resources to epidemiological, laboratory,
and clinical research on SARS. According to CDC, its involvement in
recognizing the disease began in February 2003, when CDC officials
joined WHO efforts to identify the cause of atypical pneumonia
outbreaks in southern China, Vietnam, and Hong Kong. In March 2003, CDC
set up an emergency operations center to coordinate sharing of
information with WHO's epidemiology, clinical, and laboratory networks
(see fig. 1). Under GOARN's auspices, CDC also assigned
epidemiologists, laboratory scientists, hospital infection control
specialists, and environmental engineers to provide technical
assistance in Asia. For example, CDC assigned senior epidemiologists to
help a WHO team investigate the outbreak in China. The team met with
public health officials and health care workers in affected provinces
to determine how they were responding to SARS. It also recommended
steps to bring the outbreak under control, such as hospital infection
control measures, quarantine strategies, and free health care for
individuals with suspected SARS.
In addition, because Taiwan is not a member of WHO, CDC gave direct
assistance to support Taiwan's response to SARS, serving as a link
between Taiwanese health authorities and WHO and providing technical
information and expertise that enabled Taiwan to control the outbreak.
Shortly after Taiwan identified its first case of SARS imported from
China in March 2003, Taiwanese authorities asked WHO for assistance.
WHO officials transmitted the request to CDC and asked it to respond.
Between March and July 2003, 30 CDC experts traveled to Taiwan and
advised health authorities on various aspects of the SARS response. CDC
epidemiologists recommended changes in Taiwan's approach to classifying
SARS cases, which was time consuming and resulted in a large backlog of
cases awaiting review as the outbreak expanded. They advised Taiwanese
health authorities to replace their case classification system with a
two-tiered approach that would categorize patients with SARS-like
symptoms as either "suspect" or "probable" SARS. This strategy enabled
public health authorities to institute precautionary control measures,
such as isolation, for suspected SARS patients, and according to senior
CDC and Taiwanese officials, it helped reduce transmission, including
within medical facilities, and stop the outbreak.
CDC Took Actions to Limit Spread of SARS into the United States:
When WHO issued its global SARS alert on March 12, 2003, CDC officials
attempted to limit the disease's spread into the United States by (1)
providing information for people traveling to or from SARS-affected
areas and (2) ensuring that travelers arriving at U.S. borders with
SARS-like symptoms received proper medical treatment. Beginning in mid-
March 2003, CDC posted regular SARS updates on its Web site for people
traveling to SARS-affected countries. At the same time, CDC's Division
of Global Migration and Quarantine deployed quarantine officers to U.S.
airports, seaports, and land crossings where travelers entered the
United States from SARS-affected areas. The officers distributed health
alert notices to all arriving travelers and crew (see fig. 2).
Figure 2: CDC Health Alert Notice:
[See PDF for image]
[End of figure]
The notices, printed in eight languages and describing SARS symptoms,
incubation period, and what to do if symptoms developed, also contained
a message to physicians to contact a public health officer or CDC if
they treated a patient who might have SARS. CDC staff distributed close
to 3 million health alert notices over a 3-month period. Department of
Homeland Security staff assisted CDC by passing out the notices at land
crossings between the United States and Canada. CDC's quarantine
officers also responded to dozens of reports of passengers with SARS-
like symptoms on airplanes and ships arriving in the United States from
overseas. The officers boarded the airplane or ship, assessed the ill
individuals to determine if they might have SARS and, if necessary,
arranged the individuals' transport to a medical facility.
Regulatory, Privacy, and Procedural Concerns Hampered CDC's Efforts to
Trace Travelers:
CDC officials wanted to advise passengers who had traveled on an
airplane or ship with a suspected SARS case to monitor themselves for
SARS symptoms during the virus's 10-day incubation period, but due to
airline concerns over authority and privacy, as well as procedural
constraints, CDC was unable to obtain the passenger contact information
it needed to trace travelers. Although HHS has statutory authority to
prevent the introduction, transmission, or spread of communicable
diseases from foreign countries into the United States,[Footnote 10]
HHS regulations implementing the statute do not specifically provide
for HHS to obtain passenger manifests or other passenger contact
information from airlines and shipping companies for disease outbreak
control purposes.[Footnote 11] CDC officials told us that some airlines
failed to provide necessary contact information to CDC, which may be
attributable to the lack of specific regulations in this area.
Moreover, CDC officials said that in response to their requests, some
airlines refused to give CDC passenger contact information from
frequent flier databases or credit card receipts because of privacy
concerns.[Footnote 12] Even when CDC was able to obtain passenger
information, CDC staff responsible for contacting travelers found
passenger data untimely (because some airlines provided it after SARS's
10-day incubation period), insufficient (because some airlines could
provide only passenger names but no contact information), or difficult
to use (because it was available on paper rather than electronically).
According to senior CDC officials, the inability to trace travelers who
might have been exposed to SARS could have hampered their ability to
limit the disease's spread into the United States.
CDC Exploring Options to Resolve Tracing Problems:
The obstacles to tracing travelers remain unresolved, and senior CDC
officials are concerned they will encounter difficulties in limiting
the spread of infectious diseases into the United States during future
global infectious disease outbreaks.[Footnote 13] CDC officials told us
they are exploring several options to overcome the problems they
encountered during the SARS outbreak. CDC may adopt one or more of
these options,[Footnote 14] including: clarifying CDC's authority by
promulgating regulations specifically to obtain passenger contact
information; coordinating with the Department of Homeland Security and
other federal agencies for this purpose; developing a memorandum of
understanding with airlines on sharing passenger information; and
creating a system for obtaining passenger contact information in an
electronic format. However, CDC officials said they have already faced
obstacles in pursuing some of these options. For example, both CDC and
Department of Homeland Security officials told us that Homeland
Security's computer-based passenger information system could not be
used for purposes other than national security.
State Applied Diplomatic Pressure, Helped Facilitate Agency Responses,
and Disseminated Information:
State also played an important role in the U.S. response to SARS,
primarily by applying diplomatic pressure, helping facilitate
government efforts overseas, and disseminating information. In March
2003, the U.S. Ambassador to China communicated with Chinese government
officials to encourage China to be more transparent in reporting SARS
cases and to grant WHO and CDC officials access to southern China.
State also established two working groups to facilitate the U.S.
government response to SARS in Asia. The first working group,
comprising various State offices and bureaus, issued daily reports on
the status of the outbreak to U.S. embassies and consulates. The second
working group, established in May 2003, convened various U.S.
government agencies, including State, HHS, and the Departments of
Defense and Homeland Security, to address policy and response issues.
U.S. government officials agreed that State's efforts helped provide
valuable information during an uncertain period and allowed for a
unified response to the outbreak. U.S. embassies and consulates in Asia
also disseminated information to U.S. government employees and U.S.
citizens living and traveling abroad. For example, they publicized CDC
updates on SARS through e-mail alerts and on their Web sites and
informed U.S. citizens about medical care available in-country.
State Faced Obstacles Arranging Medical Evacuations for U.S. Citizens
with Suspected SARS:
During the outbreak, even the strongest local health care systems were
overwhelmed, and State was concerned that U.S. government employees
might receive treatment that did not meet U.S. standards. For example,
in Hong Kong and China, U.S. consular staff told us they were concerned
about sending U.S. government employees to local hospitals because of
inadequate infection control practices, limited availability of health
care workers with English language skills, and controversial treatment
protocols such as administering steroids to SARS patients.
In a few cases, State worked with private medical evacuation companies
to help arrange medical evacuations for U.S. citizens with suspected
SARS.[Footnote 15] However, early in the outbreak, CDC had not yet
developed guidelines to prevent transmission during flight, and medical
evacuation companies could not obtain aircraft and crew willing to
transport SARS patients because of the perceived health risks.[Footnote
16] Even after CDC developed guidelines, medical evacuation companies
still had difficulty finding aircraft because only about 5 percent of
existing air ambulances could comply with the stringent guidelines,
according to a private air medical evacuation official. Furthermore, a
U.S. state and some medical facilities in the United States refused to
accept SARS patients brought from Asia. For example, the state of
Hawaii initially said it would accept medically evacuated SARS patients
but later reneged and prevented one air ambulance company from bringing
a U.S. citizen with suspected SARS to a medical facility in Honolulu.
Although the Department of Defense (Defense) performed one medical
evacuation for a U.S. civilian under special circumstances, officials
at State and Defense told us that military priorities and scarce
resources are likely to prevent Defense from performing civilian
evacuations in the future. Ultimately, State concluded that inadequate
local health care and difficulties arranging medical evacuations put
U.S. government employees at risk, and, in turn, State authorized
departure for nonessential employees and their dependents at several
posts.[Footnote 17]
Medical Evacuation Issues Still Pose Challenges for Future Outbreaks:
State has not developed a strategy to overcome the challenges that
staff encountered in arranging international medical evacuations during
the SARS outbreak, but it is working with other U.S. government
agencies to develop guidance on this issue. Officials at State, CDC,
Defense, and medical evacuation companies told us that the same
obstacles could resurface during a new outbreak of SARS or another
unknown infectious disease with airborne transmission. State officials
said the medical evacuation companies that provide State's medical
evacuation services have agreed to evacuate SARS patients, and the
companies with whom we spoke confirmed that since the SARS outbreak,
they have identified sufficient aircraft and crew to transport a
limited number of patients. The exact number would depend on the nature
of the disease, the patient's condition, and the type of medical care
required. State officials said they have not investigated how many SARS
patients private medical evacuation companies or Defense could
transport; they also do not know which U.S. states and medical
facilities would accept patients with SARS or another emerging
infectious disease. State officials are concerned about a scenario in
which dozens of staff at a U.S. embassy or consulate contract SARS or
another infectious disease, in which case medical evacuation would
probably not be feasible given the current constraints. This would also
pose a problem if many U.S. citizens living or traveling overseas
contracted such a disease. Private medical evacuation companies
acknowledged that they might not be able to transport large numbers of
patients; furthermore, they are unsure which destinations in the United
States would accept patients with an infectious disease such as SARS.
State officials said they are working with other U.S. government
agencies to develop guidelines for consular staff to arrange
international medical evacuations. However, it is not clear that this
guidance will resolve some of the obstacles encountered during the SARS
outbreak. For example, a CDC official said the agency is working with
medical facilities near international ports of entry to identify
treatment destinations for medically evacuated patients with
quarantinable infectious diseases such as SARS, but no agreements have
been reached yet.
After Initial Struggle, Asian Governments Brought SARS Outbreak under
Control:
The Asian governments we studied initially struggled to respond to SARS
but ultimately brought the outbreak under control. As acknowledged by
Asian government officials, poor communication within China and between
China and Hong Kong, Taiwan, and WHO obscured the severity of the
outbreak during its initial stages. As the extent of the outbreak was
recognized, the large-scale response to SARS in China, Hong Kong, and
Taiwan was hindered by an initial lack of leadership and coordination.
Further, weaknesses in disease surveillance systems, public health
capacity, and hospital infection control limited the ability of Asian
governments to track the number of cases of SARS and implement an
effective response. Improved screening, rapid isolation of suspected
cases, enhanced hospital infection control, and quarantine of close
contacts ultimately helped end the outbreak. In the aftermath of SARS,
efforts are under way to improve public health capacity in Asia to
better deal with SARS and other infectious disease outbreaks.
Poor Communication Limited Information on Severity of SARS Outbreak in
China:
The Chinese government's poor communication within the country, with
Hong Kong and Taiwan, and with WHO limited the flow of information
about the severity of the SARS outbreak in its initial stages. For
example, the Ministry of Health did not widely circulate a report
concerning the spread of atypical pneumonia (later determined to be
SARS) in Guangdong Province. The report was produced by health
officials in Guangdong Province on January 23, 2003--more than 2 weeks
before the Ministry of Health's first official public announcement on
the outbreak.[Footnote 18] The report warned all hospitals in the
province about the disease and provided advice to control its spread.
Officials in Hong Kong, which directly borders the province, were not
aware of the report, and a senior official in Taiwan, which maintains
significant travel and commercial ties with Guangdong Province, said
Taiwan did not receive the report or any official communication about
the outbreak. In addition, WHO did not receive this information.
Officials in Guangdong Province told us they could not share this
information outside of China because this is the responsibility of the
Ministry of Health. Further, according to Chinese regulations on state
secrets, information on widespread epidemics is considered highly
classified.[Footnote 19]
Chinese scientists also did not effectively communicate their findings
about the cause of SARS early in the outbreak because of government
restrictions. For example, as reported in a scientific journal and
later confirmed in our own fieldwork, Chinese military researchers
successfully identified the coronavirus as a potential cause of SARS in
early March 2003, several weeks before a network of WHO researchers
proved it was the cause of SARS.[Footnote 20] One Chinese scientist
directly involved in the effort told us that these researchers were
instructed to defer to scientists at the Chinese Center for Disease
Control and Prevention, who announced erroneously that Chlamydia
pneumoniae, a type of bacteria, was responsible for the atypical
pneumonia outbreak. In addition, we were told that these researchers
were not permitted to communicate their findings on the coronavirus
directly to WHO officials because only the Ministry of Health could
communicate directly with WHO.
Communication problems persisted as late as April 2003, 5 months after
the first cases occurred. On April 3, the Minister of Health announced
that the outbreak was under effective control and that only 12 cases of
SARS had been reported in Beijing. However, a physician working at a
military hospital in Beijing wrote a letter to an Asian news magazine
claiming that there were significantly more SARS cases in military
hospitals and that hospital officials were told not to disclose
information about SARS to the public. On April 15, in response to
rumors of underreporting, WHO officials leading an investigation into
the outbreak were granted permission to visit military hospitals but
stated that they were not authorized to report their findings. By April
20, the Ministry of Health announced the existence of 339 previously
undisclosed cases of SARS in Beijing.
An Initial Lack of Effective Leadership and Coordination in SARS-
Affected Areas in Asia Hindered Response:
As acknowledged by government officials, a lack of effective leadership
and coordination within the governments of China, Hong Kong, and Taiwan
early in the outbreak hindered attempts to organize an effective
response to SARS. In China, provincial and local authorities maintained
significant responsibility and autonomy in conducting epidemiological
investigations of SARS but failed to coordinate with one another and
national authorities early in the outbreak. However, as SARS spread
into Beijing, the highest political leaders of the Chinese Communist
Party, citing an increased number of cases and the impact on travel and
trade, advised officials to be more forthcoming about SARS cases. The
Ministry of Health also acknowledged the ministry's failure to
introduce a unified mechanism for collecting information about the
outbreak and setting guidance and requirements across the country. Soon
after those announcements, the Minister of Health and Mayor of Beijing
were dismissed from their posts for downplaying the extent of the
outbreak, and the public health response was brought under stronger
central control. A vice premier of the central government assumed
control of the Ministry of Health and convened ministerial level
officers to take the lead in the nationwide SARS control effort.
In Hong Kong, an expert committee convened after the outbreak to
investigate the government's response questioned the leadership and
coordination of the public health system.[Footnote 21] For example, the
committee found that responsibility for managing infectious disease
outbreaks was spread throughout different departments within the
Health, Welfare, and Food Bureau, with no single authority designated
as the central decision-making body during outbreaks. The committee
also stated that poor coordination between the hospital and public
health system further complicated the response. For example, the
Hospital Authority responded to an outbreak within a hospital without
informing the Department of Health, which learned of the outbreak
through media reports. Further, the Hospital Authority and Department
of Health used separate databases during the initial stages of the
outbreak and could not communicate information on new cases in real
time.
In Taiwan, a report by WHO stated that the initial response to SARS was
managed by senior political figures who sometimes did not heed the
advice of technical experts. Furthermore, WHO noted that the failure to
follow the advice of public health experts delayed the decision-making
process and slowed the response to the outbreak in Taiwan. Taiwanese
government officials noted that the leadership of the public health
system was weak during the outbreak. In addition, the process they used
to classify SARS cases was too slow to isolate suspected or probable
cases. As the outbreak worsened and spread into hospitals throughout
Taiwan, the Minister of Health and the director of the Taiwan Center
for Disease Control resigned over criticisms about failing to control
the spread of SARS.
Weaknesses in Disease Surveillance Systems and Public Health Capacity
Further Constrained Efforts:
As Asian governments monitored the spread of SARS, weaknesses in
disease surveillance systems, public health capacity, and hospital
infection control caused delays and gaps in disease reporting, which
further constrained the response.
Disease Surveillance Systems:
In China, health officials at the provincial level and WHO advisers
working in the country noted that data gathering systems established in
the epicenter of the outbreak in Guangdong Province were strong.
However, Chinese officials also found that the effectiveness of a
national disease surveillance system established in 1998 was limited.
For example, disease prevention staff below the county level did not
have access to computer terminals to report the number of SARS cases
and had to relay disease reports to central authorities by fax or mail.
In addition, the computer-based system did not permit the reporting of
suspect cases that were not yet confirmed. Further, protocols for
reporting were time consuming, since information was sent through
multiple levels of the public health system. For example, during the
outbreak, reports from doctors of suspect SARS cases could take up to 7
days to reach local public health authorities. In Beijing, an executive
vice minister stated that the large number of undetected cases of SARS
patients occurred because they could not collect information on SARS
cases that were spread across 70 hospitals in the city. In Taiwan,
duplicative reporting between municipal and federal levels led to
unclear data on the total number of cases throughout the island. A WHO
official reported that the surveillance data were entered into formats
that were difficult to analyze and could not inform the public health
response. In Hong Kong, a quickly established atypical pneumonia
surveillance system detected early cases of severe pneumonia admitted
into hospitals. However, the expert committee reviewing the response
noted that the limited access to data from private sector health care
providers and a lack of comprehensive laboratory surveillance made it
difficult for public health authorities to gain accurate information
about the full extent of the outbreak and implement necessary control
measures.
Public Health Capacity:
In China, officials told us that a lack of funding and a reliance on
market forces to finance public health services have weakened the
country's ability to respond to outbreaks. For example, the newly
established Center for Disease Control and Prevention system in China
derives more than 50 percent of its revenue from user fees for
immunizations and other services. WHO noted that the dependence on user
fees has drawn attention and resources away from nonrevenue producing
activities, such as disease surveillance, that are important for
responding to infectious disease outbreaks. Furthermore, China did not
have enough public health workers skilled in investigating diseases,
and thus staff who had never been involved in disease investigations
were used to trace SARS contacts and did not always collect the correct
data on these cases. In Hong Kong, the expert committee noted that
there was a shortage of expertise in field epidemiology and inadequate
support for information systems. In addition, the committee found
disproportionate funding of public health services compared with the
public hospital system, which receives 10 times more government funds.
Taiwanese officials cited problems in public health infrastructure,
including the lack of equipment to deal with infectious patients in
hospitals and underfunded laboratories.
Hospital Infection Control:
Another major weakness in public health capacity cited by health
officials in China, Hong Kong, and Taiwan was a lack expertise in
hospital infection control. In many SARS-affected areas, transmission
of SARS to health care workers and other hospital patients was a
significant factor sustaining the outbreak. In some instances, hundreds
of hospital-acquired infections were due to inadequate isolation of
individual patients and limited availability and use of personal
protective equipment (masks, gowns, and gloves) for hospital workers.
For example, in Taiwan, health officials reported that after initial
success in rapidly identifying and isolating cases arriving from other
SARS-affected areas, hospitals failed to recognize SARS cases occurring
within Taiwan, resulting in a secondary, and much larger, outbreak in
hospitals throughout the island. WHO, U.S. CDC, and Taiwanese officials
told us that the number of physicians trained in infection control
practices was inadequate and that infection control was not a priority
for hospital management. In Hong Kong, the expert committee noted that
there was no clear leadership from infection control doctors and that
there were insufficient numbers of nurses trained in
hospital infection control.[Footnote 22] In China, WHO officials noted
in field reports that infection control procedures were rudimentary and
relied on a range of measures, including disinfection of health care
facilities, instead of the recommended isolation measures needed to
limit spread to patients and health care workers.
Basic Public Health Strategies Eventually Worked to Control SARS
Outbreak:
The SARS outbreak was ultimately brought under control by a more
coordinated response that included the implementation of basic public
health strategies. Measures such as improved screening and reporting of
cases, rapid isolation of SARS patients, enhanced hospital infection
control practices, and quarantine of close contacts were the most
effective ways to break the chain of person-to-person transmission.
Improved Screening and Reporting:
Screening of patients with symptoms of SARS permitted the early
identification of suspect cases during the early phase of illness.
Furthermore, because SARS is transmitted when individuals have symptoms
of the disease, detecting symptomatic patients was considered critical
to stopping its spread. For example, in Beijing, fever clinics were
established to screen people with fevers before presentation to
hospitals or other health care providers to limit exposure to SARS.
Between May 7 and June 9, 2003, there were 65,321 fever clinic visits.
Through this effort, 47 probable SARS cases were identified,
representing only 0.1 percent of all fever clinic visits but 84 percent
of all probable cases hospitalized during that period. In addition,
policies were implemented requiring daily reports from all areas
regardless of whether any SARS cases were found. In Hong Kong,
designated medical centers were established to conduct medical
monitoring of close contacts of SARS patients to ensure early detection
of secondary cases. In Taiwan, hospital staff and other individuals who
had contact with SARS patients in hospitals were monitored on a daily
basis to detect SARS symptoms.
Rapid Isolation and Contact Tracing:
The identification of patients with suspect and probable cases of SARS
and their close contacts reduced the rate of contact between SARS
patients and healthy individuals in both community and hospital
settings. For example, toward the end of the outbreak, one Chinese
province decreased the average time between onset of SARS symptoms to
hospitalization from 4 days to 1, and the time to trace contacts of
these patients from 1 day to less than half a day. These declines in
the time for hospitalization and contact tracing generally coincided
with a decrease in the number of new cases. In Hong Kong, officials
facilitated tracing by linking a SARS database used by public health
officials with police databases to track and verify the addresses of
relatives and other close contacts of SARS patients. To limit the
spread of SARS in the hospital system, specific hospitals were
designated to treat suspected SARS patients in all SARS-affected areas.
Another strategy in SARS-affected areas was the cancellation of school,
large public gatherings, and holiday activities. For example, in China
the weeklong May Day celebration was shortened.
Enhanced Hospital Infection Control:
The widespread use of personal protective equipment helped contain the
spread of SARS in hospitals. For example, in China, when hospital
infection control measures were instituted toward the end of the
outbreak in a 1,000-bed hospital constructed exclusively for SARS
patients, there were no further cases of SARS transmission in health
care workers. Similarly in Hong Kong and Taiwan, these measures led to
a decline in the number of infections in health care workers. In
addition, in all these affected areas, guidelines were ultimately
established for the use of personal protective equipment in outbreak
situations.
Quarantine Measures:
China, Taiwan, and Hong Kong implemented quarantine measures to isolate
potentially infected individuals from the larger community, which, when
restricted to close contacts of SARS patients, proved to be an
efficient and effective public health strategy. In Hong Kong, for
example, close contacts of SARS patients and people in high-risk areas
were isolated for 10 days in designated medical centers or at home to
ensure early detection of secondary cases. However, more wide-scale
quarantine took place in Taiwan, where 131,000 individuals who had any
form of contact with a SARS patient or traveled to SARS-affected areas
were placed under quarantine, and in Beijing, where more than 30,000
people were quarantined. Analysis of data from these areas indicated
that the quarantine of individuals with no close contact to SARS
patients was not an effective use of resources. For example, among the
133 probable and suspect cases identified in Taiwan, most were found to
have had direct contact with a SARS patient.[Footnote 23] Similarly,
researchers found that in Beijing, limiting quarantine to close
contacts of actively ill patients would have been a more efficient
strategy and a better use of resources.[Footnote 24]
Asian Governments Have Efforts Under Way to Build Public Health
Capacity for Future Outbreaks:
Following the SARS epidemic, Asian governments have attempted to
improve public health capacity, revise their legal frameworks for
infectious disease control, increase regional communication and
cooperation, and utilize international aid to improve preparedness.
During our fieldwork, we met with public health representatives at
various levels--from senior health ministry officials to local hospital
health care workers--who provided information on efforts to improve
public health capacity. For example, after the SARS outbreak the
Chinese government provided additional budgetary support and expanded
authority to improve coordination and communication. The government
also devised a plan to build capacity in its weak rural health care
system. In Hong Kong, the government focused its efforts on early
detection and response to infectious disease outbreaks and is
developing a Center for Health Protection focused on infectious disease
control. Several drills were conducted to test the system, and the
government has identified protecting populations in senior citizen
homes, schools, and hospitals as a priority. In Taiwan, the government
responded to public health management shortcomings by establishing a
new public health command structure with centralized authority and
decision-making power and making numerous changes in health leadership
positions. The government invested public funds to upgrade its health
infrastructure--for example, to construct fever wards, isolation rooms
with negative pressure relative to the surrounding area, and other
improvements in hospitals.
The SARS outbreak also led to legal reforms specific to SARS control
and the function of public health systems in SARS-affected areas. For
example, China, Hong Kong, and Taiwan passed legislation or regulations
during the outbreak that required clinicians and public health
authorities to report cases of SARS. In China, regulations on the
prevention of SARS were passed that, among other things, were intended
to improve communication with the public and outline administrative or
criminal penalties for officials
who do not report SARS cases.[Footnote 25] A broader set of regulations
that may have a long-term impact was also passed that requires the
creation of a unified command during public health emergencies,
reporting of such emergencies within 2 hours, and improved public
health capacity at all levels of the government.[Footnote 26] In Hong
Kong, the law was revised to enhance the power of public health
authorities to isolate cases and control the spread of SARS through
international travel.[Footnote 27]
Senior government officials have taken steps to improve public health
communication and coordination in the region. Health officials in Hong
Kong and Taiwan stated it is critical that information on disease
outbreaks in mainland China be quickly reported so that neighboring
governments can take preventive actions. A post-SARS agreement among
Guangdong Province, Hong Kong, and Macau has thus far led to monthly
sharing of information on a list of 30 diseases. A senior Chinese
health official stated that the SARS outbreak taught the Chinese
government the need for international cooperation in fighting
infectious disease outbreaks. According to WHO officials, since the
2002-2003 SARS outbreak, they have experienced increased transparency
and willingness on the part of the Chinese government to work with WHO
health experts.
The international community and the United States have committed
financial and human resources to support the recent financial
investments in public health capacity made by the Chinese government.
For example, in July 2003 the World Bank announced a multidonor-
supported program to strengthen disease surveillance and reporting and
improve the skills of clinicians in China. The program is funded by
US$11.5 million in loans from the World Bank, a 3 million British pound
grant from the United Kingdom's Department for International
Development, a Can$5 million grant from the Canadian International
Development Agency, and a US$2 million regional grant from the Japan
Social Development Fund. HHS is in the process of finalizing a
multiyear, multimillion-dollar program of cooperation between HHS and
the Chinese Ministry of Health aimed at strengthening China's capacity
in public health management, epidemiology, and laboratory capacity. As
part of the initiative, CDC staff members will be stationed in China to
help strengthen the epidemiology workforce.
SARS Outbreak Decreased Consumer Confidence and Negatively Affected a
Number of Asian Economies:
During the SARS outbreak, consumer confidence temporarily declined as a
result of consumer fears about SARS and precautions taken to avoid
contracting the disease. This decline in consumer confidence in turn
led to economic losses in Asian economies estimated in the billions of
dollars. Service sectors were hit the hardest due to declines in travel
and tourism to areas with SARS outbreaks and declines in retail sales
involving face-to-face exchanges. Additionally, to counter economic
losses associated with SARS, many Asian governments implemented costly
economic stimulus programs.
Impacts from SARS Are Estimated to Have Cost Billions, Although Most
Economies Have Recovered:
While the number of cases and associated medical costs for the SARS
outbreak were relatively low compared with those for other major
historical epidemics, the economic costs of SARS were significant
because they derived primarily from fears about the disease and
precautions to avoid the disease, rather than the disease itself. As
shown in table 1, one industry and one official estimate of the
economic cost of SARS in Asia calculated the net loss in total output
at roughly $11 billion to $18 billion, respectively. (These estimates
reflect changes in growth forecasts that were calculated concurrent
with the outbreak. See app. III for a discussion of methodologies and
varied assumptions used to obtain these estimates.) For example, the
Far Eastern Economic Review estimates SARS's economic costs in Asia at
around $11 billion, with the largest losses in China, Hong Kong, and
Singapore. The Asian Development Bank also shows the largest losses in
these three economies, although they estimate the total cost at around
$18 billion.[Footnote 28] As the Asian Development Bank reported, using
its cost estimate, the cost per person infected with SARS was roughly
$2 million. While economic costs associated with a general loss in
consumer confidence are difficult to quantify exactly, they illustrate
how emerging diseases and fears associated with those diseases can have
widespread ramifications for a large number of economies.
Table 1: Estimated Economic Cost of SARS in Asia:
U.S. dollars in millions.
China;
Far Eastern Economic Review: 2,200;
Asian Development Bank: 6,100.
Hong Kong;
Far Eastern Economic Review: 1,700;
Asian Development Bank: 4,600.
Malaysia;
Far Eastern Economic Review: 660;
Asian Development Bank: 400.
Singapore;
Far Eastern Economic Review: 950;
Asian Development Bank: 2,700.
Taiwan;
Far Eastern Economic Review: 820;
Asian Development Bank: 1,300.
Thailand;
Far Eastern Economic Review: 490;
Asian Development Bank: 1,900.
Vietnam;
Far Eastern Economic Review: 111;
Asian Development Bank: 400.
Region;
Far Eastern Economic Review: 10,700;
Asian Development Bank: 18,000.
Source: GAO analysis of data from Far Eastern Economic Review and Asian
Development Bank.
Note: Regional totals may include costs in Asian countries other than
those listed in the table.
[End of table]
The economic cost of SARS in terms of a percentage loss in each
selected Asian economy's GDP has also been estimated by the Asian
Development Bank and industry organizations at roughly 0.5 percent to 2
percent, with some variation among economies depending upon the
importance of affected sectors in total output (see app. III for a more
detailed discussion of these models' assumptions and their GDP loss
estimates per country).[Footnote 29] Figure 3 shows quarterly GDP
growth for four Asian economies most affected by SARS--China, Hong
Kong, Singapore, and Taiwan--and illustrates that GDP weakened in the
second quarter of 2003, concurrent with the height of the SARS
outbreak.[Footnote 30] However, given that the outbreak was brought
under control by July 2003, the economic impacts were concentrated
primarily in this second quarter. In fact, when WHO declared that the
SARS outbreak was over in July 2003, pent-up demand during the outbreak
likely contributed to an economic rebound in the third and fourth
quarters.
Figure 3: Quarterly GDP Growth for Various Asian Economies, 2002-2003:
[See PDF for image]
[End of figure]
SARS Affected Asian Economies through a Variety of Channels:
The SARS outbreak produced negative impacts on Asian economies through
a variety of mechanisms. The most important channel through which SARS
affected these economies was by temporarily dampening consumer
confidence, particularly in the travel and tourism industry. In
addition, decreased consumer confidence likely reduced retail sales
and, to a lesser extent, some foreign trade and investment. Due to
reduced demand, employment in affected economies fell. Some businesses
also reported an increase in costs as business operations were
disrupted, international shipments of goods and trade were hampered,
and disease prevention costs rose.
The most severe economic impacts from SARS occurred in the travel and
tourism industry, with airlines being particularly hard hit. As shown
in figure 4, declines in regional airline traffic reached 40 percent to
50 percent in April and May, two months in which WHO travel advisories
for Asia Pacific were in effect.[Footnote 31] The estimated percentage
decline in overall tourism earnings amounted to 15 percent in Vietnam,
25 percent in China, and more than 40 percent in Hong Kong and
Singapore, according to the World Travel and Tourism Council.[Footnote
32] Estimated job losses resulting from these SARS-related impacts were
also significant. For example, the World Travel and Tourism Council
estimated tourism sector job losses of around 27,000 in Hong Kong and
18,000 in Singapore, while the World Bank estimated airline job losses
in the region at around 36,000.[Footnote 33]
Figure 4: Estimated Economic Impacts of SARS on Travel and Tourism:
[See PDF for image]
[End of figure]
Dampened consumer confidence from SARS also had negative impacts on
retail sales and foreign trade and investment, according to anecdotal
evidence. The retail sector was negatively affected by the SARS
outbreak as consumers curbed shopping trips and visits to restaurants
in fear of contracting SARS. For example, China shortened the weeklong
May Day celebration that it introduced in 1999 to stimulate private
consumption. As shown in figure 5, retail sales fell concurrent with
the SARS outbreak in China, Hong Kong, Singapore, and Taiwan, a decline
particularly important for Hong Kong and Taiwan due to their large
retail sectors. However, the rebound in consumer confidence is also
illustrated by an increase in retail sales in the third quarter of
2003. Regarding foreign trade and investment, trends in these variables
indicate less distinct SARS-related declines.[Footnote 34]
Nonetheless, there is some indication of the impact of SARS on these
activities, such as the reduced sales at the major Guangzhou Trade Fair
in China, which totaled only 26 percent of the previous year's amount,
or the lagged effect of a decrease in foreign direct investment into
China in July 2003.
Figure 5: Quarterly Retail Sales Growth in Selected Asian Economies,
2002-2003:
[See PDF for image]
[End of figure]
Asian Governments Provided Economic Stimulus Packages That Cost
Billions:
In response to SARS, governments in Asia implemented economic stimulus
packages that also cost billions of dollars. Asian governments provided
spending for medical and public health sectors to prevent and control
the spread of SARS as well as for fiscal policy programs to more
generally stimulate the economy. As shown in table 2, the Asian
Development Bank estimates that the cost of these stimulus packages in
the region could total nearly $9 billion. While many of the spending
and tax measures are designed to improve GDP growth, they can also be
considered an economic cost of SARS due to the diversion of government
expenditures away from investments in needed public services.
Table 2: Asian Government Stimulus Packages in Response to SARS, 2003:
(U.S. dollars in millions).
China;
Type of package:
* Temporary tax relief and subsidies for affected industries;
* Free medical treatment for the poor and some price controls on SARS-
related drugs and goods;
Cost of package: 3,500.
Hong Kong;
Type of package:
* Temporary tax relief, job creation, and loan guarantee schemes;
Cost of package: 1,500.
Malaysia;
Type of package:
* Loan programs, support for tourism-related industries, and job
training;
Cost of package: 1,920.
Singapore;
Type of package:
* Temporary reduction in tourism and transport administrative fees,
and relief measures for airlines;
Cost of package: 132.
Taiwan;
Type of package:
* Partial reimbursement of business-related losses for affected
industries;
* Partial reimbursement for medical costs;
Cost of package: 1,400.
Thailand;
Type of package:
* General funding allocated as emergency budget;
Cost of package: 468.
Source: GAO analysis of Asian Development Bank data.
[End of table]
WHO Members Will Debate Important Issues Raised by International Health
Regulations' Revision:
The SARS epidemic elevated the importance of the International Health
Regulations' revision process. The proposed revisions, currently in
draft form and scheduled for completion in May 2005, would expand the
regulations' coverage and encourage better cooperation between member
states and WHO. Member states will have to resolve at least five
important issues, regarding (1) scope of coverage, (2) WHO's authority
to conduct investigations in countries absent their consent, (3) the
public health capacity of developing country members, (4) an
enforcement mechanism to resolve compliance issues, and (5) how to
ensure public health security without unnecessary interference with
travel and trade.
Revisions Would Expand Coverage and Facilitate Cooperation, but Key
Questions Remain:
The draft regulations expand the scope of reporting beyond the current
three diseases to include all events potentially constituting a public
health emergency of international concern, such as SARS. They also
promote enhanced member state cooperation with WHO and other countries.
Additional changes under consideration include (1) designating national
focal points with WHO for notification of public health emergencies and
(2) requiring minimum core surveillance and response capacities at the
national level to implement a global health security strategy. The
overall goal of the revision process is to create a framework under
which WHO and others can actively assist states in responding to
international public health risks by directly linking the revised
regulations to the work of GOARN.
Nevertheless, the draft regulations contain several provisions that
have been the subject of ongoing debate, including:
* Scope of coverage. As part of the revision process, WHO has developed
criteria to determine whether an outbreak is serious, unexpected, and
likely to spread internationally. Furthermore, the draft regulations
broaden the definition of a reportable disease to include significant
illness caused by biological, chemical, or radionuclear sources. In its
initial comments to WHO on the draft regulations, the U.S. government
supported the use of criteria for determining what would be a public
health emergency of international concern. Nevertheless, the U.S.
strongly believed that the draft should also require reporting of a
defined list of certain known, serious, communicable diseases that have
the potential for creating such a concern.
* Authority to conduct investigations. Member states are considering
the appropriate level of authority for the regulations. Specifically,
an unresolved issue is the degree to which the regulations will require
binding international commitments or more voluntary standards. To
address this issue, member states are examining whether the benefits
that would result from agreeing to more rigorous, comprehensive, and
mandatory regulations would outweigh losses in sovereignty. For
example, the draft regulations eliminate the language in the current
regulations that specifically requires WHO to first obtain consent from
the member state involved before conducting on-the-spot investigations
of disease outbreaks.[Footnote 35] However, the draft regulations are
still somewhat ambiguous about whether consent is necessary.[Footnote
36] According to a senior WHO official, the proposed regulations were
intentionally left vague about consent because it is a subject that
members will want to debate thoroughly.
* Public health capacity of developing countries. The draft regulations
provide member states with direction regarding the minimum core
surveillance and response capacities required at the national level,
including at airports, ports, and other points of entry. However, U.S.
and WHO officials note that many developing countries currently lack
even the most rudimentary public health capacity and will be dependent
on significant international assistance to reach minimum surveillance
and response capabilities. HHS officials have expressed caution about
developing more comprehensive and demanding requirements that will be
difficult for many countries with limited resources to implement. WHO
officials acknowledge that, while WHO is able to provide technical
assistance through GOARN, multilateral institutions, such as the World
Bank, and donor countries will have to provide significant resources
for developing countries to meet minimum surveillance and response
requirements. A WHO official also indicated that while the proposed
revisions to the regulations do not have specific provisions on
technical assistance, developing countries are likely to raise the
issue of adding such a provision during the revision process.
* Enforcement mechanism. The members will have to address what kind of
enforcement mechanism they want included in the regulations to resolve
compliance issues and to deal with violations of the regulations.
According to WHO officials, failure to comply with WHO public health
requirements is often a problem. The draft regulations, like the
current regulations, include a nonbinding mechanism for resolving
disputes. Thus, the WHO Director-General is directed either to (1) make
every effort to resolve disputes or (2) refer disputes to a WHO Review
Committee, which is tasked to forward its views and advice to the
parties involved. Although WHO would continue to be dependent on the
voluntary compliance of member states, WHO officials believe that if
key countries (such as the United States) and neighboring trade
partners are sufficiently concerned about the dangers of emerging
diseases to press for compliance with the revised regulations, other
countries are likely to fulfill their obligations. Furthermore, though
it is too early to predict how China's response to SARS in 2003 will
affect future compliance, WHO officials say the negative political,
economic, and public health effects China suffered from its initial
response to SARS served as a warning to countries that ignore their
international public health responsibilities.
* International traffic. The stated purpose of the draft regulations,
which is similar to the current regulations, is to provide security
against the international spread of disease while avoiding unnecessary
interference with international traffic. Although the term
international traffic appears to refer to international travel and
trade, neither the proposed nor the current regulations define the
term. Furthermore, the draft regulations do not include detailed
criteria for determining what constitutes interference with
international trade and travel.[Footnote 37] A WHO official indicated
that it was preferable not to include detailed criteria and to allow
this issue to be decided on a case-by-case basis because of the very
broad range of situations that could ultimately cause such
interference. This issue could receive a good deal of attention in the
revision process as member states try to balance medical and economic
concerns. According to WHO officials, in past epidemics, concerns about
economic loss and restrictions on trade and travel caused some
countries not to report outbreaks within their borders and to refuse
international assistance. Furthermore, for certain outbreaks--for
example, those involving cholera in Peru in 1991 and plague in India in
1994--some experts reported that the international response may have
exceeded the level of threat and led to unwarranted trade and travel
losses in those countries.
Completing the Revision Process Seen as High Priority:
The process for revising the International Health Regulations was
intensified by a WHO World Health Assembly resolution passed in May
2003, during the SARS outbreak, urging members to give high priority to
the revision process and to provide the resources and cooperation to
facilitate this work.[Footnote 38] The resolution also requested that
the WHO Director-General consider informal sources of information to
respond to outbreaks such as SARS; collaborate with national
authorities in assessing the severity of infectious disease threats and
the adequacy of control measures; and, when necessary, send a WHO team
to conduct on-the-spot studies in places experiencing infectious
disease outbreaks. Although the resolution did not impose legally
binding obligations on members, according to WHO officials and some
observers it did lay the political groundwork for improved
international cooperation on infectious disease control.
In January 2004, WHO distributed to its member states an interim draft
of the revisions proposed by the WHO Secretariat. Composed of 55
articles and 10 technical annexes, the draft will be discussed in a
series of regional consultations throughout 2004. The degree of
consensus on the draft's technical and political issues will then
determine the need for subsequent meetings at the global level. The
goal is to convene an intergovernmental working group at the end of
2004 to finalize revisions to the draft regulations. It is hoped the
regulations will then be ready for submission to the 58th World Health
Assembly in May 2005. However, according to WHO and HHS officials,
reaching both technical and political consensus on the regulations will
be a difficult task, and they expect the revision process to extend
beyond its target date.
Conclusion:
While the 2002-2003 SARS outbreak had an impact on health and commerce
in Asia, the extensive response by WHO and Asian governments, supported
in large measure by the U.S. government, was ultimately effective in
controlling the outbreak. This event highlighted a number of important
issues, including the limited resources to support WHO's global
infectious disease network and deficiencies in Asian governments'
public health systems. It also revealed limitations in the
International Health Regulations.
In the aftermath of SARS, WHO and member states have recognized the
importance of strengthening international collaboration and
cooperation to respond to global infectious disease outbreaks. To be
successful, this effort will require a greater commitment of resources
for global infectious disease control and a concerted effort to revise
the International Health Regulations to make them more relevant and
useful in future outbreaks. As the regulations are revised, WHO and
member states face the challenge of improving the management of disease
outbreaks while mitigating adverse economic impacts. The content,
manner of acceptance, and means of enacting the final revisions are not
certain, and much work remains to be done to resolve outstanding
issues. As of April 2004, SARS has not re-emerged to cause another
major international outbreak, but outbreaks of other infectious
diseases can be expected in the future. Therefore, strengthening public
health capacity will be essential for responding to future infectious
disease outbreaks.
The SARS outbreak also revealed gaps in U.S. government protective
measures, including difficulties in arranging medical evacuations from
overseas and the inability to trace and contact individuals exposed to
SARS during travel. In regard to tracing international travelers who
may have been exposed to an infectious disease, we believe that
amending HHS regulations to specify that the agency has authority to
obtain this information would assist this effort. This action would
facilitate HHS's ability to obtain necessary contact information (1)
from airlines or shipping companies that may have concerns about
sharing passenger information with HHS, or (2) in the event that issues
involving coordination with other federal agencies cannot be
effectively resolved.
Recommendations for Executive Action:
This report is making three recommendations to improve the response to
infectious disease outbreaks. First, to strengthen the international
response, we recommend that the Secretary of Health and Human Services,
in collaboration with the Secretary of State, work with WHO and
official representatives from other WHO member states to strengthen
WHO's global infectious disease network capacity to respond to disease
outbreaks, for example, by expanding the available pool of public
health experts.
Second, to help Health and Human Services prevent the introduction,
transmission, or spread of infectious diseases into the United States,
we recommend that the Secretary of HHS complete the necessary steps to
ensure that the agency can obtain passenger contact information in a
timely and comprehensive manner, including, if necessary, the
promulgation of regulations specifically for this purpose.
Third, to protect U.S. government employees and their families working
overseas and to better support other U.S. citizens living or traveling
overseas, we recommend that the Secretary of State continue to work
with the Secretaries of Health and Human Services and Defense to
identify public and private sector resources for medical evacuations
during infectious disease outbreaks and develop procedures for
arranging these evacuations. Such efforts could include:
* working with private air ambulance companies and the Department of
Defense to determine their capacity for transporting patients with an
emerging infectious disease such as SARS, and:
* working to develop agreements under which U.S. medical facilities
near international ports of entry will accept medically evacuated
patients with infectious diseases such as SARS.
Agency Comments and Our Evaluation:
HHS, State, and WHO provided written comments on a draft of this report
(see apps. IV, V, and VI for a reprint of HHS's, State's, and WHO's
comments). They also provided technical and clarifying comments that we
have incorporated where appropriate. HHS said the report is a good
summary of the SARS outbreak in Asia and the actions taken by WHO,
affected countries, and U.S. agencies. HHS stated that the report's
recommendations are appropriate and emphasized the national and
international interagency collaboration that will be required to
implement them in preparation for the next epidemic. HHS also noted
that to carry out some of the recommendations, sensitive legal and
privacy issues and diplomatic concerns must be carefully addressed. HHS
also noted that the report contains a useful overview of WHO's efforts
to revise its International Health Regulations and correctly ties WHO's
increased effort to the impact of SARS and lessons learned. In that
regard, HHS provided additional information on coordination and
collaboration efforts it took during the outbreak.
State indicated that the report is a useful summary of the SARS
outbreak and its impact and documents important lessons for other
infectious disease outbreaks beyond the 2003 SARS epidemic. Regarding
our first recommendation, State said it is committed to working with
WHO and its member states to strengthen the response capacity of WHO's
global infectious disease network. Regarding our recommendation on
contact tracing of arriving passengers infected or exposed to
infectious disease, State noted that it has been working on this issue
with its interagency partners since the SARS outbreak but underscored
that serious legal issues still exist for both the United States and
other governments. State also agreed with our recommendation on
developing procedures for arranging medical evacuations during an
airborne infectious disease outbreak. State indicated that it is
working with CDC to develop protocols on how to handle medical
evacuations for quarantinable diseases but noted that capacity for such
medical evacuations will be limited, as will capacity of U.S. medical
facilities to handle a large influx of patients.
WHO stated that, overall, the report provides a factual analysis of the
events surrounding the emergence of SARS and addresses the major
weaknesses in national and international control efforts. WHO noted,
however, that the report presents major criticisms of the response by
China, Hong Kong, and Taiwan to SARS but does not reflect these
governments' actions throughout the SARS epidemic or the depth and
intensity of their control efforts later on. WHO also stated that the
report puts little emphasis on other countries that experienced
problems--Canada, for example. We disagree that the report does not
adequately balance the governments' shortcomings with accomplishments,
as the report includes specific sections on improved screening and
reporting of SARS cases, rapid isolation and contact tracing, enhanced
hospital infection control practices, and quarantine measures. The
report details steps Asian governments have taken in response to SARS
to build capacity for future outbreaks. The preponderance of our
evidence on Asian governments' response was provided directly by
Chinese, Hong Kong, and Taiwan government and public health officials
and from post-SARS evaluation reports produced by these governments and
WHO-sponsored conferences. We focused our report on the response of
China, Hong Kong, and Taiwan since 95 percent of the SARS cases
occurred there. The response of other countries, such as Canada was
outside the scope of our examination.
Regarding our discussion of WHO's global infectious disease network,
WHO stated that GOARN is one of the mechanisms by which WHO mobilizes
technical resources for outbreak investigation and response provided
further information about the role of the Western Pacific Regional
Office (WPRO) in the SARS response. We clarified the role of GOARN and
expanded our discussion on the activities of WPRO. WHO also said that
its response was challenged, but not constrained, by limited resources.
While we agree with this more general characterization, we believe that
not being able to obtain the appropriate multidisciplinary staff and
sustain a response over time were significant constraints that warrant
serious attention in preparing for future emerging infectious diseases.
WHO also noted that the world's dependence on a fragile process and on
the personal commitment and sacrifice of WHO and GOARN staff is a
concern.
Scope and Methodology:
To assess WHO's actions to respond to SARS in Asia, we analyzed WHO
policy, program, and budget documents, including WHO's Web-based
situation updates and guidelines that served as the primary instrument
for disseminating information on SARS. We interviewed WHO officials
responsible for managing the international response at WHO headquarters
in Geneva and public health specialists who served on country teams
that were deployed to Asia. We examined WHO's GOARN, including its
guiding principles and how it operated during the SARS outbreak. We
also interviewed Asian government officials in Beijing, Guangdong
Province, Hong Kong, and Taipei who received WHO's technical advice and
support; U.S. government officials; and recognized experts within the
public health community.
To assess the role of the U.S. government in responding to SARS in Asia
and limiting its spread into the United States, we analyzed program
documents and interviewed officials from the Departments of Health and
Human Services, State, Defense, and Homeland Security, and the U.S.
Centers for Disease Control and Prevention (CDC). To examine CDC's
ability to trace travelers who may have been exposed to an infectious
disease, we interviewed officials from the Air Transport Association
and the Department of Transportation and reviewed applicable
legislation and regulations. To assess State's ability to provide
medical evacuation of U.S. citizens, we examined CDC guidelines on air
transport of SARS patients and interviewed officials from major private
medical evacuation companies. We also interviewed U.S. embassy
(Beijing), consulate (Hong Kong and Guangzhou), and American Institute
in Taiwan officials responsible for managing the U.S. government
response at the country level.
To describe how governments in Asia responded to the SARS outbreak, we
focused on those parts of Asia most affected by SARS in the 2002-2003
outbreak, including China, Hong Kong, and Taiwan. While in the region,
we met with public health officials at various levels responsible for
managing their governments' public health response, including senior
ministry of health and provincial and municipal government officials,
as well as hospital administrators and health care workers. We also
examined government documents on public health programs and post-SARS
evaluations, and reviewed applicable China, Hong Kong, and Taiwan laws
and regulations.
To describe the economic impact of SARS in Asia, we reviewed impact
estimates provided by (1) the Asian Development Bank's Economic and
Research Department, which used a simulation model from Oxford Economic
Forecasting; (2) a simulation model using data from the Global:
Trade Analysis Project Consortium;[Footnote 39] and (3) a simulation
model by Global Insight, a leading U.S. economic data and forecasting
firm. Specifics of each of these models are discussed in appendix III.
Another organization, the Far Eastern Economic Review, a regional
economic business weekly, gathered studies and data on SARS and
reported a summary cost estimate that we also reviewed. To supplement
our analysis of these impact estimates, we examined trends in official
macroeconomic data as reported by the countries' central banks or
departments of statistics, the Asian Development Bank, the Organization
for Economic Cooperation and Development, and the World Travel and
Tourism Association.[Footnote 40] Trends in international airline
traffic were obtained from the International Air Transport Association.
We corroborated our findings with information provided by the U.S.
National Intelligence Council and interviews with government officials
in Asia.
Finally, to examine the status of efforts to update the International
Health Regulations, we reviewed the current International Health
Regulations, a draft of WHO's proposed revision of the regulations, the
initial U.S. government response to the proposed revisions, and the WHO
constitution. We also interviewed WHO and U.S. government officials who
are actively engaged in the revision process and other legal experts to
determine the potential impacts of the revised rules.
We performed our work from July 2003 to April 2004 in accordance with
generally accepted government auditing standards.
We are sending copies of this report to the Secretaries of Health and
Human Services, State, and Defense; appropriate congressional
committees; and other interested parties. We will also make copies
available to others upon request. In addition, the report will be
available at no charge on GAO's Web site at [Hyperlink, http://
www.gao.gov].
If you or your staff have any questions, please contact one of us.
Other contacts and key contributors are listed in appendix VII.
Sincerely yours,
Signed by:
David Gootnick,
Director, International Affairs and Trade:
Janet Heinrich,
Director, Health Care--Public Health Issues:
[End of section]
Appendixes:
Appendix I: SARS Cases and Deaths, November 2002-July 2003:
[See PDF for image]
Note: Numbers represent cases and deaths.
[End of figure]
[End of section]
Appendix II: SARS Chronology:
Appendix II lists key worldwide events during the SARS outbreak, from
November 2002, when the disease first emerged, to the most recent
reported cases in January 2004.
2002;
November 16; Location: Guangdong Province, China[A]; Event: First
known case of atypical pneumonia, later determined to be SARS.
November 23; Location: Beijing; Event: World Health Organization
(WHO) influenza expert attends workshop in Beijing and learns from a
participant from Guangdong Province of a "serious outbreak with high
mortality and involvement of health care staff.".
November 27; Location: Canada; Event: Global Public Health
Intelligence Network (GPHIN) picks up reports of a "flu outbreak" in
China.
Mid-December; Location: WHO Headquarters, Geneva; Event: WHO
requests further information from China on the influenza outbreak.
Chinese government replies that influenza activity in Beijing and
Guangdong is normal and that surveillance system detected no unusual
strains of the virus.
December 10; Location: Guangdong Province; Event: Infection in
second city in Guangdong Province.
Year: 2003.
January 23; Location: Guangdong Province; Event: Guangdong's
provincial health authorities produce a report about the outbreak
detailing the nature of transmission, clinical features, and suggested
preventive measures. The report is circulated to hospitals in the
province, but is not shared with WHO or Hong Kong.
February 10-11; Location: Multiple Locations; Event: WHO Beijing
office, Global Outbreak and Alert Response Network (GOARN) partners,
and U.S. Centers for Disease Control (CDC) receive reports of a
"strange contagious disease" and "pneumonic plague" causing deaths in
Guangdong Province.
February 14-20; Location: China, Hong Kong; Event: Chinese Center
for Disease Control and Prevention erroneously announces that the
probable causative agent of the atypical pneumonia is Chlamydia. At the
same time, cases of avian influenza in a family that traveled between
Hong Kong and China result in two deaths. This leads to speculation
that the atypical pneumonia outbreak is caused by avian influenza. WHO
activates its global influenza laboratory network and calls for
heightened global surveillance.
February 21; Location: Hong Kong[A]; Event: First superspreader
event in Hong Kong: A physician from Guangdong Province stays at the
Metropole Hotel in Hong Kong and is soon hospitalized with respiratory
failure. While at the hotel, he transmits the disease to at least 16
other people.
February 23; Location: China; Event: A team of WHO experts,
including CDC staff, arrives in Beijing but is given limited access to
information; Chinese authorities deny WHO's repeated requests for
permission to travel to Guangdong Province.
February 24; Location: WHO; Headquarters, Geneva; Event: GPHIN
detects Chinese newspaper report that more than 50 hospital staff in
Guangzhou are infected with "mysterious pneumonia.".
February 26; Location: Vietnam[A]; Event: Chinese-American
businessman admitted to the French Hospital in Hanoi with fever and
respiratory symptoms.
February 28; Location: Vietnam; Event: WHO official Dr. Carlo
Urbani notifies WHO office in Manila of an unusual disease. WHO
headquarters moves to heightened state of alert.
Early March; Location: United States; Event: State Department
establishes an intradepartmental working group to deal with impact of
outbreak.
March 1; Location: Singapore[A]; Event: Woman who stayed at the
Metropole Hotel in Hong Kong is hospitalized with respiratory
symptoms.
March 4; Location: Hong Kong; Event: Second superspreader event
in Hong Kong: a resident who had visited the Metropole Hotel is
admitted to hospital with respiratory symptoms; within a week, at least
25 hospital staff, all linked to the patient's ward, develop
respiratory illness.
March 5; Location: Canada[A]; Event: Toronto woman who also
stayed at the Metropole Hotel in Hong Kong dies at home. Shortly after,
her son becomes ill, is admitted to Scarborough Grace Hospital, and
dies. His admission triggers an outbreak at the hospital.
March 8; Location: Taiwan[A]; Event: Businessman with travel
history to Guangdong Province is hospitalized with respiratory
symptoms.
March 10; Location: China; Event: Chinese Health Ministry asks
WHO for technical and laboratory support to clarify cause of the
Guangdong outbreak of atypical pneumonia.
March 12; Location: WHO; Headquarters, Geneva; Event: WHO issues
global alert about cases of severe atypical pneumonia following
mounting reports of spread among hospital staff in Hong Kong and Hanoi.
CDC offers assistance to WHO.
March 13; Location: WHO; Headquarters, Geneva; Event: WHO sends
emergency alert to GOARN partners.
March 14; Location: United States; Event: CDC activates Emergency
Operations Center.
March 15; Location: WHO; Headquarters, Geneva; Event: WHO issues
rare global travel advisory, names the mysterious illness "severe acute
respiratory syndrome" (SARS), and declares it a "worldwide health
threat." WHO issues its first definitions of suspect and probable
cases, calls on travelers to be aware of symptoms, and issues advice to
airlines.
March 15; Location: United States[A]; Event: CDC issues travel
advisory suggesting postponement of nonessential travel to Hong Kong,
Guangdong Province, and Hanoi. CDC issues preliminary case definition
for suspected SARS and initiates domestic surveillance for SARS. First
suspected U.S. case is identified.
March 16; Location: United States; Event: CDC begins distributing
health alert cards to passengers arriving from Hong Kong at four
international airports.
Mid-March; Location: Taiwan; Event: CDC team arrives in Taiwan to
assist in SARS response.
March 17; Location: WHO; Headquarters, Geneva, and multiple
locations; Event: WHO sets up worldwide network of laboratories to
expedite detection of causative agent and to develop a robust and
reliable diagnostic test. A similar network is set up to pool clinical
knowledge on symptoms, diagnosis, and management. A third network is
set up to study SARS epidemiology.
March 28; Location: China; Event: China joins WHO's collaborative
networks, initially set up on March 17.
March 30; Location: Hong Kong; Event: Third superspreader event
in Hong Kong: Health authorities announce that 213 residents of Amoy
Gardens housing estate have been hospitalized with SARS.
April 2; Location: WHO; Headquarters, Geneva; Event: WHO issues
most stringent travel advisory in its 55-year history, recommending
that people postpone all but essential travel to Hong Kong and
Guangdong Province until further notice.
April 3; Location: China; Event: WHO team arrives in Guangdong.
April 4; Location: United States; Event: President Bush signs
executive order adding SARS to the list of quarantinable communicable
diseases. This order provides CDC, through its Division of Global
Migration and Quarantine, with the legal authority to implement
isolation and quarantine measures.
April 16; Location: WHO; Headquarters, Geneva; Event: WHO
laboratory network announces conclusive identification of SARS
causative agent: a new coronavirus.
April 19-20; Location: China; Event: Change in political stance
by Chinese leadership. Top leaders advise officials not to cover up
cases of SARS; mayor of Beijing and Health Minister, both of whom
downplayed the SARS threat, are removed from their posts.
April 28; Location: Vietnam; Event: First country to successfully
contain its outbreak of SARS.
May 2; Location: United States; Event: State Department holds
interagency meeting on SARS.
May 3; Location: Taiwan; Event: WHO sends officials to Taiwan to
assist CDC team.
May 17; Location: WHO; Headquarters, Geneva; Event: First global
consultation on SARS epidemiology concludes its work, confirming that
available evidence supports the control measures recommended by WHO.
May 27; Location: WHO; Headquarters, Geneva; Event: World Health
Assembly resolution recognizes the severity of the threat that SARS
poses and calls on all countries to report cases promptly and
transparently. A second resolution strengthens WHO's capacity to
respond to disease outbreaks.
June 17-18; Location: Malaysia; Event: WHO holds Global
Conference on SARS to review scientific findings on SARS and examine
public health interventions to contain it.
July 5; Location: WHO; Headquarters, Geneva; Event: WHO announces
that the global SARS outbreak has been contained.
September 8; Location: Singapore; Event: Singapore announces that
a medical researcher is infected with SARS. Based on an investigation
of this incident, WHO concludes that the patient was accidentally
infected in the laboratory.
December 17; Location: Taiwan; Event: Taiwan announces that a
researcher is infected with SARS. Public health authorities conclude
that the infection was acquired in a laboratory.
December 20-; January 5, 2004; Location: China; Event: A man in
Guangdong Province is hospitalized with SARS-like symptoms on December
20. Chinese authorities inform WHO on December 26. After initial
diagnostic tests are inconclusive, authorities send the samples to two
WHO-designated reference laboratories in Hong Kong. On January 5, the
laboratories confirm that the patient has SARS. None of the patient's
contacts contracted SARS.
December 31-January 17, 2004; Location: China; Event: A woman in
Guangdong Province is hospitalized with SARS-like symptoms on December
31. Chinese authorities inform WHO and samples are submitted to two
WHO-designated reference laboratories in Hong Kong. On January 17,
Chinese authorities announce that the patient has SARS. None of the
patient's contacts contracted SARS.
Year: 2004.
January 6-27; Location: China; Event: A man in Guangdong Province
is hospitalized with SARS-like symptoms on January 6. Chinese
authorities inform WHO and samples are submitted to WHO-designated
reference laboratories in Hong Kong. On January 27, WHO announces that
the patient has probable SARS.
January 7-30; Location: China; Event: A doctor in Guangdong
Province becomes ill with SARS-like symptoms and is diagnosed with
pneumonia on January 14. However, he was not properly isolated in
hospital until January 16, he was not declared as a suspected SARS case
to China's Ministry of Health until January 26, and WHO was not
informed until January 30.
January 9-16; Location: China; Event: A team of international
experts from WHO conducts a joint investigative mission in Guangdong
Province with colleagues from China's Ministry of Health, Ministry of
Agriculture, the Chinese Center for Disease Control and Prevention, and
the Guangdong Center for Disease Control and Prevention to identify the
sources of infection of the most recent SARS cases. The team finds no
definitive source of infection for any of the cases.
Source: GAO analysis of WHO and CDC data.
[A] Date of the first known case(s) of SARS.:
[End of table]
[End of section]
Appendix III: Estimates of the Economic Impact of SARS:
Estimates of the economic impact of SARS have been produced by multiple
sources and vary due to the inexact nature of estimating the impact of
a recent event such as SARS. When the SARS outbreak first emerged, a
number of institutions began estimating the potential economic impact
of the disease. These institutions included private investment banks,
industry organizations, academics, consulting firms, and international
financial institutions such as the Asian Development Bank. To produce
their estimates, assumptions had to be incorporated regarding the
expected duration of SARS, the number of sectors affected, and country-
specific macroeconomic conditions. As such, estimates of economic
impact have been broad in nature, have varied depending on model
assumptions, and were often revised when actual data were received. For
example, some of the initial economic impact estimates were revised
downward once data emerged showing China's strong economic growth
during the first 4 months of 2003.
To describe the economic impact of SARS in Asia, we primarily relied on
impact estimates generated from institutions using simulation models.
Table 3 provides information on the models we reviewed. As the table
shows, each of these models was used to analyze a low scenario case and
a high scenario case, which differed based on assumptions regarding the
expected duration of the SARS outbreak and hence the expected duration
of the shock to the economy resulting from SARS. To accord with the
shorter duration of the actual outbreak, the low scenario results
estimated the economic impact of SARS at roughly 0.5 percent to 2
percent of gross domestic product (GDP).[Footnote 41] All three models
show that the largest economic impacts as a percentage of GDP were
estimated for Hong Kong and Singapore, which is due to their previously
lowered consumption demand and high share of tourism and retail.
Table 3: Models Estimating the Economic Impact of SARS on GDP in Asia,
2003:
[See PDF for image]
[End of table]
In addition to the model estimates provided in table 3, we also
reviewed SARS cost estimates provided by the Far Eastern Economic
Review. The Far Eastern Economic Review's estimate of $11 billion was
generated by calculating an average estimated percentage loss in GDP
using reports from various governments and financial institutions and
applying that average to the nominal GDP figures provided by the
International Monetary Fund.[Footnote 42]
[End of section]
Appendix IV: Comments from the Department of Health and Human Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES:
Office of Inspector General:
Washington, D.C. 20201:
APR 16 2004:
Mr. David Gootnick:
Director, International Affairs and Trade
United States General Accounting Office Washington, D.C. 20548:
Dear Mr. Gootnick:
Enclosed are the Department's comments on your draft report entitled,
"Emerging Infectious Diseases: Asian SARS Outbreak Challenged
International and National Responses" (GAO-04-564). The comments
represent the tentative position of the Department and are subject to
reevaluation when the final version of this report is received.
The Department provided several technical comments directly to your
staff.
The Department appreciates the opportunity to comment on this draft
report before its publication.
Sincerely,
Signed by:
Dara Corrigan:
Acting Principal Deputy Inspector General:
Enclosure:
The Office of Inspector General (OIG) is transmitting the Department's
response to this draft report in our capacity as the Department's
designated focal point and coordinator for General Accounting Office
reports. OIG has not conducted an independent assessment of these
comments and therefore expresses no opinion on them.
COMMENTS OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES ON THE GENERAL
ACCOUNTING OFFICE'S DRAFT REPORT: "EMERGING INFECTIOUS DISEASES: ASIAN
SARS OUTBREAK CHALLENGED INTERNATIONAL AND NATIONAL RESPONSES" (GAO-04-
564):
The report is a good summary of the Severe Acute Respiratory Syndrome
(SARS) outbreak in Southeast Asia and actions taken during and after
the epidemic by the World Health Organization (WHO) and the affected
countries, as well as actions taken by the Department of Health and
Human Services (HHS) to combat the epidemic globally and to protect the
United States (U.S.), focusing on the activities of our Centers for
Disease Control and Prevention (CDC). The report also contains a useful
overview of WHO's efforts to revise its International Health
Regulations and correctly ties the newly intense efforts at WHO to the
impact of SARS and lessons learned.
The SARS outbreak did indeed challenge international and national
responses. While the report correctly focuses on the issues and events,
the intensity of the coordination and collaboration within governments
and among nations was unprecedented. The report documents many of the
activities, but does not go into detail on the substantial coordination
and collaboration efforts among U.S. executive branch agencies and
among those agencies and the governments in East and Southeast Asia.
While we recognize the latter was not the focus of this report, the
following briefly describes how HHS organized itself to manage its
response and effectively faced the new challenges.
Tommy G. Thompson, as Secretary of HHS, led the Department's response
to the SARS epidemic, thus ensuring coordinated roles and responses
across our agencies most directly involved in the response domestically
and internationally - CDC, the National Institutes of Health, and the
Food and Drug Administration. Primarily through his Office of Global
Health Affairs and Office of Public Health Emergency Preparedness, the
Secretary also provided the leadership to ensure the necessary
coordination and alignment of our domestic and international responses.
Using the cutting-edge technology of his new Command Center and face-
to-face opportunities in Geneva and Washington, the Secretary
maintained close contact with the leadership at WHO and with a number
of affected governments, including Canada, the People's Republic of
China, the Socialist Republic of Vietnam, and the Hong Kong Special
Administrative Region.
For example, after the 2003 SARS outbreak, China's Ministry of Health
committed to more open communication with HHS in any future avian
influenza outbreak and to the sharing with HHS of key laboratory
samples from a localized SARS outbreak in Guangdong that occurred last
winter. Secretary Thompson also pledged to assist China in its fight
against SARS and other emerging diseases through collaboration of HHS
scientists working with their Chinese counterparts. The signing of this
U.S.-China Emerging Infections Program in May 2004 represents a multi-
year, multi-million dollar program of cooperation between HHS and the
Chinese Ministry of Health aimed at strengthening fundamental public
health infrastructure and improving the national capacity to manage a
number of infectious diseases, including SARS and pandemic:
influenza as part of a worldwide early warning surveillance network HHS
is building. These are but a few examples of how Secretary Thompson's
diplomatic efforts and leadership, in coordination with the Department
of State (DOS), helped to obtain needed information for HHS and DOS
about the global response and the collective and individual SARS
efforts and challenges at the country-level. With assistance from DOS,
Secretary Thompson's personal interventions and diplomatic outreach
with Southeast Asian government counterparts substantially aided in
gaining access to those countries by WHO and our own experts.
The Secretary and his senior staff used the Secretary's Command Center
to hold daily briefings during which a CDC official, usually the
Director, presented the latest information on the SARS situation
worldwide and actions being taken overseas and domestically to protect
the U.S. Experts from DOS, Homeland Security, and Defense participated
in these briefings. Issues included coordination with WHO and affected
countries, plans for scientific research, communication with the
public, and communication with other national governments and
economies, etc. Daily reports and maps, prepared by the Secretary's
Command Center staff, facilitated the tracking of the epidemic and
maximized the deployment of HHS staff.
HHS believes the increased inter-agency coordination and lessons we
learned during the SARS epidemic in 2003 were highly useful in our
response to the Avian Influenza (H5N1) outbreak in Asia in 2004. The
interagency group has made progress on a number of international
operational and policy issues since the Spring of 2003, and shaped our
engagement in the process to revise the WHO International Health
Regulations.
HHS believes this report makes a valuable contribution, and we find its
recommendations to be appropriate. They identify important work that
needs to be undertaken or brought to conclusion as quickly as possible
so that we are sufficiently prepared for the next epidemic. The
recommendations stress the interagency nature of the work to be done
internationally as well as domestically. Again, the report correctly
recognizes the importance of collaboration with our partner agencies,
in particular the valuable interagency coordination activities under
the purview of DOS. To carry out some of the recommendations, sensitive
legal and privacy issues and diplomatic concerns must be carefully
addressed.
[End of section]
Appendix VI: Comments from the World Health Organization:
United States Department of State
Assistant Secretary and Chief Financial Officer:
Washington, D.C. 20520:
APR 15 2004:
Dear Ms. Williams-Bridgers:
We appreciate the opportunity to review your draft report, "EMERGING
INFECTIOUS DISEASES: Asian SARS Outbreak Challenged International and
National Responses," GAO-04-564, GAO Job Code 320198.
The enclosed Department of State comments are provided for
incorporation with this letter as an appendix to the final report.
If you have any questions concerning this response, please contact
Sara Allinder Mestre, Foreign Affairs Officer, Bureau of Oceans and
International Environment and Scientific Affairs, at (202) 647-3649.
Sincerely,
Dana Corrigan
Acting Principal Deputy Inspector General
cc: GAO - Patrick Dickriede
OES - Lee Morin
State/OIG - Mark Duda State/
H - Paul Kelly:
Department of State Comments on GAO Draft Report
EMERGING INFECTIOUS DISEASES: Asian SARS Outbreak Challenged
International and National Responses
(GAO-04-564, GAO Job Code 320198):
We appreciate the opportunity to comment on your draft report,
"Emerging Infectious Diseases, Asian SARS Outbreak Challenged
International and National Responses". The report is a useful summary
of the Severe Acute Respiratory Syndrome (SARS) outbreak and its
impact.
The Department of State agrees that the Asian SARS outbreak challenged
international and national responses. At the outset, some Asian
governments did not recognize the SARS emergency. The Department of
State applied diplomatic pressure on governments to increase
transparency and response, helped facilitate the U.S. government
response to SARS in Asia, and provided information on SARS to U.S.
government employees and citizens in the region. By the end of the
outbreak in July 2003, SARS had served to heighten awareness of the
need for surveillance and response activities and changed how nations
think about reporting disease outbreaks internationally and internally.
Both the World Health Organization (WHO) and its member states gained
real-world insights that have benefited the process, under WHO
auspices, of revising the International Health Regulations. The report
correctly identifies the challenges in such a revision, but the fact
that countries accept the need is a positive step forward.
The SARS outbreak also led to increasing coordination among Federal
agencies charged with a response, and thus provided lessons learned,
including for the Avian Influenza (H5N1) outbreak in Asia. During the
2003 SARS outbreak,
the Department of State's internal working group, the Department of
State-led Interagency Working Group, and the Department of Health and
Human Services' (HHS) Emergency Operations Centers kept in constant
contact. There were daily phone calls to exchange information, which
allowed the Department of State to support, through diplomatic means,
HHS and international efforts to gather information and to respond to
the epidemic. The Interagency Working Group has addressed international
policy and response issues, such as contact tracing and medical
evacuations, through a number of meetings since May 2003. The
interagency collaboration also allowed the group to address the Avian
Influenza outbreak when it was realized to be a major public health
issue in January 2004.
The report recommends that the Secretary of Health and Human Services,
in consultation with the Secretary of State, work with WHO and official
representatives from other WHO member states to strengthen the response
capacity of WHO's global infectious disease network. The Department of
State is committed, as a foreign policy matter, to work both with WHO
and its member states to strengthen the international response to
infectious disease outbreaks, and to achieve effective revisions of the
International Health Regulations.
The report also recommends authorities for HHS to facilitate contact
tracing of arriving passengers determined to be infected with or
exposed to SARS. We are pleased to report that the Department of State
has been working on those issues in collaboration with our interagency
partners since the SARS outbreak. The Department of State has brought
together officials of the Departments of Homeland Security and Health
and Human Services to facilitate planning and discussion on obtaining
passenger contact information. However, as the report notes, serious
legal issues still exist for both the United States and for other
governments. These center on privacy and access to personal information
and may require legislation or regulatory changes. The Department of
State will continue to work with its partners to address this issue.
The Department of State also has worked closely with HHS' Centers for
Disease Control and Prevention (HHS/CDC) to develop protocols on how to
handle medical evacuations of persons suspected or confirmed to have
quarantinable diseases, such as SARS. The Department of State's highest
priority is the safety and well being of American citizens traveling or
residing abroad, including its employees and their families. The
Department has direct responsibility for its American employees and
their families. Medical evacuation procedures, including how to
maintain liaison with HHS/CDC, have been documented, and will shortly
be disseminated to our Embassies and consulates throughout the world.
It is important to note, however, that capacity for such medical
evacuations will always be limited, as will capacity of U.S. medical
facilities to handle a large influx of quarantinable patients.
The Department of State believes that this report documents important
lessons for other infectious disease outbreaks beyond the 2003 SARS
epidemic.
[End of section]
Appendix VII: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Martin T. Gahart, (202) 512-3596 Cheryl Goodman, (202) 512-6571:
Acknowledgments:
In addition to the persons named above, Janey Cohen, Patrick Dickriede,
Anne Dievler, Suzanne Dove, Sharif Idris, Roseanne Price, Kendall
Schaefer, and Richard Seldin made key contributions to this report.
(320198):
FOOTNOTES
[1] "Summary of probable SARS cases with onset of illness from 1
November 2002 to 31 July 2003," (Geneva, Switzerland: WHO, September
26, 2003), http://www.who.int/csr/sars/country/table2003_09_23/en/
(downloaded March 12, 2004).
[2] Scientific evidence suggests that the virus originated in animals
and crossed into human populations. See Y. Guan, "Isolation and
characterization of viruses related to the SARS coronavirus from
animals in southern China," Science, vol. 302, no. 5,643 (2003).
[3] Atypical pneumonia is caused by a variety of bacteria and viruses
and has different clinical signs and a more protracted onset of
symptoms compared with other forms of pneumonia.
[4] WHO, which consists of 192 member states, is headquartered in
Geneva and has six regional offices and numerous country offices. The
Western Pacific Regional Office (WPRO) serves Asian countries and has
links to country offices in China and other Asian countries. WHO is
governed by the World Health Assembly, which meets yearly and is
attended by delegations from all member states. The assembly determines
WHO's policies and is authorized to adopt regulations concerning the
prevention of the international spread of disease and make
recommendations about any subject dealt with by WHO. China is member of
WHO, but Taiwan is not. Hong Kong's interests are represented in WHO by
China.
[5] The influenza surveillance network comprises four WHO Collaborating
Centers and 112 institutions in 83 countries, which are recognized by
WHO as "WHO National Influenza Centers." The National Influenza Centers
collect specimens in their country and perform primary virus isolation
and characterization. They ship newly isolated strains to the
Collaborating Centers for analysis, the result of which forms the basis
for WHO recommendations on the composition of influenza vaccine for the
Northern and Southern Hemisphere each year.
[6] About 40 percent of the approximately 200 outbreaks investigated
and reported to WHO each year come from the Global Public Health
Intelligence Network (GPHIN), a system developed by Canadian health
officials and used by WHO since 1997 that searches for reports of
disease outbreaks from more than 950 news feeds and discussion groups
around the world in the media and on the Internet.
[7] The Departments of Defense, Homeland Security, and Transportation
also assisted State and HHS during the SARS outbreak.
[8] The National Institute of Allergy and Infectious Diseases and the
Food and Drug Administration also played roles in the response to SARS
by conducting and supporting scientific research (e.g., on diagnostic
tests and a vaccine) during and after the outbreak.
[9] At this time, WHO defined a suspect case as one occurring after
February 1, 2003, with a history of a high fever (over 38 degrees
Celsius) and one or more respiratory symptoms, including cough,
shortness of breath, and difficulty breathing. It defined a probable
case as one in which there was close contact with a person diagnosed
with SARS; a history of recent travel to areas reporting SARS; a
diagnosis of "suspect" with chest X-ray findings of pneumonia or
respiratory distress syndrome; or an unexplained respiratory illness
resulting in death, plus an autopsy examination demonstrating the
pathology of respiratory distress syndrome without an identifiable
cause. WHO revised this definition several times, publishing the latest
revision on August 14, 2003 (see http://www.who.int/csr/sars/
postoutbreak/en/).
[10] Section 361 of the Public Health Service Act, 42 U.S.C. § 264.
[11] See 42 C.F.R. pts 70 and 71; 21 C.F.R. pts 1240 and 1250.
[12] According to airline industry association officials, under
European Union privacy laws and regulations, there could be problems
with sharing passenger names and addresses with government agencies.
[13] During the SARS outbreak, international travelers constituted an
important source of transmission. For example, CDC reported that all of
the United States' eight laboratory-confirmed SARS cases and almost all
of the 27 probable SARS cases were found in individuals who had
traveled to a SARS-affected area or came into close contact with
someone who did.
[14] CDC did not provide us with details about the various options
because they had not yet been finalized.
[15] State officials said they are responsible for providing medical
services (including medical evacuations, if necessary) only to certain
U.S. government employees and their dependents, although embassies may
assist U.S. citizens overseas in obtaining medical care on a case-by-
case basis. However, it is primarily the responsibility of U.S.
citizens to arrange their own medical evacuation. During the SARS
outbreak, State helped arrange three medical evacuations for U.S.
citizens. The first was performed by the Department of Defense from
Hanoi to Taiwan; the second was a land evacuation performed by
ambulance from Shenzhen to Hong Kong; and the third was performed by a
medical evacuation company from Taiwan to Atlanta.
[16] Most medical evacuation companies do not have their own aircraft
and crews; rather, they subcontract aircraft as medical evacuation
needs arise.
[17] When warranted by conditions at an overseas post, State can
authorize U.S. government employees and their dependents to depart the
post.
[18] The report was released during the Chinese New Year Holiday.
According to one official, the report may not have received significant
attention from health officials on leave during the holiday.
[19] See People's Republic of China, Ministry of Health, "Explanation
on Regulations on State Secrets in Health Work and Their Specific
Classification and Scope," March 1, 1991, published in Chinese Law &
Government 66 (2003) (Fei-Ling Wang trans).
[20] Martin Enserink"SARS in China: China's Missed Chance," Science,
vol. 301, no. 5,631 (2003).
[21] "SARS in Hong Kong: From Experience to Action," (Hong Kong: SARS
Expert Committee, October 2, 2003), http://www.sars-expertcom.gov.hk/
english/reports/reports/reports fullrpt.html (downloaded Oct. 3,
2003).
[22] SARS Expert Committee Report, "SARS in Hong Kong: From Experience
to Action."
[23] "Use of Quarantine to Prevent Transmission of Severe Acute
Respiratory Syndrome--Taiwan 2003," MMWR, vol. 52, no. 29 (July 25,
2003).
[24] "Efficiency of Quarantine during an Epidemic of Severe Acute
Respiratory Syndrome--Beijing, China 2003," MMWR, vol. 52, no. 43 (Oct.
31, 2003).
[25] People's Republic of China, "Regulations for the Management of
Infectious Atypical Pneumonia," May 13, 2003, published in 36 Chinese
Law & Government 91(2003) (Fei-Ling Wang, trans).
[26] People's Republic of China, "Regulations on Contingency Measures
for Public Health Emergencies," May 9, 2003, published in 36 Chinese
Law and Government 76 (2003) (Fei-Ling Wang,tran).
[27] Laws of Hong Kong, Prevention of the Spread of Infectious
Diseases, ch. 141B, regs. 27A and 27B (Apr. 17, 2003).
[28] These figures represent the net loss in GDP and take into account
the potential decline in imports that acts to partially offset the
potential decline in consumption or exports. As such, if the total loss
in spending, rather than the net loss in GDP, is estimated, the Asian
Development Bank's cost estimate rises to $60 billion.
[29] Some economies were more vulnerable to SARS than others due to
structural issues, such as the relative share of tourism in the
economy, government spending responses, and prior consumer sentiment.
For example, Hong Kong and Singapore have larger estimated GDP losses
due to SARS because of weakened consumption demand already apparent in
late 2002.
[30] We cannot, however, attribute viewed changes in quarterly GDP
growth exclusively to SARS, given that other factors were relevant,
such as the conflict in Iraq. Nonetheless, comparing Asian GDP growth
rates with the average growth rate in Organization for Economic
Cooperation and Development countries shows a much more distinct
decline in the second quarter of 2003.
[31] As with the quarterly decline in GDP, we cannot attribute the
entire decrease in airline traffic to SARS, as the outbreak occurred
during an already depressed market because of the war in Iraq.
[32] The World Travel and Tourism Association used its own model to
generate its estimates for the dollars lost from the decline in
tourism. As such, these numbers do not correspond equally to the
estimates in table 1.
[33] The duration of estimated job losses is unknown. Travel and
tourism in Asia has largely recovered, and International Airline
Traffic Association forecasts for the industry are optimistic.
[34] Foreign trade and investment were more resilient than consumption
during the initial stages of the outbreak such that estimated economic
effects were less significant due to the rapid rebound of Asian
economies in the third quarter of 2003.
[35] According to WHO officials, the language in the draft regulations
dealing with conducting on-the-spot investigations was intended to
closely reflect wording used in World Health Assembly Resolution 58.28,
adopted on May 28, 2003, which among other things, urged WHO members to
give high priority to IHR revision.
[36] For example, article 8(3) of the draft regulations states that
"the health administration in whose territory the alleged event . . .
is occurring shall collaborate with WHO in assessing the potential for
international disease spread and possible interference with
international traffic and the adequacy of control measures and, when
necessary, in conducting on-the-spot studies by a team sent by WHO . .
." (emphasis added).
[37] The draft regulations only state that "significant interference"
is a "refusal of entry or departure or delaying entry or departure for
more than 24 hours, for travelers and conveyances." WHO, Proposed
International Health Regulations, art. 7.4.
[38] WHO, World Health Assembly Res. 56.28 (May 28, 2003).
[39] Jong-Wha Lee and Warwick J. McKibbon, "Globalization and Disease:
The Case of SARS, Working Paper No. 2003/16," Research School of
Pacific and Asian Studies, Australian National University and the
Brookings Institution, Washington, D.C. (2003).
[40] To determine the reliability of the official national accounts
data, we verified that the general patterns reported were consistent
with other documentary evidence and reviewed each economy's compliance
with the International Monetary Fund's data dissemination standards. We
conclude that the data is sufficiently reliable for the purposes of
establishing decreased economic activity during the second quarter of
2003.
[41] The International Monetary Fund announced in April 2003 that the
estimated decline in GDP due to SARS was 0.2 percent for China and 0.4
percent for East Asia. The World Bank's East Asia Update in April 2003
also provided an estimate of the decline in GDP due to SARS at 0.3
percent for East Asia. However, neither organization has published a
model to describe how it arrived at these estimates.
[42] The Far Eastern Economic Review is a regional economic business
weekly. Its cost estimates of SARS are provided in a 2003 special
report on the SARS outbreak. The financial institutions that provided
economic impact estimates to the review included Merrill Lynch, Goldman
Sachs, JP Morgan, Lehman Brothers, Morgan Stanley, ING Financial
Markets, BNP Paribas Peregrine, Standard & Poor's, and IDEAGlobal.
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