1. Severe Acute Respiratory Syndrome (SARS) AA Model for Preparedness for Emerging Diseases Finding and Filling Gaps

2. What is the status of “Big Gaps” Clinical manifestations of full blown SARS Diagnosis and therapy Clinical spectrum Characteristics of transmission & transmitters Seasonality and potential geographic range Causative agent? Any important co-factors? Protective factors—do children provide clues? Where did the causative agent come from? Is there a persistent reservoir? How about those time lags— –Recognizing and publicizing new syndrome –Public health prevention measures

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

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

6. Chain of Transmission Pt “ZF” 1 2 3 * * * * 1 st, 2 nd, and 3 rd hospitalizations

8. China (and its neighbors) HK-Dhaka Flights to Bangkok BKK-DAC

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

11. Transmission Pattern Guangdong-first 1000 cases through February 28% in health care workers 20% in family members 52% unknown contacts 5% of cases were food preparers (compared with 1% of those with typical pneumonias over the previous two years)

12. Food Handlers as the Original Sentinels? Nearly 35% of the cases recognized before Feb 1, 2003 were among food handlers—many lived near “wet markets” Ample exposure to secretions, blood, urine and feces of domesticated/bred and wild animals in Guangdong Province

13. Animal Market, Guangzhou

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

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

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

17. Epidemics of Emerging or Known Diseases Early Recognition and Response What is Required? Surveillance Systems –Hospital-based focused on disease or known syndrome Enough information to recognize novel clinical or epidemiologic pattern –unusual combination of signs/symptoms –occupational clustering (may consider surveillance in sentinel populations—i.e. health care workers –Behavior-based Vinegar sales would have been a clue Antimicrobial drug sales –Physician-based via education/networks/hotlines

18. Epidemics of Emerging or Known Diseases Early Recognition and Response Surveillance Characteristics System should be easy to participate in Individual reporting should be electronic Analysis should have automated capacity with built-in pattern recognition and also flexibility for operator manipulation Trained personnel need to maintain and use it Pre-established thresholds for anomalies/prepared to respond Teams trained, ready, and available to investigate International support/trust Prepared for communication/education

19. Vietnam Singapore Toronto 63 cases 205 cases 142 cases Global Spread of a Novel Pathogen Hong Kong 1500 cases Guangdong 1500 cases

20. Big Lesson from SARS Political Will Required to Support, Enhance and Utilize Public Health Infrastructure Need for quick, transparent steps to declare presence of lethal pathogen with borders Intensify surveillance and report results Use contact tracing, quarantine, and border control measures when needed Apply stringent infection control measures in health care settings when indicated Provide public with timely information Magnitude Known risks How one can protect himself/herself and family International public health enforcement??

21. Keep Some Perspective 5,000 cases in China—population 1.3 billion 8,000 cases globally Not easy to get SARS Not the greatest health problem faced, but a test for our preparedness to respond to public health crises We can use this experience to improve ourselves

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

23. Politics and Public Health