The Global Response

                  SARS was the first emerging infectious disease of the 21^st century.  It was spread from one geographical region to 32 countries between November of 2002 and May of 2003.  As soon as the disease was reported to the World Health Organization in March 2003, a massive and global call to arms was sounded.  By July 2003, the World Health Organization, various Ministries of Health, and healthcare workers succeeded in stopping the spread of SARS.  Preventing SARS from becoming either endemic in any area or becoming a global pandemic can be considered one of the greatest public health achievements of all time.

THE PEOPLE'S REPUBLIC OF CHINA

Map taken from the CIA World Factbook.  Available online at http://www.cia.gov/cia/publications/factbook/geos/ch.html

Though SARS was experienced in the Guangdong Province of China beginning in November 2002, reports did not reach the region's Health Bureau until January 2003.   The Chinese epidemic was characterized by severe underreporting and misleading government reports.   Much of this was done with the intent of protecting Chinese economic interests and maintaining social order.  As the WHO noted in its May 2003 publication, Severe Acute Respiratory Syndrome (SARS):  Status of the Outbreak and Lessons for the Immediate Future:

"This is the most important lessen for all nations:  in a globalized, electronically connected world, attempts to conceal cases of an infectious disease, for fear of social and economic consequences, must be recognized as a short-term stop-gap measure that carries a very high price Ð loss of credibility in the eyes of the international community, escalating negative domestic economic impact, damage to the health and economies of neighboring countries, and a very real risk that outbreaks within the country's own territory can spiral out of control."

The full text is available online at:  http://www.who.int/csr/media/sars_wha.pdf

Many of the early cases in the Guangdong region were kitchen workers or individuals working in the wildlife markets.  Both groups had potential to come into contact with the civet cats and raccoon dogs that were the most likely origin of SARS. 

After January 2003, the majority of cases were the result of nosocomial transmission or household transmission.  The chain of transmission was not stopped until isolation of patients and their contacts and proper protective procedures in hospitals occurred. 

HONG KONG- SPECIAL ADMINISTRATIVE REGION, CHINA

Hong Kong is a port city in the Cantonese region of China that was leased to the British.  During the period of British rule, Hong Kong flourished as one of the world's most prominent capitalist economies.  When Hong Kong returned to China on July 1^st 1997, it was agreed that Hong Kong be a special administrative region with separate local governance from the rest of the People's Republic of China.  However, it was recognized that the Communist government in Beijing retained final authority.

As a result of this distinction, the Hong Kong experience was markedly different from that of the People's Republic of China.  Individuals in Hong Kong have fewer travel restrictions than individuals in mainland China.  This permitted Hong Kong to be the location that facilitated the spread of SARS to Vietnam, Singapore, and Canada. 

A physician who had been treating patients for what was later known to be SARS traveled to Hong Kong in late February 2003.  He stayed in the Metropole Hotel with several other international travelers, twelve of whom later developed the disease.

A significant cluster of SARS cases were centered in the Amoy Gardens Complex, a group of apartment buildings.  A SARS patient who was experiencing diarrhea spread the disease throughout the complex via substandard plumbing and subsequent person-person transmission. 

A substantial number of nosocomial cases occurred in Hong Kong's Prince of Wales Hospital.  The majority of these cases occurred in health care workers who did not use the proper personal protective equipment and performed procedures (i.e. intubations) that required prolonged close contact with patients. 

SARS transmission in Hong Kong was contained by isolating the patients and their contacts, and using personal protective equipment to protect health care workers.  The idea of personal protective equipment soon spread to the general populace who began wearing surgical masks routinely in public, an example of the extreme. 

VIET NAM

Map taken from the CIA World Factbook.  Available online at http://www.cia.gov/cia/publications/factbook/geos/vm.html

The World Health Organization was able to congratulate Viet Nam on being the first country to successfully control SARS.  The Viet Nam index case was a traveler who stayed at the Metropole Hotel in Hong Kong where he contracted SARS. Upon his return to Hanoi, he was admitted to the Hanoi French Hospital where the disease spread to nurses, doctors, health care workers, and other patients. 

The hospital's response was to close all admissions until the hospital was clear of the disease and completely disinfected.  A separate SARS hospital was quickly established where personal protective measures were strictly adhered to.  The Vietnamese Preventative Medical Service worked quickly to identify and observe contacts of known SARS cases in order to prevent secondary transmission.  Within nine weeks, Viet Nam was removed from the WHO's advisory list. 

In the same 20 May 2003 publication, Severe Acute Respiratory Syndrome (SARS):  Status of the Outbreak and Lessons for the Immediate Future, that the People's Republic of China was criticized in, the World Health Organization lauded the Vietnamese efforts:

"The SARS experience in Viet Nam has shown that immediate political commitment at the highest level can be decisive.  Viet Nam demonstrated to the world how a developing country, hit by an especially severe outbreak, can triumph over a disease when reporting is prompt and open, when WHO assistance is quickly requested and fully supported, and when rapid case detection, immediate isolation and infection control, and vigorous contact tracing are put in place."

The full text is available online at:  http://www.who.int/csr/media/sars_wha.pdf

SINGAPORE

Map taken from the CIA World Factbook.  Available online at http://www.cia.gov/cia/publications/factbook/geos/sn.html

A tiny island city-state in Southeast Asia, Singapore is one of the East Asian Tiger Economies that grew rapidly after World War II.  Singapore has many strong trading links with its free market capitalist economy.  Because of its small size and population, the economy is the primary source of power for the state.  As a result, the Singapore government has established many laws on social order and has increased the power of the government beyond that of many Western democratic societies today. 

The introduction of SARS began when an international traveler who had stayed at the Metropole Hotel in Hong Kong was admitted to a Singapore hospital on 1 March 2003.  As the number of SARS cases in Singapore increased, the government took substantial measures to reduce the rate of transmission.  Schools and other public areas were closed for weeks.  An extensive case detection and contact isolation initiative was performed.  The military was called in to help quarantine contacts.  Personal protective equipment protocol was rigidly instituted in all hospitals. 

See the Singapore Ministry of Health Website for more details:

http://www.moh.gov.sg/sars/index.html