LEARNING FROM SARS
Preparing for the Next Disease Outbreak
Workshop Summary
Stacey Knobler, Adel Mahmoud, Stanley Lemon, Alison Mack, Laura Sivitz, and Katherine Oberholtzer, Editors
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
Support for this project was provided by the U.S. Department of Health and Human Services’ National Institutes of Health, Centers for Disease Control and Prevention, and Food and Drug Administration; U.S. Agency for International Development; U.S. Department of Defense; U.S. Department of State; U.S. Department of Veterans Affairs; U.S. Department of Agriculture; American Society for Microbiology; Burroughs Wellcome Fund; Pfizer; GlaxoSmithKline; and The Merck Company Foundation. The views presented in this report are those of the editors and attributed authors and are not necessarily those of the funding agencies.
This report is based on the proceedings of a workshop that was sponsored by the Forum on Microbial Threats. It is prepared in the form of a workshop summary by and in the name of the editors, with the assistance of staff and consultants, as an individually authored document. Sections of the workshop summary not specifically attributed to an individual reflect the views of the editors and not those of the Forum on Microbial Threats. The content of those sections is based on the presentations and the discussions that took place during the workshop.
Library of Congress Cataloging-in-Publication Data
Learning from SARS : preparing for the next disease outbreak : workshop summary / Stacey Knobler … [et al.], editors ; Forum on Microbial Threats, Board on Global Health.
p. ; cm.
Includes bibliographical references.
ISBN 0-309-09154-3 (pbk.) ISBN 0-309-53034-2 (PDF)
1. SARS (Disease)
[DNLM: 1. Severe Acute Respiratory Syndrome—prevention & control—Congresses. 2. Severe Acute Respiratory Syndrome—transmission—Congresses. 3. Disease Outbreaks—prevention & control—Congresses. 4. SARS Virus—isolation & purification—Congresses. 5. SARS Virus—pathogenicity—Congresses. 6. Socioeconomic Factors—Congresses. WC 505 L438 2004] I. Knobler, Stacey. II. Institute of Medicine (U.S.). Forum on Microbial Threats. III. Institute of Medicine (U.S.). Board on Global Health. IV. Title.
RA644.S17L43 2004
614.5'92—dc22
2004007115
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THE NATIONAL ACADAMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences.
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The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
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FORUM ON MICROBIAL THREATS
ADEL MAHMOUD (Chair), President,
Merck Vaccines, Whitehouse Station, New Jersey
STANLEY LEMON (Vice-Chair), Dean,
School of Medicine, University of Texas Medical Branch, Galveston, Texas
DAVID ACHESON, Chief Medical Officer,
Center for Food Safety and Applied Nutrition, Food and Drug Administration, Rockville, Maryland
STEVEN BRICKNER, Research Advisor,
Pfizer Global Research and Development, Pfizer Inc., Groton, Connecticut
DENNIS CARROLL,
U.S. Agency for International Development, Washington, DC
NANCY CARTER-FOSTER, Director,
Program for Emerging Infections and HIV/AIDS, U.S. Department of State, Washington, DC
GAIL CASSELL, Vice President,
Scientific Affairs, Eli Lilly & Company, Indianapolis, Indiana
JESSE GOODMAN, Director,
Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, Maryland
EDUARDO GOTUZZO, Director,
Instituto de Medicina Tropical “Alexander von Humbolt,” Universidad Peruana Cayetano Heredia, Lima, Peru
MARGARET HAMBURG, Vice President for Biological Programs,
Nuclear Threat Initiative, Washington, DC
CAROLE HEILMAN, Director,
Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
DAVID HEYMANN, Director,
Polio Eradication Program, World Health Organization, Geneva, Switzerland
JAMES HUGHES, Assistant Surgeon General and Director,
National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
LONNIE KING, Dean,
College of Veterinary Medicine, Michigan State University, East Lansing, Michigan
JOSHUA LEDERBERG,
Raymond and Beverly Sackler Foundation Scholar, The Rockefeller University, New York, New York
JOSEPH MALONE, Director,
Department of Defense Global Emerging Infections System, Walter Reed Army Institute of Research, Silver Spring, Maryland
LYNN MARKS, Global Head of Infectious Diseases,
GlaxoSmithKline, Collegeville, Pennsylvania
STEPHEN MORSE, Director,
Center for Public Health Preparedness, Columbia University, New York, New York
MICHAEL OSTERHOLM, Director,
Center for Infectious Disease Research and Policy and Professor, School of Public Health, University of Minnesota, Minneapolis, Minnesota
GEORGE POSTE, Director,
Arizona BioDesign Institute, Arizona State University, Tempe, Arizona
GARY ROSELLE, Program Director for Infectious Diseases,
VA Central Office, Veterans Health Administration, Department of Veterans Affairs, Washington, DC
JANET SHOEMAKER, Director,
Office of Public Affairs, American Society for Microbiology, Washington, DC
P. FREDERICK SPARLING, J. Herbert Bate Professor Emeritus of Medicine, Microbiology, and Immunology,
University of North Carolina, Chapel Hill, North Carolina
Liaisons
ENRIQUETA BOND, President,
Burroughs Wellcome Fund, Research Triangle Park, North Carolina
EDWARD McSWEEGAN,
National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
Staff
STACEY KNOBLER, Director,
Forum on Microbial Threats
KARL GALLE, Research Associate
KATHERINE OBERHOLTZER, Research Assistant
LAURA SIVITZ, Research Associate
BOARD ON GLOBAL HEALTH
DEAN JAMISON (Chair), Senior Fellow,
Fogarty International Center, National Institutes of Health, Bethesda, Maryland
YVES BERGEVIN, Chief,
Health Section, UNICEF, New York, New York
JO IVEY BOUFFORD, Professor,
Robert F. Wagner Graduate School of Public Service, New York University, New York, New York
RICHARD FEACHEM, Executive Director,
Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
MARGARET HAMBURG, Vice President for Biological Programs,
Nuclear Threat Initiative, Washington, DC
GERALD KEUSCH, Director,
Fogarty International Center, National Institutes of Health, Bethesda, Maryland
JEFFREY KOPLAN, Vice President for Academic Health Affairs,
Emory University, Atlanta, Georgia
ADEL MAHMOUD, President,
Merck Vaccines, Whitehouse Station, New Jersey
MAMPHELA RAMPHELE, Managing Director,
The World Bank, Washington, DC
MARK ROSENBERG, Executive Director,
Task Force for Child Survival and Development, Emory University, Decatur, Georgia
JAIME SEPULVEDA AMOR, Director,
Instituto Nacional de Salud Publica, Cuernavaca, Mexico
DONALD BERWICK (IOM Council Liaison), Clinical Professor of Pediatrics and Health Care Policy,
Harvard Medical School, Boston, Massachusetts
DAVID CHALLONER (IOM Foreign Secretary), Vice President for Health Affairs,
University of Florida, Gainesville
Staff
PATRICK KELLEY, Director
HARRIET BANDA, Senior Project Assistant
ALLISON BERGER, Project Assistant
STACEY KNOBLER, Senior Program Officer
KATHERINE OBERHOLTZER, Research Assistant
LAURA SIVITZ, Research Associate
DIANNE STARE, Research Assistant/Administrative Assistant
Reviewers
All presenters at the workshop have reviewed and approved their respective sections of this report for accuracy. In addition, this workshop summary has been reviewed in draft form by independent reviewers chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the Institute of Medicine (IOM) in making the published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
The Forum and IOM thank the following individuals for their participation in the review process:
Roy M. Anderson, Imperial College London, London, United Kingdom
Ruth L. Berkelman, Emory University, Atlanta, Georgia
David L. Heymann, World Health Organization, Geneva, Switzerland
David Naylor, University of Toronto, Toronto, Ontario
Jeffrey L. Platt, Mayo Clinic, Rochester, Minnesota
Mary Wilson, Harvard University, Boston, Massachusetts
The review of this report was overseen by Enriqueta C. Bond, President, Burroughs Wellcome Fund, Research Triangle Park, North Carolina. Appointed by the National Research Council she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the editors and the institution.
Preface
The Forum on Emerging Infections was created in 1996 in response to a request from the Centers for Disease Control and Prevention and the National Institutes of Health. The goal of the Forum is to provide structured opportunities for representatives from academia, industry, professional and interest groups, and government1 to examine and discuss scientific and policy issues that are of shared interest and that are specifically related to research and prevention, detection, and management of infectious diseases. In accomplishing this task, the Forum provides the opportunity to foster the exchange of information and ideas, identify areas in need of greater attention, clarify policy issues by enhancing knowledge and identifying points of agreement, and inform decision makers about science and policy issues. The Forum seeks to illuminate issues rather than resolve them directly; hence, it does not provide advice or recommendations on any specific policy initiative pending before any agency or organization. Its strengths are the diversity of its membership and the contributions of individual members expressed throughout the activities of the Forum. In September 2003 the Forum changed its name to the Forum on Microbial Threats.
ABOUT THE WORKSHOP
The global response to the recent severe acute respiratory syndrome (SARS) epidemic has demonstrated strengths and weaknesses in national and interna-
tional capacities to address infectious disease challenges. The story of the emergence, spread, and control of SARS illustrates the considerable economic, political, and psychological effects—in addition to the impact on public health—of an unanticipated epidemic in a highly connected and interdependent world. At the same time, the rapid response to SARS reflects significant achievements in science, technology, and international collaboration.
The future is likely to bring far greater challenges. Will SARS reemerge, and with greater virulence? Can we contain a more widely disseminated epidemic? Will we have preventive or therapeutic countermeasures? Can the necessary global cooperation and resources for containment be sustained? If not SARS, are we prepared for the next emerging infection? Are our public health and research investments (human, technical, and financial) flexible enough to respond to the ever-changing profile of microbial threats?
These and other questions were explored during a September 30 and October 1 workshop of the Forum on Microbial Threats. The goals of the workshop were to:
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Discuss the origin, emergence, and spread of SARS and the ensuing global response to the epidemic.
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Evaluate measures employed to contain and control SARS, as well as its clinical management.
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Examine evidence of the economic impact of this and future epidemics.
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Look at the political repercussions of the international effort to address the threat posed by SARS.
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Explore the future of research and technological development related to SARS.
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Consider preparations for the next infectious disease outbreak.
The issues pertaining to these goals were addressed through invited presentations and subsequent discussions, which highlighted ongoing programs and actions taken, and also identified the most vital needs in these areas.
ORGANIZATION OF WORKSHOP SUMMARY
This workshop summary was prepared for the Forum membership in the name of the editors, with the assistance of staff and consultants, as a collection of individually authored papers. The sections of this summary that are not specifically attributed to an individual reflect the views of the editors exclusively—they do not reflect the views of the Institute of Medicine (IOM) or of the organizations that sponsor the Forum on Microbial Threats. The contents of the unattributed sections are based on the presentations and discussions that took place during the workshop.
The SARS workshop functioned as a venue for dialogue among representatives from many sectors about their beliefs on subjects that may merit further
attention. The reader should be aware that the material presented here reflects the views and opinions of those participating in the workshop and not the deliberations of a formally constituted IOM study committee. Moreover, these proceedings summarize only what participants stated in the workshop and are not intended to be an exhaustive exploration of the subject matter.
This summary is organized as a topic-by-topic description of the presentations and discussions from the SARS workshop. The purpose is to present lessons from relevant experience, delineate a range of pivotal issues and their respective problems, and put forth some potential responses as described by the workshop participants. The Summary and Assessment chapter discusses the core messages that emerged from the speakers’ presentations and the ensuing discussions. Chapters 1 through 5 begin with overviews provided by the editors, followed by papers that reflect the contents of invited speaker presentations. The papers in Chapter 1 describe the emergence and detection of the SARS coronavirus and the global response to the epidemic. The papers in Chapter 2 describe the economic fall-out—known and projected—of the SARS epidemic and analyze political and governmental responses to it. Chapter 3 includes papers on the microbiology, ecology, and natural history of coronaviruses, the genus of viruses to which the SARS agent belongs. The articles in Chapter 4 describe the development of diagnostics, therapeutics, and other technologies to control SARS. Finally, the papers in Chapter 5 examine how SARS might reemerge and how the world could prepare for the next major outbreak of infectious disease.
ACKNOWLEDGMENTS
The Forum on Microbial Threats and IOM wish to express their warmest appreciation to the individuals and organizations who gave valuable time to provide information and advice to the Forum through participation in the workshop (see Appendix A for the workshop agenda and Appendix F for a list of forum, speaker, and staff biographies).
The Forum is indebted to the IOM staff who contributed during the course of the workshop and the production of this workshop summary. On behalf of the Forum, we gratefully acknowledge the efforts led by Stacey Knobler, director of the Forum, and Alison Mack, technical consultant, who dedicated much effort and time to developing this workshop’s agenda, and for their thoughtful and insightful approach and skill in translating the workshop proceedings and discussion into this workshop summary. Particular recognition is given to Katherine Oberholtzer whose tireless research efforts and technical editing were essential to the framing of the workshop and its report. Considerable thanks is expressed to Laura Sivitz for her thoughtful guidance in preparing the report for review and her editing of the report. We also express our gratitude to Karl Galle who contributed greatly to the final editing and organization of the chapter overviews and technical papers. Initial drafts of the report benefited greatly from technical re-
views by James Hughes, Michael Osterholm, and David Relman. We would also like to thank the following IOM staff and consultants for their valuable contributions to this activity: Patrick Kelley, Bernadette Pryde Hackley, Marcia Lewis, Amy Giamis, Joe Esparza, Harriet Banda, Dianne Stare, Marjan Najafi, Jennifer Bitticks, Bronwyn Schrecker, Porter Coggeshall, Jennifer Otten, and Sally Stanfield.
Finally, the Forum also thanks sponsors that supported this activity. Financial support for this project was provided by the U.S. Department of Health and Human Services’ National Institutes of Health, Centers for Disease Control and Prevention, and Food and Drug Administration; U.S. Department of Defense; U.S. Department of State; U.S. Department of Veterans Affairs; U.S. Department of Agriculture; American Society for Microbiology; Burroughs Wellcome Fund; Pfizer; GlaxoSmithKline; and the Merck Company Foundation. The views presented in this workshop summary are those of the editors and workshop participants and are not necessarily those of the funding organizations.
Adel Mahmoud, Chair
Stanley Lemon, Vice-Chair
Forum on Microbial Threats
Contents
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The WHO Response to SARS and Preparations for the Future |
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The Centers for Disease Control and Prevention’s Role in International Coordination and Collaboration in Response to the SARS Outbreak |
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Role of China in the Quest to Define and Control SARS |
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SARS: Lessons from Toronto |
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Isolation and Quarantine: Containment Strategies for SARS 2003 |
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Impacts of SARS on Health Care Systems and Strategies for Combating Future Outbreaks of Emerging Infectious Diseases |
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POLITICAL INFLUENCES ON THE RESPONSE TO SARS AND ECONOMIC IMPACTS OF THE DISEASE |
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Estimating the Global Economic Costs of SARS |
SARS: Lessons from a New Disease |
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SARS: Down But Still a Threat |
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APPENDIXES |
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