Emergencies preparedness, response

The operational response to SARS

16 April 2003

On the ground - and in the air

On 15 March, when WHO issued a rare emergency travel advisory, staff at Geneva headquarters simultaneously set out a plan for combating the SARS threat urgently on four fronts. On the ground, essential supplies, particularly for infection control in hospitals, and teams of specialists would be flown to the most affected countries requesting assistance. In the "air", networks of electronically interconnected experts would be set up to concentrate the world's best intellectual power, collaborating in real time, on three problem areas: the unknown causative agent and absence of diagnostic tests, a puzzling mode of transmission with an alarming concentration of severe cases in hospital staff, and the absence of any knowledge about how to treat what was almost certainly a new disease in humans.

Alert and Response operations

A global alert
The global SARS alert issued by WHO on 12 March was a direct response to a specific threat identified by the WHO Global Alert and Response system. The system continually tracks the development and spread of outbreaks of emerging and epidemic-prone diseases around the world. In recent years, WHO has investigated from 200 to 250 outbreaks each year. On average, from 5 to 15 of these yearly outbreaks require a major international response.

Rapid case identification
Case definitions for SARS were rapidly developed using early information on this new disease provided by national and international teams on the ground. These case definitions allowed the early identification of cases in other countries and have, to a great extent, allowed those countries with imported cases to immediately reduce the risk of local transmission in their own populations.

Global reporting system, rumour management and verification
Specific and detailed measures for the surveillance of cases and contacts of SARS have been developed and disseminated and WHO now receives daily reports on the disease situation in countries having outbreaks. WHO has also requested immediate reporting of cases detected in other all other countries.

WHO is also using other information sources (media, nongovernmental organizations, other UN agencies, and partners in its Global Outbreak Alert and Response Network, or GOARN) to identify areas in which there may be new cases. Once cases are suspected, WHO and its partners immediately and actively follow up with countries to establish whether cases are actually occurring and what measures are being implemented to ensure containment. An epidemiological team systematically analyses data and conducts risk assessment.

The importance of information: constant updates and advice
All verified information is posted on the WHO web site on a daily basis with updated figures, graphs and maps detailing the impact and spread of the SARS outbreak. The SARS operational team is also providing real time 24/24 advice to countries on SARS surveillance, preparedness and response measures. In addition targeted travel advisories have been released in order to protect the health of travellers and decrease the risk of further international spread.

Focusing global resources on SARS control

On the ground - international field support and logistics coordination
The Global Outbreak Alert and Response Network (GOARN) was rapidly mobilized in response to the SARS outbreak. WHO has worked with partners in the Network to support international teams in China, Viet Nam, Singapore and Hong Kong SAR. These teams involve 60 experts representing 20 organizations and 15 nationalities working with national authorities on case management, infection control, surveillance and laboratory/epidemiological investigation. Operational teams in the field are brought together by Tele- or videoconference on a daily basis to review progress, compare experiences, and plan further action.

GOARN is providing an operational platform to mobilize clinicians, data managers, infectious disease experts, epidemiologists, laboratory experts, logistics experts, medical epidemiologists, microbiologists, media experts, pathologists public health specialists and virologists as part of the international effort to address this global public health emergency.

Institutions that have offered assistance and that are participating in these field teams include:

  • the Australian Collaborative Research Centre for Emerging Infectious Diseases;
  • Centers for Disease Control and Prevention (CDC), United States;
  • Centre for Health and Population Research (ICDDRB), Bangladesh;
  • Centre for International Health at Curtin University, Australia;
  • EPICENTRE, the WHO Collaborating Centre for Research in Epidemiology and Control of Emerging Diseases, France;
  • the European Programme for Intervention Epidemiology;
  • Field Epidemiology Training Programmes in Australia and Thailand;
  • the Global Emerging Infections System (GEIS), Health Canada;
  • Health Protection Agency, United Kingdom;
  • Institut National de Veille Sanitaire, France;
  • Institut Pasteur, France and Viet Nam;
  • Kunskapscentrum för Mikrobiologisk Beredskap (KCB), Smittskyddsinstitutet (SMI), Sweden;
  • Leicester Royal Infirmary, North Manchester General Hospital, United Kingdom;
  • Médecins Sans Frontières, (MSF) Belgium;
  • National Institute of Infectious Diseases, Japan;
  • the Robert Koch-Institut, Germany.

WHO logistics bases in Manila, Bangkok and Geneva have been working together with external agencies (MSF, USA, Australia, Japan, France) to ensure the coordinated supply of approved protective and clinical management equipment. This has ensured that the appropriate supplies are reaching countries in a rapid and orderly fashion.

Finding the answers - epidemiological networking
Epidemiologists around the world have come together to look for answers to the spread of the outbreak and to work together to constantly review the control measures that will end the outbreak. The group works using the power of global connectivity allowing each site to collaborate with others in real time and thus reach quick consensus on priorities, methods, and implementation of specialized investigations.

The outbreak has been described in great detail and the major route of transmission has been identified. However, many unanswered questions remain regarding patterns of disease transmission.

The GOARN epidemiology group has designed and is now implementing a number of targeted scientific investigations looking at disease transmission. Membership of the group includes:

  • WHO Geneva, WHO Western Pacific Regional Office and WHO European Regional Office;
  • the Australian Collaborative Research Centre for Emerging Infectious Diseases and the Curtin University Centre for International Health, Australia;
  • Centers for Disease Control and Prevention (CDC), United States;
  • the Field Epidemiology Training Programme, Ministry of Health, Thailand;
  • Health Canada;
  • the Health Protection Agency, United Kingdom;
  • the Institut National de Veille Sanitare, France;
  • the Ministry of Health, People’s Republic of China;
  • the National Institute of Infectious Diseases, Japan;
  • the Robert Koch-Institut, Germany.

The epidemiology group is also working with the WHO multi-centre collaborative networks on SARS aetiology and diagnosis and clinical management through its focal points within WHO. The results of these investigations will drive the development of guidance for disease control.

Finding the answers - clinical networking
Clinicians treating SARS case have also come together in a global collaboration, consists of representatives from 11 countries, to better understand this disease and to find ways of treating the disease effectively. Many treatment options are been actively evaluated by the group in order to rapidly find a cure. The group has also worked tirelessly to improve hospital infection control procedures around the world and provide guidelines for the management of SARS cases and their contacts.

Many front-line health workers have given their lives to help control the outbreak. All health workers need the best advice, training and equipment to ensure that those who are taking the greatest risks receive the highest level of protection.

Collaborating institutions include:

  • Adelaide Meath and National Children’s Hospital, Dublin, Ireland;
  • Bamrasnadura Hospital, Thailand;
  • Centers for Disease Control and Prevention, United States;
  • Department of Health, Hong Kong SAR;
  • French Hospital, Hanoi, Viet Nam;
  • Guangdong Institute of Respiratory Disease, China;
  • Hõpital Universitaire de Genéve, Geneva, Switzerland;
  • Mount Sinai Hospital, Toronto, Canada;
  • National Institute of Health, Slovenia
  • Prince of Wales Hospital, Princess Margaret Hospital, University of Hong Kong, Hong Kong SAR;
  • Royal Free Hospital and North Manchester NHS Trust, United Kingdom;
  • Städt. Krankenhaus Höchst, Frankfurt, Germany;
  • Singapore General Hospital, Singapore;
  • Tourcing Hospital, France.

Finding the answers - laboratory network
Seventeen laboratories from 9 countries have established a unique collaboration with the support of WHO. Laboratory staff have been working around the clock since the recognition of SARS to identify the causative agent. Many hundreds of samples have been tested from SARS patients and controls. A number of candidate viruses have been isolated during the last few weeks and many other pathogens have been removed from suspicion. A new pathogen, a member of the coronavirus family never before seen in humans, has now been identified as the cause of Severe Acute Respiratory Syndrome (SARS).

A number of different tests designed to look for the coronavirus or antibodies to the virus are currently being evaluated. The most appropriate diagnostic tests will then be developed and made widely available in the coming weeks and months. The identification of the causative agent of SARS will then allow the development of potentially effective vaccines.

Membership of the Network includes:

  • Centers for Disease Control and Prevention, United States;
  • Erasmus Universiteit, National Influenza Centre, Rotterdam, The Netherlands;
  • Government Virus Unit, Public Health Laboratory Centre, Kowloon, Hong Kong SAR;
  • Guangdong Center for Disease Control & Prevention, Guangzhou, China;
  • Institut für Medizinische Virologie im Klinikum der Johann Wolfgang Goethe-Universität , Frankfurt, Germany (in collaboration with Institute for TropicalMedicine, Hamburg, Germany and Institute of Virology, Phillips-University, Marburg, Germany);
  • Institut Pasteur, National Influenza Center (Northern-France), Paris, France;
  • National Institute of Infectious Diseases, Tokyo, Japan;
  • National Microbiology Laboratory, Population Pubic Health Branch, Health Canada;
  • Public Health Laboratory Service, Central Public Health Laboratory, London, United Kingdom;
  • University of Hong Kong Faculty of Medicine, Queen Mary Hospital, Hong Kong SAR;
  • Virological Institute, Chinese Center for Disease Control and Prevention, Beijing, China;
  • Virology laboratory, Department of Microbiology.,The Chinese University of Hong Kong;
  • Prince of Wales Hospital, Shatin, Hong Kong SAR;
  • Virology Unit, Singapore General Hospital, Singapore.

Impact and evolution
It cannot be predicted when this outbreak will end but the world is on high alert, is better prepared and is acting in a true global alliance to protect the health of the world's population against a threat of as yet unknown dimensions.