A decade after devastating outbreak, is the world better prepared for next SARS?

TORONTO – An unknown bat virus that found a way into human lungs in 2003 served as a global wake-up call to the threat of new infectious diseases. But a decade after SARS crippled health-care systems in affected cities and knocked billions out of the global economy, is the world better prepared to handle similar threats? Is Canada?

In the main, depending on where you live, the answer is likely yes, many experts say — though some are unimpressed by the degree of progress and some worry economic constraints may undermine any improvements that have been made.

And while technological advances are making it easier to track diseases like SARS, there’s no scientific magic bullet to rapidly blunt the assault of future infectious diseases.

“The world’s better prepared to respond, because they’ve had experience in it,” says Dr. David Heymann, head of the Center for Global Health Security at Chatham House (home of the Royal Institute of International Affairs) and a professor of infectious diseases epidemiology at the London School of Hygiene and Tropical Medicine.

“They’re not better prepared with vaccines, because there isn’t a (production) platform that you could easily slip a new antigen into and get a vaccine out of.”

In Ontario, where case tracking and information flow proved to be enormous challenges during the outbreak, a lot of work has been done to ensure the shortcomings identified by the various post-SARS inquiries were addressed, says Dr. Vivek Goel, president and CEO of Public Health Ontario — the provincial public health agency that owes its existence to SARS.

“We don’t have to work with sticky notes on a board. We’ve got information systems. We’ve got very skilled staff who are able to manipulate that data and turn it into reports right away, and get those out in pretty well real-time to our public health partners,” says Goel, a public health physician.

“That kind of capacity … did not exist in Ontario at the time of SARS.”

Information flow proved to be a problem both internationally and nationally. China was slow to fess up to the struggle it was having with a new disease in late 2002 and early 2003. China is not a model of transparency, but some have suggested local and regional authorities may have under-reported the extent of the outbreak out of fear of upsetting central masters.

In the aftermath of SARS, the WHO revised the International Health Regulations, a treaty designed to enhance global health security through outbreak preparedness and transparency. They require countries to report to the WHO outbreaks that might pose a health threat to other countries. But the revised IHR also allow the WHO to use unofficial sources of information — Internet reports, for example — rather than having to rely solely on information provided through official channels.

In Canada, federal health officials had difficulty getting timely information from Ontario officials running the outbreak response in Toronto, the site of the only large SARS outbreak outside of Asia.

Under the rules of the World Health Organization, reporting responsibility in a situation like SARS rests with the national government. Ottawa’s slowness to report new cases undermined Geneva’s trust that Canada had the situation under control, contributing to the global health agency’s decision to urge world travellers to avoid Toronto.

Heymann, who was head of the WHO’s communicable diseases division in 2003, says the countries that had the hardest time controlling SARS were federal states where responsibility for the delivery of health care was controlled by lower levels of government. He says countries have tried to find ways to work around the emergency response weaknesses in federal systems in the time since.

Dr. Frank Plummer, head of Canada’s National Microbiology Laboratory, says a lot of work has been done since 2003 developing and improving systems for information sharing among provinces and territories and between those levels of government and Ottawa.

Plummer, who ran the national lab during the crisis, points to the development of the Canadian Network for Public Health Intelligence, a secure web-based network. The system hosts over 70 software applications used by public health units and professionals across the country to share lab and surveillance data and alert each other of concerns. More than 4,000 people are registered and use has grown substantially since it came online in 2005.

“I think this increases the ability to communicate greatly. And it increases the efficiency as well, because previously it would be done by teleconference. But now people can log on when they need to,” Plummer says.

Dr. Allison McGeer, head of infection control at Toronto’s Mount Sinai Hospital, agrees there are signs of real progress attributable to the desire to learn from SARS. For instance, an international consortium has been set up to help clinical researchers rapidly organize and run clinical trials in during respiratory disease outbreaks. That capacity — to band together to answer key questions like whether drug X helps or whether drug Y harms — did not exist during SARS.

McGeer also points to the fact that pandemic planners at the Public Health Agency of Canada are working with national physician groups trying to develop a system for keeping doctors informed in real time in the event of an infectious disease outbreak. During SARS, there was no real way to push information out to doctors fast, which created serious problems.

“That the feds are even talking about that is in some way revolutionary,” McGeer says.

“I remember at the beginning of SARS the feds talked to the provinces. The provinces talked to their local public health units. The local public health units talked to their clinicians. Those are the rules. That’s how it works.”

“I don’t know about the rest of the federal government. But at least at the Public Health Agency, I think there’s a recognition that there are some pieces of national co-ordination and leadership that even though they don’t belong to the feds in a technical sense need to be done by them.”

But Amir Attaran, who hold a Canada research chair in law, population health and global development policy at the University of Ottawa, says the federal government — particularly the Harper government — has been unwilling to acknowledge that it may have to assume emergency powers in the event of a disease outbreak that crosses provincial boundaries. As a consequence, he says, the systems that would be needed for Ottawa to take a strong role in such an situation are not being developed.

“Just the suggestion that in times of emergency you might need a strong federal power is unwelcome in itself,” he says.

Attaran is also concerned about the financial constraints faced by the WHO. “It’s very problematic that the agency that which we rely on globally is struggling and being distracted by its resource issues rather than having at least this part of its mandate firewalled off from those discussions.”