《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2003_Shaping the Future_Chapter5 SARS：lessons from a new disease

Chapter Five SARS lessons from a new disease New diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is cer- tain to continue. The sudden and deadly arrival of SARS on the global health stage early in 2003 was in some ways per- haps the most dramatic of all Its rapid containment is one of the biggest success stories in public health in recent years But how much of that success was a result of good fortune as well as good science? How narrow was the escape from an international health disaster? What tipped the scales? The international response to SARS Will shape future strategies against intectious epidemics

SARS: lessons from a new disease 71 Chapter Five SARS: lessons from a new disease New diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is cer￾tain to continue. The sudden and deadly arrival of SARS on the global health stage early in 2003 was in some ways per￾haps the most dramatic of all. Its rapid containment is one of the biggest success stories in public health in recent years. But how much of that success was a result of good fortune as well as good science? How narrow was the escape from an international health disaster? What tipped the scales? The international response to SARS will shape future strategies against infectious epidemics

SARS essons trom a new disease The day-by-day struggle to control the outbreak of severe acute respiratory syndrome(SARS) represents a major victory for public health collaboration. Key lessons emerge that will be invaluable in shaping the future of infectious disease control- and being ready for the da hen the next new disease arrives without warning. First and most important is the need to report, promptly and openly, cases of any disease with the potential for international spread in a closely interconnected and highly mobile world. Second, timely global alerts can prevent imported cases from igniting big outbreaks in new areas. Third, travel recommendations, including screening measures at airports, help to contain the international spread of an emerg- g infection. Fourth, the worlds best scientists, clinicians and public health experts, aided by electronic communications, can collaborate to generate rapidly the scientific basis for con trol measures. Fifth, weaknesses in health systems play a key role in permitting emerging infections to spread. Sixth, an outbreak can be contained even without a curative drug or a vaccine if existing interventions are tailored to the circumstances and backed by political commitment. Finally, risk communication about new and emerging infectio challenge, and it is vital to ensure that the most accurate information is successfully and unambiguously communicated to the public. WHO is applying these lessons across the Organization as it scales up its response to the HIV/AIDS emergency. The first cases On 12 March 2003, WHO alerted the world to the appearance of a severe respiratory illness of undetermined cause that was rapidly spreading among hospital staff in Hong Kong Spe cial Administrative Region( China) and Viet Nam. Within two days, it was clear that the illness was also spreading internationally along major airline routes when hospitals in Singa pore and Toronto, Canada, reported seeing patients with similar signs and symptoms. The potential for further international spread by air travel was vividly illustrated on 15 March. In the early hours of the morning, the head of WHO's outbreak alert and response operations was woken by a call from health authorities in Singapore. A doctor who had treated the first cases of atypical pneumonia there had reported having similar symptoms shortly before board- ing an international flight returning to Singapore from New York. Asked to intervene, WHO alerted the airline and health authorities in Germany, where the flight was scheduled for stopover. The doctor and his wife disembarked in Frankfurt and were immediately hospital ized in isolation, becoming the first two cases in Europe. Because of these events, WHO sued a second, stronger alert later in the day. It set out a case definition, provided advice to

SARS: lessons from a new disease 73 5 SARS: lessons from a new disease The day-by-day struggle to control the outbreak of severe acute respiratory syndrome (SARS) represents a major victory for public health collaboration. Key lessons emerge that will be invaluable in shaping the future of infectious disease control – and being ready for the day when the next new disease arrives without warning. First and most important is the need to report, promptly and openly, cases of any disease with the potential for international spread in a closely interconnected and highly mobile world. Second, timely global alerts can prevent imported cases from igniting big outbreaks in new areas. Third, travel recommendations, including screening measures at airports, help to contain the international spread of an emerg￾ing infection. Fourth, the world’s best scientists, clinicians and public health experts, aided by electronic communications, can collaborate to generate rapidly the scientific basis for con￾trol measures. Fifth, weaknesses in health systems play a key role in permitting emerging infections to spread. Sixth, an outbreak can be contained even without a curative drug or a vaccine if existing interventions are tailored to the circumstances and backed by political commitment. Finally, risk communication about new and emerging infections is a great challenge, and it is vital to ensure that the most accurate information is successfully and unambiguously communicated to the public. WHO is applying these lessons across the Organization as it scales up its response to the HIV/AIDS emergency. The first cases On 12 March 2003, WHO alerted the world to the appearance of a severe respiratory illness of undetermined cause that was rapidly spreading among hospital staff in Hong Kong Spe￾cial Administrative Region (China) and Viet Nam. Within two days, it was clear that the illness was also spreading internationally along major airline routes when hospitals in Singa￾pore and Toronto, Canada, reported seeing patients with similar signs and symptoms. The potential for further international spread by air travel was vividly illustrated on 15 March. In the early hours of the morning, the head of WHO’s outbreak alert and response operations was woken by a call from health authorities in Singapore. A doctor who had treated the first cases of atypical pneumonia there had reported having similar symptoms shortly before board￾ing an international flight returning to Singapore from New York. Asked to intervene, WHO alerted the airline and health authorities in Germany, where the flight was scheduled for a stopover. The doctor and his wife disembarked in Frankfurt and were immediately hospital￾ized in isolation, becoming the first two cases in Europe. Because of these events, WHO is￾sued a second, stronger alert later in the day. It set out a case definition, provided advice to

The World Health Report 2003 international travellers should they develop similar symptoms, and gave the new disease its name: severe acute respiratory syndrome (SARS). The global outbreak of SarS became the focus of intense international concern, and it remained so for almost four months. Origins and international spread SARS is a newly identified human infection caused by a coronavirus unlike any other known human or animal virus in its family. Analysis of epidemiological information from the vari- ous outbreak sites is still under way, but the overall case fatality ratio, with the fate of most mission occurs E approaches 11%, but with much higher rates among elderly people.Trans- inly from person to person during face-to-face exposure to infected respi- atory droplets expelled during coughing or sneezing, or following contact with body fluids during certain medical interventions. Contamination of the environment, arising from fae cal shedding of the virus, is thought to play a small role in disease transmission, illustrated by the almost simultaneous infection in late March of more than 300 residents of a housing estate in Hong Kong where faulty sewage disposal was identified. At present, the disease has no vaccine, no curative treatment, and no reliable point-of-care diagnostic test, though anti- body tests have been developed that can reliably confirm previous infection using acute and convalescent sera. Management of SARS is supportive, and control strategies rely on stand ard epidemiological interventions: identification of those fitting the case definition, isola tion, infection control, contact tracing, active surveillance of contacts, and evidence-based recommendations for international travellers. Though demanding and socially disruptive, particularly when large numbers of people were placed in quarantine, these standard inter- ventions, supported by high-level political commitment, proved sufficiently powerful to con tain the global outbreak less than four months after the initial alert. The earliest cases of SARS are now thought to have emerged in mid-November 2002 in the southern Chinese province of Guangdong. Retrospective analysis of patient records, to date incomplete, has identified small clusters of cases, each traced to a different initial case, that occurred independently in at least seven municipalities, with the first case recorded on 16 November 2002 in Foshan City and the largest number of cases concentrated in guangzhou City. Analysis has uncovered no links among the various initial cases in the clusters. Some cases with no previous known history of exposure also occurred (1, 2). Early collaborative studies conducted in Guangdong have detected a virus almost identical to the SarS rotavirus in domesticated game animals-the masked palm civet cat and the raccoon dog sold in Guangdong live markets, suggesting that these animals might play a role in trans- mission of the virus to humans The initial phase of the Guangdong outbreak, characterized by small, independent clusters and sporadic cases, was subsequently followed by a sharp rise in cases during the first week of February 2003, thought to result from amplification during care in hospitals. Cases gradually declined thereafter. Altogether, some 1512 clinically confirmed cases occurred in the Guangdong outbreak, with health care workers in urban hospitals accounting for up to 27% of cases(1-3). This pattern -occurrence in urban areas, with most cases concentrated hospitals, and amplification during care- was repeated as the disease began to spread outside Guangdong Province to other areas in China and then internationally The first recorded case of SARS outside China occurred on 21 February 2003, when a medical doctor who had treated patients in Guangzhou City and was himself suffering from respira- tory symptoms spent a single night in a hotel in Hong Kong. Through presumed contact, the mechanism of which is not fully understood, he transmitted SARS to at least 16 other guests

74 The World Health Report 2003 international travellers should they develop similar symptoms, and gave the new disease its name: severe acute respiratory syndrome (SARS). The global outbreak of SARS became the focus of intense international concern, and it remained so for almost four months. Origins and international spread SARS is a newly identified human infection caused by a coronavirus unlike any other known human or animal virus in its family. Analysis of epidemiological information from the vari￾ous outbreak sites is still under way, but the overall case fatality ratio, with the fate of most cases now known, approaches 11%, but with much higher rates among elderly people. Trans￾mission occurs mainly from person to person during face-to-face exposure to infected respi￾ratory droplets expelled during coughing or sneezing, or following contact with body fluids during certain medical interventions. Contamination of the environment, arising from fae￾cal shedding of the virus, is thought to play a small role in disease transmission, illustrated by the almost simultaneous infection in late March of more than 300 residents of a housing estate in Hong Kong where faulty sewage disposal was identified. At present, the disease has no vaccine, no curative treatment, and no reliable point-of-care diagnostic test, though anti￾body tests have been developed that can reliably confirm previous infection using acute and convalescent sera. Management of SARS is supportive, and control strategies rely on stand￾ard epidemiological interventions: identification of those fitting the case definition, isola￾tion, infection control, contact tracing, active surveillance of contacts, and evidence-based recommendations for international travellers. Though demanding and socially disruptive, particularly when large numbers of people were placed in quarantine, these standard inter￾ventions, supported by high-level political commitment, proved sufficiently powerful to con￾tain the global outbreak less than four months after the initial alert. The earliest cases of SARS are now thought to have emerged in mid-November 2002 in the southern Chinese province of Guangdong. Retrospective analysis of patient records, to date incomplete, has identified small clusters of cases, each traced to a different initial case, that occurred independently in at least seven municipalities, with the first case recorded on 16 November 2002 in Foshan City and the largest number of cases concentrated in Guangzhou City. Analysis has uncovered no links among the various initial cases in the clusters. Some cases with no previous known history of exposure also occurred (1, 2). Early collaborative studies conducted in Guangdong have detected a virus almost identical to the SARS coronavirus in domesticated game animals – the masked palm civet cat and the raccoon dog – sold in Guangdong live markets, suggesting that these animals might play a role in trans￾mission of the virus to humans. The initial phase of the Guangdong outbreak, characterized by small, independent clusters and sporadic cases, was subsequently followed by a sharp rise in cases during the first week of February 2003, thought to result from amplification during care in hospitals. Cases gradually declined thereafter. Altogether, some 1512 clinically confirmed cases occurred in the Guangdong outbreak, with health care workers in urban hospitals accounting for up to 27% of cases (1–3). This pattern – occurrence in urban areas, with most cases concentrated in hospitals, and amplification during care – was repeated as the disease began to spread outside Guangdong Province to other areas in China and then internationally. The first recorded case of SARS outside China occurred on 21 February 2003, when a medical doctor who had treated patients in Guangzhou City and was himself suffering from respira￾tory symptoms spent a single night in a hotel in Hong Kong. Through presumed contact, the mechanism of which is not fully understood, he transmitted SARS to at least 16 other guests

SARS: lessons from a new disease and visitors, all linked to the same hotel floor. They carried the virus with them as they en- tered local hospitals or travelled on to Singapore, Toronto and viet Nam. An international outbreak that eventually spread to 30 countries had thus been seeded. Figure 5.1 maps th distribution of 8422 cases and 916 deaths that had occurred by 7 August 2003 Detection and response On 15 March 2003, when the second alert was made, the cause of Sars had not yet been identified Cases were concentrated in hospital workers and did not respond to medicines known to be effective against a number of different lung infections. Many patients were rap- idly progressing to severe pneumonia. The situation was alarming: no patients, including roung and previously healthy health workers, had recovered. Many of the patients were in a critical condition, several required mechanical ventilatory support, and two had died. The spread to major cities around the world meant that any city with an international airport was at potential risk of imported cases From the outset, WHO's objective was clear: to halt fur- ther international spread and interrupt human-to-human transmission through a global con tainment effort, and by so doing to minimize opportunities for the disease to establish endemicity(see Box 5.1) The global response to SARS was in reality the roll out of a way of detecting and responding to outbreaks that had been developed over the preceding seven years by WHO and its part ners, partly as a result of major weaknesses that came to light during the 1995 Ebola outbreak in the Democratic Republic of the Congo and during previous outbreaks of plague in India and cholera in Latin America. The SARS response depended on collaboration of the worlds top public health and laboratory experts, and took advantage of up-to-date communication technologies, including the Internet and video and telephone conferencing Figure 5.1 Probable cases of SARS worldwide, 7 August 2003 Russian Federation (1 USA (3) 水 China (5327 China, Hong Kong SAR (1755) Viet Nam( 63) Thailand⑨9) australia aFRica(1)

SARS: lessons from a new disease 75 and visitors, all linked to the same hotel floor. They carried the virus with them as they en￾tered local hospitals or travelled on to Singapore, Toronto and Viet Nam. An international outbreak that eventually spread to 30 countries had thus been seeded. Figure 5.1 maps the distribution of 8422 cases and 916 deaths that had occurred by 7 August 2003. Detection and response On 15 March 2003, when the second alert was made, the cause of SARS had not yet been identified. Cases were concentrated in hospital workers and did not respond to medicines known to be effective against a number of different lung infections. Many patients were rap￾idly progressing to severe pneumonia. The situation was alarming: no patients, including young and previously healthy health workers, had recovered. Many of the patients were in a critical condition, several required mechanical ventilatory support, and two had died. The spread to major cities around the world meant that any city with an international airport was at potential risk of imported cases. From the outset, WHO’s objective was clear: to halt fur￾ther international spread and interrupt human-to-human transmission through a global con￾tainment effort, and by so doing to minimize opportunities for the disease to establish endemicity (see Box 5.1). The global response to SARS was in reality the roll out of a way of detecting and responding to outbreaks that had been developed over the preceding seven years by WHO and its part￾ners, partly as a result of major weaknesses that came to light during the 1995 Ebola outbreak in the Democratic Republic of the Congo and during previous outbreaks of plague in India and cholera in Latin America. The SARS response depended on collaboration of the world’s top public health and laboratory experts, and took advantage of up-to-date communication technologies, including the Internet and video and telephone conferencing. Outbreaks Imported cases Canada (251) USA (33) Colombia (1) Brazil (1) South Africa (1) India (3) Kuwait (1) Europe: 11 countries (33) Russian Federation (1) Mongolia (9) China (5327) Viet Nam (63) Singapore (238) New Zealand (1) China, Macao SAR (1) Taiwan, China (665) China, Hong Kong SAR (1755) Indonesia (2) Australia (6) Republic of Korea (3) Malaysia (5) Philippines (14) Thailand (9) Figure 5.1 Probable cases of SARS worldwide, 7 August 2003

76 The World Health Report 2003 Two principal partners of the WHO Global Outbreak Alert and Response Network(GOARN) an electronically interconnected network of experts and institutes formally set up in early 2000 contributed to the detection of the sars outbreak. One was the Canadian global pub lic Health Intelligence Network(GPHIN), a worldwide web-crawling computer applicatio used by WHO since 1997, that systematically searches for keywords in seven different lan guages to identify reports of what could be disease outbreaks. Throughout the outbreak, GPHiN provided the raw intelligence that helped WHO maintain up-to-date and high-qual ity information on indications that the disease might be spreading to new areas. The second partner was the WHO Influenza Laboratory Network of 110 laboratories in 84 countries that constantly keeps the world in general and vaccine manufacturers in particular informed of which strains of influenza are circulating, so that an effective influenza vaccine can be pro- duced each year. On 10 February 2003, GPHIN and other partners of GOARN identified reports of an out break associated with health worker mortality and the closing of hospitals in Guangdong One day later the Chinese government officially reported to WHO an outbreak of respiratory illness, beginning in mid-November, involving 300 cases and five deaths in Guangdong Prov- ince. Just over a week later, on 19 February, an outbreak of avian influenza was reported to the WHO Influenza Laboratory Network by the collaborating laboratory in Hong Kong. This outbreak first came to light when a 33-year-old man died of an unknown cause after return ng from a family trip to Fujian Province, China. His 8-year-old daughter had died of a simi- lar disease while in Fujian Province and his 9-year-old son was hospitalized in Hong Kong with the same symptoms. It was from this son that avian influenza virus was isolated and reported to the Influenza Laboratory Network. The same influenza virus had been identified in Hong Kong in 1997. Control efforts at that time required the slaughter and incineration of all chickens in the many live markets there; human-to-human transmission was never established Box 5.1 The response to SARS in the Western Pacific Region More than 95% of SARS cases occurred in the Western Pacific Region. supported by a USS 3 million grant from the Govemment of Japan As an immediate response, a SARS outbreak response and prepared Countries were classified according to three levels of risk and three ness team- including international experts- was established in the levels of capability to respond to SARS cases, in order for WHO to prioritize Regional Office. The main objectives were to its support to countries. WHO worked closely with countries to ensure contain and control the outbreaks. that enhanced surveillance was put in place to enable early detection of support the health care infrastructure in affected countries cases and contact tracing Guidelines were drawn up on enhanced sur- provide guidance and assistance to enable vulnerable countries to veillance, hospital and community infection control, international travel, prepare for the possible arrival of the virus; laboratory procedures and public awareness. To improve public aware. provide the most up-to-date information to health officials and ness, close contact was established with national media focal points respond to public concerns and the web site of the Western Pacific Regional Office was regularly Teams of epidemiologists and infection control exper A regional laboratory network was established to ensure that diately sent to China, including Hong Kong Special Administrative necessary testing for SARS could be done for countries with limited labo- Region, as well as to the Philippines, Singapore and Viet Nam and across ratory capacities. National and regional reference laboratories were iden- the southern Pacific, training health care workers in infection control tified and shipping of specimens was arranged between the laboratories. procedures and preparing them for the possible arrival of the disease. WHO's efforts were paralleled by the contribution of Member States. Practical infection control and preparedness guidelines and training tools Viet Nam was the first to interrupt local transmission of the virus. Other were developed, and the first version of preparedness guidelines was countries introduced a wide range of measures, including isolation, home issued at the beginning of April. Logistic support and supplies(personal quarantine and comprehensive contact tracing. The willingness of gov protective equipment, including masks, collection materials for blood ermments in the Western Pacific Region to put public health considera- and respiratory samples, and internationally approved containers for ship. tions ahead of economic concerns about the impact of SARS was crucial ment of samples) were sent to both affected and unaffected countries, to the success of the collaborative effort

76 The World Health Report 2003 Two principal partners of the WHO Global Outbreak Alert and Response Network (GOARN), an electronically interconnected network of experts and institutes formally set up in early 2000, contributed to the detection of the SARS outbreak. One was the Canadian Global Pub￾lic Health Intelligence Network (GPHIN), a worldwide web-crawling computer application, used by WHO since 1997, that systematically searches for keywords in seven different lan￾guages to identify reports of what could be disease outbreaks. Throughout the outbreak, GPHIN provided the raw intelligence that helped WHO maintain up-to-date and high-qual￾ity information on indications that the disease might be spreading to new areas. The second partner was the WHO Influenza Laboratory Network of 110 laboratories in 84 countries that constantly keeps the world in general and vaccine manufacturers in particular informed of which strains of influenza are circulating, so that an effective influenza vaccine can be pro￾duced each year. On 10 February 2003, GPHIN and other partners of GOARN identified reports of an out￾break associated with health worker mortality and the closing of hospitals in Guangdong. One day later the Chinese government officially reported to WHO an outbreak of respiratory illness, beginning in mid-November, involving 300 cases and five deaths in Guangdong Prov￾ince. Just over a week later, on 19 February, an outbreak of avian influenza was reported to the WHO Influenza Laboratory Network by the collaborating laboratory in Hong Kong. This outbreak first came to light when a 33-year-old man died of an unknown cause after return￾ing from a family trip to Fujian Province, China. His 8-year-old daughter had died of a simi￾lar disease while in Fujian Province and his 9-year-old son was hospitalized in Hong Kong with the same symptoms. It was from this son that avian influenza virus was isolated and reported to the Influenza Laboratory Network. The same influenza virus had been identified in Hong Kong in 1997. Control efforts at that time required the slaughter and incineration of all chickens in the many live markets there; human-to-human transmission was never established. Box 5.1 The response to SARS in the Western Pacific Region More than 95% of SARS cases occurred in the Western Pacific Region. As an immediate response, a SARS outbreak response and prepared￾ness team – including international experts – was established in the Regional Office. The main objectives were to: • contain and control the outbreaks; • support the health care infrastructure in affected countries; • provide guidance and assistance to enable vulnerable countries to prepare for the possible arrival of the virus; • provide the most up-to-date information to health officials and respond to public concerns. Teams of epidemiologists and infection control experts were im￾mediately sent to China, including Hong Kong Special Administrative Region, as well as to the Philippines, Singapore and Viet Nam and across the southern Pacific, training health care workers in infection control procedures and preparing them for the possible arrival of the disease. Practical infection control and preparedness guidelines and training tools were developed, and the first version of preparedness guidelines was issued at the beginning of April. Logistic support and supplies (personal protective equipment, including masks, collection materials for blood and respiratory samples, and internationally approved containers for ship￾ment of samples) were sent to both affected and unaffected countries, supported by a US$ 3 million grant from the Government of Japan. Countries were classified according to three levels of risk and three levels of capability to respond to SARS cases, in order for WHO to prioritize its support to countries. WHO worked closely with countries to ensure that enhanced surveillance was put in place to enable early detection of cases and contact tracing. Guidelines were drawn up on enhanced sur￾veillance, hospital and community infection control, international travel, laboratory procedures and public awareness. To improve public aware￾ness, close contact was established with national media focal points, and the web site of the Western Pacific Regional Office was regularly updated. A regional laboratory network was established to ensure that necessary testing for SARS could be done for countries with limited labo￾ratory capacities. National and regional reference laboratories were iden￾tified and shipping of specimens was arranged between the laboratories. WHO’s efforts were paralleled by the contribution of Member States. Viet Nam was the first to interrupt local transmission of the virus. Other countries introduced a wide range of measures, including isolation, home quarantine and comprehensive contact tracing. The willingness of gov￾ernments in the Western Pacific Region to put public health considera￾tions ahead of economic concerns about the impact of SARS was crucial to the success of the collaborative effort