Brief Introduction
SARS (Severe Acute Respiratory Syndrome), an incurable contagious disease, has rampaged all over world recently, with 6,234 cases reported in 27 countries associated with 435 deaths. Overnight SARS has been highlighted in almost all the news media, for it is more than a mere life threat. The economic impact of SARS in affected countries has been devastating despite the relatively small number of cases as compared to cases of influenza worldwide. The key legal and ethical issue is as clear as the danger posed by the disease: Public health outweighs individual rights. Forced isolation and quarantining are fully justified. What should we human do in face of the combat with virus? What does SARS bring to us? Today people are condemning SARS, but ten years from now, after we have readily survived a bio-terrorist attack, some historian may well mutter, "Thank God for SARS!"
CAP[1] Statement before U.S. House of Representatives
Hearing
May 7, 2003
On behalf of the CAP, I appreciate the opportunity to participate in today’s hearing before House of Representatives to assess the emerging threat of Severe Acute Respiratory Syndrome (SARS) and what we can do to improve our ability to contain its spread and safeguard the public.
Assessing SARS as a Public Health Threat
Prior to assessing the impact of a SARS epidemic in the Untied States, it is important to understand why this illness has emerged as such an important global public health threat. In many ways, SARS is no different from any other flu-like illness. SARS shares many of the components of common respiratory illness—it appears to be caused by a virus, it is spread by respiratory droplets and its symptoms can mimic other respiratory infection. Why then have governments, the media and public health officials around the world moved with unprecedented speed to alert the public to the possible threat of SARS? The answer is multi-factorial. SARS appears to be a new virus and no vaccine is available, at this time, to prevent this disease. This leaves the population vulnerable to attack. SARS can spread rapidly and kill. The frequent international travel of the population; crowded living conditions; the ability to be exposed without personal contact (from respiratory droplets or from surface contact); among others all contribute to a formula for worldwide outbreaks. U.S. health officials are investigating 54 probable cases of SARS in this country with another 237 cases under close surveillance. Worldwide, 6,234 cases have been reported in 27 countries associated with 435 deaths. The economic impact of SARS in affected countries has been devastating despite the relative small number of cases as compared to cases of influenza worldwide.
Although it is encouraging to know that SARS cases are declining in some areas, we cannot become complacent. SARS is likely to follow seasonal patterns much like many other respiratory viruses. SARS could become dormant through some seasons only to return in others. That is why this apparent current lull should not be viewed as victory or that our work has been done. To the contrary, we should use this time to marshal[3] our resources and collaborate with other countries to combat this threat and enhance our local communities’ response capabilities. This is an opportunity that should not be squandered.
SARS is one of many new infections that have surfaced in the recent years—West Nile[4], Hantavirus[5], Ebola, AIDS among others. Subsequent to 9/11, we also experienced an unprecedented bioterrorist attack with anthrax. In fact, one of the anthrax attacks occurred here in our nation’s capital. There is no reason to believe that these outbreaks—either through natural occurring agents or the intentional distribution of microbiological agents will not continue. Furthermore, it is important to note that whether the infectious and dangerous agent is the result of mother nature or a terrorist, our health system both public and private must be prepared to respond. And, in many ways, the response needs are the same.
We applaud the Centers for Disease Control and Prevention in recognizing the importance of a responsive and complete public health infrastructure to meet these threats. Much has been done to improve the CDC's communication and coordination with clinical laboratories regarding bioterrorism. However, more needs to be done particularly in regional planning and ensuring a seamless link between the nation’s clinical laboratories, hospitals and public health resources if our nation is to contain this outbreak as well as other microbial threats.
Current State of Diagnostic Testing
Diagnostic tests for SARS are currently under development. The tests can give both false positive and false negative results. A recent Canadian study found that just 40% of likely SARS patients actually tested positive for the virus. At this point, the technology to perform SARS tests is available only at sophisticated public health laboratories. There is a need for readily available diagnostic tests which clinical laboratories can use at the local level. Unfortunately, tests of this nature could be years away. The uncertainty in SARS testing reinforces the important contribution of the clinical laboratories in being able to perform those tests that can clearly identify those individuals with symptoms of SARS who have the common flu or bacterial pneumonia—thereby screening[6] out individuals who are not infected with SARS. This will become extremely important when large numbers of patients with symptoms of fever and cough present for diagnosis during the onset of the next flu season.
Protecting the Clinical Laboratory Workforce
No preparedness and containment strategy can succeed without adequate health care workforce protection. We have all heard the news stories about health care workers who have contracted SARS in the course of caring for patients infected with the disease. An emphasis must be placed on finding the most effective ways to protect health care workers. Failure to do so will not only spread the disease to other hospital patients and the population at large, but will also put at risk the very individuals we will need to rely on if an outbreak occurs.
Laboratory procedures such as centrifuging and opening sample containers may release microbial agents to the air that can spread the disease to workers and patients in the area. The clinical laboratory and local medical provider community will look to the CDC and other government health agencies to provide them with the latest and most scientifically valid knowledge about respirator effectiveness and use, handling precautions and modes of transmission. With hospitals and providers operating on shoestring[7] budgets, this becomes an even more critical issue. Health care infrastructure weaknesses should not be a barrier to our preparedness efforts. As was learned from our fighting troops in Iraq, success in decreasing casualties in a war is dependent on having the very best resources, equipment and training. Nothing less should be available to our nation’s hospital and laboratory workers in their battle against bioagents.
Lessons Learned -- Need for a Strong Public-Private Health Sector Partnership
The SARS experience can teach us many lessons. From my perspective as a pathologist in my local community working with clinicians and public health officials, one of the most important lessons is the need to enhance the vital link between the private and public health sector, particularly at the local level. While it is clearly important to prepare, coordinate and respond globally, we must implement locally to successfully control the outbreak of SARS and other diseases. Actions taken at the federal, state and local levels in collaboration with our private health care system has done much to improve our response capabilities with respect to bioterrorism. We should continue to improve and refine these existing mechanisms for dual use in terms of both biological agents used in a bioterrorist act as well as microbial agents that are naturally occurring.
As a private sector initiative, the CAP has developed a Laboratory Preparedness educational tool designed for laboratories to better identify microbiological agents that could be used in a bioterrorist attack. This program sends surrogate[8] microbial samples to laboratories. These safe samples mimic biological agents and are sent to the laboratory in a blind manner so we can assess the laboratory’s ability to accurately identify select agents of bioterrorism. The program also educates laboratories about how to properly coordinate with the public health infrastructure for referral and reporting activities. There are plans underway to expand this program to ensure that clinical labs are prepared to identify emerging pathogens, including SARS.
As we think about lessons learned from this outbreak, it is comforting to know that progress has been made in terms of public health system procedures for responding to biological threats of any nature, but the system remains fragmented. Every county and state can have different procedures and methods for reporting infectious disease and handling outbreaks. This does not allow for seamless reporting from the clinical laboratories and local health providers and does not allow for integrated electronic surveillance systems. The technology is available to implement interoperability coordination and electronic reporting and its adoption should be accelerated. A March report from the prestigious Institute of Medicine indicates that today's outlook with regard to microbial threats to health is bleak. Microbial threats will present us with new surprises every year. We applaud the continued modernization of the public health system. However, there is a critical need for more coordination at the highest level in order to ensure full implementation at the local level. Our public health system would benefit from an interconnected electronic communication network to monitor for disease outbreaks. The world is interconnected on a daily basis -- our nations clinical and public health resources should be just as interconnected.
The CAP was pleased to assist CDC in providing timely communication to laboratory personnel following the anthrax outbreaks and working to improve the private sector clinical lab connection to the public health networks. We are committed to continued collaboration with the Department of Health and Human Services and other government agencies to respond to public health emergencies and bioterrorism events. We have witnessed the severe economic consequences and panic that has resulted in other countries from SARS outbreaks. We need to be sure our local communities have a coordinated plan to handle their outbreak in the near future. The CAP believes that private sector resources, such as those we offer, can contribute much to the coordination and improvement of our collective efforts in our battle against microbes from all sources.
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