Emerging Infectious Diseases:

Asian SARS Outbreak Challenged International and National Responses

GAO-04-564: Published: Apr 28, 2004. Publicly Released: Apr 28, 2004.

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Severe acute respiratory syndrome (SARS) emerged in southern China in November 2002 and spread rapidly along international air routes in early 2003. Asian countries had the most cases (7,782) and deaths (729). SARS challenged Asian health care systems, disrupted Asian economies, and tested the effectiveness of the International Health Regulations. GAO was asked to examine the roles of the World Health Organization (WHO), the U.S. government, and Asian governments (China, Hong Kong, and Taiwan) in responding to SARS; the estimated economic impact of SARS in Asia; and efforts to update the International Health Regulations.

WHO implemented extensive actions to respond to SARS, but its response was delayed by an initial lack of cooperation from officials in China and challenged by limited resources for infectious disease control. WHO activated its global infectious disease network and deployed public health specialists to affected areas in Asia to provide technical assistance. WHO also established international teams to identify the cause of SARS and provide guidance for managing the outbreak. WHO's ability to respond to SARS in Asia was limited by its authority under the current International Health Regulations and dependent on cooperation from affected areas. U.S. government agencies played key roles in responding to SARS in Asia and controlling its spread into the United States, but these efforts revealed limitations. The Centers for Disease Control and Prevention supplied public health experts to WHO for deployment to Asia and gave direct assistance to Taiwan. It also tried to contact passengers from flights and ships on which a traveler was diagnosed with SARS after arriving in the United States. However, these efforts were hampered by airline concerns and procedural issues. The State Department helped facilitate the U.S. government's response to SARS but encountered multiple difficulties when it tried to arrange medical evacuations for U.S. citizens infected with SARS overseas. Although the Asian governments we studied initially struggled to recognize the SARS emergency and organize an appropriate response, they ultimately established control. As the governments have acknowledged, their initial response to SARS was hindered by poor communication, ineffective leadership, inadequate disease surveillance systems, and insufficient public health capacity. Improved screening, rapid isolation of suspected cases, enhanced hospital infection control, and quarantine of close contacts ultimately helped end the outbreak. The SARS crisis temporarily dampened consumer confidence in Asia, costing Asian economies $11 billion to $18 billion and resulting in estimated losses of 0.5 percent to 2 percent of total output, according to official and academic estimates. SARS had significant, but temporary, negative impacts on a variety of economic activities, especially travel and tourism. The SARS outbreak added impetus to the revision of the International Health Regulations. WHO and its member states are considering expanding the scope of required disease reporting to include all public health emergencies of international concern and devising a system for better cooperation with WHO and other countries. Some questions are not yet resolved, including WHO's authority to conduct investigations in countries absent their consent, the enforcement mechanism to resolve compliance issues, and how to ensure public health security without unduly interfering with travel and trade.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: On August 26, 2008, HHS/CDC wrote to GAO saying that they are committed to expanding the pool of trained public health experts, have a Cooperative Agreement with WHO aimed at strengthening capacity to detect and respond to emerging infections, and have several programs that expand the available pool of public health experts in other countries in support of GAO's recommendation. These programs include the Global Disease Detection Program (GDD) and the Field Epidemiology and Laboratory Training Programs, which are designed to develop and strengthen public health capacity overseas to rapidly detect and respond to emerging infectious disease threats. Six GDD Centers--located in each of WHO's six regions--are collaborations between the CDC and the host nations, with the involvement of other partners, including WHO. Our report entitled Global Health: U.S. Agencies Support Programs to Build Overseas Capacity for Infectious Disease Surveillance (GAO-07-1186) discusses these programs' obligations, goals, and activities as well as U.S. agencies' monitoring of the progress achieved by these programs.

    Recommendation: To strengthen the international response, the Secretary of Health and Human Services (HHS), in collaboration with the Secretary of State, should work with WHO and official representatives from other WHO member states to strengthen WHO's global infectious disease network capacity to respond to disease outbreaks, for example, by expanding the available pool of public health experts.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: In December 2005, the HHS Inspector General wrote to GAO saying that HHS/CDC had initiated the rulemaking process to address this recommendation. The Notice of Proposed Rule Making was published in the Federal Register on November 30, 2005, for public comment. Since that time, CDC periodically informed GAO of the status of its rulemaking. On July 31, 2008, CDC notified GAO that it is finalizing its rule and planning to issue the final rule by the end of calendar year 2008.

    Recommendation: To help Health and Human Services prevent the introduction, transmission, or spread of infectious diseases into the United States, the Secretary of HHS should complete the necessary steps to ensure that the agency can obtain passenger contact information in a timely and comprehensive manner, including, if necessary, the promulgation of regulations specifically for this purpose.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Not Implemented

    Comments: In 2007, State officials told GAO that they had not been able to secure additional airlift for medical evacuations. Neither the private sector nor the Department of Defense has added additional airlift since the 2002-2003 SARS outbreak underscored the need for increased capacity. According to State officials, there is no expectation that new medical evacuation aircraft will be added in the future. As of August 2008, the relevant contacts at State did not respond to requests for information on actions taken. State's liaison with GAO suggested that the recommendation be closed as "State did not respond."

    Recommendation: To protect U.S. government employees and their families working overseas and to better support other U.S. citizens living or traveling overseas, we recommend that the Secretary of State should continue to work with the Secretaries of Health and Human Services and Defense to identify public and private sector resources for medical evacuations during infectious disease outbreaks and develop procedures for arranging these evacuations. Such efforts could include (1) working with private air ambulance companies and the Department of Defense to determine their capacity for transporting patients with an emerging infectious disease such as SARS, and (2) working to develop agreements under which U.S. medical facilities near international ports of entry will accept medically evacuated patients with infectious diseases such as SARS.

    Agency Affected: Department of State


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