Pandemic Surprise - The Monster at Our Door: The Global Threat of Avian Flu - page 32

The WHO officially declared the SARS outbreaks contained on 5 July. (A small-scale outbreak at the
end of 2003, quickly controlled by Chinese authorities, reminded the world that SARS will be a recurrent
danger until the prototype vaccine, now being field-tested, becomes widely available.) The first pandem-
ic of the twenty-first century had generated approximately 8,500 cases in 26 countries; nearly 11 percent
of SARS patients (916) died worldwide, although mortality in some localities was closer to 20 percent.
Like influenza, SARS had a very strong preference for the elderly, whose death rate was over 50 percent.
Young adults, in contrast, had only a 7 percent chance of dying, while SARS was seldom life-threatening
to children. 124
The management of the epidemic in Hong Kong and Toronto—each with an identical death rate of
17 percent—was the subject of investigation by expert panels in both cities. A summary of their respect-
ive findings was published in 2004 by the Journal of the American Medical Association ( JAMA ). As the
panel chairs emphasize: “Both areas were hampered by underinvestment in public-health infrastructure,
diminution of public-health leadership, and weak links between health care and public health.” In both
cities, moreover, the health systems were overwhelmed by the epidemic. No one had expected a disease
that targeted hospitals or took such a heavy toll on primary health-care personnel: 22 percent of SARS
cases in Hong Kong, 43 percent in Toronto. Early in the Guangdong outbreak, some 90 percent of cases
were among health-care workers. The Ontario government had to import, more or less clandestinely, sev-
eral hundred U.S. doctors to make up the shortfall caused by ill or frightened physicians. In Hong Kong
the hospital system almost broke down because of the lack of infection control in emergency rooms and
the shortage of isolation units (single, negative-pressure rooms). In any event, JAMA reported, “neither
jurisdiction had enough infection control practitioners and infectious disease specialists.” The distress-
ing spread of SARS among medical personnel, however, was not due to the virus's super-infectivity,
but, rather, to surprisingly widespread failure of hospital staff to adhere to proper protective clothing and
standard hygiene (such as simple hand-washing). In both cities, lines of authority were blurred or contra-
dictory, and general practitioners were often left totally in the dark about diagnostic and therapeutic pro-
cedures. In the end, the nineteenth century, not the twenty-first, defeated SARS: “containment of SARS
relied heavily on application of public health and clinical infection-control measures rooted in nineteenth-
century science.” 125
The laboratory manipulation of SARS also revealed dangerous flaws in the biosecurity of many re-
search institutes and universities working with respiratory viruses. In separate incidents in Singapore and
Taiwan, researchers managed to infect themselves with SARS. Robert Webster cited these cases in a Janu-
ary 2004 Lancet article in which he warned that an influenza pandemic might start with the escape of a
dangerous fossil virus such as H2N2, the 1957 pandemic strain against which no one born since 1968 has
any immunity. He reminded readers that the sudden reappearance of H1N1 in 1977, after a twenty-year
hiatus, was probably the result of a lab accident in Russia or China. 126
The SARS outbreak has also been studied as a real-life test of the preparedness of world organizations,
national governments, and local health systems to respond to an influenza pandemic. “The quick and ef-
fective response of the WHO to SARS,” reported British experts to the Royal Society, “did much to re-
store faith among the many critics of the effectiveness of international agencies with large bureaucracies
and limited resources for action.” But they warned that the successful containment of the SARS pandemic
had sowed the illusion that the “system works,” when, in their view, the system was simply “very lucky.”
The “simple public health measures that worked well for SARS” are “unlikely to be effective” in the case
of an “antigentically novel influenza virus, of both high pathogenicity and transmissibility.” “Sentiments
of the type 'we have been successful once—we will be again' may be far from the truth.” 127
What are the key differences between SARS and influenza? Although SARS produces similar symp-
toms, it is not nearly as “subtle” as influenza. 128 As Peiris and Guan emphasize, “SARS manifested sever-