From: Subject: CDC - Emerging Infections: What Have We Learned from SARS? Date: Fri, 9 Jul 2004 22:45:01 +0300 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_0086_01C46606.5EA82010"; type="text/html" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2800.1409 This is a multi-part message in MIME format. ------=_NextPart_000_0086_01C46606.5EA82010 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.cdc.gov/ncidod/EID/vol10no7/04-0166.htm CDC - Emerging Infections: What Have We Learned from = SARS?
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Vol.=20 10, No. 7
July = 2004

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Conference Summary

Emerging = Infections: What=20 Have We Learned from SARS?

Alison P. Galvani*
*University of California, Berkeley, = California, USA

Suggested=20 citation for this article: Galvani AP. = Emerging=20 infections: what have we learned from SARS? [conference summary] = Emerg=20 Infect Dis [serial on the Internet]. 2004 Jul [date cited]. = Available=20 from:=20 = http://www.cdc.gov/ncidod/EID/vol10no7/04-0166.htm

Given the current size and mobility of the human population, = emerging=20 diseases pose a continuing threat to global health. This threat = became=20 reality with the outbreak of severe acute respiratory syndrome = (SARS). The=20 emergence of a disease requires two steps: introduction into the = human=20 population and perpetuated transmission. Although preventing the=20 introduction of a new disease is ideal, containing a zoonosis is a = necessity. The lessons that we have learned from SARS were the = topic of a=20 meeting of The Royal Society on January 13, 2004, in London, = England.

Zoonoses are responsible for most emerging infectious diseases, = including infections caused by Ebola virus, West Nile virus, = monkeypox,=20 hantavirus, HIV, and new subtypes of influenza A. In the case of = SARS=20 coronavirus (SARS-CoV), serologic evidence indicates that the = virus was=20 spread through interspecies transmission from wild game markets in = Guangdong, China (Malik Peiris, University of Hong Kong). This = finding led=20 to bans in the wild meat trade from Nan Shan Zhong (Guangzhou = Respiratory=20 Disease Research Institute) similar to the ban on eating nervous = system=20 tissue from cows that was implemented after new variant = Creutzfeldt-Jakob=20 disease emerged in Britain.

Ecologic changes, concomitant with increasing contact between = humans=20 and animal disease reservoirs, contribute to zoonoses. The = emergence of=20 SARS was facilitated by increased contact between people and = animal=20 disease reservoirs as the wild meat industry expanded recently. = Global=20 warming will likely contribute to the spread of dengue beyond = tropical=20 regions (Tony McMichael, National Centre for Epidemiology and = Population=20 Health, Canberra, Australia). Habitat fragmentation by = deforestation may=20 increase the contact between people and reservoir species. For = example,=20 hemorrhagic fever virus has been linked to deforestation in South=20 America.

Containing an emerging disease depends on rapidly designing and = implementing a control strategy appropriate to the epidemiology of = the=20 disease. Interdisciplinary and international collaboration = occurred with=20 unprecedented rapidity during the SARS outbreak. The network of=20 laboratories in 17 countries organized by the World Health = Organization=20 (WHO) coordinated information sharing (David Heymann, WHO) and was = instrumental in rapidly identifying the etiologic agent of SARS = (1) and = in=20 fulfilling Koch's postulates (2) = (Albert=20 Osterhaus, Erasmus University, Rotterdam).

As is typical of an emerging disease, no vaccines or drugs to = combat=20 SARS existed, making quarantine, patient isolation, travel = restrictions,=20 and contact precautions the only means of limiting transmission.=20 Mathematic models provided a framework for evaluating alternative = control=20 measures and making predictions about the course of the epidemic = (3,4).=20 Previously, similar models had guided public health policy, for = example,=20 in halting an outbreak of hoof and mouth disease in the United = Kingdom in=20 2001 (5,6). = One=20 of the complications in setting parameters in an emerging disease = model is=20 the difficulty in estimating epidemiologic limits from the = initially small=20 sample sizes. Thus, openly sharing data and analysis of key model=20 parameters are vital.

The model must be appropriate to the nature of the disease and = the=20 accuracy of the parameter estimates (7).=20 Stochasticity inherent in transmission dynamics will be = particularly=20 pronounced when infection prevalence is low. Population = heterogeneity and=20 the network structure of human interactions will affect the spread = of an=20 emerging disease. In the 2003 SARS outbreak, healthcare workers = were at=20 particular risk (8) and = acted as bridges carrying the infection from the hospital and = causing=20 community wide epidemics. High-risk "core groups" have been a = major focus=20 of HIV/AIDS models for years (9), = but=20 the movement of SARS patients into the core (i.e., the hospital) = adds a=20 further complication (3).

=

The two waves of SARS clusters in Toronto (Robert Maunder, = Mount Sinai=20 Hospital, Toronto) highlight the need for surveillance even after = an=20 outbreak appears extinguished. Management of the SARS epidemic = also=20 demonstrated that public service infrastructure, which affords the = greatest chance of success (3), is = essential to the rapid containment of an outbreak. In areas most = affected,=20 contact tracing was important (10). = In=20 Guangdong, police departments tracked down contacts of infected = persons,=20 who were then followed up for 10 days after exposure. Evaluating = the surge=20 capacity of public health services and hospitals is one way to = assess the=20 preparedness of a medical system.

The case-fatality rate is a key determinant of the public = health impact=20 of an emerging disease and was high for SARS at approximately 15% = (11). = The=20 relationship between infectiousness and onset of symptoms is also=20 important. Patient isolation has greater potential as a control = strategy=20 if the illness can be diagnosed before the person becomes = infectious (Roy=20 Anderson, Imperial College London). In contrast, persons infected = with=20 influenza virus are highly infectious before they become = symptomatic.

The rapidity of pathogen turnover means that evolution in = pathogen=20 populations can occur on a time scale that is epidemiologically = relevant.=20 Indeed, SARS-CoV evolved during the course of the SARS outbreak in = China=20 (12).=20 Similarly, influenza is perpetuated in the human population by the = evolution of new antigenic variants every year (Robin Bush, = University of=20 California, Irvine) (13). = Even=20 if the transmissibility of an emerging disease is initially below = the=20 threshold necessary to sustain it in a population, the potential = for the=20 organism's evolution to higher levels may exist (14,15)= .=20 Thus, one should not become complacent about diseases that are = repeatedly=20 introduced through zoonosis, but teeter on the edge of = sustainability=20 within the human population.

The success with which WHO coordinated the global collaboration = in=20 containing SARS galvanized the World Health Assembly to grant WHO = greater=20 authority to verify outbreaks, conduct investigations of outbreak=20 severity, and evaluate the adequacy of control measures. The = outcome of=20 this new authority will depend on integrating the expertise of = public=20 health officials, medical doctors, and epidemiologists worldwide = with=20 guidance from disease transmission models. The SARS outbreak = demonstrated=20 that an epidemic in one part of the world is not just an = individual=20 nation's problem but a global problem.

References

  1. Kuiken T, Fouchier RA, Schutten M, = Rimmelzwaan GF, van=20 Amerongen G, van Riel, et al. Newly discovered coronavirus as the primary = cause of=20 severe acute respiratory syndrome. Lancet. = 2003;362:263=9670.=20
  2. Fouchier RA, Kuiken T, Schutten M, van Amerogen G, van = Doornum GJ,=20 van Hoogen BG, et al. Aetiology: Koch's postulates fulfilled for SARS = virus.=20 Nature. 2003;423:240.=20
  3. Lloyd-Smith JO, Galvani AP, Getz WM. Curtailing transmission of severe acute = respiratory=20 syndrome within a community and its hospital. Proc R Soc = Lond B Biol=20 Sci. 2003;270:1979=9689.=20
  4. Riley S, Fraser C, Donnelly CA, Ghani AC, Abu-Raddad LJ, = Hedley AJ,=20 et al. Transmission dynamics of the etiological agent = of severe=20 acute respiratory syndrome (SARS) in Hong Kong: the impact of = public=20 health interventions. Science. 2003;300:1961=966.=20
  5. Ferguson NM, Donnelly CA, Anderson RM. Transmission intensity and impact of control = policies on=20 the foot and mouth epidemic in Great Britain. Nature.=20 2001;413:542=968.=20
  6. Keeling MJ, Woolhouse ME, Shaw DJ, Matthews L, Chase-Topping = M,=20 Haydon DT, et al. Dynamics of the 2001 UK foot and mouth epidemic: = stochastic dispersal in a heterogenous landscape. Science.=20 2001;294:813=967.=20
  7. May RM. Uses and abuses of mathematics in biology. = Science.=20 2004;303:790=963.=20
  8. Lee N, Hui D, Wu A, Chan P, Cameron P, Joynt GM, et al. A major outbreak of severe acute respiratory = syndrome in=20 Hong Kong. N Engl J Med. 2003;348:1986=9694.=20
  9. Anderson RM, May RM. Infectious diseases of humans: dynamics = and=20 control. Oxford: Oxford University Press; 1990.=20
  10. Tsang KW, Ho PL, Ooi GC, Yee WK, Wang T, Chan-Yeung M, et = al.=20  A cluster of cases of severe acute respiratory = syndrome in=20 Hong Kong. N Engl J Med. 2003;348:1977=9685.=20
  11. Galvani AP, Lei X, Jewell NP. Severe acute respiratory syndrome: temporal = stability and=20 geographic variation in case-fatality rates and doubling = times.=20 Emerg Infect Dis. 2003;9:991=964.=20
  12. Chinese SARS Molecular Epidemiology Consortium. Molecular evolution of the SARS coronavirus = during the=20 course of the SARS epidemic in China. Science. = 2004;303:1666=969. Epub=20 2004 Jan 29.=20
  13. Treanor  J.  Influenza vaccine=97outmaneuvering antigenic = shift and=20 drift. N Engl J M. 2004; 350:218=9620.=20
  14. Antia R, Regoes RR, Koella JC, Bergstrom CT. The role of evolution in the emergence of = infectious=20 diseases. Nature. 2003;426:658=9661.=20
  15. May RM, Gupta S, Mclean AR. Infectious disease dynamics: what characterizes = a=20 successful invader? Philos Trans R Soc Lond B Biol Sci.=20 2001;356:901=9610.
   
     
   
Comments to the = Authors

Please use=20 the form below to submit correspondence to the authors = or=20 contact them at the following address:

Alison P.=20 Galvani, Department of Integrative Biology, University = of=20 California, Berkeley, CA 94720-3140, USA. fax: = 410-643-6264;=20 email: agalvani@nature.berkeley.edu=

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