Wednesday, April 23, 2014

China SARS Containment Strategy: Lessons for MERS and Ebola?

Due to its vast industry and population density, China has often been at the forefront of disease containment strategies, from which we in Europe, could benefit. By all accounts the emergence of SARS (Severe Acute Respiratory Syndrome) was something the global health community had not foreseen and was not prepared to counter. China, a country which was ground zero for SARS-CoV is in many ways an ideal case study of how to conduct rapid disease containment particularly, as was the case at the time, when an unknown emerging and highly pathogenic disease struck. While China was heavily criticized at the the time for delays in identification and containment, any nation would have struggled, given the location of the index case and the fact that this was a completely unknown virus at the time. It is easy perhaps to criticize with hindsight the handling of this outbreak, but the Chinese response was highly effective and essential in containing SARS-CoV. Had it not been for their efforts it is highly likely SARS-CoV would have become a pandemic. In contrast to Germany, which has struggled to identify and contain disease in some instances (see: http://www.dw.de/germany-europe-struggle-to-contain-bird-flu/a-1910438), China has a robust response strategy worth reviewing, as we face Ebola in Guinea and Liberia. SARS-CoV is a zoonotic viral resperatory disease. Between November 2002 and July 2003, an outbreak of SARS in southern China resulted in 8,273 reported cases and 775 deaths across several countries. 

In the case of China, both quarantine and isolation were effectively utilized. In Beijing, construction workers built a hospital to isolate up to 1,000 suspected cases and recovering SARS patients.Beijing authorities ordered public entertainment facilities closed to contain the spread. "Several important lessons can be gained from the experience of countries where large-scale quarantine measures were imposed in response to SARS. First, when the public was given a clear message about the need for quarantine, it was well accepted--far better in fact than many public health officials would have anticipated. Indeed voluntary quarantine was effective in the overwhelming majority of cases. As SARS unfolded in China, containment strategies were developed and implemented. Yanzhong Huang writes in a publication entitled "Learning from SARS: Preparing for the Next Disease Outbreak,"  See: http://www.ncbi.nlm.nih.gov/books/NBK92479/


"On April 17, an anti-SARS joint team was created for the city of Beijing, which included leading members from the Ministry of Health and the military (Xinhua News, 2003a). On April 23, a task force known as the SARS Control and Prevention Headquarters of the State Council was established to coordinate national efforts to combat the disease. Vice Premier Wu Yi was appointed as commander-in-chief of the task force, and similar arrangements were made at the provincial, city, and county levels. On May 12, China issued a set of Regulations on Public Health Emergencies. According to these regulations, the State Council shall set up an emergency headquarters to deal with any public health emergencies, which are referred to as serious epidemics, widespread unidentified diseases, mass food and industrial poisoning, and other serious public health threats (Xinhua News, 2003b)." []interactions between the state and society unleashed dynamics that prompted the central party-state to intervene on society’s behalf. The direct involvement of the Party strengthened authority links, increased program resources, and maximized the potential for interdepartmental and intergovernmental cooperation. In this manner, the party-state remains capable of implementing its will throughout the system without serious institutional constraints. The government’s capacity for crisis management has been further enhanced by a series of measures taken in the post-SARS era. http://www.ncbi.nlm.nih.gov/books/NBK92479/ Since the SARS outbreak, China has made significant investment in its public health infrastructure and increased its coordination of public health response. 

EU Response

While China was indeed ground zero for SARS and therefor was determined to mount an aggressive approach with regard to containment, the EU in contrast was rather removed in its initial approach. In May of 2003, the European Health Ministers convened a meeting in Brussels to discuss the threat of SARS. At that moment, France, Britain, Germany, Italy, Ireland, Sweden, Poland and Spain have so far recorded probable or confirmed SARS cases. "A UK Government spokesman said there was no specific new plan on the table.
"The Commission is doing an excellent job in its role monitoring communicable diseases, and so far there are few cases of Sars in Europe. " See: http://news.bbc.co.uk/2/hi/europe/3003345.stm
While the EU may have been prepared certainly to compare measures taken is like comparing apples and oranges. The EU at the time was considering plans for a European centre for disease prevention and control - loosely modelled on a US equivalent. The European Commission has a centre should be established by 2005. ECDC is now established but its function remains limited. 

Conclusion

In terms of emerging, reemerging and unknown pathogens such as Middle East Respiratory Syndrome (MERS) and Ebola, response requires many of the same actions taken by China during the SARS-CoV outbreak. With both MERS and Ebola, the EU has been somewhat distant in its approach to what could become epidemic or pandemic outbreaks of disease. While MERS appears limited to the ME and Ebola has now crossed into Liberia and hit the capital of Guinea, it is time the EU step up its game and consider some of the instrumental actions, taken by China in the initial phase of SARS and not the fog in the boiling pot of water approach. 

Note: As of 24 April, 2014, Saudi Arabia announced 11 new cases of MERS in the capital Riyadh including one in the Holy City of Mecca.  Several new cases have been reported in Jeddah the second largest Saudi city. The latest cases bring the total number of confirmed cases in the Kingdom to 272, of whom 81 have died. MERS emerged in the Middle East in 2012 and is from the same family as SARS virus. "Although the worldwide number of MERS infections is fairly small, the more than 40% death rate among confirmed cases and the spread of the virus beyond the Middle East is keeping scientists and public health officials on alert." See:http://www.foxnews.com/health/2014/04/23/saudi-arabia-reports-11-new-cases-mers-virus-first-in-mecca/?intcmp=obnetwork 

Meanwhile the Ebola outbreak in Guinea and Liberia has now claimed 142 lives of 208 clinical cases reported in Guinea. See:http://www.bloomberg.com/news/2014-04-23/ebola-death-toll-rises-to-142-in-guinea-and-liberia-who-says.html The EU's response to what could become quite a critical health issue since Ebola was identified in the capital is this: "Following the recent outbreak of Ebola in West Africa, the European Commission is giving €500 000 to help contain the spread of the deadly virus in Guinea and neighbouring countries. The Commission has also sent a health expert to Guinea to help assess the situation and liaise with the local authorities.  "We are deeply concerned about the spread of this virulent disease and our support will help ensure immediate health assistance to those affected by it," said Kristalina Georgieva, EU Commissioner for International Cooperation, Humanitarian Aid and Crisis Response. "It's vital that we act swiftly to prevent the outbreak from spreading, particularly to neighbouring countries." Should we see cases in Europe one would hope a rapid protocol would be instituted across the EU to swiftly contain it these public health threats.




For further interest see: 
http://evolution.berkeley.edu/evolibrary/news/060101_batsars
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