Infectious Disease – SARS:What have we learned?

David Butler-Jones MD MHSc CCFP FRCPC FACPM

TorontoMarch 4, 2005

Big Risks?

Bright Future?

Something’s Gonna Getcha

David Butler-Jones MD MHSc CCFP FRCPC FACPM

Chief Public Health Officer for Canada

Or Maybe Not

SARS Corona Virus

Outline

1. Infectious disease in context

2. SARS in retrospect

3. What we learned

4. What went right?

Outline (cont’d)

5. Preparing for the next pandemic

6. Actions taken

7. Where the Agency fits in

8. Closing thoughts

9. Q & A

“One Half of children die before their 8th year. This is nature’s law. Why try to contradict it?”

Rousseau

1. Infectious disease in context

• Plague wiped out 1 in 3 in Europe

• 90-95% of population of Americas lost within two centuries of Columbus’ arrival

• Typhus Napolean and Russia

• GC/syphilis Allied casualties in Italy

• Malaria & Vietnam

Context (cont’d)

• Infection/malnutrition kills 40,000 children/day

• Children’s deaths in Afghanistan 100X risk of Western forces

• 1 Million deaths from malaria/year

Context (cont’d)Population health

Prerequisites• Peace• Shelter• Education• Food• Income• Stable ecosystem• Sustainable resources• Social justice & equity

Determinants• Child development• Working conditions• Education• Choices & coping• Income & social status• Physical environments• Health services• Social support network

Context (cont’d)

Health & Global Change

• Urbanization

• Climate change

• Globalization

• Economic gaps

• Technology

• Social change

Context (cont’d)

Health & Global Change

But…• The basics still matter!!!

The Fog of SARS

2. SARS in retrospect• 27 November Guangdong Province, China:

• 11 February Guangdong Province, China:

• 14 February Guandong Province, China:

• 18 February Hong Kong:

• 13 March Singapore

• 15 March

Hanoi 43 Hong Kong >100 Singapore 16 Canada 7

Chain of transmission among guests at Hotel M (Hong Kong, 2003)

Source: MMWR Weekly, March 28, 2003 / 52 (12); 241-248 (found on CDC webs20ite at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5212a1.htm)

SARS in retrospect (cont’d)

Epidemiology

• Incubation period – 2-10 days

• Prodromal illness:

• Lower respiratory phase

• Transmission from an asymptomatic person is very unlikely

SARS in retrospect (cont’d)

Transmission

• “Close contact” with symptomatic person

• Most ill = most communicable

• Maximum infectivity around day 14

• Medical procedures that are likely to generate respiratory aerosols are high risk

SARS in retrospect (cont’d)

Case Fatality (Canada)

• 43 deaths

• Median age 75 years (range 39-99 years)

• Health workers at greatest risk

• Antibiotics/anti-virals not effective.

• Rx-supportive care and steroids (Chinese herbs?)

SARS in retrospect (cont’d)

Ontario & British Columbia

• A tale of 2 outbreaks

• First case in BC

• First case in Ontario

“To Prevent Disease,

to Relieve Suffering, and to Heal the Sick,-This Is Our Work” Sir William Osler

3. What we learned

• Nature inventive & unpredictable – the greatest bioterrorist threat

• Infections have little respect for borders or sensibilities

• Next PH crisis just a plane ride away

• Huge potential economic toll from new infections

What we learned (cont’d)

• Preparation & response not uniform across country

• Confusion & in-fighting compromise responses

• Effective coordination & communication essential

• Clear decision lines matter

What we learned (cont’d)

• Hospitals = magnifiers of risk

• Better coordination between hospital I/C and PH

• Strong PH infrastructure, expertise & surge capacity essential

• Need for new national PH agency

• Political & PH leadership needed

4. What went right?

• Practitioners & public rose to challenge

• Swift collaboration to identify organism & basic epidemiology

• Broad public cooperation

• Fortunately not as infectious as some

What went right? (cont’d)

• Heightened media/public interest in PH

• Silver lining – broad consensus on need for new national agency

CDC

5. Preparing for the next pandemic

Planning, Planning, Planning!

• “Victory awaits him who has everything in order – luck people call it. Defeat is certain for him who has neglected to take the necessary precautions in time – this is called bad luck” – Roald Amundsen

• “Dig a well before you are thirsty” – Chinese proverb

Preparing for the next pandemic (cont’d)

• Not if, but when

• Coordination & preparation across all levels of government (F/P/T/R)

• Table top exercise – Constant Vigil

• Stockpiling of antivirals

Preparing for the next pandemic (cont’d)

• Rebuild capacity (PH & I/C)

• Enhanced surveillance

• Rapid response & surge capacity

• Strengthen communications channels

6. Actions taken

• Real-time alert system

• Hospital-based surveillance network

• Global Public Health Intelligence Network (GPHIN)

• National case definitions

Actions taken (cont’d)

• Standardized lab tests

• Guidelines, protocols & tools

• But, there’s a caveat…and it has a lot to do with communication

7. Where the Agency fits in

• A focal point for Canada’s expertise & research in public health

• Our role is to support, facilitate & coordinate

• Build & expand PH partnerships nationally & internationally

8. Closing thoughts

Closing thoughts (cont’d)

“The Health of The Public is the Foundation Upon Which Rests the Happiness of The People, and the Welfare of The State” – Disraeli

Hang in There-

Spring Has Always Followed Winter (so far)

9. Questions & answers

Infectious Disease – SARS:What have we learned?

David Butler-Jones MD MHSc CCFP FRCPC FACPM

TorontoMarch 4, 2005