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Report to the Chairman, Subcommittee on Asia and the Pacific, Committee 
on International Relations, House of Representatives:

April 2004:

EMERGING INFECTIOUS DISEASES:

Asian SARS Outbreak Challenged International and National Responses:

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-564]:

GAO Highlights:

Highlights of GAO-04-564, a report to the Chairman, Subcommittee on 
Asia and the Pacific, Committee on International Relations, House of 
Representatives 

Why GAO Did This Study:

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.

What GAO Found:

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.

What GAO Recommends:

GAO is recommending that the Secretaries of Health and Human Services 
(HHS) and State work with WHO and other member states to strengthen 
WHO’s global infectious disease network. GAO is also recommending that 
the Secretary of HHS complete steps to ensure that the agency can 
obtain passenger contact information in a timely manner, including, if 
necessary, the promulgation of specific regulations; and that the 
Secretary of State work with other relevant agencies to develop 
procedures for arranging medical evacuations during an airborne 
infectious disease outbreak. HHS, State, and WHO generally concurred 
with the report’s content and its recommendations. 

[End of section]

Contents:

Letter: 

Results in Brief: 

Background: 

WHO's Response to SARS Was Extensive, but Was Delayed by an Initial 
Lack of Cooperation from China and Challenged by Limited Resources: 

U.S. Government Had Key Role in Response to SARS, but Efforts Revealed 
Problems in Ability to Respond to Emerging Infectious Diseases: 

After Initial Struggle, Asian Governments Brought SARS Outbreak under 
Control: 

SARS Outbreak Decreased Consumer Confidence and Negatively Affected a 
Number of Asian Economies: 

WHO Members Will Debate Important Issues Raised by International Health 
Regulations' Revision: 

Conclusion: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Scope and Methodology: 

Appendixes:

Appendix I: SARS Cases and Deaths, November 2002-July 2003: 

Appendix II: SARS Chronology: 

Appendix III: Estimates of the Economic Impact of SARS: 

Appendix IV: Comments from the Department of Health and Human Services: 

Appendix V: Comments from the Department of State: 

Appendix VI: Comments from the World Health Organization: 

Appendix VII: GAO Contacts and Staff Acknowledgments: 

GAO Contacts: 

Acknowledgments: 

Tables: 

Table 1: Estimated Economic Cost of SARS in Asia: 

Table 2: Asian Government Stimulus Packages in Response to SARS, 2003: 

Table 3: Models Estimating the Economic Impact of SARS on GDP in Asia, 
2003: 

Figures: 

Figure 1: Timeline of SARS Events and Actions: 

Figure 2: CDC Health Alert Notice: 

Figure 3: Quarterly GDP Growth for Various Asian Economies, 2002-2003: 

Figure 4: Estimated Economic Impacts of SARS on Travel and Tourism: 

Figure 5: Quarterly Retail Sales Growth in Selected Asian Economies, 
2002-2003: 

Abbreviations: 

CDC: Centers for Disease Control and Prevention:

GDP: gross domestic product: 

GOARN: Global Outbreak Alert and Response Network:

GPHIN: Global Public Health Intelligence Network:: 

HHS: Department of Health and Human Services: 

SARS: severe acute respiratory syndrome: 

WHO: World Health Organization:

WPRO: Western Pacific Regional Office:

Letter April 28, 2004:

The Honorable James A. Leach 
Chairman, Subcommittee on Asia and the Pacific 
Committee on International Relations 
House of Representatives:

Dear Mr. Chairman:

Severe acute respiratory syndrome (SARS), the first major new 
infectious disease of the 21st century, emerged in southern China in 
November 2002. SARS is a contagious respiratory disease with a 
substantial mortality rate, and there is no vaccine, no reliable rapid 
diagnostic test, and no specific treatment for the disease. The disease 
spread rapidly along international air routes through Asia, North 
America, and Europe in early 2003, eventually infecting 8,098 people 
and causing 774 deaths.[Footnote 1] Asian countries were the hardest 
hit, with 7,782 cases and 729 deaths. The 2002-2003 SARS outbreak 
presented a challenge to Asian health care systems and disrupted Asian 
economies. The World Health Organization (WHO), the U.S. government, 
and Asian governments all played a role in controlling the SARS 
outbreak in Asia. The history of this effort raises important issues 
regarding international and national preparedness for recognizing and 
responding to emerging infectious diseases such as SARS, including the 
effectiveness of the International Health Regulations, WHO's legal 
framework for preventing the international spread of infectious 
diseases.

In light of these concerns, you asked that we assess the impact of SARS 
on health and commerce in Asia. In this report we examine (1) WHO's 
actions to respond to the SARS outbreak in Asia, (2) the role of the 
U.S. government in responding to SARS in Asia and limiting its spread 
into the United States, (3) how governments in the areas of Asia most 
affected by SARS responded to the outbreak, (4) the estimated economic 
impact of SARS in Asia, and (5) the status of efforts to update the 
International Health Regulations.

The primary focus of our report is on those parts of Asia most severely 
affected by SARS during the 2002-2003 outbreak, including China, Hong 
Kong, and Taiwan. To examine the response to the SARS outbreak by WHO, 
the U.S. government, and Asian governments, we conducted fieldwork in 
Beijing, Hong Kong and Guangdong Province, China; and in Taipei, 
Taiwan, where we met with public health officials, including senior 
Ministry of Health staff, international epidemiologists, and local 
hospital workers. We supplemented our field-level information with 
interviews with WHO and U.S. government officials responsible for 
managing the response to SARS and recognized public health experts; we 
also reviewed relevant documents and reports. To describe the economic 
impact of SARS in Asia, we reviewed official macroeconomic and sector 
data as well as economic impact studies from international financial 
institutions, industry associations, and public policy research 
organizations. We determined that the official national accounts data 
were sufficiently reliable for the purposes of our analysis by 
reviewing supplementary documentary evidence and each economy's 
compliance with data dissemination standards. The scope of our summary 
of economic analyses included other Asian economies strongly impacted 
by the disease: Malaysia, Singapore, Thailand, and Vietnam. Finally, we 
examined a draft of WHO's proposed revision of the International Health 
Regulations and interviewed WHO and U.S. government officials and other 
legal experts to determine the potential impacts of the revised rules. 
See pages 46-48 for a more complete description of our scope and 
methodology. We performed our work from July 2003 to April 2004 in 
accordance with generally accepted government auditing standards.

Results in Brief:

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. At the heart of WHO's response to 
SARS was the activation of its global infectious disease network. This 
effort, combined with assistance from WHO's Asian regional office, 
included deploying public health specialists to affected areas in Asia 
to provide technical assistance and establishing international teams of 
researchers and clinicians who worked together to identify the cause of 
SARS, investigate modes of transmission, and develop guidance for 
managing the outbreak. WHO played a major role in controlling the 
spread of SARS by issuing global alerts and recommending against travel 
to countries with SARS outbreaks. It also issued guidance and 
recommendations to affected areas and the international community on 
surveillance, preparedness, and response. Although the response was 
ultimately successful, WHO's actions were delayed because China did not 
initially provide information about the SARS outbreak or invite WHO to 
assist in investigating and managing the outbreak in a timely manner. 
WHO's ability to respond to SARS in China, and elsewhere, was limited 
by its authority under the current International Health Regulations and 
dependent on cooperation from affected areas. In addition, WHO's 
ability to provide timely and appropriate expertise was challenged by 
the limited resources available to its global infectious disease 
network, which was stretched to capacity during the outbreak.

U.S. government agencies played significant roles in responding to SARS 
in Asia and controlling its spread into the United States, but these 
efforts revealed limitations in their ability to respond to emerging 
infectious diseases. The Department of Health and Human Services' (HHS) 
Centers for Disease Control and Prevention (CDC) was involved in early 
international efforts to identify the disease, provided a significant 
proportion of the public health experts deployed by WHO to Asia, and 
gave direct assistance to Taiwanese health authorities. CDC also helped 
limit the spread of SARS into this country by disseminating information 
to travelers and attempting to identify and contact passengers from 
flights and ships on which travelers were diagnosed with SARS after 
arriving in the United States. However, CDC encountered obstacles that 
made it unable to perform this important outbreak control measure 
because of airline concerns over CDC's authority and the privacy of 
passenger information, as well as procedural issues. CDC is exploring 
options to overcome the problems it encountered, although it has faced 
obstacles in pursuing some of them. The State Department (State) 
applied diplomatic pressure on governments to increase transparency and 
response, helped facilitate the U.S. government response to SARS in 
Asia, and provided information on SARS to U.S. government employees and 
citizens in the region. State also attempted to coordinate medical 
evacuations for a small number of U.S. citizens infected with SARS 
overseas but encountered multiple difficulties. These difficulties have 
not been resolved and could present challenges in the future. Although 
State has not developed a strategy to address these problems, it is 
working with other agencies to develop guidance for arranging medical 
evacuations.

Although the Asian governments we studied initially struggled to 
recognize the SARS emergency and organize an appropriate response, they 
ultimately established control. As Asian government officials 
acknowledged, poor communication, a lack of effective leadership and 
coordination, and weaknesses in disease surveillance systems and public 
health capacity constrained their response. In China, poor 
communication within the country, with Hong Kong and Taiwan, and with 
WHO obscured the severity of the outbreak during its initial stages. 
For example, a detailed report produced by provincial officials 2 weeks 
before China officially announced the SARS outbreak was not shared with 
other governments or WHO. An initial lack of effective leadership and 
coordination within the governments of China, Hong Kong, and Taiwan 
hindered the implementation of a large-scale control effort and led to 
the dismissal of high-ranking officials. As the outbreak progressed, 
problems with disease surveillance systems and overall public health 
capacity further delayed control of the outbreak in many of the 
affected areas. For example, officials in China noted that a large 
number of cases in Beijing were not reported because there was no 
system to collect this information from hospitals in the city. In 
Taiwan, officials acknowledged that a lack of expertise in hospital 
infection control contributed to a secondary, and more severe, outbreak 
in hospitals throughout the island. However, improved screening, rapid 
isolation of suspected cases, enhanced hospital infection control, and 
quarantine of close contacts ultimately helped end the outbreak in 
Asia. In the aftermath of SARS, efforts are under way to improve public 
health capacity in Asia to better deal with SARS and other infectious 
disease outbreaks.

The SARS crisis temporarily dampened consumer confidence, costing 
selected Asian economies around $11 billion to $18 billion and 
resulting in an estimated loss of 0.5 percent to 2 percent of their 
total economic output, according to official and academic estimates. 
Though sectors most affected by SARS have now recovered, the outbreak 
had a significant negative impact on a variety of economic activities. 
The most severe economic impacts occurred in the travel and tourism 
industry, particularly the airline industry. Anecdotal evidence 
suggests that retail sales, and to a lesser degree some foreign trade 
and investment, also temporarily declined as a result of SARS. In 
response to the outbreak, governments in Asia provided economic 
stimulus packages that also cost billions.

The SARS outbreak added impetus to efforts to revise WHO's 
International Health Regulations, and an interim draft of revised 
regulations is currently being circulated. Recognizing that emerging 
and re-emerging diseases have made the regulations obsolete, WHO and 
its member states are considering (1) expanding the scope of reporting 
beyond the three diseases that are currently required to be reported 
(cholera, plague, and yellow fever) to include all potential public 
health emergencies of international concern and (2) devising a system 
for better member state dialogue and cooperation with WHO and other 
countries. However, important questions about the proposed regulations' 
scope of coverage, WHO's authority to conduct investigations in 
countries absent their specific consent, the limited public health 
capacity of developing countries, the enforcement mechanism used to 
resolve compliance issues, and how to ensure public health security 
without unnecessary interference with travel and trade will have to be 
resolved in the debate leading to the adoption of the final 
regulations.

We are recommending that the Secretary of Health and Human Services, in 
collaboration with the Secretary of State, work with WHO and official 
representatives from other WHO member states to strengthen the response 
capacity of WHO's global infectious disease network. In light of the 
unresolved problems of identifying and contacting travelers arriving in 
the United States who may have been exposed to an infectious disease, 
and evacuating U.S. government employees overseas who have an airborne 
infectious disease, we are making two additional recommendations. 
First, we are recommending that the Secretary of Health and Human 
Services complete steps to ensure that the agency can obtain passenger 
contact information in a timely manner, including, if necessary, the 
promulgation of regulations specifically for this purpose. Second, we 
are recommending that the Secretary of State work with other relevant 
agencies to identify public and private sector resources and develop 
procedures for arranging medical evacuations during an airborne 
infectious disease outbreak in foreign countries.

In providing written comments on a draft of this report, HHS, State, 
and WHO generally concurred with the report's content and its 
recommendations (see apps. IV, V, and VI for a reprint of their 
comments). They also provided technical and clarifying comments that we 
have incorporated where appropriate. HHS and State commented that the 
report provided a good summary of the SARS outbreak and the impact upon 
and actions taken by affected countries, WHO, and the U.S. government. 
They endorsed GAO's recommendations but noted that sensitive legal and 
privacy issues and diplomatic concerns must be carefully addressed in 
regard to contact tracing of passengers who may have been exposed to an 
infectious disease. WHO commented that the report provides a factual 
analysis of the events surrounding the emergence of SARS and the major 
weaknesses in national and international control efforts. WHO also 
commented that Asian governments should be better credited for the 
depth and intensity of their response effort, but we believe the report 
presents a balanced view. WHO also provided clarifying language on the 
role of its global response network, which we have incorporated.

Background:

SARS is a severe viral infection that is sometimes fatal. The disease 
first emerged in China in 2002 and then spread through Asia to 26 
countries around the world. Although national governments are 
responsible for responding to infectious disease outbreaks such as 
SARS, WHO plays an important role in coordinating the response to the 
global spread of infectious diseases and assisting countries with their 
public health response to outbreaks. The U.S. government plays a role 
during international outbreaks in assisting WHO and affected countries 
and protecting U.S. citizens and interests at home and abroad.

Characteristics of SARS:

The virus that causes SARS is a member of a family of viruses known as 
coronaviruses, which are thought to cause about 10 percent to 15 
percent of common colds.[Footnote 2] Within 2 to 10 days after 
infection with the SARS virus, an individual may begin to develop 
symptoms--including cough, fever, and body aches--that are difficult to 
distinguish from those of other respiratory illnesses. The primary mode 
of transmission appears to be direct or indirect contact with 
respiratory secretions or contaminated objects. Another feature of the 
disease is the occurrence of "superspreading events," where evidence 
suggests that the disease is transmitted at a high rate due to a 
combination of patient, environmental, and other factors. According to 
WHO, the global case fatality rate for SARS is approximately 11 percent 
and may be more than 50 percent for individuals over age 65.

Prevention and Control of SARS:

The management of a SARS outbreak relies on the use of established 
public health measures for the control of infectious diseases--
including case identification and contact tracing, transmission 
control, and exposure management, defined as follows:

* Case identification and contact tracing: defining what symptoms, 
laboratory results, and medical histories constitute a positive case in 
a patient and tracing and tracking individuals who may have been 
exposed to these patients.

* Transmission control: controlling the transmission of disease-
producing microorganisms through use of proper hand hygiene and 
personal protective equipment, such as masks, gowns, and gloves.

* Exposure management: separating infected and noninfected individuals. 
Quarantine is a type of exposure management that refers to the 
separation or restriction of movement of individuals who are not yet 
ill but were exposed to an infectious agent and are potentially 
infectious.

The 2002-2003 SARS Outbreak:

The emergence of SARS in China can be traced to reports of cases of 
atypical pneumonia[Footnote 3] in several cities throughout Guangdong 
Province in November 2002. (See fig. 1 for a timeline of the emergence 
of SARS cases and WHO and U.S. government actions.) Because atypical 
pneumonia is not unusual in this region and the cases did not appear to 
be connected, many of these early cases were not recognized as a new 
disease. However, physicians were alarmed because of the unusual number 
of health care workers who became severely ill after treating patients 
with a diagnosis of atypical pneumonia. The international outbreak 
began in February 2003 when an infected physician who had treated some 
of these patients in China traveled to Hong Kong and stayed at a local 
hotel. Some individuals who visited the hotel acquired the infection 
and subsequently traveled to Vietnam, Singapore, and Toronto and seeded 
secondary outbreaks. Throughout spring 2003, the number of cases 
continued to spread through Asia to 26 countries around the world, and 
at its peak--in early May--hundreds of new SARS cases were reported 
every week. (See app. I for a map of total SARS cases and deaths.) In 
July 2003, WHO announced that the outbreak had been contained. (See 
app. II for a detailed chronology of the SARS outbreak.):

Figure 1: Timeline of SARS Events and Actions:

[See PDF for image] 

[End of figure] 

Global Infectious Disease Control and the Role of the World Health 
Organization:

Although national governments bear primary responsibility for disease 
surveillance and response, WHO, an agency of the United Nations, plays 
a central role in global infectious disease control. WHO provides 
support, information, and recommendations to governments and the 
international community during outbreaks of infectious disease that 
threaten global health or trade. The International Health Regulations 
outline WHO's authority and member states' obligations in preventing 
the global spread of infectious diseases. Adopted in 1951 and last 
modified in 1981, the International Health Regulations are designed to 
ensure maximum security against the international spread of diseases 
with a minimum of interference with world traffic (that is, trade and 
travel). The current regulations require that member states report the 
incidence of three diseases within their borders--cholera, plague, and 
yellow fever--and WHO can investigate an outbreak only after receiving 
the consent of the government involved. Efforts to revise the 
regulations began in 1995, and the revised regulations are scheduled to 
be ready for submission to the World Health Assembly, the governing 
body of WHO, in May 2005.[Footnote 4]

While the International Health Regulations provide the legal framework 
for global infectious disease control, WHO's Global Outbreak Alert and 
Response Network (GOARN), established in April 2000, is the primary 
mechanism by which WHO mobilizes technical resources for the 
investigation of, and response to, disease outbreaks of international 
importance. Because WHO does not have the human and financial resources 
to respond to all disease outbreaks, GOARN relies on the resources of 
its partners, including scientific and public health institutions in 
member states, surveillance and laboratory networks (e.g., WHO's Global 
Influenza Surveillance Network)[Footnote 5], other U.N. organizations, 
the International Committee of the Red Cross, and international 
humanitarian nongovernmental organizations. WHO collects intelligence 
about outbreaks through various sources, including formal reports from 
governments and WHO officials in the field as well as informal reports 
from the media and the Internet.[Footnote 6] When WHO receives a formal 
request for assistance from a national government, it responds 
primarily through GOARN. GOARN's key response objectives are to ensure 
that appropriate technical assistance rapidly reaches affected areas 
during an outbreak and to strengthen public health response capacity 
within countries for future outbreaks. Its response activities may 
include providing technical advice or support (e.g., public health 
experts and laboratory services), logistical aid (e.g., supplies and 
vaccines), and financial assistance (e.g., emergency funds). In 
addition to the support provided through GOARN, technical assistance 
and deployments are also arranged through WHO's regional offices.

U.S. Government Agencies Responsible for Responding to Global 
Infectious Disease Outbreaks:

Two departments of the U.S. government, the Department of Health and 
Human Services (HHS) and State, play major roles in responding to 
infectious disease outbreaks overseas.[Footnote 7] Within HHS, the 
Office of Global Health Affairs and CDC work closely with WHO and 
foreign governments in response efforts.[Footnote 8] CDC also works 
with other federal agencies, state and local health departments, and 
the travel industry to limit the introduction of communicable diseases 
into the United States. State's roles include protecting U.S. 
government employees working overseas and disseminating information 
about situations that may pose a threat to U.S. citizens living and 
traveling abroad. In addition, State may coordinate the provision of 
technical assistance by various U.S. government agencies and use its 
diplomatic contacts to engage foreign governments on policy issues 
related to infectious disease response.

Infectious Disease Control in China, Hong Kong, and Taiwan:

In recent years, Asia has become increasingly vulnerable to emerging 
infectious disease outbreaks, and governments have had to deal with 
diseases such as avian influenza and dengue fever. In China, Hong Kong, 
and Taiwan, such infectious disease outbreaks are managed through the 
public health authorities of these governments:

* China: The Ministry of Health maintains lead authority over health 
policy at the national level, although provincial governments exercise 
significant authority over local health matters. In January 2002, the 
national Center for Disease Control and Prevention was established, 
along with centers at the provincial and local levels, and charged with 
matters ranging from infectious disease control to chronic disease 
management.

* Hong Kong: The Health, Welfare, and Food Bureau has overall policy 
responsibility for health care delivery and other human services in 
Hong Kong. Within the bureau, the Department of Health and its Disease 
Prevention and Control Division, which was established in July 2000, 
are responsible for formulating strategies and implementing measures in 
the surveillance, prevention, and control of communicable diseases. The 
Hospital Authority is responsible for the management of 43 public 
hospitals in Hong Kong.

* Taiwan: The Department of Health is responsible for national health 
matters and for guiding, supervising, and coordinating local health 
bureaus. A division of the department, the Taiwan Center for Disease 
Control, was established in 1999 and consolidated the disease 
prevention work of several national public health agencies involved in 
infectious disease control.

WHO's Response to SARS Was Extensive, but Was Delayed by an Initial 
Lack of Cooperation from China and Challenged by Limited Resources:

WHO's actions to respond to the SARS outbreak were extensive, but its 
response was delayed by an initial lack of cooperation from officials 
in China and challenged by limited resources. WHO's actions included 
direct technical assistance to affected areas and broad international 
actions such as alerting the international community about this serious 
disease and issuing information, guidance, and recommendations to 
government officials, health professionals, the general public, and the 
media. (See fig. 1 for key WHO actions during the SARS outbreak.) 
However, an initial lack of cooperation on the part of China limited 
WHO's access to information about the outbreak, and WHO had to stretch 
its resources for infectious disease control to capacity.

WHO Provided Direct Assistance to Affected Areas:

WHO's response to SARS was coordinated jointly by WHO headquarters and 
its Western Pacific Regional Office (WPRO). At headquarters, WHO 
activated its GOARN. Although GOARN had been used before to respond to 
isolated outbreaks of Ebola, meningitis, viral hemorrhagic fever, and 
cholera in African countries and elsewhere, the SARS outbreak was the 
first time the network was activated on such a large scale for an 
international outbreak of an unknown emerging infectious disease. There 
were two primary aspects to WHO's activities during the SARS outbreak: 
One was the direct deployment of public health specialists from around 
the world to affected Asian governments to provide technical 
assistance; the other was the formation of three virtual networks of 
laboratory specialists, clinicians, and epidemiologists who pooled 
their knowledge, expertise, and resources to collect and develop the 
information WHO needed to issue its guidance and communications about 
SARS.

Deployment:

Under GOARN's auspices, WHO rapidly deployed 115 specialists from 26 
institutions in 17 countries to provide direct technical assistance to 
SARS-affected areas. WPRO also facilitated the deployment of an 
additional 80 public health specialists to SARS-affected areas. Asian 
governments identified their needs for technical assistance--
consisting primarily of more senior, experienced staff--and then WHO 
issued a request for staff from its partners. WHO officials at 
headquarters and at WPRO worked jointly to quickly process contracts 
and send teams into the field within 48 hours of the request. The work 
of the teams varied, depending on local need. For example, a team of 5 
public health experts sent to China reviewed clinical and epidemiologic 
data to improve the detection and surveillance of SARS cases in 
Guangdong. A team of 4 public health experts sent to Hong Kong included 
environmental engineers to help investigate the spread of SARS in a 
housing complex.

Virtual Networks:

WHO also formed several international networks of researchers and 
clinicians, including a laboratory network, a clinical network, and an 
epidemiologic network. These networks operated "virtually," 
communicating through a secure Web site and teleconferences. The SARS 
laboratory network, based on the model of WHO's global influenza 
surveillance network and using some of the same laboratories, consisted 
of 13 laboratories in 9 countries. Within one month of its creation, 
participants in this network had identified the SARS coronavirus and 
shortly afterward sequenced its genome. The SARS clinical network 
consisted of more than 50 clinicians in 14 countries. Clinicians in 
this network helped to develop the SARS case definition and wrote 
infection control guidelines. The SARS epidemiologic network, which 
consisted of 32 epidemiologists from 11 institutions, collected data 
and conducted studies on the characteristics of SARS, including its 
transmission and control. WHO and other public health experts noted 
that there was a high level of collaboration and cooperation in these 
scientific networks.

WHO Alerted the International Community and Made Important 
Recommendations amid Scientific Uncertainty:

During the SARS outbreak, WHO played a key role in alerting the world 
about the disease and issuing information, guidance, and 
recommendations to government officials, health professionals, the 
general public, and the media that helped raise awareness and control 
the outbreak.

Global Alerts and Travel Recommendations:

When WHO became concerned about outbreaks of atypical pneumonia in 
China, Hong Kong, and Vietnam, it issued a global alert on March 12, 
2003, warning the world about the appearance of a severe respiratory 
illness of undetermined cause that was rapidly spreading among health 
care workers. Three days later, on March 15, WHO issued a second, 
higher-level global alert in which it identified the disease as SARS 
and first published a definition of suspect and probable 
cases.[Footnote 9] At the same time, WHO also issued its first 
emergency travel advisory to international travelers, calling on all 
travelers to be aware of the main symptoms of SARS. When, on March 27, 
it became clear to WHO that 27 cases of SARS were linked to exposure on 
five airline flights, WHO recommended the screening of air passengers 
on flights departing from areas where there was local transmission of 
SARS. On April 2, WHO began issuing travel advisories--recommendations 
that travelers should consider postponing all but essential travel to 
designated areas where the risk of exposure to SARS was considered 
high. The first designated areas were Hong Kong and Guangdong Province, 
China; later, the list was expanded to include other parts of China; 
Toronto; and Taiwan. During the SARS outbreak, WHO also publicized a 
list of areas with recent local transmission of SARS.

Guidelines and Recommendations on the Management of SARS:

In addition to travel recommendations, WHO developed more than 20 other 
guidelines and recommendations for responding to SARS during the 
outbreak. These included advice on the detection and management of 
cases, laboratory diagnosis of SARS, hospital infection control, and 
how to handle mass gatherings of persons arriving from an area of 
recent local transmission of SARS. These guidelines and recommendations 
were disseminated through WHO's SARS Web site, which was updated 
regularly and received 6 million to 10 million hits per day.

WHO Faced Challenges in Issuing Guidance and Recommendations:

In issuing guidance and recommendations about SARS, WHO had to respond 
immediately while making the best use of limited scientific knowledge 
about the disease (e.g., its cause, mode of transmission, and 
treatment), and it had to communicate effectively to public health 
professionals and the general public. This situation posed challenges, 
and WHO's efforts came under some criticism. For example, officials in 
Canada, Taiwan, and Hong Kong--areas that were directly affected by the 
travel recommendations--criticized WHO for not being more transparent 
in the process it used to issue and lift the recommendations. They also 
stated that the evidentiary foundation for issuing the recommendations 
was weak and the process did not allow countries enough time to prepare 
(e.g., to develop press releases and inform the tourism industry). WHO 
officials and others also acknowledged that communicating effectively 
about the risks of transmitting SARS and recommending appropriate 
action were major challenges for the organization. For example, even 
though WHO officials believed that the use of face masks by the general 
public was ineffective in preventing SARS, it had a difficult time 
communicating this fact and educating the general public about 
appropriate preventive measures. In addition, WHO recommended screening 
of airline passengers before departure, but the recommendation was 
vague and allowed countries to execute it in different ways.

Initial Lack of Cooperation from China Limited WHO's Access to 
Information and Delayed Its Response:

Although WHO officials at headquarters and in the field received 
various informal reports of a serious outbreak of atypical pneumonia in 
China's Guangdong Province early in the SARS outbreak, WHO did not 
issue its global alerts until mid-March 2003. This delay occurred both 
because there was scientific uncertainty about the disease and because 
of initial lack of cooperation by China, which limited WHO's access to 
information and its ability to assist in investigating and managing the 
outbreak. As detailed in appendix II, WHO first received informal 
reports about a serious disease outbreak in Guangdong Province in 
November 2002. At the time, influenza was suspected as the primary 
cause of this outbreak. When WHO requested further information from 
Chinese authorities, it was told that influenza activity in China was 
normal and that there were no unusual strains of the virus. Despite 
WHO's repeated requests, Chinese authorities did not grant it 
permission to go to Guangdong Province and investigate the outbreak 
until April 2, 2003.

WHO lacked authority under the International Health Regulations to 
compel China to report the SARS outbreak and to allow WHO to assist in 
investigating and managing it. WHO officials told us that, in general, 
the organization tries to play a neutral, coordinating role and relies 
on government cooperation to investigate problems and ensure that 
appropriate control measures are being implemented. Vietnam, for 
example, cooperated with WHO early in the outbreak, which may have 
contributed to a less severe outbreak in that country. In the case of 
China, WHO exerted some pressure, as did the U.S. government, and the 
international media, which eventually helped persuade China to become 
more open about the situation and to allow WHO to assist in 
investigating and managing the outbreak.

WHO's Response to SARS Was Challenged by Limited Resources:

While extensive, WHO's response to SARS in Asia was challenged by 
limited resources devoted to infectious disease control and in 
particular to GOARN. WHO's ability to respond in a timely and 
appropriate manner to outbreaks such as SARS is dependent upon the 
participation and support of WHO's partners and adequate financial 
support. During the SARS outbreak, GOARN's human resources were 
stretched to capacity. GOARN experienced difficulty in sustaining the 
response to SARS over time and getting the appropriate experts out into 
the field. WHO officials in China told us that they could not obtain 
experienced epidemiologists and hospital infection control experts and 
that ultimately they had to look outside the network to find 
assistance. GOARN was largely dependent on CDC staff to deploy to Asia 
to manage the epidemic response. According to a senior CDC official, if 
the United States had experienced many SARS cases during the global 
outbreak, CDC might not have been able to make as many of these staff 
available. Furthermore, some GOARN partners told us that the staffing 
requests that they received from GOARN, WPRO, and WHO country offices 
were not well coordinated. This issue was raised at a GOARN Steering 
Committee meeting in June 2003, and it was suggested that a stronger 
regional capacity for coordination could help ensure the necessary 
public health experts are mobilized and deployed to the field.

The SARS outbreak also highlighted the limitations in GOARN's financial 
resources. Historically, the network has received limited financial 
support from WHO's core budget, which consists of assessed 
contributions from members. The network tries to make up for shortfalls 
by soliciting additional contributions from member states, foundations, 
and other donors. There are limited resources to pay for headquarters 
staff and technical resources such as computer mapping software and to 
support management initiatives such as strategic planning and 
evaluation activities. While acknowledging that planning and evaluation 
are important both for responding to future outbreaks and for ensuring 
epidemic preparedness and capacity building, WHO officials told us that 
GOARN is usually focused on the response to an immediate emergency and 
thus lacks the time and resources to retrospectively review what worked 
well and what did not.

U.S. Government Had Key Role in Response to SARS, but Efforts Revealed 
Problems in Ability to Respond to Emerging Infectious Diseases:

CDC, as part of HHS, and State played major roles in responding to the 
SARS outbreak, but their actions revealed limits in their ability to 
address emerging infectious diseases. CDC worked with WHO and Asian 
governments to identify and respond to the disease and helped limit its 
spread into the United States. However, CDC encountered obstacles that 
made it unable to trace international travelers because of airline 
concerns over CDC's authority and the privacy of passenger information, 
as well as procedural issues. State applied diplomatic pressure to 
governments, helped facilitate U.S. government efforts to respond to 
SARS in Asia, and supported U.S. government employees and citizens in 
the region. However, State encountered multiple difficulties in helping 
to arrange medical evacuations for U.S. citizens infected with SARS 
overseas. Based in part on this experience, State ultimately authorized 
departure of all nonessential U.S. government employees at several 
Asian posts.

CDC Played Central Role in Fighting SARS in Asia:

Throughout the SARS outbreak, CDC was the foremost participant in WHO's 
multilateral efforts to recognize and respond to SARS in Asia, with CDC 
officials constituting about two-thirds of the 115 public health 
experts deployed to the region under the umbrella of GOARN. CDC also 
contributed its expertise and resources to epidemiological, laboratory, 
and clinical research on SARS. According to CDC, its involvement in 
recognizing the disease began in February 2003, when CDC officials 
joined WHO efforts to identify the cause of atypical pneumonia 
outbreaks in southern China, Vietnam, and Hong Kong. In March 2003, CDC 
set up an emergency operations center to coordinate sharing of 
information with WHO's epidemiology, clinical, and laboratory networks 
(see fig. 1). Under GOARN's auspices, CDC also assigned 
epidemiologists, laboratory scientists, hospital infection control 
specialists, and environmental engineers to provide technical 
assistance in Asia. For example, CDC assigned senior epidemiologists to 
help a WHO team investigate the outbreak in China. The team met with 
public health officials and health care workers in affected provinces 
to determine how they were responding to SARS. It also recommended 
steps to bring the outbreak under control, such as hospital infection 
control measures, quarantine strategies, and free health care for 
individuals with suspected SARS.

In addition, because Taiwan is not a member of WHO, CDC gave direct 
assistance to support Taiwan's response to SARS, serving as a link 
between Taiwanese health authorities and WHO and providing technical 
information and expertise that enabled Taiwan to control the outbreak. 
Shortly after Taiwan identified its first case of SARS imported from 
China in March 2003, Taiwanese authorities asked WHO for assistance. 
WHO officials transmitted the request to CDC and asked it to respond. 
Between March and July 2003, 30 CDC experts traveled to Taiwan and 
advised health authorities on various aspects of the SARS response. CDC 
epidemiologists recommended changes in Taiwan's approach to classifying 
SARS cases, which was time consuming and resulted in a large backlog of 
cases awaiting review as the outbreak expanded. They advised Taiwanese 
health authorities to replace their case classification system with a 
two-tiered approach that would categorize patients with SARS-like 
symptoms as either "suspect" or "probable" SARS. This strategy enabled 
public health authorities to institute precautionary control measures, 
such as isolation, for suspected SARS patients, and according to senior 
CDC and Taiwanese officials, it helped reduce transmission, including 
within medical facilities, and stop the outbreak.

CDC Took Actions to Limit Spread of SARS into the United States:

When WHO issued its global SARS alert on March 12, 2003, CDC officials 
attempted to limit the disease's spread into the United States by (1) 
providing information for people traveling to or from SARS-affected 
areas and (2) ensuring that travelers arriving at U.S. borders with 
SARS-like symptoms received proper medical treatment. Beginning in mid-
March 2003, CDC posted regular SARS updates on its Web site for people 
traveling to SARS-affected countries. At the same time, CDC's Division 
of Global Migration and Quarantine deployed quarantine officers to U.S. 
airports, seaports, and land crossings where travelers entered the 
United States from SARS-affected areas. The officers distributed health 
alert notices to all arriving travelers and crew (see fig. 2).

Figure 2: CDC Health Alert Notice:

[See PDF for image] 

[End of figure] 

The notices, printed in eight languages and describing SARS symptoms, 
incubation period, and what to do if symptoms developed, also contained 
a message to physicians to contact a public health officer or CDC if 
they treated a patient who might have SARS. CDC staff distributed close 
to 3 million health alert notices over a 3-month period. Department of 
Homeland Security staff assisted CDC by passing out the notices at land 
crossings between the United States and Canada. CDC's quarantine 
officers also responded to dozens of reports of passengers with SARS-
like symptoms on airplanes and ships arriving in the United States from 
overseas. The officers boarded the airplane or ship, assessed the ill 
individuals to determine if they might have SARS and, if necessary, 
arranged the individuals' transport to a medical facility.

Regulatory, Privacy, and Procedural Concerns Hampered CDC's Efforts to 
Trace Travelers:

CDC officials wanted to advise passengers who had traveled on an 
airplane or ship with a suspected SARS case to monitor themselves for 
SARS symptoms during the virus's 10-day incubation period, but due to 
airline concerns over authority and privacy, as well as procedural 
constraints, CDC was unable to obtain the passenger contact information 
it needed to trace travelers. Although HHS has statutory authority to 
prevent the introduction, transmission, or spread of communicable 
diseases from foreign countries into the United States,[Footnote 10] 
HHS regulations implementing the statute do not specifically provide 
for HHS to obtain passenger manifests or other passenger contact 
information from airlines and shipping companies for disease outbreak 
control purposes.[Footnote 11] CDC officials told us that some airlines 
failed to provide necessary contact information to CDC, which may be 
attributable to the lack of specific regulations in this area. 
Moreover, CDC officials said that in response to their requests, some 
airlines refused to give CDC passenger contact information from 
frequent flier databases or credit card receipts because of privacy 
concerns.[Footnote 12] Even when CDC was able to obtain passenger 
information, CDC staff responsible for contacting travelers found 
passenger data untimely (because some airlines provided it after SARS's 
10-day incubation period), insufficient (because some airlines could 
provide only passenger names but no contact information), or difficult 
to use (because it was available on paper rather than electronically). 
According to senior CDC officials, the inability to trace travelers who 
might have been exposed to SARS could have hampered their ability to 
limit the disease's spread into the United States.

CDC Exploring Options to Resolve Tracing Problems:

The obstacles to tracing travelers remain unresolved, and senior CDC 
officials are concerned they will encounter difficulties in limiting 
the spread of infectious diseases into the United States during future 
global infectious disease outbreaks.[Footnote 13] CDC officials told us 
they are exploring several options to overcome the problems they 
encountered during the SARS outbreak. CDC may adopt one or more of 
these options,[Footnote 14] including: clarifying CDC's authority by 
promulgating regulations specifically to obtain passenger contact 
information; coordinating with the Department of Homeland Security and 
other federal agencies for this purpose; developing a memorandum of 
understanding with airlines on sharing passenger information; and 
creating a system for obtaining passenger contact information in an 
electronic format. However, CDC officials said they have already faced 
obstacles in pursuing some of these options. For example, both CDC and 
Department of Homeland Security officials told us that Homeland 
Security's computer-based passenger information system could not be 
used for purposes other than national security.

State Applied Diplomatic Pressure, Helped Facilitate Agency Responses, 
and Disseminated Information:

State also played an important role in the U.S. response to SARS, 
primarily by applying diplomatic pressure, helping facilitate 
government efforts overseas, and disseminating information. In March 
2003, the U.S. Ambassador to China communicated with Chinese government 
officials to encourage China to be more transparent in reporting SARS 
cases and to grant WHO and CDC officials access to southern China. 
State also established two working groups to facilitate the U.S. 
government response to SARS in Asia. The first working group, 
comprising various State offices and bureaus, issued daily reports on 
the status of the outbreak to U.S. embassies and consulates. The second 
working group, established in May 2003, convened various U.S. 
government agencies, including State, HHS, and the Departments of 
Defense and Homeland Security, to address policy and response issues. 
U.S. government officials agreed that State's efforts helped provide 
valuable information during an uncertain period and allowed for a 
unified response to the outbreak. U.S. embassies and consulates in Asia 
also disseminated information to U.S. government employees and U.S. 
citizens living and traveling abroad. For example, they publicized CDC 
updates on SARS through e-mail alerts and on their Web sites and 
informed U.S. citizens about medical care available in-country.

State Faced Obstacles Arranging Medical Evacuations for U.S. Citizens 
with Suspected SARS:

During the outbreak, even the strongest local health care systems were 
overwhelmed, and State was concerned that U.S. government employees 
might receive treatment that did not meet U.S. standards. For example, 
in Hong Kong and China, U.S. consular staff told us they were concerned 
about sending U.S. government employees to local hospitals because of 
inadequate infection control practices, limited availability of health 
care workers with English language skills, and controversial treatment 
protocols such as administering steroids to SARS patients.

In a few cases, State worked with private medical evacuation companies 
to help arrange medical evacuations for U.S. citizens with suspected 
SARS.[Footnote 15] However, early in the outbreak, CDC had not yet 
developed guidelines to prevent transmission during flight, and medical 
evacuation companies could not obtain aircraft and crew willing to 
transport SARS patients because of the perceived health risks.[Footnote 
16] Even after CDC developed guidelines, medical evacuation companies 
still had difficulty finding aircraft because only about 5 percent of 
existing air ambulances could comply with the stringent guidelines, 
according to a private air medical evacuation official. Furthermore, a 
U.S. state and some medical facilities in the United States refused to 
accept SARS patients brought from Asia. For example, the state of 
Hawaii initially said it would accept medically evacuated SARS patients 
but later reneged and prevented one air ambulance company from bringing 
a U.S. citizen with suspected SARS to a medical facility in Honolulu. 
Although the Department of Defense (Defense) performed one medical 
evacuation for a U.S. civilian under special circumstances, officials 
at State and Defense told us that military priorities and scarce 
resources are likely to prevent Defense from performing civilian 
evacuations in the future. Ultimately, State concluded that inadequate 
local health care and difficulties arranging medical evacuations put 
U.S. government employees at risk, and, in turn, State authorized 
departure for nonessential employees and their dependents at several 
posts.[Footnote 17]

Medical Evacuation Issues Still Pose Challenges for Future Outbreaks:

State has not developed a strategy to overcome the challenges that 
staff encountered in arranging international medical evacuations during 
the SARS outbreak, but it is working with other U.S. government 
agencies to develop guidance on this issue. Officials at State, CDC, 
Defense, and medical evacuation companies told us that the same 
obstacles could resurface during a new outbreak of SARS or another 
unknown infectious disease with airborne transmission. State officials 
said the medical evacuation companies that provide State's medical 
evacuation services have agreed to evacuate SARS patients, and the 
companies with whom we spoke confirmed that since the SARS outbreak, 
they have identified sufficient aircraft and crew to transport a 
limited number of patients. The exact number would depend on the nature 
of the disease, the patient's condition, and the type of medical care 
required. State officials said they have not investigated how many SARS 
patients private medical evacuation companies or Defense could 
transport; they also do not know which U.S. states and medical 
facilities would accept patients with SARS or another emerging 
infectious disease. State officials are concerned about a scenario in 
which dozens of staff at a U.S. embassy or consulate contract SARS or 
another infectious disease, in which case medical evacuation would 
probably not be feasible given the current constraints. This would also 
pose a problem if many U.S. citizens living or traveling overseas 
contracted such a disease. Private medical evacuation companies 
acknowledged that they might not be able to transport large numbers of 
patients; furthermore, they are unsure which destinations in the United 
States would accept patients with an infectious disease such as SARS. 
State officials said they are working with other U.S. government 
agencies to develop guidelines for consular staff to arrange 
international medical evacuations. However, it is not clear that this 
guidance will resolve some of the obstacles encountered during the SARS 
outbreak. For example, a CDC official said the agency is working with 
medical facilities near international ports of entry to identify 
treatment destinations for medically evacuated patients with 
quarantinable infectious diseases such as SARS, but no agreements have 
been reached yet.

After Initial Struggle, Asian Governments Brought SARS Outbreak under 
Control:

The Asian governments we studied initially struggled to respond to SARS 
but ultimately brought the outbreak under control. As acknowledged by 
Asian government officials, poor communication within China and between 
China and Hong Kong, Taiwan, and WHO obscured the severity of the 
outbreak during its initial stages. As the extent of the outbreak was 
recognized, the large-scale response to SARS in China, Hong Kong, and 
Taiwan was hindered by an initial lack of leadership and coordination. 
Further, weaknesses in disease surveillance systems, public health 
capacity, and hospital infection control limited the ability of Asian 
governments to track the number of cases of SARS and implement an 
effective response. Improved screening, rapid isolation of suspected 
cases, enhanced hospital infection control, and quarantine of close 
contacts ultimately helped end the outbreak. In the aftermath of SARS, 
efforts are under way to improve public health capacity in Asia to 
better deal with SARS and other infectious disease outbreaks.

Poor Communication Limited Information on Severity of SARS Outbreak in 
China:

The Chinese government's poor communication within the country, with 
Hong Kong and Taiwan, and with WHO limited the flow of information 
about the severity of the SARS outbreak in its initial stages. For 
example, the Ministry of Health did not widely circulate a report 
concerning the spread of atypical pneumonia (later determined to be 
SARS) in Guangdong Province. The report was produced by health 
officials in Guangdong Province on January 23, 2003--more than 2 weeks 
before the Ministry of Health's first official public announcement on 
the outbreak.[Footnote 18] The report warned all hospitals in the 
province about the disease and provided advice to control its spread. 
Officials in Hong Kong, which directly borders the province, were not 
aware of the report, and a senior official in Taiwan, which maintains 
significant travel and commercial ties with Guangdong Province, said 
Taiwan did not receive the report or any official communication about 
the outbreak. In addition, WHO did not receive this information. 
Officials in Guangdong Province told us they could not share this 
information outside of China because this is the responsibility of the 
Ministry of Health. Further, according to Chinese regulations on state 
secrets, information on widespread epidemics is considered highly 
classified.[Footnote 19]

Chinese scientists also did not effectively communicate their findings 
about the cause of SARS early in the outbreak because of government 
restrictions. For example, as reported in a scientific journal and 
later confirmed in our own fieldwork, Chinese military researchers 
successfully identified the coronavirus as a potential cause of SARS in 
early March 2003, several weeks before a network of WHO researchers 
proved it was the cause of SARS.[Footnote 20] One Chinese scientist 
directly involved in the effort told us that these researchers were 
instructed to defer to scientists at the Chinese Center for Disease 
Control and Prevention, who announced erroneously that Chlamydia 
pneumoniae, a type of bacteria, was responsible for the atypical 
pneumonia outbreak. In addition, we were told that these researchers 
were not permitted to communicate their findings on the coronavirus 
directly to WHO officials because only the Ministry of Health could 
communicate directly with WHO.

Communication problems persisted as late as April 2003, 5 months after 
the first cases occurred. On April 3, the Minister of Health announced 
that the outbreak was under effective control and that only 12 cases of 
SARS had been reported in Beijing. However, a physician working at a 
military hospital in Beijing wrote a letter to an Asian news magazine 
claiming that there were significantly more SARS cases in military 
hospitals and that hospital officials were told not to disclose 
information about SARS to the public. On April 15, in response to 
rumors of underreporting, WHO officials leading an investigation into 
the outbreak were granted permission to visit military hospitals but 
stated that they were not authorized to report their findings. By April 
20, the Ministry of Health announced the existence of 339 previously 
undisclosed cases of SARS in Beijing.

An Initial Lack of Effective Leadership and Coordination in SARS-
Affected Areas in Asia Hindered Response:

As acknowledged by government officials, a lack of effective leadership 
and coordination within the governments of China, Hong Kong, and Taiwan 
early in the outbreak hindered attempts to organize an effective 
response to SARS. In China, provincial and local authorities maintained 
significant responsibility and autonomy in conducting epidemiological 
investigations of SARS but failed to coordinate with one another and 
national authorities early in the outbreak. However, as SARS spread 
into Beijing, the highest political leaders of the Chinese Communist 
Party, citing an increased number of cases and the impact on travel and 
trade, advised officials to be more forthcoming about SARS cases. The 
Ministry of Health also acknowledged the ministry's failure to 
introduce a unified mechanism for collecting information about the 
outbreak and setting guidance and requirements across the country. Soon 
after those announcements, the Minister of Health and Mayor of Beijing 
were dismissed from their posts for downplaying the extent of the 
outbreak, and the public health response was brought under stronger 
central control. A vice premier of the central government assumed 
control of the Ministry of Health and convened ministerial level 
officers to take the lead in the nationwide SARS control effort.

In Hong Kong, an expert committee convened after the outbreak to 
investigate the government's response questioned the leadership and 
coordination of the public health system.[Footnote 21] For example, the 
committee found that responsibility for managing infectious disease 
outbreaks was spread throughout different departments within the 
Health, Welfare, and Food Bureau, with no single authority designated 
as the central decision-making body during outbreaks. The committee 
also stated that poor coordination between the hospital and public 
health system further complicated the response. For example, the 
Hospital Authority responded to an outbreak within a hospital without 
informing the Department of Health, which learned of the outbreak 
through media reports. Further, the Hospital Authority and Department 
of Health used separate databases during the initial stages of the 
outbreak and could not communicate information on new cases in real 
time.

In Taiwan, a report by WHO stated that the initial response to SARS was 
managed by senior political figures who sometimes did not heed the 
advice of technical experts. Furthermore, WHO noted that the failure to 
follow the advice of public health experts delayed the decision-making 
process and slowed the response to the outbreak in Taiwan. Taiwanese 
government officials noted that the leadership of the public health 
system was weak during the outbreak. In addition, the process they used 
to classify SARS cases was too slow to isolate suspected or probable 
cases. As the outbreak worsened and spread into hospitals throughout 
Taiwan, the Minister of Health and the director of the Taiwan Center 
for Disease Control resigned over criticisms about failing to control 
the spread of SARS.

Weaknesses in Disease Surveillance Systems and Public Health Capacity 
Further Constrained Efforts:

As Asian governments monitored the spread of SARS, weaknesses in 
disease surveillance systems, public health capacity, and hospital 
infection control caused delays and gaps in disease reporting, which 
further constrained the response.

Disease Surveillance Systems:

In China, health officials at the provincial level and WHO advisers 
working in the country noted that data gathering systems established in 
the epicenter of the outbreak in Guangdong Province were strong. 
However, Chinese officials also found that the effectiveness of a 
national disease surveillance system established in 1998 was limited. 
For example, disease prevention staff below the county level did not 
have access to computer terminals to report the number of SARS cases 
and had to relay disease reports to central authorities by fax or mail. 
In addition, the computer-based system did not permit the reporting of 
suspect cases that were not yet confirmed. Further, protocols for 
reporting were time consuming, since information was sent through 
multiple levels of the public health system. For example, during the 
outbreak, reports from doctors of suspect SARS cases could take up to 7 
days to reach local public health authorities. In Beijing, an executive 
vice minister stated that the large number of undetected cases of SARS 
patients occurred because they could not collect information on SARS 
cases that were spread across 70 hospitals in the city. In Taiwan, 
duplicative reporting between municipal and federal levels led to 
unclear data on the total number of cases throughout the island. A WHO 
official reported that the surveillance data were entered into formats 
that were difficult to analyze and could not inform the public health 
response. In Hong Kong, a quickly established atypical pneumonia 
surveillance system detected early cases of severe pneumonia admitted 
into hospitals. However, the expert committee reviewing the response 
noted that the limited access to data from private sector health care 
providers and a lack of comprehensive laboratory surveillance made it 
difficult for public health authorities to gain accurate information 
about the full extent of the outbreak and implement necessary control 
measures.

Public Health Capacity:

In China, officials told us that a lack of funding and a reliance on 
market forces to finance public health services have weakened the 
country's ability to respond to outbreaks. For example, the newly 
established Center for Disease Control and Prevention system in China 
derives more than 50 percent of its revenue from user fees for 
immunizations and other services. WHO noted that the dependence on user 
fees has drawn attention and resources away from nonrevenue producing 
activities, such as disease surveillance, that are important for 
responding to infectious disease outbreaks. Furthermore, China did not 
have enough public health workers skilled in investigating diseases, 
and thus staff who had never been involved in disease investigations 
were used to trace SARS contacts and did not always collect the correct 
data on these cases. In Hong Kong, the expert committee noted that 
there was a shortage of expertise in field epidemiology and inadequate 
support for information systems. In addition, the committee found 
disproportionate funding of public health services compared with the 
public hospital system, which receives 10 times more government funds. 
Taiwanese officials cited problems in public health infrastructure, 
including the lack of equipment to deal with infectious patients in 
hospitals and underfunded laboratories.

Hospital Infection Control:

Another major weakness in public health capacity cited by health 
officials in China, Hong Kong, and Taiwan was a lack expertise in 
hospital infection control. In many SARS-affected areas, transmission 
of SARS to health care workers and other hospital patients was a 
significant factor sustaining the outbreak. In some instances, hundreds 
of hospital-acquired infections were due to inadequate isolation of 
individual patients and limited availability and use of personal 
protective equipment (masks, gowns, and gloves) for hospital workers. 
For example, in Taiwan, health officials reported that after initial 
success in rapidly identifying and isolating cases arriving from other 
SARS-affected areas, hospitals failed to recognize SARS cases occurring 
within Taiwan, resulting in a secondary, and much larger, outbreak in 
hospitals throughout the island. WHO, U.S. CDC, and Taiwanese officials 
told us that the number of physicians trained in infection control 
practices was inadequate and that infection control was not a priority 
for hospital management. In Hong Kong, the expert committee noted that 
there was no clear leadership from infection control doctors and that 
there were insufficient numbers of nurses trained in 
hospital infection control.[Footnote 22] In China, WHO officials noted 
in field reports that infection control procedures were rudimentary and 
relied on a range of measures, including disinfection of health care 
facilities, instead of the recommended isolation measures needed to 
limit spread to patients and health care workers.

Basic Public Health Strategies Eventually Worked to Control SARS 
Outbreak:

The SARS outbreak was ultimately brought under control by a more 
coordinated response that included the implementation of basic public 
health strategies. Measures such as improved screening and reporting of 
cases, rapid isolation of SARS patients, enhanced hospital infection 
control practices, and quarantine of close contacts were the most 
effective ways to break the chain of person-to-person transmission.

Improved Screening and Reporting:

Screening of patients with symptoms of SARS permitted the early 
identification of suspect cases during the early phase of illness. 
Furthermore, because SARS is transmitted when individuals have symptoms 
of the disease, detecting symptomatic patients was considered critical 
to stopping its spread. For example, in Beijing, fever clinics were 
established to screen people with fevers before presentation to 
hospitals or other health care providers to limit exposure to SARS. 
Between May 7 and June 9, 2003, there were 65,321 fever clinic visits. 
Through this effort, 47 probable SARS cases were identified, 
representing only 0.1 percent of all fever clinic visits but 84 percent 
of all probable cases hospitalized during that period. In addition, 
policies were implemented requiring daily reports from all areas 
regardless of whether any SARS cases were found. In Hong Kong, 
designated medical centers were established to conduct medical 
monitoring of close contacts of SARS patients to ensure early detection 
of secondary cases. In Taiwan, hospital staff and other individuals who 
had contact with SARS patients in hospitals were monitored on a daily 
basis to detect SARS symptoms.

Rapid Isolation and Contact Tracing:

The identification of patients with suspect and probable cases of SARS 
and their close contacts reduced the rate of contact between SARS 
patients and healthy individuals in both community and hospital 
settings. For example, toward the end of the outbreak, one Chinese 
province decreased the average time between onset of SARS symptoms to 
hospitalization from 4 days to 1, and the time to trace contacts of 
these patients from 1 day to less than half a day. These declines in 
the time for hospitalization and contact tracing generally coincided 
with a decrease in the number of new cases. In Hong Kong, officials 
facilitated tracing by linking a SARS database used by public health 
officials with police databases to track and verify the addresses of 
relatives and other close contacts of SARS patients. To limit the 
spread of SARS in the hospital system, specific hospitals were 
designated to treat suspected SARS patients in all SARS-affected areas. 
Another strategy in SARS-affected areas was the cancellation of school, 
large public gatherings, and holiday activities. For example, in China 
the weeklong May Day celebration was shortened.

Enhanced Hospital Infection Control:

The widespread use of personal protective equipment helped contain the 
spread of SARS in hospitals. For example, in China, when hospital 
infection control measures were instituted toward the end of the 
outbreak in a 1,000-bed hospital constructed exclusively for SARS 
patients, there were no further cases of SARS transmission in health 
care workers. Similarly in Hong Kong and Taiwan, these measures led to 
a decline in the number of infections in health care workers. In 
addition, in all these affected areas, guidelines were ultimately 
established for the use of personal protective equipment in outbreak 
situations.

Quarantine Measures:

China, Taiwan, and Hong Kong implemented quarantine measures to isolate 
potentially infected individuals from the larger community, which, when 
restricted to close contacts of SARS patients, proved to be an 
efficient and effective public health strategy. In Hong Kong, for 
example, close contacts of SARS patients and people in high-risk areas 
were isolated for 10 days in designated medical centers or at home to 
ensure early detection of secondary cases. However, more wide-scale 
quarantine took place in Taiwan, where 131,000 individuals who had any 
form of contact with a SARS patient or traveled to SARS-affected areas 
were placed under quarantine, and in Beijing, where more than 30,000 
people were quarantined. Analysis of data from these areas indicated 
that the quarantine of individuals with no close contact to SARS 
patients was not an effective use of resources. For example, among the 
133 probable and suspect cases identified in Taiwan, most were found to 
have had direct contact with a SARS patient.[Footnote 23] Similarly, 
researchers found that in Beijing, limiting quarantine to close 
contacts of actively ill patients would have been a more efficient 
strategy and a better use of resources.[Footnote 24]

Asian Governments Have Efforts Under Way to Build Public Health 
Capacity for Future Outbreaks:

Following the SARS epidemic, Asian governments have attempted to 
improve public health capacity, revise their legal frameworks for 
infectious disease control, increase regional communication and 
cooperation, and utilize international aid to improve preparedness. 
During our fieldwork, we met with public health representatives at 
various levels--from senior health ministry officials to local hospital 
health care workers--who provided information on efforts to improve 
public health capacity. For example, after the SARS outbreak the 
Chinese government provided additional budgetary support and expanded 
authority to improve coordination and communication. The government 
also devised a plan to build capacity in its weak rural health care 
system. In Hong Kong, the government focused its efforts on early 
detection and response to infectious disease outbreaks and is 
developing a Center for Health Protection focused on infectious disease 
control. Several drills were conducted to test the system, and the 
government has identified protecting populations in senior citizen 
homes, schools, and hospitals as a priority. In Taiwan, the government 
responded to public health management shortcomings by establishing a 
new public health command structure with centralized authority and 
decision-making power and making numerous changes in health leadership 
positions. The government invested public funds to upgrade its health 
infrastructure--for example, to construct fever wards, isolation rooms 
with negative pressure relative to the surrounding area, and other 
improvements in hospitals.

The SARS outbreak also led to legal reforms specific to SARS control 
and the function of public health systems in SARS-affected areas. For 
example, China, Hong Kong, and Taiwan passed legislation or regulations 
during the outbreak that required clinicians and public health 
authorities to report cases of SARS. In China, regulations on the 
prevention of SARS were passed that, among other things, were intended 
to improve communication with the public and outline administrative or 
criminal penalties for officials 
who do not report SARS cases.[Footnote 25] A broader set of regulations 
that may have a long-term impact was also passed that requires the 
creation of a unified command during public health emergencies, 
reporting of such emergencies within 2 hours, and improved public 
health capacity at all levels of the government.[Footnote 26] In Hong 
Kong, the law was revised to enhance the power of public health 
authorities to isolate cases and control the spread of SARS through 
international travel.[Footnote 27]

Senior government officials have taken steps to improve public health 
communication and coordination in the region. Health officials in Hong 
Kong and Taiwan stated it is critical that information on disease 
outbreaks in mainland China be quickly reported so that neighboring 
governments can take preventive actions. A post-SARS agreement among 
Guangdong Province, Hong Kong, and Macau has thus far led to monthly 
sharing of information on a list of 30 diseases. A senior Chinese 
health official stated that the SARS outbreak taught the Chinese 
government the need for international cooperation in fighting 
infectious disease outbreaks. According to WHO officials, since the 
2002-2003 SARS outbreak, they have experienced increased transparency 
and willingness on the part of the Chinese government to work with WHO 
health experts.

The international community and the United States have committed 
financial and human resources to support the recent financial 
investments in public health capacity made by the Chinese government. 
For example, in July 2003 the World Bank announced a multidonor-
supported program to strengthen disease surveillance and reporting and 
improve the skills of clinicians in China. The program is funded by 
US$11.5 million in loans from the World Bank, a 3 million British pound 
grant from the United Kingdom's Department for International 
Development, a Can$5 million grant from the Canadian International 
Development Agency, and a US$2 million regional grant from the Japan 
Social Development Fund. HHS is in the process of finalizing a 
multiyear, multimillion-dollar program of cooperation between HHS and 
the Chinese Ministry of Health aimed at strengthening China's capacity 
in public health management, epidemiology, and laboratory capacity. As 
part of the initiative, CDC staff members will be stationed in China to 
help strengthen the epidemiology workforce.

SARS Outbreak Decreased Consumer Confidence and Negatively Affected a 
Number of Asian Economies:

During the SARS outbreak, consumer confidence temporarily declined as a 
result of consumer fears about SARS and precautions taken to avoid 
contracting the disease. This decline in consumer confidence in turn 
led to economic losses in Asian economies estimated in the billions of 
dollars. Service sectors were hit the hardest due to declines in travel 
and tourism to areas with SARS outbreaks and declines in retail sales 
involving face-to-face exchanges. Additionally, to counter economic 
losses associated with SARS, many Asian governments implemented costly 
economic stimulus programs.

Impacts from SARS Are Estimated to Have Cost Billions, Although Most 
Economies Have Recovered:

While the number of cases and associated medical costs for the SARS 
outbreak were relatively low compared with those for other major 
historical epidemics, the economic costs of SARS were significant 
because they derived primarily from fears about the disease and 
precautions to avoid the disease, rather than the disease itself. As 
shown in table 1, one industry and one official estimate of the 
economic cost of SARS in Asia calculated the net loss in total output 
at roughly $11 billion to $18 billion, respectively. (These estimates 
reflect changes in growth forecasts that were calculated concurrent 
with the outbreak. See app. III for a discussion of methodologies and 
varied assumptions used to obtain these estimates.) For example, the 
Far Eastern Economic Review estimates SARS's economic costs in Asia at 
around $11 billion, with the largest losses in China, Hong Kong, and 
Singapore. The Asian Development Bank also shows the largest losses in 
these three economies, although they estimate the total cost at around 
$18 billion.[Footnote 28] As the Asian Development Bank reported, using 
its cost estimate, the cost per person infected with SARS was roughly 
$2 million. While economic costs associated with a general loss in 
consumer confidence are difficult to quantify exactly, they illustrate 
how emerging diseases and fears associated with those diseases can have 
widespread ramifications for a large number of economies.

Table 1: Estimated Economic Cost of SARS in Asia:

U.S. dollars in millions.

China; 
Far Eastern Economic Review: 2,200; 
Asian Development Bank: 6,100.

Hong Kong; 
Far Eastern Economic Review: 1,700; 
Asian Development Bank: 4,600.

Malaysia; 
Far Eastern Economic Review: 660; 
Asian Development Bank: 400.

Singapore; 
Far Eastern Economic Review: 950; 
Asian Development Bank: 2,700.

Taiwan; 
Far Eastern Economic Review: 820; 
Asian Development Bank: 1,300.

Thailand; 
Far Eastern Economic Review: 490; 
Asian Development Bank: 1,900.

Vietnam; 
Far Eastern Economic Review: 111; 
Asian Development Bank: 400.

Region; 
Far Eastern Economic Review: 10,700; 
Asian Development Bank: 18,000. 

Source: GAO analysis of data from Far Eastern Economic Review and Asian 
Development Bank.

Note: Regional totals may include costs in Asian countries other than 
those listed in the table.

[End of table]

The economic cost of SARS in terms of a percentage loss in each 
selected Asian economy's GDP has also been estimated by the Asian 
Development Bank and industry organizations at roughly 0.5 percent to 2 
percent, with some variation among economies depending upon the 
importance of affected sectors in total output (see app. III for a more 
detailed discussion of these models' assumptions and their GDP loss 
estimates per country).[Footnote 29] Figure 3 shows quarterly GDP 
growth for four Asian economies most affected by SARS--China, Hong 
Kong, Singapore, and Taiwan--and illustrates that GDP weakened in the 
second quarter of 2003, concurrent with the height of the SARS 
outbreak.[Footnote 30] However, given that the outbreak was brought 
under control by July 2003, the economic impacts were concentrated 
primarily in this second quarter. In fact, when WHO declared that the 
SARS outbreak was over in July 2003, pent-up demand during the outbreak 
likely contributed to an economic rebound in the third and fourth 
quarters.

Figure 3: Quarterly GDP Growth for Various Asian Economies, 2002-2003:

[See PDF for image] 

[End of figure] 

SARS Affected Asian Economies through a Variety of Channels:

The SARS outbreak produced negative impacts on Asian economies through 
a variety of mechanisms. The most important channel through which SARS 
affected these economies was by temporarily dampening consumer 
confidence, particularly in the travel and tourism industry. In 
addition, decreased consumer confidence likely reduced retail sales 
and, to a lesser extent, some foreign trade and investment. Due to 
reduced demand, employment in affected economies fell. Some businesses 
also reported an increase in costs as business operations were 
disrupted, international shipments of goods and trade were hampered, 
and disease prevention costs rose.

The most severe economic impacts from SARS occurred in the travel and 
tourism industry, with airlines being particularly hard hit. As shown 
in figure 4, declines in regional airline traffic reached 40 percent to 
50 percent in April and May, two months in which WHO travel advisories 
for Asia Pacific were in effect.[Footnote 31] The estimated percentage 
decline in overall tourism earnings amounted to 15 percent in Vietnam, 
25 percent in China, and more than 40 percent in Hong Kong and 
Singapore, according to the World Travel and Tourism Council.[Footnote 
32] Estimated job losses resulting from these SARS-related impacts were 
also significant. For example, the World Travel and Tourism Council 
estimated tourism sector job losses of around 27,000 in Hong Kong and 
18,000 in Singapore, while the World Bank estimated airline job losses 
in the region at around 36,000.[Footnote 33]

Figure 4: Estimated Economic Impacts of SARS on Travel and Tourism:

[See PDF for image] 

[End of figure] 

Dampened consumer confidence from SARS also had negative impacts on 
retail sales and foreign trade and investment, according to anecdotal 
evidence. The retail sector was negatively affected by the SARS 
outbreak as consumers curbed shopping trips and visits to restaurants 
in fear of contracting SARS. For example, China shortened the weeklong 
May Day celebration that it introduced in 1999 to stimulate private 
consumption. As shown in figure 5, retail sales fell concurrent with 
the SARS outbreak in China, Hong Kong, Singapore, and Taiwan, a decline 
particularly important for Hong Kong and Taiwan due to their large 
retail sectors. However, the rebound in consumer confidence is also 
illustrated by an increase in retail sales in the third quarter of 
2003. Regarding foreign trade and investment, trends in these variables 
indicate less distinct SARS-related declines.[Footnote 34] 
Nonetheless, there is some indication of the impact of SARS on these 
activities, such as the reduced sales at the major Guangzhou Trade Fair 
in China, which totaled only 26 percent of the previous year's amount, 
or the lagged effect of a decrease in foreign direct investment into 
China in July 2003.

Figure 5: Quarterly Retail Sales Growth in Selected Asian Economies, 
2002-2003:

[See PDF for image] 

[End of figure] 

Asian Governments Provided Economic Stimulus Packages That Cost 
Billions:

In response to SARS, governments in Asia implemented economic stimulus 
packages that also cost billions of dollars. Asian governments provided 
spending for medical and public health sectors to prevent and control 
the spread of SARS as well as for fiscal policy programs to more 
generally stimulate the economy. As shown in table 2, the Asian 
Development Bank estimates that the cost of these stimulus packages in 
the region could total nearly $9 billion. While many of the spending 
and tax measures are designed to improve GDP growth, they can also be 
considered an economic cost of SARS due to the diversion of government 
expenditures away from investments in needed public services.

Table 2: Asian Government Stimulus Packages in Response to SARS, 2003:

(U.S. dollars in millions).

China; 
Type of package: 
* Temporary tax relief and subsidies for affected industries; 
* Free medical treatment for the poor and some price controls on SARS-
related drugs and goods; 
Cost of package: 3,500.

Hong Kong; 
Type of package: 
* Temporary tax relief, job creation, and loan guarantee schemes; 
Cost of package: 1,500.

Malaysia; 
Type of package: 
* Loan programs, support for tourism-related industries, and job 
training; 
Cost of package: 1,920.

Singapore; 
Type of package: 
* Temporary reduction in tourism and transport administrative fees, 
and relief measures for airlines; 
Cost of package: 132.

Taiwan; 
Type of package: 
* Partial reimbursement of business-related losses for affected 
industries; 
* Partial reimbursement for medical costs; 
Cost of package: 1,400.

Thailand; 
Type of package: 
* General funding allocated as emergency budget; 
Cost of package: 468.

Source: GAO analysis of Asian Development Bank data.

[End of table]

WHO Members Will Debate Important Issues Raised by International Health 
Regulations' Revision:

The SARS epidemic elevated the importance of the International Health 
Regulations' revision process. The proposed revisions, currently in 
draft form and scheduled for completion in May 2005, would expand the 
regulations' coverage and encourage better cooperation between member 
states and WHO. Member states will have to resolve at least five 
important issues, regarding (1) scope of coverage, (2) WHO's authority 
to conduct investigations in countries absent their consent, (3) the 
public health capacity of developing country members, (4) an 
enforcement mechanism to resolve compliance issues, and (5) how to 
ensure public health security without unnecessary interference with 
travel and trade.

Revisions Would Expand Coverage and Facilitate Cooperation, but Key 
Questions Remain:

The draft regulations expand the scope of reporting beyond the current 
three diseases to include all events potentially constituting a public 
health emergency of international concern, such as SARS. They also 
promote enhanced member state cooperation with WHO and other countries. 
Additional changes under consideration include (1) designating national 
focal points with WHO for notification of public health emergencies and 
(2) requiring minimum core surveillance and response capacities at the 
national level to implement a global health security strategy. The 
overall goal of the revision process is to create a framework under 
which WHO and others can actively assist states in responding to 
international public health risks by directly linking the revised 
regulations to the work of GOARN.

Nevertheless, the draft regulations contain several provisions that 
have been the subject of ongoing debate, including:

* Scope of coverage. As part of the revision process, WHO has developed 
criteria to determine whether an outbreak is serious, unexpected, and 
likely to spread internationally. Furthermore, the draft regulations 
broaden the definition of a reportable disease to include significant 
illness caused by biological, chemical, or radionuclear sources. In its 
initial comments to WHO on the draft regulations, the U.S. government 
supported the use of criteria for determining what would be a public 
health emergency of international concern. Nevertheless, the U.S. 
strongly believed that the draft should also require reporting of a 
defined list of certain known, serious, communicable diseases that have 
the potential for creating such a concern.

* Authority to conduct investigations. Member states are considering 
the appropriate level of authority for the regulations. Specifically, 
an unresolved issue is the degree to which the regulations will require 
binding international commitments or more voluntary standards. To 
address this issue, member states are examining whether the benefits 
that would result from agreeing to more rigorous, comprehensive, and 
mandatory regulations would outweigh losses in sovereignty. For 
example, the draft regulations eliminate the language in the current 
regulations that specifically requires WHO to first obtain consent from 
the member state involved before conducting on-the-spot investigations 
of disease outbreaks.[Footnote 35] However, the draft regulations are 
still somewhat ambiguous about whether consent is necessary.[Footnote 
36] According to a senior WHO official, the proposed regulations were 
intentionally left vague about consent because it is a subject that 
members will want to debate thoroughly.

* Public health capacity of developing countries. The draft regulations 
provide member states with direction regarding the minimum core 
surveillance and response capacities required at the national level, 
including at airports, ports, and other points of entry. However, U.S. 
and WHO officials note that many developing countries currently lack 
even the most rudimentary public health capacity and will be dependent 
on significant international assistance to reach minimum surveillance 
and response capabilities. HHS officials have expressed caution about 
developing more comprehensive and demanding requirements that will be 
difficult for many countries with limited resources to implement. WHO 
officials acknowledge that, while WHO is able to provide technical 
assistance through GOARN, multilateral institutions, such as the World 
Bank, and donor countries will have to provide significant resources 
for developing countries to meet minimum surveillance and response 
requirements. A WHO official also indicated that while the proposed 
revisions to the regulations do not have specific provisions on 
technical assistance, developing countries are likely to raise the 
issue of adding such a provision during the revision process.

* Enforcement mechanism. The members will have to address what kind of 
enforcement mechanism they want included in the regulations to resolve 
compliance issues and to deal with violations of the regulations. 
According to WHO officials, failure to comply with WHO public health 
requirements is often a problem. The draft regulations, like the 
current regulations, include a nonbinding mechanism for resolving 
disputes. Thus, the WHO Director-General is directed either to (1) make 
every effort to resolve disputes or (2) refer disputes to a WHO Review 
Committee, which is tasked to forward its views and advice to the 
parties involved. Although WHO would continue to be dependent on the 
voluntary compliance of member states, WHO officials believe that if 
key countries (such as the United States) and neighboring trade 
partners are sufficiently concerned about the dangers of emerging 
diseases to press for compliance with the revised regulations, other 
countries are likely to fulfill their obligations. Furthermore, though 
it is too early to predict how China's response to SARS in 2003 will 
affect future compliance, WHO officials say the negative political, 
economic, and public health effects China suffered from its initial 
response to SARS served as a warning to countries that ignore their 
international public health responsibilities.

* International traffic. The stated purpose of the draft regulations, 
which is similar to the current regulations, is to provide security 
against the international spread of disease while avoiding unnecessary 
interference with international traffic. Although the term 
international traffic appears to refer to international travel and 
trade, neither the proposed nor the current regulations define the 
term. Furthermore, the draft regulations do not include detailed 
criteria for determining what constitutes interference with 
international trade and travel.[Footnote 37] A WHO official indicated 
that it was preferable not to include detailed criteria and to allow 
this issue to be decided on a case-by-case basis because of the very 
broad range of situations that could ultimately cause such 
interference. This issue could receive a good deal of attention in the 
revision process as member states try to balance medical and economic 
concerns. According to WHO officials, in past epidemics, concerns about 
economic loss and restrictions on trade and travel caused some 
countries not to report outbreaks within their borders and to refuse 
international assistance. Furthermore, for certain outbreaks--for 
example, those involving cholera in Peru in 1991 and plague in India in 
1994--some experts reported that the international response may have 
exceeded the level of threat and led to unwarranted trade and travel 
losses in those countries.

Completing the Revision Process Seen as High Priority:

The process for revising the International Health Regulations was 
intensified by a WHO World Health Assembly resolution passed in May 
2003, during the SARS outbreak, urging members to give high priority to 
the revision process and to provide the resources and cooperation to 
facilitate this work.[Footnote 38] The resolution also requested that 
the WHO Director-General consider informal sources of information to 
respond to outbreaks such as SARS; collaborate with national 
authorities in assessing the severity of infectious disease threats and 
the adequacy of control measures; and, when necessary, send a WHO team 
to conduct on-the-spot studies in places experiencing infectious 
disease outbreaks. Although the resolution did not impose legally 
binding obligations on members, according to WHO officials and some 
observers it did lay the political groundwork for improved 
international cooperation on infectious disease control.

In January 2004, WHO distributed to its member states an interim draft 
of the revisions proposed by the WHO Secretariat. Composed of 55 
articles and 10 technical annexes, the draft will be discussed in a 
series of regional consultations throughout 2004. The degree of 
consensus on the draft's technical and political issues will then 
determine the need for subsequent meetings at the global level. The 
goal is to convene an intergovernmental working group at the end of 
2004 to finalize revisions to the draft regulations. It is hoped the 
regulations will then be ready for submission to the 58th World Health 
Assembly in May 2005. However, according to WHO and HHS officials, 
reaching both technical and political consensus on the regulations will 
be a difficult task, and they expect the revision process to extend 
beyond its target date.

Conclusion:

While the 2002-2003 SARS outbreak had an impact on health and commerce 
in Asia, the extensive response by WHO and Asian governments, supported 
in large measure by the U.S. government, was ultimately effective in 
controlling the outbreak. This event highlighted a number of important 
issues, including the limited resources to support WHO's global 
infectious disease network and deficiencies in Asian governments' 
public health systems. It also revealed limitations in the 
International Health Regulations.

In the aftermath of SARS, WHO and member states have recognized the 
importance of strengthening international collaboration and 
cooperation to respond to global infectious disease outbreaks. To be 
successful, this effort will require a greater commitment of resources 
for global infectious disease control and a concerted effort to revise 
the International Health Regulations to make them more relevant and 
useful in future outbreaks. As the regulations are revised, WHO and 
member states face the challenge of improving the management of disease 
outbreaks while mitigating adverse economic impacts. The content, 
manner of acceptance, and means of enacting the final revisions are not 
certain, and much work remains to be done to resolve outstanding 
issues. As of April 2004, SARS has not re-emerged to cause another 
major international outbreak, but outbreaks of other infectious 
diseases can be expected in the future. Therefore, strengthening public 
health capacity will be essential for responding to future infectious 
disease outbreaks.

The SARS outbreak also revealed gaps in U.S. government protective 
measures, including difficulties in arranging medical evacuations from 
overseas and the inability to trace and contact individuals exposed to 
SARS during travel. In regard to tracing international travelers who 
may have been exposed to an infectious disease, we believe that 
amending HHS regulations to specify that the agency has authority to 
obtain this information would assist this effort. This action would 
facilitate HHS's ability to obtain necessary contact information (1) 
from airlines or shipping companies that may have concerns about 
sharing passenger information with HHS, or (2) in the event that issues 
involving coordination with other federal agencies cannot be 
effectively resolved.

Recommendations for Executive Action:

This report is making three recommendations to improve the response to 
infectious disease outbreaks. First, to strengthen the international 
response, we recommend that the Secretary of Health and Human Services, 
in collaboration with the Secretary of State, 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.

Second, to help Health and Human Services prevent the introduction, 
transmission, or spread of infectious diseases into the United States, 
we recommend that the Secretary of HHS 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.

Third, 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 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:

* 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:

* 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 Comments and Our Evaluation:

HHS, State, and WHO provided written comments on a draft of this report 
(see apps. IV, V, and VI for a reprint of HHS's, State's, and WHO's 
comments). They also provided technical and clarifying comments that we 
have incorporated where appropriate. HHS said the report is a good 
summary of the SARS outbreak in Asia and the actions taken by WHO, 
affected countries, and U.S. agencies. HHS stated that the report's 
recommendations are appropriate and emphasized the national and 
international interagency collaboration that will be required to 
implement them in preparation for the next epidemic. HHS also noted 
that to carry out some of the recommendations, sensitive legal and 
privacy issues and diplomatic concerns must be carefully addressed. HHS 
also noted that the report contains a useful overview of WHO's efforts 
to revise its International Health Regulations and correctly ties WHO's 
increased effort to the impact of SARS and lessons learned. In that 
regard, HHS provided additional information on coordination and 
collaboration efforts it took during the outbreak.

State indicated that the report is a useful summary of the SARS 
outbreak and its impact and documents important lessons for other 
infectious disease outbreaks beyond the 2003 SARS epidemic. Regarding 
our first recommendation, State said it is committed to working with 
WHO and its member states to strengthen the response capacity of WHO's 
global infectious disease network. Regarding our recommendation on 
contact tracing of arriving passengers infected or exposed to 
infectious disease, State noted that it has been working on this issue 
with its interagency partners since the SARS outbreak but underscored 
that serious legal issues still exist for both the United States and 
other governments. State also agreed with our recommendation on 
developing procedures for arranging medical evacuations during an 
airborne infectious disease outbreak. State indicated that it is 
working with CDC to develop protocols on how to handle medical 
evacuations for quarantinable diseases but noted that capacity for such 
medical evacuations will be limited, as will capacity of U.S. medical 
facilities to handle a large influx of patients.

WHO stated that, overall, the report provides a factual analysis of the 
events surrounding the emergence of SARS and addresses the major 
weaknesses in national and international control efforts. WHO noted, 
however, that the report presents major criticisms of the response by 
China, Hong Kong, and Taiwan to SARS but does not reflect these 
governments' actions throughout the SARS epidemic or the depth and 
intensity of their control efforts later on. WHO also stated that the 
report puts little emphasis on other countries that experienced 
problems--Canada, for example. We disagree that the report does not 
adequately balance the governments' shortcomings with accomplishments, 
as the report includes specific sections on improved screening and 
reporting of SARS cases, rapid isolation and contact tracing, enhanced 
hospital infection control practices, and quarantine measures. The 
report details steps Asian governments have taken in response to SARS 
to build capacity for future outbreaks. The preponderance of our 
evidence on Asian governments' response was provided directly by 
Chinese, Hong Kong, and Taiwan government and public health officials 
and from post-SARS evaluation reports produced by these governments and 
WHO-sponsored conferences. We focused our report on the response of 
China, Hong Kong, and Taiwan since 95 percent of the SARS cases 
occurred there. The response of other countries, such as Canada was 
outside the scope of our examination.

Regarding our discussion of WHO's global infectious disease network, 
WHO stated that GOARN is one of the mechanisms by which WHO mobilizes 
technical resources for outbreak investigation and response provided 
further information about the role of the Western Pacific Regional 
Office (WPRO) in the SARS response. We clarified the role of GOARN and 
expanded our discussion on the activities of WPRO. WHO also said that 
its response was challenged, but not constrained, by limited resources. 
While we agree with this more general characterization, we believe that 
not being able to obtain the appropriate multidisciplinary staff and 
sustain a response over time were significant constraints that warrant 
serious attention in preparing for future emerging infectious diseases. 
WHO also noted that the world's dependence on a fragile process and on 
the personal commitment and sacrifice of WHO and GOARN staff is a 
concern.

Scope and Methodology:

To assess WHO's actions to respond to SARS in Asia, we analyzed WHO 
policy, program, and budget documents, including WHO's Web-based 
situation updates and guidelines that served as the primary instrument 
for disseminating information on SARS. We interviewed WHO officials 
responsible for managing the international response at WHO headquarters 
in Geneva and public health specialists who served on country teams 
that were deployed to Asia. We examined WHO's GOARN, including its 
guiding principles and how it operated during the SARS outbreak. We 
also interviewed Asian government officials in Beijing, Guangdong 
Province, Hong Kong, and Taipei who received WHO's technical advice and 
support; U.S. government officials; and recognized experts within the 
public health community.

To assess the role of the U.S. government in responding to SARS in Asia 
and limiting its spread into the United States, we analyzed program 
documents and interviewed officials from the Departments of Health and 
Human Services, State, Defense, and Homeland Security, and the U.S. 
Centers for Disease Control and Prevention (CDC). To examine CDC's 
ability to trace travelers who may have been exposed to an infectious 
disease, we interviewed officials from the Air Transport Association 
and the Department of Transportation and reviewed applicable 
legislation and regulations. To assess State's ability to provide 
medical evacuation of U.S. citizens, we examined CDC guidelines on air 
transport of SARS patients and interviewed officials from major private 
medical evacuation companies. We also interviewed U.S. embassy 
(Beijing), consulate (Hong Kong and Guangzhou), and American Institute 
in Taiwan officials responsible for managing the U.S. government 
response at the country level.

To describe how governments in Asia responded to the SARS outbreak, we 
focused on those parts of Asia most affected by SARS in the 2002-2003 
outbreak, including China, Hong Kong, and Taiwan. While in the region, 
we met with public health officials at various levels responsible for 
managing their governments' public health response, including senior 
ministry of health and provincial and municipal government officials, 
as well as hospital administrators and health care workers. We also 
examined government documents on public health programs and post-SARS 
evaluations, and reviewed applicable China, Hong Kong, and Taiwan laws 
and regulations.

To describe the economic impact of SARS in Asia, we reviewed impact 
estimates provided by (1) the Asian Development Bank's Economic and 
Research Department, which used a simulation model from Oxford Economic 
Forecasting; (2) a simulation model using data from the Global:

Trade Analysis Project Consortium;[Footnote 39] and (3) a simulation 
model by Global Insight, a leading U.S. economic data and forecasting 
firm. Specifics of each of these models are discussed in appendix III. 
Another organization, the Far Eastern Economic Review, a regional 
economic business weekly, gathered studies and data on SARS and 
reported a summary cost estimate that we also reviewed. To supplement 
our analysis of these impact estimates, we examined trends in official 
macroeconomic data as reported by the countries' central banks or 
departments of statistics, the Asian Development Bank, the Organization 
for Economic Cooperation and Development, and the World Travel and 
Tourism Association.[Footnote 40] Trends in international airline 
traffic were obtained from the International Air Transport Association. 
We corroborated our findings with information provided by the U.S. 
National Intelligence Council and interviews with government officials 
in Asia.

Finally, to examine the status of efforts to update the International 
Health Regulations, we reviewed the current International Health 
Regulations, a draft of WHO's proposed revision of the regulations, the 
initial U.S. government response to the proposed revisions, and the WHO 
constitution. We also interviewed WHO and U.S. government officials who 
are actively engaged in the revision process and other legal experts to 
determine the potential impacts of the revised rules.

We performed our work from July 2003 to April 2004 in accordance with 
generally accepted government auditing standards.

We are sending copies of this report to the Secretaries of Health and 
Human Services, State, and Defense; appropriate congressional 
committees; and other interested parties. We will also make copies 
available to others upon request. In addition, the report will be 
available at no charge on GAO's Web site at [Hyperlink, http://
www.gao.gov].

If you or your staff have any questions, please contact one of us. 
Other contacts and key contributors are listed in appendix VII.

Sincerely yours,

Signed by:  

David Gootnick, 
Director, International Affairs and Trade:

Janet Heinrich, 
Director, Health Care--Public Health Issues:

[End of section]

Appendixes: 

Appendix I: SARS Cases and Deaths, November 2002-July 2003:

[See PDF for image] 

Note: Numbers represent cases and deaths.

[End of figure]

[End of section]

Appendix II: SARS Chronology:

Appendix II lists key worldwide events during the SARS outbreak, from 
November 2002, when the disease first emerged, to the most recent 
reported cases in January 2004.

2002; 

November 16; Location: Guangdong Province, China[A]; Event: First 
known case of atypical pneumonia, later determined to be SARS.

November 23; Location: Beijing; Event: World Health Organization 
(WHO) influenza expert attends workshop in Beijing and learns from a 
participant from Guangdong Province of a "serious outbreak with high 
mortality and involvement of health care staff.".

November 27; Location: Canada; Event: Global Public Health 
Intelligence Network (GPHIN) picks up reports of a "flu outbreak" in 
China.

Mid-December; Location: WHO Headquarters, Geneva; Event: WHO 
requests further information from China on the influenza outbreak. 
Chinese government replies that influenza activity in Beijing and 
Guangdong is normal and that surveillance system detected no unusual 
strains of the virus.

December 10; Location: Guangdong Province; Event: Infection in 
second city in Guangdong Province.

Year: 2003.

January 23; Location: Guangdong Province; Event: Guangdong's 
provincial health authorities produce a report about the outbreak 
detailing the nature of transmission, clinical features, and suggested 
preventive measures. The report is circulated to hospitals in the 
province, but is not shared with WHO or Hong Kong.

February 10-11; Location: Multiple Locations; Event: WHO Beijing 
office, Global Outbreak and Alert Response Network (GOARN) partners, 
and U.S. Centers for Disease Control (CDC) receive reports of a 
"strange contagious disease" and "pneumonic plague" causing deaths in 
Guangdong Province.

February 14-20; Location: China, Hong Kong; Event: Chinese Center 
for Disease Control and Prevention erroneously announces that the 
probable causative agent of the atypical pneumonia is Chlamydia. At the 
same time, cases of avian influenza in a family that traveled between 
Hong Kong and China result in two deaths. This leads to speculation 
that the atypical pneumonia outbreak is caused by avian influenza. WHO 
activates its global influenza laboratory network and calls for 
heightened global surveillance.

February 21; Location: Hong Kong[A]; Event: First superspreader 
event in Hong Kong: A physician from Guangdong Province stays at the 
Metropole Hotel in Hong Kong and is soon hospitalized with respiratory 
failure. While at the hotel, he transmits the disease to at least 16 
other people.

February 23; Location: China; Event: A team of WHO experts, 
including CDC staff, arrives in Beijing but is given limited access to 
information; Chinese authorities deny WHO's repeated requests for 
permission to travel to Guangdong Province.

February 24; Location: WHO; Headquarters, Geneva; Event: GPHIN 
detects Chinese newspaper report that more than 50 hospital staff in 
Guangzhou are infected with "mysterious pneumonia.".

February 26; Location: Vietnam[A]; Event: Chinese-American 
businessman admitted to the French Hospital in Hanoi with fever and 
respiratory symptoms.

February 28; Location: Vietnam; Event: WHO official Dr. Carlo 
Urbani notifies WHO office in Manila of an unusual disease. WHO 
headquarters moves to heightened state of alert.

Early March; Location: United States; Event: State Department 
establishes an intradepartmental working group to deal with impact of 
outbreak.

March 1; Location: Singapore[A]; Event: Woman who stayed at the 
Metropole Hotel in Hong Kong is hospitalized with respiratory 
symptoms.

March 4; Location: Hong Kong; Event: Second superspreader event 
in Hong Kong: a resident who had visited the Metropole Hotel is 
admitted to hospital with respiratory symptoms; within a week, at least 
25 hospital staff, all linked to the patient's ward, develop 
respiratory illness.

March 5; Location: Canada[A]; Event: Toronto woman who also 
stayed at the Metropole Hotel in Hong Kong dies at home. Shortly after, 
her son becomes ill, is admitted to Scarborough Grace Hospital, and 
dies. His admission triggers an outbreak at the hospital.

March 8; Location: Taiwan[A]; Event: Businessman with travel 
history to Guangdong Province is hospitalized with respiratory 
symptoms.

March 10; Location: China; Event: Chinese Health Ministry asks 
WHO for technical and laboratory support to clarify cause of the 
Guangdong outbreak of atypical pneumonia.

March 12; Location: WHO; Headquarters, Geneva; Event: WHO issues 
global alert about cases of severe atypical pneumonia following 
mounting reports of spread among hospital staff in Hong Kong and Hanoi. 
CDC offers assistance to WHO.

March 13; Location: WHO; Headquarters, Geneva; Event: WHO sends 
emergency alert to GOARN partners.

March 14; Location: United States; Event: CDC activates Emergency 
Operations Center.

March 15; Location: WHO; Headquarters, Geneva; Event: WHO issues 
rare global travel advisory, names the mysterious illness "severe acute 
respiratory syndrome" (SARS), and declares it a "worldwide health 
threat." WHO issues its first definitions of suspect and probable 
cases, calls on travelers to be aware of symptoms, and issues advice to 
airlines.

March 15; Location: United States[A]; Event: CDC issues travel 
advisory suggesting postponement of nonessential travel to Hong Kong, 
Guangdong Province, and Hanoi. CDC issues preliminary case definition 
for suspected SARS and initiates domestic surveillance for SARS. First 
suspected U.S. case is identified.

March 16; Location: United States; Event: CDC begins distributing 
health alert cards to passengers arriving from Hong Kong at four 
international airports.

Mid-March; Location: Taiwan; Event: CDC team arrives in Taiwan to 
assist in SARS response.

March 17; Location: WHO; Headquarters, Geneva, and multiple 
locations; Event: WHO sets up worldwide network of laboratories to 
expedite detection of causative agent and to develop a robust and 
reliable diagnostic test. A similar network is set up to pool clinical 
knowledge on symptoms, diagnosis, and management. A third network is 
set up to study SARS epidemiology.

March 28; Location: China; Event: China joins WHO's collaborative 
networks, initially set up on March 17.

March 30; Location: Hong Kong; Event: Third superspreader event 
in Hong Kong: Health authorities announce that 213 residents of Amoy 
Gardens housing estate have been hospitalized with SARS.

April 2; Location: WHO; Headquarters, Geneva; Event: WHO issues 
most stringent travel advisory in its 55-year history, recommending 
that people postpone all but essential travel to Hong Kong and 
Guangdong Province until further notice.

April 3; Location: China; Event: WHO team arrives in Guangdong.

April 4; Location: United States; Event: President Bush signs 
executive order adding SARS to the list of quarantinable communicable 
diseases. This order provides CDC, through its Division of Global 
Migration and Quarantine, with the legal authority to implement 
isolation and quarantine measures.

April 16; Location: WHO; Headquarters, Geneva; Event: WHO 
laboratory network announces conclusive identification of SARS 
causative agent: a new coronavirus.

April 19-20; Location: China; Event: Change in political stance 
by Chinese leadership. Top leaders advise officials not to cover up 
cases of SARS; mayor of Beijing and Health Minister, both of whom 
downplayed the SARS threat, are removed from their posts.

April 28; Location: Vietnam; Event: First country to successfully 
contain its outbreak of SARS.

May 2; Location: United States; Event: State Department holds 
interagency meeting on SARS.

May 3; Location: Taiwan; Event: WHO sends officials to Taiwan to 
assist CDC team.

May 17; Location: WHO; Headquarters, Geneva; Event: First global 
consultation on SARS epidemiology concludes its work, confirming that 
available evidence supports the control measures recommended by WHO.

May 27; Location: WHO; Headquarters, Geneva; Event: World Health 
Assembly resolution recognizes the severity of the threat that SARS 
poses and calls on all countries to report cases promptly and 
transparently. A second resolution strengthens WHO's capacity to 
respond to disease outbreaks.

June 17-18; Location: Malaysia; Event: WHO holds Global 
Conference on SARS to review scientific findings on SARS and examine 
public health interventions to contain it.

July 5; Location: WHO; Headquarters, Geneva; Event: WHO announces 
that the global SARS outbreak has been contained.

September 8; Location: Singapore; Event: Singapore announces that 
a medical researcher is infected with SARS. Based on an investigation 
of this incident, WHO concludes that the patient was accidentally 
infected in the laboratory.

December 17; Location: Taiwan; Event: Taiwan announces that a 
researcher is infected with SARS. Public health authorities conclude 
that the infection was acquired in a laboratory.

December 20-; January 5, 2004; Location: China; Event: A man in 
Guangdong Province is hospitalized with SARS-like symptoms on December 
20. Chinese authorities inform WHO on December 26. After initial 
diagnostic tests are inconclusive, authorities send the samples to two 
WHO-designated reference laboratories in Hong Kong. On January 5, the 
laboratories confirm that the patient has SARS. None of the patient's 
contacts contracted SARS.

December 31-January 17, 2004; Location: China; Event: A woman in 
Guangdong Province is hospitalized with SARS-like symptoms on December 
31. Chinese authorities inform WHO and samples are submitted to two 
WHO-designated reference laboratories in Hong Kong. On January 17, 
Chinese authorities announce that the patient has SARS. None of the 
patient's contacts contracted SARS.

Year: 2004.

January 6-27; Location: China; Event: A man in Guangdong Province 
is hospitalized with SARS-like symptoms on January 6. Chinese 
authorities inform WHO and samples are submitted to WHO-designated 
reference laboratories in Hong Kong. On January 27, WHO announces that 
the patient has probable SARS.

January 7-30; Location: China; Event: A doctor in Guangdong 
Province becomes ill with SARS-like symptoms and is diagnosed with 
pneumonia on January 14. However, he was not properly isolated in 
hospital until January 16, he was not declared as a suspected SARS case 
to China's Ministry of Health until January 26, and WHO was not 
informed until January 30.

January 9-16; Location: China; Event: A team of international 
experts from WHO conducts a joint investigative mission in Guangdong 
Province with colleagues from China's Ministry of Health, Ministry of 
Agriculture, the Chinese Center for Disease Control and Prevention, and 
the Guangdong Center for Disease Control and Prevention to identify the 
sources of infection of the most recent SARS cases. The team finds no 
definitive source of infection for any of the cases.

Source: GAO analysis of WHO and CDC data.

[A] Date of the first known case(s) of SARS.: 

[End of table]

[End of section]

Appendix III: Estimates of the Economic Impact of SARS:

Estimates of the economic impact of SARS have been produced by multiple 
sources and vary due to the inexact nature of estimating the impact of 
a recent event such as SARS. When the SARS outbreak first emerged, a 
number of institutions began estimating the potential economic impact 
of the disease. These institutions included private investment banks, 
industry organizations, academics, consulting firms, and international 
financial institutions such as the Asian Development Bank. To produce 
their estimates, assumptions had to be incorporated regarding the 
expected duration of SARS, the number of sectors affected, and country-
specific macroeconomic conditions. As such, estimates of economic 
impact have been broad in nature, have varied depending on model 
assumptions, and were often revised when actual data were received. For 
example, some of the initial economic impact estimates were revised 
downward once data emerged showing China's strong economic growth 
during the first 4 months of 2003.

To describe the economic impact of SARS in Asia, we primarily relied on 
impact estimates generated from institutions using simulation models. 
Table 3 provides information on the models we reviewed. As the table 
shows, each of these models was used to analyze a low scenario case and 
a high scenario case, which differed based on assumptions regarding the 
expected duration of the SARS outbreak and hence the expected duration 
of the shock to the economy resulting from SARS. To accord with the 
shorter duration of the actual outbreak, the low scenario results 
estimated the economic impact of SARS at roughly 0.5 percent to 2 
percent of gross domestic product (GDP).[Footnote 41] All three models 
show that the largest economic impacts as a percentage of GDP were 
estimated for Hong Kong and Singapore, which is due to their previously 
lowered consumption demand and high share of tourism and retail.

Table 3: Models Estimating the Economic Impact of SARS on GDP in Asia, 
2003:

[See PDF for image]

[End of table]

In addition to the model estimates provided in table 3, we also 
reviewed SARS cost estimates provided by the Far Eastern Economic 
Review. The Far Eastern Economic Review's estimate of $11 billion was 
generated by calculating an average estimated percentage loss in GDP 
using reports from various governments and financial institutions and 
applying that average to the nominal GDP figures provided by the 
International Monetary Fund.[Footnote 42]

[End of section]

Appendix IV: Comments from the Department of Health and Human Services:

DEPARTMENT OF HEALTH & HUMAN SERVICES:

Office of Inspector General:

Washington, D.C. 20201:

APR 16 2004:

Mr. David Gootnick:

Director, International Affairs and Trade 
United States General Accounting Office Washington, D.C. 20548:

Dear Mr. Gootnick:

Enclosed are the Department's comments on your draft report entitled, 
"Emerging Infectious Diseases: Asian SARS Outbreak Challenged 
International and National Responses" (GAO-04-564). The comments 
represent the tentative position of the Department and are subject to 
reevaluation when the final version of this report is received.

The Department provided several technical comments directly to your 
staff.

The Department appreciates the opportunity to comment on this draft 
report before its publication. 

Sincerely,

Signed by: 

Dara Corrigan:

Acting Principal Deputy Inspector General:

Enclosure:

The Office of Inspector General (OIG) is transmitting the Department's 
response to this draft report in our capacity as the Department's 
designated focal point and coordinator for General Accounting Office 
reports. OIG has not conducted an independent assessment of these 
comments and therefore expresses no opinion on them.

COMMENTS OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES ON THE GENERAL 
ACCOUNTING OFFICE'S DRAFT REPORT: "EMERGING INFECTIOUS DISEASES: ASIAN 
SARS OUTBREAK CHALLENGED INTERNATIONAL AND NATIONAL RESPONSES" (GAO-04-
564):

The report is a good summary of the Severe Acute Respiratory Syndrome 
(SARS) outbreak in Southeast Asia and actions taken during and after 
the epidemic by the World Health Organization (WHO) and the affected 
countries, as well as actions taken by the Department of Health and 
Human Services (HHS) to combat the epidemic globally and to protect the 
United States (U.S.), focusing on the activities of our Centers for 
Disease Control and Prevention (CDC). The report also contains a useful 
overview of WHO's efforts to revise its International Health 
Regulations and correctly ties the newly intense efforts at WHO to the 
impact of SARS and lessons learned.

The SARS outbreak did indeed challenge international and national 
responses. While the report correctly focuses on the issues and events, 
the intensity of the coordination and collaboration within governments 
and among nations was unprecedented. The report documents many of the 
activities, but does not go into detail on the substantial coordination 
and collaboration efforts among U.S. executive branch agencies and 
among those agencies and the governments in East and Southeast Asia. 
While we recognize the latter was not the focus of this report, the 
following briefly describes how HHS organized itself to manage its 
response and effectively faced the new challenges.

Tommy G. Thompson, as Secretary of HHS, led the Department's response 
to the SARS epidemic, thus ensuring coordinated roles and responses 
across our agencies most directly involved in the response domestically 
and internationally - CDC, the National Institutes of Health, and the 
Food and Drug Administration. Primarily through his Office of Global 
Health Affairs and Office of Public Health Emergency Preparedness, the 
Secretary also provided the leadership to ensure the necessary 
coordination and alignment of our domestic and international responses. 
Using the cutting-edge technology of his new Command Center and face-
to-face opportunities in Geneva and Washington, the Secretary 
maintained close contact with the leadership at WHO and with a number 
of affected governments, including Canada, the People's Republic of 
China, the Socialist Republic of Vietnam, and the Hong Kong Special 
Administrative Region.

For example, after the 2003 SARS outbreak, China's Ministry of Health 
committed to more open communication with HHS in any future avian 
influenza outbreak and to the sharing with HHS of key laboratory 
samples from a localized SARS outbreak in Guangdong that occurred last 
winter. Secretary Thompson also pledged to assist China in its fight 
against SARS and other emerging diseases through collaboration of HHS 
scientists working with their Chinese counterparts. The signing of this 
U.S.-China Emerging Infections Program in May 2004 represents a multi-
year, multi-million dollar program of cooperation between HHS and the 
Chinese Ministry of Health aimed at strengthening fundamental public 
health infrastructure and improving the national capacity to manage a 
number of infectious diseases, including SARS and pandemic:

influenza as part of a worldwide early warning surveillance network HHS 
is building. These are but a few examples of how Secretary Thompson's 
diplomatic efforts and leadership, in coordination with the Department 
of State (DOS), helped to obtain needed information for HHS and DOS 
about the global response and the collective and individual SARS 
efforts and challenges at the country-level. With assistance from DOS, 
Secretary Thompson's personal interventions and diplomatic outreach 
with Southeast Asian government counterparts substantially aided in 
gaining access to those countries by WHO and our own experts.

The Secretary and his senior staff used the Secretary's Command Center 
to hold daily briefings during which a CDC official, usually the 
Director, presented the latest information on the SARS situation 
worldwide and actions being taken overseas and domestically to protect 
the U.S. Experts from DOS, Homeland Security, and Defense participated 
in these briefings. Issues included coordination with WHO and affected 
countries, plans for scientific research, communication with the 
public, and communication with other national governments and 
economies, etc. Daily reports and maps, prepared by the Secretary's 
Command Center staff, facilitated the tracking of the epidemic and 
maximized the deployment of HHS staff.

HHS believes the increased inter-agency coordination and lessons we 
learned during the SARS epidemic in 2003 were highly useful in our 
response to the Avian Influenza (H5N1) outbreak in Asia in 2004. The 
interagency group has made progress on a number of international 
operational and policy issues since the Spring of 2003, and shaped our 
engagement in the process to revise the WHO International Health 
Regulations.

HHS believes this report makes a valuable contribution, and we find its 
recommendations to be appropriate. They identify important work that 
needs to be undertaken or brought to conclusion as quickly as possible 
so that we are sufficiently prepared for the next epidemic. The 
recommendations stress the interagency nature of the work to be done 
internationally as well as domestically. Again, the report correctly 
recognizes the importance of collaboration with our partner agencies, 
in particular the valuable interagency coordination activities under 
the purview of DOS. To carry out some of the recommendations, sensitive 
legal and privacy issues and diplomatic concerns must be carefully 
addressed.

[End of section]

Appendix VI: Comments from the World Health Organization:

United States Department of State 
Assistant Secretary and Chief Financial Officer:

Washington, D.C. 20520:

APR 15 2004:

Dear Ms. Williams-Bridgers:

We appreciate the opportunity to review your draft report, "EMERGING 
INFECTIOUS DISEASES: Asian SARS Outbreak Challenged International and 
National Responses," GAO-04-564, GAO Job Code 320198.

The enclosed Department of State comments are provided for 
incorporation with this letter as an appendix to the final report.

If you have any questions concerning this response, please contact 
Sara Allinder Mestre, Foreign Affairs Officer, Bureau of Oceans and 
International Environment and Scientific Affairs, at (202) 647-3649.

Sincerely,

Dana Corrigan
Acting Principal Deputy Inspector General

cc:	GAO - Patrick Dickriede 
OES - Lee Morin 
State/OIG - Mark Duda State/
H - Paul Kelly:

Department of State Comments on GAO Draft Report 
EMERGING INFECTIOUS DISEASES: Asian SARS Outbreak Challenged 
International and National Responses 
(GAO-04-564, GAO Job Code 320198):

We appreciate the opportunity to comment on your draft report, 
"Emerging Infectious Diseases, Asian SARS Outbreak Challenged 
International and National Responses". The report is a useful summary 
of the Severe Acute Respiratory Syndrome (SARS) outbreak and its 
impact.

The Department of State agrees that the Asian SARS outbreak challenged 
international and national responses. At the outset, some Asian 
governments did not recognize the SARS emergency. The Department of 
State applied diplomatic pressure on governments to increase 
transparency and response, helped facilitate the U.S. government 
response to SARS in Asia, and provided information on SARS to U.S. 
government employees and citizens in the region. By the end of the 
outbreak in July 2003, SARS had served to heighten awareness of the 
need for surveillance and response activities and changed how nations 
think about reporting disease outbreaks internationally and internally. 
Both the World Health Organization (WHO) and its member states gained 
real-world insights that have benefited the process, under WHO 
auspices, of revising the International Health Regulations. The report 
correctly identifies the challenges in such a revision, but the fact 
that countries accept the need is a positive step forward.

The SARS outbreak also led to increasing coordination among Federal 
agencies charged with a response, and thus provided lessons learned, 
including for the Avian Influenza (H5N1) outbreak in Asia. During the 
2003 SARS outbreak,

the Department of State's internal working group, the Department of 
State-led Interagency Working Group, and the Department of Health and 
Human Services' (HHS) Emergency Operations Centers kept in constant 
contact. There were daily phone calls to exchange information, which 
allowed the Department of State to support, through diplomatic means, 
HHS and international efforts to gather information and to respond to 
the epidemic. The Interagency Working Group has addressed international 
policy and response issues, such as contact tracing and medical 
evacuations, through a number of meetings since May 2003. The 
interagency collaboration also allowed the group to address the Avian 
Influenza outbreak when it was realized to be a major public health 
issue in January 2004.

The report recommends that the Secretary of Health and Human Services, 
in consultation with the Secretary of State, work with WHO and official 
representatives from other WHO member states to strengthen the response 
capacity of WHO's global infectious disease network. The Department of 
State is committed, as a foreign policy matter, to work both with WHO 
and its member states to strengthen the international response to 
infectious disease outbreaks, and to achieve effective revisions of the 
International Health Regulations.

The report also recommends authorities for HHS to facilitate contact 
tracing of arriving passengers determined to be infected with or 
exposed to SARS. We are pleased to report that the Department of State 
has been working on those issues in collaboration with our interagency 
partners since the SARS outbreak. The Department of State has brought 
together officials of the Departments of Homeland Security and Health 
and Human Services to facilitate planning and discussion on obtaining 
passenger contact information. However, as the report notes, serious 
legal issues still exist for both the United States and for other 
governments. These center on privacy and access to personal information 
and may require legislation or regulatory changes. The Department of 
State will continue to work with its partners to address this issue.

The Department of State also has worked closely with HHS' Centers for 
Disease Control and Prevention (HHS/CDC) to develop protocols on how to 
handle medical evacuations of persons suspected or confirmed to have 
quarantinable diseases, such as SARS. The Department of State's highest 
priority is the safety and well being of American citizens traveling or 
residing abroad, including its employees and their families. The 
Department has direct responsibility for its American employees and 
their families. Medical evacuation procedures, including how to 
maintain liaison with HHS/CDC, have been documented, and will shortly 
be disseminated to our Embassies and consulates throughout the world. 
It is important to note, however, that capacity for such medical 
evacuations will always be limited, as will capacity of U.S. medical 
facilities to handle a large influx of quarantinable patients.

The Department of State believes that this report documents important 
lessons for other infectious disease outbreaks beyond the 2003 SARS 
epidemic.

[End of section]

Appendix VII: GAO Contacts and Staff Acknowledgments:

GAO Contacts:

Martin T. Gahart, (202) 512-3596 Cheryl Goodman, (202) 512-6571:

Acknowledgments:

In addition to the persons named above, Janey Cohen, Patrick Dickriede, 
Anne Dievler, Suzanne Dove, Sharif Idris, Roseanne Price, Kendall 
Schaefer, and Richard Seldin made key contributions to this report.

(320198):

FOOTNOTES

[1] "Summary of probable SARS cases with onset of illness from 1 
November 2002 to 31 July 2003," (Geneva, Switzerland: WHO, September 
26, 2003), http://www.who.int/csr/sars/country/table2003_09_23/en/
(downloaded March 12, 2004).

[2] Scientific evidence suggests that the virus originated in animals 
and crossed into human populations. See Y. Guan, "Isolation and 
characterization of viruses related to the SARS coronavirus from 
animals in southern China," Science, vol. 302, no. 5,643 (2003).

[3] Atypical pneumonia is caused by a variety of bacteria and viruses 
and has different clinical signs and a more protracted onset of 
symptoms compared with other forms of pneumonia. 

[4] WHO, which consists of 192 member states, is headquartered in 
Geneva and has six regional offices and numerous country offices. The 
Western Pacific Regional Office (WPRO) serves Asian countries and has 
links to country offices in China and other Asian countries. WHO is 
governed by the World Health Assembly, which meets yearly and is 
attended by delegations from all member states. The assembly determines 
WHO's policies and is authorized to adopt regulations concerning the 
prevention of the international spread of disease and make 
recommendations about any subject dealt with by WHO. China is member of 
WHO, but Taiwan is not. Hong Kong's interests are represented in WHO by 
China. 

[5] The influenza surveillance network comprises four WHO Collaborating 
Centers and 112 institutions in 83 countries, which are recognized by 
WHO as "WHO National Influenza Centers." The National Influenza Centers 
collect specimens in their country and perform primary virus isolation 
and characterization. They ship newly isolated strains to the 
Collaborating Centers for analysis, the result of which forms the basis 
for WHO recommendations on the composition of influenza vaccine for the 
Northern and Southern Hemisphere each year.

[6] About 40 percent of the approximately 200 outbreaks investigated 
and reported to WHO each year come from the Global Public Health 
Intelligence Network (GPHIN), a system developed by Canadian health 
officials and used by WHO since 1997 that searches for reports of 
disease outbreaks from more than 950 news feeds and discussion groups 
around the world in the media and on the Internet.

[7] The Departments of Defense, Homeland Security, and Transportation 
also assisted State and HHS during the SARS outbreak.

[8] The National Institute of Allergy and Infectious Diseases and the 
Food and Drug Administration also played roles in the response to SARS 
by conducting and supporting scientific research (e.g., on diagnostic 
tests and a vaccine) during and after the outbreak.

[9] At this time, WHO defined a suspect case as one occurring after 
February 1, 2003, with a history of a high fever (over 38 degrees 
Celsius) and one or more respiratory symptoms, including cough, 
shortness of breath, and difficulty breathing. It defined a probable 
case as one in which there was close contact with a person diagnosed 
with SARS; a history of recent travel to areas reporting SARS; a 
diagnosis of "suspect" with chest X-ray findings of pneumonia or 
respiratory distress syndrome; or an unexplained respiratory illness 
resulting in death, plus an autopsy examination demonstrating the 
pathology of respiratory distress syndrome without an identifiable 
cause. WHO revised this definition several times, publishing the latest 
revision on August 14, 2003 (see http://www.who.int/csr/sars/
postoutbreak/en/). 

[10] Section 361 of the Public Health Service Act, 42 U.S.C. § 264. 

[11] See 42 C.F.R. pts 70 and 71; 21 C.F.R. pts 1240 and 1250. 

[12] According to airline industry association officials, under 
European Union privacy laws and regulations, there could be problems 
with sharing passenger names and addresses with government agencies.

[13] During the SARS outbreak, international travelers constituted an 
important source of transmission. For example, CDC reported that all of 
the United States' eight laboratory-confirmed SARS cases and almost all 
of the 27 probable SARS cases were found in individuals who had 
traveled to a SARS-affected area or came into close contact with 
someone who did. 

[14] CDC did not provide us with details about the various options 
because they had not yet been finalized.

[15] State officials said they are responsible for providing medical 
services (including medical evacuations, if necessary) only to certain 
U.S. government employees and their dependents, although embassies may 
assist U.S. citizens overseas in obtaining medical care on a case-by-
case basis. However, it is primarily the responsibility of U.S. 
citizens to arrange their own medical evacuation. During the SARS 
outbreak, State helped arrange three medical evacuations for U.S. 
citizens. The first was performed by the Department of Defense from 
Hanoi to Taiwan; the second was a land evacuation performed by 
ambulance from Shenzhen to Hong Kong; and the third was performed by a 
medical evacuation company from Taiwan to Atlanta.

[16] Most medical evacuation companies do not have their own aircraft 
and crews; rather, they subcontract aircraft as medical evacuation 
needs arise.

[17] When warranted by conditions at an overseas post, State can 
authorize U.S. government employees and their dependents to depart the 
post.

[18] The report was released during the Chinese New Year Holiday. 
According to one official, the report may not have received significant 
attention from health officials on leave during the holiday.

[19] See People's Republic of China, Ministry of Health, "Explanation 
on Regulations on State Secrets in Health Work and Their Specific 
Classification and Scope," March 1, 1991, published in Chinese Law & 
Government 66 (2003) (Fei-Ling Wang trans).

[20] Martin Enserink"SARS in China: China's Missed Chance," Science, 
vol. 301, no. 5,631 (2003).

[21] "SARS in Hong Kong: From Experience to Action," (Hong Kong: SARS 
Expert Committee, October 2, 2003), http://www.sars-expertcom.gov.hk/
english/reports/reports/reports fullrpt.html (downloaded Oct. 3, 
2003).

[22] SARS Expert Committee Report, "SARS in Hong Kong: From Experience 
to Action."

[23] "Use of Quarantine to Prevent Transmission of Severe Acute 
Respiratory Syndrome--Taiwan 2003," MMWR, vol. 52, no. 29 (July 25, 
2003).

[24] "Efficiency of Quarantine during an Epidemic of Severe Acute 
Respiratory Syndrome--Beijing, China 2003," MMWR, vol. 52, no. 43 (Oct. 
31, 2003). 

[25] People's Republic of China, "Regulations for the Management of 
Infectious Atypical Pneumonia," May 13, 2003, published in 36 Chinese 
Law & Government 91(2003) (Fei-Ling Wang, trans).

[26] People's Republic of China, "Regulations on Contingency Measures 
for Public Health Emergencies," May 9, 2003, published in 36 Chinese 
Law and Government 76 (2003) (Fei-Ling Wang,tran).

[27] Laws of Hong Kong, Prevention of the Spread of Infectious 
Diseases, ch. 141B, regs. 27A and 27B (Apr. 17, 2003).

[28] These figures represent the net loss in GDP and take into account 
the potential decline in imports that acts to partially offset the 
potential decline in consumption or exports. As such, if the total loss 
in spending, rather than the net loss in GDP, is estimated, the Asian 
Development Bank's cost estimate rises to $60 billion.

[29] Some economies were more vulnerable to SARS than others due to 
structural issues, such as the relative share of tourism in the 
economy, government spending responses, and prior consumer sentiment. 
For example, Hong Kong and Singapore have larger estimated GDP losses 
due to SARS because of weakened consumption demand already apparent in 
late 2002.

[30] We cannot, however, attribute viewed changes in quarterly GDP 
growth exclusively to SARS, given that other factors were relevant, 
such as the conflict in Iraq. Nonetheless, comparing Asian GDP growth 
rates with the average growth rate in Organization for Economic 
Cooperation and Development countries shows a much more distinct 
decline in the second quarter of 2003.

[31] As with the quarterly decline in GDP, we cannot attribute the 
entire decrease in airline traffic to SARS, as the outbreak occurred 
during an already depressed market because of the war in Iraq.

[32] The World Travel and Tourism Association used its own model to 
generate its estimates for the dollars lost from the decline in 
tourism. As such, these numbers do not correspond equally to the 
estimates in table 1.

[33] The duration of estimated job losses is unknown. Travel and 
tourism in Asia has largely recovered, and International Airline 
Traffic Association forecasts for the industry are optimistic.

[34] Foreign trade and investment were more resilient than consumption 
during the initial stages of the outbreak such that estimated economic 
effects were less significant due to the rapid rebound of Asian 
economies in the third quarter of 2003.

[35] According to WHO officials, the language in the draft regulations 
dealing with conducting on-the-spot investigations was intended to 
closely reflect wording used in World Health Assembly Resolution 58.28, 
adopted on May 28, 2003, which among other things, urged WHO members to 
give high priority to IHR revision.

[36] For example, article 8(3) of the draft regulations states that 
"the health administration in whose territory the alleged event . . . 
is occurring shall collaborate with WHO in assessing the potential for 
international disease spread and possible interference with 
international traffic and the adequacy of control measures and, when 
necessary, in conducting on-the-spot studies by a team sent by WHO . . 
." (emphasis added).

[37] The draft regulations only state that "significant interference" 
is a "refusal of entry or departure or delaying entry or departure for 
more than 24 hours, for travelers and conveyances." WHO, Proposed 
International Health Regulations, art. 7.4.

[38] WHO, World Health Assembly Res. 56.28 (May 28, 2003).

[39] Jong-Wha Lee and Warwick J. McKibbon, "Globalization and Disease: 
The Case of SARS, Working Paper No. 2003/16," Research School of 
Pacific and Asian Studies, Australian National University and the 
Brookings Institution, Washington, D.C. (2003).

[40] To determine the reliability of the official national accounts 
data, we verified that the general patterns reported were consistent 
with other documentary evidence and reviewed each economy's compliance 
with the International Monetary Fund's data dissemination standards. We 
conclude that the data is sufficiently reliable for the purposes of 
establishing decreased economic activity during the second quarter of 
2003.

[41] The International Monetary Fund announced in April 2003 that the 
estimated decline in GDP due to SARS was 0.2 percent for China and 0.4 
percent for East Asia. The World Bank's East Asia Update in April 2003 
also provided an estimate of the decline in GDP due to SARS at 0.3 
percent for East Asia. However, neither organization has published a 
model to describe how it arrived at these estimates.

[42] The Far Eastern Economic Review is a regional economic business 
weekly. Its cost estimates of SARS are provided in a 2003 special 
report on the SARS outbreak. The financial institutions that provided 
economic impact estimates to the review included Merrill Lynch, Goldman 
Sachs, JP Morgan, Lehman Brothers, Morgan Stanley, ING Financial 
Markets, BNP Paribas Peregrine, Standard & Poor's, and IDEAGlobal.

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