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Biodefense May Hold Clue to SARS Containment in USA - 2003-05-04

After returning in late April from a trip to China, Senator Bill Frist, a medical doctor by training, had this to say about the new disease SARS: “With a virus like this, which knows no borders and has no geographic boundaries, the world is at risk, including Americans.” But while China and other countries around the world struggle to contain the SARS virus, the United States has thus far managed to stave off outbreaks around the country. Is this due to luck or to the benefits of biodefense systems that have been put in place after September 11 and the anthrax attacks of 2001?

In early March, America’s top infectious disease specialists watched nervously as an unknown respiratory disease spread throughout Asia and into Canada. For U.S. medical planners, the disease, called SARS, or Severe Acute Respiratory Syndrome, represented their worst nightmare: an outbreak of a new, life-threatening contagion for which there is no diagnosis, treatment or vaccine.

But it was also the kind of event medical experts had been planning for since the anthrax attacks of October 2001. Though SARS is thought to be a naturally occurring disease that jumped from animal to humans in China’s eastern Guangdong Province, the U.S. Government put into action procedures designed to address a bioterror attack.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, says hard work over the past year and a half has helped to keep SARS at bay.

“Ever since September 11 and the anthrax attacks, we have been in a state of very proactive public health surveillance and preparedness and responsiveness,” the doctor says. “Our mindset -- that is part of our background vis ? vis our preparedness for bioterrorism -- put us in much better stead with regard to a naturally occurring epidemic like the SARS epidemic because bioterrorism is nothing more than a deliberate form of an emerging and reemerging infection.”

To combat SARS, the Center for Disease Control and Prevention, or CDC, America’s leading public health agency, directed a nationwide response. In record time, it isolated the SARS virus using samples flown in from Asia and began developing diagnostic tests and vaccines. In just two weeks, scientists at the C-D-C and in Canada decoded the genetic sequence of the virus. This work will help provide clues on the origin of the new disease.

On the local level, the CDC supplied state and community health officials with updated information on the disease. The U.S. government also issued travel warnings and monitored people arriving from Asia. And in a sign of the gravity with which the U.S. government regarded SARS, President Bush added the new virus to the short list of deadly diseases for which individuals can be legally quarantined.

Some analysts say that at the core of America’s response to SARS is a revamped public health system that is called the country’s first line of defense in case of a bioterror attack. Since 2001, hospitals and medical centers in the United States have been bolstered with more funding and stronger links to leading federal agencies like the CDC in Atlanta.

In the case of Loudoun County, Virginia, additional resources and better communication paid off handsomely in February. A month before the World Health Organization declared SARS a worldwide health threat, medical authorities in Loudoun County contained a possible outbreak from what is believed to have been America’s first SARS case. As director of Loudoun County’s Health Department, Dr. David Goodfriend coordinated the county’s response to SARS.

“Bioterrorism preparedness strengthened our ability to respond to any outbreak by not only increasing our staffing level -- we have two positions in our local health department paid for by a federal bioterrorism grant which help us respond to any outbreak situations -- but also by getting all of us working together on outbreak type issues,” Dr. Goodfriend says.

But some observers say the focus on biopreparedness is overblown. What the United States needs most, in their opinion, is a solid health system that responds to known medical emergencies. So far, in America’s response to SARS, it’s not technology or biopreparedness but tried and true medical procedures that have made the difference. Dr. Peter Alcabes is a professor of epidemiology at the Hunter College School of Health Sciences in New York City.

“We’ve been well prepared to deal with SARS for some time now,” he says. “We know how to deal with old-fashioned contagions. We know about quarantine and isolating infectious patients. We’ve known about that for decades. We would have done as well 20 or 30 years ago as we are doing now.”

If fears about bioterrorism have resulted in improvements in public health, then the United States will be better off. But the danger, Dr. Alcabes says, is that in its rush to prepare for unforeseeable threats, America may be hurting basic medicine.

“Our concerns about bioterrorism and the furor to protect ourselves against this possibly chimerical threat is taking away from some public health programs that we really need,” he says. “We don’t want to close primary care clinics or deliver less good prenatal care or cut back on recent gains in infant mortality because we are preparing for some invisible menace.”

Much about SARS remains unknown, including how it originated and is transmitted and its mortality rate. In the face of such mysteries, thus far America has been fortunate, particularly in comparison to Canada.

Both America and Canada are developed countries with advanced health care systems. In late February and early March, each country welcomed home an elderly woman from a trip in Asia. Both women were stricken with SARS. But the outcomes were far different.

In the city of Toronto alone, there are close to 40 active SARS cases and at least 20 people have died. All these cases are linked to an elderly Chinese-Canadian woman who returned from a trip to Hong Kong in late February with the new disease. She infected family members and dozens of hospital workers before succumbing to SARS. Almost 500 people are in quarantine in Toronto. And in late April, the World Health Organization issued a travel advisory for Toronto, the first for a North American city in the organization’s 55-year history.

But in the United States, an elderly American woman returning from a trip to China in early February did not spread SARS to family members or health care workers in Loudoun Country, Virginia. She was treated and released from a hospital and is now fully recovered. Among America’s 52 SARS cases, no one has died.

Dr. Goodfriend of Loudoun County’s Health Department says good health care played a part. When the ill woman checked into the hospital with an unusual case of pneumonia, hospital officials immediately called the Health Department for advice. The patient was then placed in an isolated room with restricted air circulation. And nurses and doctors wore protective gear. But that doesn’t explain everything.

““We may never know why in her case it wasn’t spread to others, whereas in other cases it was spread quickly,” Dr. Goodfriend says. “We do know that once she was in the hospital, the steps the hospital took were very important to make sure it didn’t get spread to health care workers.”

In an age of global travel and porous borders, the United States has learned once again that what happens in a remote part of the world can affect its citizens. This reality calls for an expansion of domestic preparedness beyond U.S. borders, says Dr. Donald Burke, Director of the Center for Public Health Preparedness at Columbia University.

“The one place that we have not put our attention to in our overall biodefense preparation has been in the international arena,” he says. “A good bit of the funding and preparation so far has been to repair and bolster the public health infrastructure in the US as a top priority, and now we are seeing that we need to extend beyond just our domestic concerns to engage emerging infections around the world. We have now learned the all too painful lesson that a microbe anywhere in the world can be in the US in a relatively short period of time.”

With a combination of good fortune and investment in public health, the United States has thus far fended off the world’s latest deadly disease. However, the success of future efforts to contain outbreaks of infectious disease, whether naturally occurring or terror-driven, may well depend on America’s ability to expand biodefense preparations beyond its own borders.