Emerging Infectious Diseases: Asian SARS Outbreak Challenged International and National Responses

Emerging Infectious Diseases: Asian SARS Outbreak Challenged
International and National Responses (28-APR-04, GAO-04-564).

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.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-04-564
ACCNO: A09860
TITLE: Emerging Infectious Diseases: Asian SARS Outbreak
Challenged International and National Responses
DATE: 04/28/2004
SUBJECT: Disease detection or diagnosis
Economic analysis
Health resources utilization
Infectious diseases
International cooperation
Public health legislation
Public health research
Respiratory diseases
Public health
SARS
Severe Acute Respiratory Syndrome
Asia

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GAO-04-564

United States General Accounting Office

GAO 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

GAO-04-564

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

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.

www.gao.gov/cgi-bin/getrpt?GAO-04-564.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact David Gootnick at (202)
512-3149 or Janet Heinrich at (202) 512-7119.

April 2004

EMERGING INFECTIOUS DISEASES

Asian SARS Outbreak Challenged International and National Responses

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.

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

1 2 6

39 43 44 45 46

Appendixes

Appendix I: Appendix II: Appendix III: Appendix IV:

Appendix V: Appendix VI: Appendix VII:

SARS Cases and Deaths, November 2002-July 2003

SARS Chronology

Estimates of the Economic Impact of SARS

Comments from the Department of Health and Human Services

Comments from the Department of State

Comments from the World Health Organization

GAO Contacts and Staff Acknowledgments

GAO Contacts Acknowledgments

50 52 56

67 67 67

Tables Table 1: Estimated Economic Cost of SARS in Asia 33
Table 2: Asian Government Stimulus Packages in Response to
SARS, 2003 39
Table 3: Models Estimating the Economic Impact of SARS on GDP
in Asia, 2003 57

Contents

Figures Figure 1: Figure 2: Timeline of SARS Events and Actions CDC 8 18
Health Alert Notice
Figure 3: Quarterly GDP Growth for Various Asian
Economies,
2002-2003 34
Figure 4: Estimated Economic Impacts of SARS on
Travel and
Tourism 36
Figure 5: Quarterly Retail Sales Growth in Selected
Asian
Economies, 2002-2003 38

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

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separately.

United States General Accounting Office Washington, D.C. 20548

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.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.

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).

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 largescale
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.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:

o 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.

2Scientific 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).

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

o 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 pneumonia3 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.)

3Atypical 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.

Figure 1: Timeline of SARS Events and Actions

Global Infectious Disease Although national governments bear primary
responsibility for disease Control and the Role of the surveillance and
response, WHO, an agency of the United Nations, plays a World Health
Organization 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 2005.4

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)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

4WHO, 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.

5The 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.

the media and the Internet.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.7 Within HHS, the Office of Global Health
Affairs and CDC work closely with WHO and foreign governments in response
efforts.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.

6About 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.

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

8The 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.

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:

o 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.

o 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.

o 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

Deployment

Virtual Networks

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.

Under GOARN's auspices, WHO rapidly deployed 115 specialists from 26
institutions in 17 countries to provide direct technical assistance to
SARSaffected 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.

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

Global Alerts and Travel Recommendations

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.

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.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-

9At 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/).

Guidelines and Recommendations on the Management of SARS

WHO Faced Challenges in Issuing Guidance and Recommendations

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.

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.

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

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,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.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.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.

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

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

12According 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.

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.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,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

13During the SARS outbreak, international travelers constituted an
important source of transmission. For example, CDC reported that all of
the United States' eight laboratoryconfirmed 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.

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

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.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.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

15State 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-bycase 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.

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

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.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

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

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.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,

18The 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.

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.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.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

19See 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).

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

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.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
decisionmaking 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

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).

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 As Asian governments monitored the spread of SARS,
weaknesses in Surveillance Systems and disease surveillance systems,
public health capacity, and hospital infection Public Health Capacity
control caused delays and gaps in disease reporting, which further

Further Constrained Efforts 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 computerbased 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.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

Improved Screening and Reporting

Rapid Isolation and Contact Tracing

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.

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.

The identification of patients with suspect and probable cases of SARS and
their close contacts reduced the rate of contact between SARS patients and

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

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 The widespread use of personal protective
equipment helped contain the

Control spread of SARS in hospitals. For example, in China, when hospital
infection control measures were instituted toward the end of the outbreak
in a 1,000bed 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.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.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

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).

with the public and outline administrative or criminal penalties for
officials who do not report SARS cases. 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.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.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

25People'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).

26People'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).

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

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-toface 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.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

28These 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.

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

Far Eastern Economic Review Asian Development Bank

China 2,200 6,100
Hong Kong 1,700 4,600
Malaysia 660 400
Singapore 950 2,700
Taiwan 820 1,300
Thailand 490 1,900
Vietnam 111 400
Region 10,700 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.

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).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.30 However, given that the outbreak was brought under
control by July 2003, the economic impacts were

29Some 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.

30We 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.

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

SARS Affected Asian The SARS outbreak produced negative impacts on Asian
economies Economies through a through a variety of mechanisms. The most
important channel through Variety of Channels 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.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.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 36,000.33

31As 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.

32The 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.

33The 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.

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

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.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.

34Foreign 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.

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

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)

Type of package Cost of package

China o Temporary tax relief and subsidies for affected industries

o Free medical treatment for the poor and some price controls on
SARS-related drugs and goods 3,500

Hong Kong o Temporary tax relief, job creation, and loan
guarantee schemes 1,500
Malaysia o Loan programs, support for tourism-related
industries, and job training 1,920
Singapore o Temporary reduction in tourism and transport
administrative fees, and relief measures for airlines

Taiwan o Partial reimbursement of business-related losses for affected
industries

o Partial reimbursement for medical costs 1,400

Thailand o General funding allocated as emergency budget

Source: GAO analysis of Asian Development Bank data.

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:

o 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.

o 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.35 However, the draft regulations are still somewhat ambiguous
about whether consent is necessary.36 According to a senior

35According 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.

36For 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-thespot studies by a team sent by WHO . . ." (emphasis
added).

WHO official, the proposed regulations were intentionally left vague about
consent because it is a subject that members will want to debate
thoroughly.

o 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.

o 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.

o 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.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.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

37The 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.

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

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 reemerged 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

o 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

o 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 To assess WHO's actions to respond to SARS in Asia, we analyzed
WHO policy, program, and budget documents, including WHO's Web-based

Methodology 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;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.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 http://www.gao.gov.

39Jong-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).

40To 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.

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,

David Gootnick
Director, International Affairs and Trade

Janet Heinrich
Director, Health Care-Public Health Issues

Appendix I

SARS Cases and Deaths, November 2002-July
2003

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

Note: Numbers represent cases and deaths.

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.

Year Location Event
First known case of atypical pneumonia,
November 16 Guangdong later determined to be SARS.
Province, Chinaa
World Health Organization (WHO) influenza
November 23 expert attends workshop in Beijing and
Beijing learns
from a participant from Guangdong Province
of a "serious outbreak with high mortality
and
involvement of health care staff."
Global Public Health Intelligence Network
November 27 Canada (GPHIN) picks up reports of a "flu outbreak"
in
China.
Mid-December WHO WHO requests further information from China
on the influenza outbreak. Chinese
Headquarters, government replies that influenza activity
in Beijing and Guangdong is normal and that
Geneva surveillance system detected no unusual
strains of the virus.
December 10 Infection in second city in Guangdong
Guangdong Province.
Province
January 23 Guangdong

Guangdong's provincial health authorities produce a report about the outbreak
detailing the Province

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 Multiple Locations 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 China, Hong Kong 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 Hong Konga 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.
A team of WHO experts, including CDC staff,
China arrives in Beijing but is given limited access
February 23 to
information; Chinese authorities deny WHO's
repeated requests for permission to travel to
Guangdong Province.
WHO GPHIN detects Chinese newspaper report that more
February 24 than 50 hospital staff in Guangzhou are
Headquarters, infected with "mysterious pneumonia."
Geneva
Vietnama Chinese-American businessman admitted to the
February 26 French Hospital in Hanoi with fever and
respiratory symptoms.

Appendix II SARS Chronology

(Continued From Previous Page)

Page 53 GAO-04-564 Emerging Infectious Diseases
WHO
official first to develop postpone
Dr. admitted to after, her reports of respiratory definitions Guangdong SARS and a robust knowledge all but
Carlo hospital linked to Toronto son becomes Businessman Chinese WHO spread syndrome" of suspect Province, initiates and on China joins essential
Urbani headquarters with the woman who ill, is admission with travel Health the issues among CDC WHO issues (SARS), and and and Hanoi. domestic CDC team reliable symptoms, WHO's Amoy Gardens travel to
notifies moves to Woman who respiratory patient's also admitted to triggers history to Ministry Guangdong global hospital activates rare declares it probable and CDC issues CDC issues surveillance arrives diagnostic diagnosis, collaborative housing WHO issues Hong Kong
Year Location Event Vietnam WHO heightened United outbreak. March stayed at symptoms. March Second symptoms; ward, March Canadaa stayed at Scarborough an March Taiwana Guangdong symptoms. March China asks WHO outbreak March WHO alert Headquarters, staff in Geneva WHO. March WHO Headquarters, Geneva March United Emergency March WHO global Headquarters, a Geneva cases, issues March United travel preliminary for SARS. March United CDC begins international Mid-March Taiwan in Taiwan March WHO WHO sets up Headquarters, test. A Geneva, and multiple SARS March China networks, March Third estate have WHO most Headquarters, and Geneva China
office state of States 1 the 4 superspreader within a develop 5 the Grace outbreak 8 Province is 10 for of 12 about Hong Kong 13 14 States Operations 15 travel "worldwide calls on advice to 15 Statesa advisory case First 16 States distributing airports. to assist 17 worldwide similar and management. locations epidemiology. 28 initially set 30 superspreader been stringent Guangdong
in alert. State Department Metropole event in Hong week, at respiratory Metropole Hospital, at the hospitalized technical atypical cases of and Hanoi. Center. advisory, health travelers airlines. suggesting definition suspected health alert in SARS network of network is A third up on March event in Hong hospitalized travel Province
Manila establishes an Hotel in Kong: a least 25 illness. Hotel in and dies. hospital. with and pneumonia. severe CDC offers WHO sends names the threat." to be aware postponement for U.S. case is cards to response. laboratories set up to network is 17. Kong: Health with SARS. advisory in until
of an intradepartmental Hong Kong is resident who hospital Hong Kong His respiratory laboratory atypical assistance emergency mysterious WHO issues of of suspected identified. passengers to expedite pool set up to authorities its 55-year further
unusual working group to hospitalized had visited staff, all dies at support to pneumonia to alert to illness its symptoms, nonessential arriving detection of clinical study announce that history, notice. WHO team
February disease. Early deal with impact with Hong the Metropole home. clarify following GOARN "severe travel to from Hong causative Hong 213 residents April recommending April arrives in
28 WHO March of Singaporea respiratory Kong Hotel is Shortly cause of mounting partners. acute Hong Kong, Kong at four agent and Kong of 2 that people 3 Guangdong.

Appendix II SARS Chronology

(Continued From Previous Page)

Year Location Event
United States President Bush signs executive order adding SARS
April 4 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.
WHO WHO laboratory network announces conclusive
April 16 identification of SARS causative agent: a
Headquarters, new coronavirus.
Geneva
Change in political stance by Chinese
China leadership. Top leaders advise officials not to
April 19-20 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 Vietnam First country to successfully contain its
outbreak of SARS.
May 2 United States State Department holds interagency meeting on
SARS.
May 3 Taiwan WHO sends officials to Taiwan to assist CDC
team.
WHO First global consultation on SARS epidemiology
May 17 concludes its work, confirming that available
Headquarters, evidence supports the control measures
recommended by WHO.
Geneva
WHO World Health Assembly resolution recognizes the
May 27 severity of the threat that SARS poses and
Headquarters, calls on all countries to report cases promptly
and transparently. A second resolution
Geneva strengthens WHO's capacity to respond to disease
outbreaks.
June 17-18 WHO holds Global Conference on SARS to review
Malaysia scientific findings on SARS and examine
public health interventions to contain it.
WHO WHO announces that the global SARS outbreak has
July 5 been contained.
Headquarters,
Geneva
Singapore announces that a medical researcher is
September 8 Singapore infected with SARS. Based on an
investigation of this incident, WHO concludes
that the patient was accidentally infected in
the
laboratory.
December 17 Taiwan Taiwan announces that a researcher is infected
with SARS. Public health authorities
conclude that the infection was acquired in a
laboratory.

December 20- China A man in Guangdong Province is hospitalized with
SARS-like symptoms on December 20.
January 5, 2004 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- China A woman in Guangdong Province is hospitalized with
SARS-like symptoms on December 31.
January 17, 2004 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.

2004

January 6-27 China 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.

Appendix II SARS Chronology

(Continued From Previous Page)

Year Location Event

January 7-30 China 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 China 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.

aDate of the first known case(s) of SARS.

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).1 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.

1The 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.

Appendix III Estimates of the Economic Impact of SARS

Table 3: Models Estimating the Economic Impact of SARS on GDP in Asia, 2003
Estimated decline in GDP (percentage)

Low scenario

High scenario

Source Model description Key assumptions Country Asian Development Bank:

Simulation modelfrom Low scenario: SARS shock China 0.2

the Oxford Economic Forecasting consulting firm May 2003 ERD Policy Brief
No. 15

lasts through second quarter Hong Kong 1.8 4.0
of 2003 Malaysia 0.6 1.5
Singapore 1.1 2.3
High scenario: SARS shock Taiwan 0.9 1.9
extends into third quarter of Thailand 0.7 1.6
2003

Jong-Wha Lee and Warwick McKibbin:

"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)
"G-Cubed" Asia Pacific world macroeconomic simulation model based on data
from the Global Trade Analysis Project Consortium Low scenario: SARS shock
occurs in 2003

High scenario: SARS shock reoccurs after 2003 and fades over 10 years

o SARS shock hits China and Hong Kong and affects other countries based
on trade and tourist flows

o SARS shock in 2003 lasts 6 months

o Country risk premium increases by 200 basis points

o Output falls by 15 percent and costs rise by 5 percent in affected
service sectors

China 1.1 2.3
Hong Kong 2.6 3.2
Malaysia 0.2 0.2
Singapore 0.5 0.5
Taiwan 0.5 0.5
Thailand 0.2 0.2

Global Insight: In-house Low scenario: SARS shock China 1.0 1.9
simulation
model lasts through second Hong Kong 1.4 2.2
quarter
May 2003 Executive of 2003 Malaysia 0.3 1.4
Summary of Asia and Singapore 1.2 1.8
Oceania, "SARS High scenario: SARS Taiwan 0.8 1.7
Epidemic's shock
Economic Impact on extends to the end of Thailand 0.7 1.6
Asia" 2003
Vietnam 0.1 0.8

Source: GAO analysis of studies from the Asian Development Bank, Brookings
Institution, and Global Insight.

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

Appendix III Estimates of the Economic Impact of SARS

from various governments and financial institutions and applying that
average to the nominal GDP figures provided by the International Monetary
Fund.2

2The 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.

Appendix IV

Comments from the Department of Health and Human Services

Appendix IV
Comments from the Department of Health
and Human Services

Appendix V

Comments from the Department of State

Appendix V
Comments from the Department of State

Appendix VI

Comments from the World Health Organization

Appendix VI
Comments from the World Health
Organization

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.

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