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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Global Surveillance, National Surveillance, and SARS</title><author><name sortKey="Heymann, David L" sort="Heymann, David L" uniqKey="Heymann D" first="David L." last="Heymann">David L. Heymann</name><affiliation><nlm:aff id="aff1">World Health Organization, Geneva, Switzerland</nlm:aff></affiliation></author><author><name sortKey="Rodier, Guenael" sort="Rodier, Guenael" uniqKey="Rodier G" first="Guénaël" last="Rodier">Guénaël Rodier</name><affiliation><nlm:aff id="aff1">World Health Organization, Geneva, Switzerland</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">15040346</idno><idno type="pmc">3322938</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3322938</idno><idno type="RBID">PMC:3322938</idno><idno type="doi">10.3201/eid1002.031038 </idno><date when="2004">2004</date><idno type="wicri:Area/Pmc/Corpus">000783</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000783</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Global Surveillance, National Surveillance, and SARS</title><author><name sortKey="Heymann, David L" sort="Heymann, David L" uniqKey="Heymann D" first="David L." last="Heymann">David L. Heymann</name><affiliation><nlm:aff id="aff1">World Health Organization, Geneva, Switzerland</nlm:aff></affiliation></author><author><name sortKey="Rodier, Guenael" sort="Rodier, Guenael" uniqKey="Rodier G" first="Guénaël" last="Rodier">Guénaël Rodier</name><affiliation><nlm:aff id="aff1">World Health Organization, Geneva, Switzerland</nlm:aff></affiliation></author></analytic><series><title level="j">Emerging Infectious Diseases</title><idno type="ISSN">1080-6040</idno><idno type="eISSN">1080-6059</idno><imprint><date when="2004">2004</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc article-type="article-commentary"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Emerg Infect Dis</journal-id><journal-id journal-id-type="iso-abbrev">Emerging Infect. Dis</journal-id><journal-id journal-id-type="publisher-id">EID</journal-id><journal-title-group><journal-title>Emerging Infectious Diseases</journal-title></journal-title-group><issn pub-type="ppub">1080-6040</issn><issn pub-type="epub">1080-6059</issn><publisher><publisher-name>Centers for Disease Control and Prevention</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">15040346</article-id><article-id pub-id-type="pmc">3322938</article-id><article-id pub-id-type="publisher-id">03-1038 </article-id><article-id pub-id-type="doi">10.3201/eid1002.031038 </article-id><article-categories><subj-group subj-group-type="heading"><subject>Commentary</subject></subj-group></article-categories><title-group><article-title>Global Surveillance, National Surveillance, and SARS</article-title><alt-title alt-title-type="running-head">Commentary</alt-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Heymann</surname><given-names>David L.</given-names></name><xref ref-type="aff" rid="aff1">*</xref></contrib><contrib contrib-type="author"><name><surname>Rodier</surname><given-names>Guénaël</given-names></name><xref ref-type="aff" rid="aff1">*</xref></contrib><aff id="aff1"><label>*</label>World Health Organization, Geneva, Switzerland</aff></contrib-group><author-notes><corresp id="cor1">Address for correspondence: David L. Heymann, World Health
Organization, Avenue Appia 20, CH-1211 Genève 27, Switzerland; fax:
41 22 791 2212; email: <email xlink:href="heymannd@who.int">heymannd@who.int</email></corresp></author-notes><pub-date pub-type="ppub"><month>2</month><year>2004</year></pub-date><volume>10</volume><issue>2</issue><fpage>173</fpage><lpage>175</lpage><related-article related-article-type="commentary-article" id="ra1" ext-link-type="pubmed" xlink:href="8903186" vol="1" page="141"><string-name><surname>Tauxe</surname><given-names>RV</given-names></string-name>, <string-name><surname>Mintz</surname><given-names>ED</given-names></string-name>, <string-name><surname>Quick</surname><given-names>RE</given-names></string-name>. <article-title>Epidemic cholera in the New World: translating field
epidemiology into new prevention strategies.</article-title><source>Emerg Infect Dis</source>.
<year>1995</year>;<volume>1</volume>:<fpage>141</fpage>–<lpage>6</lpage>.
<pub-id pub-id-type="doi">10.3201/eid0104.950408</pub-id></related-article></article-meta></front><body><fig id="Fa" fig-type="figure" position="float"><caption><p><bold>David L. Heymann</bold>
Executive Director, Communicable
Diseases, World Health Organization, Geneva, Switzerland</p></caption><graphic xlink:href="03-1038-F"></graphic></fig><p>The international response to the severe acute respiratory syndrome (SARS) outbreak, from
March to July 2003, tested the assumption that a new and emerging
infection–one that had not yet demonstrated its full epidemiologic potential
but was spreading from person to person and continent to continent–could be
prevented from becoming endemic. Within 4 months after the first global alert about the
new disease, all known chains of transmission had been interrupted in an outbreak that
affected 27 countries on all continents. Most public health experts and scientists
believe that the question of whether SARS has become endemic can only be answered after
at least 12 months of postoutbreak surveillance. The SARS experience, however, made one
lesson clear early in its course: inadequate surveillance and response capacity in a
single country can endanger national populations and the public health security of the
entire world. As long as national capacities are weak, international mechanisms for
outbreak alert and response will be needed as a global safety net that protects other
countries when one nation’s surveillance and response systems fail.</p><p>During the last decade of the 20th century, several outbreaks, including cholera in Latin
America, pneumonic plague in India, and Ebola hemorrhagic fever in the Democratic
Republic of the Congo, caused great international concern (<xref ref-type="bibr" rid="R1"><italic>1</italic></xref>–<xref ref-type="bibr" rid="R3"><italic>3</italic></xref>). These events demonstrated the consequences that delayed national recognition
and response to outbreaks could have: illness and death of national populations
including health workers, potential spread to other countries, and significant
disruptions of travel and trade. These outbreaks also emphasized the need for a global
surveillance and response mechanism. The Global Outbreak Alert and Response Network
(GOARN), set up in 1997 and formalized in 2000, was one major response to this need
(World Health Organization [WHO], unpub. data and <xref ref-type="bibr" rid="R4"><italic>4</italic></xref>). Though the network, which now has 120 partners throughout the world, currently
identifies and responds to more than 50 outbreaks in developing countries each year, the
SARS outbreak was the first time that GOARN identified and responded to an outbreak that
was rapidly spreading internationally.</p><p>One of the partners in GOARN is the WHO Global Influenza Surveillance Network, which was
established in 1947 to guide the annual composition of vaccines and provide an early
alert to variants that might signal the start of a pandemic of rapidly evolving
influenza viruses. This network was placed on alert in late November, when the Canadian
Global Public Health Intelligence Network (GPHIN), also a partner in GOARN, picked up
media reports of an influenza outbreak in mainland China (<xref ref-type="bibr" rid="R5"><italic>5</italic></xref>). Simultaneously, another GOARN partner, the U.S. Global Emerging Infections
Surveillance and Response System (GEIS), became aware of similar reports about a severe
outbreak, with influenza B the suspected cause, in Beijing and Guangzhou. As GOARN
continued to receive reports about influenza outbreaks in China, WHO requested
information from Chinese authorities on December 5 and 11. On December 12, WHO received
a detailed report on data collected at Chinese influenza surveillance sites, indicating
that investigation of 23 influenza virus isolates had confirmed type B strains in all
but one and that the number of cases was consistent with the seasonal pattern in
previous years. The information was reassuring and an indication that the influenza
surveillance system was working well.</p><p>Although information is incomplete, retrospective case identification by Chinese and
GOARN epidemiologists since May 2003 suggests that two respiratory disease outbreaks
occurred in Guangdong Province in late November 2002: influenza and what now appears to
have been a first wave of SARS cases—an atypical pneumonia that was
characterized by small, seemingly unrelated clusters of cases scattered over several
municipalities in Guangdong, with low-level transmission to healthcare workers (<xref ref-type="bibr" rid="R6"><italic>6</italic></xref>). This first wave of atypical pneumonia appears to have continued until a second
wave of disease with amplified transmission to health workers began occurring during the
first 10 days of February (WHO, unpub. data). On February 10, 2003, the WHO office in
Beijing received an email message describing an infectious disease in Guangdong Province
said to have caused more than 100 deaths. On February 11, the Guangzhou Bureau of Health
reported to the press more than 100 cases of an infectious atypical pneumonia outbreak
that had been spreading in the city for more than 1 month. That same day, the Chinese
Ministry of Health officially reported to WHO 300 cases and 5 deaths in an outbreak of
acute respiratory syndrome, and the next day reported that the outbreak dated back to
November 16, 2002, that influenza virus had not yet been isolated, and that the outbreak
was coming under control (<xref ref-type="bibr" rid="R7"><italic>7</italic></xref>).</p><p>When the reports of a severe respiratory disease were received by WHO on February 11,
2003, a new strain of influenza virus was the most feared potential cause, and the WHO
Global Influenza Network was again alerted. Concern grew on February 20, when the
network received reports from Hong Kong authorities confirming the detection of A(H5N1)
avian influenza virus in two persons, and WHO activated its influenza pandemic
preparedness plans (<xref ref-type="bibr" rid="R8"><italic>8</italic></xref>).</p><p>During that same week, laboratories of the WHO Global Influenza Surveillance Network
began analyzing specimens from a patient with severe atypical pneumonia hospitalized in
Hanoi after travel to Hong Kong. Concurrently, GOARN response teams in Vietnam and Hong
Kong began collecting clinical and epidemiologic information about the patient and a
growing number of others with similar symptoms. As more specimens entered the network
laboratories, influenza viruses were ruled out as the causative agent. WHO made its
first global alert on March 12, followed by a second, on March 15, when more than 150
suspected new cases had been reported from several geographic areas, including Hong
Kong, Singapore, Vietnam and Canada (<xref ref-type="bibr" rid="R9"><italic>9</italic></xref>,<xref ref-type="bibr" rid="R10"><italic>10</italic></xref>). With the second alert, WHO provided a case definition and name, thus beginning
a coordinated global outbreak response that brought heightened vigilance everywhere and
intense control efforts. GOARN linked some of the world’s best laboratory
scientists, clinicians, and epidemiologists electronically, in virtual networks that
provided rapid knowledge about the causative agent, mode of transmission, and other
epidemiologic features (<xref ref-type="bibr" rid="R11"><italic>11</italic></xref>). This real-time information made it possible for WHO to provide specific
guidance to health workers on clinical management and protective measures to prevent
further nosocomial spread. It also made possible recommendations to international
travelers to curtail international spread. Recommendations were at first nonspecific,
urging international travelers to have a high level of suspicion if they had traveled to
or from areas where the outbreak was occurring. But as more information became
available, airports were asked to screen passengers for history of contact with SARS and
for persons with current illness that fit the SARS case definition. Finally, when these
recommendations did not completely stop international spread, passengers themselves were
asked to avoid travel to areas where contact tracing was unable to link all cases to
known chains of transmission (<xref ref-type="bibr" rid="R12"><italic>12</italic></xref>). Within 4 months, transmission of SARS had been interrupted at all sites, and
on July 5, 2003, the SARS outbreak was declared contained (<xref ref-type="bibr" rid="R13"><italic>13</italic></xref>).</p><p>As many times occurs with emerging and reemerging infectious diseases, national
surveillance mechanisms failed to identify and respond to the emerging outbreak of SARS
early enough to prevent its toll of sickness, death, and international spread (<xref ref-type="bibr" rid="R14"><italic>14</italic></xref>). In May 2003, ministers of health from the 192 member countries of WHO
expressed their deep concern about the impact of SARS and its implications for future
outbreaks, which were considered inevitable. In two resolutions, they called for
increased national capacity development for surveillance and response and endorsed the
ways in which GOARN obtained information about SARS and supported containment efforts
(<xref ref-type="bibr" rid="R15"><italic>15</italic></xref>,<xref ref-type="bibr" rid="R16"><italic>16</italic></xref>). The resolutions stressed the need for countries to give more attention, with
WHO support, to the strengthening of national surveillance and response capacity, and
encouraged WHO to continue to strengthen GOARN, its safety net for global alert and
response. As SARS so amply demonstrated, protection against the threat of emerging and
epidemic-prone diseases requires strong defense systems at national as well as
international levels.</p></body><back><fn-group><fn fn-type="citation"><p><italic>Suggested citation for this article</italic>: Heyman DL, Rodier G. Global
surveillance, national surveillance, and SARS. Emerg Infect Dis [serial online]
2003 Feb [<italic>date cited</italic>]. Available from: URL: <ext-link ext-link-type="uri" xlink:href="http://www.cdc.gov/ncidod/EID/vol10no2/03-1038.htm">http://www.cdc.gov/ncidod/EID/vol10no2/03-1038.htm</ext-link></p></fn></fn-group><bio><p>Dr. Heymann is a medical epidemiologist who began his career in India with the
smallpox eradication program. After completing the Epidemic Intelligence Service,
Dr. Heymann spent 13 years working for CDC in sub-Saharan Africa in
infectious diseases that range from Ebola, yaws, and yellow fever to the routine
childhood immunizable diseases and malaria. On joining the World Health
Organization, Dr. Heymann worked with the AIDS program, then set up and directed the
Department of Emerging and other Infectious Diseases before becoming Executive
Director for the Communicable Disease program, followed by his present assignment as
the Representative of the Director General, heading the Polio Eradication
Initiative.</p></bio><bio><p>Dr. Rodier is currently the Director, Department of Communicable Disease Surveillance
and Response, World Health Organization (WHO). His main professional experience
includes the development of new approaches for communicable disease surveillance and
response at national and global levels, and comprehensive field experience in
epidemic response, particularly in viral hemorrhagic fever.</p></bio><ref-list><title>References</title><ref id="R1"><label>1. </label><mixed-citation publication-type="journal"><string-name><surname>Tauxe</surname><given-names>RV</given-names></string-name>, <string-name><surname>Mintz</surname><given-names>ED</given-names></string-name>, <string-name><surname>Quick</surname><given-names>RE</given-names></string-name><article-title>Epidemic cholera in the New World: translating
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