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      Responding to global infectious disease outbreaks: Lessons from SARS on the role of risk perception, communication and management

      Social Science & Medicine (1982)

      Elsevier Ltd.

      Risk perception, Risk communication, Infectious disease, SARS, Economy

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          Abstract

          With increased globalisation comes the likelihood that infectious disease appearing in one country will spread rapidly to another, severe acute respiratory syndrome (SARS) being a recent example. However, although SARS infected some 10,000 individuals, killing around 1000, it did not lead to the devastating health impact that many feared, but a rather disproportionate economic impact. The disproportionate scale and nature of this impact has caused concern that outbreaks of more serious disease could cause catastrophic impacts on the global economy. Understanding factors that led to the impact of SARS might help to deal with the possible impact and management of such other infectious disease outbreaks. In this respect, the role of risk—its perception, communication and management—is critical.

          This paper looks at the role that risk, and especially the perception of risk, its communication and management, played in driving the economic impact of SARS. It considers the public and public health response to SARS, the role of the media and official organisations, and proposes policy and research priorities for establishing a system to better deal with the next global infectious disease outbreak. It is concluded that the potential for the rapid spread of infectious disease is not necessarily a greater threat than it has always been, but the effect that an outbreak can have on the economy is, which requires further research and policy development.

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          Most cited references 38

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          Evaluation of control measures implemented in the severe acute respiratory syndrome outbreak in Beijing, 2003.

          Beijing, China, experienced the world's largest outbreak of severe acute respiratory syndrome (SARS) beginning in March 2003, with the outbreak resolving rapidly, within 6 weeks of its peak in late April. Little is known about the control measures implemented during this outbreak. To describe and evaluate the measures undertaken to control the SARS outbreak. Data were reviewed from standardized surveillance forms from SARS cases (2521 probable cases) and their close contacts observed in Beijing between March 5, 2003, and May 29, 2003. Procedures implemented by health authorities were investigated through review of official documents and discussions with public health officials. Timeline of major control measures; number of cases and quarantined close contacts and attack rates, with changes in infection control measures, management, and triage of suspected cases; and time lag between illness onset and hospitalization with information dissemination. Health care worker training in use of personal protective equipment and management of patients with SARS and establishing fever clinics and designated SARS wards in hospitals predated the steepest decline in cases. During the outbreak, 30 178 persons were quarantined. Among 2195 quarantined close contacts in 5 districts, the attack rate was 6.3% (95% confidence interval [CI], 5.3%-7.3%), with a range of 15.4% (95% CI, 11.5%-19.2%) among spouses to 0.36% (95% CI, 0%-0.77%) among work and school contacts. The attack rate among quarantined household members increased with age from 5.0% (95% CI, 0%-10.5%) in children younger than 10 years to 27.6% (95% CI, 18.2%-37.0%) in adults aged 60 to 69 years. Among almost 14 million people screened for fever at the airport, train stations, and roadside checkpoints, only 12 were found to have probable SARS. The national and municipal governments held 13 press conferences about SARS. The time lag between illness onset and hospitalization decreased from a median of 5 to 6 days on or before April 20, 2003, the day the outbreak was announced to the public, to 2 days after April 20 (P<.001). The rapid resolution of the SARS outbreak was multifactorial, involving improvements in management and triage in hospitals and communities of patients with suspected SARS and the dissemination of information to health care workers and the public.
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            SARS: experience at Prince of Wales Hospital, Hong Kong

            The Prince of Wales Hospital (PWH) has been at the forefront of the outbreak of severe acute respiratory syndrome (SARS) in Hong Kong. 1 We relate our experience at this hospital. A working definition of SARS is important, 2 although clinical conditions rarely remain within artificial boundaries. Some patients might not have all features, others may present unusually. Fever is a cardinal symptom but not always so, and is sometimes absent in elderly patients. Some patients have presented with diarrhoea or, in at least two cases, with severe acute abdominal pain requiring exploratory laparotomy. All these patients developed typical SARS. Patients presenting with other respiratory infections must now all be regarded as potential SARS cases until proven otherwise. Contact with a known case is an important discriminator but, if emphasised too strongly in the diagnostic process, may lead to false positives or negatives. The difficulty of making a firm diagnosis until chest radiographic changes appear has important implications for health-care personnel and for surveillance. Three major reasons for spread of infection to health-care workers have been: failure to apply isolation precautions to cases not yet identified as SARS, breaches of procedure, and inadequate precautions. Every patient must now be assumed to have SARS, which has major long-term implications for the health-care system. Another reason for spread among health-care workers is infected workers continuing to work despite symptoms, such as mild fever. Such individuals must now cease working. However, staying at home can also have disastrous consequences for exposed family members. Potential cases therefore require early isolation from both workplace and household. Extreme measures are required to protect health-care workers, who account for about 20% of cases. Early diagnosis by virus isolation or serological testing is essential to halt the spread of SARS. Progress has been made with the isolation of the coronavirus.3, 4, 5 A metapneumovirus was also identified in Canada 4 and in many of the cases at PWH. Coronavirus appears to be the main pathogen, but dual infections may be possible. Such situations are uncommon in human disease, apart from HIV-related infections, but in veterinary medicine combined infections with coronavirus and other agents have been described.6, 7 The first cases probably occurred in Guangdong Province in southern China in November, 2002. 8 The term SARS appears to have been first used for a patient in Hanoi who became ill on Feb 26, 2003, and was evacuated back to Hong Kong where he died on March 12. The physician who raised the alarm in Hanoi, Carlo Urbani, subsequently contracted SARS and died. The first case in Hanoi had stayed at a hotel in Kowloon, Hong Kong, at the same time as a 64-year-old doctor who had been treating pneumonia cases in southern China. This doctor was admitted to hospital on Feb 22, and died from respiratory failure soon afterwards. 9 He was the first known case of SARS in Hong Kong and appears to have been the source of infection for most if not all cases in Hong Kong as well as the cohorts in Canada, Vietnam, Singapore, USA, and Ireland, and subsequently Thailand and Germany. 10 The index patient at PWH was admitted on March 4, 2003, and had also visited this hotel. He had pneumonia which progressed initially despite antibiotics, but after 7 days he improved without additional treatment. 1 On March 10, 18 health-care workers at PWH were ill and 50 potential cases among staff were identified later that day. Further staff, patients, and visitors became ill over the next few days and there was subsequent spread to their contacts. By March 25, 156 patients had been admitted to PWH with SARS, all traceable to this index case. 1 One important factor in the extensive dissemination of infection appears to have been the use of nebulised bronchodilator, which increased the droplet load surrounding the patient. Overcrowding in the hospital ward and an outdated ventilation system may also have contributed. The second major epicentre in Hong Kong, accounting for over 300 cases, has been an apartment block called Amoy Gardens. The source has been attributed to a patient with renal failure receiving haemodialysis at PWH who stayed with his brother at Amoy Gardens. 11 He had diarrhoea, and infection may have spread to other residents by a leaking sewage drain allowing an aerosol of virus-containing material to escape into the narrow lightwell between the buildings and spread in rising air-currents. Sewage also backflowed into bathroom floor drains in some apartments. Spread to people in nearby buildings also occurred, probably by person-to-person contact and contamination of public installations. Although the rapid spread of the disease in some situations may have been explained, many uncertainties remain. Why the disease spread in the Kowloon hotel has not been clarified, and there are many other important issues. “Super-spreaders” may be prone to carry a high viral load because of defects in their immune system, as could be the case in the patient with end-stage renal failure implicated in the Amoy Gardens outbreak and another with renal failure at the centre of an outbreak in Singapore. Subclinical infections may also occur and will not be recognisable until reliable diagnostic tests are available. Procedures causing high risk to medical personnel include nasopharyngeal aspiration, bronchoscopy, endotracheal intubation, airway suction, cardiopulmonary resuscitation, and non-invasive ventilation procedures. Cleaning the patient and the bedding after faecal incontinence also appears to be a high-risk procedure. Treatments have been empirical. Initial patients were given broad-spectrum antibiotics but, after failing to respond for 2 days, were given ribavirin and corticosteroids. Patients who continued to deteriorate with progression of chest radiographic changes or oxygen desaturation, or both, were given pulsed methylprednisolone. 1 Steroids were used on the rationale that progression of the pulmonary disease may be mediated by the host inflammatory response, similar to that seen in acute respiratory distress syndrome, and produced by a cytokine or chemokine “storm”. The clinical impression is that pulsed steroids sometimes produce a dramatic response. However, apparent benefits of steroid treatment have proven to be incorrect before, as in infection with respiratory syncytial virus. 12 Lack of knowledge of SARS' natural history adds to the difficulty of determining the effectiveness of therapy. Some patients have a protracted clinical course with potential for relapses continuing into the second or third week, or beyond. Long hospital stays, even in less ill patients, are required, and the high proportion of patients requiring lengthy intensive care, with or without ventilation (23% in the 138 cases from PWH 1 ), and the susceptibility of health-care workers bodes ill for the ability of health-care systems to cope. Even when the acute illness has run its course, unknowns remain. Continued viral shedding and the possible development of long-term sequelae, such as pulmonary fibrosis or late post-viral complications, means that patients will require careful surveillance.
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              Ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats.

              The appearance and spread of severe acute respiratory syndrome (SARS) on a global level raised vital legal and ethical issues. National and international responses to SARS have profound implications for 3 important ethical values: privacy, liberty, and the duty to protect the public's health. This article examines, through legal and ethical lenses, various methods that countries used in reaction to the SARS outbreak: surveillance and contact tracing, isolation and quarantine, and travel restrictions. These responses, at least in some combination, succeeded in bringing the outbreak to an end. The article articulates a set of legal and ethical recommendations for responding to infectious disease threats, seeking to reconcile the tension between the public's health and individual rights to privacy, liberty, and freedom of movement. The ethical values that inform the recommendations include the precautionary principle, the least restrictive/intrusive alternative, justice, and transparency. Development of a set of legal and ethical recommendations becomes even more essential when, as was true with SARS and will undoubtedly be the case with future epidemics, scientific uncertainty is pervasive and urgent public health action is required.
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                Author and article information

                Contributors
                Journal
                Soc Sci Med
                Soc Sci Med
                Social Science & Medicine (1982)
                Elsevier Ltd.
                0277-9536
                1873-5347
                15 September 2006
                December 2006
                15 September 2006
                : 63
                : 12
                : 3113-3123
                Affiliations
                Health Economics Group, School of Medicine, Health Policy & Practice, University of East Anglia, Norwich NR4 7TJ, UK
                Article
                S0277-9536(06)00406-0
                10.1016/j.socscimed.2006.08.004
                7130909
                16978751
                Copyright © 2006 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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                Health & Social care

                economy, sars, infectious disease, risk communication, risk perception

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