Still Learning From SARSFREE

Eleven years ago, a novel coronavirus sparked the first major global outbreak of an emerging infectious disease of the 21st century (1). Branded “SARS” for “severe acute respiratory syndrome,” the new illness quickly engulfed the world's medical, scientific, and public health communities and garnered a worried public's attention. Since then and to date, the global reach of SARS has only been matched by the 2009 H1N1 influenza pandemic (2), but its societal effect remains unsurpassed. SARS endures as a vivid reminder of the capacity of emerging infectious diseases to quickly travel the globe, exacting a major human toll of illness and death and causing significant economic, political, and social consequences. More recently, the emergence of another novel coronavirus causing severe respiratory illness (termed “Middle East respiratory syndrome”) in the Middle East and Europe (3) and a novel avian influenza A (H7N9) virus in China (4) continues to demonstrate the ongoing threat of emerging infections. With illness, death, and spread reminiscent of SARS, Middle East respiratory syndrome is particularly alarming. From September 2012 through October 2013, more than 140 cases and 60 deaths have been reported among persons with direct or indirect linkages to areas of the Middle East. Although not sustained, person-to-person transmissions have been documented, including transmissions in health care settings. Genetic analysis shows a close relationship between the Middle East respiratory syndrome coronavirus and coronaviruses in bats, suggesting once again a zoonotic origin of this latest emerging infection. Cases of H7N9 also present specific concerns because they represent the first known human cases of this virus. Since early 2013, more than 135 cases and 45 deaths have occurred in China, including Taiwan—mostly among persons who had contact with infected poultry or contaminated environments. Although no sustained spread has been found and reports of new cases remain sparse, concerns for the pandemic potential of an H7N9 virus persist.

SARS underscored the critical importance of well-prepared, flexible, and highly connected public health systems, exercised by the day-to-day public health functions of tracking and responding to endemic infectious diseases, such as seasonal influenza and foodborne illnesses. Ensuring that these connections extend to the local level is essential because local health departments and health care providers play a vital role in recognizing the unusual and sounding the alarm so that scalable and effective responses can be mounted. This commentary is a reflection on the events and the successful global response surrounding the 2003 SARS outbreak. In the decade since, many lessons have been learned and enhancements made, but significant challenges remain. Foremost is the urgent need to build and sustain effective public health capacities and modernize public health systems at all levels.