In recent years, several regional epidemics of previously unidentified infectious diseases have occurred around the world. Then, at the end of last year, came severe acute respiratory syndrome (SARS). The World Health Organization's (WHO) efforts in collecting information on SARS cases and sharing information between countries via video conferencing shows how disease prevention now involves the whole world.
In addition to focusing on professionalism and internationalization, the prevention work must take into account updated epidemiological data accumulated locally and globally. Based on solid scientific information, it is easier to formulate the most effective and comprehensive prevention policies with foresight and a pragmatic attitude.
During an epidemic caused by a new etiologic agent with unknown modes of transmission, preventing the spread of the disease becomes the primary concern. Developing prevention strategies requires field investigation, brainstorming and experimental laboratory support.
Before scientific breakthroughs are made in identifying the pathogen, what general aspects of disease prevention can we focus on? Determining the "period of communicability" is the most important issue in preventing a respiratory epidemic. When can pathogenic microorganisms be transmitted from one person to another? At which stage of an infection is the chance of transmission highest?
Before these questions are resolved, disease prevention measures can be divided into five levels.
First, detecting those infected with the disease early and immediately implementing infection controls are the most effective strategy. This is why US President George W. Bush recently issued an executive order to demand that all suspected cases of SARS must be isolated.
The effort aims at identifying SARS patients by three integrated surveillance systems, including:
-- Thorough understanding of the symptoms (fever or respiratory problems) to allow early detection of those who have been infected.
-- Epidemiological surveillance by asking patients things such as whether they or their relatives have traveled to affected areas or come into contact with other SARS patients over the past two to three weeks.
-- Virological laboratory surveillance by collecting proper specimens from SARS patients for final proof of etiologic agent.
Second, "high-risk" populations must be protected from infection. Those considered at high risk are those in close contact with SARS patients, those with chronic bronchitis or pneumonia (including tuberculosis), miners, silicon workers, heavy smokers and those with impaired immune systems (including bone marrow or organ transplant patients, and AIDS patients).
Third, the spread of the disease in the community must be controlled. When an epidemic starts spreading through a community, the public will begin to panic. As a result, prevention work must emphasize tracking down those who had contact with SARS patients and teaching those who already have the disease or who may have an asymptomatic infection (infection without the symptoms) to immediately disinfect their respiratory secretions and frequently wash their hands. The habit of spitting should also be discouraged.
Fourth, international quarantine and multinational cooperation on disease prevention are needed to check the spread of the disease. At a time when international travel is popular, passengers should be required to declare before they board planes or ships which countries they have visited during the previous month and where they plan to travel.
I would like to sincerely appeal to the epidemiologists and microbiologists at the academic institutions in those areas with most SARS cases in China, such as Sun Yat-sen University, Peking University, Fudan University and ShanXi Military Medical University, to learn from the valuable experience of the Taiwanese SARS Advisory Committee and establish a SARS advisory working group.
Fifth, ecological investigation is needed to prevent further outbreaks. For example, after the 1997 outbreak of a new type of avian influenza A virus (H5N1), we should analyze how animal viruses survive in the natural habitat and how they suddenly infect human beings. Using epidemiological investigation to thoroughly discover all the intermediate hosts in the "chains of transmission" can strengthen disease prevention and decrease the possibility of future pandemics.
King Chwan-chuen is a professor and an epidemiologist at the Institute of Epidemiology, College of Public Health, National Taiwan University.
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