Taiwan has now been taken off the World Health Organization's (WHO) list of areas with recent cases of local transmission of SARS. As the first wave of this summer's global epidemic comes to an end, it is worth examining the successes and failures of our efforts at each stage of the SARS epidemic curve and consider what direction our efforts should take in the future.
There were three major shortcomings in the first stage of the epidemic (November last year to early April this year) -- the period when the newly emerging infectious disease was the least well understood.
First, the best opportunity for learning about the epidemiology of SARS came in November last year when the disease had just began to spread in China and media reports that the public was scrambling to buy vinegar were followed by the peak of the epidemic's curve in Guangdong Province in February. It is unfortunate that authorities in Taiwan didn't work proactively to gather accurate information about the epidemic or put in place any epidemic prevention measures.
Second, at daily meetings of the Taiwan SARS Advisory Committee, most of the time was spent trying to discern between "probable" and "suspected" SARS cases at an individual level so that a more far-sighted public health vision was lacking.
Third, and most importantly, although several different infectious disease surveillance systems had already been established in Taiwan, their sensitivity to newly emerging infectious diseases was low. They were completely dependent on the vigilance of doctors and personal enthusiasm for public health.
During this initial period of the epidemic, three other aspects of the response were handled well. These include, first, paying close attention to the WHO's daily SARS briefings and responding immediately beginning in mid-March. It was fortunate that the son of the first index case was an employee of the Center for Disease Control and thus close cooperation was achieved to prevent further transmission.
Second, the Department of Health subsequently established the SARS Advisory Committee for the purpose of allowing the daily number of SARS cases to be transparent and having scholars provide the most updated information on international research findings to clarify the state of the epidemic.
Finally, in this period, apart from two small clusters of SARS cases, the majority of probable cases were related to people's travel histories and manifested in a "sporadic" distribution. Rapid quarantining of patients prevented the spread of the disease.
By the middle period of the epidemic, between mid-April and mid-May, clinical symptoms of SARS were already reasonably well understood. The etiologic agent of the new coronavirus pathogen was discovered, and its molecular diagnosis became feasible. This was the best opportunity to understand the epidemic scientifically.
Unfortunately, medical personnel had a low awareness of the epidemic and their day-to-day training in preventing the spread of infectious diseases was insufficient. Therefore, the majority of cases were associated with hospitals, and outbreaks appeared in one hospital after another. In addition, public health policy at that time failed to make medical personnel feel safe and secure in a timely manner.
The media reported the status of the epidemic far more rapidly than epidemiological investigations by government officials took place, and hourly television news reports on the grieving relatives of medical personnel who died caring for SARS patients as well as the daily increasing number of cumulative cases created a public panic. This was the chaotic period of Taiwan's SARS epidemic.
Fortunately, government health agencies discussed the direction of future efforts with experts at the US Centers for Disease Control and Prevention and the World Health Organization (WHO) on a daily basis, and many scholars and members of the public volunteered to join in the fight against SARS. At the same time, many members of the public complied cooperatively with policies established for public areas, mass transportation, and A-level quarantine. Thus, high numbers of fatal SARS cases, like those seen in Hong Kong's Amoy Gardens apartment complex, have not yet occurred.
The epidemic was brought under control in the period between late May and late last month. During this time, incentives for caring for SARS patients and the policy of punishing those who failed to report probable SARS cases resulted in many "false alarms" that clogged medical facilities and wasted desperately needed manpower resources. Furthermore, many deceased patients were never examined scientifically to determine a cause of death, and this created a panic as well.
Finally, the flurry of action by officials at the Control Yuan and investigative agencies together with critical media reports dealt a severe blow to the morale of local public health personnel. More and more academics discovered systemic problems in infection control and public health. Being given responsibility, but no rewards, administrative officials mistakenly felt that attempting to do more would only make one's faults that much greater, thus leading to a quick turnover rate among experienced public health professionals.
Unfortunately, at this time officials failed to clarify their understanding of the WHO's expectations regarding SARS data at the earliest opportunity, with the result that Taiwan faced many unnecessary difficulties in removing itself from the list of nations most affected by SARS.
Due to the team efforts of academics, however, Web-based reporting of SARS cases and contact history databases were seen for the first time. This made statistics on the epidemic more transparent. Screening procedures were put in place for feverish patients in the hospitals, veteran's homes, and asylums -- and infection control guidelines were implemented in each hospital.
In this way, the problems of the spread of SARS within hospitals and infections of medical personnel were brought under control. Even more impressively, when an outbreak of SARS occurred at Yangming Hospital, the CDC carried out an immediate epidemiological investigation and demonstrated that for the first time they were ahead of the news media. At the same time, Taiwanese academics and health officials in charge of the government's epidemic prevention efforts joined with the WHO and US public health experts to begin establishing a real-time surveillance system for detecting emerging/re-emerging infectious diseases.
In Taiwan's academic society, infectious disease specialists, virologists, and biostatisticians have begun unprecedented interdisciplinary research that will speed up the pace of our gaining control over SARS.
Certainly, long-term neglect of matters such as cultivating infectious disease epidemiologists and organizational reform caused the recent wave of SARS to resemble the cholera epidemic of the 1960s in Taiwan. Only the best reward policy and far-sighted vision can attract and cultivate outstanding talent, and when we have talented public health professionals, any threat of infectious disease can be rapidly defused and minimized.
King Chwan-chuen is a professor at the Institute of Epidemiology in National Taiwan University's College of Public Health.
Translated by Ethan Harkness
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