Learning From SARS
Sep 15, 2009

The H1N1 virus is here in Canada and it is a pandemic. Given these facts, it offers us the opportunity to see if we have learned some key lessons from our experience with severe acute ­respiratory syndrome (SARS).

A pandemic, by definition, is the global spread of a new virus by human-to-human contact and for which humans have no resistance.

SARS was a new corona virus, which went from spreading occasionally from animals to humans to a virus that spread human to human. We had no resistance and it was a very serious virus in that it made people very ill and killed 10-15% of people who caught it. It did not however spread well in the community and for this reason it did not spread around the world and thus never became a pandemic.

H1N1 has formed from four other viruses and have already spread by human-to-human contact around the world. Currently, however, it is an example of a mild pandemic because, though it spreads easily and affects large numbers of people, to date, its mortality rate has been low. Similar to the 1918-1919 avian virus, which caused very large numbers of deaths worldwide, the H1N1 virus does affect special groups beyond those normally at risk from flu. For instance, it affects young persons in late teens and early twenties and pregnant women; this will change some of the strategies normally used to combat the pandemic.

The elderly and those with chronic disease are still most at risk from the seasonal flu we see every year and which kill several thousand Canadians every flu season.

Given that the H1N1 virus has been mild to date, some are suggesting that the publicity is an over reaction. We reacted aggressively in SARS once we realized the size and magnitude of the problem we faced. I believe the vigorous actions taken substantially reduced the number of cases in Ontario and ultimately saved lives. Therefore the H1N1 virus also must be taken seriously. It has been stable to date but, like any virus, it could mutate at any time and pose a much more serious threat with higher mortality. Even if it does not mutate further or become more lethal, we face challenges over the next months. This article is being prepared in mid-September and changes and new problems may arise by the time of publication. At this point, it is easy to predict at least three potential problems, even if the virus remains mild.

The first predictable thing is that people will die of the virus. We can try to slow the spread of the virus and the operative word is slow, while a vaccine is produced. We cannot stop the spread, no matter what we do, even if large numbers of us try hiding in our homes until the pandemic was over. We must recognize that some disease and death is inevitable, and take sensible precautions to slow the virus down, but we cannot paralyze our society through panic, fear and inappropriate actions. Hand washing, cleaning surfaces and staying home when sick will remain the key elements of slowing the spread. Withdrawing from society and hiding from the virus will not be a key strategy.

In fact, overcoming the urge of people to try to avoid the virus and keeping them working is the second challenge that even a mild pandemic will pose. The federal finance department did some excellent modeling post SARS, using absentee data. They showed that during a pandemic the number of people absent from work with the pandemic flu and other illness during the peak two weeks of a flu wave should be about 15-20%. This means that any absenteeism greater than this probably reflects people trying to hide from the flu. A pandemic, even a mild one, needs to be compared to a war effort. We need everyone possible at work contributing to the society. We need manufacturing to be producing the obvious things such as medicines, masks and gowns but we also need food, electricity, transportation, communications and all other goods and services. The more people are away, the greater the disruption and the greater the social and economic effect of the pandemic.

Illness like the flu (influenza) and colds are caused by viruses that infect the nose, throat, and lungs. The flu and colds usually spread from person to person when an infected person coughs or sneezes. (Photo: James Gathany)

SARS showed us at least three important ways to minimize the tendency of people to want to hide from the virus. The first and obvious way to do this is with proper planning. Generally, I feel that governments and large industries have done a good job of learning this lesson from SARS. However, many smaller businesses, many of whom may be key suppliers to large industry, seem to be minimizing the potential of the pandemic to disrupt their activities and could face serious challenges starting this fall when they try to play catch-up. The second way to minimize overall impact is through aggressive communication. Some would argue that you wait to communicate much of the information until the pandemic is an obvious problem – when people are listening and absorbing, however SARS showed us that the public is very capable of grasping complex disease concepts such as quarantine.

The key concepts in a pandemic (even a mild one) are to minimize panic and keep people working while slowing the spread of disease. Information is the way to do this, and it needs to be detailed – beyond the correct but simple advice of washing hands and staying home when sick.

People need to understand both what a pandemic is and what it is not. They need to know who is at risk and why it is important that they keep working if they are not sick. Governments are starting to get this message out, but more needs to be done. A large public education campaign has been run in Britain and we are beginning to follow. The Ontario government recently sent an informational brochure to every household in the province and governments are beginning to do public information advertising. This detailed advertising worked in SARS and needs to be done before and during an outbreak.

The responsibility to inform and educate is not that of government alone. It seems to me that it is in the best interests of any company to use the time before an outbreak to educate workers about what to really expect and to minimize the chances of massive absenteeism.

The third way to minimize the effects of a mild pandemic is for governments, industry and the general public to minimize the unintended consequences of taking inappropriate actions. During emergencies – and pandemics in particular – there is a strong pressure on governments to be seen to be doing something. During SARS in 2003, this was illustrated by the well-meaning but ­misguided attempt to put travel advisories in place. They were intended to try to slow or stop the spread of disease to other countries, particularly those in the developing world. It turned out that the nature of the SARS virus did not do well in these environments anyway, and there is no evidence that the measure had any positive benefit. Millions of people were screened for fever in airports with no benefit whatsoever. The unintended consequences of these actions served to cause greater anxiety and panic, interfered with the flow of necessary goods and services needed to battle the outbreak, and imposed unwarranted economic punishment on some countries.

Electron micrograph of the matured SARS-CoV (coronavirus) particles (arrows). (Photo: Dr. Mary NG Mahlee.)

We have done a little better during the early stages of H1N1, but we have still seen inappropriate travel advisories placed. Additionally, as the disease spreads around the world, there is confusion about what level the pandemic has reached,. The present classification system considers the spread but not the severity of the illness.

In our current situation, an example of a policy which may have an unintended consequence is the WHO advice on school closures. Currently they are advising that schools close when 1% of students have the H1N1 virus. This is, in part, recognition of the higher risk that young people face from this virus and also recognition that schools are great breeding grounds for disease to spread. The problem is that there is no evidence that this will work and certainly if children, especially young ones are at home, then parents will need to stay home as well and increase absenteeism in the workplace. This is especially true with younger children and, in fact, they are not the higher risk group with this virus, the older young adults are.

We had limited experience in closing schools and classrooms during the SARS outbreak, and it was a disaster at a high school or university level. Students need their social contact and, if schools close, they visit each other or go to the malls. Wisely, Canadian authorities seem to understand this, and are currently saying they do not intend to close schools with such low levels of disease.

The same caution is necessary in other areas, such as not over-using antiviral medicines for what is currently a mild disease, and not over-using masks outside of medical settings. Again our public health leaders in Canada to date have shown that they are aware of and sensitive to these common sense issues.

The final problem that we will face this flu season, even if the pandemic remains mild, is the stress that it will put on our health care system. Even on its best days, the health care system operates above capacity. Large numbers of people with flu could overburden the system and cause serious consequences. Part of their answer is to divert flu patients away from hospital emergency departments and doctors offices. This was done during SARS, when we ran special clinics that paid special attention to infection control. The health care system is gearing up for such a delivery system and the public will need to be educated about how to use it.

Operating such a system does divert resources, creating consequences in overall delivery of health care. Even during a mild pandemic, there is potential of serious pressure on hospital beds in general, and ICU beds specifically, due to greater numbers of people getting very ill, This could involve difficult decisions such as who gets hospitalized and who does not. Criteria are being developed, but they must be ethical, consistent across the country, and transparent. The public needs to be informed ahead of time of the problem we face, and how the beds will be allocated.

Electron micrograph of H1N1 (Photo: C. Goldsmith)

Finally, a few words about the potential good news. Work is well underway to produce the specific vaccine for the H1N1 virus. Vaccines take time to develop and test but we are in better shape for an early vaccine in this pandemic then ever before. Canada is in a particularly good position. We have a first-rate vaccine manufacturing facility in Canada, and a government contract to produce it.

A decision has been made in Canada to produce the vaccine in a manner that requires less vaccine and so will result in greater supply. This will take slightly longer to produce but, given the current nature of the disease, is the correct decision in my mind. The important thing for all of us is to take advantage of government programs and get both the H1N1 vaccine and the regular seasonal flu vaccine.

I am often asked if I and my family will be rolling up our sleves to get the H1N1 flu shot. The answer is an emphatic yes and we will get the seasonal flu shot when available as well.

Dr James Young is Medical Director of Pandemic 101™. He was Chief Coroner for Ontario and Commissioner of Public Safety and Security during the 2003 SARS crisis.
© FrontLine Security 2009