Severe Acute Respiratory Syndrome (SARS) Lessons Learned

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Ashlynn Merritt
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Organization, Department of Pandemic and Epidemic Disease Department of Medicine & Interdepartmental Division Critical

1 GLOBAL HEALTH RISK FRAMEWORK: A WORKSHOP ON RESILIENT AND SUSTAINABLE HEALTH SYSTEMS TO RESPOND TO GLOBAL INFECTIOUS DISEASE OUTBREAKS Severe Acute Respiratory Syndrome (SARS) Lessons Learned Rob Fowler, MDCM, MS(Epi), FRCP World Health Organization, Department of Pandemic and Epidemic Disease Department of Medicine & Interdepartmental Division Critical Care Medicine Institute of Health Policy Management and Evaluation University of Toronto fowlerr@who.int; rob.fowler@sunnybrook.ca

2 We acknowledge lives lost and the importance of strengthening health systems to prevent future morbidity and mortality

3 Outbreaks and Pandemics are Unpredictable but Predictably Recurrent

4 Our modern day capacity for care is exposed during times of increased demand: SARS, Influenza, MERS, Ebola

Influenza A(H1N1) appeared in US in early 1918 Fall of 1918, virulent strain in France, West Africa and US 2 mutations in surface hemagglutinin allowed it to bind

5 Influenza A(H1N1) appeared in US in early 1918 Fall of 1918, virulent strain in France, West Africa and US 2 mutations in surface hemagglutinin allowed it to bind tightly to receptors in the human upper respiratory tract Called Spanish Flu after hit Spain in November 1918 By June 1920 approximately 50 million (3% global population) died

6 In 1918: those with severe infection died In 2015: with resources, most can live

7 Severe Respiratory Infection: H1N1

8 H1N1 Clinical Outcomes Canada Mexico

9 West African Ebola Outbreak 27,784 patients infected and over 11,000 deaths so far

11 EMERGENCY NGO Goderich, Sierra Leone Courtesy of Prof Antonio Pesenti

12 SARS Toronto 2003

13 *

14 Toronto 2003 SARS Epi Curve

15 SARS Patient Outcomes 196 patients with SARS admitted to hospitals during study period 20% patients became critically ill 76% of those required mechanical ventilation 10% died (50% were dead/on ventilator at 1-month)

16 Nosocomial Amplification 77% of Toronto Patients with SARS were exposed in the hospital 18% of SARS patients were Healthcare Workers Among All Toronto Hospitals 6 of 13 ICUs quarantined (>1000 ICU healthcare workers) 41% of the ICU beds in Toronto lost

18 Dispersion of High-flow Oxygen Fowler RA, Scales DC, Ilan R. N Engl J Med 2004;351

19 Risk to Healthcare Workers During Intubation Fowler RA, Simor AE, et al Am J Resp Crit Care Med 2004;169

20 Risk to Healthcare Workers With Ventilation Fowler RA, Simor AE et al Am J Resp Crit Care Med 2004;169

21 Medical Treatments 95% received empirical antibiotic therapy Ribavirin was used in 126/144 (88%) - 76% had evidence of hemolysis - 49% had decreased hemoglobin >2 g/dl after ribavirin 40% received corticosteroids Clinical Trials (in Toronto) were delayed, with small numbers of patients, limited inferences

22 SARS* Lessons Learned 1. SYSTEM Lessons - Little Knowledge of our System s Capacity - Little Coordination among Response Components 2. CLINICAL CARE Lessons - Not Prepared for Surges in Demand - Personnel; medicines, devices - We Amplified Transmission and Illness in Hospital - Poor baseline Infection Prevention & Control - We used Non-Evidence-Based Treatments 3. RESEARCH Lessons - Without pre-existing protocols, studies were delayed - Actual clinical trials were not able to start in time

23 Since SARS

24 Post-Mortem*

26 SYSTEM Improvements

27 Creation of National and Provincial Public Health Agencies

28 Creation of Coordinated System of Acute Care & Transportation

29 Improving Knowledge of Real-time Capacity Region # Hospitals with ICUs with Ventilation Capacity* ICU Beds Capable of Invasive Ventilation Ventilators Capable of Invasive Ventilation Number HFOs in ICUs ICUs with ino ICUs with ECMO Newfoundland Nova Scotia PEI New Brunswick Quebec Ontario Saskatchewan Manitoba Alberta BC Territories Canada

30 Understanding Variation Crit Care 2015;19(1):133

31 CLINICAL CARE Improvements

32 Strengthening of IPC

33 Improving Clinical Guidance

34 Collaborating with International Partners

35 RESEARCH Improvements

Recognition of Time-to-Initiate Research SARI Screening 2013-14 (N= 5735) however, time to start up was a median of 335 days Protocols focused upon unanticipated outbreaks and pandemics must

36 Recognition of Time-to-Initiate Research SARI Screening (N= 5735) however, time to start up was a median of 335 days Protocols focused upon unanticipated outbreaks and pandemics must carry out this process during inter-outbreak and inter-pandemic periods A reactive approach will not allow sufficient time to initiate research before most outbreaks are advanced or completed 36

International Preparedness Activities USA USCIIT-PREP - FDA and BARDA

Develop and pre-position influenza treatment protocol and test the data

Objective is to facilitate development of medical counter measures to

37 EUROPE PREPARE European Union FP7-Health 2014-2019, 24M Objective is

investigators, within 48 hours of a severe outbreak AUSTRALIA/NEW ZEALAND

37 International Preparedness Activities USA USCIIT-PREP - FDA and BARDA funding (U$6M; ). Develop and pre-position influenza treatment protocol and test the data collection and reporting system during peak times. Objective is to facilitate development of medical counter measures to protect against threats. 37 EUROPE PREPARE European Union FP7-Health , 24M Objective is to mount a rapid, coordinated deployment of Europe s clinical investigators, within 48 hours of a severe outbreak AUSTRALIA/NEW ZEALAND NHMRC to fund $5-10M PREPARE pre-planned & pre-approved protocol & support for central coordination infrastructure Objective is to coordinate a national approach to preventing & responding to emerging health threats

38 ISARIC s vision is to change the approach to global collaboratve patient- oriented research between and during epidemics of SARI and other rapidly emerging public health threats to generate new knowledge, maximize the availability of clinical informayon, and thereby save lives. Global federation of >40 existing clinical research networks Launched December 2011 ISARIC Coordinating Centre based at Oxford University

41 Lessons Learned We need to build capacity during the interoutbreak period (no nation is immune to this need) to provide a coordinated health systems response, clinical care and real-time practice-informing investigation when an emerging disease, outbreak or pandemic occurs.

43 ICU beds per 100,000 Population

44 Number of ICU Beds by Country Adhikari N, Fowler RA, Bhagwanjee S, Rubenfeld GD. Lancet 2010

45 Health Care Spending and ICU beds per 100,000 Population

46 Number of ICU Beds per Population and ICU Mortality

47 Life Expectancy and per capita Health Spending Fowler RA, Adhikari N, et al Crit Care 2008 adapted from OECD: Health Data

48 Advocacy for Appropriate Global Health Spending

49 Canadian Critical Care Capacity Region Hospitals with ICUs per 100,000 Population ICU Beds with Ventilation Capacity per 100,000 Population Invasive Ventilators per 100,000 Population Newfoundland Nova Scotia Prince Edward Island New Brunswick Quebec Ontario Saskatchewan Manitoba Alberta British Columbia Territories Canada

50 Goderich, SIERRA LEONE Italian Emergency NGO

51 Courtesy of Prof Antonio Pesenti & Dr. Gino Strada

GAPS The overarching lessons learned are the need to build capacity (health systems, clinical and research infrastructure) during the inter-pandemic period to provide a coordinated response, provide

54 GAPS The overarching lessons learned are the need to build capacity (health systems, clinical and research infrastructure) during the inter-pandemic period to provide a coordinated response, provide care and perform real-time practice-informing research when an emerging disease/pandemic occurs. Outbreak Gaps Identified SARS H1N1 Ebola 54 Clinically we were unprepared. Delays in approval for observational & treatment trials hampered the ability to control the situation, care for patients and limited knowledge advancement. Observational studies at the patient level provide essential information to guide the response but depended upon existing research networks and were plagued with delays.. Despite the lessons learned over the prior decade once again research initiatives to help control the disease and care for patients were just getting ramped up as the epidemic curve was rapidly trailing off. Again few advances are likely.

55 Global airline transportation network visualized by the flight pathways of all commercial flights worldwide Where will the next outbreak or pandemic occur?

The World Health Organization: Does it have a Role in Critical Illness?

The World Health Organization: Does it have a Role in Critical Illness? Rob Fowler, MDCM, MS(Epi), FRCP Department of Medicine & Critical Care Medicine Sunnybrook Hospital, University of Toronto rob.fowler@sunnybrook.ca