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May 26, 2004

Learning From SARS in Hong Kong and Toronto

Author Affiliations

Author Affiliations: Faculty of Medicine, University of Toronto, Toronto, Ontario (Dr Naylor); Kings Fund, London, England (Dr Chantler); and Department of Public Health, University of Oxford, Oxford, England (Dr Griffiths).

JAMA. 2004;291(20):2483-2487. doi:10.1001/jama.291.20.2483

The recurrence of severe acute respiratory syndrome (SARS) in China during 2004 has highlighted the continuing threat to human health from infectious disease outbreaks. A zoonosis caused by a novel coronavirus,1,2 SARS first emerged among humans in the southern Chinese province of Guangdong during November 2002. By March 2003, SARS had spread to neighboring Hong Kong and from there to Toronto, Ontario, and many other areas in a matter of days.

The World Health Organization (WHO) has reported that by July 2003 when the epidemic had waned, in Hong Kong there were 1755 probable cases of SARS with 300 deaths (17%) and in Canada there were 251 probable cases with 43 deaths (17%).3 Most Canadian cases and all deaths were in the Toronto area. Both areas had serious difficulties managing the outbreak, and several inquiries into public health and epidemic management have since been performed. We led the panels that first reported on SARS and public health in each jurisdiction. Both panels worked through the summer of 2003 and issued their reports within a week of one another in early October 2003.4,5 Herein, we compare our findings, highlight common conclusions, and suggest some general lessons that may be applicable to other areas.

Contrasting Health Care Systems

In Toronto and throughout Canada, health care is provided through universal health insurance plans administered by each province. Hospitals rely on public grants and physicians work primarily as private state-dependent contractors.6 About 45% of Ontario's 12 million individuals live in the greater Toronto area. Coordination of the response to SARS in the Toronto area was limited by 4 factors. First, Ontario is the only Canadian province that has no regional health authorities; thus, 28 general hospitals in Toronto function semiautonomously. Second, although they are paid by public insurance, physicians work as private fee-for-service practitioners. Third, public health units are funded partly by municipalities, and therefore also operate semiautonomously. Four different public health units in the Toronto area worked to contain the SARS outbreak, but did not share even the same information system. Finally, the federal role in public health and clinical care is limited constitutionally, creating potential challenges for national and international coordination during a health emergency.

Hong Kong is a Special Administrative Region of the People's Republic of China and its 6.8 million residents live on a 1100-km square area at the southeastern tip of the country. Population density is among the highest in the world at 6300 individuals per square kilometer. Hong Kong's economy is closely linked to the neighboring Pearl River Delta, and large numbers of individuals move daily between Hong Kong and the mainland. Hong Kong is therefore an international transit zone for infectious diseases that continue to emerge in south China. Overall responsibility for health in Hong Kong rests with the Health, Welfare, and Food Bureau. Both the Department of Health, which oversees public health among other services, and the Hospital Authority, which runs the public hospitals and related outpatient services for Hong Kong, report to the Secretary of Health, Welfare, and Food. However, while the public health system is available for all citizens, a fee-for-service private sector also exists. The private sector is substantial, providing primary, specialized, and institutional care services to a large number of individuals.

The Canadian system operates on 3 levels (federal, provincial, and municipal) while Hong Kong operates using 1. However, common features include the prominent role of autonomous private health care institutions and clinicians, uneven connections between public health and private sector health care, and financial pressures on publicly funded clinical systems.

SARS Brought Similar Challenges to Both Areas

In Hong Kong, the outbreak spread first in the community, but eventually 22% of all persons affected were health care workers. In Toronto, where community spread was more limited, the proportion of SARS cases among health care workers was even higher at 43%.3 Straightforward protection measures against droplet and contact transmission proved reasonably effective,7 but the spread of the infection to health care workers added to the stress both areas faced in combating the outbreak. Along with other jurisdictions, the 2 areas fought an outbreak in which, initially, no satisfactory laboratory tests were available to confirm the diagnosis in suspected cases. Even after reverse-transcriptase polymerase chain reaction methods were instituted, rapid confirmation was not possible during the presymptomatic or early stage of infection. Furthermore, both areas also dealt with travel advisories from other jurisdictions that contributed to economic dislocation and public upset.

Outbreak Responses in Toronto and Hong Kong

In both Toronto and Hong Kong, containment of SARS relied heavily on application of public health and clinical infection-control measures rooted in 19th-century science. Both jurisdictions struggled to overcome several key problems with capacity, preparedness, coordination, and communication. We believe similar inadequacies exist in other countries.8

Alert systems proved inadequate. Authorities from the WHO in Beijing were informed in December 2002 about an unusual outbreak in Guangdong, but the WHO global alert about SARS was not issued until March 2003; and China itself did not issue appropriate alerts. Thus, the Hong Kong government was unaware of an outbreak of a novel form of atypical pneumonia in southern China during the months of November and December 2002. Fortunately, background surveillance was in place because of anxiety about the avian influenza virus, and this was enhanced in February as accounts of an unusual epidemic in China surfaced. Canadian alert systems were slow and fragmentary, although the province of British Columbia successfully forewarned regional clinicians, hospitals, and public health units through its well-organized Centre for Disease Control.

Absent outbreak plans, coordination across institutions and health service sectors was poor and strong linkages between public health and the health care system for epidemic response were absent. Moreover, when SARS appeared, alerts and directives initially targeted acute care institutions, while long-term care institutions and general physicians received little guidance and support until well into the outbreak in Toronto and Hong Kong.

As a corollary, overall lines of authority were blurred. In the Toronto outbreak, confusion was initially compounded by a management structure involving distinct leadership for health care, public health, and general emergency response. In Hong Kong, it was not clear who was in charge of the epidemic overall.

Both areas were hampered by underinvestment in public health infrastructure, diminution of public health leadership, and weak links between health care and public health. Health professionals and administrators in the Toronto area criticized poor coordination across public health units. Also, there was general criticism of the weak analytical capacity of the Ontario Public Health Branch and its performance in leading the outbreak response. In Hong Kong, health professionals criticized the Department of Health for a deficiency shared by the public health system and the private health sector: a failure to establish a common population-based approach to outbreak management and weak links between public health and private sector health services in institutional and community settings.

As was true for other Canadian provinces, Ontario lacked interjurisdictional agreements for sharing public health and clinical personnel. Toronto therefore remained short of specialized staff for the first few weeks of the outbreak. Hong Kong accommodated the increase in demand at first through diversion of patients into a cluster of public hospitals and service networks, but that system was finally overwhelmed by the massive increase in health care demand caused by SARS. All Toronto-area hospitals were initially subject to provincial directives that shut down elective activity, leading to a massive backlog of deferred services. During a second wave of SARS, a network of 4 Toronto hospitals focused on SARS care, allowing full activity to be maintained at the other 24 hospitals. Moreover, regularized processes were not in place in either region for sharing and compensating staff appropriately during an emergency.

Institutional infection control was undercut by shortages in personnel and deficits in knowledge of frontline caregivers. Neither jurisdiction had enough infection control practitioners and infectious disease specialists. For example, 42% of Canadian hospitals fail to meet the current US standard of 1 infection control practitioner (generally nurses or laboratory technologists) per 250 active care beds; 80% cannot attain the new Canadian standard of 1 infection control practitioner per 175 active care beds.6,9 In both Hong Kong and Toronto, failure of institutional syndromic surveillance allowed SARS cases to go undetected and contributed to secondary spread of the outbreak after an initial wave of SARS cases. Both reviews highlighted concerns about a widespread lack of knowledge of basic principles of infection control on the part of health care workers, presumably because few had ever faced a serious outbreak of infectious disease. This situation, along with deficiencies in provision of personal protective equipment in multiple sectors of both health care systems, contributed to complaints and grievances about occupational health and safety in health care settings in Hong Kong and Toronto.

Physical institutional deficiencies were also evident. Hong Kong had poorly designed ventilation systems, lack of basic hand-washing and sanitary facilities, and a shortage of single rooms with independent bathrooms. In the Toronto area, only 3.8% of acute hospital beds were in single, negative-pressure rooms. A number of hospitals in both jurisdictions lacked infection-control areas in their emergency departments.

Both reports noted issues with laboratory coordination and research responses to the outbreak. In Toronto, SARS testing was performed increasingly by local hospital laboratories after the regional public health reference laboratories were overwhelmed by the volume of testing. None of the laboratories was adequately linked to each other, to clinicians, or to clinical and epidemiological data in general. Hong Kong was better able to establish laboratory capacity and link data sources through its E-SARS network. Researchers in both Hong Kong and Toronto were active in delineating the cause of SARS, characterizing the agent, developing diagnostic tests, and generating initial clinical descriptions. However, data integration greatly enhanced research in Hong Kong, underpinning an outpouring of epidemiological studies during and after the outbreak. Notwithstanding its smaller outbreak and larger research infrastructure, Toronto generated much less clinical and epidemiological research on SARS.

Risk communication to health care workers and with the general public was uneven, compounded by the lack of certainty about diagnosis, treatment, and epidemiology throughout the outbreaks. Confusion in Hong Kong was augmented by open public conflict between senior health care professionals and lack of identification of a single source for information. This was remedied later in the epidemic when daily press briefings were instituted with the director of health. In Toronto, similar leadership tensions were kept from public view, but regular press briefings involved 3 and sometimes 4 spokespersons, and the overall communications strategy was strongly criticized by expert commentators.10

Various jurisdictions issued advice against travel to both Toronto and Hong Kong during the outbreak. The WHO also began issuing travel advisories for the first time. The WHO's advice to postpone all but essential travel to Hong Kong and China's Guangdong Province was issued on April 2, 2003. Three weeks later, the WHO added Toronto, Beijing, and China's Shanxi Province to areas that travelers should avoid. The epidemiological foundation for these travel advisories was weak and international inconsistencies were apparent, but the adverse economic effects were profound.

Health-related border controls were another source of controversy throughout the outbreak and afterward.6 Toronto airports used information cards with screening questions and secondary assessments and interviews as needed. A large-scale Canadian pilot project involving thermal scanners resulted in millions of screening transactions and thousands of referrals of passengers for further assessment by nurses or quarantine officers, but not a single case of SARS was identified. In Hong Kong, border controls using temperature checking and screening forms remain in place, especially now that SARS has recurred in China. There is no international consensus on appropriate travel screening and border controls.

Recommendations and Government Actions

The recommendations from both reports respond to parallel problems in organization, capacity, and structure of health care and public health systems (Box 1). Our comparison of the 2 reports also suggests 5 overarching lessons (Box 2).

Box Section Ref IDBox 1. Issues and Recommendations in Common From the SARS Outbreaks in Hong Kong and Toronto

Public Health Capacity

Review and revise legislation and regulations regarding public health and health emergencies; invest in training public health and infectious disease specialists as well as infection-control training for all staff; develop improved analytical and leadership capacity for public health; train more epidemiologists, public health nurses, and microbiologists; do more cross-training to link health care and public health clinicians; and develop flexible and progressive career paths for public health professionals.

Create new Canadian public health agency with administrative headquarters in nation's capital and major collaborating centers across Canada; invest in provincial public health capacity; generate business process agreements to link provincial and federal public health activities. Create a center for health protection in Hong Kong and review central government departmental structures for public health and health care.

Surveillance Systems

Enhance communications with mainland China (especially Guangdong Province) through network for communicable disease control and strengthen 2-way information technology for disease surveillance and outbreak management across all sectors of health care in Hong Kong.

Adopt an Internet-enabled public health information system across all jurisdictions throughout Canada and link public health information system with electronic patient records and other health care data sources.

Infection Control Policies, Plans, and Procedures

Develop integrated protocols for outbreak management at a population level in Toronto and Hong Kong, linking institutional and noninstitutional clinicians; test protocols through simulated outbreaks and emergencies; audit preparedness on a regular basis; train health care staff in infection control and outbreak response as applicable.

Develop efficient information systems for contact tracing, concatenating laboratory with clinical and epidemiological data, and tracking patients through the health care system in Toronto and in Hong Kong.

Surge Capacity

Create multidisciplinary health care emergency teams and specific epidemic response teams; develop standardized and efficient business processes for rapid epidemic and outbreak investigation; ensure availability of personal protective equipment.

Agree on mutual aid arrangements across jurisdictions throughout Canada and remove interprovincial barriers to certification and licensure. Ensure policies for outbreak response are graded to minimize impact on routine patient care in Toronto and Hong Kong.

Health Care Facilities

Ensure adequate numbers of isolation and negative-pressure rooms across differing levels of acuity, including emergency departments. Improve hospital ward design including ventilation systems, hand-washing stations, and other sanitary facilities.

Laboratory Facilities and Research Capacity

Develop mechanisms for laboratory data sharing; define the roles of laboratory facilities in health care and public health under outbreak scenarios; ensure quality control for laboratories testing for infectious pathogens.

Strengthen capacity for outbreak investigation and related infectious disease research; support research to establish best practices for infection control and outbreak response; collect and share evidence for optimal public health protection; set up protocols in advance for rapid activation of research response to other potential disease outbreaks.


Enhance communication within health care and public health to ensure rapid dissemination of alerts, updates, and directives. Train institutional, public health, and health care leaders in risk and crisis communication.

Occupational Health Issues

Determine special compensation for staff who take on extraordinary responsibilities during future epidemics and disasters; ensure availability of personal protective equipment at all relevant sites; and improve internal communication regarding infection-control policies. Strengthen occupational health systems in institutions and other sectors of the health system.

International Aspects

Work with the World Health Organization and other international partners on the rational provision of travel advice and revision of international health regulations and strengthen international links in infectious disease surveillance. Review access control measures (eg, airport and border screening) in Hong Kong and across Canada, including Toronto.

Box Section Ref IDBox 2. Five Key Lessons From the SARS Outbreaks in Hong Kong and Toronto

Infectious Diseases Remain a Serious Global Threat

Despite many serious new epidemics starting with human immunodeficiency virus and AIDS, the continued challenges of antibiotic resistance, and the reality of global spread of novel pathogens in hours or days, the global health community continues to underinvest in infectious disease control measures.

Governments Underinvest in Public Health

Because of its preventive and population focus, the public health system is consistently overshadowed by other areas of health care. However, investments in public health are vitally important for health protection (including safe food and water supplies and effective sanitation), disease and injury prevention (including outbreak containment), and health promotion.

An Outbreak Requires Attention in Advance to Clarity, Collaboration, Communication, Coordination, and Capacity

Clarity is needed to determine the lines of authority and responsibilities during an outbreak. Collaboration—whether within jurisdictions or across them—presupposes shared values and goals, trust, goodwill, and agreed rules of engagement. Communication within health care and the public health system, with the media and public, and between nations is a cornerstone of crisis management. Coordination of activities is essential and depends on all the foregoing elements. No outbreak can be contained efficiently and effectively without prior investments in capacity at all levels of health care and the public health system.

Integration Within Health Care and Between Health Care and the Public Health System Facilitates Crisis Management

Integration and alignment of incentives leads to enhanced quality and efficiency of usual and customary health care services. However, severe acute respiratory syndrome (SARS) has highlighted that integration is even more valuable in the face of a health crisis. Given its nosocomial transmission, the SARS outbreak particularly underscores the importance of seamless integration between health care and the public health system.

A Global Public Health System Is Essential

A global, interdependent health system is essential for detection and containment of infectious threats, whether naturally emerging or products of bioterrorism. Every nation should maintain integrated surveillance systems for infectious diseases and bioterrorist threats, and share information on potential threats fully and freely with all other nations. As a corollary, humanitarian measures taken by wealthier nations to support health protection and disease control in less wealthy nations may pay dividends in global safety and security, while promoting a fairer and stronger global economy.

Not surprisingly, there were differences in emphasis between the 2 reports. The Hong Kong report points to a potential role for traditional Chinese medicine. Canada's National Advisory Committee on SARS and Public Health addressed federal and provincial issues not applicable to Hong Kong. However, the Hong Kong report highlights the need for a clearer relationship with mainland China, and this may be seen as an analog for the federal and provincial challenges identified in Canada. Even on matters as specific as legislation, there are more similarities than differences. For example, building on the debates and experiences of quarantining residents from Amoy Gardens, the Hong Kong report highlights out-of-date legislation and recommends a review and revision of public health and health-related emergency regulation. The Canadian quarantine experience was not as controversial, but a similar review of legislation and regulations was recommended for health emergencies across the provincial and federal governments.

On a positive note, the involved governments have been responding. The Canadian federal government is moving forward to create a national agency for public health, spun out from the current bureaucratic structures. The 2004 federal budget in Canada committed additional funds for the new agency, for a network of collaborating centers to protect and promote health across the country, for enhancing local public health capacity, and for provincial immunization programs. Meanwhile, the Ontario government is actively framing its responses to a recently released provincial report on SARS, whose recommendations strongly reinforce the federal report in regard to provincial investment and restructuring.11 Nonetheless, progress toward frontline preparedness for another major outbreak has been slow and problems with inadequate capacity for public health persist in most provinces.

In Hong Kong, the administration is progressing steadily toward the creation of the Centre for Health Protection as recommended by the international panel. This includes physical infrastructure, recruitment of personnel, funding, and active links with Guangdong. Work is also under way on developing information systems and surveillance. Officials from Hong Kong have acknowledged the importance of integrated training for specialists in infectious diseases, microbiology, and public health. Infection-control measures in Hong Kong nursing homes have been augmented, and closer links are being forged slowly between the private sector, particularly family physicians, and the public sector. Linkages with the Hospital Authority are still suboptimal, and the suggested review and reorganization of the central administration of health has not occurred.


The SARS story as we saw it in Hong Kong and Toronto had both tragic and heroic elements. The outbreak took a major toll, with deaths, illness, upheaval, and hardship on multiple levels in both these major metropolitan areas. Thousands of public health and health care workers rose to the occasion and ultimately contained the SARS outbreak in the 2 areas, notwithstanding systems and resources that were suboptimal.

It remains a mystery why other major areas were spared. However, in this era of rapid global travel, any city and area could face an outbreak at any time. In comparing the findings of 2 inquiries after SARS in Toronto and Hong Kong, we have been struck that these 2 areas, among others, missed opportunities to learn from each other during the outbreak, notwithstanding electronic communication and the laudable attempts at brokerage and facilitation by the WHO.

The challenge now is to ensure better preparation on a global scale for the next epidemic or threat, whether from SARS, a bioterrorism attack, or a novel infectious agent. International communication and collaboration, including sharing these lessons learned, remains an essential part of that process of preparation.

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