Back to the future: SARS Expert Committee Co-chairs Prof Sian Griffiths and Sir Cyril Chantler brief the media on their just-released report. It includes 46 recommendations aimed primarily at helping Hong Kong stamp out any future outbreaks.

The most important lesson from the SARS (severe acute respiratory syndrome) experience is the need to be prepared, the SARS Expert Committee said in its just-released report on the handling of the outbreak.

The committee's overall conclusion was that Hong Kong had tackled the epidemic well - although there were significant shortcomings in the system during its early phase.

The committee's co-chairpersons, Sir Cyril Chantler and Prof Sian Griffiths, submitted the report to Chief Executive Tung Chee Hwa this morning. The full report and its summary were released simultaneously to the public and have been posted to the committee's website, www.sars-expertcom.gov.hk.

The committee, with 11 renowned experts from the UK, US, Australia, Mainland China and Hong Kong selected for their wide range of relevant experience, was set up on May 28.

It was asked to conduct a review on the management and control of the epidemic and identify lessons to be learned to better prepare Hong Kong for any future outbreaks.

Committee commends HK people's courage, dignity

In its report, the committee commended the people of Hong Kong for the courage and dignity that they had shown during the SARS epidemic, and expressed sympathy for those who had suffered from the epidemic.

"We wish on behalf of all members of our committee to express our admiration to the people of Hong Kong for the way they coped with what was a very severe and very dangerous outbreak," Sir Cyril said at a midday press conference.

"We would particularly like to express our condolences to the families of those who died. In a very real sense, we believe that our task over the last four months has been to do the very best we can to ensure that their sacrifice has not been in vain."

The Committee had undertaken a full and comprehensive review, he said. 

"We have conducted a lot of interviews and met a wide variety of people from different backgrounds who had been involved in or affected by the epidemic, and we have had extensive discussions to arrive at the conclusions based on the facts that we have found and established.

"Where appropriate, additional information and clarification has been obtained, and the relevant authorities and persons have been given the opportunity to respond." 

Sir Cyril quoted an analogy a fellow committee member, former head of the Centre for Diseases Control in Atlanta Dr Jeffrey Koplan, had made.

You build a wall to stop your house from getting flooded, and for 50 years it keeps you safe. Then you get a flood you did not expect - so you build a bigger wall.

"Our report is designed to help you build a bigger wall," Sir Cyril said.

Report findings truly independent

The findings and recommendations contained in the Report represent the collective opinions and judgements of members of the committee alone, Sir Cyril said.

"We all have our own roles and responsibilities in our own country, and our integrity actually matters to us.

"We have endeavoured to learn the lessons and to pass them on to you, to protect this society in the future, and to protect the world in the future.

"We have examined issues most relevant to the terms of reference of the committee from the perspectives of public health, disease control, contingency planning, outbreak-control mechanism and actions, as well as system designs to critically and professionally assess whether the Administration, the health authorities and the hospital management had properly discharged their duties and functions under the very difficult situations at that time," Sir Cyril said.

Findings put in context

Sharing Sir Cyril's view, Prof Griffiths said that in reaching judgements, full account had been taken of the hazards of retrospective judgement, and therefore efforts had been made by the committee in each instance to examine the subject matter in the context of what was known, and what could have been done, at the time.

"Over time our understanding of the disease changed," Prof Griffiths reminded reporters. "When you think about the report, understand that there was a changing picture.

"There were significant shortcomings of system performance during the early phase of the epidemic when little was known about the disease or its cause, some of which were aggravated by key personnel becoming ill with SARS as the epidemic progressed," she said.

"Many shortcomings were rapidly put right, while others were compensated for by the extraordinary hard work of people at all levels of the system and in very difficult circumstances.

Report does not pinpoint individuals

Sir Cyril noted that the committee had examined the actions of individuals as well as the system. "As I said in August, if we deemed any individual to be culpable in terms of negligence, non-diligence or maladministration, we would draw their names to your attention in our report. We have not found any individuals to be culpable in that sense."

He noted that he understood the need for justice, especially for those who had lost loved ones to the disease. But justice is not served only by blame, he said.

"Justice is also served by ensuring that, if and when another outbreak occurs - and I should say when, that a system is in place."

Through retrospective analysis, the committee identified things that could have been done better, and areas in which further improvement should be made.

Looking forward, the committee came up with 46 recommendations grouped under 12 strategic themes to better prepare Hong Kong should an emergency or crisis strike. Details can be picked up from Chapter 18 of the full report.

Sir Cyril stressed the need to recruit people in the media to help should there be a future outbreak. Steps should be taken now to find out how to better communicate, he said.

Report highlights key lessons, challenges for future

In general, the report noted the SARS experience had helped to identify a number of positive lessons as well as highlighting a number of challenges for future preparedness.

Speaking at the press conference, committee member Prof Lee Shiu-hung restated a message from the World Health Organisation: SARS was the first epidemic of the 21st century - but it will not be the last. That is why it is important to be ready.

The report stated: "The underlying concept is that of resilience, that is, the ability at every level of the system to detect, prevent, control and recover from disruptive challenges. It depends on a well planned, carefully orchestrated and fully integrated emergency-management response."

The report recommended that the organisational structure and the relationship between the Health, Welfare & Food Bureau and the Government departments under the bureau be reviewed with a view to improving the capacity for coordination, and facilitating policymaking and commissioning for health-protection matters.

Centre for Health Protection key recommendation

Specifically, it recommended setting up a Centre for Health Protection with responsibility, authority and accountability for the prevention and control of communicable diseases. As it develops, the centre should also have responsibility for advising on all aspects of health protection, including food safety and hygiene, veterinary issues, non-communicable diseases and their risk factors.

The report stressed that strengthening surveillance would be an urgent priority to provide early warning to the system. It also pointed out that an important gap in the system was the absence of comprehensive laboratory surveillance.

"There needs to be a high level of vigilance and alertness throughout all parts of the health system. This requires a culture where everyone recognises that their work, whether in primary care or hospital care, may have wider public health implications, and that an illness in one patient may have consequences for the whole community," the report said.

Further technology investment necessary

While noting the success of advanced information technology applications - e-SARS and MIIDSS (Major Incident Investigation & Disaster Support System) - developed during the epidemic, the report said investment should be made so that the technology is harnessed to better prepare the Department of Health/CHP to meet the challenges of future outbreaks.

It also recommended that efforts should be made to ensure that all laboratories promptly and routinely report all laboratory diagnosis of public health importance to the Department of Health/CHP. A more fundamental reform would be to integrate all hospital microbiology laboratories within the new CHP.

"Establishing a CHP will deal with many of the shortcomings in public-health resources, particularly the need for more communicable disease epidemiologists and public health specialists which is critical," the report said.

Contingency planning vital

The report placed heavy emphasis on contingency planning which would serve as the basis for dealing with most health service and public health emergencies, including communicable disease outbreaks.

It suggests that the Health, Welfare & Food Bureau, the Department of Health, the Hospital Authority, and each regional office, cluster and hospital develop and implement a major outbreak-control plan. It should specify in detail the composition of the outbreak-control team, roles and responsibilities of key individual team members and the mechanism of activating the plan.

It should be developed in collaboration with Centre for Health Protection and adopt a population-based approach, and be regularly tested. Management of communicable disease outbreaks should be viewed as an integral part of contingency planning, the report said.

"There is also a need for site-specific plans, event or scenario-specific plans, and plans that take account of the increasingly international dimension of public-health incidents."

"Similar plans and arrangements should exist in the private sector and in other support agencies and organisations," the report said.

Clear chain of command needed

In case of a public-health emergency, the report recommended that a clear chain of command would be needed for effective management as the Committee had observed that various mechanisms and bodies were established on an ad hoc basis in response to the SARS epidemic.

"These arrangements need to be clarified and formalised in preparation for any future emergency," it said.

"A framework of command is needed to manage the response at one or more of three levels: operational; tactical and strategic. Command and control arrangements need to reflect the fact that the chain of control is normally activated from the bottom upwards."

The report recommended the establishment of a small command group, chaired by the Secretary for Health, Welfare & Food, with a limited number of people - such as the Permanent Secretary, the Director of Health, the Head of the Centre for Health Protection and the Chief Executive of the Hospital Authority - responsible for taking all major decisions during an outbreak.

Legislation needed to ensure appropriate response

"A suitable legislative framework is also needed to enable an appropriate public health response. Contingency planning cannot be carried out in isolation, but must involve close collaboration with neighbours in the Pearl River Delta region, Mainland China generally, and the international community as a whole," the report said.

In this respect, the committee stressed the importance of international links and the need to engage with the WHO.

The report noted that inadequate surge capacity in hospitals and the public health system had clearly been a major problem with SARS.

Hospital improvements urged

It recommended that the Hospital Authority urgently invest in improvements to hospital facilities, especially isolation rooms, and to review shortages in some clinical skills and specialty areas and make plans to redress them.

The committee also endorsed the Government's proposal to develop infectious-disease units attached to selected acute hospitals, rather than to build a single standalone infectious-disease hospital.

It also urged the authority to develop detailed plans on how resources would be shared to deal with an incident that would overwhelm the capacity of any one part of the health system.

Seniors' homes need stronger infection-control measures

Noting that probably the group most vulnerable to infection are older people living in residential care homes, the report recommended that infection-control arrangements in residential care homes for the elderly, including infection-control training for staff and improving isolation facilities, should be strengthened; and that the Visiting Medical Officer scheme should be made permanent.

On communication with the public, the report noted that communicating risk to the public has never been easy, particularly in the face of an overwhelming crisis.

"It is important to build a level of trust within the community by ensuring that professionals with appropriate expertise and seniority are properly trained in dealing with the media, that long-term partnerships are built with the media and that they are involved in the contingency-planning process, and that there is an on going programme of public education on public-health issues," the report said.

Media has role to play in communicating risk

The committee also noted the contribution of the media in the SARS outbreak and suggested that the media should have a responsibility of communicating risk.

It also offered observations and comments on several key issues that were prominent and about which concern or dissatisfaction was expressed in the committee's discussion with various parties. Details can be found in Chapter 4 of the full report.

The committee had formed two groups to focus on hospital management and administration, and public health. The hospital group convened its meeting on June 26-28 while the public health group had its meeting on July 7-11. The committee held its plenary session on August 13-19.