Further Memorandum by the Academy of Medical
SEVERE ACUTE RESPIRATORY SYNDROME
SCIENCES, 10 CARLTON
LONDON SW1 ON
9 JUNE 2003
The Academy convened a meeting in London on
9 June to consider the recent SARS outbreak. Working group members
were invited to take stock of current activity in the UK and worldwide
and to identify ongoing concerns or issues for further work. The
group was chaired by Professor Tony Minson, FMedSci, Professor
of Virology in the University of Cambridge. A full list of members
is given below.
International position/data collection
Infection rates are slowing and can be concluded
to be under control, although there is still uncertainty about
China because of the limited information available. The most affected
countries initiated very large public health interventions that
would not be sustainable in the longer term. In lesser-affected
countries, there is a problem of "high noise to signal"
ratio in data collection and comparisons are complicated by different
national policies in declaring suspect cases. The predictive value
of clinical diagnosis is likely to be high in those countries
with high infection rates but less in countries such as the UK
because of the higher "noise" level.
One continuing issue is the lack of consistency
in case confirmation by laboratory testing (seroconversion, PCR)
and it remains important to standardise quality control across
all regional laboratories globally.
The WHO performed well and there was generally
good international collaboration. There is an issue relating to
problems of linkage between datasets (different professional groups):
there was successful laboratory collaboration between virologists
and (to a lesser extent) between epidemiologists but there are
concerns about database integration between laboratory sampling
and clinical case finding and between virology and epidemiology.
The weakness in linkage is a problem for crisis managementthe
real-time evaluation and interpretation of data in order to manage
riskand is attributable not just to lack of coordination
but also to inadequate IT infrastructure. In the absence of real-time
information, there is the temptation to extrapolate from previous
epidemics (eg FMD) that may actually be dissimilar (eg in terms
of viral persistence). This weakness may be compounded by the
historical preference of public health systems to rely on epidemiology
forecasts rather than engage with the implications of scientific
There is a need for the UK to build more infrastructure
to support research across a broad area (because of the uncertain
nature of future threats). While the UK might not be able to match
the intensity of activity in Hong Kong (influenza epicentre) or
the US CDC (response to bio terrorism), it is important that the
UK has sufficient infrastructure to capitalise on the expertise
currently availableand to prepare the next generation expertise.
Concern was expressed that the Health Protection
Agency (HPA) may not recognise the importance of the R&D agendaassuming
that Standard Operating Procedures will suffice to underpin responsivenessand
that too much attention has been devoted to bacterial pathogens
(because of food microbiology as a political priority), at the
expense of respiratory viruses. There is also a continuing need
to build research capacity in the regional public health laboratories,
so that they do not become dominated by the imperative of service
provision. The importance of building research capacity regionally
(as well as centrally) reinforces the recommendations in the Academy
Report on Academic Medical Bacteriology.
In short, it was concluded, that the UK was
luckyin the low incidence of SARSbut if there had
been a crisis, the UK may have struggled to respond in consequence
of the weakening of surveillance structures.
It was also concluded that the UK is lucky because
of the available corona virus expertisebut equivalent expertise
may not be available "next time", for a different virus,
for example a flavivirus (eg West Nile and related viruses). There
is a need to review expertise in the UK and to ensure coordination
of activities such that resources are not wasted on excessive
duplication and a fast response can be mounted against new threats.
There appears to be no mechanisms for providing funding in an
emergencyCorona virus expertise in Bristol was mobilised
efficiently to support the HPA, but only through the use of University
funds. Such ad hoc arrangements do not offer much confidence
that the UK will respond effectively to future emergencies. More
funding is required to build academic research capacity in pathogen
discovery and host specificityprioritising according to
perceived risk but also ensuring cover and response capability.
The UK is losing competitiveness in this field and the weakness
is exacerbated by unnecessary divisions between human and animal
health research (divorced at both funding and policy levels).
Insufficient notice has been taken of the interface between human
and animal infectious diseases in allocating priorities for funding;
there is a need for more connectivity between the funding bodies
in order to encourage and support joint programmes in veterinary
and human medicine.
There are critical matters relating to both
animal research and safety (containment) regulations. For animal
research, it could have been difficult to initiate a SARS-primate
study rapidly in the UK, if that had been deemed necessary. It
is important that the UK raises preparedness by having a generic
Home Office project licence in place to enable such research to
proceed in the event of a public health imperative.
With regard to the provision of containment
facilities, the difference was noted between UK practice (primary
protection of researcher) and EU practice (physical containment
of risk)international inconsistencies in containment practice
should be resolved. In the UK, there is probable need to upgrade
facilities (from category 3 to 3+, particularly at the regional
level), to identify whether more category 4 facilities are required,
to improve funding for running costs and to maintain a cadre of
appropriately trained staff. While it seems appropriate for the
early research groups (with HSE) to decide on containment status
in a novel episode, there is room for clarification of the ACDP
role in deciding national status in a timely manner once the organism
In addition to the issues already described
(responsiveness, facilities, research culture), there is also
the issue of whether SARS can be perceived as a paradigm for bio
terrorism. Does SARS serve as a wake-up call to the EU and the
UK to evaluate preparedness? Would increasing preparedness in
bio defence help the responsiveness to other new, infectious diseases?
If bio defence plans were in place, the UK would not have to rely
on luck next time.
Clinical expertise is needed to identify and
manage patients with SARS (and the successors to SARS) and to
develop a research agenda to explore pathogenesis, prohylaxis
and treatment. Clinical investigators will wish to explore issues
such as cross-infection policies, treatment strategies, and capacity
in relation to clinical expertise.
Role of industry
Much of the healthcare industry would be dependent
on academic research leads in new infectious diseases, and there
are issues for facilitating the interface between the sectors.
It is unlikely that there are major HPA-spin off company opportunities;
it would be easier to commercialise new areas with pre-existing
companies, particularly if there is pre-existing hardware to serve
as the template. But, for industry to be interested (in developing
diagnostic kits, vaccines, therapeutics) there must be sufficient
market incentive and, hence, political will to create the incentive.
Many of the academia/Public Health
Laboratory issues raised echo the weaknesses identified in the
Academy (2001) Report "Academic Medical Bacteriology in the
21st Century" (that had alluded to significant problems in
clinical virology). The report may be downloaded from the Academy
web site: www.acmedsci.ac.uk.
Related issues (surveillance, responsiveness,
industry role) have also been raised in the Academy's input to
the House of Commons, Science and Technology Committee Inquiry
on "The Scientific Response to Terrorism" and the publication
of the findings from that Inquiry may help to clarify roles for
The issues raised are also highly
relevant to current discussions on the programme of the Academy
Forum (eg role of industry/partnership in response to new and
emerging infections/bio terrorism) and specific proposals will
be reviewed shortly.
The initial output from this SARS
Working Group will be used to open discussions with key policy-makers.
Without wanting to pre-empt these further discussions, key areas
are likely to include: public health surveillance and crisis management;
research funding flexibility and capability; coherent strategy
for animal-human research interfaces; filling the impending knowledge
gap by succession planning/training.
Working group members: Professor Tony Minson
(Chairman), Dr Maria Zambon, Sir John Skehel, Professor Peter
Openshaw, Professor Stuart Siddell, Dr Mike Crumpton, Dr Phil
Minor, Ms Mary Manning and Dr Robin Fears (Secretary).
1 See oral evidence p 33. Back