SARS 10 Years Later: The impact on Public Health Surveillance

Medical journalist Paul C. Webster analyses the after-effects of SARS and its impact on chronic diseases and their risk factors in Canada.  What progress has been made from the invested efforts and dollars?

The SARS epidemic that hit Canada almost exactly a decade ago claimed 44 lives, including three nurses. Confidence in public health was severely shaken. International confidence in Canadian disease surveillance and control suffered. So, when the SARS threat receded in mid-2003, the federal government acknowledged that big changes were needed. Although reforms to infectious disease control were prioritized, improved surveillance of chronic diseases and risk factors was also emphasized.

For guidance after the SARS debacle, Health Canada turned to the University of Toronto’s then dean of medicine, Dr. David Naylor, who assembled a high-level panel of public health experts. They didn’t waste any time: In October, 2003, just eight months after SARS arrived in Canada, Naylor’s panel issued a report recommending 118 major changes. 

Not surprisingly, the Naylor panel–which included five Toronto-based public health experts alongside six others from cities across Canada–mostly addressed the need for new infectious disease control measures. But the panelists took care to acknowledge that their SARS probe revealed a weak national non-communicable disease surveillance fabric as well. 

“More and more chronic diseases now seem to be caused by infections or at least have infectious cofactors”, the panel noted while pointing to the link between Human papillomavirus and cervical cancer as an example. “Strong genetic risk factors for chronic diseases have been identified” they added. As a result, a “new integrative approach to preventing chronic diseases” was recommended, within “a public health strategy that can anticipate and channel these new surveillance opportunities”.  

To integrate chronic diseases and their risk factors into a comprehensive national public health surveillance system, the panelists made three very specific recommendations: (1) Ottawa should bolster a “system that will collect, analyze, and disseminate laboratory and health care facility data on infectious diseases and non-infectious diseases”; while (2) extending “the business processes for infectious disease surveillance” to a national system for non-communicable diseases and population health factors”; and (3) investing in electronic information systems “to enhance disease surveillance and link public health and clinical information systems”.

Ten years later, many observers give Ottawa substantial credit for making progress on bolstering data capabilities and for extending chronic disease surveillance capacity. But they say progress has been slow on developing a national electronic surveillance system.  

In Calgary, Larry Svenson, who serves as Director of Alberta Health’s Epidemiology and Surveillance Team and chairs the Pan-Canadian Public Health Network Council’s National Surveillance Infrastructure Task Group, says recent progress on the surveillance of non-communicable diseases got started a few years before the SARS crisis following highly critical reports from the federal Auditor General. These concerns, Svenson explains, helped kickstart “a pilot project on diabetes done by the prairie provinces that pre-dated the recommendations found in the Naylor report”.

In Winnipeg, University of Manitoba community health professor Lisa Lix, who chairs the Canadian Chronic Disease Surveillance System Scientific Committee, describes “tremendous progress” on the use of population databases for surveillance of diabetes, hypertension, arthritis, osteoporosis, heart disease and mental illness. 

After describing a “maturation process” leading from data gathering to data interpretation to data usage that improves public health, Lix suggests “we’re probably in the middle of understanding and interpreting the data.” 

Tom Noseworthy, Professor of Health Policy and Management at the University of Calgary, agrees that there has been “a wave of enthusiasm” for the use of administrative data for surveillance purposes, and that “whether you attribute it to SARS and the Naylor report or not, PHAC [Public Health Agency of Canada] deserves credit”. 

But Noseworthy cautions that national surveillance of chronic diseases and risk factors is still “largely piecemeal” and lacks a comprehensive platform.

Dr. Vivek Goel, President and CEO of Public Health Ontario, says although SARS acted as an important trigger for the creation both of his agency and PHAC, both of which have expanded chronic disease surveillance, “we all need to now move surveillance upstream to cover risk factors”.

So far, the only risk factor that has attracted widespread attention is childhood obesity, Goel notes. The time has come to look at a far wider array of social determinants for health, he stresses. “For many of them it’s going to have to come from surveys that are expensive to do.”

Researchers looking for data from the national electronic health system that the Naylor panelists recommended will find little satisfaction, Goel and Noseworthy warn. 

Although Health Canada has invested well over $100-million in Panorama, a national surveillance system developed by Canada Health Infoway (CHI), a federal crown corporation, “the concept has gone almost nowhere,” says Noseworthy.

“We are now looking towards a world where people are working with tablets, and we’re going to see some very disruptive innovations.”

According to Dr. Goel, jurisdictional barriers are largely to blame, and after years of delay–although in 2004 Infoway promised that Panorama would be serviceable by 2009, in 2010 PHAC indicated in its Emergency Preparedness and Response audit that the CHI Panorama project was not well connected and integrated and may never be fully implemented–some elements of the system may start coming on-line in 2014. 

Both Goel and Noseworthy worry that the Infoway’s decade-old technological framework for Panorama may have been overtaken by rapid technological changes. “We are now looking towards a world where people are working with tablets,” Goel notes, “and we’re going to see some very disruptive innovations”. <>