SARS not only elicited a strong immune response in its hosts, it also elicited a strong global healthcare response. The actions taken by healthcare administrations to combat SARS were largely shaped by the speed at which the disease can be spread. It is difficult to diagnose quickly as its symptoms are highly variable and are not unique. Since the pathogen itself was initially unknown, there was no reliable way of testing for its presence in a patient in the first cases. There was also no good way to combat the virus with known antivirals, so our arsenals of drugs were relatively useless against it. It is thus challenging to pinpoint a case of SARS until the disease had spread to other hosts and an outbreak has occurred. Therefore, broad health measures requiring high levels of cooperation were taken to combat the spread of this unknown virus. These measures were largely successful, at least in the short run, as there are no known cases of SARS at the moment.

There were several different levels of activity:
Global
National
City/Provincial
Hospital
Personal

Global

The global nature of the outbreaks of SARS gave the World Health Organization a chance to try a revolutionary new way of combating disease. They linked governments, hospitals, airports and othe travel hubs, healthcare providers and researchers so that open sharing of information on all aspects of SARS could occur. This network, called the Global Outbreak Alert and Response Network, coordinated efforts against SARS across the globe, kept tabs on the movement of cases and documented the emerging epidemiology of the disease as well. The WHO created a network of laboratories to cope with the task of searching for the causative pathogen. It was through teamwork and real-time cooperation between 13 labs in 10 countries across the world that advances in the fight against SARS were made extremely rapidly. Information was available in real time through a password-controlled global database of the up-to-date findings of each lab working on the project. This pooling of resources allowed researchers to discover the agent of infection within a week. This cooperation in turn provided a strong network of information to supplement each country's battle with the disease. For more information about the Global Outbreak Alert and Response Network, visit http://www.who.int/csr/sars/goarn/en/

National

Recognition of the presence of the disease by ministries of health was a key step in mobilizing the populace in efforts to battle outbreaks. Often, outbreaks of SARS occurred because of a late recognition of its presence in the population. Once the existence of a case (or cases) in a nation was recognized, governments took active steps towards neutralizing the threat. National mobilization involved press conferences and the release of definitions of the disease, modes of transmission, and other essential information on the disease. Governments employed methods such as the release of educational state-sponsored T.V. spots, handwashing programmes, the placement of banners encouraging care around health, and posters detailing symptoms and other pertinent details of SARS. The widespread dissemination of information better equipped people to cope with outbreaks and obey local protocols (like quarantine) for containment of the disease.

Airport security was heightened in affected countries to prevent possible cases from travelling and nations cooperated in global traveller location when a suspected case was . Suspected cases were traced and located on airplanes and in destination countries through international cooperation.

In countries with a possible animal reservoir (civet cats in China and chickens in Viet Nam, for instance), these animals were slaughtered in large numbers and destroyed in order to eliminate possible SARS hiding places.

Many of the real initiatives taken against SARS were organized on a state level but instituted at the city or provincial level.

City/Provincial

In light of the fact that there was no good medical treatment for the disease, quarantine was the major tool used to halt the spread of SARS. In most areas, quarantine initially lasted 14 days. As greater knowledge about the incubation time of the disease was gained, quarantine time was reduced to 10 days. Orders were swiftly issued to persons having had close contact with an infected individual. Close contact was defined differently across national structures, but the definition is largely intuitive. Classmates, fellow riders of public transportation, family members, and healthcare workers all fell into the category of close contacts. Essentially, it includes anyone who one could have shared air with, thus breathing droplets containing the virus. Quarantine was instituted in affected persons' homes, in travel hubs at designated airport hotels, at military hospitals, and in civilian hospitals. Visiting to quarantined individuals was restricted in all locales. However, motions of community support were made through phone calls and card-writing, along with limited, regulated visits. Quarantine was enforced with the threat of large fines and jail time. It was also encouraged in some regions by the offering of a small sum upon completion of quarantine.

While isolated, individuals were required to report temperatures two to three times a day. Local health officials monitored the status of these individuals and any possible cases were referred to designated hospitals.

Quarantine was supplemented with massive public information campaigns on how to prevent the spread of disease and to encourage compliance with quarantine and other health measures (i.e. honestly answering health questionnaires).

In Beijing, the hardest hit in terms of caseload, there were fever check stations set up on the main roads in and out of the city to catch any commuters or travelers carrying the disease. Fevers were also checked at the entrance to restaurants and other public places. Beijing also split the triage of patients up further than other places. There, there existed "fever clinics" where febrile individuals could seek attention and suspected SARS cases could be snagged and sent on to designated hospitals. This complex differentiation of the healthcare structure was garnered by the magnitude of the outbreak in Beijing.

Hospital

Many of the infections (21% of infections worldwide) occurred in healthcare workers. Because doctors and nurses were at risk, there were policies of containment instituted in the hospital setting as well. The details of these policies tend to be fairly universal in character.

Environmental protection
In all hospitals treating SARS patients, there were isolation wings for these patients. This was because of the rapid spread of disease from infected patients in a hospital to non-infected patients or visitors. The problem with this outbreak was that most hospitals were not equipped to handle a large influx of patients in need of isolation. In many cases, whole wards were converted into SARS isolation wards. In some cities and provinces, entire hospitals were deemed SARS hospitals. Within the hospitals, isolation rooms were equipped with either negative pressure ventilation or outward-blowing fans equipped with HEPA filters to expel airborne virus from the rooms and decrease the possibility of spread to healthcare workers or other patients in the hospital.

When hospital-wide outbreaks occurred, hospitals (at least those in Toronto) closed off contact to the outside world by severely limiting the emergency room and ambulatory clinics and preventing their workers from working at other institutions.

Personal Protection
Healthcare workers treating SARS patients were required to wear full body isolation gear. This includes a gown, gloves, show covers, and an N-95 or other thick, layered respiratory mask. Protocols for mask fitting were strict in all hospitals with "police nurses" to observe that proper droplet and body substance isolation protocols were observed. This included the disposal of all gowns, gloves, and masks after treatment of a patient. Every hospital also included a strict handwashing routine. Hands were to be washed before donning gloves and after removing them. Each day, training videos and presentations reminded healthcare workers of the importance of strict isolation.

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In addition, all studies indicated that procedures in which greater patient aerosol is released (i.e. positive pressure ventilation, orotracheal intubation, etc.) required high levels of suspicion, strict isolation of the patient, and the greatest care in protection of the care provider. The doctors were encouraged to wear goggles or other eye protection in addition to other protective wear.

All instruments and devices that came into contact with patients were cleaned and disinfected thoroughly or disposed of. Even the computers and office equipment in SARS wings of hospitals were disinfected twice daily.

These measures were quite successful in limiting healthcare worker infection. In some cases, even protected healthcare workers were infected, but usually this was avoided when the 4 essential points of handwashing, gloves, gowns, and masks were observed. Another element in personal protection was an increaased vigilance in the community of healthcare workers around personal sickness. Most healthcare workers would ignore a mild fever and cough and attend work as if nothing was wrong. However, in the case of SARS, viral shedding would be occurring and infection would be spreading, so higher levels of attentiveness to personal health became necessary (45).

This higher level of suspicion spread to the larger community Some effort was made to work with polymers in creating breathable isolation gear but these garments were relatively fallible and did not provide a sufficient degree of safety for use in the field (48).

Beijing, the area hardest hit in terms of number of infected patients, even constructed a SARS hospital that embodied these isolation protocols (93).

Personal

Public health campaigns aimed at frequent handwashing, monitoring of personal health conditions, awareness of the health status of others, and the completion of health questionnaires were all programs affecting individual health during the SARS outbreaks.   Some people wore N-95 masks or other air-filtering apparatuses to attempt to limit viral contact originating from viral shedding by individuals in the environment who had not recognized their SARS status.