In 2020, the medical literature was filled with information about the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19. Similarly, from 2003 to 2017, much was documented regarding pandemic preparedness and the public health implications of two novel coronaviruses: SARS-CoV and Middle East Respiratory Syndrome (MERS-CoV). This review raises the question of why there was such a lack of preparation despite extensive knowledge from previous coronavirus outbreaks.  States, territories, and healthcare systems should promptly evaluate the efforts made during this past pandemic, with a strong historical awareness of responses to past coronavirus outbreaks.

Severe acute respiratory syndrome coronavirus 2, Pandemic preparedness, World Health Organization, Public health consequences, Outbreak response.

“It is our responsibility to learn from our experiences with SARS and, as front-line clinicians, familiarize ourselves with epidemiology and clinical presentation,” stated Matthew Muller.[1] “Are we any better off today than our 1918 counterparts in handling a public health epidemic?” said Monica Schoch-Spana.[2]

Medical and nursing students were pulled from their classrooms. Retired healthcare workers (HCW) were asked to return to assist with the care of hospitalized patients. Police officers, firefighters, and postal workers fell ill and died. This was how one author from the Center for Civilian Biodefense Strategies at Johns Hopkins University described the 1918 Influenza Pandemic. The United States experienced more than 500,000 deaths and an estimated case mortality rate of 2.5% from that early 20th-century pandemic. Questions arose about hospitals’ ability to manage the large influx of patients, the ongoing need and availability of HCW, how to protect them from contagion, and the availability of supplies and equipment.[2] This review aims to highlight the numerous studies and publications that have emerged due to previous novel coronavirus outbreaks and during the early part of this decade. Despite this wealth of information available to the public and to legislative and business leaders, the world was unprepared for SARS-CoV-2.

This paper reviews observations and recommendations in the medical and public health literature from 2002 to 2017.

In early 2003, a 60-bed hospital in Hanoi contacted the World Health Organization (WHO) about a patient who exhibited what appeared to be an atypical influenza-like illness. Carlo Urbani, a WHO physician and infectious disease specialist, was asked to investigate the outbreak. His calming and collegial approach fostered a significant level of trust between him and the Vietnamese health authorities. New infection control procedures were swiftly implemented. Additional specialists from the WHO and Médecins Sans Frontières obtained permission from the Vietnamese government to investigate the novel disease.

Urbani and the Vietnamese health authorities organized the first meeting on March 9, 2003. On his return flight to Bangkok, he fell ill and advised his colleague, who was picking him up from the airport, not to touch him. Urbani passed away on March 29, 2003, eighteen days after his stay in a makeshift isolation tent. Five additional healthcare providers would also succumb to the soon-to-be identified infectious agent, SARS.[3]

China was identified as the country of origin for SARS. The first recorded case in the country occurred on November 16, 2002, but it was not reported to the WHO until February 11, 2003. In January 2003, China also experienced a significant hospital-wide outbreak, which resulted in the transmission of the virus to 59 healthcare workers and 19 family members. When China reported the outbreak to the WHO, there had been 305 additional cases documented along with five deaths. On February 21, 2003, a nephrologist involved in the initial treatment of the first cohort of hospitalized Chinese patients was identified as the individual responsible for transmitting the disease, leading to an eventual SARS outbreak in six countries, including the United States. The physician traveled from China to Hong Kong for a wedding, and within 24 hours, sixteen guests were hospitalized. The others returned home to Vietnam, Canada, Singapore, the Philippines, and the United States. On March 12, approximately four months after the first documented case, the WHO released its first global alert.[1]

As the response to SARS unfolded, warnings and recommendations were issued simultaneously regarding the highly pathogenic avian influenza A (H5N1), which had caused the 1977 influenza pandemic in Hong Kong. One scientist commented that the H5N1 influenza pandemic, which occurred before the new SARS pandemic, noted that the world was probably one or two mutational events away from a pandemic.[4] As early as 2003, a warning had appeared in The Lancet that health authorities worldwide needed to have plans in place to develop reliable and inexpensive diagnostic testing reagents rapidly.

Eighteen months after the first case of SARS was reported in China, the epidemic was declared under control. The strict isolation of patients was crucial in limiting the spread of the disease. More than 8,000 cases were confirmed, with a 10% mortality rate. Within six months, 29 countries were impacted. In the United States, 156 suspected SARS cases were identified. By 2005, it was believed that transmission occurred through airborne droplets.[5] Lung pathology revealed diffuse alveolar damage. Regarding therapy, steroids were administered but had no documented effect. In 2005, the WHO recommended developing vaccines to respond to and manage coronavirus infections. It was also suggested that wild bats were the reservoirs for SARS. Additionally, it was recommended that surveillance of these mammals continue to assess their threat to human health.[6]

“The recognition of a single case of probable SARS should prompt the immediate activation of local, national, and international public health strategies to contain SARS; contact tracing should begin immediately. The prevention of future outbreaks requires ongoing vigilance, both by public health authorities and my front-line clinicians,” said Matthew Muller.[1]

Following the SARS pandemic and before the 2009 H1N1 influenza outbreak, the WHO developed formal preparedness guidelines for the whole of society.[7] The document serves as a readiness framework outlining key principles of preparedness. It also guides businesses on what to expect during a significant pandemic and how to plan, emphasizing the sharing and alignment of business continuity plans at the local, state, and national levels. This WHO document highlights the crucial role of government leadership and the use of simulation exercises and drills in reviewing and updating communication and coordination activities. Anticipating transborder issues, plans were established to provide guidance in an ethical and humane manner.

Governments were expected to rely on the best available science and socioeconomic data. A pandemic readiness checklist for state governments and businesses was made available for all to use.

As the SARS era began to settle, there was increased international discussion and recommendations on preventing the next animal-to-human (zoonosis) pandemic. New mathematical models and enhanced diagnostic, communication, and informatics technologies were discussed and reviewed. Public health opinion at the time emphasized the need for these resources and their critical importance. SARS was expected to put scientists and governments in a better position to identify unknown viral agents and develop new risk assessment approaches.

The SARS pandemic also brought to fruition two decades of recommendations by expert panels on the need to strengthen global public health surveillance. After SARS, the WHO, Canada, and the United States developed enhanced initiatives to create novel pathogen search models and surveillance systems. The Emerging Pandemic Threats Program was a significant new arrival in the field, initiated in 2009 by the United States Agency for International Development (USAID). A key component of this USAID program was the Pandemic Risk Evaluation and Detection Integrated Control Tool (PREDICT). This program developed models to identify the emergence of infectious diseases that spread from animals to humans. By 2012, PREDICT was active in 20 low- and middle-income countries identified as global hotspots.[8] Funding for PREDICT was halted in September 2019.

The second novel coronavirus of the 21st century was the Middle East Respiratory Syndrome Coronavirus (MERS), first identified in Saudi Arabia in 2012. Compared to SARS, MERS had fewer cases and deaths; however, the international mortality rate ranged from 14.5% to 69.2%. The virus originated from exposure to dromedary camels. Like SARS, MERS exhibited a high infection rate among HCW.[9,10] A consensus emerged that effective contact tracing and isolation procedures could reduce the pandemic risk.[11] During the MERS outbreak, it was also noted that a single negative test could not reliably rule out an active infection, leading to recommendations for repeat testing.[12]

SARS, MERS, and the H1N1 pandemic prompted further discussions about readiness for surge capacity, which is vital for pandemic mitigation and response planning. The challenges raised from 2006 to 2017 highlight the ability of both small and large hospitals to shift their focus from individual patients to the population, thus offering a distinct perspective on population health.[13] With the WHO Health Promoting Hospital program as an example, some Asian and European hospitals adopted a health promotion approach. Meanwhile, the United States focused on reducing healthcare costs, managing acute illnesses, and promoting competition within the healthcare system.[14] In 2006, the Academic Emergency Medicine Consensus Conference developed a simple model to help hospitals operate from a population perspective. Emphasis would be placed on four elements: staff, stuff, structure, and system. [15-17]

The health and well-being of healthcare workers (HCW) during pandemics has been a topic of study for nearly two decades. Throughout the SARS outbreak, significant staff shortages occurred for various reasons beyond direct illness affecting the workers. Balicer et al. [18] commented on healthcare workers’ concerns regarding the manageability of the threat and the potential loss of control over the events they were to encounter. Although most HCW came to work, a small but significant proportion chose to leave their jobs during the outbreak. It was also observed that many HCW reported for work even when ill, with that number increasing during staff shortages.[19]

The 2003 SARS pandemic significantly impacted air travel. Singapore and Hong Kong saw a dramatic decline in flights and passenger traffic. The WHO and the Centers for Disease Control and Prevention (CDC) issued formal travel warnings three weeks after identifying the first index case. A month passed after the first index case was identified before formal control measures were implemented at Singapore and Hong Kong international airports. From this experience, recommendations included optimal temperature screening and the development of better technology to enhance early detection.[20]

In 2009, the Institute of Medicine (now known as the National Academy of Sciences, Engineering, and Medicine) convened national experts for a workshop to discuss and provide recommendations on defining and preparing for medical surge capacity in a disaster.[21] This gathering was timely, especially as the WHO declared the H1N1 virus a pandemic. Some notable organizations in attendance included the American Hospital Association, the National Governors Association, the Department of Defense, the American Medical Association, the White House, the Department of Homeland Security, and the Emergency Nurses Association. The topics and subsequent white papers addressed the role of government and hospitals in surge crises, issues related to vulnerable populations, and the financial losses associated with national disasters. The event also covered the need and availability of ventilators, staff, and beds in preparation for a pandemic.[22]

Limitations
This paper provides a historical review of available medical and public information from a specific period. The focus is on the critical information accessible before the last pandemic, raising the question of why politicians, healthcare systems, and public health officials did not utilize this information. This paper does not explicitly address past failures in preparedness and their consequences; more comprehensive reviews are available for such insights. Papers written in English were used to facilitate the development of this manuscript.

Despite two decades of experience, advice, and recommendations, many countries remained unprepared for the 2020 COVID-19 pandemic. International cooperation concerning timely reporting of index and subsequent cases, understanding global hotspots, stay-at-home advisories, testing, the availability and use of personal protective equipment, surge issues related to ventilators, HCW, and intensive care unit (ICU) beds, as well as the morbidity and mortality of healthcare workers, closures of schools and businesses, and the adverse effects on air travel had all been previously reviewed at regional, national, and international levels. Renowned organizations, such as the WHO and the National Academies of Sciences, Engineering, and Medicine, developed recommendations and guidelines and reported on these findings.  We were aware of coronaviruses and their potential for increased global lethality. Finally, in addition to the coronavirus outbreaks discussed in this article, the Bipartisan Commission on Biodefense, a group of high-ranking and influential Democrats and Republicans, asserted in 2015 that the United States was not prepared for biological threats, whether initiated by terrorists or through the reemergence of infectious diseases.[23]

Leadership has been identified as key to fostering citizens’ trust and successfully implementing pandemic preparedness plans. Many countries, including the United States, faced criticism for lacking such leadership.[24] Some countries were better prepared. South Korea initiated healthcare reform after the MERS outbreak. Vietnam, with its strong public health infrastructure, was able to begin testing and containment early. Germany’s response was mixed, exhibiting both challenges and successes. As individual states possessed the power to respond to the crisis, testing and containment varied. However, the country could share reliable information quickly and had early testing capabilities.[25]

The upcoming decade will also confront growing environmental challenges due to climate change.[26] What can we do now to face this challenging future? As concerned citizens, we must identify and support empathetic, decisive public health leaders who recognize the lifesaving importance of science taking the lead in catastrophic health-related emergencies. As many cities in the United States have done, alliances should be formed to enable optimal communication, trust, and the sharing of personnel, ICU beds, medicines, and ventilators.[27,28] This discussion brings us closer to the clinical and public health benefits of a national health system. Pandemic preparedness plans must identify and keep the key state and city stakeholders informed. Broad-based decision-making models should be established and continually updated.[29]

Healthcare systems focused on competition and governmental and managed care reimbursement must change course and better define how system operations can be prepared to respond to large population-based incidents. Front-line HCW, who have risked their lives during this pandemic, need to be ready to challenge the status quo of our United States health care system, or we risk more events in which their lives will be put at risk.

To enable state and local governments, healthcare systems, and businesses to prepare for the next surge, variant, or global disaster whether caused by a virus or global warming, it’s essential to formally evaluate what these entities have done in response to the current pandemic to extrapolate lessons learned for a more ideal and efficient level of preparedness. Professor Edmund Ricci and his co-authors of Disaster Evaluation Research: A Field Guide have developed a manual that should be referenced by health systems and public health governmental agencies on how to implement ongoing and final evaluations of disasters, such as a pandemic.[30] Lastly, regarding global environmental events, and until the government’s trust is reestablished, healthcare and business leaders should consider identifying and partnering directly with national and international health organizations. In April of 2025, the World Health Organization (WHO) finalized a multinational agreement negotiated by 194 countries. This treaty will enable the global community to prevent, prepare for, and respond to future pandemics. In January of 2025, the U.S. withdrew its membership from the WHO. This decision by the Trump administration “actually rallied the international community, particularly Europe,” says Lawrence Gostin, a Law professor at Georgetown University. Tedros Adhanom Ghebreyesus, Director-General of the WHO, offers this: Multilateralism is alive and well, and in our divided world, nations can still work together to find common ground and a shared response to shared threats.[31,32]

History, however, may be repeating itself. The CDC is facing over $11 billion in funding cuts, with one journal proposed for elimination: Emerging Infectious Diseases and Preventing Chronic Disease.[33,34] Pandemic preparedness at all levels of management and organization will be impacted by the budgetary clawbacks of this administration. Healthcare systems, businesses, and local and state pandemic preparedness and evaluation playbooks will become increasingly important in the upcoming years.[35-40]

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Corresponding Author:
Matthew G. Masiello
Department of Pediatrics
Martha’s Vineyard Hospital, Martha’s Vineyard, Massachusetts, US
Member Hospital of Mass General Brigham, Boston, Massachusetts
Email: masiellomatt@gmail.com

Co-Author:
Edmund Ricci
Department of Behavioral and Community Health Sciences
University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, US

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation, and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

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https://doi.org/10.63096/medtigo3062325

Masiello MG, Ricci E. Pandemic Public Health Recommendations from 2003 to 2017: Why Were We Not Prepared for SARS-CoV-2? medtigo J Med. 2025;3(2):e3062325. doi:10.63096/medtigo3062325 Crossref