Seventeen years ago, North Carolina officials had a SARS case on their hands. What they learned then changed the way they approach infectious diseases.

By Rose Hoban

Even though it happened 17 years ago, Leah Devlin remembers exactly where she was when she learned there was a patient in North Carolina with Severe Acute Respiratory Syndrome, or SARS.

“I was driving back from D.C. and I got a call,” she said.

At the time, Devlin was the state health director, North Carolina’s public health leader, and her deputy called with the news while she was still on I-95.

“It was a sentinel moment,” she remembered recently.

North Carolina handled one of the eight confirmed cases of SARS, the last new coronavirus that emerged in 2003. Like the coronavirus, COVID-19, that’s recently emerged in China, SARS swept the globe, causing widespread concern, and in some places, panic. Over the course of 10 months, SARS caused more than 8,400 confirmed cases, mostly in China. About 11 percent of patients died, a total of 916 people.

Only 33 cases total were confirmed in the United States, with no deaths. North Carolina had the eighth confirmed case, a man who had visited Canada, where there was a more widespread outbreak. He’d been to see a family member in a hospital where SARS patients were being treated.

Jeff Engel was the state epidemiologist at the time. He was in his office when his phone rang with the news.

“My surveillance coordinator said, ‘Jeff I think we have a problem here… This guy has a huge risk factor, he had been in a hospital in Toronto and was sick with a community-acquired pneumonia,’” he remembered.

Engel got a sinking feeling in his stomach, then he said he started implementing his plans.

SARS was only one of several disease outbreaks in the early 2000s that in many ways defined the careers of a number of state health leaders in North Carolina. This state had one of the only anthrax cases that emerged in the confusion after the World Trade Center bombings of 9/11. The state managed SARS in 2003, then pandemic H1N1 flu in 2009. All of these incidents left a legacy in the state that those same leaders say have poised North Carolina for a better response today than if those disease outbreaks had never occurred.

From paper to pixels

It was actually anthrax that got the preparedness ball rolling, said Jean-Marie Maillard, a medical epidemiologist who’s been with the Division of Public Health since the early 1980s. When several people were sent anthrax spores through the mail in 2002, disease surveillance was still being done with paper and telephones.

“Congress realized public health needed significant resources to modernize and to have the tools that were needed to do public health surveillance,” he said.

“The public health enterprise was completely unprepared for anthrax,” Engel said. “And the response was laggard. So the funding began to pour in in 2002, and public health finally, was resourced and got, you know, the billions of dollars that was needed to build a modern infrastructure.”

Hospitals in North Carolina were already collecting electronic data about patients walking into their emergency departments for billing. Devlin got the then-North Carolina Hospital Association on board with having hospitals send that data to one central location so state epidemiologists could scan for patterns.

The result is NC DETECT, an electronic system collecting data from EDs every 12 hours. It’s how the state tracks the incidence of flu, for instance, collecting information on people who walk into EDs coughing and sneezing with a fever every winter. The system collects data on a slew of other symptoms too, allowing for fast identification of sudden surges in people with the same disease appearing at hospital doors.

“We collect information that will allow us to recognize whatever the disease is, whether it’s a rash or a febrile respiratory illness,” said Maillard, who worked on the design and implementation. “We can construct any kind of group of symptoms that are collected in the system and say, ‘if I had a case of that disease, what would it look like before I have lab results.’”

North Carolina was the first state to construct such a system, now every state has a similar capacity.

Come on up to the lab

Sitting in a windowless building on a block between the legislature and the governor’s mansion in Raleigh was the old public health lab. In Devlin’s mind, in the wake of anthrax, it had to go.

“It was underpowered electricity-wise,” she said. “When you plugged in one piece of equipment, you had to unplug another. It was dark, it was cramped.”

Devlin walked some legislative leaders across the street for a tour, several commented to her that their local hospital labs were in better shape.

Then Devlin took those same leaders to Virginia to see that state’s new state-of-the-art facility. She spent the next few years walking the halls of the legislature, advocating for funds to build a new state lab, one that could handle bioterror agents such as anthrax or smallpox, or COVID-19.

It took years of asking, but the General Assembly finally appropriated $101 million in 2006 to build a new state lab.

“It’s essential when you’re managing something like anthrax or SARS or any of these other infectious diseases,” Devlin said.

She also insisted the lab be located in its current location outside of the Beltline, instead of downtown.

“You understand that there were school children touring the governor’s mansion and state government buildings, and they were walking right by the lab, which itself could be a target for an act of terrorism,” she said.

The other thing health leaders got from the legislature was more statutory ability to enforce quarantine on sick patients and see their medical records, as well as more due process protections for those people stricken by diseases.

On the ground

Like the others, David Weber remembers well North Carolina’s SARS case. He returned from a meeting in New York, donned personal protective equipment and helped provide care for the SARS patient who was being treated at UNC Hospital in Chapel Hill.

The man, who was employed at the university, had been to the doctor several times for his flu-like symptoms before being diagnosed and had also been to work. In the process, he potentially exposed as many as 200 co-workers and family members. Weber, an infectious disease physician who now leads infectious disease response at UNC and for the state, remembers there was a need to screen all of the patient’s contacts.

Overnight, teams from UNC set up tents on the old airfield north of the university, rather than have all of those people show up at the hospital ED.

“They came in and they were screened initially at a desk outside,” he remembered. “And then once they were seen, they were triaged to three different tents where nurses reviewed their symptoms and issues and their exposures. If they were more ill they would then refer to another tent where the physicians examine them. We had a tent that had basic laboratory equipment and X-ray capability right on site.

“We actually found a few people had medical problems, who got sent to the hospital, but none of them were related to SARS,” he said.

Will it be enough?

Weber said that since that time, through the emergence of other diseases, like H1N1, West Nile Virus, Ebola, Zika virus and multiple flu seasons, he and his colleagues have been practicing and preparing for inevitabilities such as COVID-19. His institution and others have been performing “tabletop” exercises, mass casualty practice events and drills, and keeping their staff up to date on a regular basis.

And in his job as the state director of infection control and epidemiology, Weber also pointed to pandemic preparation plans at the regional and state levels.

“I think the early part of the 21st century really got the nation prepared,” Engel agreed.

That’s especially true for leaders from North Carolina, who faced down some of these challenges in person. But Weber and Engel and Maillard and Devlin are all scientists and epidemiologists, trained to plan for the worst while hoping for the best.

That means that they’re not completely sanguine about how COVID-19 will play out in the U.S. From his current perch as the head of a national organization for state epidemiologists, Engel said he’s definitely concerned about the virus’ potential to wreak havoc both in the state and in the country, something expressed by all.

“I think hospitals have been keeping up their preparedness plans and exercising them and I think we’re as prepared as we can be,” Engel said. But, he warned, “there’s no preparation for a severe pandemic, there’s just not enough capacity anywhere in the world.”