Newly Appointed PSC Scholars At The Pre-Departure Course 2003

21 Jul 2003

By Dr Balaji Sadasivan

Venue: Treasury Building

SARS - current situation

I am pleased to be here today to share with you some of our experiences with SARS. Life is almost back to normal for many people. However, it is not quite back to normal yet for the staff in our hospitals and health care institutions. They still go about their duties wearing full personal protection - that means masks, gloves, goggles and gown. They still monitor their temperatures twice a day. If more than two staff members in the same area have fever, their supervisors and the hospital management monitor the situation very closely. Patients who are admitted to hospital with atypical pneumonia are isolated, investigated fully and closely monitored.

Impact of SARS

They do this because it takes just one case of SARS to set off an outbreak that can take weeks to control. This was our experience here in Singapore. Just one case set off the entire outbreak that lasted more than two months, resulted in 206 cases and claimed 32 lives. It also resulted in a huge impact on our economy. Flash estimates released about 10 days ago showed that our Gross Domestic Product contracted 11.8% in the second quarter as compared to the first quarter of this year. In Parliament, the Government stated that it had spent more than $300 million on combating SARS. The cost is much more if you factor in the manpower that was involved in combating SARS. Many workers in different Government ministries and agencies stopped doing their usual work and devoted all their time and energies to work on combating SARS. Then there are also jobs which were lost as businesses were hit hard by SARS.

SARS - In the beginning

Let me take you back to the later part of February this year, before SARS was known. Four Singaporeans had gone to Hong Kong for a holiday. Unknown to them, a 64-year old Chinese doctor who had been infected with SARS from treating patients in Guangdong province was staying on the same floor of the hotel in which they were staying. The Chinese doctor stayed only one night (21 February) but went on to infect three of the four women who would bring SARS back to Singapore. He also infected others who would spread the infection to Hong Kong, Toronto and Hanoi. How he actually infected all these other people is still not quite known. The Chinese doctor was admitted to a hospital in Hong Kong the next day and several days later, dies.

On 26 February, a 48-year old Chinese-American businessman was admitted to the French Hospital in Hanoi with fever and respiratory symptoms. He had arrived in Hanoi from Hong Kong on 23 February. In Hong Kong, he had stayed on the ninth floor of the Metropole Hotel in a room across the hall from the Chinese doctor from Guangdong. In the French hospital in Hanoi, the Chinese-American businessman is attended by a doctor working for WHO, Dr Carlo Urbani.

On 28 February, Dr Urbani, who had become alarmed by the unusual disease and concerned that it might be a case of avian influenza ? a deadly strain of influenza spread to humans from infected chickens, notifies the WHO office in Manila, who in turn notifies the WHO Headquarters in Geneva. In mid- February, there had actually been two cases (a father and son) of avian influenza in Hong Kong. So, Dr Urbani was the person who first raised the alarm about SARS. He continued to treat the businessman and other cases in Hanoi and help the hospital contain further spread of the disease. Dr Urbani unfortunately contracted SARS himself and later succumbed to the disease.

WHO had received a report earlier, on 11 February, from the Chinese Ministry of Health of an outbreak of respiratory disease involving 300 cases and 5 deaths in Guangdong province. The Chinese Ministry of Health later on 14 February informs WHO that the outbreak in Guangdong is consistent with atypical pneumonia and states that the outbreak is coming under control. A team of WHO experts arrived in Beijing on 23 February but is not allowed to travel to Guangdong to investigate the outbreak. Perhaps, if WHO had been notified and allowed to investigate earlier, things may have been different.

Back to our four Singaporean tourists in Hong Kong. At the end of their holiday there on 25 February, two of them were already beginning to feel unwell and feverish. Another developed fever on 28 February. They return to Singapore and two are admitted to Tan Tock Seng Hospital and one to the Singapore General Hospital at the beginning of March. On 6 March, my Ministry receives an email from the WHO regional office in Manila informing us of a unusual outbreak of pneumonia in Hanoi involving several health care workers in a hospital there who had cared for a Chinese-American businessman who had just traveled from Hong Kong and who had been admitted for severe pneumonia. The businessman had been air evacuated to Hong Kong on 5 March. We knew that the medical evacuation company operated out from Singapore and were concerned that the evacuation staff were at risk. SARS was still unknown then but we were concerned about avian influenza due to the two cases in Hong kong in February. The Ministry asked the company to get its staff who had flown with the businessman during the evacuation to get themselves checked at the Communicable Diseases Centre in TTSH. Fortunately, they were well as they had taken precautions while attending to the patient during the evacuation. They were given anti-viral medication against influenza as a precaution.

Coincidentally, on the same day, 6 March, the Ministry was informed by an infectious diseases physician, of the three Singapore women who had stayed in the same hotel in Hong Kong and who were now in Tan Tock Seng and Singapore General Hospital with atypical pneumonia. Various tests had been done to find the organism responsible for the pneumonia. So far, they had all returned negative results. Further results were pending. The doctors were wondering whether the women had legionella pneumonia as this has to be considered whenever several people have atypical pneumonia after staying in or visiting the same building. Legionella bacteria sometimes multiply in poorly maintained air-conditioning cooling towers in buildings. Legionella pneumonia does nor spread from person-to-person but as a precaution, the Ministry tells the two hospitals to isolate the three women. Further test results came in, including tests for known viruses that can cause pneumonia. They were all negative. The Ministry informed its counterparts in Hong Kong about the three cases but no new information was obtained.

On 12 March, WHO issues a global alert about cases of severe atypical pneumonia following increasing reports of spread of this unusual disease among hospital staff in Hong Kong and Hanoi. Due to the time difference between Geneva and Singapore, we heard about this alert on 13 March. The Ministry of Health issued a press release on the same day about the three cases of atypical pneumonia who had recently traveled to Hong Kong. We also stated that no link had been established with the outbreak of atypical pneumonia in Hong Kong and Hanoi.

On 14 March, the Ministry is notified that 6 nurses in Tan Tock Seng Hospital had been admitted for fever and respiratory illness. Alarm bells were now beginning to ring loudly. The Director of Medical Services formed a Task Force comprising relevant experts in infectious diseases and virology to draw up measures to contain the outbreak in Singapore. During the Task Force?s first meeting the next morning on 15 March, the Ministry was informed that one of our infectious disease physicians who had cared for two of the three women who had gone to Hong Kong and had atypical pneumonia was unwell overseas. He had gone to New York for a medical conference with his wife and mother-in-law. Before his return flight, he had called and informed his colleague that he was unwell. He had sought medical attention in New York and was told that he had pneumonia. When the Ministry was informed, he had just left New York with his wife and mother-in-law. We were very concerned that he could spread the infection to the other passengers on the plane. The flight was due to transit in Frankfurt and the Ministry quickly informed the German health authorities through WHO of the case.

That was not as straightforward as it sounds as that was a Saturday and it took some time to reach the relevant authorities in Frankfurt. Anyway, the urgent communication was made in time and the doctor, his wife and mother-in-law was taken off the flight in Frankfurt and isolated in the University Hospital there. The German health authorities also informed passengers who had disembarked in Frankfurt and monitored their health status closely. Fortunately, none became ill. When the flight finally returned to Singapore, we too informed the passengers and advised them on what symptoms to look out for and to report to the Communicable Diseases Centre in Tan Tock Seng should they become ill. Again, fortunately no one became ill.

It was also on 15 March that WHO first described the new disease as SARS or Severe Acute Respiratory Syndrome and the first case definitions for the disease. This was a very important step as it helped health authorities around the world in their disease surveillance efforts.

I have given you an account of what happened at the beginning of the SARS outbreak. Following that, we fought hard to contain the outbreak. WHO finally removed Singapore from the list of areas with recent local transmission of SARS on 31 May after 20 days elapsed with no new cases since the isolation of the last SARS probable case on 11 May. Singapore has not had any local cases of SARS for over 70 days since our last case was isolated. Nevertheless, we continue to be vigilant and have continued many of the control and prevention measures against SARS.

For an outbreak of SARS to occur again in Singapore, the SARS virus must first cross our borders through an infected person and enter into the community. It must escape detection by the primary health care system and, again after the infected person?s admission to the hospital, it must escape detection in the hospital system.

To ensure that this chain of events does not occur, we have instituted comprehensive control measures that serve as four concentric rings of defense around our hospitals. The first defense ring protects our hospitals. The next defense ring is around the primary healthcare system. The third defense ring is in the community and the last defense ring is at our borders.

THE FIRST DEFENCE? - Protecting the Hospitals

Our first defense ring is in the hospitals. Our strategy in the hospitals is to detect and isolate SARS early and protect all healthcare workers against SARS. All potentially infectious patients will be promptly isolated. Hospital staff are fully protected with mask, gloves, goggles and gown. All healthcare workers have their temperature monitored twice a day and any cluster of fever among the healthcare workers will be investigated.

The risk of SARS outbreaks are greatest in the hospitals. To prevent the spread of SARS between hospitals, we designated one hospital to treat all SARS cases, reduced the movement of patients and healthcare workers between hospitals during the outbreak and did not allow any visitors into hospitals, with the exception of children and women going for deliveries ? they were allowed one visitor each. Some of these measures have been carefully relaxed recently. For example, we now allow hospital patients one visitor each. Children and women admitted to hospitals for deliveries are allowed two visitors. These visitors can be chosen from a list of 4 registered visitors. The movement of doctors between hospitals has also been progressively allowed. However, hospitals have to ensure that they maintain close temperature monitoring and adopt the strict infection control practices of the institution.

To ensure that hospitals comply strictly with the necessary infection control practices, the Ministry of Health carries out regular on-site audits on all hospitals and health care institutions including nursing homes. Shortcomings are promptly highlighted to the hospital or institution?s management.

THE SECOND DEFENCE? - The Primary Healthcare System

In Singapore, a SARS infected person is very likely to consult a medical general practitioner or a traditional Chinese medicine practitioner when he first falls sick. They are the first contact between the SARS virus and the health system. We have trained these practitioners to detect SARS and to take adequate protective measures to ensure they don?t catch SARS. The workflow of their clinics has been modified to isolate patients with fever. Special ambulances will also take the patients to the hospital for further observation, if SARS is suspected.

THE THIRD DEFENCE? - Social Responsibility in the Community

Through an intensive public education program, that included a special SARS television channel until recently, Singaporeans have access to information about SARS. SARS creates fear, and the fear of SARS may create more problems than SARS itself. Information is a powerful tool in the fight against fear. It empowers every Singaporean and allows him to fight SARS by becoming socially responsible. Singaporeans are encouraged to take their temperature daily and if they develop a fever, they are advised to seek medical attention and not go to work or school.

Our school children, about 600,000 students in all, are given a thermometer each. Every home has also been given a thermometer and every citizen has the ability to monitor his temperature and his family?s temperature daily. This is an important measure as the SARS infected person is not infectious until he is febrile.

To ensure that cases of SARS are picked up as early as possible and isolated, Singapore has beefed up its contact tracing capacity and put in place the necessary laws and logistic framework to quarantine all close contacts of suspected and probable SARS cases.

THE FOURTH DEFENCE? - Preventing Transborder Spread

The last barrier to the spread of the SARS virus is at our border checkpoints. Through health declaration forms and thermal scanning technology developed by our local scientists, we are screening both outbound as well as inbound travelers for fever. We also work with other countries to trace the contacts of suspected SARS patients who have traveled across borders.

It is evident from my description of our defences against SARS that the impact of SARS extends beyond just health to other sectors such as transport, tourism, education, immigration, recruitment of foreign workers and foreign affairs. The Cabinet formed an Executive Group comprising Permanent Secretaries and heads of relevant government agencies chaired by the Permanent Secretary of Home Affairs and a Ministerial Committee chaired by the Minister for Home Affairs. The different ministries and agencies could thus coordinate their efforts against SARS.

Can SARS be eradicated or eliminated?

Can SARS be eradicated or eliminated? This was discussed at the Global SARS Conference in Kuala Lumpur on 17-18 June 2003. WHO has stated that it is too early to say as it cannot rule out the possibility that SARS will re-surface during the winter period. There is also the possibility of an unknown animal reservoir that can re-transmit to humans.

In the meantime, we maintain the necessary defences, watch and wait.