POINTER - Supplements - The SAF SARS Diaries (May 2004)

Table 3.1: Profile of Probable Cases

Category	No.	%
Healthcare workers	97	40.8
Family / household members	55	23.1
Inpatients	31	13.0
Visitors to hospital	20	8.4
Social contacts	15	6.3
Imported	8	3.4
Co-workers in market	3	1.3
Taxi drivers	2	0.8
Flight stewardess	1	0.4
Undefined	6	2.5
Total	238	100

Transmission was not confined to the hospitals but also the community. Other workplaces and workers including storekeepers at the Pasir Panjang Wholesale Market and taxi-drivers were affected (Table 3.2).

Table 3.2: Location of Transmission

Category	No.	%
Hospital / Nursing Home	178	74.8
Household	33	15.5
Overseas	8	3.4
Community	7	2.9
Pasir Panjang Wholesale Market	3	1.3
Taxi	2	0.8
Flight	1	0.4
Undefined	6	2.5
Total	238	100

Besides clinical respiratory infections, there were a number of SARS-associated medical conditions that arose among caregivers. Anecdotal incidents included work-related stress, hand dermatitis due to repeated alcohol hand washes and pressure facial dermatitis due to prolonged use of respirators.3

There were social implications that could not be ignored and had to be managed with sensitivity. This included:

Irrational Fear and Paranoia

Healthcare workers from the designated SARS hospital (TTSH) were reported to be discriminated against; patients themselves did not want to be treated at TTSH. Singapore schools were also pressured by the public to close for a period of time following reported cases of SARS. Selfish behaviour such as those who flouted their HQOs (openly or otherwise) demonstrated the other extremes of human behaviour.

Social and Cultural Mindset Changes.

These had to be modified to promote personal and environmental health. Examples were the enforcement of no-spitting or disposal of contaminated objects (like tissues with sputum) in public areas.

SARS and the Workplace

Any suspect case could transmit SARS at the workplace. This was a potential source for community spread. To counter this threat, organisations had to implement anti-SARS preventive measures. These included daily temperature checks, use of personal protective equipment and instituting alternate shifts for critical operations.

The fallout was the higher operating costs for the affected companies. For example, six local restructured hospitals were reported claiming S$126m for the loss of business due to SARS under the business interruption insurance coverage.4

SARS and the Economy

The Singapore economy appeared to be heading for a recovery at the beginning of 2003, until it was hit hard, firstly, by US-Iraq War and then by the SARS outbreak. Almost all the industries were affected, but this was especially so for tourism, hospitality and retail. All sustained increased operational and administrative overheads with the implementation of workplace SARS control measures. It was reported that the Singapore Government incurred S$192m in direct operating expenditure related to SARS as at 31 May 2003, and committed an additional S$105m development expenditure of hospitals for additional isolation rooms and medical facilities to treat SARS and other infectious diseases.5 In addition, an economic relief package worth S$230m was created to aid businesses hit by SARS.

Lesson 2: First Principles in Managing An Emerging Infectious Disease

Uncertainty prevailed in the initial phase of the SARS outbreak. Fundamental principles were boldly used and proved to be successful in controlling the SARS outbreak. These could be summarised as follows:

For those who were or suspected to be infected:

Detection
Isolation
Containment

For those who were not infected:

Protect
Monitor

For those who might import SARS:

Safeguard borders

These first principles provided the cornerstone, and must be reviewed during any outbreak response management.

Lesson 3: SARS is a Nosocomial Infection

SARS appeared to be a primarily nosocomial (hospital-acquired) infection.6 Hospitals also seemed to amplify the disease and cases not contained within the hospital resulted in spread within the community.

The local medical facilities thus played a vital role in the control of the outbreak, and control strategies targeted here probably reaped the greatest yield. Healthcare workers must continue medical surveillance and infection control measures despite the absence of SARS-affected countries globally.

Such measures would be effective for similar emerging infections, but the pattern of transmission will change drastically if air-borne transmission occurs. By which time, community clusters may become more prevalent.

Lesson 4: Conventional Infection Control Measures Inadequate

The infection control programme was the primary means of protecting the healthcare workers. Conventional infection control measures comprised procedures traditionally referred to as universal precautions. These focused on preventing disease spread from healthcare workers to immuno-compromised patients and thus was a form of “reverse” barrier nursing. It was inadequate, having been limited to management of needle-stick injuries and barrier protection to body fluids like face shield, gown, gloves and goggles.

Enhanced infection control measures had to be employed during SARS.7 These measures built upon isolation and personal protection practices:

• Isolation and Review of Work Processes

Centralised management of all suspect and probable SARS cases in TTSH.
Conversion of private rooms to isolation rooms.
Forward triage e.g. fever screening stations.
Designated “hot wards” .
Designated ambulance service to transfer suspect cases.
Responsive contact tracing within hospitals.
Visitation privileges in hospitals.
Restrict inter-hospital patient movements.
Restrict practice of doctors and nurses to one hospital.

• Protection

Strict use of personal protective equipment by health-care workers and visitors.
PAPR / N99 respirator for high risk procedures e.g. intubations, ventolin nebulisors.

• Monitoring / Surveillance

Temperature taking for staff.
Temperature screening for visitors.
Monitoring of discharged patients.
Surveillance of healthcare workers and patients for febrile clusters.

When TTSH implemented these enhanced measures on 25 March 2003, there were no new hospital transmissions after that time (see Table 3.3).

Table 3.3: Effectiveness of Barrier Precautions in Healthcare Workers

It is thus worth considering the use of enhanced infection control measures during the initial phase of uncertainty for any major infectious disease outbreak. Measures can be progressively stepped down as the disease becomes controlled locally
and globally.

Lesson 5: SARS (And Respiratory Infections) Have High Demands on the Healthcare System

SARS stretched the various strata of healthcare delivery systems severely. Not only were the healthcare workers at highest risk, the disease outcomes also culminated in about 20% of cases requiring critical care, requirement for isolation facilities (the private wards with single rooms had to be converted to isolation rooms), wards with suspect SARS cases had to be closed ( “no in-no out” policy until last patient was discharged) and the nation-wide (and regional) competing demands for personal protective equipment.8

There are other clinical communicable diseases such as diarrhoeal diseases (e.g. salmonella, rotavirus), haemorrhagic (e.g. dengue), conjunctivitis (e.g. viral conjunctivitis) and neurological (meningoccocus). In general, most of them are self-limiting, not associated with significant morbidity and mortality, and there is availability of diagnostics, chemo-prophylaxis or vaccines.

Outbreaks of respiratory tract infections thus have the greatest potential to stress the healthcare system. Medical preparedness and contingency planning should place priority on respiratory outbreaks. More research is required to understand local respiratory disease profiles and review clinical policies for respiratory infections.

Lesson 6: Implementation of SARS Management Policies at Work

In such a national crisis, it was inevitable that there would be national policies which impacted upon each and every Singaporean resident. Indeed such policies impinged on the workplace operations, and they had to be executed in such a manner to ensure compliance while at the same time limiting disruption to the work processes and impact on costs.

Issue of HQOs

Contacts of both probable and suspect SARS cases were issued with HQOs to stay at home. Organisations had to source for replacements for the affected employees whose responsibilities were not undertaken by his colleagues. Some companies had gone further to remove contacts of these persons with HQOs outside of certain critical operations as an added precaution.

Closure of Schools

In response to public pressure, all schools up to polytechnics and universities were closed during one period when there were a few SARS cases among the students. Parents with children in childcare were probably the most affected, and working parents had to take leave to look after their children thus impacting upon workplace operations.

Travel Advisories and Restrictions

Travel to other SARS-affected countries was strongly discouraged; a number of countries also advised against travel to Singapore during the SARS period. This resulted in some countries relocating their operational headquarters during the interim and also discouraged new investors.

Quarantine of Foreign Workers

All foreign workers especially those arriving from SARS-affected countries were required to be quarantined for a period of 10 days before being declared “free from SARS” and allowed to work.

Workplace policies had to be implemented to ensure alignment with national policies as well as to prevent the transmission of SARS. They can be broadly classified into the following categories:

Minimising SARS exposure and risk to workers through health declaration and temperature monitoring for all employees; health declaration and temperature screening for visitors; restricting travel to other SARS-affected countries (and some-times the company required the individual who had returned from a SARS-affected country to stay away from the workplace for 10 days before returning to work if symptom free).

Protecting the individual through health education to increase awareness and limiting any irrational fear and use of personal protective equipment such as respirators, gloves for personnel conducting temperature screening.

Contact tracing was important to identify close contacts when SARS was suspected / detected in the workplace. Inability to conduct contact tracing effectively resulted in the closure of the whole unit as in the case of Pasir Panjang Wholesale Market. For tracing, the assistance by the affected company was crucial to identify and quarantine the contacts early by providing the work schedule to the contact tracing team. Some companies had also gone ahead to register their employees from different departments or offices either manually or electronically (“tagging” as in the case of Alexandra Hospital).

Having additional administrative / precautionary measures to minimise the impact of SARS in the workplace including the use of backup teams or functional units in critical areas of the company (“Team A and Team B” concept; “One in three or more shift” concept i.e. having additional shifts such that there would always be a shift available not in contact with the affected shift) and alternate workplaces such as working from home.

Anecdotally, it was the last group of measures that proved most costly and caused the most stress to the affected employees. For instance, while having more shifts reduced the duration of work, it usually meant fewer persons per shift and higher work demands during the shift.

Contingency Planning and Preparedness Policies came to the fore. It was very likely that most organisations in Singapore were not initially prepared for a national infectious disease outbreak. The risk was perceived to be low and no such event had ever occurred since Singapore’s independence. There is an upside to SARS – all organisations and agencies would now have a blueprint contingency plan in response to an infectious disease outbreak, be it a new disease, a recurrence of SARS or even bio-terrorism. The policies to address workplace operations, response, surveillance and human resource issues will be useful references for future outbreaks.

Lesson 7: Rapid Evolution Of Organisational Policies

As more was known about SARS, new policies were rapidly included and existing ones revised. Organisations and their people need to be flexible and readily adapt. It is also important for the policy makers to consider ground implementation issues which can be easily overlooked in the fluidity of the situation.

Lesson 8: Importance of Diagnostic Tests and Influenza Vaccination

In an outbreak where there is person-to-person spread, having a reliable diagnostic test becomes an essential tool in one’s arsenal. It was precisely the lack of one in SARS that suspect cases could not be differentiated from non-SARS infections (especially influenza that matches the same SARS case definition), that contacts of suspect cases had to be quarantined. When serology 9 and polymerase chain reaction (PCR)10 tests for SARS became available, the next step was to develop a kit which could give conclusive results in the shortest possible time.11

Until the development of an effective diagnostic test, influenza vaccination has been recommended for healthcare workers to reduce the “false positives” by the influenza virus thereby cutting down the burden of responding to these cases, which would lead to an unnecessary state of heightened medical management, further stretching the limited resources required to deal with the possible / positive SARS cases.12

Lesson 9: Management Emphasis, Multi-Disciplinary Involvement and Accountability

There must be management emphasis from the highest level within the company to ensure that the difficult measures are complied with. As with any other crisis management, command emphasis is essential and there needs to be the involvement of all departments within the company. A SARS taskforce could be set up to ensure all bases were covered. This is akin to the pivotal role played by the Prime Minister (as shown in his open letter to all Singaporeans) and the creation of the Inter-Ministerial SARS Executive Group which addressed the SARS policies in Singapore.13

Lesson 10: Information Management and Communications

National policies were being created, promulgated and subsequently revised at a rapid rate in response to the outbreak. An organisation must ensure that all its personnel are kept updated and understand the rationale behind both the national as well as the organisation’s SARS policies.

Where national policies require a change in socio-cultural mindsets (such as personal hygiene, staying at home if unwell; sharing of food at meals), the organisation has a significant role to play.14 It also requires a sensitive and responsive management to prevent social discrimination (such as alienation of those on HQO, or contacts and SARS cases who have returned to work).

Lesson 11: Business Continuity Plan

With the global SARS outbreak being contained as evidenced by the absence of SARS-affected countries, it would be opportune to both phase down measures as well as prepare increasing levels of precautionary measures in response to various SARS risk levels.15

Firstly, stratifying the risk based upon transmission both externally and locally based upon the classification used by the WHO. Subsequently, the level and type of control measures could then be matched with the risk level thereby forming the basic Business Continuity Plan (see Table 3.4 for example).

A plan to exercise organisation readiness to SARS recurrence should be done to keep the system “warm”. For instance, the Ministry of Health conducts regular audits and contact tracing exercises in all healthcare institutions. This is also the case for the other ministries including that of education and defence.

Lesson 12: Emerging Infections and Bio-terrorism

The use of biological agents as a tool for terrorism has been discussed extensively ever since the anthrax attacks in the United States after September 11. The ideal bio-weapon would be one that is easily transmitted and not easily detected, causes severe injury, affects the public psychologically and drains national resources during the response.

Compare these characteristics with SARS, an emerging infection which has proven to have the above capabilities. The difference between SARS and that of known bio-terrorism pathogens is the lack of diagnostics and the absence of vaccines and chemoprophylaxis – thus, an emerging infection would arguably be more difficult to manage compared with a bio-terrorist act.

It should be reiterated that the same principles and measures also apply to defence against a bio-terrorist attack. The public health infrastructure of control and response, thus serve a dual-purpose.

Conclusion

“May we never have to face another crisis like this. But if we do, let us inspire each other, fight as one and win the battles as we did with SARS.”

Prime Minister Goh Chok Tong

The SARS outbreak has demonstrated emphatically the strengths of the Singapore response - that commitment, cooperation and rational public and occupational health policies will prevail in a national crisis. On the other hand, it has also exposed the deficiencies of the healthcare and industrial infrastructure and response. The lessons learnt ought to be studied closely within the individual organisations, and subsequent rectifications taken seriously. It is quite unlikely that we will see the end of SARS or any other emerging infections any time soon.

Endnotes

1 Leo Y.S., “SARS Singapore Clinical Experience”, Presentation during HQMC SARS Workshop (11 Aug 2003). Unpublished data.

2 Enserink M., “Infectious Diseases: Singapore Lab Faulted in SARS Case”, Science (26 Sep 2003) 301(5641), p1824; Lau T.N., Teo N., Tay K.H. et al., “Is Your Interventional Radiology Service Ready for SARS?: The Singapore Experience”, Cardiovascular Intervention Radiologist (13 Oct 2003); Samaranayake, L.P., FDI Science Commission, “Severe Acute Respiratory Syndrome (SARS): An Interim Information Paper for Dental Health Care Workers”, International Dent Journal (Jun 2003), 53(3), pp117-8.

3 Dermatitis refers to a condition of the skin in which it becomes red, swollen and sore, sometimes with small blisters, resulting from direct irritation of the skin by an external agent or an allergic reaction. See Shaw J.C., “Dermatology In The Time Of SARS”, Arch Dermatol (Jul 2003), 139(7), pp853-4.

4 Tan L., “Hospitals Said To Be Claiming $126m After SARS”, The Straits Times ( 26 Jul 2003). Available at http://www.sars.gov.sg/archive/

5 Statement from the Ministry of Trade and Industry (MTI). “Government Unveils $230m SARS Relief Package” ( 24 Apr 2003). Available at http://www.stb.com.sg/media/ press/20030424a.stm

6 Varia M., Wilson S., Sarwal S. et al, “Investigation of a Nosocomial Outbreak of Severe Acute Respiratory Syndrome (SARS) in Toronto, Canada”, CMAJ (9 Aug 2003), 169(4), pp285-92; Abdullah A.S., Tomlinson B., Cockram C.S. et al, “Lessons from The Severe Acute Respiratory Syndrome Outbreak in Hong Kong”, Emerging Infectious Diseases (Sep 2003), 9(9), pp1042-5 and Emanuel E.J., “The Lessons of SARS”, Ann Intern Med (7 Oct 2003), 139(7), pp589-91.

7 MOH, “SARS Information for Health-care Professionals” ( 27 Jun 2003). Available at http://www.moh.gov.sg/sars/information/ healthcare.html; MOH, “Government’s ‘Lines of Defence’– Measures To Combat SARS” (1 Jun 2003). Available at http://www.moh.gov.sg/sars/defence/ default.html; Jiang S., Huang L., Chen X. et al, “Ventilation of Wards and Nosocomial Outbreak of Severe Acute Respiratory Syndrome among Health-care Workers”, China Medical Journal (English) (Sep 2003),116(9), pp1293-7; Normile D., “Infectious Diseases: SARS Experts Want Labs to Improve Safety Practices”, Science (3 Oct 2003), 302(5642), p31; Ho A.S., Sung J.J., Chan-Yeung M., “An Outbreak of Severe Acute Respiratory Syndrome among Hospital Workers in a Community Hospital in Hong Kong”, Ann Intern Med (7 Oct 2003), 139(7), pp564-7; “SARS Inquiry: Nurses Demand Open, Transparent Investigation”, Canadian Nurse (Aug 2003), 99(7), p13; Chan L.Y., Li P.K., Sung J., “Risk Of SARS Transmission to Persons in Close Contact with Discharged Patients”, American Journal of Medicine (Sep 2003), 115(4), p330; Wong D.T., “Protection Protocol in Intubation of Suspected SARS Patients”, Can J Anaesth (Aug-Sep 2003), 50(7), pp747-8; Ng P.C., So K.W., Leung T.F. et al, “Infection Control For SARS In A Tertiary Neonatal Centre”, Arch Dis Child Fetal Neonatal Ed (Sep 2003), 88(5), ppF405-9; Leong R.M., “SARS Wars: Family Physicians Undeployed Soldiers”, Canadian Family Physician (Aug 2003), 49, pp962-3; “Mechanical Ventilation of SARS Patients: Safety Issues Involving Breathing-Circuit Filters”, Health Devices (Jun 2003), 32(6), pp220-2; “Protecting Against SARS During Equipment Maintenance”, Health Devices (Jun 2003), 32(6), pp213-9; Kissoon N., “Severe Acute Respiratory Syndrome: Providing Care While Minimizing Personal Risks”, Indian Pediatrician (Jul 2003), 40(7), pp645-51; Thompson D.R., “SARS: Some Lessons for Nursing”, Journal of Clinical Nursing, (Sep 2003),12(5), pp615-7; Chee Y.C., “Heroes And Heroines of The War on SARS”, Singapore Medical Journal (May 2003), 44(5), pp221-8; Lange J.H., “SARS Respiratory Protection”, CMAJ (16 Sep 2003), 169(6), pp541-2 and “SARS Affects Hospital Plans?”, CMAJ (16 Sep 2003), 169(6), p593.

8 Chowell G., Fenimore P.W., Castillo-Garsow M.A. et al, “SARS Outbreaks in Ontario, Hong Kong and Singapore: The Role of Diagnosis and Isolation as a Control Mechanism”, Journal of Theoretical Biology ( 7 Sep 2003), 224(1), pp1-8 and Lee S.H., “The SARS Epidemic in Hong Kong”, J Epidemiol Community Health (Sep 2003), 57(9), pp652-4.

9 Serology is the study of a patient ’s serum (blood after centrifugation to remove blood cells) to determine antibody levels to specific pathogens (e.g. viruses). Some pathogens stimulate the body ’s defence system to produce antibodies against them, and these antibodies can be measured in the laboratory.

10 Polymerase chain reaction (PCR) test is a highly sensitive and relatively rapid test to detect the presence of pathogens (for example viruses or bacteria) in the patient ’s blood or body fluids. It relies on enzymes to amplify minute quantities of genetic material (DNA) from any source, including pathogens to detectable levels. If SARS virus DNA is detected in a patient ’s blood using PCR, it is highly suggestive of an infection.

11 Snijder E.J., Bredenbeek P.J., Dobbe J.C. et al, “Unique and Conserved Features of Genome and Proteome of SARS-Coronavirus: An Early Split-Off from the Coronavirus Group 2 Lineage”, Journal of Molecular Biology (29 Aug 2003), 331(5), pp991-1004; Yam W.C., Chan K.H., Poon L.L. et al, “Evaluation of Reverse Transcription: PCR Assays for Rapid Diagnosis of Severe Acute Respiratory Syndrome Associated With A Novel Coronavirus”, Journal of Clinical Microbiology (Oct 2003), 41(10), pp4521-4; Zhang J., Meng B., Liao D. et al, “De Novo Synthesis of PCR Templates for the Development of SARS Diagnostic Assay”, Molecular Biotechnology (Oct 2003), 25(2), pp107-12; Poon L.L., Chan K.H., Wong O.K. et al, “Early Diagnosis of SARS Coronavirus Infection by Real Time RT-PCR”, Journal of Clinical Virology (Dec 2003), 28(3), pp233-8; Hsueh P.R., Hsiao C.H., Yeh Shet et al, “Micro-biologic Characteristics, Serologic Responses and Clinical Manifestations in Severe Acute Respiratory Syndrome, Taiwan.” and Li G., Chen X. and Xu A., “Profile of Specific Antibodies to the SARS-Associated Coronavirus”, North England Journal of Medicine (31 Jul 2003), 349(5), pp508-9.

12 Wilder-Smith A., Leong H.N., Villacian J.S., “In-Flight Transmission of Severe Acute Respiratory Syndrome (SARS): A Case Report”, Journal of Travel Medicine (Sep-Oct 2003), 10(5), pp299-300; Wilder-Smith A., Paton N.I., Goh K.T., “Experience of Severe Acute Respiratory Syndrome in Singapore: Importation of Cases and Defense Strategies at the Airport”, Journal of Travel Medicine, (Sep-Oct 2003), 10(5), pp259-62; Wilder-Smith A. and Freedman D.O., “Confronting the New Challenge in Travel Medicine: SARS”, Journal of Travel Medicine (Oct 2003),10(5), pp257-258 and Schlagenhauf P., “Influenza Vaccine Enlisted to Prevent SARS Confusion”, Lancet (6 Sep 2003), 362(9386), p809.

13 “Fighting SARS Together”, Singapore Government Press Release, statement by Mr Goh Chok Tong, Prime Minister, MITA (22 Apr 2003). Available at http://app.sprinter.gov.sg.data/pr/ 2003042204.htm

14 Lee A. and Abdullah A.S., “Severe Acute Respiratory Syndrome: A Challenge for Public Health Practice in Hong Kong”, Journal of Epidemiology and Community Health (Sep 2003), 57(9), pp655-8; Bernstein M. and Hawryluck L., “Challenging Beliefs and Ethical Concepts: The Collateral Damage of SARS”, Critical Care ( 7 Aug 2003), 7(4), pp269-71. E-published on 29 May 2003; Vastag B., “SARS Attack: Reality vs. Perception Collide During Students’Beijing Visit”, JAMA ( 1 Oct 2003), 290(13), pp1698-9 and Hsieh Y.H., “SARS and the Internet”, North England Journal of Medicine ( 14 Aug 2003), 349(7), pp711-2.

15 Chiu Y.T., “Taiwanese Scientists Brace for Second Season of SARS”, National Medicine (Oct 2003), 9(10), p1229; Schlagenhauf P., “SARS in Hiding: WHO Calls for Vigilance” , Lancet Infectious Diseases (Aug 2003), 3(8), p458 and Augustine J.J., “Developing a Highly Contagious Disease Readiness Plan: The SARS Experience” , Emerging Med Serv (Jul 2003), 32(7), pp77-83.

Last updated on 31 Mar 2011