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Chapter 1: SARS and The SAF
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Severe Acute Respiratory Syndrome (SARS) was 2003’s most prominent global health threat. It was a new entry which was missed from everyone’s radar screen, due in no small way to the fact that SARS was caused by a new variant of coronavirus that was not previously recognised.

The global outbreak had an insidious onset. By the time suspicion was aroused that the world had an unprecedented pathogen in mid-March 2003, it had already culminated in simultaneous outbreaks in 28 countries. By the beginning of June, there was an accumulative total of more than 8,430 probable cases and close to 800 deaths.1

Table 1.1: SARS Coronavirus Fact Sheet
Pathogen SARS Coronavirus, SARS Co-V 
Country of origin Probably Guangdong, Southern China. 
Reservoir Probably rodent and avian origins such as wild civet cats, and subsequently person-to-person spread. 
Type of disease Zoonosis but has become highly adapted to humans. May be regarded as a human virus. 
Mode of transmission Direct contact with strong evidence of fomite transmission. 
Incubation period 3 - 7 days up to a maximum of 10 days. 
Infectiousness Evidence suggests transmission occurs only when the patient is symptomatic. 
Clinical manifestations Case definitions are typical. But atypical presentations occur when symptoms are masked by other diseases or lack of an obvious positive contact or travel history 
Diagnosis Confirmatory diagnosis with serology and PCR available. 
Treatment No specific effective treatment available. 
Morbidity 20 - 25% require critical care. 
Case-fatality rate Depends on age and co-morbidity. About 15% in Singapore. 
Singapore’s Fight Against SARS

Singapore’s fight could be traced back to late February 2003, when a 65 year-old Professor of Medicine from Guangdong travelled to Hong Kong where he stayed at the Metropole Hotel to attend a wedding. He fell ill and was admitted to one of the hospitals in Hong Kong. Unfortunately, he passed away the following day. It is believed that he might have transmitted the infectious disease to at least 12 persons staying at the same hotel.

Among the infected was a 48 year-old American who would bring the infection to Hanoi, three Singapore women on holiday in Hong Kong, an elderly Canadian lady from Toronto and a Hong Kong resident who visited a guest at the hotel. They were all admitted to hospitals in Hanoi, Toronto, Singapore and Hong Kong and started outbreaks in these cities.

Table 1.2: SARS Chains of Transmission in Singapore

Singapore first declared her war against SARS on 6 March 2003 when the cluster of three Singaporeans with atypical pneumonia was reported.

Singapore’s response was to fundamentally revert to basic public health principles of isolation and quarantine. What this entailed was a containment strategy isolating suspect and probable SARS cases and imposing home quarantine for close contacts of these SARS cases. The latter meant that if any of the contacts developed symptoms of SARS, they would already be isolated and subsequent chains of transmission would have been avoided.

For the strategy to be effective, one hospital, Tan Tock Seng Hospital (TTSH), was designated to isolate and manage all SARS cases. All potential cases were thus sent to the hospital for screening and all SARS patients (probable, suspect or for observation) were admitted and managed within this one hospital. As there was a preponderance of cases affecting healthcare workers, all hospitals adopted strict infection control measures to ensure all healthcare workers were adequately protected. The control measures appeared to be successful until a number of clusters emerged in two other hospitals, a nursing home and a wholesale market. There were probably two contributory factors: missed cases because of the atypical presentation of patients who had multiple illnesses and were immuno-compromised; and the difficulty of obtaining a thorough contact history of such patients. The lessons were learnt quickly and the relevant policies adjusted.

Eventually, the World Health Organisation (WHO) declared Singapore SARS free on 30 May 2003 . A total of 206 probable SARS cases with 31 deaths were reported during that period.2
Controlling SARS Within the SAF

As the Singapore Government introduced various measures to contain the SARS outbreak, so too did the Singapore Armed Forces (SAF) while maintaining its operational readiness – to defend against SARS without compromising its core duty of defending the nation.

This chapter examines the strategies used by the SAF; their rationale, effectiveness and the limitations encountered. The fight against SARS was real and not a theoretical exercise against an infectious disease threat. The lessons gleaned in this experience were far more instructive than didactic teaching and will undoubtedly over-ride much of our existing policies. It will form the basis for infectious disease outbreak and bioterrorism contingencies in the future.

Table 1.3: SARS Chain of Transmission and Concept of Defence

SAF Planning Considerations

Differentiating Between Critical and Non-Critical Units

The SAF is a cornucopia of diverse workplaces, a series of well-synchronised cogwheels that systematically revolve to perform its mission. In the SAF, certain units are more critical than others. In that respect, the national control measures for the general public would represent the minimum standards and more stringent precau-tionary measures applied to the more critical areas.

Medical Surveillance and Response

The SAF will need to have a highly sensitive surveillance and response system in place. As a relatively closed institution where servicemen are in close proximity, sometimes accommodated in confined and shared quarters, there is an inherent risk of transmission once someone succumbs to an infectious disease. The military is known to be a risk for outbreaks like chicken pox, conjunctivitis, tuberculosis and meningitis, and certainly should be no different in the case of SARS. And a missed diagnosis can prove to be extremely unforgiving.

Cross-Border Transmission Risks

The SAF spends a significant amount of training time overseas. When a health alert warned of the SARS hazards for travellers to Singapore, it was our responsibility not to inadvertently export the disease to any country (be it SARS or non-SARS affected). Con-versely, the SAF should not expose its servicemen to SARS risk by proceeding to train in an SARS-affected country for which the WHO or when the local Ministry of Health has already issued a travel advisory.

Consider “Staying In”

It could be argued that risk of infection occurring in the SAF is lower than the community because a significant proportion of its servicemen stays in. But the consequences of missing a case are higher for that same reason. Hence screening for potential cases is important especially for visitors, Operationally Ready National Servicemen (NSmen) and pre-enlistees due to the lack of control over activities prior to entering SAF units.

Understanding the “Enemy” and its Capability

Initially, SARS was not an enemy that the SAF was familiar with. But we did not start from a clean slate. We have successfully managed infectious disease outbreaks from time to time. We have an infectious disease surveillance and notification system in place. We also have ready access to rapid diagnostic tools to provide rapid identification of suspected pathogens within hours.

Nevertheless, there were significant differences:

The SARS pathogen could not be isolated and that made confirmatory diagnosis impossible. SARS was a diagnosis by exclusion and even then, the case definitions could only be dichotomously classified into two groups, whether it was probable or suspect.3

As an added dimension of complexity, it could not be ascertained which suspect case would turn probable. Initial limited national resources dictated that contact tracing be initiated only for probable cases and these contacts to be given Home Quarantine Orders (HQOs).4 Suspect cases which subsequently became probable meant that there was a lag time in isolating their contacts and a longer time potentially exposing the community. There was also no means with which to predict how and when a suspect case would become probable. The SAF could not accept similar risks and applied contact tracing to all suspect and probable cases.

Little was known about SARS’mode of transmission, infectiousness and the lethality of its “weaponry” or the mortality rate. The situation was aggravated by the absence of specific treatment, vaccination or chemoprophylaxis5 available for SARS.

When translated into terminology that we were familiar with, i.e. bio-terrorism, it could be said that SARS was worse, because of what little we knew of the pathogen. There was no vaccination or chemoprophylaxis available that we could use to break the enemy’s “logic” .

SAF Defence Strategies


“To maintain our operational readiness, training and operations have to carry on in the midst of SARS. The SAF must continue our mission of defending the country. This remains unchanged. However, the specific form in which we train and conduct operations may have to change.”

– MG Ng Yat Chung, CDF

The SAF’s defence strategies focused on three levels of containment:

  • Public health response and medical care.

  • Organisational and administrative measures.

  • Social and personal adaptations.

Thus the goals were twofold: firstly, to detect SARS cases early and break any chain of transmission and secondly, to prevent the occurrence of infection within the SAF population in the first place.

Public Health Response and Medical Care


There is a strong public health infrastructure in place in the SAF. The promulgation of policies originates from the Preventive Medicine Branch, HQ SAF Medical Corps (HQMC). Its Epidemiology6 section obtains and analyses relevant medical information pertaining to infectious diseases and environmental health both within and outside of the SAF. When there is an alert of a possible outbreak, an investigation team will be deployed. Environmental Control Officers are designated at all SAF camps to manage hygiene and environmental management issues. Audits and consultations are provided by the Public Health Inspectorate. Close collaborations with the medical centres and external agencies like the Defence Medical and Environmental Research Institute, Ministry of Health and the National Environmental Agency further enhance the organic SAF public health framework.

The effectiveness of any public health infrastructure is only as good as its delivery and implementation. The “buy-in” by the various ground units was driven through the operations channel with tenacious command emphasis, providing the impetus to initiate mandatory measures while continual education won the units over during the later phase.

The public health infrastructure could be described rather neatly by its three pillars: detection, isolation and containment.

Detection refers to the methodologies of picking-up and identifying a possible case. The aim is to “pick-up” the case early to prevent subsequent transmission of the disease. Optimal detection is a function of a reliable screening tool and selecting the population most likely to introduce infection.

The SARS pathogen fortunately had chinks in its armour – it was not the ideal bio-agent that we initially feared. The clinical evidence pointed towards its earliest manifestation as that of a temperature and being infectious only when fever occurred.

The case definition adopted was intentionally made sensitive and based on the presence of a fever (more than 380 Celsius), with respiratory symptoms and the presence of a positive travel history to a SARS-affected country, local SARS-affected area or a positive contact history.

The combination of a declaration and temperature screening proved to be an effective screening mechanism, and neither declaration nor temperature taking were complicated procedures. Temperature taking was thus introduced early into the SAF with priority given first to the medical personnel (the frontline of detection) and to critical areas (where it would be most damaging should a case be missed), while the whole SAF quickly completed a one-off declaration to identify the populations most at risk.

Isolation meant separating someone or a cohort of individuals from the others at the workplace either spatially (geographical) or temporally (different times). Immediate close contacts were sent home with a temperature monitoring regime and the understanding that should they become unwell, they would report directly to the designated SARS hospital for evaluation.

In principle, the numbers affected with each transmission cycle increases exponentially in an uncontrolled outbreak. Consequently, detection and isolation of the first or index case and its immediate contacts should drastically reduce the infectiousness and break the chain of transmission.

Containment is a term which is used here to signify the capability to respond, investigate and institute control measures whenever there is a suspect SARS case. Therein lay the importance of contact tracing. The SAF had rostered contact tracing teams within the Medical Corps. When activated, the primary role of these teams was to identify the close contacts and trace the source. They also ensured that appropriate decontamination was done on-site.

SAF medical centres adopted similar public health principles in the form of enhanced infection control. Febrile patients were segregated from non-febrile patients using separate reporting sick times as well as physical separation within the medical centre. To limit infectious disease exposure, suspect cases did not undergo routine investigations like blood tests or chest X-rays; instead they were referred directly to the designated SARS hospital. In addition, dedicated national SARS ambulances were used for suspect cases. All medical personnel also had to have the appropriate level of personal protective equipment (N957 respirators, gloves and gowns).

Organisational and Administrative Measures


SARS was not merely the fight of the healthcare professionals. Everyone in the SAF had a part to play. The nature of their role depended on the risk assessment and management of the various units and activities.

The nature of the units had varying impact on SAF’s operational readiness. Hence, additional precautionary measures had to be taken for added insurance. Thus should a case slip through, contingency measures would already be in place to ensure that the unit’s readiness was not affected. A number of private businesses who could ill-afford a shutdown also adopted these “enhanced” measures to their critical areas including sub-division to form functional entities, having separate teams working at different locations or the inclusion of an additional shift.

A risk assessment matrix of organisational measures could prove useful whereby the risk of SARS transmission within the SAF was matched with the categorisation of the significance of the workplaces or the activities involved. This included policy decisions to manage overseas exercises, local in-camp training, travel to SARS-affected countries, management of contacts of suspect SARS cases, management of personnel who lived in the same household as someone issued with a HQO and the litany of mass activities and ceremonies.

Every serviceman had to be aligned with the strategies and rallied support for the sometimes difficult preventive measures and policies. The SAF had to ensure that policies were communicated and understood. It also had to allay public fears by being transparent and offer explanations when queried. Information communication and management was crucial in the bid to overcome ignorance and fear. Various media in the form of posters, cascade briefings and intranet were employed to educate. Patient confidentiality had to be maintained to assure affected servicemen while on the other hand, affected units had to be reassured that fellow colleagues who had recovered were not at risk of transmission.

Compliance with measures had to be enforced. Audits had to be conducted to ensure compliance with the measures put in place, and even though they initially appeared to be unnecessary, the audits were crucial as they highlighted non-conformities in protective measures, allowed alignment and reinforcement of policies, and demonstrated the commitment of the higher headquarters.

Indicators of Effectiveness


A number of performance indicators were used to evaluate the effectiveness of our measures within the SAF. These were divided into “hard” outcome measures which allowed for trending (comparing our efforts with the national trend) and assessment of
risk within SAF:

  • Number of probable SARS cases.

  • Number of suspect SARS cases.

  • Number of personnel with a positive contact history (including those on HQOs).

  • Number of personnel with a positive travel history to SARS-affected countries.

  • Number of pneumonia cases (non-SARS related).

And “softer” or secondary outcome indicators:

  • Incidents where secondary transmission occurred (meaning that secondary cases arising from an SAF contact) which would have implied that detection, contact tracing and control measures were not responsive enough.

  • Incidents of export of SARS to other countries by SAF personnel – implies the lack of social responsibility.

  • Level of operational readiness.

While the SAF did have SARS cases, our measures were effective. There was no secondary transmission. The response time between identification and isolation of contacts was kept efficiently to within a few hours. Risk was further minimised by keeping the number of contacts and positive travel history low.

Overcoming the Hurdles

The process of policy development and policy management, was continuously and extensively tested. Because these policies were time sensitive, policies were sometimes promulgated far quicker than it could be implemented. Personal healthcare protective measures, disinfection guidelines, temperature regime were examples where they were highly “hardware-” or logistically-dependent, and they had to be procured before directives could be implemented.

Resources were scarce and there was a shortage of medical personal protective equipment including N95 respirators, protective gowns and thermometers. The decision to stock-pile versus acquisition-on-demand had to be weighed in the face of competing demands not only locally, but also regionally.

Policy decisions within the SAF were partly driven by national policies, and there was a requirement to ensure consistency. Issues had to be carefully studied whenever there was a new (usually more stringent) policy proposed. The initial phases saw a degree of resistance in adopting more stringent measures, but as the risk became more apparent, this reversed and discussions instead focused on how measures could be even more protective.

The milieu of issues that had to be addressed was substantial. There were a huge number of advisories, directives and communications guidance (new and reviewed) within the first month of outbreak. And they had to be continually updated as more information became known of the virus and calibrated to the outbreak situations of Singapore and the region.

Sustainability of measures would have become a serious issue had the outbreak become prolonged. The implementation of measures came with a price, not only in terms of actual costs – operations were run less efficiently and took an unhealthy toll on the personnel involved. This was especially so for the personnel in the medical centres and the critical areas and will be a follow-up issue as part of sustainability studies.

Returning to Normalcy

“We cannot be looking for the flood and miss the little leaks. The little leaks can burst the dyke.”

-RADM(NS) Teo Chee Hian,
Minister for Defence warning
against complacency.

It is unlikely for the SAF or Singapore for that matter, to return to the familiar lifestyle and habits of pre-SARS days. The authors remain quietly optimistic that as an organisation, we have emerged stronger, more aware and far more prepared following the management of the SARS outbreak.

This event has convinced the organisation to retain certain habits and practices which will raise the standards for preventing, not just SARS, but all other infectious diseases. Personal hygiene practices such as hand washing and not spitting in public; cleanliness of buildings and toilets; non-sharing of food and utensils; hygiene of canteen operators and food-handlers have to be continued. Infection control measures in the medical centres can be scaled down, not to the pre-SARS era, but to an elevated basic level. For example, febrile patients will now be seen separately from non-febrile patients.

SAF Moving Ahead


As experience is the greatest teacher and innovator, the lessons gleaned in our fight against SARS should not be filed away into a drawer or worse still, left undistilled within an individual’s mind.

For a start, there needs to be a review of the current healthcare operations framework in the infectious disease outbreak situation especially for an emerging disease. This is probably the only instance where a medical disease can potentially cripple national security. The management of the SARS outbreak has also been a very good dry run for bio-terrorism response and has reinforced the importance of public health measures, even during low threat states.

The global response has shown that much can be achieved with well-coordinated cooperation between agencies. It is unprecedented that containment of a novel infectious agent was accomplished in the span of a few short months including the identification of the agent, development of diagnostic capabilities and implementation of effective control strategies. It is due in no small part to the present information era, the epoch of expeditious advancements in biotechnology and information technology. It cannot be ignored and the SAF will do well to leverage upon this knowledge in the enhancement of its medical surveillance and response.

Endnotes

1 “Cumulative Number of Reported Probable Cases of SARS from 1 Nov 2002 to 20 Jun 2003”, World Health Organisation (WHO) ( 20 Jun 2003). Available at http://www.who.int/csr/sars/ country/en. Also see Ksiazek TG et al, “A Novel Coronavirus Associated with Severe Acute Respiratory Syndrome”, North England Journal of Medicine (15 May 2003). Available at http://content.nejm.org/cgi/content/ abstract/ nejmoa030781v2 and Falsey AR and Walsh EE, “Novel Coronavirus and Severe Acute Respiratory Syndrome”, Lancet ( 8 Apr 2003). Available at http://image.thelancet. com/extras/03cmt87web.pdf

2 In Singapore, five patients accounted for 103 out of 205 probable SARS cases. The underlying mechanism is still unclear, but there are two postulates: firstly, it is a coincidence of multiple factors (unlikely); alternatively, the phenomenon is real, that there is greater transmission, higher viral loads or some other unknown factor in these super-spreaders. The issue is whether there can be early recognition of potential super-spreaders in such an outbreak. More details about the pattern of transmission can be found in the following document: “Severe Acute Respiratory Syndrome, Singapore 2003”, MMWR Weekly, ( 9 May 2003). Available at http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm5218a1.htm

3 “Case Definitions for Surveillance of Severe Acute Respiratory Syndrome (SARS)”, WHO ( 23 Jun 2003). Available at http://www.who.int/csr/sars/ casedefinitions/en

4 HQOs, when issued by Ministry of Health (MOH), are a legal document (part of Singapore’s Infectious Disease Act) which binds the affected person to remain within the confines of his home. Any breach would possibly mean fines or jail sentence.

5 Chemoprophylaxis refers to the use of drugs to prevent disease.

6 Epidemiology is the study of how disease is distributed in populations and of the factors that influence or determine this distribution. It originally meant the study of epidemics. In the SAF context, it includes disease surveillance and the evaluation to identify disease patterns. In acute infectious diseases, it is used to examine disease transmission and elucidate the source of the outbreak.

7 N95 refers to a grade of respirators which has a filtration efficacy of at least 95% for particles up to 0.3 micron in size.
Last updated on 31 Mar 2011
 
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