Statement From The Minister For Health: Health Measures Against Sars Outbreak

24 Apr 2003

By Mr Lim Hng Kiang

Current state of knowledge on SARS

The World Health Organisation (WHO) has stated that SARS is a serious threat to international health and could become the first severe new disease of the 21st century with global epidemic potential. So this is a very serious problem confronting Singapore and the rest of the world.

Let me start by summarizing what we know and what we do not know.

It is now six weeks since WHO first issued its global health alert on 12 March on cases of atypical pneumonia. For the Healthcare Workers (HCW) at the frontline combating SARS, this has been a long and demanding six weeks. But six weeks is a relatively short period for a completely new disease.

The WHO announced on 16 April that a newly discovered virus from the coronavirus family is the cause of SARS. Identification and characterization of the exact causative virus will allow development of better diagnostic tests and treatment protocols. A significant step towards this was the recent sequencing of the viral genome by scientists in the US, Canada, Hong Kong and Singapore.

We are learning more about the spectrum of clinical presentations. Most patients present with typical features with a sudden onset of high fever with or without muscle aches. Some patients may also have chills, shivering, cough and headache. After 3 to 7 days, patients may start to have shortness of breath, and X-ray changes of pneumonia. In about 80 to 90% of cases, the patient gradually recovers. However, in 10 to 15% of cases, after about 7 days, the pneumonia progresses and the patient needs treatment in the intensive care unit with most requiring a ventilator to help them breathe. About 6% of cases die despite intensive care. The majority of patients who succumb to the disease are older persons above the age of 40 years. But we have had 3 deaths from patients below 40 years.

We have observed a number of cases where the symptoms have not been typical. This has made the disease even more difficult to combat. This has occurred in patients with many pre-existing chronic medical conditions such as heart disease and bacterial infections that mask the symptoms and signs of SARS. In such cases, the fever may be low-grade at the beginning and signs of lung infection occur very late in the course of illness. Such cases are very difficult to recognise early and pose a major challenge for our healthcare professionals.

How is SARS transmitted? Both WHO and the US CDC believe that the main way SARS spreads is through transmission of infectious droplets, for example, when a SARS patient coughs or sneezes droplets into the air and someone else close by breathes these droplets in. Our own experience in Singapore supports this view since most of our cases have occurred either among healthcare workers caring for SARS patients in hospital, or family members and friends of the patients who had visited and come into close contact with them. Based on our experience, patients appear to be most infectious when they are ill. Most of the SARS patients in Singapore have passed on the infection to a small number of people only, and through close contact. However, we have also noted that there a small number of SARS patients who appear to be highly infectious, infecting a large number of people (super-spreaders). This may also have been due to the fact that their SARS illness had not been picked up earlier and they had infected a large number of persons in close contact with them by the time they were diagnosed with SARS. Hence, 5 SARS patients have been responsible for the transmission of the infection to the vast majority of the 182 non-imported patients that we have seen so far in Singapore (up to 23 Apr 03).

However, there may be situations where SARS may have been transmitted through other routes. For example, the outbreak involving a large number of residents in an apartment block in Hong Kong suggest that SARS may be transmitted perhaps through some common environmental route. Transmission through contaminated surfaces also cannot be ruled out. That is why we emphasise the need for a higher standard of personal and environmental hygiene.

So far, three diagnostic tests have been developed for SARS. However, all the tests have limitations. There is a test for antibodies to SARS in the blood. However, this is present only from about 20 days after the onset of clinical symptoms. It therefore cannot be used to detect cases at an early stage. The second test, an immunofluorescence assay (IFA), detects antibodies reliably as of day 10 of infection, but is a comparatively slow test that requires the growth of virus in cell culture. The third test is a molecular test for detection of SARS virus genetic material. This is useful in the early stages of infection but at this stage of development, the test kit fails to pick up many patients with SARS. WHO has stated that more work is needed to produce a robust test that is capable of rapidly and reliably detecting cases at an early stage of infection. Many laboratories, including those in Singapore, are working to achieve this.

There is as yet, no specific treatment for SARS. WHO has stated that no treatment beyond good intensive and supportive care has been shown to improve the outcome in patients with SARS. About 8-9% of our cases have died compared to the global average of 6%. The case fatality rate in Hong Kong has also been about 7% but that in Canada has been about 9%. A likely reason for the slightly higher fatality rate in Singapore compared to Hong Kong is that the daily occurrence of new cases here has been much lower than that in Hong Kong. In Canada, most of the fatalities have occurred among elderly patients with co-existing chronic illnesses.

Current situation of SARS in Singapore

I had previously explained our strategy to contain SARS in Singapore. The main components of this strategy are to identify and isolate symptomatic cases early, to quarantine contacts who have been exposed to patients with SARS and to minimize the number of new imported cases.

My Ministry decided early on to concentrate all SARS cases in TTSH and CDC. Enhanced infection controls were put in place. No TTSH staff looking after known SARS patients have caught the disease for the last six weeks.

An important characteristic of SARS is that it is more infectious when the patient is sicker. Hence, it tends to be transmitted quickly among healthcare workers who are not appropriately protected when they take care of SARS patients. The lack of a rapid diagnostic test that can be applied early, the non-specific nature of SARS symptoms (fever, cough) and the possibility of the co-existence of multiple illnesses masking the presence of SARS in the same patient have made it difficult to identify SARS patients early and reliably. The outbreak in SGH that started in early April involved a single super-spreader with multiple illnesses. The outbreak in SGH led to a cluster of SARS cases in NUH. We are still mopping up the consequences of that setback.

My Ministry has implemented additional measures to contain the outbreaks in hospitals and other health care institutions, including nursing homes. Firstly, all health care workers in all hospitals are now required to wear N95 masks, gloves and gowns and to practice frequent handwashing after every patient contact. In isolation facilities, Emergency departments and ICUs, they are also required to wear goggles. This is to ensure that they do not get infected by patients who have SARS but have not been diagnosed to have the disease. Secondly, all health care institutions are now required to monitor their staff closely through twice-daily temperature monitoring. Strict instructions have been given to disallow any staff member who has fever or is unwell to start or continue working. Thirdly, all health care institutions have set up special teams to prevent and control SARS. The Ministry is carrying out audits on health care institutions to ensure compliance with the infection control practices. The Ministerial SARS Combat Unit headed by SMS Khaw Boon Wan will give leadership and political weight to the hospital audit teams.

In response to Mdm Ho Geok Choo's questions, selective closure of affected areas of SGH have been carried out instead of closing SGH completely. For example, the patients and staff in wards 57 and 58 were all transferred to Tan Tock Seng Hospital en-bloc. At the same time, staff who may have been exposed to SARS patients have all been quarantined. SGH has also changed its work practices so that teams of doctors work in only one physical site, hence limiting the potential of cross-infection. All public hospitals are closely monitoring their capacity so that they can take the necessary measures to match the need against their capacity. As for using private hospitals, to supplement the public hospitals, this is being explored. One option is to refer some subsidised patients for selected treatment in private hospitals.

The outbreak in SGH in early April also led to a cluster of SARS cases at the Pasir Panjang Wholesale Centre. We shut down the Centre for ten days and imposed Home Quarantine Orders on all the stallholders and their workers in the Centre. The aim is to keep them isolated at home and prevent the infection from spreading. Regular buyers at the Wholesale Centre are closely monitored through telephone surveillance. This is a massive effort to systematically isolate and contain the spread. We have harnessed all the government resources to this end. We need the co-operation of all those involved, in order to break the chain of infection.

We have also put in place a number of measures to ensure that clusters of infection do not develop from new imported cases of SARS. To reduce the number of imported cases, we are carrying out health screening through temperature checks on incoming air and sea passengers from affected areas. This complements the checks that airlines have put in place at check-in counters. Flight crews are also on the lookout for ill passengers on board aircraft. All visitors to Singapore have been required to complete a Health Declaration Card from 9 April 2003. All travellers who enter Singapore from affected areas are also given a Health Alert Notice to explain the symptoms of SARS and how they can get help if they fall ill with suspected SARS. We will continue with these measures for the long term.

About 120,000 persons enter Singapore from Malaysia each day and half of those travel daily. My Ministry is working closely with our Malaysian counterparts on measures to prevent and control SARS in our countries. A delegation of MOH and MHA officials met with their Malaysian counterparts last week to discuss joint measures and the regular exchange of health information.

But we have to be realistic. Global travel means that new imported cases will occur in the future. Screening of travellers is limited in its effectiveness as it will not pick up persons during the incubation period. Persons can therefore be well as they pass through the screening procedures and develop SARS later. A single imported case can trigger off an outbreak involving many cases, especially if he or she is a super-spreader even though we quickly institute the control measures to isolate and ring-fence ill persons and their contacts so as to limit disease transmission. Hence, we must all be prepared to accept that we are in this for the long haul.

Measures for Singaporeans living in SARS affected areas

Dr Amy Khor asked about measures taken for Singaporeans living in SARS affected areas. They should follow the advice given by the local health authorities where they live. They should also check on the information provided by MOH through its website on how they can reduce the risk of catching the infection.

Measures to recognise our health care workers

Mr Gan Kim Yong, Dr Michael Lim and Dr Chong Weng Chiew asked how we are recognising the professionalism and contributions by our health care workers. Let me put on record that we are proud of them and we commend them highly for their dedication and professionalism. I am pleased to inform the House that the two health care clusters, as employers of these health care workers have already implemented a policy of covering the complete medical bills of their staff and their families should they fall ill with SARS in the line of duty. For these staff, the medical expenses and medical leave will not be deducted from their yearly entitlement. A Courage Fund has been set up by the two health care clusters, the Singapore Medical Association, Singapore Nurses Association and Singapore Press Holdings to help the families of needy SARS patients in honour of all health care workers in Singapore. The clusters have in place a mechanism to review the salary of our nurses and other health-care workers regularly. Apart from salary review, we will look into other ways to honour and recognize the exceptional contributions made by all our health-care workers at an appropriate time.

Going Forward

My Ministry has put in place all the necessary measures to minimise the risk of new clusters of infection from unrecognised cases of SARS in our hospitals and from imported cases. However, I would like to caution Members that in the absence of a definitive diagnostic test, it is very difficult to identify and isolate such cases early.

Right now, we only have two weapons to work with. First, the clinical symptoms, of which the onset of high fever is an important indicator. Second, the contact history which points to the possibility of being infected by a SARS patient.

To win the battle against SARS, we need a change in mindset, a higher level of social discipline and social responsibility. To make full use of the first weapon, we must encourage everyone to take their temperature daily. If you detect that you have fever or are unwell, do not go to work. If your child has a fever, do not send your child to school. See a doctor and stay at home until you are well. When you go to the doctor's clinic, wear a face mask to as to reduce the risk of spreading infection to others. If you cough, cover your mouth and nose with tissue paper or a handkerchief. Do not spit on the floor or in the open. Practise good personal hygiene and wash your hands frequently.

During this difficult period, Singaporeans should look out for one another. If your family member or colleague or neighbour is sick, advise him to see a doctor and stay at home.

Next, we must be truthful about our contact history. If we suppress information about our travel history, our likely contacts with probable or suspect SARS patients, our visits to the hospitals or other venues where we may have contact with SARS patients, then we are giving false information and giving up a very important weapon in our fight against SARS. To the GP, for example, without knowing your contact history, he may arrive at the wrong diagnosis and think that your fever and cough are just the symptoms of a cold or a flu.

Singaporeans must recognize that it is in your interest to work together with the Government to prevent and control SARS in our community. If you are sick and you seek medical treatment immediately, your chances of recovery are better. You are less likely to infect your family. If everyone who has fever and is unwell stays at home and away from crowds, then Singaporeans will have greater confidence that the likelihood of their meeting a very infectious person in a crowd will be much reduced. In this way, we prevent the Battle Against SARS from becoming a Crisis of Fear.

In the Battle Against SARS, if all Singaporeans work together, with our healthcare workers at the frontline in the hospitals, with all the Government resources backing them and all Singaporeans playing their part with higher social discipline and social responsibility, I am confident that we can contain the disease.