Update On SARS - 10 Apr

10 Apr 2003

As at 10 April 03, 77 SARS patients have been discharged. 47 SARS patients remain hospitalised.

There were 7 additional SARS cases reported today, 5 of whom are linked to the SGH cluster comprising 1 SGH staff, 2 inpatients and 2 visitors.

The other two additional cases are a TTSH nurse who was in contact with a SARS patient before the patient was diagnosed to be a SARS case and a family member of a SARS patient. This family member is the husband of the woman who broke quarantine and was transferred from NUH to TTSH on 5 April 03. She is in intensive care.

SGH Ward 57 and 58 cluster

On 5 April 03, SGH noted that a total of 21 staff from Wards 57 and 58, had developed fever since the 1 April 03; one on 1 and 2 April 03, 2 on 3 April 03, 9 on 4 April 03 and 8 on 5 April 03. SGH sent the affected staff to TTSH and while waiting for the medical assessment of the cases, stood down that surgical team.

On 6 April 03, as a precautionary measure and in order to ring-fence the source of infection, SGH transferred all patients from Wards 57 and 58 to TTSH. All patients who were formerly in Wards 57 and 58 during the period from 20 March 03 till 5 April 03 and who were still in SGH were also transferred to TTSH. Nurses, doctors, therapists and other staff working in these 2 wards were also transferred to TTSH. The transfer, involving 80 patients and 91 staff was completed on 7 April 03. SGH also contacting discharged patients who were formerly in Wards 57 and 58 during the period from 20 March 03 till 5 April 03, as well as visitors to these wards during this period, to ensure their well being.

So far, 52 persons are linked to the SGH cluster at Wards 57 and 58, comprising 19 probable and 33 suspect SARS cases. They comprise 26 SGH staff, 14 visitors and 12 inpatients. In addition, 2 SGH staff and 4 inpatients were admitted for observation. All 19 are stable except for 2 who are in serious condition in intensive care.

Epidemiological investigations have traced the source of this cluster of infections to a Chinese man in his 60s who had been admitted to TTSH from 5 to 20 March 03 for chronic kidney disease and diabetes. He was admitted to SGH Ward 57 Intermediate Care Area on 24 March 03 for gastrointestinal bleeding. He had a diabetic foot ulcer and was noted to have a low grade fever since admission. A chest X-ray on 24 March was clear. He was treated for his medical conditions and was started on antibiotics.

On 28 March, he developed high fever. A repeat chest X-ray on that day was normal. He was treated with antibiotics and on 29 March 03, he was transferred to Ward 58 B2. Tests showed that he had an infection of the blood by a bacteria, E.Coli. Chest X-ray on 30 March was again normal. He was given a stronger antibiotic and on 3 April 02, he no longer had fever. However, his chest x-ray on 4 April 03 showed signs of pneumonia and he has been diagnosed as a SARS case by the doctors in TTSH.

Although the clinical picture of this patient is not typical of SARS, it is likely that the typical symptoms of SARS were masked by his other underlying medical conditions. It is believed that he had come in contact with a SARS patient who had not yet been diagnosed during the time that he was admitted to TTSH.

The 19 persons with probable SARS in the SGH cluster, comprising 1 doctor, 9 nurses, 1 radiographer, 1 housekeeper, 4 inpatients and 3 visitors, are all linked to Wards 57 and 58. The hospital staff attended to the Chinese man when he was in Wards 57 and 58. One visitor was his brother who visited him while he was in SGH.

Apart from ring fencing the staff and inpatients from Ward 57 and 58 at TTSH, to prevent further spread of infection, SGH has implemented mandatory twice daily temperature checks for all staff, the use of N95 masks by all their staff and limiting visitors to two per patient. SGH has also reorganised their teams of doctors to only work in specified locations. This will help localise patient-doctor interactions to specific physical sites and will facilitate future epidemiological investigations, if necessary.

Orange Valley Nursing Home cluster

It was reported that a nurse from Orange Valley Nursing Home was admitted to CGH on 4 April 03 for pneumonia and transferred to TTSH on 6 April 03 for probable SARS. He has been in intensive care since transfer to TTSH.

Investigations have revealed that a resident of the nursing home was admitted to CGH on 25 March 03 and died of pneumonia on 30 March 03. This nursing home resident had been earlier discharged from TTSH on 23 March 03 for non-SARS related condition. When the patient was in TTSH she was warded next to a patient who was later diagnosed as a SARS case. The male nurse from the nursing home had been attending to this resident. The daughter-in-law of this nursing home resident, a mediaCorp staff, was admitted to TTSH on 7 April 03 for SARS. She is in serious condition in intensive care. A friend of hers who was in contact with her when she was unwell has also been admitted to TTSH on 8 April 03. She is in stable condition.

The girlfriend of the nurse from Orange Valley Nursing Home and the teenage son of the MediaCorp staff who is a student of Zhonghua Secondary School have been admitted as suspect SARS.

Although it is believed that the resident of Orange Valley Nursing Home was the source of infection, investigations are still on-going to exclude other sources.

TTSH Rehab Dept at Ang Mo Kio Community Hospital

At this point in time, investigations suggest that the source of infection for the TTSH occupational therapist might have been due to contact with the SARS patient who presented at the NUH Emergency Department on 23 March 03.

Implications of the SGH cluster of infections

To reduce the spread of SARS, Singapore has adopted an isolate and contain strategy, involving comprehensive and practical measures, and at times stronger than what is being done in other affected countries.

One key thrust is to identify symptomatic cases as early as possible so that they can receive treatment and are isolated early. As a precautionary measure, close contacts of SARS patients are ring fenced through home quarantine. Though contact tracing is not 100% foolproof, it helps to significantly reduce any further transmission of SARS, especially to the community at large.

The isolate and contain approach is also adapted for schools. When a case is discovered in school or institute of higher learning, it will be shut down for three days. This will facilitate active contract tracing, and epidemiological investigations, while reducing the risk of exposure of students to SARS.

For healthcare facilities, Tan Tock Seng Hospital Hospital/Communicable Disease Centre (TTSH/CDC) is the only hospital designated to screen and treat both adults and children with or suspected to have SARS. These patients are treated in isolation rooms under strict infection control procedures. They are not allowed visitors. SARS is a very new disease and we are learning that it can present in atypical ways particularly in patients with other types of medical conditions. These medical conditions mask the typical features of SARS and make it very difficult for the diagnosis to be made early. This is illustrated by the case in SGH.

In view of this, MOH has, this week, further enhanced its infection control requirements in all hospitals. The types of cases that hospitals need to identify early and isolate has been broadened to include all cases of atypical pneumonia and fever without a known cause, as well as healthcare workers who present with fever and/or respiratory symptoms of undetermined cause. All hospitals are required to ensure that the temperatures of all its healthcare workers are checked at least twice daily with the first check being done before the staff start work.

Febrile staff should not be allowed to work. The number of visitors to hospitals is also being limited and their details should be noted, to facilitate contact tracing should the need arise. This is on top of the procedures which MOH has already established with Accident and Emergency Departments in all hospitals, on how to handle patients who are unwell and suspected to have SARS. Staff are required to adopt full infection control precautions and if they come across any such patients, they are instructed to transfer them to TTSH for further examination. A system of protected triage staff in SOCs and polyclinics has also been established.

Our isolate and contain strategy seems to be holding up. SARS cases are referred to TTSH as soon as they are detected in other hospitals. This will help contain the spread and chance of outbreak in other hospitals and reduce the risk of spread into the community. In SGH, patients in the affected wards were transferred to TTSH for treatment. We should expect that from time to time, clusters of infections may occur in our hospitals mainly from atypical cases that later turn out to be SARS. The public should be reassured that there is a robust system in place to minimise and respond quickly to such situations.

Affordable Hospitalisation for SARS patients

Currently, screening for SARS are provided free for all SARS suspect cases at TTSH A&E. Local SARS suspect and probable patients who are hospitalised would be charged at the prevailing class C rate for all the services rendered. MOH has also decided to absorb the full cost for the use of the anti-viral drug ribavarin. Foreign patient with SARS who are required by MOH to be admitted for public health reasons would be also be charged at C class rates.

The prevailing Medisave and Medishield withdrawals would apply for SARS patients. Patients who have difficulty paying their bills could seek assistance from the hospitals' Medical Social Workers. We have also informed our hospitals to proactively identify patients who may need assistance and extend to them the necessary help.

For healthcare workers, both clusters have agreed to bear the full cost of medical treatment for their respective staff.

Disposal of bio-hazardous wastes

Since 1988, our hospitals have put in place a system to ensure that all bio-hazardous medical wastes (including masks, gloves, needles, etc.) are segregated from general waste and safely disposed of. Bio-hazardous wastes can only be collected by specially licensed waste collectors (only three of them in Singapore), transported in dedicated vehicles and brought to specially designed and dedicated incinerators for disposal. Our procedures for handling bio-hazardous medical wastes are in accordance with WHO guidelines.

In Singapore, all wastewater is discharged into a closed sewerage system. The wastewater is conveyed through deep underground pipes to wastewater treatment plants for treatment. At the plants, our workers too do not come into contact with the sewage. As a precaution, our workers are provided with protective gear ang gloves etc. when they carry out maintainance work. These underground sewers keep all wastewater out of contact with the public thus ensuring public health safety.

Home Quarantine

From today, MOH is engaging the services of CISCO to serve Home Quarantine Orders and ensure that contacts of probable SARS cases comply with the orders. The measure follows a limited number of incidents in which the home quarantine order was flouted. In one such incident, the contact who eventually became a SARS case went down to see her GP on 3 April 03 and did not disclose that she was under home quarantine. When her condition did not improve, her relative also broke quarantine and ferried her in his car to NUH instead of using the available ambulance service to TTSH. This irresponsible behaviour presents not just a risk to the public but can also cause other hospitals to become contaminated with SARS.

The CISCO officers who serve the Order will site an electronic picture (ePIC) camera at the home of each contact. The contacts will be called at random intervals daily and requested to turn on the camera and present themselves in front of the camera to show their presence. Anyone found breaking the quarantine will be served a written warning and given an electronic wrist tag. The tag is linked to a dedicated telephone line and will alert the authorities if the person leaves the house again or tries to break the tag.

Under section 65 of the Infectious Diseases Act, persons found guilty of an offence shall be liable on conviction to a fine not exceeding $5,000 and in the case of a second or subsequent offence, liable to a fine not exceeding $10,000 or to imprisonment for a term not exceeding 6 months or to both.

Health screening for incoming air passengers

All passengers from SARS affected countries disembarking at Changi Airport were required to complete a Health Declaration Card since 7 Apr 03. This was extended to all passengers and crew arriving by sea on 8 April. From 9 April, this requirement would be further extended to include passengers from all incoming flights who disembark at Changi Airport.

Today, 53 passengers from affected areas required further screening by the nurses at the airport. None were referred to TTSH for further assessment.

Summary of SARS cases

To date, the total number of people diagnosed with SARS is 133. Among these are 3 children below 18 years of age. Out of the 47 patients still hospitalised, 13 are in intensive care. The Ngee Ann Polytechnic student was discharged from intensive care yesterday. There were no new admissions to intensive care.

The number of suspect cases admitted is 82, including 5 children (below 18 years old). The number of people under Home Quarantine Orders is 490.

Travel advisory

MOH urges the public to heed World Health Organisation (WHO)'s advice to postpone travel to Hong Kong and Guangdong until another time. We would also like to advise the public to avoid travel to other SARS affected areas - Shanxi, Taiwan, Hanoi and Toronto, unless absolutely necessary.