Remembering SARS: 10 Years On

Defence against outbreaks boosted
But most important measure is to be psychologically prepared: PM Lee
By Andrea Ong And Melissa Pang, The Straits Times, 1 Jun 2013

SINGAPORE has strengthened its defences against infectious diseases on many fronts, after overcoming the severe acute respiratory syndrome (SARS) crisis a decade ago.

But the most important defence is to be psychologically prepared for any future outbreak, which could be more lethal and contagious than Sars, said Prime Minister Lee Hsien Loong yesterday.

He was speaking at a SARS memorial event held by the Ministry of Health at the University Cultural Centre, 10 years to the day the World Health Organisation (WHO) declared Singapore free of the disease, which infected 238 people and claimed 33 lives here.

"We owe it to every Singaporean to do our best to protect ourselves from any future outbreak," said Mr Lee at a simple but poignant ceremony.

Tears welled up in the eyes of many when Mr Lee read out the names of the five health-care workers who died in the line of duty, battling the then mysterious disease that had no cure. Equally moving was a video showing a survivor, a nurse, a grassroots leader and the wife of a doctor who died recalling their ordeals.

The experience has led Singapore to increase, for instance, its public health capacities.

Mr Lee cited two such improvements. One is the National Centre for Infectious Disease, with about 300 beds, that will be at Tan Tock Seng Hospital. Expected to be ready by mid-2018, it replaces the Communicable Disease Centre.

The Saw Swee Hock School of Public Health will do epidemiological research and build up national disease control capabilities.

Singapore will also strengthen its partnerships with WHO and other international public health agencies, said Mr Lee.

On the home front, national agencies are kept vigilant with regular exercises. The entire system was "tested in a small way" and did well during the 2009 H1N1 influenza pandemic, he said.

He cautioned that with a more connected world today, "a new contagious disease will spread even more swiftly and widely, and no country can expect to be spared in a pandemic".

Ultimately, Singapore's most important defence is to be psychologically prepared and for people to remain calm and be socially responsible, he added.

Earlier, Mr Lee recounted the fear that gripped the nation, with people shunning contact with others and public spaces deserted.

But Singaporeans rallied to help in whatever way they could.

Above all, he said, "none were stronger or braver than our healthcare workers". He paid tribute to them, some of whom were not Singaporean. "We are forever grateful to these brave and selfless men and women."

Mr Lee recalled the five healthcare workers who died: Doctors Ong Hok Su and Alexandre Chao, nurses Hamidah Ismail and Jonnel Pabuyon Pinera, and hospital attendant Kiew Miyaw Tan.

His voice choking with emotion, he said: "We remember and honour them always."

Calling SARS a defining moment for the nation, he said if a similar tragedy were to happen again, "I trust that we will support one another, and fight to win the battle just as we did with SARS".

The 400 guests - including former SARS patients, former ministers and health-care professionals - observed a minute of silence for those who died.

Emeritus Senior Minister Goh Chok Tong, who was then PM, said he teared up during the ceremony. "It was our most tragic moment but also our most glorious for the way we responded."

The Singapore Medical Association held a commemorative symposium last night. Its president Chin Jing Jih praised the less publicised health-care heroes: those in primary care like general practitioners and polyclinic staff who were the first to screen suspected SARS victims.

Today marks the 10th anniversary of our fight against SARS. SARS was a difficult trial, but we overcame it as one people...
Posted by Lee Hsien Loong on Friday, May 31, 2013

Survivors reunite with health-care workers
By Melissa Pang And Andrea Ong, The Straits Times, 1 Jun 2013

MS ANDREA Lim was 11 years old when her godmother infected her with severe acute respiratory syndrome, or SARS, 10 years ago.

Too young to know what SARS was, she recalled that "I just felt sad I was the only person in my family who had to go to hospital".

She was the first child patient at Tan Tock Seng Hospital, the designated SARS hospital.

But one thing struck her: The dedication of the nurses who would spend one to two hours, three times a day, coaxing her to take her medication.

She remembers especially one Filipino nurse's patience. "She is the person who made me who I am today," said the nursing diploma graduate, who is now waiting to do a nursing degree.

Yesterday, the 21-year-old was among SARS survivors, health- care workers and members of the community who reunited at the University Cultural Centre for a commemoration.

Speaking at the event, Prime Minister Lee Hsien Loong paid tribute to those who died and ordinary Singaporeans who made a difference.

Mr Lee singled out taxi driver Haniff Mahbob, who made it a point to pick up health-care workers, especially nurses in uniform, after he read that other cabbies were turning them away.

"The nurses were already putting their lives at risk by going to work. It's the least I could do for them," said Mr Haniff, 61.

Help also came from Yio Chu Kang grassroots leader Low Chuan Seng, who headed a constituency SARS task force then. The team visited markets and hawker centres at 5am daily to take the temperature of stallholders.

Mr Low, 62, said his team's experience in fighting SARS is now handy in spreading the word on the current dengue epidemic.

Mr Lee hailed people like Mr Haniff and Mr Low, saying: "Each act gave us strength, and helped us to defeat the disease."

SARS survivor Azman Abdullah, 47, has never forgotten the support from then medical social worker Lee Lay Beng.

Ms Lee, now in her late 50s, helped his wife Jamaliah with the family's finances and would call to check on him even after he was discharged from hospital.

Yesterday, he and his family were reunited with Ms Lee for the first time in 10 years.

The train driver had contracted SARS from his older sister Painah, one of 33 people who died from the disease.

For Mr Azman, the human touch got him through those dark days. When he could not breathe, other patients would rub Vicks on his chest or pour drinks for him.

Asked what his ordeal taught him, he said: "We have to stand united as a family, a big Singaporean family."

All ready for next virus outbreak
Exactly 10 years ago, Singapore was declared free of SARS by the World Health Organisation. The virus wreaked havoc but also sparked important changes in policies and procedures that have made countries more prepared to deal with a similar crisis. The Straits Times' foreign correspondents in China, Hong Kong and Taiwan, together with Melissa Pang in Singapore, examine the aftermath of SARS and catch up with the people whose lives it irrevocably changed. Health systems have been beefed up to deal with future crises
By Melissa Pang, Li Xueying And Ho Ai Li, The Straits Times, 1 Jun 2013

WHEN news broke last September that a novel coronavirus had been discovered, an alert was sent to medical staff all over Singapore to look out for symptoms in patients, especially those who had been to the Middle East.

A week later, the alarm bells rang.

A woman who returned from Saudi Arabia in July and was admitted to the National University Hospital (NUH) for severe pneumonia had died.

NUH's epidemiology unit swung into action. Her samples were immediately tested for the coronavirus, now known as the Middle East respiratory syndrome coronavirus.

Meanwhile, NUH officers started the tedious process of contact tracing, tracking the patient's last known movements and informing anyone who had made contact with the patient about what had happened.

In the end, it turned out that the patient did not have the contagious coronavirus which has infected 49 and killed 27 globally since September last year.

But if someone does have the virus, Singapore's hospitals and health-care professionals now know exactly what to do next.

Ten years ago, on March 12, the world was hit by severe acute respiratory syndrome (SARS), an atypical pneumonia that killed more than 700 people globally, many in Asia.

Governments in this region struggled to contain the spread of the virus amid a general lack of preparedness and rising public panic.

The experience left a deep impact on the authorities and health-care workers in places like Singapore, China, Hong Kong and Taiwan. In the last decade, they have plugged gaps in their hospital systems, refashioned processes and built new capabilities to better deal with a similar crisis.

"SARS was a landmark practice-changing event," says Singapore General Hospital's (SGH) emergency medicine specialist Dr Fatimah Lateef. "Whatever was put in place during SARS, continues until today."

In Hong Kong, this has meant relooking at fundamentals like hospital design.

"Ten years ago, there were no isolation rooms, and so we used general medical wards where you can pack in 40 patients but with no partitions," says Professor David Hui, the head of respiratory medicine at Chinese University of Hong Kong.

"There was overcrowding of wards with less than one metre between beds and we changed the air in the wards three or four times per hour," adds the professor, who was at the frontline of the SARS crisis.

"Since 2005, however, the government has injected millions of dollars to upgrade every major hospital. Now we have isolation wards, with 12 air changes per hour," says Prof Hui.

The isolation wards now also have double doors for added protection. Exhaust fans that pump fresh air from the ceiling force any droplets emitted from a patient's cough to the floor so they will be removed quickly.

Governments have also made sure that medical staff have access to enough medical supplies.

Many still remember the acute shortage in 2003 of N95 face masks, which offered the best protection to the nose and mouth from the virus.

In Hong Kong, masks had to be rationed in the hospitals that treated SARS patients. This led many to blame the subsequent death of frontline health-care workers on the shortage.

"Now, in fact we have an over-supply," says Prof Hui. "Whenever we enter the wards to perform rounds, we use it."

In Singapore, the Ministry of Health (MOH) also maintains a stockpile of personal protective equipment (PPE) for frontline healthcare workers.

There is also anti-viral flu medication to treat confirmed cases. In 2010 it was reported that MOH had a stockpile of Tamiflu enough for 1.39 million adults and 300,000 children.

Most recently, Singapore announced it would build a new infectious diseases hospital to replace its ageing Communicable Disease Centre.

Taiwan has also boosted its emergency readiness levels, improving collection of disease surveillance data and establishing a high-tech Epidemic Intelligence Centre that can integrate, analyse, and report on this data.

A network of laboratories can now perform diagnostic tests and rapidly report results, and the island has developed its own ability to manufacture vaccine.

But governments are going beyond just hospital rooms and supplies.

In Singapore, one key area of emphasis post-SARS has been on limiting the spread of the disease among the general population.

This means pre-emptively isolating groups of potential sufferers and ensuring those that have come in contact with them are quickly traceable.

At SGH's accident and emergency department, for example, fever screening is done before patients are triaged.

They also have to fill up a form which contains questions on their travel history.

Suspected high-risk cases are then grouped in a fever management area to minimise their interactions with other patients, a practice that helped to sieve out several patients suspected of contracting the novel coronavirus.

Visitors to hospitals now also have to register their personal particulars and their numbers are limited.

Should there be an outbreak, procedures are in place to quickly set up phones and laptops, and activate staff from both MOH and other agencies for contact tracing. To maintain a high-level of preparedness, regular training and mock-up exercises are carried out.

Among the wider population, the advent of SARS has meant a renewed emphasis on good public hygiene.

In Hong Kong, the use of face masks has become prevalent. Toilets are assiduously maintained by a battalion of cleaners.

But SARS has also had far-reaching effects that extend beyond the health sector.

In China, the outbreak of the virus forced the government to do a rethink of the way it disseminates information in a national crisis.

In 2003, the outbreak of the virus coincided with China's annual political sessions and Beijing kept mum about atypical pneumonia cases found in southern Guangdong as early as November 2002 and downplayed patient numbers.

Health Minister Zhang Wenkang even falsely declared in early April that the epidemic had been put under control.

By April 20, however, he and Beijing mayor Meng Xuenong had both lost their jobs. China finally admitted it was a crisis and allowed World Health Organisation officials to conduct checks.

These days, China has set up mechanisms to inform the world about public health emergencies.

Beijing seems to have learnt that it is impossible and unhelpful to withhold information in this digital age, says Dr Huang Yanzhong from the Council on Foreign Relations, a New York-based think-tank.

Internally, the country has also beefed up its information gathering.

Even in cities like Beijing, nurses and doctors didn't know in 2003 how to protect themselves against infectious diseases - one-third of the 349 Chinese who eventually died of SARS were medical personnel.

It was also hard to collate information from the hospitals, which were run separately by various authorities such as the local government, military or universities. It reportedly took a week for vice-health minister Gao Qiang to gather patient figures from 175 Beijing hospitals.

A year after the crisis, Beijing moved quickly to set up an online reporting system that allows hospitals to report suspected disease cases directly to the Communicable Disease Centre (CDC) and the Ministry of Health.

It is one of the best online disease reporting systems in the world, says Dr Joan Kaufman, who is from Columbia University and is based in Beijing.

In Singapore, SARS underlined the need for a cross-Government approach, and in its aftermath, other agencies made themselves more battle-ready.

In schools (which were shut down for more than 10 days in a move that affected over 600,000 children), every new school-going child is now given an oral digital thermometer. Standard procedures are in place to respond to an influenza pandemic. These include temperature-taking, contact tracing, and closing schools and home-based learning should the need arise.

The National Environment Agency (NEA) has also been enforcing hygiene in public spaces.

During the SARS crisis, it oversaw the clean-up of the Pasir Panjang Wholesale Centre which was closed when a wholesaler became infected. It conducted fever checks for all stallholders at wet markets and hawker centres.

With viral threats coming from different sources, such as the H7N9 bird flu, its work has also been expanded to oversee the removal of dead birds from public places and the disposal of culled birds by incineration.
SARS may have claimed many lives in its wake. But 10 years later, the lessons it has taught are helping to save countless others.

From outbreak to eradication

March 1, 2003: Patient No. 1 is admitted to Tan Tock Seng Hospital (TTSH) for suspected pneumonia. She and two other women fell ill after visiting Hong Kong.

March 12: The World Health Organisation (WHO) issues a global alert on outbreaks of a severe form of atypical pneumonia in Hong Kong, Vietnam and Guangdong.

March 15: The term "SARS" is coined. Singapore reports 16 cases and its Ministry of Health (MOH) forms a SARS task force.

March 16: MOH issues hospital guidelines to screen emergency department patients for fever and travel history to SARS-affected areas. It also issues infection-control guidelines.

March 22: TTSH is designated the SARS hospital and a SARS hotline is set up. The number of cases rises to 44.

March 24: The Infectious Diseases Act is invoked and about 740 people are home-quarantined for 10 days.

March 25: Singapore experiences its first SARS death - Patient No. 1's father.

March 26: Pastor Simon Loh, who visited Patient No. 1, becomes the second person to die of SARS.

March 27: All schools are shut till April 6. MOH stipulates that those who die of SARS must be cremated within 24 hours.

March 29: Temperature checks are introduced for all passengers entering Singapore through Changi Airport.

April 5: Singapore General Hospital (SGH) is hit by a SARS outbreak. The closure of schools is extended.

April 6: A ministerial committee is formed as the death toll hits six.

April 7: TTSH doctor Ong Hok Su becomes the first hospital worker to die from SARS. Patient No. 1's mother also dies.

April 9 to 16: Schools finally reopen.

April 22: SARS kills SGH vascular surgeon Alexandre Chao.

April 28: Visitors banned from all six public hospitals, as death toll rises to 21.

May 11: Nurse Hamidah Ismail, one of the first nurses hospitalised for SARS, dies on Mother's Day.

May 18: Last SARS patient detected.

May 30: WHO declares Singapore SARS-free.

July 16: SARS eradicated in Singapore.



















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