2004;10:201–6. SGH On 19 May, the WHO Annual Meeting was held in Geneva. [35] On 29 March, Urbani died in Bangkok of a heart attack. [62][63] On 27 May, the Taichung City Government, led by mayor Jason Hu, established a command center in central Taiwan to handle SARS. It was confirmed that the virus spread via droplets, but this later outbreak made officials question the possibility that the virus could be spread through the air. Among the decisions made were the setting-up of a ministerial-level task force and uniform pre-departure health screening in airports. Dr. Gopalakrishna is an epidemiologist with the Communicable Disease Division of the Ministry of Health, Singapore. WHO raised the concern that substandard care of the infected patients might contribute to the spread of the disease. Even though he was evacuated to Hong Kong, he died on 13 March. Therefore, on March 22, the decision was made to close TTSH’s normal operations and dedicate the hospital solely to treating probable and suspected SARS case-patients (Figure 2). COVID-19 and SARS are both deadly – but different. The PRC Health Minister also claimed that the disease has been under control in most parts of mainland China. These three wards were subjected to a no-admission, no-discharge policy, and the two groups of patients were transferred to TTSH. She was treated in a six-bed ward (ward 5A) until she was isolated on March 6. However, one of the earliest reports from Wuhan, China, where severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified, found 40 health care workers among the first consecutive 138 patients hospitalized. As a result of these measures, when fever developed in two nurses 2 days after the outbreak, they were quickly recognized and isolated the same day. Otherwise SARS infection could rapidly spread to other healthcare facilities. [38], On 9 April, James Earl Salisbury died of SARS at a hospital in Hong Kong. The patient was later determined to be suffering from pneumonia and not SARS. They were the first two high-rank officials in the PRC to be dismissed because of the fallout of the epidemic. In the SGH outbreak, failing to identify the NCC and radiology departments as exposed areas led to missing exposed healthcare workers and patient contacts, and a small cluster of 10 secondary cases arose as a result. One of these patients (patient AAA) had multiple medical problems, including diabetes, gram-negative bacteremia, and ischemic heart disease that required her admission to the coronary care unit (CCU) from March 12 to 19. The first case of infection was traced to Foshan. Non-SARS patients were discharged if they had no known exposure to SARS. Strictly adhering to the use of personal protective equipment by healthcare workers mitigated spread in all three outbreaks. Severe acute respiratory syndrome—Singapore, 2003. Patient B was admitted to an open ward, ward 57, in SGH on March 24 for gastrointestinal bleeding. Importantly, the team showed that patients who recovered from SARS 17 years ago after the 2003 outbreak, still possess virus-specific memory … This visitor was unidentified until probable SARS developed on April 11, by which time two family contacts had been infected. In the three hospital outbreaks, three different containment strategies were used to contain spread of infection: closing an entire hospital, removing all potentially infected persons to a dedicated SARS hospital, and managing exposed persons in place. He himself became infected and died on 29 March. There was an unexpected error. [16][17], Early in the epidemic, the Chinese government discouraged its press from reporting on SARS, delayed reporting to WHO, and initially did not provide information to Chinese outside Guangdong province, where the disease is believed to have originated. On 17 March, an international network of 11 laboratories was established to determine the cause of SARS and develop potential treatments. However, a large part of an effective response will rely on thoroughly understanding the disease. Comment submitted successfully, thank you for your feedback. [citation needed]. Twenty-seven people at the CCU were infected, including five doctors, 13 nurses, one ultrasonographer, one attendant, two cardiac technicians, and five visitors. One person died and nine were infected in the outbreak which was first reported on 22 April. [66], On 23 June, Hong Kong was removed from WHO's list of 'Affected Areas', while Toronto, Beijing, and Taiwan remained. 189 people were released from quarantine. [13] The People's Republic of China notified the World Health Organization (WHO) about this outbreak on 10 February 2003, reporting 305 cases including 105 health-care workers and five deaths. Some of these difficulties can be overcome by better planning and preparedness. [45] In Toronto, three more people died of SARS, bringing the Canadian death toll to 13. [56], In Taiwan, administrators and staff of Taipei Municipal Hospital's Hoping branch faced disciplinary action from the Taipei City Government. On the basis of this experience, three key factors must be considered when deciding on the appropriate containment response. The Table summarizes the profile of the outbreak in the three hospitals. [41] His son Michael "Mickey" Salisbury was with him in China and also contracted the disease, but he survived it. [24] Carlo Urbani, a World Health Organization (WHO) infectious disease specialist, was among the staff who examined Chen. She had close contact with some friends while on medical leave, leading to infection in four of them, one of whom infected four family members. [49], After several cases of SARS were diagnosed in Taiwan throughout the month of April,[50] including a cluster at Taipei Municipal Hospital's Hoping branch,[51][52] the Taipei City Government closed that hospital and quarantined its 930 staff and 240 patients for two weeks. At least 21 cases resulted from spread by hospital visitors to family and community contacts. Of these, 774 died. Key areas of her contribution and research interests include communicable disease epidemiology and surveillance in Singapore and formulation of national public health policies. We review the three hospital containment strategies and the effectiveness of these strategies. Although she recovered, various family members did not. These included eight nurses, one health attendant, five patients in the same ward, and 10 visitors. [73] "The cases had been linked to experiments using live and inactive SARS coronavirus in the CDC's virology and diarrhea institutes where interdisciplinary research on the SARS virus was conducted. SARS Transmission and Hospital Containment. Severe Acute Respiratory Syndrome (SARS) – multi-country outbreak – Update 6. Similarly in the NUH outbreak, temperature surveillance identified two ward 64 nurses who were isolated the same day. The first group identified was the 80 patients in wards 57 and 58 on April 5. Third, can a complete list of all contacts be obtained within 48 hours? In China, Asian palm civets were culled in markets (the civets were thought to be a reservoir for the disease). She had fallen victim to the deadly SARS (Severe Acute Respiratory Syndrome) and needed special care. Patient C sought treatment at the emergency department of NUH on April 8 (Figure 2). Emerg Infect Dis. On 24 May, the number of newly infected patients reached zero for in Hong Kong, the first time since the outbreak in the territory in March. First, with 1,600 beds, SGH is the largest acute hospital in Singapore. The outbreak started in February 2003 with three Singapore travellers to Hong Kong. On 29 April, leaders of member countries of ASEAN and the PRC premier held an emergency summit in Bangkok, Thailand to address the outbreak. Next identified were a total of 135 patients admitted to the two affected wards during the hot period and subsequently transferred to three other wards in SGH. Please use the form below to submit correspondence to the authors or contact them at the following address: Chorh Chuan Tan, Ministry of Health, College of Medicine Building, 16 College Road, Singapore 169854; fax: 0065-6222-2416. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. To contain the outbreak in Singapore, we used three separate hospital strategies: 1) closing the hospital, 2) removing an exposed group to a designated hospital, and 3) managing an exposed cohort in place. He was admitted to the French Hospital of Hanoi on 26 February, where he infected at least 38 members of the staff. Because of her multiple medical problems, SARS infection was not suspected, and healthcare workers caring for her did not use N95 masks. Through excretion, the virus spread through drainage. Unfortunately, one healthcare worker in the radiology area was given medical leave when she became febrile. On 11 March, Carlo Urbani travelled to Bangkok, Thailand, to attend a medical conference. Infection control precautions were also enhanced in TTSH, including providing separate triage facilities for patients with suspected SARS who may seek treatment at emergency departments and requiring healthcare workers (in the emergency department, intensive-care unit [ICU], isolation wards, triage points, and wards which had been exposed to patients with possible SARS) to wear personal protective equipment consisting of N95 masks, gowns, and gloves. The first component was prevention through the use of N95 masks, gowns, and gloves by healthcare workers in high-risk clinical areas and triaging febrile patients at emergency departments and outpatient clinics, followed by isolating infectious patients early. On 2 April, Chinese medical officials began reporting the status of the SARS outbreak. A 59-year-old Chinese man was admitted on March 24, 2003, to the Singapore General Hospital. An American Mormon[39] and a teacher at Shenzhen Polytechnic,[40] he had been sick for approximately one month before his death, but he was originally diagnosed with pneumonia. [57][58][59][60] The Control Yuan also launched an investigation into the hospital's closure. [10][11] This first outbreak affected people in the food industry, such as farmers, market vendors, and chefs. In other hospitals, staff could check and report their own temperatures. On 3 April, a WHO team of international scientists landed in Guangzhou from Beijing to discuss with officials, but the team was yet to inspect any suspected origin or any medical facilities on the progress of infection control. The index case, patient A, was admitted to TTSH, a 1,400-bed hospital, on March 1, 2003 for atypical pneumonia. Despite feeling ill he visited with his family and they traveled around Hong Kong. In addition, the epidemic strain of SARS that caused at least 774 deaths worldwide by June 2003 has not been seen outside of a laboratory since then. Patient B had not been identified as a contact of patient A at that time and was subsequently readmitted to an open ward in SGH. He warned staff that he was very sick and to put him in isolation. Two of these five inpatients had direct contact with patient B, and infections in the other three were likely acquired either from one of the infected healthcare workers or inpatients. The outbreak in TTSH spread to two other tertiary hospitals (Singapore General Hospital [SGH], and National University Hospital [NUH]) despite initial containment efforts (Figure 1). On 22 April, schools in Hong Kong started to reopen in stages. The WHO also advised travellers to avoid Hong Kong and Guangdong during a press briefing.[36]. Abstract. It had spread through China and worldwide. The SGH outbreak was identified on April 4 (Figure 2) when fever developed in a cluster of 13 healthcare workers. The first medical worker infected with SARS died in Hong Kong. According to government officials, the virus was brought into the estate by an infected kidney patient (the type of kidney illness was not specified) after discharge from Prince of Wales Hospital, who visited his elder brother living on the seventh floor. He was discharged when the announcement was made. The NUH outbreak was identified on April 11 when a doctor who had attended to patient C was noted to have fever. On 26 April, Wu Yi was named Zhang Wenkang's replacement as PRC health minister. The syndrome caused the 2002–2004 SARS outbreak. In the SGH outbreak, fever surveillance enabled the rapid detection of 11 probable cases that arose from the NCC and radiology departments. [20][21], The first super-spreader, Zhou Zuofen, a fishmonger, checked in to the Sun Yat-sen Memorial Hospital in Guangzhou on 31 January, where he infected 30 nurses and doctors. As a result, two exposed clinical areas were missed in the initial containment strategy. Staff members were put on work quarantine (i.e., they continued to work but were quarantined after work in separate quarters) and 3x/day temperature monitoring. On 31 January, China announced the fourth case of SARS as a 40-year-old doctor from the southern city of Guangzhou, and gave his family name as Liu. If all contacts of the initial SARS case-patients detected on March 15 had been identified, patient AAA could have been cared for in isolation in CCU by staff with full personal protective equipment. Guangzhou was also the site of the first case in December and was thought to be the origin of the virus in the original outbreak. The 199-year-old Singapore General Hospital (SGH) is the oldest public healthcare institution in the country. Patient A returned to Singapore and was admitted to an acute care hospital, Tan Tock Seng Hospital (TTSH), on March 1. The second component was detecting possible SARS clusters early through surveillance for clusters of febrile healthcare workers or patients. Liu is believed to have been a SARS super-spreader: 23 other Metropole guests developed SARS, including seven from the ninth floor. His wife became ill after caring for him, and both were admitted to National Taiwan University Hospital. An outbreak of severe acute respiratory syndrome (SARS) was detected in Singapore at the beginning of March 2003. He remained isolated in the ICU until the morning of April 9 when he was transferred to TTSH; probable SARS was diagnosed after a complete history of contact was elicited. [26], On 4 March, a 27-year-old man, who had visited a guest on the Metropole's 9th floor 11 days earlier, was admitted to Hong Kong's Prince of Wales Hospital. By 29 May, more than 7,000 people were instructed to quarantine themselves in Canada by authorities seeking to control the potential spread of the SARS outbreak. … All patient admissions and discharges should be stopped. At that time, 206 probable SARS cases had been diagnosed, of which 40.8% were in healthcare workers; 39.8% were in family, friends, or visitors to hospitals; and 12.2% were in inpatients. Junior colleges were to reopen on 9 April, secondary schools would reopen on 14 April and primary schools and pre-schools would reopen on 16 April. On 10 January, a restaurant worker in Guangdong was confirmed as the second wild source SARS since the outbreak was contained. On 20 April, Beijing's mayor Meng Xuenong and the health minister of the PRC Zhang Wenkang were replaced respectively by Wang Qishan from Hainan and the former deputy health minister Gao Qiang. The hospital limited visitors; visits to SARS case-patients were initially permitted, but visitors were required to use personal protective equipment (i.e., N95 masks, gowns, and gloves). None of these patients had fever, and all were called by phone 3x/day for 10 days. [14] Later it reported that the outbreak in Guangdong had peaked in mid-February 2003. Medical staff members in wards 57 and 58 were sent to TTSH to care for the transferred patients. It is the first winter without a case since the initial outbreak in late 2002. If a no-visitor policy had been implemented in TTSH on March 15, at least 17 new SARS cases outside of TTSH could theoretically have been prevented. These components should be part of a hospital preparedness plan. This containment strategy was adopted for the SGH outbreak and resulted in controlling intrahospital infection spread within 10 days. All were infected before the transfer. Probable SARS subsequently developed in these five healthcare workers. On 8 April, SARS started to plague the Lower Ngau Tau Kok Estate near Amoy Gardens in Kowloon. Persons in at least six wards and the CCU in TTSH had been exposed, but those in additional wards could have been exposed due to movements of infected healthcare workers.