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IPCRG 2nd World Conference
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Program Highlights - Day 3
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Keynote 6
SARS war - defending the frontline, a Singapore perspective
P Y Cheong
Community Occupational & Family Medicine Dept,
National University of Singapore
Purpose:
The Severe Acute Respiratory Syndrome (SARS) epidemic in Singapore began on 1st March 2003 and ended three months later with 238 persons infected, 42% of them healthcare workers (HCW) and 33 deaths. This paper chronicles the experience of setting up the rings of defence as the epidemic wore on.
Methods:
The strategy that evolved of detect, isolate and ring-fencing (DIR) the virus using 4 rings of defence against this hitherto unknown disease is described. The sources of this chronicle are from local and world-wide mass media and medical literature Results: The Border Defence All local cases in the epidemic can be traced to just one of the 8 imported cases. The border is thus a defence ring. Thermal scanning and health declaration of passengers were implemented from April. A retrospective study however revealed that of about 443 thousands persons screened, 136 were sent for further screening but none was diagnosed as SARS. The enormous economic risk of even one in-bound SARS patient causing community spread is nevertheless justification enough.
The Hospital Defence.
The learning curve of defending the hospitals was steep. In Tan Tock Seng Hospital (TTSH) where the first patients were warded, universal Personal Protection Equipment (PPE) of N95 masks, gloves, gowns & goggles (M3G) plus barrier nursing in single patient isolation rooms were instituted once it was clear that SARS was very infectious to both HCW and patients and can be lethal. These measures and strong clinical leadership to maintain staff discipline and morale stopped all nocosomial transmission by 5th April. However, it was not known then that signs of SARS may be masked in immuno-compromised patients. A few such patients (with the virus but not considered SARS suspects) discharged from ‘TSH were later admitted to other hospitals forming clusters of cases. This lesson learnt led to swift global implementation of strict same hospital re-admission policy, home quarantine orders (HQO) for 10 days for all discharged patients, no visitor rule, and mandatory PPE, temperature monitoring and restricted movements of every HCW. SARS suspect patients were immediately transferred to the SARS hospital, TTSH by special ambulances.
The Community Defence.
Community defence initially emphasised knowledge of SARS and personal hygiene. A watershed event was the closure of a large wholesale food market on 20Lh April and deployment of the army to trace within 24 hours more than 2000 people for HQO. Three days later, the Prime Minister invoked a total defence doctrine involving personal responsibility encompassing every sector of society to ensure that ‘there are no holes in our ring-fence against SARS’. Community and civic organizations rallied.
Twice daily temperature taking was implemented at schools and workplaces to detect fever as an early sign of SARS. and also as a mass psychological defence exercise. A Courage Fund for public donation and a mass public campaign to appreciate (and not ostracise) HCW boosted morale. Intense efforts were made to ensure that the SARS messages of DIR reached groups at risk of being uninformed for example elderly illiterates.
The Primary Care Defence.
The primary care defence ring had the arduous tasks of detecting suspect SARS from other common flu-like febrile illnesses for immediate isolation in TTSH. A SARS workgroup set up by the College of Family Physicians was crucial in translating Ministry of Health (MOH) directives into practical measures. Such advisories were disseminated by print, e-mails and web-casting. The community outbreak in the wholesale market created fear of wider community spread. Contact with suspect SARS patients and travel history can no longer be relied upon. Amongst other measures, a telephone hotline manned by doctors was thus set up on 7 May to clarify diagnostic, PPE and HQO difficulties.
Conclusions:
The SARS virus spread by jet from Hong Kong incognito to Singapore and other affected countries. It spread to a few hospitals and into the community. This epidemic showed that erecting the four rings of defence to detect, isolate and ring-fence the virus, is crucial to rapidly contain outbreaks caused by SARS.
Associate Professor Cheong Pak Yean, FRCPE, FACP,
FCFP
Faculty of Medicine, National University of
Singapore,
Singapore
Tel: 65-64686311
Email: pakyean@starhub.net.sg,
Workshop 10
Paediatric Asthma
Hancock K, Levy M
Australia, United Kingdom
Underdiagnosis and delayed diagnosis leads to under- and inappropriate treatment of asthma.
In this workshop, we will present an overview of the reasons for delayed diagnosis of childhood asthma in the 1980’s. (1-6) (7)
It is twenty five years since Speight suggested that asthma was being underdiagnosed and twenty since his landmark study in which the authors suggested that GPs were to blame for underdiagnosing asthma in childhood and just as long since Levy and Bell first published data on the delay in diagnosing asthma in childhood. (2)
While there is no doubt that asthma is being diagnosed earlier in primary care, it is questionable whether there has been much improvement in the accuracy, and there is recent data demonstrating that many children are being treated with asthma medication before the diagnosis has been made. (8)
The main aim of this workshop will be to focus upon possible ways we can improve the diagnosis and ensure this is made earlier. We will draw upon the new IPAG Guidelines, (9) as an example of how this may be achieved.
Reference List
©IPCRG Melbourne 2004