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SARS SINGAPORE EXPERIENCE

SARS SINGAPORE EXPERIENCE. 2003 Asia Pacific SARS Prevention Forum 29 Sept 2003 Taipei. TTSH - Daily Activities *. 140 Admissions. 1,600 SOC Attendances. 180 Operations 42% Inpatients 58% Ambulatory. 360 ED Attendances 75 Ambulance Cases. Overview of TTSH.

JasminFlorian
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SARS SINGAPORE EXPERIENCE

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  1. SARS SINGAPORE EXPERIENCE 2003 Asia Pacific SARS Prevention Forum 29 Sept 2003 Taipei

  2. TTSH - Daily Activities * 140 Admissions 1,600 SOC Attendances • 180 Operations • 42% Inpatients • 58% Ambulatory • 360 ED Attendances • 75 Ambulance Cases Overview of TTSH * Based on year 2002

  3. INDEX CASE Ms EM, 23-yr-old Chinese female Was in HK 20-25 Feb 03 Developed fever and headache since 25 Feb Had dry cough on 28 Feb Admitted on 1 March CXR on 1 March 2003 Hsu LY, Leo YS et al

  4. INDEX CASE • She progressively worsened while in hospital, with persistent fever despite the use of IV Levofloxacin. • Developed hypoxia and required close monitoring in HD Hsu LY, Leo YS et al

  5. INDEX CASEConclusion • IV Vancomycin and oral Oseltamivir were added, but these did not seem to help • She finally started improving around 10 March 2003, and is due for discharge soon 11 March 2003 Hsu LY, Leo YS et al

  6. Nursing Home SGH TTSH CGH NUH Transmission of infection from TTSH, Mar – Apr 2003 Index Ward 5A TKC YT Ward 7D A GTL Ward 8A J P TSC GTL TSC Ward 6A Community Heng BH et al

  7. Mark Chen, Leo YS et al

  8. Location of transmission (n=204) No. % Hospital/Nursing Home 151 74.0 Household 35 17.2 Overseas 7 3.4 Pasir Panjang Wholesale Market 3 1.5 Community 3 1.5 Taxi 2 1.0 Flight 1 0.5 Undefined 2 1.0 Heng BH et al

  9. Type of contact (n=204) No. % Healthcare worker 84 41.1 Family 49 24.0 Inpatients 24 11.8 Visitors to hospital 19 9.3 Friends/social contacts 13 6.4 Imported 7 3.4 Co-workers in market 3 1.5 Taxi drivers 2 1.0 Undefined 2 1.0 Flight stewardess 1 0.5 Heng BH et al

  10. Distribution by nationality and gender (n=204) Singaporean 80.8% Filipino 7.8% Chinese 4.9% Indonesian 2.9% Malaysian 2.5% Indian 1.0% Heng BH et al

  11. 7 generations of SARS transmission Index 1st generation (n=21) 2nd generation (n=39) 3rd generation (n=79) 4th generation (n=33) 5th generation (n=14) 6th generation (n=4) 7th generation (n=1) Imported, 6 cases Heng BH et al

  12. Epidemic curve by generations Heng BH et al

  13. Age distribution of 204 cases of SARS Heng BH et al

  14. SARS Management • Disease Management • New pathogen • Holistic patient care • Safety of HCWs • Containment • Cases: detect, insolate, manage • Expose: contact tracing, quarantine • Prevent: travel, personal/environment hygiene • Planning Ahead

  15. SARS Management Characteristic of New Pathogen • Incubation • Mode of transmission • Infectiousness • Period of infectiousness • Case manifestations

  16. SARS : Outbreak ManagementConfronting an Unknown Enemy Time is an essence • Determine outbreak • Etiologic agent • Characteristic of the new disease • Formulate counter-measure • Review • Harness support from all level

  17. SARS Management Containment • Hospital Infection Control • SARS intrahospital transmission • Patient to Patient • Patient to Staff • Patient to Visitor • Staff to Patient • Staff to Staff • Community • Home quarantine • National • Border control

  18. Patient x Staff • Early identification/detection • Isolation • Staff don • PPE - N95 face mask - glove - goggle - hand washing

  19. Patient x Patient • Early identification/detection • Isolation • Minimise patient movement

  20. Patient x Visitor • No visitor • Video /Teleconference • Compassionate case, visitor in full PPE

  21. Staff x Patient Staff x Staff • Monitor temperature 3x /D • Report temperature • Designated staff clinic • No external medical leave • Early isolation if febrile • Full PPE

  22. No new hospital transmissions with onset after 25 Mar Local Barriers Hospital-wide Barriers Effectiveness of Barrier Precautions in Healthcare Workers Leo YS et al

  23. Heng BH et al

  24. n No. of secondary cases Mean duration to isolation (days) 153 0 3.0 26 1 4.5 10 2 5.7 3 3 6.0 1 (S) 12 4.0 1 (A) 20 6.0 1 (E) 22 9.0 1 (P) 25 8.0 1 (K) 40 10.0 Correlation between duration to isolationand secondary transmission * Interval between date of onset and isolation Heng BH, Leo YS et al

  25. 16 June 2003 Chen M, Leo YS et al

  26. SARS – Challenges to the Health Care System • No treatment/no vaccine • Initial Symptom non specific and common • Epidemiology/pathogenesis poorly understood • Diagnostic tests have important limitations • Affect HCWs – vital human resource • Intensive care – strain on health care system

  27. SARS Management Planning Ahead • Vaccine • Better diagnostic tools • Re-define case definition post SARS • Enhanced surveillance • Preparedness

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