A plan to exercise organisation readiness to SARS recurrence should be done to keep the system “warm”. For instance, the Ministry of Health conducts regular audits and contact tracing exercises in all healthcare institutions. This is also the case for the other ministries including that of education and defence.
Lesson 12: Emerging Infections and Bio-terrorism
The use of biological agents as a tool for terrorism has been discussed extensively ever since the anthrax attacks in the United States after September 11. The ideal bio-weapon would be one that is easily transmitted and not easily detected, causes severe injury, affects the public psychologically and drains national resources during the response.
Compare these characteristics with SARS, an emerging infection which has proven to have the above capabilities. The difference between SARS and that of known bio-terrorism pathogens is the lack of diagnostics and the absence of vaccines and chemoprophylaxis – thus, an emerging infection would arguably be more difficult to manage compared with a bio-terrorist act.
It should be reiterated that the same principles and measures also apply to defence against a bio-terrorist attack. The public health infrastructure of control and response, thus serve a dual-purpose.
Conclusion“May we never have to face another crisis like this. But if we do, let us inspire each other, fight as one and win the battles as we did with SARS.”
- Prime Minister Goh Chok Tong
The SARS outbreak has demonstrated emphatically the strengths of the Singapore response - that commitment, cooperation and rational public and occupational health policies will prevail in a national crisis. On the other hand, it has also exposed the deficiencies of the healthcare and industrial infrastructure and response. The lessons learnt ought to be studied closely within the individual organisations, and subsequent rectifications taken seriously. It is quite unlikely that we will see the end of SARS or any other emerging infections any time soon.
Endnotes1 Leo Y.S., “SARS Singapore Clinical Experience”, Presentation during HQMC SARS Workshop (11 Aug 2003). Unpublished data.
2 Enserink M., “Infectious Diseases: Singapore Lab Faulted in SARS Case”, Science (26 Sep 2003) 301(5641), p1824; Lau T.N., Teo N., Tay K.H. et al., “Is Your Interventional Radiology Service Ready for SARS?: The Singapore Experience”, Cardiovascular Intervention Radiologist (13 Oct 2003); Samaranayake, L.P., FDI Science Commission, “Severe Acute Respiratory Syndrome (SARS): An Interim Information Paper for Dental Health Care Workers”, International Dent Journal (Jun 2003), 53(3), pp117-8.
3 Dermatitis refers to a condition of the skin in which it becomes red, swollen and sore, sometimes with small blisters, resulting from direct irritation of the skin by an external agent or an allergic reaction. See Shaw J.C., “Dermatology In The Time Of SARS”, Arch Dermatol (Jul 2003), 139(7), pp853-4.
4 Tan L., “Hospitals Said To Be Claiming $126m After SARS”, The Straits Times ( 26 Jul 2003). Available at http://www.sars.gov.sg/archive/
5 Statement from the Ministry of Trade and Industry (MTI). “Government Unveils $230m SARS Relief Package” ( 24 Apr 2003). Available at http://www.stb.com.sg/media/ press/20030424a.stm
6 Varia M., Wilson S., Sarwal S. et al, “Investigation of a Nosocomial Outbreak of Severe Acute Respiratory Syndrome (SARS) in Toronto, Canada”, CMAJ (9 Aug 2003), 169(4), pp285-92; Abdullah A.S., Tomlinson B., Cockram C.S. et al, “Lessons from The Severe Acute Respiratory Syndrome Outbreak in Hong Kong”, Emerging Infectious Diseases (Sep 2003), 9(9), pp1042-5 and Emanuel E.J., “The Lessons of SARS”, Ann Intern Med (7 Oct 2003), 139(7), pp589-91.
7 MOH, “SARS Information for Health-care Professionals” ( 27 Jun 2003). Available at http://www.moh.gov.sg/sars/information/ healthcare.html; MOH, “Government’s ‘Lines of Defence’– Measures To Combat SARS” (1 Jun 2003). Available at http://www.moh.gov.sg/sars/defence/ default.html; Jiang S., Huang L., Chen X. et al, “Ventilation of Wards and Nosocomial Outbreak of Severe Acute Respiratory Syndrome among Health-care Workers”, China Medical Journal (English) (Sep 2003),116(9), pp1293-7; Normile D., “Infectious Diseases: SARS Experts Want Labs to Improve Safety Practices”, Science (3 Oct 2003), 302(5642), p31; Ho A.S., Sung J.J., Chan-Yeung M., “An Outbreak of Severe Acute Respiratory Syndrome among Hospital Workers in a Community Hospital in Hong Kong”, Ann Intern Med (7 Oct 2003), 139(7), pp564-7; “SARS Inquiry: Nurses Demand Open, Transparent Investigation”, Canadian Nurse (Aug 2003), 99(7), p13; Chan L.Y., Li P.K., Sung J., “Risk Of SARS Transmission to Persons in Close Contact with Discharged Patients”, American Journal of Medicine (Sep 2003), 115(4), p330; Wong D.T., “Protection Protocol in Intubation of Suspected SARS Patients”, Can J Anaesth (Aug-Sep 2003), 50(7), pp747-8; Ng P.C., So K.W., Leung T.F. et al, “Infection Control For SARS In A Tertiary Neonatal Centre”, Arch Dis Child Fetal Neonatal Ed (Sep 2003), 88(5), ppF405-9; Leong R.M., “SARS Wars: Family Physicians Undeployed Soldiers”, Canadian Family Physician (Aug 2003), 49, pp962-3; “Mechanical Ventilation of SARS Patients: Safety Issues Involving Breathing-Circuit Filters”, Health Devices (Jun 2003), 32(6), pp220-2; “Protecting Against SARS During Equipment Maintenance”, Health Devices (Jun 2003), 32(6), pp213-9; Kissoon N., “Severe Acute Respiratory Syndrome: Providing Care While Minimizing Personal Risks”, Indian Pediatrician (Jul 2003), 40(7), pp645-51; Thompson D.R., “SARS: Some Lessons for Nursing”, Journal of Clinical Nursing, (Sep 2003),12(5), pp615-7; Chee Y.C., “Heroes And Heroines of The War on SARS”, Singapore Medical Journal (May 2003), 44(5), pp221-8; Lange J.H., “SARS Respiratory Protection”, CMAJ (16 Sep 2003), 169(6), pp541-2 and “SARS Affects Hospital Plans?”, CMAJ (16 Sep 2003), 169(6), p593.
8 Chowell G., Fenimore P.W., Castillo-Garsow M.A. et al, “SARS Outbreaks in Ontario, Hong Kong and Singapore: The Role of Diagnosis and Isolation as a Control Mechanism”, Journal of Theoretical Biology ( 7 Sep 2003), 224(1), pp1-8 and Lee S.H., “The SARS Epidemic in Hong Kong”, J Epidemiol Community Health (Sep 2003), 57(9), pp652-4.
9 Serology is the study of a patient ’s serum (blood after centrifugation to remove blood cells) to determine antibody levels to specific pathogens (e.g. viruses). Some pathogens stimulate the body ’s defence system to produce antibodies against them, and these antibodies can be measured in the laboratory.
10 Polymerase chain reaction (PCR) test is a highly sensitive and relatively rapid test to detect the presence of pathogens (for example viruses or bacteria) in the patient ’s blood or body fluids. It relies on enzymes to amplify minute quantities of genetic material (DNA) from any source, including pathogens to detectable levels. If SARS virus DNA is detected in a patient ’s blood using PCR, it is highly suggestive of an infection.
11 Snijder E.J., Bredenbeek P.J., Dobbe J.C. et al, “Unique and Conserved Features of Genome and Proteome of SARS-Coronavirus: An Early Split-Off from the Coronavirus Group 2 Lineage”, Journal of Molecular Biology (29 Aug 2003), 331(5), pp991-1004; Yam W.C., Chan K.H., Poon L.L. et al, “Evaluation of Reverse Transcription: PCR Assays for Rapid Diagnosis of Severe Acute Respiratory Syndrome Associated With A Novel Coronavirus”, Journal of Clinical Microbiology (Oct 2003), 41(10), pp4521-4; Zhang J., Meng B., Liao D. et al, “De Novo Synthesis of PCR Templates for the Development of SARS Diagnostic Assay”, Molecular Biotechnology (Oct 2003), 25(2), pp107-12; Poon L.L., Chan K.H., Wong O.K. et al, “Early Diagnosis of SARS Coronavirus Infection by Real Time RT-PCR”, Journal of Clinical Virology (Dec 2003), 28(3), pp233-8; Hsueh P.R., Hsiao C.H., Yeh Shet et al, “Micro-biologic Characteristics, Serologic Responses and Clinical Manifestations in Severe Acute Respiratory Syndrome, Taiwan.” and Li G., Chen X. and Xu A., “Profile of Specific Antibodies to the SARS-Associated Coronavirus”, North England Journal of Medicine (31 Jul 2003), 349(5), pp508-9.
12 Wilder-Smith A., Leong H.N., Villacian J.S., “In-Flight Transmission of Severe Acute Respiratory Syndrome (SARS): A Case Report”, Journal of Travel Medicine (Sep-Oct 2003), 10(5), pp299-300; Wilder-Smith A., Paton N.I., Goh K.T., “Experience of Severe Acute Respiratory Syndrome in Singapore: Importation of Cases and Defense Strategies at the Airport”, Journal of Travel Medicine, (Sep-Oct 2003), 10(5), pp259-62; Wilder-Smith A. and Freedman D.O., “Confronting the New Challenge in Travel Medicine: SARS”, Journal of Travel Medicine (Oct 2003),10(5), pp257-258 and Schlagenhauf P., “Influenza Vaccine Enlisted to Prevent SARS Confusion”, Lancet (6 Sep 2003), 362(9386), p809.
13 “Fighting SARS Together”, Singapore Government Press Release, statement by Mr Goh Chok Tong, Prime Minister, MITA (22 Apr 2003). Available at http://app.sprinter.gov.sg.data/pr/ 2003042204.htm
14 Lee A. and Abdullah A.S., “Severe Acute Respiratory Syndrome: A Challenge for Public Health Practice in Hong Kong”, Journal of Epidemiology and Community Health (Sep 2003), 57(9), pp655-8; Bernstein M. and Hawryluck L., “Challenging Beliefs and Ethical Concepts: The Collateral Damage of SARS”, Critical Care ( 7 Aug 2003), 7(4), pp269-71. E-published on 29 May 2003; Vastag B., “SARS Attack: Reality vs. Perception Collide During Students’Beijing Visit”, JAMA ( 1 Oct 2003), 290(13), pp1698-9 and Hsieh Y.H., “SARS and the Internet”, North England Journal of Medicine ( 14 Aug 2003), 349(7), pp711-2.
15 Chiu Y.T., “Taiwanese Scientists Brace for Second Season of SARS”, National Medicine (Oct 2003), 9(10), p1229; Schlagenhauf P., “SARS in Hiding: WHO Calls for Vigilance” , Lancet Infectious Diseases (Aug 2003), 3(8), p458 and Augustine J.J., “Developing a Highly Contagious Disease Readiness Plan: The SARS Experience” , Emerging Med Serv (Jul 2003), 32(7), pp77-83.