SARS 10 YEARS LATER

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

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.

melpang@sph.com.sg

xueying@sph.com.sg

hoaili@sph.com.sg

Additional reporting by Lee Seok Hwai, Taiwan Correspondent