National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG...
Transcript of National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG...
![Page 1: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/1.jpg)
National Response to SARS:Singapore
TAN Chorh ChuanDirector of Medical ServicesMinistry of Health, Singapore
![Page 2: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/2.jpg)
National Response to SARS: Singapore
• SARS transmission pattern
• 3 key lessons learnt & our response
• What we think has workedContainment of community transmission: Surveillance, contact tracing, quarantine
![Page 3: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/3.jpg)
Patient Zero
TTS Hospital Cluster 109
Orange Valley NH 7
SG Hospital Cluster 50
Social group Cluster 7
NU Hospital Cluster 11
PP Market Cluster 13
6 imported cases
SARS Transmission pattern - Singapore
![Page 4: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/4.jpg)
Key elements of national response
• Strong, coordinated national effort involving government, multiple agencies & public
• Prevention of import & export of cases• Detect, isolate & contain strategy• International info exchange &
coordination
![Page 5: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/5.jpg)
3 KEY LESSONS LEARNT
• Intrahospital transmission is the most importantamplifier of SARS infection
![Page 6: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/6.jpg)
Amplification of SARS infection through hospital transmission
SARS introduced into hospital
Amplified through intrahospitaltransmission
Spreads to other healthcarefacilities
#1
#2
Spills out into community usually throughHCWs, visitors
#3
![Page 7: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/7.jpg)
3 KEY LESSONS LEARNT
• Intrahospital transmission is the most importantamplifier of SARS infection
• “Superspreaders” are unforgiving
![Page 8: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/8.jpg)
Superspreaders are unforgiving
In Singapore
5 patients accounted for 103 of the 205
probable SARS cases
![Page 9: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/9.jpg)
3 KEY LESSONS LEARNT
• Intrahospital transmission is the most importantamplifier of SARS infection
• “Superspreaders” are unforgiving
• Atypical SARS patients pose the greatest risk
![Page 10: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/10.jpg)
Our first “atypical” SARS case - 10 March 03
• Diabetes, hypertension, bad heart disease• Admitted 10 March 03 with fever & pneumonia• Blood cultures grew gram negative bacteria• Deteriorated 12 March• Diagnosis- worsening community acquired pneumonia &
heart failure• Treated in CCU
• Infected 23 (18 HCWs, 5 family members & visitors)• Unrecognised exposure to another SARS patient
![Page 11: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/11.jpg)
0
10
20
30
40
50
60
70
0 1 2 3 4 5-6 7-8 >8Time from onset to isolation (days)
Cas
es
0
1
2
3
4
5
6
7
8
Secondary cases/primary case
PrimarySecondaryS/P
Atypical SARS cases are very difficult to detect early
![Page 12: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/12.jpg)
Public health implications
Intrahospital transmissionis a major disease amplifier
SuperspreadersAtypical SARS cases
Early detection and rapid containment
Very “Wide-net”surveillance & quarantine policy
![Page 13: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/13.jpg)
What has worked for us
• Designating 1 hospital as the SARS hospital
• Stringent temperature surveillance of all staff & patients
- isolation of staff, monitoring for fever clusters
• Enforced use of personal protective gear, fit-tested N95 masks, in all healthcare facilities
Containment of hospital infection clusters
![Page 14: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/14.jpg)
What we think has worked
• Broad-based & sensitive surveillance system
• Rapid, effective contact-tracing
• Low threshold for enforced quarantine duringoutbreak
Control of community transmission
![Page 15: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/15.jpg)
Surveillance system: Sources
• Mandatory notification of suspected cases by email/fax within 24 hours by all doctors
• All suspicious cases sent to TTSH (SARS hospital)GPs, TCM, other hospitals, nursing homes, walk-in
• System for daily monitoring for fever clustersin all hospitals, nursing homes
• Temperature screening at points of entry and in community eg markets, schools
![Page 16: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/16.jpg)
Epi team in TTSH tointerview all patients(prob/suspect/obs)
All suspiciouscases
DAILY EPI MEETING AT MOH
11am review & classification of allcases by senior drs
TTS Hospital
![Page 17: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/17.jpg)
Epi team in TTSH tointerview all patients(prob/suspect/obs)
Contact tracing teamin hospitals/schools/army camps/etc
Notifications by drs
All suspiciouscases
Fever clusters in hospitals, nursinghomes
DAILY EPI MEETING AT MOH
MOH ContactTracing Centre
Trace in 24 hoursHQO same day
FRT
HQOPhone surveillance
![Page 18: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/18.jpg)
Triggers for quarantine
• Contacts of all probable and suspect cases
• Contacts of atypical or suspicious pneumonia patients without travel or contact history(or phone surveillance)
• Clusters of febrile healthcare workers or patientsin a work area
Mandatory Home quarantine x 10 days
Hospital quarantine or other measures
![Page 19: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/19.jpg)
Weekly average time from onset of symptomsto isolation of SARS cases
0
1
2
3
4
5
6
7
8
9
10
25/02
-03/03
04/03
-10/03
11/03
-17/03
18/03
-24/03
25/03
-31/03
01/04
-07/04
08/04
-14/04
15/04
-21/04
22/04
-28/04
Week of onset
Tim
e fr
om o
nset
to is
olat
ion
(day
s)
![Page 20: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/20.jpg)
Period No. of Previously Onset to isolationcases suspects (%) (days)
3/3 - 9/3 15 0% 6.8 (5-9)
10/3- 16/3 39 41% 4.5 (0-11)
17/3-23/3 33 48.5% 3.5 (0-8)
31/3-6/4 44 63.6% 2.9 (0-10)
21/4-27/4 8 87.5% 1.3 (0-4)
Early isolation of Probable SARS cases
![Page 21: National Response to SARS: Singapore - WHO · TTS Hospital Cluster 109 Orange Valley NH 7 SG Hospital Cluster 50 Social group Cluster 7 NU Hospital Cluster 11 PP Market Cluster 13](https://reader033.fdocuments.net/reader033/viewer/2022042916/5f576201ff858e47113f97a0/html5/thumbnails/21.jpg)
Conclusion
In an outbreak situation
• Rapid containment of hospital clusters critical
• Intensive “wide-net” surveillance with low threshold for mandatory quarantine & phonesurveillance
• Surveillance needs to be intensified whenchain of transmission appears to have been broken