key: cord-022473-l4jniccw authors: Wilder-Smith, Annelies title: As Travel Medicine Practitioner during the SARS Outbreak in Singapore date: 2009-11-16 journal: Travel Medicine DOI: 10.1016/b978-0-08-045359-0.50041-5 sha: doc_id: 22473 cord_uid: l4jniccw nan common problem in Singapore. He consulted a physician in New York. Indeed, leukopenia and thrombocytopenia was noted, thus confirming his suspicion of dengue. However, his chest X-ray also showed pneumonia. There was no way he could have connected his symptoms with that of his patient he had seen in the previous week. This all occurred in the couple of days before the term 'SARS' was coined and before the WHO sent out the alert on 13 March. Dr. L felt so unwell that he decided to cut short his stay in New York and he embarked on the next Singapore Airlines flight to return to Singapore. Just before he departed, he called a doctor friend in Singapore to announce that he was diagnosed with pneumonia and was returning home. Meanwhile, back in Singapore, 'all hell' had broken loose. On Friday after our morning grand rounds, several nurses, friends and visitors came down with the same symptoms -and all had been in contact with Elly in the preceding week. They were admitted and immediately isolated. By the end of the weekend, we had numerous admissions and we knew that something really unusual was happening. We had staff working around the clock, we had huge media attention and atop this we received a visit by the Minister of Health. By early Monday morning, the first list of the most common symptoms and laboratory findings was put together. I will never forget the staff meeting on that Monday morning. The Director of the Communicable Diseases Center announced, "We have an outbreak at hand, and it appears to be bigger than we thought". We had no clue how big it was going to be, or what sinister effects it would have... The next two weeks, we lived with great uncertainty. These were the worst two weeks of the epidemic, for we neither knew what the causative agent was nor its mode of transmission nor its treatment. We were horrified to see one medical or nursing colleague after the other coming down with the disease. By now, the first patients that we had seen were starting to die. In the first week after our first cases, the WHO named the disease "SARS", and they sent out global alerts. Meanwhile Dr. L was on his flight back to Singapore, unaware of what was going on in Singapore. His friend, whom he had contacted just prior to his departure, was astute enough to conclude, however, that the symptoms Dr. L displayed, and his recent contact with the index case, were highly suggestive of this new disease and he alerted the Ministry of Health. The Ministry in turn alerted Singapore Airlines and this led to the halt of the flight in Frankfurt. To his amazement, Dr. L was escorted from the airport in full protective gear, admitted to a Frankfurt hospital. Within hours, his name was in all the news media around the world. His pregnant wife also fell ill, but his mother-in-law for some mysterious reasons did not, although all three of them had been in close contact over a prolonged time. The passengers and crew were debriefed about SARS, the recognition of its symptoms and signs, and they were given advice to seek care if they developed any such indications. Four days later, a 22-year-old stewardess of that flight sought help at our clinic when she developed a fever and cough. During the flight, Dr. L was kept isolated in the back of the plane. The stewardess had only brief contact with him while serving food, picking up trays, and the like. She kept as much distance as possible and this included minimal communication. SARS was confirmed in the stewardess making her the first reported case of in-flight transmission. Let me go back to the first few days when the outbreak started to unfold. As you can imagine, my travel clinic was swamped by the public demanding the flu vaccine and any other information about SARS. Our Communicable Diseases Centre turned into a major screening hub. We screened hundreds of contacts in made up tents using portable X-rays. It soon became clear that as a sole department, we would not be able to cope with all the screening. The screening was therefore moved to the main building of Tan Tock Seng Hospital under the auspices of the Accident & Emergency Department. My travel clinic was closed and my staff had a change of job: from advising travelers and administering vaccines to taking their temperatures and asking about any respiratory symptoms. 22 March, the hard decision. Close down our hospital completely. It became the designated SARS hospital, admitting only probable and suspect SARS cases. Large numbers were seen and although we were a 1,400 bed hospital, we were soon short of isolation rooms.... SARS came suddenly and caught us unaware. It's novelty, ease of transmission, and the speed of its spread, put us all in a state of fear. The epidemic progressed rapidly, and it was tragically associated with high death rates. One after another of Elly's relatives and friends died: first her father, then her pastor, her mother and finally her uncle. Her grandmother was also in the ICU, but mysteriously she survived. Elly herself survived. We kept her in hospital for a very long time, partly because we were unsure how long she would be able to transmit the disease to others, partly also to protect her from all the media attention. I often wondered how she was coping. Characterized by a high rate of transmission to healthcare workers, SARS struck deep and hard and affected every one of us with varying degree. The constant fear of getting infected was felt throughout. This fear intensified, as colleagues became patients and young patients died. More distressing was the fear of inadvertently transmitting the infection to loved ones, especially children. Many moved out of their usual abode and did not touch their children or spouses for weeks. We became also suspicious of each other. I remember vividly how one colleague wanted to whisper something into my ear, and I jumped away out of fear of getting infected. Fear of death became a daily reality. N95 masks soon became a shortage, and we had to learn how to use the same mask for one whole day. N95 masks muffled speech, hid expressions of your face, and worse, if one quickened the pace of walking, then we ended up gasping breathlessly for air. In the smouldering humid heat of Singapore, the sweat would drop underneath our hair covers, soak the masks and slowly droop down our faces, leaving us in doubt whether the masks were still working. We also had to rationalize our gowns and gloves. Frustrations abounded as policies were changed almost daily. We wrote so many guidelines; and every day seemed to bring up a new revision of those from the previous day. Although Singapore was exemplary in its transparency and abundance of information, as healthcare workers we felt we were scrambling for information. I was literally glued to the websites to gain more up-to-date information of the global outbreak. In the view of the public, the outbreak was mainly associated with our hospital. Healthcare workers were shunned by the public. There were stories of nurses not being allowed to return to their rented apartments. Buses would not stop at our hospital so that transportation home was not possible. Taxis refused to come by. We felt stigmatized. Instead of the moral support that we craved for, we felt left alone. My children were not invited to birthday parties anymore. Our neighbors did not let their children play with ours. I became infuriated about the way the press dealt with Elly. The media also obtained information on patient's names that were eventually published. The atmosphere in the hospital was eerie. Instead of the usual buzz with visitors, restaurants and coffee shops, the hospital was empty. I only met masked healthcare workers. Movements within the hospital were restricted. Visitors were not allowed. Every minute of the day, we were geared up. In one of my e-mails, I wrote to my friends back home: "I am masked, gloved, gowned -but not yet cloned". The end time atmosphere in the hospital was accentuated by the TV sets that aired the start of the war in Iraq. In April, the previously hidden large number of SARS cases in China was suddenly revealed to the world. This news made me loose all hope. I imagined that the epidemic would now turn into global proportions sweeping the world, thereby killing 15% of its population. I imagined my life as a doctor from now to be a life geared up physically in masks and gowns, psychologically geared for death. In Singapore, the outbreak was initially only hospital based, but in April the news was out that SARS had affected a large vegetable market. Overnight, thousands of people had to be quarantined. The market was closed. That evening I went shopping and realized that there were no more vegetables in supply! Many patients had died, but death struck really home when a young medical officer died on 7 April. His mother, a doctor, who had cared for him initially during his illness, was also struck by the disease. She eventually died. One of my infectious disease colleagues was admitted to hospital because of fever. Fortunately, her fever turned out to be due to the flu that she had caught from her kids, and she was discharged. Not long after, I started feeling unwell myself. I wondered "Am I going to be the next?" I was afebrile, but I decided to separate myself from my family, said farewell to my children and my dear husband from the distance, and spent the night isolated in a room. I measured my temperature every hour, ready to get myself admitted if it reached the threshold. Alone like this, I reflected over my life and wondered whether I was ready to die. That night was a life-changing experience. The news of the death of Carlo Urbani, the Italian WHO doctor who was instrumental in the control of SARS in Vietnam, sent our hospital staff into depression. There was both grief and shock in the air. The final blow came when the husband of a friend of mine contracted SARS. He was a surgeon in his mid-thirties, a very bright and popular consultant. He deteriorated rapidly and because of the strict isolation regulations in practice, there was no time for adequate farewell. From his isolation room, he communicated with his wife via text messages. I was grief stricken when I later heard that he had succumbed to SARS. Even worse, there was no funeral, only a rushed cremation the very next day, as these were the rules for SARS-related deaths. With this tragedy, my facade crumbled and I broke down, the first time during all these weeks. I sobbed. I grieved for his widow, a friend and colleague with whom I still teach in community medicine, often finding myself wakening up at night and praying for her. The worst about dying during SARS was the fact that this was a lonely death. In total, we lost a total of five healthcare workers to SARS in Singapore: 2 doctors, 1 nursing officer, 1 nursing aide and 1 hospital attendant. There was a strong group spirit of commitment and determination amongst us, and this enabled us to continue working. Voices to quit were few; almost everyone stayed on. Dr. Carlo Urbani's words were a reality for us: "Health and dignity are in-dissociable in human beings. It is a duty to stay close to victims and guarantee their rights". After the initial stigmatization, and ostracization, against healthcare workers, there was a turning point in public opinion. All of a sudden, we became the heroes of the nation. We were in a battle against SARS together. We were showered with thank you cards, gifts, vitamins and herbal medicine. The walls of our hospital were plastered with well wishers comments and 'thank you' posters sent by companies, institutions, schools, churches, non-government organizations, individuals, etc. Almost every day, the media highlighted a healthcare worker with a full story and pictures in the newspapers. Emotional support and positive affirmations were morale boosters. The hospital management under the leadership of Dr. Lim Suet Wuen arranged frequent staff updates; and the transparency increased our trust in the authorities. Our status as healthcare workers was elevated, and with it our morale. Progressively stricter infection control measures were put in place. Our temperatures were measured three times per day. Audits were made to ensure compliance with all the measures. Infection control was now part of our daily lives. Two to three weeks into the epidemic it became clear, that infection control measures were effective; no more new cases occurred amongst the staff of our hospital. We started feeling safe at work. In fact, we became the safest hospital to work in as new cases continued to arise in the other hospitals in Singapore. It may sound strange but because of the implemented strict infection control measures I even felt safer in the hospital than outside. Never did I think that I should leave Singapore. There was only one moment when I seriously considered it: the newspaper suddenly announced that doctors whose spouses were also doctors but working in different hospitals should be separated. My husband is indeed a doctor in another hospital. I thought "if they separate us, then I will separate myself from Singapore". Luckily, the plan was never put in action, as it turned out that a vast majority of Singapore's doctors are married to other doctors who often happen to work in different hospitals or practices. By May, it became evident that SARS was under control in Singapore. On 31st May we were declared SARS free. Worldwide, also, cases were diminishing. My despair had turned into hope -a hope that SARS will not continue to have a deathly grip on our daily lives. Once we had hope, life at the SARS hospital now also meant facing up to the scientific challenges of this newly emerging coronavirus. The operation center at our hospital became a large center where dozens of people sat long hours every day, even weekends, to do data entry, to analyze data and interpret new findings. I was tasked to do a seroepidemiological cohort study among healthcare workers exposed to SARS in the first month of our nosocomial outbreak. The goal of the study was to investigate the incidence of and factors associated with asymptomatic SARS-CoV infection. While I took blood samples from the more of 100 study subjects, I listened to heartbreaking stories. The findings were interesting. Of all exposed (before infection control measures were instituted) healthcare workers, 7.5% had asymptomatic SARS (SARS serology positive). Multivariate analysis showed that asymptomatic SARS was associated with lower SARS antibody titers and higher use of masks compared to SARS that presented with pneumonia. This was an interesting study, however, my main interest circled around SARS and its relationship to travel. SARS, travel and travel medicine were intricately interlinked. Travelers belonged to those primarily affected in the early stages of the outbreak, travelers became vectors of the disease, and finally, travel and tourism themselves became the victims. In fact, travelers not only turned a newly emergent local virus into a global outbreak, but travelers were also the first to unmask the mysterious disease in Southern China. I followed up all imported cases of SARS, and all incoming flights to Singapore with SARS cases on board. Of the six imported cases, which all occurred before screening measures were implemented at the airport, only the first resulted in extensive secondary transmission. None of these cases resulted in in-flight transmission. Of 442,973 air passengers screened after measures were implemented, 136 were sent to our designated hospital for further SARS screening; none was diagnosed as having SARS. The SARS outbreak in Singapore can be traced to the first imported case. The absence of transmission from the other imported cases was most likely a result of relatively prompt identification and isolation of cases. New imported SARS cases therefore need not lead to major outbreaks if systems are in place to identify and isolate them early. Screening at entry points is costly, has a low yield and is not sufficient in itself. However, the costs and efforts may be justified in light of the major economic, social and international impact, which even a single imported SARS case can have. Use of simple laboratory features to distinguish the early stage of severe acute respiratory syndrome from dengue fever Experience of severe acute respiratory syndrome in Singapore: Importation of cases and defense strategies at the airport Low risk of in-flight transmission of severe acute respiratory syndrome: The Singapore experience Asymptomatic SARS coronavirus infection among health care workers This article is dedicated to my friend and colleague, Dr. Woon Puay Koh, who lost her surgeon husband to SARS.