The outbreak of severe acute respiratory syndrome (SARS) in Singapore began in February 2003 when a young woman who had been infected while holidaying abroad returned to Singapore. She set off a series of transmissions that spread the SARS virus to 238 people, 33 of whom died. Besides Singapore, more than 20 other countries also reported SARS cases during this global epidemic. After the implementation of various stringent measures, including home quarantine, blanket screening of incoming travellers and school closures, the outbreak in Singapore was finally contained in May 2003.1
Background[]
SARS first reached Singapore in late February 2003 with the return of three Singaporean women from Hong Kong. While there, they had stayed at Metropole Hotel2 and caught the virus from an infected hotel guest (a doctor from Guangzhou, China).3 They were hospitalised for pneumonia between 1 and 3 March.4 Two of them recovered without infecting anyone.5 However one of them, Esther Mok, infected 22 close contacts and sparked the outbreak in Singapore.6
Five persons were classified as super-spreaders of the SARs outbreak in Singapore.7 Most of those infected during the outbreak were healthcare workers (40.8 percent) and family members (23.8 percent). The last SARS case was isolated in early May and Singapore was removed from the World Health Organization’s list of SARS-affected areas on 31 May.8
Infections and transmissions[]
Mok started the first cluster of 42 cases linked to Tan Tock Seng Hospital (TTSH). On 1 March, she was admitted to TTSH, where she infected 22 close contacts. She was isolated on 6 March and eventually recovered.9 One of those she infected was a nurse who was subsequently linked to probable SARS infection in 23 persons and to suspected SARS in five persons.10 The nurse was admitted to TTSH on 10 March.11 By the time she was isolated on 13 March, she had already infected 21 people.12 A patient whom she infected while sharing the same ward was transferred to the TTSH coronary care unit on 12 March.13 While there, the patient in turn infected 21 health care workers and five family members before she was placed in isolation eight days later.14 She died on 29 March.15
A man who had been infected during his hospital stay in TTSH from 5 to 20 March was admitted to the Singapore General Hospital (SGH) on 24 March for gastro-intestinal bleeding.16 He gave rise to a cluster of 57 cases linked to SGH,17 starting with the 40 people he infected before he was isolated on 2 April.18 One of them, his brother, then sparked another SARs cluster linked mainly to the Pasir Panjang wholesale market where he worked, and to the National University Hospital where he was admitted on 8 April.19 He died on 12 April.20 By then, he had directly infected 15 people, including two taxi drivers who had ferried him to and from his workplace.21 The wholesale market was closed for 15 days after this cluster was identified.22
Key response measures[]
Prevention and control within the community This strategy involved the early detection and isolation of suspected and probable cases.23 The measures included educating the public on symptoms of the disease and how it can be spread, and urging people to seek immediate medical attention if they developed such symptoms after possible exposure to the virus.24 The government even distributed thermometers to more than one million households.25 Temperature checks were carried out at schools and workplaces, and general practitioners, polyclinics and hospitals were given all necessary information to help them identify cases.26 Suspected or probable cases were quickly isolated in TTSH or at the Communicable Disease Centre (CDC).27
After a case was identified, investigations were carried out immediately to trace all individuals who had come in close contact with the infected person.28 The Ministry of Health invoked the Infectious Diseases Act on 24 March 2003 to quarantine and monitor all such contacts.29 SARS patients who had recovered were also placed under home quarantine upon their discharge.30 To prevent the spread of the disease through taxis and the public transport system, a dedicated private ambulance service was commissioned to transport suspected and probable cases to TTSH.31
Prevention and control within hospitals[]
On 22 March 2003, TTSH and the CDC were made the designated facilities for isolating and treating suspected and probable SARS cases.32 Enhanced infection control measures were implemented to prevent new transmissions in both facilities.33 For example, staff had to wear protective gear such as face masks, gloves and gowns34 when attending to patients, and monitor their own temperatures daily.35 Even staff at other hospitals took extra precautions when handling patients with fever and pneumonia.36
In addition, hospitals checked the temperature of all visitors and took down their personal details to facilitate contact tracing. All public hospitals also restricted the number of visitors, even barring them completely at one stage. Those visiting non-SARS patients had to wear masks and pass temperature checks.37
Prevention of imported cases[]
All airlines operating flights to Singapore were required to screen passengers at their check-in counters.38 Those who appeared unwell would need to obtain a doctor’s certification in order to board the flight to Singapore.39 Incoming travellers were required to complete a health declaration card and subjected to temperature checks upon arrival.40 In addition to visual checks by on-site nurses, thermal imaging scanners were deployed at air, sea and land checkpoints to help pick out those with a high temperature.41 Passengers arriving from SARS-affected areas were also handed health advisory cards providing information on SARS symptoms and how to seek help if they became ill with such symptoms.42
Impact of SARS[]
Economic impact[]
Visitor arrivals and hotel occupancy rates plunged, revenues at retail shops and restaurants dived, taxi drivers reported fewer passengers, stock prices fell, and more people lost their jobs.43 At the height of the outbreak in mid-April, the government cut Singapore’s economic growth forecast for 2003 from 2–5 percent to 0.5–2.5 percent, reflecting the severity of the situation.44 During the April-June quarter, when the full impact was felt, the economy contracted sharply by 4.2 percent year-on-year.45
Recognising the difficulties facing businesses and hoping to save jobs, the government announced a S$230-million relief package on 17 April, specifically to help affected industries. The package included property tax rebates for hotels and commercial properties, fee rebates for airlines and cruise operators, and diesel tax rebates for taxis.46
Social impact[]
The most immediate impact of the new disease was fear. People stayed home more and avoided public or crowded places like swimming pools and shopping centres.47 Many also curbed their wanderlust and shelved travel plans. However, one positive effect was the heightened awareness of proper hygiene habits and of the importance of good hygiene.48
Singaporeans also demonstrated their community spirit during the crisis. Volunteers came forward to help in various ways, such as conducting temperature checks at public events and helping those who had been quarantined at home. Individuals and organisations donated generously to the Courage Fund, which was set up to help healthcare workers and victims of SARS.
See also[]
References[]
1. Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, pp. 27, 67, 194–197. (Call no.: RSING 614.592 CHU); World Health Organization. (2004). Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003. Retrieved 2016, July 30 from World Health Organization website: http://www.who.int/csr/sars/country/table2004_04_21/en/print.html
2. Update on SARS in Singapore. (2003, April). Epidemiological News Bulletin, 29(4), 13. Retrieved 2016, July 30 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb04_03w.pdf; World Health Organization. (2003, May 9). Severe acute respiratory syndrome – Singapore, 2003. Weekly Epidemiological Record, 78(19), 157. Retrieved 2016, July 30 from World Health Organization website: http://www.who.int/docstore/wer/pdf/2003/wer7819.pdf
3. Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, p. 27. (Call no.: RSING 614.592 CHU) 4. World Health Organization. (2003, May 9). Severe acute respiratory syndrome – Singapore, 2003. Weekly Epidemiological Record, 78(19), 159. Retrieved 2016, July 30 from World Health Organization website: http://www.who.int/docstore/wer/pdf/2003/wer7819.pdf; Severe acute respiratory syndrome in Singapore. (2003, March). Epidemiological News Bulletin, 29(3), 16. Retrieved 2016, July 30 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb03_03w.pdf
5. Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, pp. 28, 66. (Call no.: RSING 614.592 CHU)
6. SARS: How a global epidemic was stopped. (2006). Geneva: World Health Organization, p. 101. (Call no.: RSING 614.592 SAR); Heng, B. H., & Lim, S. W. (2003, July). Epidemiology and control of SARS in Singapore. Epidemiological News Bulletin, 29(7), 43-44. Retrieved 2016, July 30 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb07_03w_0.pdf
7. World Health Organization. (2003, May 9). Severe acute respiratory syndrome – Singapore, 2003. Weekly Epidemiological Record, 78(19), 159. Retrieved 2016, July 30 from World Health Organization website: http://www.who.int/docstore/wer/pdf/2003/wer7819.pdf
8. Heng, B. H., & Lim, S. W. (2003, July). Epidemiology and control of SARS in Singapore. Epidemiological News Bulletin, 29(7), 44, 47. Retrieved 2016, July 30 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb07_03w_0.pdf
9. Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, pp. 27, 28, 296. (Call no.: RSING 614.592 CHU)
10. Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, p. 28. (Call no.: RSING 614.592 CHU); SARS: How a global epidemic was stopped. (2006). Geneva: World Health Organization, p. 102. (Call no.: RSING 614.592 SAR); World Health Organization. (2003, May 9). Severe acute respiratory syndrome – Singapore, 2003. Weekly Epidemiological Record, 78(19), 159. Retrieved 2016, July 30 from World Health Organization website: http://www.who.int/docstore/wer/pdf/2003/wer7819.pdf
11. World Health Organization. (2003, May 9). Severe acute respiratory syndrome – Singapore, 2003. Weekly Epidemiological Record, 78(19), 159. Retrieved 2016, April 6 from World Health Organization website: http://www.who.int/docstore/wer/pdf/2003/wer7819.pdf; SARS: How a global epidemic was stopped. (2006). Geneva: World Health Organization, p. 102. (Call no.: RSING 614.592 SAR)
12. Heng, B. H., & Lim, S. W. (2003, July). Epidemiology and control of SARS in Singapore. Epidemiological News Bulletin, 29(7), 44. Retrieved 2016, July 30 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb07_03w_0.pdf 13. World Health Organization. (2003, May 9). Severe acute respiratory syndrome – Singapore, 2003. Weekly Epidemiological Record, 78(19), 159. Retrieved 2016, July 30 from World Health Organization website: http://www.who.int/docstore/wer/pdf/2003/wer7819.pdf; SARS: How a global epidemic was stopped. (2006). Geneva: World Health Organization, p. 102. (Call no.: RSING 614.592 SAR)
14. Heng, B. H., & Lim, S. W. (2003, July). Epidemiology and control of SARS in Singapore. Epidemiological News Bulletin, 29(7), 44. Retrieved 2016, July 30 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb07_03w_0.pdf 15. World Health Organization. (2003, May 9). Severe acute respiratory syndrome – Singapore, 2003. Weekly Epidemiological Record, 78(19), 159. Retrieved 2016, July 30 from World Health Organization website: http://www.who.int/docstore/wer/pdf/2003/wer7819.pdf
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18. Heng, B. H., & Lim, S. W. (2003, July). Epidemiology and control of SARS in Singapore. Epidemiological News Bulletin, 29(7), 46. Retrieved 2016, July 30 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb07_03w_0.pdf; World Health Organization. (2003, May 9). Severe acute respiratory syndrome – Singapore, 2003. Weekly Epidemiological Record, 78(19), 160. Retrieved 2016, July 30 from World Health Organization website: http://www.who.int/docstore/wer/pdf/2003/wer7819.pdf
19. Update on SARS in Singapore. (2003, April). Epidemiological News Bulletin, 29(4), 15. Retrieved 2016, April 6 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb04_03w.pdf; World Health Organization. (2003, May 9). Severe acute respiratory syndrome – Singapore, 2003. Weekly Epidemiological Record, 78(19), 160. Retrieved 2016, July 30 from World Health Organization website: http://www.who.int/docstore/wer/pdf/2003/wer7819.pdf; Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, pp. 57, 60, 73. (Call no.: RSING 614.592 CHU)
20. World Health Organization. (2003, May 9). Severe acute respiratory syndrome – Singapore, 2003. Weekly Epidemiological Record, 78(19), 160. Retrieved 2016, July 30 from World Health Organization website: http://www.who.int/docstore/wer/pdf/2003/wer7819.pdf; Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, pp. 60, 73. (Call no.: RSING 614.592 CHU)
21. World Health Organization. (2003, May 9). Severe acute respiratory syndrome – Singapore, 2003. Weekly Epidemiological Record, 78(19), 160. Retrieved 2016, July 30 from World Health Organization website: http://www.who.int/docstore/wer/pdf/2003/wer7819.pdf; Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, pp. 60, 73. (Call no.: RSING 614.592 CHU); Heng, B. H., & Lim, S. W. (2003, July). Epidemiology and control of SARS in Singapore. Epidemiological News Bulletin, 29(7), 46. Retrieved 2016, July 30 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb07_03w_0.pdf
22. Update on SARS in Singapore. (2003, April). Epidemiological News Bulletin, 29(4), 15. Retrieved 2016, July 30 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb04_03w.pdf; Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, p. 57. (Call no.: RSING 614.592 CHU)
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41. Update on SARS in Singapore. (2003, April). Epidemiological News Bulletin, 29(4), 17. Retrieved 2016, July 30 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb04_03w.pdf; Chia, S. A. (2003, April 25). Front-line defence: Fever checks. The Straits Times, p. 1. Retrieved from NewspaperSG.
42. Update on SARS in Singapore. (2003, April). Epidemiological News Bulletin, 29(4), 17. Retrieved 2016, July 30 from Ministry of Health website: https://www.moh.gov.sg/content/dam/moh_web/Statistics/Epidemiological_News_Bulletin/2003/enb04_03w.pdf
43. Wong, W. K. (2003, April 18). Govt cuts GDP forecast; unveils aid package. The Business Times, p. 1; Teo, A. (2003, August 12). MTI sees robust GDP improvement in H2. The Business Times, p. 2. Retrieved from NewspaperSG; Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, pp. 114–115. (Call no.: RSING 614.592 CHU)
44. Wong, W. K. (2003, April 18). Govt cuts GDP forecast; unveils aid package. The Business Times, p. 1. Retrieved from NewspaperSG.
45. Teo, A. (2003, August 12). MTI sees robust GDP improvement in H2. The Business Times, p. 2. Retrieved from NewspaperSG.
46. Wong, W. K. (2003, April 18). Govt cuts GDP forecast; unveils aid package. The Business Times, p. 1. Retrieved from NewspaperSG.
47. Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, pp. 95, 98–99. (Call no.: RSING 614.592 CHU)
48. Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, pp. 93, 104. (Call no.: RSING 614.592 CHU)
49. Chua, M. H. (2004). A defining moment: How Singapore beat SARS. Singapore: Institute of Policy Studies, pp. 105–107, 143–149. (Call no.: RSING 614.592 CHU)
Further resources
Koh, T., Plant, A., & Eng, H. L. (Eds.). (2003). The new global threat: Severe acute respiratory syndrome and its impacts. Singapore: World Scientific. (Call no.: RSING 616.241 NEW)
Leung, P. C., & Ooi, E. E. (Eds.). (2003). SARS war: Combating the disease. New Jersey/Singapore: World Scientific. (Call no.: RSING 616.24 SAR)
Tay, C. S. K. (2003). Infectious diseases law & SARS. Singapore: Times Editions. (Call no.: RSING 344.5957043 TAY)
Acknowledgements[]
This article was written by Valerie Chew and published on Singapore Infopedia.