Severe acute respiratory syndrome (SARS) outbreak, 2003

The 2003 outbreak of severe acute respiratory syndrome (SARS) apparently started in Foshan in Guangdong, China, with the first case being seen on 16 November 2002.¹ From there it spread through China and worldwide as far as Canada. The outbreak officially ended on 5 July 2003 when the World Health Organization (WHO) declared SARS contained worldwide.²

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. Consequently, a chain of transmission that spread the SARS virus in Singapore developed. By the time the infection was brought under control, there were 238 cases here, 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 2003.³

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 Hotel⁴ and caught the virus from an infected hotel guest (a doctor from Guangzhou, China).⁵ The three women were hospitalised for atypical pneumonia between 1 and 3 March.⁶ However, a chain of transmission developed when the virus spread from the youngest patient to 21 contacts. This marked the start of the outbreak in Singapore.⁷

Five persons were classified as super-spreaders of the SARS outbreak in Singapore.⁸ 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.⁹

Transmissions
The first cluster of more than 40 cases was linked to the youngest of three infected women who had returned from Hong Kong. She had been admitted to Tan Tock Seng Hospital (TTSH) on 1 March, was isolated on 6 March, and eventually recovered.¹⁰ One of the 21 contacts who caught the virus from her was a nurse who was subsequently linked to probable SARS infections in 23 persons and suspected infections in five more persons.¹¹

This nurse was admitted to TTSH on 10 March.¹² By the time she was isolated on 13 March, the virus had spread from her to more than 20 people.¹³ One of these patients, who shared the same ward with this nurse, was transferred to the TTSH coronary care unit on 12 March.¹⁴ While there, the virus spread from the transferred patient  to more than 20 health care workers and five family members before she was placed in isolation eight days later.¹⁵ This transferred patient died on 29 March.¹⁶

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.¹⁷ A cluster of almost 60 cases linked to him and SGH developed,¹⁸ starting with the 40 people who had caught the infection from him before he was isolated near the start of April.¹⁹ From one of them, his brother, the virus spread, creating 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.²⁰ The brother died on 12 April.²¹ By then, 15 people had caught the infection from the brother, including two taxi drivers who had ferried him to and from his workplace.²² The wholesale market was closed for 15 days after this cluster was identified.²³

Key response measures
Prevention and control within the community
This strategy involved the early detection and isolation of suspected and probable cases.²⁴ 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.²⁵ The government even distributed thermometers to more than one million households.²⁶ 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.²⁷ Suspected or probable cases were quickly isolated in TTSH or at the Communicable Disease Centre (CDC).²⁸

After a case was identified, investigations were carried out immediately to trace all individuals who had come in close contact with the infected person.²⁹ The Ministry of Health invoked the Infectious Diseases Act on 24 March 2003 to quarantine and monitor all such contacts.³⁰ SARS patients who had recovered were also placed under home quarantine upon their discharge.³¹ 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.³²

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.³³ Enhanced infection control measures were implemented to prevent new transmissions in both facilities.³⁴ For example, staff had to wear protective gear such as face masks, gloves and gowns³⁵ when attending to patients, and monitor their own temperatures daily.³⁶ Even staff at other hospitals took extra precautions when handling patients with fever and pneumonia.³⁷

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.³⁸

Prevention of imported cases
When the WHO recommended on 27 March that airlines start screening passengers for potential exposure to SARS, Singapore immediately requested that all airlines flying into and out of Singapore comply.³⁹ Changi Airport started screening on 29 March just as a fourth imported case was identified (someone infected overseas but diagnosed in Singapore).⁴⁰ All airlines operating flights to Singapore were required to screen passengers at their check-in counters.⁴¹ Those who appeared unwell would need to obtain a doctor’s certification in order to board the flight to Singapore.⁴² Incoming travellers were required to complete a health declaration card and subjected to temperature checks upon arrival.⁴³ 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.⁴⁴ 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.⁴⁵

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.⁴⁶ 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.⁴⁷ During the April-June quarter, when the full impact was felt, the economy contracted sharply by 4.2 percent year-on-year.⁴⁸

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.⁴⁹

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.⁵⁰ 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.⁵¹

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.⁵²



Author
Valerie Chew


References
1. Zhong N. S. et al., “Epidemiology and Cause of Severe Acute Respiratory Syndrome (SARS) in Guangdong, People’s Republic of China, in February, 2003,” Lancet 362, no. 9393 (25 October 2003): 1353–58.
2. “Special Feature: Severe Acute Respiratory Syndrome (SARS),” Ministry of Health, Singapore, accessed 10 February 2020.
3. Chua Mui Hoong, A Defining Moment: How Singapore Beat SARS (Singapore: Institute of Policy Studies, 2004), 27, 67, 194–97 (Call no. RSING 614.592 CHU); “Summary of Probable SARS Cases With Onset of Illness From 1 November 2002 to 31 July 2003,” World Health Organization, accessed 20 February 2020.  
4. Ministry of Health, Singapore, “Severe Acute Respiratory Syndrome (SARS)”; World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” Weekly Epidemiological Record 78, no. 19 (8 May 2003): 157.
5. Chua, A Defining Moment: How Singapore Beat SARS, 27.
6. Elisabeth Rosenthal Hunde, “A Grisly Bug’s Tale,” Business Times, 2 May 2003, 12. (From NewspaperSG)
7. SARS: How a Global Epidemic Was Stopped (Geneva: World Health Organization, 2006), 101 (Call no. RSING 614.592 SAR); Hunde, “A Grisly Bug’s Tale.”
8. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 159; Goh Kee-Tai, et al., “Epidemiology and Control of SARS in Singapore,” Annals of the Academy of Medicine, Singapore, 35, no. 5 (May 2006): 303.
9. Goh, “Epidemiology and Control of SARS in Singapore,” 307, 315.
10. Chua, A Defining Moment: How Singapore Beat SARS, 27, 28, 296.
11. Chua, A Defining Moment: How Singapore Beat SARS, 28; SARS: How a Global Epidemic Was Stopped, 102; World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 159.
12. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 159; SARS: How a Global Epidemic Was Stopped, 102.
13. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 159.
14. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 159; SARS: How a Global Epidemic Was Stopped, 102.
15. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 159.
16. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 159.
17. Ministry of Health, Singapore, “Severe Acute Respiratory Syndrome (SARS)”;  World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 160; Chua, A Defining Moment: How Singapore Beat SARS, 57.
18. Ministry of Health, Singapore, “Severe Acute Respiratory Syndrome (SARS)”; World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 159.
19. Ministry of Health, Singapore, “Severe Acute Respiratory Syndrome (SARS)”; World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 160. 
20. Ministry of Health, Singapore, “Severe Acute Respiratory Syndrome (SARS)”; World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 160; Chua, A Defining Moment: How Singapore Beat SARS, 57, 60, 73.
21. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 160; Chua, A Defining Moment: How Singapore Beat SARS, 50, 73.
22. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 160; Chua, A Defining Moment: How Singapore Beat SARS, 60, 73; Ministry of Health, Singapore, “Severe Acute Respiratory Syndrome (SARS).”
23. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 160; Chua, A Defining Moment: How Singapore Beat SARS, 57.
24. Ministry of Health, Singapore, “Severe Acute Respiratory Syndrome (SARS).”
25. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 160; Chua, A Defining Moment: How Singapore Beat SARS, 130.
26. Chia Su-Ann, “Front-Line Defence: Fever Checks,” Straits Times, 25 April 2003, 1. (From NewspaperSG)
27. Chia, “Front-Line Defence: Fever Checks”; Ministry of Health, Singapore, “Severe Acute Respiratory Syndrome (SARS).” 
28. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 161.
29. Ministry of Health, Singapore, “Severe Acute Respiratory Syndrome (SARS).” 
30. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 161.
31. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 161.
32. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 161.
33. Singapore. Ministry of Information, Communications and the Arts, “Enhanced Precautionary Measures To Break SARS Transmission,” press release, 22 March 2003. (From National Archives of Singapore document no. 2003032203)
34. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 161.
35. Singapore. Ministry of Information, Communications and the Arts, “Enhanced Precautionary Measures To Break SARS Transmission.”
37. Grace Tay, “Fear and Faith,” Today, 8 April 2003, 2. (From NewspaperSG)
38. World Health Organization, “Severe Acute Respiratory Syndrome – Singapore, 2003,” 161; Chua, A Defining Moment: How Singapore Beat SARS, 45, 57, 68.
39. Bertha Henson, “Airport Checks on Sars Tightened,” Straits Times, 31 March 2003, 1. (From NewspaperSG)
40. Krist Boo and Ginnie Teo, “Screening To Start at Changi Airport Today,” Straits Times, 29 March 2003, 2. (From NewspaperSG)
41. “SARS Virus More Infectious Than Previously Thought,” Business Times, 31 March 2003, 2. (From NewspaperSG)
42. “SARS Virus More Infectious Than Previously Thought.”
43. “Temperature Checks for Travellers From Sars-Hit Areas.,” Straits Times, 7 April 2003, 3; “SARS Virus More Infectious Than Previously Thought.”
44. Ministry of Health, Singapore, “Severe Acute Respiratory Syndrome (SARS)”; Chia, “Front-Line Defence: Fever Checks.” 
45. “SARS Virus More Infectious Than Previously Thought.”
46. Wong Wei Kong, “Govt Cuts GDP Forecast; Unveils Aid Package,” Business Times, 18 April 2003, 1; Teo, A. “MTI Sees Robust GDP Improvement in H2,” Business Times, 12 August 2003, 2 (From NewspaperSG); Chua, A Defining Moment: How Singapore Beat SARS, 114–15.
47. Wong, “Govt Cuts GDP Forecast; Unveils Aid Package.”
48. Anna Teo, “MTI Sees Robust GDP Improvement in H2,” Business Times, 12 August 2003, 2. (From NewspaperSG)
49. Wong, “Govt Cuts GDP Forecast; Unveils Aid Package.”
50. Chua, A Defining Moment: How Singapore Beat SARS, 95, 98–99.
51. Chua, A Defining Moment: How Singapore Beat SARS, 93, 104.
52. Chua, A Defining Moment: How Singapore Beat SARS, 105–07, 143–49.



Further resources
“CDC To Handle Future Sars Cases So Hospital Can See Patients Again,” Straits Times, 19 May 2003, 2. (From NewspaperSG)

Tommy Koh, Aileen Plant and Eng Hin Lee, eds., The New Global Threat: Severe Acute Respiratory Syndrome and Its Impacts (Singapore: World Scientific, 2003). (Call no. RSING 616.241 NEW)

Leung Ping-Chung and Ooi Eng Eong, eds., SARS War: Combating the Disease (Singapore: World Scientific, 2003). (Call no. RSING 616.24 SAR)

“New Enemy, New Security Measures,” New Paper, 7 May 2003, 7. (From NewspaperSG)

Ng Wan Ching, “Doctor Death,” New Paper, 6 April 2003, 5. (From NewspaperSG)

Catherine Tay Swee Kian, Infectious Diseases Law & SARS (Singapore: Times Editions, 2003). (Call no. RSING 344.5957043 TAY)



The information in this article is valid as at February 2020 and correct as far as we are able to ascertain from our sources. It is not intended to be an exhaustive or complete history of the subject. Please contact the Library for further reading materials on the topic.