SARS War: Combating the Disease, edited by Ping Chung Leung and Ooi Eng Eong, is a collection of essays on the SARS outbreak. 

Here, we reproduce excerpts from the book touching on super infectors of the disease, the ostracisation of healthcare workers that occurred during the outbreak and public reactions toward quarantine measures.

Leung is an Emeritus Professor of Orthopaedics & Traumatology at the Institute of Chinese Medicine in the University of Hong Kong, while Ooi is a Professor and Deputy Director of the Programme in Emerging Infectious Diseases at Duke-NUS Graduate Medical School.

SARS War: Combating the Disease is published by World Scientific and you can get a copy here.

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By Ping Chung Leung and Ooi Eng Eong

SARS is highly contagious

SARS is a lot more infectious than originally thought - such were the words from Singapore's Health Minister Lim Hng Kiang as he stepped into the room filled with reporters on March 31.

It was the same room that top health personnel of the island meets regularly to discuss health matters that affect everyone in the country.

Since the middle of March, however, it has doubled up as the venue where health experts and representatives from relevant departments field questions from the press, giving them updates on developments in the severe acute respiratory syndrome or SARS.

Mr Lim maintained that SARS is spread by droplets discharged when a person sneezes or coughs and that transmission is restricted to having close contact with the infected person - defined as within a 3-feet (about 1-metre) radius or two rows in front and behind the person in an aircraft.

Singapore General Hospital virologist Ling Ai Ee explained that such droplets are heavier than the airborne ones which are so light that they "can be blown down the corridor".

Examples of airborne particles are found in tuberculosis and measles, while droplets are spotted in influenza.

Still, SARS can be very infectious. Mr Lim emphasised that the disease in question is a new one and information on it is being disseminated at all times.

Spread has been exacerbated by the presence of super infectors

He added that the assessment that SARS is more infectious is enhanced by the presence of what is termed "super infectors".

These are people who are "full of the virus" and are capable of infecting a large pool of people.

Such characteristic has been prevalent in Hanoi and Hong Kong too, Mr Lim said.

One of the first super infector beyond Singapore, for example, was the American-Chinese who had given the virus to more than 50 people and led to the closure of the Hanoi French Hospital in Vietnam, another could be the man responsible for infecting many others in the Amoy Gardens apartment building in Hong Kong, added Mr Lim.

Out of the over 90 SARS patients in Singapore, three have been identified to be super infectors.

Of the first three index cases that contracted the disease from Hong Kong's Metropole Hotel, Mr Lim elaborated, only one by the name of Esther Mok is a super infector.

She infected 20 people in five days, including her parents who passed away, while the two others who brought the virus back from Hong Kong have not infected anyone and have since recovered and discharged from the hospital.

The second Singapore super infector was a nurse who was infected by Esther Mok.

She caught the virus when Singapore was still largely unaware of SARS and did not isolate her.

The nurse subsequently passed the virus to 16 people, including Madam Painah Abdullah who died on March 30. Madam Painah was Super Infector Number Three and had infected more than 20 others.

Mr Lim said that the presence of super infectors, coupled with the discovery that the coronavirus - the family of virus that SARS is believed to belong - can stay in the environment for up to three hours, implied that "the whole picture can be quite different".

"If index cases are not super infectors, the situation will not be so drastic, but Singaporeans cannot be lulled into complacency. The problem cannot be stopped next week and we will still continue to face new index cases. If any of the new index cases is a super infector, we can have a new huge cluster of infected people to start a chain of reactions," cautioned Mr Lim.

As of April 3, the number of index cases climbed to seven, most having gone to Hong Kong and China and contracted the virus there. No news on whether these are super infectors yet.

Mr Lim added that in the same way that some people are very good hosts and some are not, the former have a lot of viruses in them. If they are kept in the Intensive Care Unit, their chances of infecting people are lower than if they are moving around in the community.

The characteristics of super infectors have, however, not been identified, although Dr Ling Ai Ee said that could be due to pre-conditions such as lung problem or that the patients are already weak in one way constitutionally, such as in the case of a diabetic.

Healthcare workers were shunned by the public

Medical personnel who are risking their lives to attend to SARS patients are unexpectedly finding themselves being shunned by the general public.

A nurse who works at the Tan Tock Seng Hospital said in an interview with the media that she is disappointed with the reaction of the public. She disclosed that this is the first time in her 40 years of nursing career that she has witnessed medical workers being ostracised.

She said, "When we are in our hospital uniforms, people are afraid to sit beside us in buses or the MRT." She also cited instances of commuters throwing disapproving glances or even pointing fingers at them.

It seems that it was no better even if they chose to travel by taxis. Some healthcare workers, having experienced the difficulty of stopping taxis when they are in hospital uniforms, have resorted to changing to normal clothes before they leave the hospital.

Hospital administration staff are not spared either.

An administrator, who works in the same hospital, has been asked by friends to refrain from attending a birthday party, for fear that other people might become worried or anxious.

The reason given is that she is working in the hospital that is tasked to combat the deadly disease. Her friends have even requested her to conceal her identity if she insists on attending the function.

She has decided not to attend.

Healthcare workers infected during course of work

At a time when everyone is living in fear of SARS, medical personnel are at the frontline battling to save lives and care for the patients who are down with the virus.

Unfortunately, some of them are infected in the course of their work, although all possible precautions have been taken.

Ms. Tan, a Singaporean nurse, fell sick and was warded soon after attending to a SARS patient.

Fortunately, her condition stabilised very quickly. While still recuperating from the illness, she was already rearing to re-join her colleagues in the battle against the SARS virus.

In another case, a nursing student came down with the flu-like disease in early March when the outbreak was still not very widespread.

She did not seek medical attention immediately after developing a fever. For six days, her high fever came on and off. It was only until her temperature had reached 40°C that her mother sent her to the Accident and Emergency department of the Tan Tock Seng Hospital.

The doctors warded her at once. For the three days that followed, her condition worsened and she developed a very bad cough.

She would cough uncontrollably even while drinking water. She was then sent to the isolation ward.

In an interview with reporters later, she said, "Once the respirator is taken off, i will cough very badly." She also described herself as very tired and depressed, and felt like she was dying.

After 12 days in hospital, she recovered and was well enough to go home.

How did medical workers catch SARS from a patient? It's unclear.

Looking back, she could not understand why she had caught the disease. She believed that she was infected by one of the index cases, but she had very little contact with that patient.

Her colleague, who was looking after the index patient, was not infected though.

The Tan Tock Seng Hospital, which is tasked to specifically handle SARS cases, have implemented precautionary measures very early on to prevent its medical staff from catching the virus.

All personnel who come into contact with SARS patients have to wear surgical face masks, protective garb and gloves.

Before they leave the wards, they have to discard the gloves and garb. They are also required to wash and disinfect their hands.

Doctors and nurses who look after non-SARS patients are required to wear surgical face masks and wash and disinfect their hands as well. Pregnant healthcare workers are not deployed to attend to SARS cases.

Quarantine was not well-received by some

Due to the highly contagious nature of SARS, many governments have to resort to quarantine as a means of containing the disease.

The reactions of those who had to be confined to their homes have been mixed: while some lamented at the sudden loss of personal freedom, others took the opportunity to rest and spend time with their families.

The Hong Kong authorities decided to quarantine the residents of Block E of the Amoy Gardens apartment when it was found that more than 250 cases of infection were detected among them.

Some residents have complained that being confined to their homes was worse than being in jail, as even prisoners are allocated time for outdoor activities.

Another complaint was that the daily rations provided by the government were unpalatable.

One resident who declined to be named was particularly annoyed by the fact that he was "not even given any butter" to go with the bread for breakfast.

As the quarantine was imposed suddenly, some families became separated as some residents were not in the apartment compounds when the police sealed off the place.

Many were caught off-guard

Some of them had had to plead with the authorities to be allowed to return to their homes so that they could help take care of their children or the elderly in their families.

In Singapore, the government invoked the Infectious Disease Act, and quarantined all the people who came into close contact with infected cases, for 10 days.

Many families were caught unprepared, and had to resort to asking family members or friends to supply them with daily groceries and necessities.

However, the advent of the Internet has made online shopping possible, so grocery shopping during the quarantine period did not really pose a problem.

Some people adopted a positive attitude towards the quarantine.

One such person was Mr. Wong. In a telephone interview with a radio station, he said that the members in his family were usually busy with their own work, and had little time for interaction.

Ironically, the quarantine period provided his family with a valuable opportunity to take a break and spend some quality time with one another. He jovially said, "... at least this is a blessing in disguise!"

However, people from the lower income group, especially those who received daily wages, were frustrated that they could not report for work.

A blue-collar worker lamented, "I'm the sole bread winner in the family but now I'm stuck at home. My kids need me to go out and work to bring home the dough!"

Top image courtesy of National Archives of Singapore