Employers Guide To Information on SARS.

Introduction
SARS is the short form for Severe Acute Respiratory Syndrome. This is an atypical pneumonia of unknown aetiology. The causative agent has yet to be identified. The main symptoms and signs include high fever (>38 degrees C), cough, shortness of breath or breathing difficulties. A proportion of patients with SARS develop severe pneumonia; some of whom have needed ventilator support. To date there has been no reported cases of workplace infection.

Overview of SARS Situation in Singapore
Since the first 3 index cases of SARS infection were reported in Singapore on 13 March 2003, a total of 101 SARS cases have been reported as at 4 April 2003. Among them, 69 have recovered from SARS and have been discharged from hospital. There are 26 patients still hospitalized, of which 12 patients are in serious condition Six SARS patients have died. The chronology of SARS event in Singapore is at Annex.

Of the 101 SARS cases, there are 7 imported index cases, 46 healthcare workers and 48 family, friends or contacts who have come into close contact with the index cases and infected SARS patients. There are 45 suspect SARS cases admitted, including 3 children (below 18 years old).

Current State of Knowledge on SARS
SARS is a new form of infection which has been recognized for less than a month. We have learnt much about the characteristics of this illness over the past month but there is much that is still not known.

Firstly, the cause of the infection has not been found. However, both the WHO and the US Centres for Disease Control (CDC) have reported that the infection is likely to be due to a virus from the corona virus family. Some corona viruses are known to cause the common cold in humans. However, the virus associated with SARS is unlike any known human or animal member of this virus family. So, it is likely to be a new type of corona virus we are dealing with.

Not knowing the exact virus responsible for SARS means that we still do not have a test which we can use to diagnose if patients are suffering from SARS. We also do not know the specific properties and behavior of the virus when they affect the humans. However, we can draw upon some information that is known about members of the corona virus family in general. For example, it is known that corona viruses can survive in the environment for up to three hours.

Secondly, we know the incubation period of SARS. WHO and the US CDC have both stated that the incubation period ranges between 2 and 10 days. In the majority of cases, the incubation period ranges from 3 to 7 days. This information helps us in our contact tracing investigations and in deciding on the period of quarantine for close contacts.

Thirdly, we have a good idea of how the disease develops from our local experience of more than 100 cases so far, and the experience reported by others in the rest of the world. The earliest symptom is a sudden onset of high fever with or without muscle aches. Some patients may also have chills, shivering, cough and headache. After 3 to 7 days, patients may start to have cough and shortness of breath, and X-ray changes of pneumonia, usually after a further 3 to 4 days. In about 90% of cases, the patient gradually recovers. However, in 10-15% of cases, the pneumonia progresses and the patient needs treatment in the intensive care unit with most requiring a ventilator to help them breathe. About 4-5% of cases die despite intensive care.

Fourthly, the consensus among the medical community and reflected by the WHO and the US CDC is that persons are most likely to be infectious when they have symptoms, such as fever and cough. From our own experience, it also appears that persons are more infectious when they become more ill. Most of the SARS patients in Singapore have passed on the infection to a small number of people only, and through close contact. However, we have also noted that there are a small number of SARS patients who appear to be highly infectious, infecting a large number of people (super-spreaders). Hence, 3 SARS patients have been responsible for the transmission of the infection to 91 non-imported patients that we have seen so far.

Both WHO and the US CDC believe at present that the main way SARS appears to be spread is through droplet transmission. That is when a SARS patient coughs or sneezes droplets into the air and someone else breathes these droplets in. Our own experience in Singapore supports this view since almost all of our cases have occurred either among healthcare workers caring for the cases in hospital, or their family members and friends who had visited and come into prolonged close contact with them.

At present, the bulk of the evidence is that there is little airborne transmission of the infection. Airborne transmission means that the viral particles remain suspended in the air for prolonged periods of time and therefore can infect far greater numbers of people at greater distances. For example, people can get infected by just being in the same room or same plane as an infected person. This has not been the case so far. WHO has stated that thousands of passengers who traveled in the same flights as persons ill with SARS have been traced in Germany, Canada, Singapore and the United States but no cases of SARS had been found among them. This would not be the case if SARS spreads by airborne transmission. We know only of one flight crew who developed SARS and she was an air stewardess who had attended to a person who had SARS on board the flight.

However, we cannot exclude the possibility that there may be some situations where SARS is much more infectious, perhaps through other routes of transmission. For example, the reports on 31 March, of a large number of residents becoming affected by SARS in an apartment block in Hong Kong and the infection of several visitors staying in the Metropole Hotel in Hong Kong suggests that SARS may be transmitted more broadly eg through objects that have become contaminated.

There is as yet, no specific treatment for SARS. WHO has stated that no treatment beyond good intensive and supportive care has been shown to improve the outcome in patients with SARS. With good supportive and intensive care, 80-90% of patients with SARS will recover without any complications. Unfortunately, about 4-5% will die despite good intensive care. Treatment with serum from patients who have recovered is still being evaluated.

Strategy to Control SARS in Singapore
A) Education:
    1) Advisories/Guidelines
    Health advisories on SARS for hospitals, primary healthcare providers, airport, seaport, schools, work places, tour operators and housing have been issued. The advisories explain the symptoms of SARS and the precautionary measures to be taken.
    2) Public education programme
    MOH has carried out extensive public education on SARS through the mass media. Facts about SARS are published in four languages on the local newspapers. There were also radio interviews with the MOH health officials to answer some of the queries posted by the public. Posters and pamphlets on SARS will be distributed in the four languages
B) Protection:
    1) Early identification of cases
    Suspect and probable cases of SARS are being identified as early as possible so that they can receive treatment and are isolated early.

    The public has been advised to look out for symptoms of SARS and to seek immediate medical attention if they develop such symptoms. The public has been made to understand that they should only suspect that they may have SARS if they have a relevant travel history and/or had close contact with a person who has been diagnosed with SARS.

    Regular updates are being provided to all doctors and hospitals.

    Early identification of SARS cases is also being done through contact tracing of known cases.
    2) Contact tracing and home quarantine
    Each time a SARS patient is identified, MOH officers quickly carry out investigations to trace all those who have come into contact with them so that these contacts can be ring-fenced through home quarantine. Persons who are quarantined are given instructions to monitor their temperatures daily and to call MOH when they feel unwell. We also check on them daily. We thus ensure that we pick any person who develops the disease as early as possible and isolate them in the hospital.

    This quarantine measure also prevents any potential spread to others in the community from delays in getting to hospital. Contact tracing is not 100% foolproof. MOH may not be able to trace everyone who is a contact. Appeals have been made to all Singaporeans that if they or their children are sick with fever, and if they suspect that they have come into contact with a SARS patient, they are advised not go to work, their children should not go to school and that they should see a doctor immediately.
    3) Isolation of patients
    In order to contain the transmission of SARS, all suspected and probable SARS cases are centralized and treated at Tan Tock Seng Hospital/Communicable Disease Centre (TTSH/CDC). These patients are treated in isolation rooms under strict infection control procedures. To prevent SARS transmission, SARS patients are not allowed visitors.
C) Precaution:
    1) Infection control procedures in hospitals
    An important characteristic of SARS is that it tends to be transmitted quickly among healthcare workers who are not appropriately protected when they take care of SARS patients. Hospitals staff have to observe enhanced infection control procedures when dealing with suspect cases of SARS. These measures include wearing tight fitting facemasks, gowns, gloves and thorough hand washing. Staff also monitors their own temperatures three times during their shift so that any healthcare worker who becomes unwell is quickly isolated. A dedicated set of staff also takes care of the SARS patients and they do not see other than non-SARS patients.

    Besides TTSH and CDC, staff members in all hospitals also exercise the necessary precautions when handling patients with fever and pneumonia. Patients who come to the Emergency Departments with a fever and who could be a suspect SARS case are identified quickly and managed separately from the other patients.
    2) Airport screening
    To reduce the number of imported cases, MOH is carrying out health screening on incoming passengers from affected areas in both Changi and the Cruise Centre. This complements the checks that airlines have put in place at check-in counters and checks that the flight crew practice to detect ill passengers on board aircraft. All travelers who enter Singapore are given a Health Alert Notice to explain the symptoms of SARS and how they can get help if they fall ill with suspected SARS. We will also be requiring all visitors to Singapore to complete a Health Declaration Card.
    3) Safeguarding public transport
    To minimize public exposure to SARS, the MOH has made special arrangements for 4 categories of persons with a higher likelihood of being SARS patients to be transported to TTSH by private ambulance, so that they would not need to use the public transport system. The 4 categories are:
      a) Persons on Home Quarantine Order who develop SARS symptoms;
      b) Cases identified by General Practitioners and private dentists;
      c) Incoming Passengers who receive Travel Advisory and develop SARS symptoms subsequently; and
      d) Cases identified during medical screening at Changi Airport and Singapore Cruise Centre.

    On notification of the above cases, the MOH will arrange for a private ambulance to pick them up and send them to TTSH directly for medical assessment.


What can employers do to minimize the risk of SARS infection in the workplace
A) Education:

Employees should be briefed on good hygiene practices.
  • Maintain good personal hygiene, and wash hands with soap and water frequently.
  • Avoid sharing towels or eating utensils. Cough or sneeze into tissue or paper napkins and dispose.
  • Wash hands after sneezing, coughing or cleaning the nose
  • Do not spit onto the floor or ground.
B) Protection:

Not everyone who has traveled to SARS-affected countries will be infected with SARS and the current evidence is that infected persons become infectious only when they develop fever and other symptoms. Workplace managers should check if any of their employees have traveled to SARS-affected countries in the preceding 2 weeks or have come into contact with a known SARS patient. Such employees should be advised to monitor their health closely. If they develop any of the symptoms in para 2, they should go to TTSH Emergency Department for assessment. They should be told not to come to work first or to mix around with other employees. If a worker who has been to a SARS-affected area remains well after 2 weeks, he is unlikely to develop SARS infection later.

C) Precaution:

All employees should go about their normal work routine in the workplace. There is no need to wear gloves or masks or take special steps to disinfect premises, as SARS is spread through close contact* with an infected person. All SARS patients have been isolated for treatment at TTSH/ CDC, and those who had close contact with infected persons but do not have any symptoms have been quarantined at home under the Infectious Disease Act.

What should be done if a worker is suspected to have SARS
If a worker is suspected to have SARS, he or she should be kept in a separate room or area, away from other employees. If available, the worker should be asked to wear a mask (surgical mask is preferable) If available, the worker should use separate toilet facilities from the other employees.

Call the following numbers: 91788477 or 91788478. Transport will be arranged to bring the worker to TTSH for assessment.

Take down the names and contact details (IC number, address, telephone number) of all the people who are working in the same place as the affected worker or who have come into contact with the affected person. If the worker is confirmed to have SARS, MOH officers will come to the workplace to trace all those who had come into contact with the patient.

In general, there is no need to disinfect the work area of the worker who has fallen ill with SARS. However, if the company so desires such cleaning for added precaution and for peace of mind of the other employees the following is recommended:
  • Clean the work area with a chemical household germicide/disinfectant and allow to air dry.


  • Persons doing the cleaning should wear disposable gloves and wash their hands immediately with soap and water after removing the gloves.


Officers from the Ministry of Health (MOH) will also contact the company and advise on which are the employees who need to be quarantined at home. These persons will be served with Home Quarantine Orders under the Infectious Diseases Act for 10 days.

Tripartite Guidelines On Leave Of Absence Relating To SARS
In consultation with the Singapore Business Federation (SBF), Singapore National Employers Federation (SNEF) and National Trades Union Congress (NTUC), the Ministry of Manpower (MOM) has recommended the following for reference to employers in dealing with leave of absence relating to Severe Acute Respiratory Syndrome (SARS):

A) Absence from work under Home Quarantine Order
    In line with the Ministry of Health's Directive, employees who are served a Quarantine Order will be deemed to be on medical leave. The period of absence from work would be treated as paid hospitalization leave, as part of the employee's hospitalization leave eligibility under their employment contracts, collective agreements or as per the Employment Act.

    For employees who have used up their hospitalization leave, their employers are urged to exercise flexibility and compassion in granting additional leave, bearing in mind that the employees may face financial hardship.
B) Absence from work without Quarantine Order
    For employees who are requested by their employers to stay at home for reasons related to SARS, the following arrangements may be considered during the period of absence:
    • Employees could continue to receive their full day's salaries on the days that they are not required to work. Under this arrangement, employees would be required to take half day's paid leave while employers would make up the other half day's pay.
    • Employers could pay the affected employees not less than half of their daily pay during the period of absence.
    • Employers could request employees to take their annual leave and if the employees' leave has been used up, they should continue to receive not less than half day's pay.
    • By mutual agreement, employers and employees/unions could also agree on other arrangements for employees' leave of absence relating to SARS.


    As for employees who need to take leave to take care of their children or choose to stay away from work on their own accord, employers are encouraged to adopt a flexible and enlightened approach in granting time-off, implementing flexible work arrangements as well as allowing employees to take their annual leave. For employees who have used up their annual leave, employers could consider granting them no-pay leave.



Singapore's Position on SARS
Singapore believes public education, prevention and social responsibility are the keys to reduce SARS transmission. While Singapore can take specific measures to identify SARS cases early, isolate the SARS patients and their close contacts, the SARS problem can only be contained if the public are socially responsible and take precautions and seek medical attention when unwell with high fever. Public education on SARS is important so that our daily living activities would not be disrupted.

SNEF's Position on SARS
SNEF strongly advises all employers to deal with medical leave arising from the home quarantine of some of their workers in a flexible and compassionate manner. For parents with young children affected by the school closure, employers are also advised to be understanding to help them cope with making any special child care arrangements. Co-workers who are affected should also cooperate to deal with any work disruptions that may arise.

Going Forward
Singapore believes public education, prevention and social responsibility are the keys to reduce SARS transmission. While Singapore can take specific measures to identify SARS cases early, isolate the SARS patients and their close contacts, the SARS problem can only be contained if the public are socially responsible and take precautions and seek medical attention when unwell with high fever. Public education on SARS is important so that our daily living activities would not be disrupted.

Contact Information
For further information on SARS, please call the Ministry of Health Hotline at 1800-2254122 or visit the MOH website at www.moh.gov.sg

For clarifications on employment terms and conditions related to hospitalisation sick leave, please contact MOM's Call Centre at 6438 5122.

Useful Information on SARS
Employment Related FAQs on SARS

SNEF Press Statement on SARS

The Tripartite Guidelines On Leave Of Absence Relating To SARS

Interim Advisory On Temperature Screening And Registration List (Outside The Healthcare Setting)

Interim Health Advisory On SARS For Work Places

Frequently Asked Questions From Employers About Sars At The Workplace

Statement By Dr Lee Boon Yang Minister For Manpower on SARS and Foreign Manpower Related Issues

Quarantine Measures For Foreign Manpower Entering Singapore From Sars-affected Areas

Download the Health Declaration Card recommended by MOH to be used at various check points

SARS Relief Tourism Training Assistance (SRTTA)

The Workmen's Compensation Act (Amendment of Second Schedule) Order 2003

Related Websites
Ministry of Health
www.moh.gov.sg

Ministry of Manpower
www.mom.gov.sg

World Health Organization (WHO) SARS Site
http://www.who.int/csr/sars/en/

Centers For Disease Control & Prevention, United States
www.who.int/csr/sars/resources/en/

Hong Kong DOH Atypical Typical Pneumonia Site
www.info.gov.hk/dh/ap.htm

Taiwan Center For Disease Control (also available in Chinese)
www.cdc.gov.tw/en/

Health Canada SARS Site
www.hc-sc.gc.ca/english/protection/warnings/sars/index.html

(SOURCE: Ministry of Health, 9 April 2003; Ministry of Manpower, 10 April 2003)

 
       

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