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Question:
What are the measures NCC has undertaken to contain SARS?
Dr
Khoo:
Protection
The first thing we’ve done is to protect our staff and
to some extent also to protect our patients and visitors.
We do so by making sure that they don appropriate personal
protection equipment depending on which area they work in.
For example… at the triage level, they are exposed to
unselected patients who have never been screened before –
so they are giving full protection (PPE)
At the
height of SARS when we need to protect everyone … one
can never be sure that the screening is 100%. Almost everyone
working in the clinical area is donning the full PPE. And
protection extents even to the non-clinical area, where we
require people to at least put on a mask.
So these are some of the measures…main idea of protection.
In very
high-risk areas, we go beyond that, people even have to wear
PAPR (Positive Air Pressure Respirator) if they come into
contact with secretions of incubating patients … these
are less done in NCC. It’s something that offers an
even better protection than N95 mask, cap, gown and gloves.
This prepared
for specific situation where the risk of transmission is the
highest, for example when you’re operating on a patient
or incubating patient, but fortunately we have not had the
need to use this so far for a suspect patient. Of course,
we’ll continue to use this thing in the operating theatre.
Detection
We have to detect any potential infective patients, and we
do so by (using) stringent screening procedures, by asking
questions about the travelling history, the contact history,
and the symptoms they may have in last 10-14 days. And that’s
for patients.
We also
have our staff temperature taken three times a day. That’s
the attempt to find the earliest possible signs of potential
SARS. We know for a fact – there is strong evidence
to suggest -- that patients who have contracted SARS do not
become infective until they manifest a fever. So fever screening
is an effective form of screening and we see that this is
done very diligently.
Once you
detect them, the idea is to isolate them, and if there is
a patient who is a confirmed SARS, we’ll have to isolate
them to cut the chain of transmissions. And so with all these
3 measures carried through very diligently, SARS can be brought
under control, both for the centre and the community.
Isolation
Isolation is once you detect a patient with probable SARS,
suspected SARS, you must quickly isolate the patient -- isolate
means to cut him off from the rest of the patients and medical
health care workers until the period of infection is over.
Question
: Why is it important that we undertake these measures?
Dr
Khoo:
These measures will ensure that we minimise the risk of any
potential infected patients coming into the centre, and in
contact with other patients or health-care workers within
the Centre. These measure will minimise infection or to ensure
that the chain of transmission can be broken at the earliest
opportunity.
Making
sure that our staff is adequately protected will give them
the confidence and the psychological comfort to continue to
work in the Centre, in spite of the fact that this campus
does have SARS patients.
Question:
Now that Singapore is off the WHO SARS list, what are the
measures will NCC continue to implement?
Dr
Khoo:
We follow very closely the directives and guidelines, firstly
from the Ministry and secondly, from the Outram Campus Taskforce.
NCC worked within the framework of the Outram Campus Taskforce
which will come up with the policies and guidelines on what
sort of measures to take.
Over the
last month and a half, some of the stringent measures have
been retired and stepped down as the overall situation of
SARS in Spore and the rest of the world becomes better. So,
some of you may have noticed that doctors working within the
outpatient clinic are no longer wearing the full PPE, lest
those with very specific situations where the risk of contamination
is still exist.
Question: Are cancer patients
more prone to catch SARS or to transmit it?
Dr
Khoo:
Well,
there’s no evidence that cancer patients are more likely
to contract SARS or to transmit SARS.
But it is becoming more that apparent patients with chronic
illness, who are immuno-suppressed – those with lower
immunity, in particular patients with renal diseases, may
not manifest the same clinical features as a normal healthy
patient. Some of the symptoms may be masked, for example,
fever -- they may not have a typical presentation of cough,
fever and therefore, it may have gone on undetected for some
time before the diagnosis is made. Therefore, now more precautions
are taken to isolate these patients whenever there is a slightest
suspicion.
Not high
risk for contracting SARS, but because they may not manifest
SARS in the usual way, and they may have gone undetected.
When you’re looking for typical symptoms – fever,
cough and bone pain-- they not have any of these things, and
yet, they may have already contracted SARS and transmitting
SARS.
Although
we broadly classify these patients, we think that all immuno-comprised
patients and immuno suppressed patients, may be so. But I
think evidence is strongest for patients with renal diseases,
patients who are on chronic immuno-suppressants. They are
on medicine to suppress their immune system with a purpose.
For example, patients with a renal transplant – they
are taking immune suppressants to prevent rejection. Steroids,
which is a very commonly used medicine for a variety of inflammatory
diseases, is also one of the culprit.
But to
answer that question specifically, no we do not think that
cancer patients are more prone to getting SARS. They are just
as likely or just as unlikely to get SARS. The only thing
that one need to be more aware of is that some of these patients,
especially those who are long term immune suppressants may
not manifest the usual clinical features.
Question: Fever and coughing
are common symptoms of SARS, and these are not uncommon in
cancer patients, hence how to make the distinction from SARS?
Dr
Khoo:
Well,
this is quite right. Fever and coughing are common symptoms
of anything from an upper respiratory tract infection to pneumonia.
Obviously, not all these are SARS. How one approach this has
to do with what the environment is like, and the overall situation
with SARS.
At the
height of SARS, when there is clear evidence that there’s
still local transmission taking place, then one has to make
the assumption that any of these patients who present with
such a symptom has to be treated as a potential SARS, until
proven otherwise. That means -- detection and isolation.
But as
the overall SARS situation improved, the likelihood that these
are SARS becomes less. So one will have to exercise his judgement.
There are certain criteria for people to use to see whether
these are likely to be SARS or not.
One, we
can fall back again on the history of contact, history of
close contact with a SARS patient. For example, either a patient
or a person who was home quarantined because of contact with
SARS patient, as a health care worker who have been working
in a hospital or an environment where SARS was present --
so these are contact history.
Or they
have travelled to a SARS affected area or on certain blood
test they found that the counts are low which can be SARS…then
the index of suspicion must be there. But it’s not always
easy because a typical pneumonia is not uncommon, especially
in elderly patients.
There
is no foolproof way of distinguishing pneumonia from SARS
– from other types of pneumonia. So again a very well
taken contact history is probably one of the most critical
ways to go. Obviously, there are other things that can help
us -- the x-ray appearances, the blood test result and now
we can do serology of corona virus – we can do PCR to
detect the virus in the blood. Some of these tests take time
and one may not get the answer immediately. What one may have
to do is that in cases where there is suspicion because of
contact history, we’ll have to isolate the patient first.
Protection,
detection and isolation and be familiar with common symptoms
and presentations of SARS, to always take detail contact and
travel history and always have a high index of suspicion.
So these are the key message.
Then,
the other message we can bring across is that NCC has done
all the things to ensure that this is a safe environment.
The last case that we have was more than … 15 April
until now—about 2 ½ months. The last confirmed
case of SARS at NCC is more than 2 months ago and since then,
we have been named SARS free.
Orange
alert – this is for … it’s like an army
– whether your alert level is green… means very
low—all clear, then yellow, then red.
So the
higher the level of alertness, the more stringent the measures
to be instituted.
Orange
means, yes, things are better, but we still have to be on
the lookout… that’s why we have continued to don
N95 mask, to continue to screen patients. All patients coming
to NCC will have to be screened for temperature. And for those
with the fever will be treated in a separate setting, so that
they don’t mix with the rest of the patients.
Question:
When do we stop doing these things?
Dr
Khoo:
We still
have to do all these things…the directive of when to
stop will have to come from the Ministry. Obviously we are
very aware of the potential of SARS raising its head during
winter as predicted by many infectious disease expert. Preparing
ourselves for any contingency in the event that SARS will
come back again.
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