title: The outbreak of SARS at Tan Tock Seng Hospital--relating epidemiology to control.
abstract: BACKGROUND
  The outbreak of severe acute respiratory syndrome (SARS) began after the index case was admitted on 1 March 2003. We profile the cases suspected to have acquired the infection in Tan Tock Seng Hospital (TTSH), focussing on major transmission foci, and also describe and discuss the impact of our outbreak control measures.
  
  
  METHODS
  Using the World Health Organization (WHO) case definitions for probable SARS adapted to the local context, we studied all cases documented to have passed through TTSH less than 10 days prior to the onset of fever. Key data were collected in liaison with clinicians and through a team of onsite epidemiologists.
  
  
  RESULTS
  There were 105 secondary cases in TTSH. Healthcare staff (57.1%) formed the majority, followed by visitors (30.5%) and inpatients (12.4%). The earliest case had onset of fever on 4 March 2003, and the last case, on 5 April 2003. Eighty-nine per cent had exposures to 7 wards which had cases of SARS that were not isolated on admission. In 3 of these wards, major outbreaks resulted, each with more than 20 secondary cases. Attack rates amongst ward-based staff ranged from 0% to 32.5%. Of 13 inpatients infected, only 4 (30.8%) had been in the same room or cubicle as the index case for the ward.
  
  
  CONCLUSIONS
  The outbreak of SARS at TTSH showed the challenges of dealing with an emerging infectious disease with efficient nosocomial spread. Super-spreading events and initial delays in outbreak response led to widespread dissemination of the outbreak to multiple wards.
authors.affiliation: Communicable Diseases Centre, Tan Tock Seng Hospital. Mark_Chen@pacific.net.sg
authors.forename: Mark  I C
authors.initials: M
authors.lastname: Chen
authors.forename: Yee-Sin
authors.initials: YS
authors.lastname: Leo
authors.forename: Brenda  S P
authors.initials: B
authors.lastname: Ang
authors.forename: Bee-Hoon
authors.initials: BH
authors.lastname: Heng
authors.forename: Philip
authors.initials: P
authors.lastname: Choo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003428:Cross Infection / Q000453:epidemiology* / Q000517:prevention & control*; D004196:Disease Outbreaks; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010356:Patient Isolation / Q000379:methods*; D012189:Retrospective Studies; D045169:Severe Acute Respiratory Syndrome / Q000453:epidemiology* / Q000517:prevention & control*; D012846:Singapore / Q000453:epidemiology