Mr Speaker, Sir, I would like to start off by responding to Dr Lily Neo's question about how the SGH outbreak started and whether it could have been averted, and also how did that lead to the outbreak in the Pasir Panjang Wholesale Centre. I hope in explaining how these got started, Members can appreciate the difficulties that we are dealing with. We do not have a reliable and quick diagnostic test system now. We have to depend on clinical symptoms and we have to depend on very rapid contact tracing in order to ringfence the contacts to prevent the spread from widening, which is also the second question which Dr Lily Neo presented. This index case in SGH that caused this cluster was an ex-patient in Tan Tock Seng Hospital. He had a multitude of problems and he was discharged from Tan Tock Seng Hospital on 20th March. He recovered from some of his problems, and this was a regular discharge on 20th March. On 22nd March, we decided that Tan Tock Seng Hospital would be a hospital dedicated for SARS. So this was in the middle of the problems that we were having in Tan Tock Seng Hospital. He was discharged on a regular basis because he recovered. Because of that decision to make Tan Tock Seng Hospital the dedicated hospital for SARS, when this man had gastrointestinal bleeding on 24th March, he had to go to SGH because Tan Tock Seng Hospital was only admitting patients for SARS. He went to SGH. SGH took all the necessary precautions - screened the person. He had gastrointestinal bleeding. He also had a foot ulcer and a low grade fever. SGH took a chest X-ray, which was done on the date of admission on 24th March. The chest X-ray was clear. Because of the symptoms he presented, SGH did not consider him to be a suspect SARS case, and treated him for his problems and put him in an open general ward (Ward 57). On the 5th day of admission, on 28th March, he developed high fever. So SGH took note and gave him a repeat chest X-ray. The repeat chest X-ray was normal again. He was treated with antibiotics on 29th March and the temperature came down, indicating that this could be a bacterial infection and not a viral infection. A blood culture showed that he had infection of the blood by a bacteria, E. Coli. A third chest X-ray was done on 30th March, and this was again normal. He was given a stronger antibiotic on 4th April, and he did not have fever anymore. But his chest X-ray on 4th April showed signs of pneumonia, and SGH did the right thing, which was to send him to TTSH, because with a chest manifestation, he was considered as a suspect SARS case. At that time, SGH management also began to notice a group of their staff and healthcare workers coming down with fever, and they went into alert. A cluster of potential problems was growing. So on 5th April, they decided to transfer Wards 57 and 58 to Tan Tock Seng Hospital. The process took some time and the transfer was completed. The transfer started on 6th April, and it was completed on 7th April. In transferring two wards, we had to move all the patients, many of whom were fairly sick, and the staff together with them. We initiated contact tracing, involving 120 people - the patients and the staff - to find out whom they were in contact with. Because if they were infected, we did not know who else could be infected in the two wards. So the contact traced everybody. From the 120, we have to contact trace a few hundreds to see who they are. By the time we detected his brother who had visited him in SGH, that was already 8th April, one day later. By then, his brother who caused this cluster of problems in Pasir Panjang had onset of fever on 4th April. He still went to work at Pasir Panjang Wholesale Centre on 5th April. He was unwell on 6th April; so he did not work on 6th April. But he went back on 7th April, and again on the 8th. By the 8th of April, he was quite unwell; he was sent to NUH. So by the time we realised he was a contact of his brother in SGH, he had already been admitted to NUH on the 8th. So this illustrates the difficulties we face. When a patient is presented with all kinds of chronic problems, it masks the typical symptoms that we associate with SARS - high fever and all the other symptoms, plus pneumonia and chest problem. In this case, they did three X-rays, they did a blood test, and this did not manifest itself till much later. We have to do contact tracing very quickly, but it still takes us 24 hours. We set a target of completing contact tracing within 48 hours. So in this case, even if we meet the limit of 48 hours, by that time the onset was on the 5th of April, he was very sick, and on the 8th he was already in NUH. On hindsight, could we have done better? The problem is a significant one. Obviously we could have done better. I think SGH management could be on greater alert when it comes to staff coming down unwell, which is now the new standard that we impose. Any two healthcare workers having fever in the same department now sends out a red flag. But having set the standard of two healthcare workers having fever sending out a red flag, I hope Members realise now a lot of red flags are showing because it is not unusual to have fever. And we set our fever threshold now at 37.5oC, which is not a very high grade fever. So, everybody is on very high alert. And contact tracing is not 100% foolproof. We need people to be very truthful about their contact history. Otherwise, if they give us half a story, we miss out some of the contacts and we cannot ringfence these people. So I would like to say that this SARS challenge is a tremendous challenge for us. We are flying blind. We only have two instruments which are the clinical symptoms - fever, chills, cough, muscle aches - and then only much later, ie, three days, five days, or seven days later, you get the chest manifestations. The second instrument we have is contact history so that we know that, even if you have got fever and cough, but, because of your contact history, we must suspect that you have SARS. And that is why I said in my statement that we have to depend on people taking temperature, and we have to depend on people being truthful to us in their contact history. Dr Lily Neo asked about WHO guidelines, why we have to follow them and why do we not set our own guidelines. We have to follow a certain set of international guidelines because we have to report to WHO. This is a global problem. We cannot have a different set of guidelines. Then WHO would not have a true picture of our situation. But for the clinical guidelines set by WHO where we can be more conservative, we have done so, for example, WHO guidelines on what is deemed a recovery. When a person is deemed to have recovered from SARS, WHO says he must have no fever for 48 hours. In Singapore, we set it at 72 hours. Then they insist on a series of blood tests to see the white blood count. We do that too. They insist on X-rays. We do that. They say you need 10 days' medical leave at home. Our rule is 14 days' home quarantine, that means, not just 10 days' medical leave at home, but we insist that the person stays at home for 14 days on Home Quarantine Order, and he has to come back to TTSH regularly through the ambulance for his blood tests and chest X-ray. So we follow WHO guidelines, in terms of reporting of statistics, otherwise, there would not be sensible comparisons across the countries. When it comes to clinical guidelines, our staff here always try to be more conservative, as I have illustrated on the criteria for recovery. Dr Lily Neo asked about epidemiological study group. We are doing this constantly, trying to piece this together and trying to get a picture of the disease pattern. We also have two WHO consultants with us and one consultant from US CDC helping us to track this pattern. They of course provide the link to their parent organisations, and whatever we do is completely transparent to them and audited by them. And so they have high confidence in their parent headquarters that whatever we report is the truth and not something which we are doctoring to give a different picture to the world. Dr Lily Neo also asked about the healthcare workers. Are they adequately protected? We try to have as stringent a level of protection as possible. But a lot depends on correct usage of this protection. For example, if any of you have used the N95 mask, you will find that it is very, very uncomfortable. It is very hard to breathe. When I put it on, I find that I was being suffocated. And I cannot imagine how I could ever be a nurse. But the nurse has it on for eight hours, 10 hours, 12 hours. And it is very uncomfortable. In the open wards, it is very warm with the gown and the mask. These are not easy conditions. It has to be very tight-fitting, so it is hard to breathe and if it is not tight-fitting, then it does not work. So it requires a lot of vigilance and a lot of discipline. Day in and day out, keeping this protection on because you know that if you make a slip-up, it will be a very costly slip-up. So for the healthcare workers, it is a lot of stress, and they are over-stretched in the wards. But the situation varies. When we have a big cluster like in SGH and in the Pasir Panjang Wholesale Centre, then of course the workload increases. But if you look at the situation across the public hospitals today, Tan Tock Seng Hospital is well protected. As we mentioned in our statements, we have not had any of our healthcare worker being infected for the last six weeks. So the morale is high. They know that if they are diligent and they take good care of themselves through the protection, they will continue to be protected. But once there is a slip-up, it will be a real setback. The resources in Tan Tock Seng Hospital are bearing up. Our critical resources are the ICU and the isolation rooms. In the ICU, we are doing okay because we have nearly 40 ICU rooms and we are using about 20 each time. So we still have some capacity. Our isolation rooms are now very stretched because, with the Pasir Panjang Wholesale Centre cluster, we encourage people to come forward for screening. Because we do not have a diagnostic kit, we have to keep them in individual isolation suites to watch over them for some time. And therefore the isolation rooms are filling up very quickly. The other hospitals are bearing up reasonably well. As I have said, KK Hospital is also clean of SARS and I think they are managing very well. Alexandra Hospital has not had an episode of SARS. As a result, the public goes there and they are now feeling the strain because Alexandra Hospital is a very small hospital and it is not used to this load. So a lot of the load that used to go to TTSH and SGH now goes to Alexandra Hospital. Changi Hospital, after their episode in end-March, has not had another episode. So they are again gearing up. So, today, I would say TTSH, KK, Changi and AH are bearing up well. We have the problems in SGH. They were doing okay until the recent episode with Dr Alex Chao. And in NUH, we still have the cluster that was started by the brother of the index case in SGH which created a cluster there. That one, we are still trying to keep it under control. So we have the Ministerial Combat Team under SMS Khaw Boon Wan. He and his team have gone down to the hospitals to button down the protection guidelines, the execution of those protection guidelines, to raise the standards and the morale and the capabilities of the hospitals. I think they are doing a great job and we should be able to see the situation improving day by day. Sir, our hospitals are coping fairly well with the public services. As to hospital charges, we have explained this before. Screening is free. So if you come forward for screening in Tan Tock Seng Hospital, it is free. If you are kept for observation, then you are charged C class rates. So it is heavily subsidised. And if you have financial problems, then our medical social worker would apply Medifund for you. So I do not think Singaporeans should be concerned about the medical costs of coming forward for screening or treatment. The other group of questions which Members raised and which I thought it is worthwhile for me to go through, in some detail, is the Home Quarantine Order. When we detect a probable SARS or a high suspect SARS case, we start contact tracing and the people whom we determine to have contact with this patient, a probable SARS or a high suspect SARS, we will then issue the Home Quarantine Order. As far as this contact is concerned, he is still healthy, he is still well, but because of his contact history with a probable SARS or a suspect SARS case, he is given a Home Quarantine Order. And the reason why we do so is that we want him to stay at home, monitor his health constantly and the minute he has a high fever or other symptoms, he will call us and we will dispatch an ambulance to fetch him to Tan Tock Seng Hospital straightaway. So in that way, we minimise the likelihood of him infecting other people in his family as well as in the community. But the other family members are not contacts of a probable SARS or a suspect SARS patient. So if they are not contacts, they will not be issued a Home Quarantine Order. But if the other family members are contacts, they will also be issued a Home Quarantine Order accordingly. Then how do we treat the children? Because we felt that as schools are very sensitive institutions, we took the extra care of asking the children to also be quarantined even though the children will not be infected until the adult is infected. Let me go through this again. If we detect a probable or a suspect SARS case, we determine the contacts. Let us say, there are 20 contacts. Then we issue a Home Quarantine Order on each of these 20 contacts. These 20 contacts will have an incubation period before they become infectious. The incubation period is between three and 10 days. But we insist that he stays at home so that, whenever he has a fever or he shows symptoms and becomes infectious, we will pull him out to TTSH. The adult family members will not get infected until the contact gets infected. Then they themselves will take another incubation period of three to 10 days before they become infectious. So the other family members can continue with their work and their life, because they are not infectious and they will not be infectious until the contact becomes infectious himself. Why do we not do the same for children? Medically, we should do the same for children. But knowing the sensitivity of parents over the children in the schools, we decided that, for children of a contact, we will be extra kiasu and we also issue a Home Quarantine Order on them. When we started, of course, we stipulated it as a requirement in the Home Quarantine Order, as Mr Tan Soo Khoon raised. This has caused some confusion in the public's mind. Recently, we decided that we would actually issue an individual Home Quarantine Order on each of these children. There is another situation where a family member is a probable or a suspect SARS case, in which case all the family members are contacts and all the family members would be issued Home Quarantine Orders, including the children. So to minimise this confusion, nowadays, when a child is asked to stay at home, we will issue a Home Quarantine Order and there would not be any confusion among the public. Some Members asked what about financial support for this group. If the contact is given a Home Quarantine Order and the other family members are not at risk until the contact becomes infectious, then the other family members can go about with their life as usual, go and buy grocery, etc. But we do have a situation where the entire family is served with the Home Quarantine Order. Then of course we will come in to provide support to them, in case they need grocery, etc. But if they can make their own arrangements, ie, if their relatives can bring the food to them and leave it outside their door, it is all right. This is just to be extra safe because, if they follow the rules that we set for them, they are not infectious until they exhibit the symptoms. So the workman can go to their house and do the repair as long as these people are responsible. If they do not exhibit any symptoms, they are not infectious and life goes on. But the minute they have a fever and they have symptoms, then they will call us and we will bring them to TTSH for screening. When we serve the Home Quarantine Order on a person, the CISCO police who serves the order will set up the camera and give the instructions. I accept Mr Tan Soo Khoon's point that we should give it in four languages. We will do that. But the CISCO police will explain to the person, who is served with the Home Quarantine Order, what he has to do and how he reports through the camera whenever we call him up. At the same time, we will send a nurse to visit the person under Home Quarantine Order and the nurse will have a kit with a thermometer, a face mask and also instructions, so that he knows how to take his temperature on his own and, if he is sick, then he puts on the surgical mask and wait for the ambulance to come. So, this is the way we explain to the person what he has to do and, of course, it would help if we put it in four languages, and we will do so. The third group of questions which I thought is important for me to elaborate on is the situation in Tan Tock Seng Hospital and why Singaporeans fear going there. We have come out several times to explain the very high level of infection control in Tan Tock Seng Hospital and that it has been screening hundreds of people since the beginning of the SARS outbreak, and people have been discharged, they go on with life as usual. So, cross-infection in Tan Tock Seng Hospital has not taken place. If, after screening, the Tan Tock Seng clinicians feel that you should be warded for further observation, then you are kept in an isolation room. You will not infect others and others will not infect you. And the healthcare workers who come to look after you will all be fully gowned and fully protected. So, again, a very high level of infection control. If you are down with SARS, as I explained in my statement, the main treatment is to give you medical support and allow your body's immune system to combat the virus itself. The problem is when you have other complications. Then you need the full medical support system to address these medical complications. But the actual combating of the SARS virus would really be done by the person's own immune system. Of course, if you ask yourself, logically the earlier you come forward for treatment, the better your chances of recovery, because if you do not have the full medical support, especially in the ICU, when you have congestion in your lungs and you cannot breathe, then no oxygen gets into your blood stream and your chances of survival are very low. But if you are in the ICU, then they can intubate you, they can force oxygen into your lungs and cause your body to continue to absorb the oxygen, and so you have a fighting chance. So, people can stay in the ICU, intubated, ventilated, and then the body will have a chance to fight the virus. So, the earlier Singaporeans who are down with SARS present themselves for treatment and for this full medical support to help them fight the SARS, the higher the chances of survival. If you track the kind of cases that come to our hospitals, when they come in very, very sick and very, very late, and they have to go to ICU almost immediately, then I think the chances are all very, very slim. If you have been following stories, those who come very late and very sick and go to ICU straightaway, they have much lower chances of recovery. Overall, our recovery rate is still very good. 85% fully recover. Those who go to ICU, more than half recover too. So, again, I urge Singaporeans to come forward if you have SARS. Seek early treatment and you will have better chances of recovery, you do not infect your family, and you do not cause infection in the community. Dr Warren Lee asked whether we need special accommodation for the people on Home Quarantine Orders. As I explained, it is not necessary, because these people are not infectious. We just want them to be isolated in their own homes and, if they have a fever or other symptoms, then they present themselves immediately for treatment. The next set of issues is really the level of information that we give out, ie, whether we should publicise the names of patients and people on Home Quarantine Orders. Generally, we are reluctant to do so, because I think we should try to preserve medical confidentiality as much as possible. But where there is a public health need, then we will do it. If we need an accelerated contact tracing because the way we go about it through detective work takes 24 or 48 hours and that takes too long and the risk is too high, then, of course, we will publish the names in the media. But for recalcitrants and defaulters, I think we should publish their names and shame them because, otherwise, such Singaporeans will continue not to do what is necessary of them. So, although we try to preserve medical confidentiality, people who default and wantonly break the rules, we will definitely name them so that we can shame them. On the supply of equipment, eg, masks, gowns, goggles, thermometers, etc, there is a shortage of masks worldwide. But we are using all our resources that we have in Singapore, eg, from MINDEF, MTI, IE Singapore, ST Logistics, to get ourselves the necessary supplies to keep our healthcare workers protected. So, our commitment to our healthcare workers is that we will leave no stones unturned to get this equipment for them. Thermometers are less of a problem. We have ordered more than a million. I think these will be available over the next few months. Mdm Cynthia Phua asked whether there is a difference in the minimum number of days in the Home Quarantine Orders. We have used 10 days because that is the incubation period. But some employers, for example, impose a voluntary quarantine of 14 days to make it even safer. I think there is nothing to lose if you want to extend it to 14 days. But, for us, we use a minimum of 10 days because that is the incubation period. Next is the sort of resources that we have. As you have heard from the DPM, the full resources of the Government are behind the Ministry of Health to combat this problem. We have used resources from every agency. From MINDEF, we have used the medics; we have people from the People's Association to help us in contact tracing; we have used detectives from the CID to help us in contact tracing; we have used all resources in the Government to tackle this problem. And as you would have heard from the responses of the various Ministers, all the Ministries are gearing up to tackle the different aspects of how to deal with SARS. Some Members asked about the treatment regime. When we started off, as I said, there is no specific treatment regime. The Hong Kong experience, they tried to use Ribavirin, the anti-viral regime. But as we all know, it has toxic side effects and so we have to use it very carefully. The American clinicians are more conservative, and they prefer not to use this very aggressive approach. So, our clinicians have to make professional judgments, ie, when to use the full array of antibiotics and anti-viral regimes. Dr Lily Neo asked about the situation in NUH Wards 55 and 68. These are the kinds of problem that we are confronted with nowadays, because our threshold of alert is now set very, very low. When you have two staff with high fever and patients with high fever, everybody gets very excited. So, in SGH, on Good Friday, we transferred Ward 74 to TTSH because of this combination of staff and patients having fever. It was a precautionary measure. We transferred lock, stock and barrel, ie, one whole ward across - a lot of resources and effort. As it turned out, it was, thankfully, a false alarm. The fever of the staff came down, and the patients in that ward, because of their other medical problems, were showing this fever. But we would rather be safe than sorry. Similarly, for NUH Wards 55 and 68, we had been tracking the situation, and it is a combination of staff and patients having fever. Some days the fever is up, on other days the fever is down. The patients there are diabetic and kidney patients and, according to what the doctors tell me, fevers in such situations are not uncommon. But, at the same time, we are always on very high alert, and we have to make a professional decision when a combination of red flags comes up. Do we just ringfence them in NUH or do we physically move them across to Tan Tock Seng Hospital? So the Director of Medical Services and the Chairman of the Medical Board in each hospital are confronted with such professional decisions every time they are faced with situations like this. I think I have answered most of the questions. I am sure there will be many other questions which I have not answered, in which case, I will respond later on. I do not want to hold up the others.