41 confirmed cases of Zika in Aljunied

TAN WEIZHEN Today Online 29 Aug 16;

SINGAPORE — A day after confirming the first locally transmitted case of Zika, the Ministry of Health (MOH) revealed that 40 more patients have been confirmed in the Aljunied Crescent-Sims Drive area, through the tracing of past cases.

And more cases could emerge, given that the majority of Zika cases have no symptoms or only mild ones, and mosquitoes in affected areas may already have been infected, the ministry said on Sunday (Aug 28), at a press conference held by MOH and the National Environment Agency (NEA).

The MOH, warning of further community transmission, said other areas of concern at this point include Khatib Camp, Sembawang Drive and places where the construction workers live, including Kranji Road, Joo Chiat Place, Senoko South Road, Toh Guan Road East and Lorong 101 Changi.

Of the 41 Zika cases, 34 patients have fully recovered. Seven still have symptoms and are recovering at Tan Tock Seng Hospital, the MOH said. Isolation of positive cases may have limited effect in managing the spread, the authorities said, as it announced intensified operations to clamp down on mosquito breeding.

The Zika virus is spread by the Aedes mosquito, which also transmits dengue. The virus has been linked to serious birth defects in children whose mothers were infected during the pregnancy.

On Saturday, the ministry disclosed that a 47-year-old Malaysian woman living in Block 102 on Aljunied Crescent had become the first to contract the disease locally. The woman, referred to as Patient A, was diagnosed on August 25.

But even before that, a clinic in the Aljunied area — Sims Drive Medical Clinic — had informed MOH of an “unusual increase” in cases with fever, rash and joint pain on Aug 22. The next day, MOH officials had visited the clinic and discussed the cases with the general practitioner. The “initial hypothesis”, it said, was that it was a cluster of mild viral illness transmitted from person to person.

It then made arrangements for the clinic to refer new cases to the Communicable Diseases Centre (CDC) for further testing, and started tracing past cases for further review and if needed, testing.

On Aug 25, the MOH had gone to the contractor of a nearby construction site for records of workers with fever. That day same, Patient A had gone to the doctor after she developed a fever, rash and conjunctivitis, and was referred to the CDC.

Explaining the developments on Sunday, the MOH said so far the earliest case dates back to July 31. Among the patients, 36 are foreign workers working at a construction site on 60 Sims Drive, four are Singaporeans and one – Patient A - is Malaysian.

Unlike the first case of Zika to emerge in Singapore in May, these 41 patients had not travelled to Zika-infected areas recently so they were likely to have been infected in Singapore.

Asked why the MOH only announced the case of Patient A two days after she was diagnosed - when testing only takes about three to four hours - Health Minister Gan Kim Yong said that the ministry was only alerted to the possibility of more cases when Patient A was confirmed.

“Now that we know there is a case ..we’ve therefore gone back to all these cases that were surfaced before, and checked their blood tests and thats why we have discovered more cases...out of the 41 cases, I think some 36 cases were a result of this active testing of the patients who were in the areas of concern,” said Mr Gan, speaking to reporters after the press conference on Sunday.

Pressed further, he added that some cases required “double confirmation”.

Dr Derrick Heng, the MOH’s group director for public health, pointed out during the press conference that test results of the other cases only came back late Saturday night.

Infectious diseases expert Leong Hoe Nam, who diagnosed Singapore’s first Zika case at Mount Elizabeth Novena Hospital earlier this year, called the MOH out on not starting investigations earlier.

“Every single mild case of fever, they should have investigated, it was a chance to break the cycle. Kudos to the GP who picked up the trend. We must remember that Zika is very mild, compared to dengue. Patients may not be sick enough to go to hospital but to the GP instead. So the GP now is the gatekeeper,” Dr Leong said.

MacPherson Member of Parliament Tin Pei Ling, who oversees the ward that Patient A lives in, said that it would have been ideal if the MOH had acted on any suspicion earlier.

“It would have been most ideal to take a more conservative approach at that point in time, if there had been early suspicion, to check if there were any positive cases. But I suppose MOH would have taken the balanced approach between alarming everyone, and doing proper checks,”said Ms Tin.

But Member of Parliament Chia Shi-Lu (Tanjong Pagar GRC), head of the Government Parliamentary Committee for Healthcare, pointed out that none of the cases had a travel history, which “significantly” reduced the likelihood that they were infected.

“It depends on the risk profile, we have to remember that the problem with Zika is that most cases have no symptoms. It’s not like Sars or Mers, or dengue, which are easier to detect,” said Dr Chia, an orthopaedic surgeon.

He added: “It was very good that the GP detected the cases, all credit to this GP who was alert enough.”


Why the MOH did not announce the Zika cases earlier
TAN WEIZHEN Today Online 29 Aug 16;

Q) When was the earliest case that Ministry of Health backtracked to?

Dr Derrick Heng (MOH Group Director for Public Health Group): The (earliest) case that we know of was July 31. We would not have picked up on all the cases, (so) we would not be able to pinpoint definitively the first index case (patient zero).

Mr Koh Peng Keng (MOH Group Director, Operations): The first case we knew of was patient A (the 47-year-old Malaysian woman whose case was reported on Saturday). The rest of it we had to work with the GPs, to do a lot of tracking to try and look back.

Dr Heng: We went back to look at people who were part of the GP (cases), and (at the) construction site, the people who had reported symptoms in the past. We took samples...the samples (tested) positive sometime late last night (on Saturday).

Mr Koh: The GP alerted us of this unusual cluster of cases with mild symptoms, it’s only (then) we went back to check....most of them had already recovered. So it was a look back...Initial hypothesis was that it was just some mild viral infection that transmits from person to person. Zika was not specifically suspected at that point when the GP was seeing this group.

Q) Saturday was confirmation that the woman (patient A) had Zika. But you had preliminary results, did you start looking before Saturday, or did you only start work on Saturday when you had confirmed results?

Dr Heng: We started preparations when the preliminary results (came out). But we had to wait for confirmation in order not to create false alarm.

Q) Patient A was at CDC on Aug 25, and it takes about three hours to do the test. So you should have known by that night.

Professor Leo Yee Sin (clinical director of Communicable Disease Centre): Her presence at CDC from the time we received her as a case, to the time she did the blood test, all this is actually a very compressed period of time, including getting her back for further assessment.

Q) The first case was announced on Saturday, and it jumped to 41 cases. Could the MOH have announced all these cases earlier?

Health Minister Gan Kim Yong: Part of the reason that we have discovered more cases is because we have now gone back to the cases that were seen before by doctors. They were not suspected to have Zika, because they have no travel history and so on. Now that we know there is a case ...we’ve therefore gone back to all these cases that were surfaced before, and checked their blood tests, and that’s why we have discovered more cases, as a result of the first case. So out of the 41 cases, I think some 36 cases were a result of this active testing of the patients who were in the areas of concern, whom we felt there was the potential they would be infected by Zika. Then we went back to relook at their test results. Some were even retested to determine whether they were infected by Zika.

Q) Why did it take two days before the MOH announced patient A’s case?

Mr Gan: Some required double confirmation. So first we tested them on the urine test...various steps of testing.

Q) So it’s not like you knew about it earlier, but was keeping quiet about it?

Mr Gan: No, of course not.


41 cases of locally transmitted Zika infection in Singapore: MOH, NEA
Channel NewsAsia 28 Aug 16;

SINGAPORE: The Ministry of Health (MOH) has confirmed 41 cases of locally transmitted Zika virus infection in Singapore, it announced on Sunday (Aug 28). Of these, 34 people have fully recovered while the other seven, who are still symptomatic and potentially infectious, are recovering at Tan Tock Seng Hospital.

In a press conference on Sunday, MOH and the National Environment Agency (NEA) said that all the cases are residents or workers in the Aljunied Crescent or Sims Drive area. They are not known to have travelled to Zika-affected areas recently, and are thus likely to have been infected in Singapore.

"At this point, the community transmission appears to be localised within the Aljunied Crescent or Sims Drive cluster," said Associate Professor Benjamin Ong, Director of Medical Services at MOH.

Of the cases, 36 are foreign workers who worked at a construction site at 60 Sims Drive. Others include four Singaporean men aged between 21 and 65.

The announcement comes a day after NEA and MOH said a 47-year-old Malaysian woman living at Block 102 Aljunied Crescent was Singapore's first reported case of locally transmitted Zika. She is the only female out of the 41 cases.

AREAS OF CONCERN

Aside from the Aljunied and Sims Drive cluster, areas of concern include Khatib Camp, where a 21-year-old patient is serving National Service, and Sembawang Drive, where a 30-year-old patient who works at the Sims Drive construction site lives. Places where the construction workers live – Joo Chiat Place, Senoko South Road, Toh Guan East and Lorong 101 Changi – are the other areas of concern.

“Given that the Zika virus is spread by the Aedes mosquito vector, MOH cannot rule out further community transmission in Singapore, since some of those tested positive also live or work in other parts of Singapore,” said Assoc Prof Ong.

MOH will continue to screen the close contacts of confirmed cases. It is also carrying out Zika testing on others living and working in the Aljunied Crescent or Sims Drive and other areas of concern who have symptoms of fever and rash.

The Health Ministry has also worked with the contractors at a construction site at Sims Drive to screen the workers who were recently reported by a general practitioner to have symptoms of fever, rash and conjunctivitis. The authorities have also verified that so far, there are no symptomatic cases at Khatib Camp.

MOH has also alerted all GPs, polyclinics and hospitals to be extra vigilant and to immediately report patients with symptoms associated with Zika to the ministry.

Since Saturday, NEA has intensified vector control operations to control the Aedes mosquito population in the vicinity of Aljunied Crescent or Sims Drive. More than 200 officers have been deployed to inspect the area.

“We expect to identify more positive cases. Given that the majority of Zika cases are asymptomatic or mildly symptomatic, and mosquitoes in the affected area may already have been infected, isolation of positive cases may have limited effect to managing the spread," said NEA and MOH in a joint press release on Sunday.

HEALTH ADVISORY FOR PREGNANT WOMEN

According to studies, the microcephaly risk for babies born to Zika-infected mothers is between 1 and 10 per cent, said Associate Professor Arijit Biswas, Head and Senior Consultant of the Department of Obstetrics and Gynaecology at National University Hospital.

Microcephaly is a birth defect where a baby’s head is smaller than expected compared to babies of the same sex and age.

According to MOH and NEA, pregnant women should take precautions if living, working, studying or travelling to an affected area. If they do not have symptoms, routine antenatal care is sufficient. Individuals working, studying or living in an affected area should adopt safe sex practices or consider abstinence throughout the women's pregnancies, MOH and NEA added.

Besides Singapore, 57 other countries have reported cases of locally transmitted Zika virus infection.

- CNA/jq


More Zika cases expected to emerge: Health Minister Gan Kim Yong
Linette Lim Channel NewsAsia 28 Aug 16;

SINGAPORE: More local Zika cases are expected to emerge over time, said Health Minister Gan Kim Yong on Sunday (Aug 28). This will be partly due to the fact that active testing is being carried out in affected areas, as well as the possible emergence of new imported cases, he added.

Mr Gan was speaking to the media after the Ministry of Health confirmed 41 cases of locally-transmitted Zika virus infection at a press conference.

“Singapore has a very high volume of international travel, therefore imported cases are almost inevitable,” said Mr Gan, explaining that as many Zika cases are asymptomatic, there is a “very high likelihood” of the virus being imported to Singapore.

He added that for these imported cases, the likelihood of local transmission “is also very high“. This is why the Health Ministry is also working with doctors to be on the lookout for Zika cases, in order to identify clusters and carry out vector control.

Mr Gan also said that vector control is the most effective way to protect against zika - not just for residents in affected areas but for people living in all locations. “This is because the Aedes mosquito is present in Singapore, and it is very likely for this disease to be transmitted locally.” Vectors are organisms that transmit diseases.

On Saturday, a 47-year-old Malaysian woman living in Aljunied Crescent was confirmed as Singapore's first reported case of locally-transmitted Zika virus infection.

After tests results came in overnight, the Health Ministry confirmed on Sunday that there are 41 cases of locally transmitted Zika virus infection. Of these, 34 people have fully recovered.

Mr Gan said that part of the reason for the jump in numbers is that after the first locally transmitted case was reported, the Health Ministry looked back into cases where people were seen by doctors but were not suspected to have Zika. These cases were initially not suspected for Zika as the patients had no travel history, said Mr Gan.

“Now that we know that there’s a case in the Sims Drive area, we have therefore gone back.... to all these cases that were surfaced before, and checked their blood tests and so on. And this is why we discovered more cases, as a result of the first case,” he said.

“It was not a case whereby we did not know, and there’s sudden emergence of these cases. Out of 41 cases, 36 were (detected) due to this active testing.”

- CNA/mz


No attempts to cover up Zika cases: Chee Hong Tat
Channel NewsAsia 29 Aug 16;

SINGAPORE: Minister of State for Health Chee Hong Tat late Sunday (Aug 28) rejected suggestions that there have been attempts to cover up Zika cases in Singapore.

The Ministry of Health (MOH) and National Environment Agency (NEA) had announced earlier Sunday that there were a total of 41 cases of locally transmitted Zika in the Aljunied Crescent/Sims Drive area, up from one case the day before.

Mr Chee noted on Facebook that some people have been wondering about the jump in the number of cases. "A few even asked if there had been attempts to cover up these cases. This is certainly not true," he wrote.

Mr Chee, who is also Minister of State for Communications and Information, referred to the timeline of events outlined by MOH and NEA. Following confirmation from the Communicable Disease Centre that a 47-year-old woman living in Aljunied Crescent was infected with Zika in Singapore, tests were conducted on 123 people who were recently or currently symptomatic, MOH and NEA said.

The Minister of State added that his colleagues in MOH and NEA have been "working hard over the past few days" to provide timely updates on the latest developments and to coordinate with residents, community leaders and healthcare professionals on the follow-up actions. "This includes colleagues from the laboratories who are doing confirmation tests for suspected cases - they have been working till way past midnight to complete the tests, so that the results can be announced in a timely manner," he stated.

"You can see from the timeline that MOH and NEA have been proactive in engaging the different stakeholders to identify possible cases, conducting screening and testing to identify the confirmed cases, and promptly announcing such cases to the public once they have been confirmed," Mr Chee said.

The opposition Workers' Party had earlier released a statement calling on the Government to clarify the timeline for public notification of the Zika cases. "Prompt public notification of Zika cases is important so that members of the public in the affected areas can take the necessary precautions and so that stakeholders can take vector control measures," it said.

Mr Chee noted that Zika is generally a mild disease and 80 per cent of patients do not show symptoms. "It is possible that more people may have been infected by the virus but they are not aware," he wrote. He urged people in Singapore to take precautions by helping to curb mosquito breeding, and by applying insect repellent regularly.

- CNA/ly


Battle against mosquitoes to be stepped up over next fortnight
TAN WEIZHEN Today Online 29 Aug 16;

SINGAPORE — Intensified operations to control mosquito breeding, which began on Saturday, will continue in Aljunied Crescent and Sims Drive over the next two weeks.

These operations include inspecting all premises, ground and congregation areas, ultra-low volume (ULV) misting and spraying of premises and thermal fogging of outdoor areas, more frequent drain flushing and oiling to prevent breeding, and public outreach and distribution of insect repellent.

They will also be carried out in “areas of concern” flagged by the authorities, namely Khatib Camp, Sembawang Drive, Kranji Road, Joo Chiat Place, Senoko South Road, Toh Guan Road East and Lorong 101 Changi.

Yesterday, the Ministry of Health (MOH) revealed that there were 41 confirmed Zika cases in the Aljunied Crescent and Sims Drive area — the first cases of local transmission here. The area includes a construction site at Sims Drive and dormitories and workers’ quarters.

In total, the National Environment Agency’s (NEA) operations and checks are set to cover more than 6,000 premises including 5,000 HDB flats and workers’ quarters.

More than 200 NEA officers were deployed on Saturday to inspect the area, conduct vector control, as well as to reach out to residents. The NEA said it has successfully accessed more than 1,800 premises to carry out checks for mosquito breeding.

Nineteen breeding habitats were detected and destroyed, of which 13 were in homes and six in common areas. Of the two dormitories in Kranji and Senoko South that were inspected, one breeding site was detected in Kranji. A stop work order was also issued to the construction site at Sims Drive on Saturday, for creating conditions for mosquito breeding.

The NEA said its staff had visited 14 blocks in the vicinity of Aljunied Crescent and Sims Drive, distributed Zika information leaflets and insect repellent, and continued to reach out to the rest of the blocks in the area yesterday. NEA staff started visiting residents in Sembawang Drive yesterday evening.

From as early as 9am yesterday, the typically sleepy residential estate of Aljunied Crescent was abuzz with a flurry of activity, as officers conducted fogging and misting operations, checked drains, and knocked on residents’ doors to hand out flyers and bottles of insect repellent.

Senior Minister of State for Health and Ministry of Environment and Water Resources Dr Amy Khor, who was distributing flyers to residents in the Sims Drive area, said that residents so far had been “cooperative” and were willing to open up their homes for officers to check for potential mosquito breeding areas and let their premises be misted. Homeowners who were not in will find letters left for them instructing them to make future appointments.

When asked if the ministry would expand efforts islandwide, Dr Khor would only say that the priority is to reduce the size of the Aedes mosquito population. “Residents should play their role in helping to control the population by taking steps like the five-step mozzie wipeout, checking their homes are free of mosquito breeding sites and being vigilant by informing a doctor of potential symptoms, as well as (sharing) their travel history, especially if they have been to areas affected by Zika.”

Speaking to reporters after a media briefing on the spate of cases yesterday, Health Minister Gan Kim Yong said that vector control efforts need to be “redoubled”, to reduce mosquito breeding sites and minimise the risk of transmission.

“I think this is an effort that must be sustained, and we must continue to do so. It’s not easy to achieve good results, partly because of weather conditions in the tropical area, which is very conducive for mosquitoes to breed. Therefore, we need to re-double our efforts in managing our vector control,” he said.

In a joint statement, the MOH and the NEA advised those working or living in the Aljunied Crescent and Sims Drive area, especially pregnant women, to monitor their health.

They should seek medical attention especially if they have symptoms of fever and rash, and inform their doctors of the location of their homes and workplaces.

Pregnant women are especially susceptible as Zika, which is transmitted by the bite of an infected Aedes mosquito, can cause microcephaly, a birth defect where the head of the infant is abnormally small, in their unborn foetuses. ADDITIONAL REPORTING BY TOH EE MING


Sudden spike in complaints triggered alarm: Doctors
KELLY NG Today Online 30 Aug 16;

SINGAPORE — The three doctors at Sims Drive Medical Clinic who raised the alarm that led to the discovery of the first locally-transmitted Zika cases said they first sensed something amiss in the second week of this month.

Dr Tan May Yen was the first to flag the sudden spike in complaints of fever, rashes and joint pain. At its peak, there was an “unusually high” number of about 10 such cases a day, compared to between zero and three cases normally, said her co-worker Dr Lim Chien Chuan on Monday (Aug 29).

What stumped them was how the patients who agreed to be tested for dengue, chikungunya, measles and rubella were cleared of these conditions, even after repeated tests.

The possibility of them contracting Zika was not raised, as most of these patients — a bulk of whom are foreign workers who worked at a construction sites in the vicinity — had not travelled to countries with ongoing Zika outbreaks. “Most of them had very mild symptoms ... But we were seeing more than (the) usual (number of cases) and all with the same symptoms ... (We were) not sure about (whether it could be) Zika as most of the cases did not exhibit the relevant travel history,” said Dr Lim.

Dr Tan, Dr Lim and a third colleague, Dr Chi Wei Ming, started discussing the diagnoses of cases each of them handled, and decided to bring the matter up to the Ministry of Health (MOH) on Aug 22.

After some tracing, 41 confirmed patients have been found in the Aljunied Crescent-Sims Drive area, as of noon Sunday. Of the 41 Zika cases, 34 patients have fully recovered. Seven still have symptoms and are recovering at Tan Tock Seng Hospital, the MOH said. Thirty-six of the patients are foreign workers working at a construction site on 60 Sims Drive.

As of noon on Monday, five patients who visited Sims Drive Medical Clinic — two women and three men — were sent to the CDC for further tests.

When the MOH confirmed on Saturday that their patients had Zika, the doctors at Sims Drive Medical Clinic felt torn. While their puzzle had been solved, it meant there were now locally-transmitted Zika cases.

“On one hand, we know what is wrong with these patients. But on the flipside, it means Zika is now in the community, so everybody has to put in efforts and (take) the necessary steps to control the symptoms,” said Dr Chi.

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