Singapore's million-dollar defence against flu pandemic

Current vaccine stocks to be boosted - enough to treat 1.5 million patients
Salma Khalik, Straits Times 2 Oct 08;
SINGAPORE will be spending millions of dollars more taking out additional 'insurance' to protect against a flu pandemic - by buying a vaccine as well as more flu medicine.

It has already spent $31 million on 1.05 million courses of Tamiflu and 50,000 courses of Relenza - the only two medicines that are effective in reducing the effects of flu caused by any virus type.

It now wants to buy 650,000 more courses of Tamiflu. Patients need to take a course of 10 capsules over five days.

This arsenal will give Singapore enough to treat 1.5 million patients - 1.2 million projected to be infected by a pandemic flu bug, and the remainder who would be down with a different strain.

The extra medicine is expected to cost $19 million.

The Ministry of Health (MOH) will also be stocking up on a vaccine for the H5N1 virus, the bird flu virus which experts think will cause the next serious flu pandemic. It will call a tender to choose a vaccine this month.

There is no certainty that the H5N1 would cause a pandemic, when infections would sweep the world and cause untold numbers of illness and death.

But at least 16 drug companies think it might, and are at various stages of developing a 'pre-pandemic vaccine' against that strain.

Ireland and Switzerland have each bought enough of such a vaccine for every man, woman and child in the country.

Singapore will not be going that far, purchasing only 'a limited quantity'.

Dr Jeffery Cutter, MOH's deputy director for communicable diseases, said that underpinning the reasons for the decision were: Should Singapore pay for a stock of vaccines that may not be used? What is the bet the next attack would be from H5N1, and not, say, H7N2?

The vaccine would be useless against any other strain of flu. It may even lose its effectiveness against H5N1 if that virus mutates enough.

But not buying the vaccine means joining the global rush for limited stocks should expert predictions of an H5N1 outbreak pan out and the death toll starts moving into the hundreds of thousands.

More than 40 million people died of the Spanish flu in 1918. The flu pandemics of 1957 and 1968 took only six months to spread across the world. The first killed two million people and the second caused one million deaths.

Should the next attack be caused by H5N1, as experts widely predict, the results could be lethal, as there is no resistance in humans against this new virus. So far, it has killed more than 60 per cent of the 385 people infected.

Furthermore, the current capacity of all vaccine companies combined is about 40 million vaccine doses a year - not even enough for 1 per cent of the global population.

Dr Cutter said if Singapore had the vaccine, it would use the supplies as soon as the World Health Organisation declares a Phase Four - when human-to-human transmission increases. Right now, there is very limited transmission of the virus between people.

That will hopefully take place weeks before the first avian flu case is seen here.

For this vaccine to be effective, people need two doses three weeks apart, unlike a single shot for normal flu.

After essential personnel, priority for the vaccine would go to children aged between six months and 12 years, and sick people who are at higher risk of complications.

Associate Professor Leo Yee Sin, the head of communicable diseases at Tan Tock Seng Hospital, said: 'Getting the pre-pandemic vaccine gives a level of security. But you hope never to need it.'

The vaccine is expected to remain effective for three years. Fresh supplies would be needed beyond that.

Singapore has placed a deposit to ensure it is among the first to get any pandemic vaccine - no matter what strain of flu virus causes it.

But manufacturers will need three to six months to make the vaccines after a pandemic is declared.

At risk would be more than one million people here - about a quarter of Singapore's population - who are expected to be infected in the first wave of about six weeks.

But it should protect the population against a second wave that could surface some months later.

Treat patients in pandemic? Some GPs may quit: Poll
They fear being infected, but in fact, doctors will be among the first to get any vaccines
Salma Khalik, Straits Times 2 Oct 08;

NOT all doctors are willing to be in the line of fire in a flu pandemic.

A survey of general practitioners (GPs) and polyclinic doctors, who would be in the front lines of a massive infection here, found that almost three in 10 doctors felt they should not have to look after patients at the height of a pandemic.

One in eight would stop work to avoid the risk of catching a virus that could prove deadly, with some willing to quit their jobs rather than treat patients.

The results of the survey, by a team of doctors from the National University of Singapore and several polyclinics, were published in the June edition of Annals, the monthly journal of Singapore's Academy of Medicine.

They might be worrying too much. Primary-care doctors and their staff would be among the best protected people in the country in the event of a disastrous outbreak.

With their roles as the first caregivers that the sick would turn to, GPs are a precious commodity to be well looked after.

Singapore's emergency plans provide for GPs to be among the first to get any vaccines available. In the meantime, they will be given six weeks' supply of Tamiflu, which is believed to have some effectiveness in preventing the flu.

The Ministry of Health (MOH) will also rush them six weeks' worth of protective gear, like masks, gloves and gowns.

But the majority of doctors responding to the survey, which was done in 2006 and its results released only recently, would soldier on, even though almost all of them fear catching the dreaded virus in the course of their work.

According to MOH projections, primary-care physicians will treat 97 per cent of the more than one million flu patients expected to become ill in the first six weeks of a pandemic in Singapore.

Dr Jeffery Cutter, the ministry's deputy director of communicable diseases, said the vast majority of the sick will need only outpatient care, even in a pandemic.

Some 700 GP clinics, slightly more than half the total GP clinics in the country, have signed up to help in such an emergency.

Singapore is not alone in giving health-care workers priority during a pandemic.

In the United States, the authorities may consider protecting even health workers' families, at the urging of the head of the Centres for Disease Control and Prevention, Dr Julie Gerberding, who said that people worked best when they knew their families were safe.

This was reflected in the survey here, where about 96 per cent of the doctors in the survey said they feared for the safety of their parents, spouses and children. They were also concerned that they might face social ostracism.

The team that did the survey felt that addressing these concerns 'are crucial in the planning for and during any outbreak'.

The next big one
SINGAPORE has been preparing for the next flu pandemic since early 2004, following a surge of bird flu cases among people in countries such as Vietnam and Thailand.

The H5N1 virus is considered particularly dangerous, with a fatality rate of 63 per cent. Of the 387 known cases, 245 have died.

A flu pandemic could occur if a totally new virus emerges to infect humans. Lacking prior exposure to the virus, people would have no protection against it.

The virus would spread quickly around the world, infecting far larger numbers than seen in a normal flu season.

Death toll
Thousands have died in Singapore during previous flu pandemics over the last century.

2,400 Spanish flu in 1918. Caused by the H1N1 virus.

500 Asian flu in 1957. Caused by the H2N2.

300-400 Hong Kong flu in 1968. Caused by the H3N2.

1,900? Expected toll from next flu pandemic.