On high alert for bugs from abroad

KELLY NG Today Online 2 Jan 17;

SINGAPORE — It was a year in which infectious diseases — namely Zika and tuberculosis (TB) — claimed the spotlight. And the threat is set to stay and might even intensify as Singapore continues to see large numbers of people and goods flow in and out of its borders, say experts.

While Singapore is now better equipped with hardware to tackle various infectious diseases, its health system will continue to be tested more frequently, as recent events have shown. And this calls for the ability to be flexible and to respond in a nimble way, the experts said.

“Singapore is constantly in a vulnerable position in receiving emerging and re-emerging bugs … We are as ready as we can be, but every bug has its own characteristic. We need to be flexible and learn to adapt,” said Professor Leo Yee Sin, who heads the Institute of Infectious Diseases and Epidemiology at Tan Tock Seng Hospital.

The list of infections that have leapt from parts of the world miles away to the Republic’s shores has grown in the past two years, alongside the re-emergence of those endemic to the region.

While Singapore is now better equipped with hardware to tackle various infectious, its health system will continue to be tested more frequently, as recent events have shown.

Last August, the Ministry of Health (MOH) announced the first localised community spread of the Zika virus, with the number of cases shooting up to more than 150 within a week. The mosquito-borne infection, discovered in the 1940s, had spread wildly after it was reported in Brazil in May 2015 in Latin America, the Caribbean, the United States and South-east Asia. But exactly how the Zika virus found its way to Singapore — infecting almost 400 — remains a mystery.

In June the same year, the MOH announced that a cluster of six multi-drug-resistant tuberculosis cases had formed at a Housing and Development Board Block in Ang Mo Kio, casting a forgotten disease back into the spotlight.

In 2015, lapses at the Singapore General Hospital led to a hepatitis C outbreak that affected 25 patients, of whom eight have died — seven with the virus likely contributing to their deaths.

COLLABORATE WIDELY, COMMUNICATE CLEARLY

Singapore’s status as a transport hub — a key port-of-call between Australasia and Europe — makes it particularly vulnerable to pandemics from abroad, as seen in the Severe Acute Respiratory Syndrome (Sars) outbreak in 2003, and influenza threats in 2004, 2005 and 2009.

“Flights come and take off from (Singapore). It is good for commerce, good for logistics, good for viruses and epidemics too. They take the same trade routes,” said Dr Leong Hoe Nam, an infectious diseases specialist at Mount Elizabeth Novena Specialist Centre.

Complex distribution systems and food-handling protocols have also led to sporadic food-borne outbreaks — such as the Group B Streptococcus infection in 2015, which led the authorities to ban the use of freshwater fish in raw fish dishes, and the salmonella enteritidis infection behind the PrimaDeli food poisoning in 2007.

“Sars was a baptism by fire. We learnt it hard, and hopefully well. But we will need different ways to tackle different viruses … We need to be flexible as new attacks come. We will expect more of such attacks,” Dr Leong Hoe Nam said.

The Republic has the “basic pieces” in place to deal with any outbreak, but the region in which it is situated poses significant risks, said general practitioner Dr Leong Choon Kit, who sits on the Singapore Medical Council.

He said: “We must not forget that they (there?) are much bigger countries. Their size will add a lot more complexity and difficulty to managing any outbreak.”

Professor Duane Gubler, founding director of the Programme in Emerging Infectious Diseases at the Duke-NUS Medical School, urged the Government to be more pro-active in collaborating with neighbouring countries in infectious disease control.

“Singapore has a good surveillance and control system. This is where it can play a leadership role in imparting its knowledge to neighbours, and getting more involved with their healthcare infrastructure development,” said Prof Gubler.

Among a suite of recommendations proposed by a task force — established in the wake of the hep C outbreak in 2015 — to strengthen outbreak detection and response in Singapore include letting healthcare professionals report outbreaks anonymously and beefing up IT systems used to track these incidents.

Dr Paul Tambyah, secretary-general of the Asia Pacific Society of Clinical Microbiology and Infection, added: “Recognising that infectious diseases do not go through passport control, as was apparent with Ebola and Zika, has highlighted the need for international collaboration, research, and transparency in data reporting.”

Public communication is another area the authorities need to work on, especially in an era when inaccurate information can be rapidly disseminated via the Internet and social media.

“There is a high level of transparency now that we have not seen before. But how this information is communicated can be better … The ministry maintains its high bureaucratic style in communication, which doesn’t fit well (with the public) … Social media, on the other hand, generates too much buzz for something unimportant,” said Dr Leong Hoe Nam.

“With the Internet, information flow is rapid, so much so that the public assumes that there is some form of cover up … We need an authoritative and central voice during any outbreak. The public must learn to trust those who are in charge,” said Dr Leong Choon Kit.

MAKING THE COMMUNITY PART OF THE BATTLE PLAN

Besides the Government and infectious disease specialists, primary-care physicians and the community play a critical role in Singapore’s battle plan in the war against emerging and re-emerging diseases, health experts told TODAY, citing this year’s Zika episode as a prime example.

Three doctors at Sims Drive Medical Clinic — Dr Tan May Yen, Dr Lim Chien Chuan and Dr Chi Wei Ming — raised the alarm that led to the discovery of the first locally transmitted Zika cases when they saw a sudden spike in patients complaining of fever, rash and joint pain.

Dr Leong Choon Kit said: “We see diseases at its early stages and are experts in the undifferentiated stage. Often we may not be able to nail down the exact diagnosis. Training would allow us to raise alerts far ahead of an epidemic. We are like watchmen of the old days.”

Dr Leong added that GPs and community leaders are well-positioned to advocate for vaccinations and good hygiene practices, which are often key to preventing the spread of diseases.

Besides being the “sentinels in the front-line of surveillance”, GPs play a key part in educating patients on the responsible use of antibiotics, noted Dr Jeremy Lim, who leads the health and life sciences and public sector practices of consulting firm Oliver Wyman in the Asia-Pacific.

Dr Leong Choon Kit concurred, calling for an end to “indiscriminate” antibiotic prescription for common coughs and colds to thwart the rise of drug-resistant “super bugs”.

Dr Leong Hoe Nam also urged caution when importing food from other countries. “We need to be cautious when we import (food) ... What they feed in their country will create antimicrobial resistance in the animals that are sold as meat to us. And it comes over to us,” said Dr Leong.

Dr Tambyah added that a majority of antiobiotic use is in agriculture. “Many people are coming into hospitals with antibiotic-resistant bacteria in (their) intestines. That is why a comprehensive approach is needed to ensure that farmers have alternatives to antibiotics in ensuring healthy animals and plants,” he said.

The experts also called for individuals to uphold personal responsibility in keeping healthy. Said Dr Leong Choon Kit: “When they do not feel well, they should seek help. They should also keep abreast of the latest updates and instructions, and not spread baseless hearsay gleaned from social media of (or?) their own assumptions.”

For instance, while the link between the Zika virus and microcephaly has not been fully established, it has generated much fear worldwide and among Singaporeans, he said.

Dr Tambyah added that the community can help by not discriminating against infected individuals to encourage people to come forward to be tested.

“This is very important for infectious diseases such as TB and HIV (Human Immunodeficiency Virus) infection, where early detection can lead to successful treatment and prevention of spread,” he said.