INFLUENZA A (H1N1-2009) OUTBREAK

INFLUENZA A (H1N1-2009) OUTBREAK: 3.

Mdm Cynthia Phua asked the Minister for Health in light of the current outbreak of Influenza A (H1N1-2009) (a) what is the charge for calling the designated ambulance service 993; (b) what can the Ministry do to lower the related charges including the cost of testing for Influenza A (H1N1-2009) and the cost of Tamiflu; (c) whether the Ministry has a recommended guideline for fees charged by neighbourhood Pandemic Preparedness Clinics; and (d) how can the Ministry help lower income families affected by Influenza A (H1N1-2009).

The Minister for Health (Mr Khaw Boon Wan): Sir, Mdm Cynthia Phua has asked four specific questions on Influenza A (H1N1-2009). As this is the first time we are discussing this subject in this House, I shall give a comprehensive reply on this subject.

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On 24th April, Sir, that was three months ago, the World Health Organization sounded the alert on a novel virus then circulating in Mexico and initially referred to as "the swine flu" by the media. As pig farmers raised their objection, the new virus picked on different names, including "the Mexican flu", "the North American flu". When cases began to appear in California, somebody suggested that it be called the "Schwarzenegger virus" and somebody even suggested calling it the "Terminator". The World Health Organization is less colourful and settled on naming it "Influenza A (H1N1)". While ground zero was Mexico, the virus quickly became a global pandemic and World Health Organization declared it as such on 11th June. This was of historic significance because in the last century there were only three such pandemics declared.

The initial reaction by the world was one of grave concern. The data coming out of Mexico were serious. They reported a very high case fatality rate of some 6.2% during the initial period. The normal case fatality rate was less than 0.1% for seasonal flu so this was more than sixtyfold. Moreover, the casualties in Mexico were largely coming from the young adult population, including pregnant women.

Three months after the WHO alert, the world has learnt a lot more about this novel virus and how to cope with it. While some serious issues remain, experts have generally come to the conclusion that this virus is behaving more like the seasonal flu: it can spread easily but the vast majority of the patients can recover fully, even without hospitalisation. WHO has classified this disease as one with "moderate risk". By now, all countries have shifted their strategy from "containment", in other words, trying to contain the spread and minimising the number of infected patients, to what is

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called "mitigation", which is treating the high-risk patients and trying to minimise the number of deaths. In line with this approach, the World Health Organization has stopped counting the number of patients and doctors are now treating the patients clinically rather than subjecting every suspect case to Influenza A (H1N1-2009) laboratory testing. Moreover, most patients are now being treated by GPs as outpatients. Only the high-risk patients are referred to hospitals and hospitalisation is now the exception, rather than the norm. Likewise, travel advisory, temperature screening at airports, contact tracing and home quarantine measures have by now been largely stepped down.

In Singapore, we have moved our outbreak alert level from green to yellow, then briefly to orange before we moved it back to yellow. Singaporeans have done well in this battle against the first wave of the Influenza A (H1N1-2009) outbreak. Our media have done a good job of keeping everyone informed. There was no hysteria or panic, neither was there any complacency. Singaporeans took the pandemic seriously, but also carried on their lives normally, going on June holidays and taking part in the Great Singapore Sale. Schools re-opened in July uneventfully and we had a successful hosting of the first Asian Youth Games, without any major incident.

I want to thank all our front line staff – at the borders, in hospitals and clinics, in schools, in the laboratories, in childcare centres, Aloha and Pasir Ris holiday chalets, in 993 and 995 ambulances, in hotline call centres – for their dedication and diligence. They do their jobs seriously and put up with the discomfort of wearing N95s and surgical gowns. Many had their own travel plans cancelled and many worked long hours, pulling extra shifts to cope with the sudden surge in the number of suspect cases and patient load.

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I want to thank Singaporeans for their sense of social responsibility. Temperature scanners at the borders picked up only one-quarter, 25% of the returned travellers with Influenza A (H1N1-2009). The other three-quarters slipped through the borders because they had no symptoms at the time of arrival, but they promptly came forward to be tested when symptoms emerged. Many had to suffer long, agonising and uncomfortable waiting under the tent outside the hospital Emergency Department while their lab tests were being processed. I thank them for their patience and tolerance.

After Mexico, US and Canada went into community spread of the virus almost immediately. They had to move straight into the mitigation phase. They had no time, no opportunity to even do any kind of containment measures. In Asia, some countries went into community spread after a month, despite very strong containment measures. Singapore was into community spread after seven weeks. We were lucky

but I think the efforts jointly put in by all Singaporeans must have contributed to this outcome.

The seven-week lag was valuable. It allowed us to better prepare our people psychologically for the eventual community spread. It allowed us to gear up our Pandemic Preparedness Clinics (PPCs) and our hospitals to free up isolation and ICU beds to treat the more complicated cases.

We are now in the last leg of our battle against the first wave of the Influenza A (H1N1-2009) outbreak. But the war is not over yet. The enemy is still out there. Going by the experience elsewhere, more Singaporeans will get infected, reaching a peak before the numbers start to decline, as we observed in New York City, where the wave peaked in May-June and has been declining since. Experts refer to this phenomenon as the community acquiring "herd immunity".

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We track this development by a robust surveillance system of sampling patients with flu-like symptoms and determining the precise cause of their symptoms. Prior to community spread, none of the samples revealed any patient with positive Influenza A (H1N1-2009). Four weeks ago, the surveillance system showed that 13% of the samples were found to be Influenza A (H1N1-2009) positive. The figure moved up to 30%, two weeks ago. The latest data showed that 53% (more than half) of patients with flu-like symptoms had been infected with Influenza A (H1N1-2009). This number will continue to grow as the Influenza A (H1N1-2009) strain displaces the other influenza strains and becomes the dominant strain for this season. What it means is this. There are many influenza strains. Influenza A (H1N1-2009) is just one of them. If you happen to catch influenza during this period, say, the last few weeks or the next few weeks, the chances are, very likely, that it will be Influenza A (H1N1-2009) rather than the other traditional strains of Influenza.

As the current virus strain is mild, this development is largely benign as almost all patients will fully recover. But there will be complications among some high-risk patients and even deaths. The overall risk of death is similar to normal seasonal flu, but the risk groups are slightly different. In normal flu, those over 65 years old are at highest risk along with the very young, under two years. But in this flu, younger adults are at higher risk than those over 65, if they have underlying medical problems, such as asthma, chronic problems with breathing, gross obesity (so do keep your weight), low immunity or are pregnant. That is why we are still in yellow alert.

Over the past few days, we have stepped down many control measures, at the borders, at mass events, in factories

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and in offices. Temperature taking remains in schools and SAF camps. The influenza surveillance data suggests that Influenza A (H1N1-2009) prevalence should peak within a week or two and we can expect to step down temperature taking in schools from 1st August. For SAF camps, they will step down their control measures appropriately, in accordance with their specific operational needs. However, our hospitals remain on high vigilance and we continue to discourage visitation and remind all to practise infection control measures. In the hospitals and in various places, we provide reminders as well as surgical masks for the visitors to use.

During this phase of the outbreak, there are three priorities. First, we are focusing on the high-risk patients and helping them enhance their chance of a full recovery. These are patients with underlying medical conditions, where the experience elsewhere suggests that they may face complications, including deaths. We have a few cases already. They had to be admitted to ICU for intensive care. With effective treatment, a couple have fully covered. But, unfortunately, one with a severe heart disease had succumbed to heart attack, with Influenza A (H1N1-2009) infection as well. Right now, there are still a handful in ICU, fighting for their lives and our doctors and nurses are doing their best to help save their lives. We need patients to come forward promptly, and not wait until their symptoms have become too serious to reverse.

Second, we are reviewing our control measures in the past three months. There are valuable lessons to extract from this experience and we must plug any gaps and deficiency.

Third, we are preparing Singapore for the next wave of Influenza A (H1N1-2009). Experts believe that the next wave may come when winter returns to the northern hemisphere and they worry that

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the virus may then become more deadly. This is not a certainty, as viruses mutate all the time and, often, they also attenuate and become less deadly. While we hope for the best, we must, of course, always prepare for the worst.

An important aspect of the preparation is to ensure we have access to an adequate supply of a safe and effective vaccine. None exists today although there are many claims by vaccine manufacturers of such a supply before year end. We have an ongoing contract with an established vaccine manufacturer for a pandemic vaccine sufficient for our population. We are supplementing this contract with an order for one million doses from the vaccine manufacturer who can promise the quickest delivery.

But we should not put all our eggs in the vaccine basket. Any vaccine based on the current mild strain may not be effective if the virus turns more deadly. And if the virus remains mild, there may be little demand for the vaccine.

Instead, the most basic strategy against an influenza pandemic is a very high standard of personal hygiene by all Singaporeans. This can be learnt by all and incorporated into our daily life. Singaporeans must also learn the sound habit of staying at home and away from crowds when unwell and have a runny nose, fever or cough. It is no fun falling sick and we must not inflict this on others around us. And if you must go out, please put on a surgical mask.

Let me now address the specific queries by Mdm Cynthia Phua. Calls to 993 ambulance service were not charged. They are free. As the demand for 993 has shrunk considerably, we are winding up the service. In fact, we will stop the service tomorrow.

The laboratory testing of Influenza A (H1N1-2009) is costly, at about $250 per

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test, but the Ministry of Health (MOH) absorbs the cost in full. So again, it is free of charge to the patients. Tamiflu is quite affordable, at $45 for a standard treatment cycle. It is chargeable, in line with our philosophy of co-payment.

We do not regulate the charges by the Pandemic Preparedness Clinics (PPCs) but generally our GPs are price competitive and their fees are largely affordable. Those who need subsidised care can get it at the polyclinics. Let me assure Members that the lower-income families with Influenza A (H1N1-2009) or, for that matter, any other disease, will all be helped, if they have difficulty paying their medical bills. Medisave, MediShield and Medifund – the three Ms – are specifically designed for this purpose.

Dr Lam Pin Min (Ang Mo Kio): Mr Speaker, I would like to thank the Ministry of Health for doing an excellent job in helping Singaporeans battle Influenza A (H1N1-2009) pandemic. I would like to ask the Minister one question which is, whether there are any clear and timely guidelines to the PPCs on when to offer Influenza A (H1N1-2009) testing. The reason I ask this is because there were reports in the papers that patients were turned away, treated symptomically and later found to have Influenza A (H1N1-2009) infection. There are down stream effects such as the duration of MCs to be given, whether the need for Tamiflu prophylaxis for the close contacts in the family as well as to prevent the further spread of the disease to the surrounding family members.

Mr Khaw Boon Wan: Mr Speaker, Sir, we do issue guidelines to the PPCs and, in fact, we have organised several workshop sessions for the GPs. More than 500 of them have come forward to take part in this PPC network and we thank them for their service. The reasons for some of the confusing media reports were because we

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were in transition then. Remember all these happened just only in the last three months. We went through a lot, but it was just three months ago when this novel virus suddenly appeared. Inevitably, there was some "clumsiness" in implementation but, by and large, we have stabilised.

What the guidelines are focusing now are on high-risk patients. As a doctor, Dr Lam knows that it is very difficult to make, without laboratory testing, a distinction between ordinary influenza and this particular strain, as the symptoms are practically identical. So, short of doing a laboratory test, we cannot establish whether it is due to Influenza A (H1N1-2009). But now that we know the mild or moderate risk nature of this virus, we can be a little bit more relaxed as to whether we make a mistake or not in the classification. Critically, we focus on the high-risk groups, certainly pregnant women, those with transplant history or with renal failure, etc. We can then focus our mind on their condition and, if necessary, admit them to the hospitals for testing.

MCs are the same thing. In the earlier days, we were not sure how long the period ought to be and therefore there were some inconsistencies. But I think, by and large, the system would have stabilised by now.

Mdm Halimah Yacob (Jurong): Sir, I would like to ask a supplementary question. The Minister mentioned that the supply of Tamiflu will not be enough. Are there efforts to try and increase the supply? Some countries like the UK, for instance, have decided to provide the vaccinations to almost the entire population. Is that feasible and desirable in Singapore's context? If not, is it practical or possible to focus on the high-risk groups and to vaccinate them in view

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of the fact that there may be a more virulent strain of this virus that may develop in later months?

Mr Khaw Boon Wan: There have been a lot of media reports on what different countries intend to do. Some of the media reports quote statements by pharmaceutical companies. I suggest that we take it with a pinch of salt, although we should not take too much salt as it is bad for your heart. The reality is there is a lot of uncertainty over when we will get this vaccine. And the key question is: Will it be safe? Will it be effective? Like all new drugs, we do need time and proper clinical trials to decide whether the drugs that we will be injecting into people are safe and effective. And all those studies take time. I doubt there will be any country which will go straight into vaccinating its population, let alone, in large numbers. Instead, many talk in terms of getting access to the supply of vaccines as an insurance policy. But whether you decide to start vaccinating, they will take it as a second-order decision. And we will be taking the same approach here.

Singapore, being small, is at an advantageous position, as our needs are not that big. But for countries with a huge population, inevitably, they will have to prioritise. WHO gathered a group of experts, two weeks ago, and they published a set of very useful guidelines, totally unpoliticised, based purely on clinical arguments, setting out the priorities. Those at the top of the priority will be essential workers – to make sure that essential services can continue to function – including hospitals and the Home Team, for example, in the case of Singapore. And beyond the essential personnel, for the general population, we will start targeting the high risk groups. So, definitely, pregnant women will be quite high up on the priority, kids with other underlying medical conditions will also be given the priority.

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Mr Speaker: Last question, Mdm Cynthia Phua.

Mdm Cynthia Phua (Aljunied): Sir, I would like to ask the Minister whether he could consider a dedicated website for such epidemics. The reason is I notice that MOH does have in the website itself certain issues related to Influenza A (H1N1-2009). But you may want to go into the details and also the concerns of the people at each stage of the epidemic, for example, currently, the use of Tamiflu, whether it is a preventive measure or it is a cure. Such matters are of concern to people at each

stage of the epidemic. If you have a dedicated website, then there could be some interactive communication with the people.

Mr Khaw Boon Wan: Sir, that is certainly a sound suggestion, and we did do that. We started a "flu.gov.sg" website. The associated website, whether it is from the Ministry of Health or some other Ministries, will also point towards that website.

So, information is available, including the type of questions that Mdm Phua mentioned. I do not think Singaporeans were poorly informed in this particular exercise. As I said, the main media did a very good job, and so did the new media. Periodically, we do surveys on Singaporeans, how they react to this Influenza A (H1N1-2009). By and large, I would say the awareness level is very high.