HAND, FOOT AND MOUTH DISEASE (Update on outbreak)

Mr Inderjit Singh asked the Acting Minister for the Environment if he will (i) give an update on the outbreak of the hand, foot and mouth disease; (ii) state whether the disease is under control; and (iii) inform what precaution his Ministry will take to avoid similar situation in the future.

The Senior Minister of State for the Environment (Encik Sidek bin Saniff) (for the Acting Minister for the Environment): Mr Speaker, Sir, hand, foot and mouth disease (HFMD) is a common mild childhood disease. Very rarely does it result in deaths. However, on the morning of 30th September, two siblings aged one and two died, within two hours of each other. Upon notification that morning, the Commissioner of Public Health immediately activated the Task Force that was formed two years ago following the outbreaks of HFMD in the region in 1998.

The Task Force recommended the closure of all pre-schools effective from 2nd October. The objective was to isolate the children and protect them from contracting the disease. The Minister for the Environment accepted the recommendation. The directive went out immediately to all the pre-schools on the same day.

The quick and decisive action by the Government, together with the concerted efforts of the public, pre-schools, media and employers proved to be effective. I am pleased to report to the House that the outbreak has been brought under control. The number of reported cases per day reached a peak of 258 on 4th October, and declined steadily to 9 on 31st October. All pre-schools have reopened since 16th October. The situation is now back to normal.

On behalf of the multi-agency task force, I would like to take this opportunity to thank the parents and members of the public, pre-school and kindergarten teachers, doctors at the Kandang Kerbau Women and Children Hospital, the National University Hospital, the Singapore General Hospital and doctors in private practice, affected employers, and various Government agencies for their understanding, support and cooperation.

HFMD is spread through close contact among children. The most effective measure to prevent future outbreaks is to maintain a high standard of hygiene in pre-school centres and at home. Parents and teachers also need to remain vigilant, and keep infected children away from other children. The multi-agency task force will continue to strengthen guidelines relating to hygiene standards and sick bay operations to prevent future outbreaks as much as we can.

Mr Inderjit Singh (Ang Mo Kio): Sir, is the Minister confirming that we have completely eliminated or at least we have brought it down to the level that it was at the previous outbreak status in terms of the number of children contracting the disease?

In terms of precaution, is the Minister saying that just cleanliness and hygiene is an issue or can we actually take other medical precautions to prevent our children from contracting this disease in the first place?

The Acting Minister for the Environment (Mr Lim Swee Say): Sir, the hand, foot and mouth disease is an endemic disease, ie, it is there all the time. Last year, before we imposed the compulsory reporting of HFMD, we had about 25 cases a week. During the recent outbreak, it went up to as high as 258 cases per day. Since then, it has come down to about 10 cases per day. 10 cases per day will work out to about 70 cases per week. It would appear to be still higher than the 25 cases per week last year. However, there was no compulsory reporting last year whereas today there is compulsory reporting. Our assessment is that at 10 cases per day, we are now back to the normal situation.

Mr Inderjit Singh also asked whether beyond cleanliness, is there a medical solution. Sir, at this moment, there is no medical cure to the hand, foot and mouth disease, in particular, the EV71 virus. There is also no vaccine available. However, I want to highlight that when we say "there is no cure", it does not mean that every child who has contracted the disease will face the danger of death. As an illustration, in the outbreak in Taiwan, there were about 1.4 million cases and over 70 death cases, ie, one casualty out of 20,000 cases. I want to emphasise that there is no need for the public to be alarmed that the hand, foot and mouth disease is there all the time. What is important is for us to continue to take measures to reduce the number and to keep it to as low as possible, bearing in mind that this disease is, generally speaking, not harmful.

Dr Lily Neo (Kreta Ayer-Tanglin): May I ask the Minister whether, for the control of the disease spread, child care centre operators are being facilitated by his Ministry on correct maintenance of the child care centres and on the proper screening of the students in the centres? May I also ask whether there is a new protocol for vigilance and pro-active closing of an infected centre to curb the disease spread and also avoid a nation-wide closure of the child care centres in the future?

Mr Lim Swee Say: Mr Speaker, Sir, there are two types of pre-school centres in Singapore. They are the kindergartens and the child care centres. The child care centres are licensed by the Ministry of Community Development and Sports (MCDS) and the kindergartens by the Ministry of Education. Both types of pre-school centres are subjected to hygiene guidelines issued by the Ministry of the Environment, Ministry of Education and MCDS. In fact, the last time we updated our guidelines was in March this year. As a result of the recent outbreak, the Task Force has decided to further update the guidelines. A new set of guidelines will be issued soon.

On Dr Lily Neo's second question regarding the screening of children, it is true that many teachers and parents were not aware of the proper actions to be taken during the recent outbreak. What has happened was that we actually had cases of children who had contracted the hand, foot and mouth disease but continued to attend school. For the child care centres, sick bay is a standard facility. We do not have much problem because the infected children are isolated. But in the case of kindergartens, there is no practice of having a sick bay. As a result, some of the children were allowed to continue to interact with the other children. As a result of the recent outbreak, we have now issued clear guidelines to all kindergartens that for those without sick bay facility, they would still have to isolate the children, using the principal's office or any other facility. At the same time, they have to notify the parents immediately. This practice has been put in place. Over the last one month, we are seeing a very effective decline in the number of cases. So we intend to continue to enforce such hygiene practices so that, hopefully, we will not see another outbreak and we do not have to close the schools in the future.

Mr Inderjit Singh: I would like to ask the Minister whether through the process we have identified any highly susceptible facilities like sand bays, playgrounds or swimming pools and so on, that are actually causing a bigger probability of this disease being spread and are we going to review the building and maintenance policy of such facilities.

The other question I have, which is still not very clear, is why we have had this disease at a steady state and what was the reason for the sudden increase this time round.

Mr Lim Swee Say: Sir, the spread of the disease is basically through direct contact among the children. For example, if a child were to pick up a piece of toy and puts it into his or her mouth and before the saliva dries up another child picks it up and puts into his or her mouth, it can be transmitted. Therefore, in the case of sand bays and so on, it is probably not the primary mode of transmission. What we have done, as I have mentioned earlier, is to enforce the hygiene practices in the schools. For example, in our hygiene guidelines, there is a clear regulation that all toys must be washed at the end of the day every day and any items where the children can put into their mouth are not supposed to be placed in a common area for the children to share. All these guidelines will now be further enforced.

As to the sudden increase, prior to 1st October, the hand, foot and mouth disease was not a notifiable disease. As a result, we have to rely on the reporting from the child care centres. The information we were getting was not complete and not up to date. Since 1st October this year, all hand, foot and mouth disease cases will have to be reported because it is now a notifiable infectious disease. Henceforth, we should be able to monitor very closely. Should there be any increase, we will be able to take responsive action before it gets out of control.

Dr Lily Neo: May I ask the Minister what was the reason for the long delay in confirming the diagnosis of the recent hand, foot and mouth disease occurrence, whether there is now an improved channel for speedier laboratory confirmation of the hand, foot and mouth virus, and whether this virology testing is available to all doctors for earlier and correct diagnosis?

Mr Lim Swee Say: Mr Speaker, Sir, in the case of unnatural death, it is a standard practice that we will do a post-mortem. In the process, there are actually two steps involved. The first step is to detect the presence of the relevant virus. And the second step is to identify exactly what strain of virus it is. Take, for example, in the case of the hand, foot and mouth disease, the most common virus is the family under the enterovirus, and there are over 60 different strains. Within a few days, we are able to identify the presence of enterovirus. But the next step is to identify if it is a coxsackie A16 or EV71, or something else. For that to happen, the medical laboratory will have to isolate the sample. They have to culture the virus to see whether there are any reactions. So that typically will take a few weeks.

Just to give you an example. We actually did the isolation in parallel in a Singapore facility as well as to send a sample to the CDC (Communicable Disease Centre) in Atlanta. In fact, both centres identified the presence of EV71 almost at the same time. It shows that there was no delay on our part, because even with a very reputable facility in Atlanta, it takes about the same time. This is because we have to go through that period of time for the virus to be cultured, to be grown, and to be identified.

Sir, I want to assure the public that we do have an up-to-date facility and that there was no delay in identifying the virus. Unfortunately, the process does take time. But having said that, it does not mean that we will not further invest in upgrading our capability. In fact, the Task Force is now looking into what kind of new facilities and capabilities we ought to invest in Singapore so that in future, should there be any infectious disease outbreak, we will be able to continue to respond very rapidly.