AVIAN FLU EPIDEMIC (Impact and safeguards)

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AVIAN FLU EPIDEMIC:

(Impact and safeguards): 3.

Mdm Halimah Yacob asked the Minister for Health (a) what is the likelihood of an avian flu epidemic breaking out worldwide; (b) what will be the impact on Singapore and how is Singapore prepared for this; and (c) are enough funds and resources being invested to develop Singapore's capabilities to deal with the avian flu.

4.

Dr Geh Min asked the Minister for Health in the light of a likely increase in the foreseeable future of global and regional epidemics and Singapore's increased vulnerability to these diseases due to its dense urban population and global positioning, what long-term strategy does the Ministry have or will

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develop for the prevention, early detection, effective control and treatment of infectious diseases.

The Minister for Health (Mr Khaw Boon Wan): Sir, with your permission, can I take Question Nos. 3 and 4 together, please?

Mr Speaker: Yes.

Mr Khaw Boon Wan: Global and regional epidemics are immense challenges. The world had a taste of such challenges during SARS. Past flu pandemics also provided valuable lessons. The current bird flu outbreak may trigger the next global flu pandemic. Mdm Halimah asked about the likelihood of it happening. The World Health Organisation (WHO) has warned repeatedly that it is not a question of whether it will happen but when it will happen. However, no one knows when that time will be. What is certain is that a major disease outbreak such as a flu pandemic will be very costly in terms of human lives as well as economic losses. International cooperation is the key to avoiding such calamities, or when they occur, to minimise the damage.

That is why we maintain very strong links with health authorities in other countries and with key international health agencies such as the WHO and the US CDC. This facilitates the rapid exchange of critical information and expertise and will help us better prepare ourselves or deal with any outbreaks. With globalisation and jet travel, we are all vulnerable to global epidemics and must collaborate with one another to manage any outbreak.

Domestically, we are progressively gearing up for such major outbreaks. Preparations can never be complete as it is not possible to know the nature or the extent of the next outbreak. With more funds and resources, we can certainly do

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more. But the major pieces are in place. Let me just briefly outline what those pieces are.

First, we have established the organisational structure to deal with such crises. There is a Ministerial Committee chaired by the Deputy Prime Minister and Minister for Home Affairs. I am a member of that Committee. The Committee is supported by an Executive Group comprising Permanent Secretaries and chiefs of key Government agencies. My Permanent Secretary heads the Crisis Management Group for Health which reports to the Executive Group. This command and control structure is to ensure a coordinated Government response to any major health threat. It was tested during SARS and further refined after that crisis.

Second, we have formulated various outbreak scenarios and planned our specific response strategies. This exercise can never be exhaustive but by thinking through them, we develop useful insights into our strengths and our weaknesses. We can then try to enhance our capabilities.

The response strategy to each disease outbreak would depend on the nature of the disease - how it is transmitted, availability of diagnostic tests and whether there are treatments or vaccines. Mdm Halimah asked specifically about our flu pandemic preparedness and response plan. We have just recently reviewed and refined it further. It is now published on our website, both to inform as well as to consult. It is based on what we know about past pandemics, nature of the flu virus, and availability of drug treatments and vaccines. We will continue to review and strengthen the pandemic plan.

Third, we have learnt extensively from the SARS experience and have significantly strengthened our capabilities

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and capacity. In particular, we have augmented our surveillance and response systems, operational and emergency preparedness capabilities. This has been done through increasing manpower and other resources such as isolation facilities in hospitals.

Fourth, we have constituted our various response strategies into what is called a DORS, Disease Outbreak Response System. Briefly, this framework comprises (a) an effective surveillance system and (b) a rapid response system.

Our surveillance system has external and internal components. External surveillance continuously scans foreign and international news and health websites and information exchange networks on infectious diseases. Our internal surveillance comprises continuous evaluation of atypical pneumonia cases, laboratory surveillance of influenza viruses and through the implementation of new IT systems to rapidly capture, analyse and monitor cases of infectious diseases of concern.

Under this DORS framework, my Ministry will mount a rapid response to major disease outbreaks by mobilising teams to investigate the outbreak, analyse epidemiological findings and then contain the outbreak as quickly as possible through appropriate control measures such as contact tracing and quarantine, treatment or vaccination.

Fifth, we regularly exercise our plans. This is important to ensure that the players know what to do if and when a real crisis happens. It also allows us to learn from the exercises to refine our plans.

Finally, we must involve all Singaporeans in our preventive and response strategy. What can Singaporeans do?

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When there is a specific outbreak, we will seek specific actions from the people. But, meanwhile, I think Singaporeans can do a lot on the preventive front: aim for a much higher standard of personal and public hygiene.

Let us get back to basics. Do not spread germs: so do not spit, wear masks when unwell, do not touch your face unnecessarily, wash hands thoroughly and often, keep public toilets clean and dry and please do not litter. Simple acts like these can go a long way to minimising the spread of infectious diseases.

Mdm Halimah Yacob (Jurong): Three questions, Sir. I would like to ask the Minister whether it is necessary for Singaporeans to get a flu vaccination, if that is useful, if not for all Singaporeans, at least for those who are travelling overseas. Will that be an advice that the Ministry of Health thinks useful for those who are travelling to avian flu infected areas to have the flu vaccination?

Secondly, my question is whether there is sufficient quantum of the Tamiflu vaccine available because there appears to be a severe shortage in the US, and the US is trying to increase production. Is there a shortage in Singapore?

Thirdly, I would like to ask what kind of cooperation exists with the countries in the region, particularly those countries where avian flu is particularly serious. The Minister did talk about international cooperation and support. Is there some regional cooperation on this?

Mr Khaw Boon Wan: On flu vaccination, I think let us be clear. There is the usual seasonal winter flu and, of course, there is this dreaded flu pandemic which we will not know yet what exactly will be the virus and what form it will take. For seasonal flu, the advice has always been to apply only for the high-risk group. We are in the tropics and, quite

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unlike US, when winter comes, the elderly there would be advised to take a flu jab - voluntary, not compulsory - but that is the advisory. They leave it to the people to decide. In the case of Singapore, there is really not much need unless you are in the high-risk group. The high-risk group is defined as those who are doctors or healthcare workers who have to work with patients who are likely to have flu. So this is one category of the flu vaccine which varies with each season. WHO gives advice regularly, twice a year, on what is the latest cocktail of flu jabs to take.

But specific to flu pandemic, it depends on what particular virus strain will crop up. It may evolve from the H5N1, nobody knows. But if it does, the effort would be towards that direction. Currently, there is no such vaccine because we do not know yet what exactly this particular mutant will look like, but there are a lot of research efforts going in this direction. We ourselves are helping in some research efforts with our Australian partner and, hopefully, some results can show in due course.

As for Tamiflu, there is now a worldwide shortage especially now that the H5N1 has been found in Europe. You can expect a huge demand and it will grow but, unfortunately, there is only one supplier, so there is a global shortage. And every country has been advised to do some stockpile. We do. We have a certain target to work towards,

which is enough Tamiflu for one quarter of the population, which means one million courses. We are building it up progressively. We started quite early, so that was helpful. As first mover, we have some advantage here. We have built up to quite a significant proportion. Probably by sometime next year, we should build up to this targeted one quarter of the population's requirement.

The third point is on international cooperation - this is crucial. I think every

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country has been developing its internal response plan. My main criticism has always been that while those activities are useful and important, I think not enough attention is being paid upstream. The pandemic will be so disastrous that I think if we can avoid it, so much the better. And to avoid it, one really should go upstream. And, here, international cooperation is key. So I am quite glad President Bush called for an International Partnership when he addressed United Nations recently. Last week, you see his Health Secretary spending a couple of weeks in this region on areas which have such outbreak of H5N1 already happening, and we hope such activities will continue. There are various forums now within ASEAN, within APEC, within ASEM. It reminded me of the Y2K crisis. Remember Y2K? It is not biological, but it is a millennium bug. But I think by thinking about it, and thinking through what are the steps that one can do to cooperate with each other and within limits, we can avoid a calamity and a whole industry of Y2K experts were built up. And now in this case, we hope that a whole industry of flu pandemic experts will also be built up. Along the way, we can teach each other, learn from each other and hopefully we can avoid this, if nothing else can postpone this, for as long as possible.

Dr Lily Neo: Mr Speaker, Sir, I would like to ask the Minister whether his utmost task will be on the containment and the prevention of spread of the avian flu virus, especially the virulent human transmittable, should an outbreak occur? How does he plan to do it? Has he got any protocol of actions in place involving the various Ministries, drawing from our past experience of SARS and preventing past mistakes? What will constitute the key point for him to call for immediate action? And lastly, on Tamiflu, is it wise not to switch to other anti-viral agents such as Relenza, because now there is a possibility of mutated avian flu virus that

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is not effective to be treated with Tamiflu?

Mr Khaw Boon Wan: Sir, I agree with Dr Lily Neo that prevention is better than cure. So, likewise, with the flu pandemic, if we can prevent it so much the better. In the case of Singapore, because we do not have a significant agricultural sector, the risk of a flu pandemic emerging from here is very small. Therefore, the likelihood of a cluster appearing somewhere will probably be in the region outside of Singapore. If we can have what people call forward defence - push the boundary, push our border as far as possible - so we have some interest in helping our neighbours to, if we can help it, prevent a cluster from happening or when it happens, quickly isolate and ringfence the cluster.

At some stage if there were to be a flu pandemic, a human cluster will emerge. So on a theoretical basis, if within the first 36, 48 or 72 hours this cluster is identified, we have a rapid medical team to move in, isolate, inject Tamiflu, cull the animals, and so on, it is possible to prevent this from spreading. But the first 36 or 72 hours are crucial. For that to happen, we need two ingredients: one, the moment suspicious incidents like that happen, somebody will blow the whistle; two, you have a rapid response force - doctors, scientists, together with the anti-virals that can be brought to the cluster zone. Both have to be in place for this to happen and much of the international preventive efforts are driving in that direction. Let us try to create this outcome. It is not easy, but I think we should try.

The second point is about what will trigger our reaction within Singapore. As I said, there is a DORS system and in the case of flu pandemic, we have colour

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coded it. We are right now in colour green, meaning there is no efficient man-to-man transmission yet. The next colour code will be yellow. Yellow is when the first imported human case appears in Singapore. That will be yellow. And then you have the other colour codes, ending up with a very dark scenario of black. Black is when the outbreak gets out of hand and then there is huge trouble.

As for resistance to Tamiflu, these findings are not surprises because viruses are not stupid, just like dengue mosquitoes or dengue virus. They mutate, they change, and they will react and, in due course, there will be resistance to Tamiflu. There are some recent studies where laboratory testings show its resistance. It may or may not be. It will take some time and therefore part of our flu pandemic plan includes testing out other anti-virals like Relenza which Dr Lily Neo mentioned. In fact, the plan is when we stockpile Tamiflu, we will also stockpile some Relenza, so that we have some diversification.

Dr Geh Min (Nominated Member): Mr Speaker, may I ask the Minister: is Singapore positioning herself to be the regional centre for infectious diseases, if we are not already one? And if so, do we have the medical and paramedical capacity to do this? Secondly, may I ask the Minister: are we going to expand our R&D in infectious diseases? Are we going to spend more research funds on R&D in the development, for example, of vaccines? It seems to me that with our biotechnology industry, we are well positioned to do so instead of depending on other countries for anti-virals or vaccines. And, thirdly, may I ask the Minister what lessons have we learned from SARS on weak areas which we could improve on? May I take the opportunity here to compliment the Minister and the Government on handling SARS very effectively, inspiring confidence in the public while at the same

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time maintaining transparency. But it has been said that SARS -

Mr Speaker: Dr Geh Min, keep it to within avian flu, please.

Dr Geh Min: It has been said that SARS is a very small thing compared to what we may face in future. So may I ask the Minister for assurance for an equally effective response?

Mr Khaw Boon Wan: On Dr Geh Min's question on Singapore being a regional centre for infectious disease, I presume she meant a regional scientific centre, not an incubator of infectious disease or a treatment centre for infectious disease. Certainly, particularly as we are in the tropics where infectious diseases are common. Do we have special expertise? Yes and no. I think this requires international effort. If you look at SARS when it happened, the whole international scientific community responded to it and therefore within weeks, the whole genome was mapped out. So the same thing is likely to happen for the flu pandemic. Increasingly, this is global business and we certainly should be an active player. Can we be THE player? I doubt it very much because you cannot beat, first, the billions of dollars of NIH funds in US or the number of scientific expertise there. But, in Singapore, we are building up our Biopolis and we have a life science interest and certainly we ought to be a player in this game.

What lessons we learned from SARS? Many, many lessons were learned. We did something right, we did many things which, on hindsight, we could have done it better, and we have responded to the deficiencies. Some of the capacities were inadequate, isolation rooms were inadequate which we have built up over the last two to three years, and we continue to build up. But I think a lesson from SARS is to take a commonsensical approach because the next outbreak we

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can have all kinds of scenario planning, it will turn out quite different from what the scenario planners would like it to be. So there are bound to be surprises, but take a commonsensical approach. We have to understand whether the virus is airborne, droplets-based or what? How infectious is it? Fortunately, when we look at influenza virus, it is still largely droplets-based. It may be more infective than SARS but it is still droplets-based. And being droplets-based, what it means is common public health personal hygiene practices go a long way.

Mr Speaker: Mdm Halimah, last question. We have 40 more Questions to go.

Mdm Halimah Yacob: Sir, the Minister mentioned that there is about enough flu vaccine for 25% of the population. I wonder, if there is an outbreak, whether there will be a problem with allocation of the vaccine. Secondly, the Minister mentioned about the need to involve stakeholders. I wonder whether the Ministry involves companies as well because there was a report which says that companies are not very prepared for the eventuality of such an outbreak.

Mr Khaw Boon Wan: First, a correction. When I said 25%, I was talking about anti-virals, not vaccine, because there is no vaccine yet because we do not know what kind of creature we will be fighting. So we are talking about anti-virals and, in any case, there is no need for anti-viral for the entire population; vaccine, yes. For vaccine, you must reach out to the entire population but anti-viral is only temporary prophylaxis. But you need to cover a critical mass of population, but it is not feasible nor desirable to have anti-viral for the entire population.

In our pandemic flu plan on the website, there is a significant section on business and companies; how they should

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react, and some simple advisories. But, really, companies among themselves have to think it through, and I read a similar report where they found that many companies are still not geared up. My advice is for them today to check into MOH website, study the few hundred pages on flu pandemic plan and think through what are the steps that you should be preparing yourselves for.

Dr Geh Min: I would like to ask a supplementary question, if I may.

Mr Speaker: We have got 40 more Questions to go. I will allow you a short one.

Dr Geh Min: It seems to me that the medical profession is understandably somewhat market-driven. So we have a lot of specialists in obstetrics and gynaecology, in cardiology, in the more lucrative fields, I hate to say. May I ask the Minister if there is going to be any move to try and encourage more specialisation in epidemiology in infectious diseases, in clinical and laboratory diagnostic areas where I think we will be well advised to build up these areas.

Mr Khaw Boon Wan: The short answer is yes, but we are market-driven too because we can encourage and promote the courses but there must be takers. But, fortunately, for every cohort of three hundred over students, there will be some who have an interest in different areas. In fact, we have just doubled the intake for infectious diseases and hope that the trend will continue.