HAND, FOOT AND MOUTH DISEASE (Update)

Column: 1685

HAND, FOOT AND MOUTH DISEASE:

(Update): 3.

Mdm Halimah Yacob asked the Minister for Health whether he will give an update on the hand, foot and mouth disease outbreak and what measures are being taken to prevent infection among children in schools, kindergartens and childcare centres.

4.

Dr Lily Neo asked the Minister for Health how dangerous is the resurgence

Column: 1686

of the hand, foot and mouth disease (HFMD) enterovirus-71 strain and what are the steps taken by the Ministry to prevent death from this HFMD virus.

5.

Dr Amy Khor Lean Suan asked the Minister for Health (a) how many cases of hand, foot and mouth disease (HFMD) have been reported over the last six months; (b) if there is any evidence or cause for worry that we may be affected by the enterovirus-71 strain; (c) what precautions has his Ministry, together with other relevant Ministries, taken to prevent the spread of HFMD; and (d) what advice will the Ministry give to parents of young children regarding the HFMD.

The Senior Minister of State for Health (Dr Balaji Sadasivan) (for the Minister for Health): Mr Speaker, Sir, with your permission, may I take Question Nos. 3, 4 and 5 together?

Mr Speaker: Yes.

Dr Balaji Sadasivan: Mdm Halimah, Dr Lily Neo and Dr Khor have asked for an update and information on the Hand, Foot and Mouth Disease (HFMD) situation and the measure we should take to manage the disease. Let me first give Members a little background information about this disease. HFMD is a common childhood infection caused by a family of viruses called enterovirus. One member of this family is enterovirus 71 or EV71. HFMD infections are usually mild. Every week, there are between

100 and 500 children who develop the infection. Rarely, when the virus involved is the EV71 virus, the disease can affect the brain or even cause a fatal outcome. Every few years, the EV71 virus will be the predominant virus responsible for most of the cases of HFMD. In 2000 and 2001, it was the predominant strain and caused a total of seven deaths. In 2003, it was again the predominant strain and caused about 65% of the HFMD cases but there were no deaths.

Column: 1687

Let me now give an update on the current situation. This year, EV71 is again the predominant strain. In the first 13 weeks of this year, 3,680 cases were reported, which is lower than the 3,901 cases reported for the corresponding period last year. So the weekly average this year has been 283 cases, which is the usual range for this disease. Although the weekly average this year is lower when compared to last year, there was a surge of cases in the week ending 25th March when 785 cases were reported. For the week ending 1st April, the number of cases reported has come down to 721. Most years, including last year, there is a surge of cases between the months of March and June. So the surge in the number of cases is not in itself unusual. Most infections as expected are mild, self limiting, and do not require hospitalisation. Sixty-nine children did require hospitalisation at KK Hospital and NUH but none of them developed severe complications.

We cannot eradicate HFMD but we can slow its spread. The risk of infection spreading can be lowered by good hygiene practices. The single most important measure is hand washing. Although it is a common practice to ask affected children to be excluded from a group setting like a kindergarten or a childcare centre, this measure may not prevent additional cases from occurring, because the virus is excreted by well children for weeks after they have recovered from the HFMD. That is why washing hands is the most important measure in prevention. We have worked closely with MCYS and MOE in educating all childcare, kindergarten and preschool operators on hygiene measures. My Ministry has also alerted doctors to be vigilant for complications from HFMD as the predominant strain this year is the EV71 strain.

Parents and caregivers can play their part too by encouraging good hygiene in children, through proper hand washing.

Column: 1688

They should also consult a doctor early if their child is unwell. In addition, they must ensure that the child with HFMD rests at home.

Dr Lily Neo (Jalan Besar): Sir, may I ask the Senior Minister of State how proactive and stringent are kindergartens and schools in identifying children with possible HFMD and in the prevention of the spread of HFMD.

The Senior Minister of State earlier said that there were seven cases of deaths from HFMD in 2000 and 2001. May I ask him what were the causes of deaths at that time and how can we prevent a recurrence?

Dr Balaji Sadasivan: Mr Speaker, Sir, the cause of death is usually encephalitis, that is inflammation of the brain. Most of the viruses that cause HFMD do not cause this complication. And if it occurs, it is very rare. When it occurs, it is usually associated with EV71. But even then, it is a very rare occurrence. The strain of virus, EV71 virus which affects the brain, again varies from year to year. As I have mentioned, in 2003, EV71 was the predominant strain and there were no cases. But in 2000 and 2001, the strain that occurred caused some complications and so there were seven deaths. This year, the strain so far has not caused any complications.

As for the prevention of hand, foot and mouth disease, the primary way of preventing this disease is hand washing. The reason is that this is a virus that spreads through, what we call, oral-faecal route. As parents - and I notice that all three Members who asked questions are parents - it is hard to imagine that something in the stool of one child would enter the mouth of another child. But the amount of virus required to cause this infection is very small. So if a child or an adult goes to the bathroom and he comes out and does not wash his hands, he

Column: 1689

carries a tiny amount of this virus on his hands. When he touches objects, he contaminates the objects with the virus. That is why the first rule is to try and teach everyone to wash their hands after going to the bathroom.

The second important thing is that if you play with these objects or you touch these objects, your hands get contaminated. And if you eat or touch food, then you contaminate the food that you are eating and that is how the virus enters your system. So the second important rule is: you must wash your hands well before you eat. This is something that every child must be taught. This is something every parent has a responsibility to do. And more important, adults must show a good example in hand washing. I hope, through this outbreak, everyone, adults and children, will understand the importance of a simple hygiene measure like washing hands and that this will reduce the spread of the infection significantly.

Mdm Halimah Yacob (Jurong): Sir, I have three questions. I just would like to ask the Senior Minister of State at what point and under what circumstances will the EV71 virus turn deadly. Secondly, the Senior Minister of State mentioned that in certain months, the disease seems to peak. What are the factors causing the disease to escalate in certain months and whether there is any way we can prevent it? Thirdly, there are some parents who are concerned, especially mothers, because when there is an escalation in the number of cases, and even if it is not hand, foot and mouth disease, the childcare centres and kindergartens are worried and they do not take the children. But mothers cannot take leave at short notice. So is there some service that can be provided by the Ministry of Health in

Column: 1690

collaboration with some agencies? These mothers cannot automatically take leave and stay at home to take care of their sick child. But, at least, if there is a daycare facility for them to put a sick child, this will be a great help.

Dr Balaji Sadasivan: There are several important issues that Mdm Halimah has brought up. First is this surge in the number of cases. We do not know why certain months have a higher incidence than other months, but that is a pattern that is noticed. But it does not mean that the virus is more dangerous because there is an increased number of cases in that month. The danger to the child depends on the type of virus, what particular strain causes the HFMD that year. If it is EV71, the risk is higher. But again, if it is EV71, the EV71 strain every year does not have the same risk. As shown in 2003, when EV71 was the strain that caused most of the infections, yet there were no fatalities. So, why in some years the strain causes more complications and in other years, it does not? We do not know.

The next issue that she has brought up is the closure of schools. The closure of schools causes parents quite a lot of disruption because they have to adjust their work schedule and find someone to look after their children. MCYS and the preschools are working with parents to try and minimise this disruption.

Dr Amy Khor Lean Suan: Sir, I would like to ask the Minister if GPs are required to inform MOH if a child or a patient comes down with HFMD and whether they are required to state in their medical certificates (MCs) that a patient has got HFMD, the reason being that I understand that some parents, for various reasons, are actually not informing the schools, and the MCs do not state that the child has HFMD.

Column: 1691

Also, I would like to ask the Minister, in view of the fact that this is a recurrent kind of sickness every year, whether the Ministry will consider mounting some kind of public education effort to make sure that every individual knows how to protect himself and the children from HFMD as well as not spreading it to others.

Dr Balaji Sadasivan: First, the GPs have been instructed to give seven days of MC. This is to ensure that the child has sufficient rest and has recovered from the illness. This is for the benefit of the child. But all the well children who go back to the school continue to spread EV71 virus and they will continue to do so for several weeks. So because they are well and they go back to school, it does not mean that the EV71 virus is prevented from entering the school. That is why hand washing is the mainstay for trying to slow the spread.

On the second issue of putting the diagnosis on an MC, in general, doctors do not indicate the diagnosis on an MC unless it is specifically requested by the parent or the patient. This is because the confidentiality must be preserved. When you write down a diagnosis, you are revealing what the diagnosis is. So the general principle is that in an MC, there is no diagnosis. For example, a worker in one of the companies was ill and came down to see a doctor, and if the medical certificate was to state the diagnosis, then the employer has access to that information. In general, we do not give the employer that information unless there is specific consent from the worker. So the same principle applies everywhere. That is why the diagnosis is not written on the MC.

But I would urge parents to be responsible and keep the child at home and allow the child to rest for seven days because one way of reducing the risk of

Column: 1692

any complication occurring is for the child to rest during a viral infection and not be out there playing.

Dr Lily Neo: Mr Speaker, Sir, the Senior Minister of State did not answer my questions at all. Therefore, I will repeat them again. May I ask him what were the causes of deaths of the HFMD cases in 2000 to 2001 and how do you prevent such recurrence. The other question I asked was how proactive and stringent are kindergartens and schools in identifying and preventing the spread of HFMD.

Dr Balaji Sadasivan: Mr Speaker, Sir, I think I have answered that question. I said that in 2000 and 2001, the complication was encephalitis. Encephalitis is basically brain inflammation. If you have brain inflammation and it is very severe, then the person can have a fatal outcome.

Second, she asked why sometimes they get complications and sometimes they do not get complications. I think I have explained this. It depends on the strain of the virus. The strain of the virus in 2000 and 2001 caused the deaths, but the strain that caused the infection in 2003 did not cause any deaths. And the strain this year so far has not caused any deaths.

With regard to the measures that my Ministry has taken, basically, the measures cover two areas. The first and the most important thing is to promote good public hygiene. And that is why we keep emphasising hand washing. The second is the advice to doctors, parents and schools on how many days a child should rest and having children resting at home. But I want to point out again that

that is not the key measure in preventing the spread of the virus because, even if the child is well and goes back to school for several weeks, the child will still be spreading the virus.

Column: 1693

Mr Steve Chia Kiah Hong (Non-Constituency Member): Sir the Senior Minister of State said that after the child has recovered, for the next few weeks, the child would still continue to spread the virus. Should we not quarantine the child for that period until he is fully cured of the virus, so as to stop the spread of the virus? On this matter, could the MCYS help with the subsidy for home medicare?

Dr Balaji Sadasivan: Sir, the only way to stop the spread of enterovirus in our schools, short of good hand washing measures, is to close down the schools the whole year round. This means that there will be no schooling for children. Many children who have hand, foot and mouth disease have asymptomatic disease. When they go back to school, no one knows that they had the infection because it is asymptomatic. The parents do not know. The children do not know, and they are going to spread the virus in school. If we try to take measures that we learnt from SARS, which is for the spread of droplets, and then try and use these measures in the school setting, thinking that it will work, it will fail. So, if someone wants an ultimate 100% way of ensuring that there is no spread of hand, foot and mouth disease in schools, the only way to get 100% is to close down all the schools, and have all the children stay at home.

Mr Speaker: Last question, Dr Amy Khor.

Dr Amy Khor Lean Suan: Sir, I would like to ask the Minister whether the Ministry could review this MC policy. Whilst I understand the confidentiality involved, for a contagious disease like hand, foot and mouth disease, though it may not be that deadly, especially for younger children, could the doctors be required, especially for young children, to state the cause for the MC, so that the childcare centres and kindergartens can

Column: 1694

take the necessary remedial action? Because this has happened in one of my centres where they were not aware of it. They could not do anything till they found out later that the child actually had hand, foot and mouth disease.

Dr Balaji Sadasivan: Sir, if the childcare centre requires that parents provide the diagnosis and the parents give their consent to the doctor, the doctor will provide it.