Dengue Alert

Letter to the Prime Minister - Make Singapore dengue-free

To: The Prime Minister of Singapore - Mr Lee Hsien Loong

cc: Minister for Health - Mr Khaw Boon Wan
cc: Minister for the Environment and Water Resources - Mr Yaacob Ibrahim

Date: 1 Sept 2005

Dear Mr Prime Minister Lee,

I attach below copies of my letter to the press on the above subject (sent a couple of days ago) and the subsequent publication in the Today newspaper of today (Straits Times has however decided not to publish the letter).

As I mentioned in the letter, we need strong political will from the government to attain dengue-free status as this requires efforts the different ministries. The recent newspaper reports seem to have focused on the efforts of NEA, but as outlined in my letter, the MOH's active involvement is just as important (I note in today's Straits Times the MOH is beginning to be involved). As the leader of the Cabinet, I sincerely urge you to put in place preventive strategies to eradicate this menace that is causing precious lives to be lost (eight so far this year). As I said, this can be done, but only with strong political will. Let's strive to make Singapore dengue-free. Thank you.

Yours faithfully,

Jeffrey Ho
http://www.denguealert.blogspot.com/


"I refer to recent articles and letters on the significant rise in dengue cases in recent months and the various stepped-up measures being taken to fight the menace.

I am heartened to read of more measures being taken, the heightened awareness and the collective efforts of all to combat this potentially life-threatening disease.

However, I can’t help but feel that despite the above-mentioned efforts from all, something is still missing: nothing is mentioned about what needs to be done on the “real” source of the problem, the infected person. Based on recent estimates, more than 400 are infected every week, and unless they are “prevented” from being bitten by the Aedes mosquitoes, the problem will perpetuate itself. It is a known fact that dengue can only be transmitted if an Aedes mosquito bites an infected person and then passes it on to the next victim. As in all infectious cases (SARS being the recent experience), efforts should be directed at BOTH the carrier (the mosquito) and the “real” source of the virus (the infected person). It seems efforts all this while have been mostly directed at the carrier but nothing on the source, the infected person. Therefore, something must be done to isolate those already infected to prevent the disease from having the chance to multiply. (It is interesting to note that a recent study finds that an infected person with malaria is more likely to attract the malaria-causing Anopheles mosquito – refer link, http://www.newscientist.com/article.ns?id=dn7816 for article in NewScientist.com (9 Aug 2005) – “Mosquitoes are drawn to people with malaria”, so this may also be the case with the Aedes mosquitoes. Therefore, it would be helpful if studies are made to find if the Aedes mosquitoes have such tendencies). For such initiatives to be implemented, it will involve a multi-ministry and multi-disciplinary approach, as was the case with SARS a couple of years ago.

At the micro level, town councils, housing developers, cleaning contractors, pest control companies and home owners/residents can do their part by being vigilant in their respective efforts to prevent mosquitoes from being bred through the various means already in place – no stagnant water, fogging, mosquito coil, mosquito plants, ointment/repellent, electronic devices, etc. Besides the increased manpower, cleaning and flushing of drains, etc, the government may also consider mandating roof gutters (a source of breeding that is hard to maintain because of accessibility) be changed/improved to prevent ponding, especially the older houses – just like mandating aluminium rivets in HDB be changed to steel rivets because they endanger lives!

At the macro level, I feel the Ministry of Health (MOH) has to take responsibility and ownership to bring infection down through policies targeting the management of infected patients and vaccination. The long-term plan is of course to find a suitable vaccine for this disease (this is already being done not just in Singapore but throughout the world). However, this may take time, so a near term solution is needed. Here is where my suggestion comes in – make use of our SARS experience to bring the infection down to zero (i.e. be dengue-free) over 3 or 6 months (or shorter) from the current 414 weekly cases. We can do this by adopting the SARS strategy of requiring confirmed dengue cases to be quarantined at a designated “quarantine hospital” – either an existing hospital or free up large-enough dorms or hostels/hotels where such premises are “fortified” (enclosed - with aromatherapy/repellent, electronic anti-mosquito devices, etc.) to prevent the Aedes mosquitoes from having a chance to bite these patients. Of course, there is an “exposure” period (between infection and diagnosis/quarantine) during which the infected person may be bitten by the mosquito, but with the shortening of the diagnostic period from about a week previously to a few hours with rapid-detection kits using polymerase chain reaction or PCR, the chances of exposure of infected persons to the Aedes can now be decreased – better still if people are encouraged to go for PCR testing upon being bitten by mosquitoes (if the high cost of PCR testing is prohibitive, perhaps the government can consider providing some form of subsidy). As is the case during the SARS outbreak, all doctors (including private GPs) should be required to conduct dengue-testing on all fever patients and report all suspected cases for quarantine to ensure nothing falls through the crack. Only by preventing the Aedes (as best as we can) from biting an infected person can we hope to break the chain and get to the root of the problem – the Chinese saying, “zhan cao chu gen” – “cut the weeds and remove the roots” for complete eradication. Otherwise, the problem will keep perpetuating and we may see further increases in cases as long as these Aedes mosquitoes have access to infected persons.

Once we have achieved “zero” infection, we have to be vigilant on minimizing “imported” cases: visitors entering Singapore – again, use our tested SARS experience for fever screening at entry points, contact tracing mechanism, etc…

It is hoped that the government will not wait till dengue cases escalate to 5000/week before implementing more drastic preventive measures, by which time, irreparable damage may have been done (like tourists avoiding Singapore because it is classified “high risk”, not to mention the loss of lives and the suffering of those poor souls unfortunate enough to succumb to this highly preventable infection). Indeed, the MOH should have a vested interested to ensure zero infection as the high dengue cases are causing a strain in the hospital beds being stretched to breaking point with reported cases of patients being turned away at Tan Tock Seng Hospital because of insufficient beds. There may be pain initially if patients were to be quarantined en masse, but with total eradication of dengue cases, the hospitals will be able to free up some 400 beds for other uses in the long run.

It may be worthwhile to ponder on why malaria has not been as pervasive here – it is precisely because it has not been allowed to take root here!! So, dengue must not be allowed to take root too by bringing infection down to zero. I hope the government and its officials (especially those at the NEA and MOH) do not have the defeatist attitude that achieving dengue-free status is impossible, because if there is a will, there is a way. Singapore may never ever be Aedes-free but certainly, it can be dengue-free!"

Jeffrey Ho
=========================================

Edited letter published in Today, 1 Sept, "Dengue: Fight it the Sars way"

Dengue: Fight it the Sars way

Government shouldn't wait for cases to rise before implementing drastic measures

Letter from jeffrey ho loon poh

I refer to the recent articles and letters on the significant rise in dengue cases and the stepped-up measures to fight the menace.

Nothing is mentioned about what needs to be done about the "real" source of the problem — the infected person.

Based on recent estimates, more than 400 people are infected every week, and unless they are "prevented" from being bitten by the Aedes mosquito, the problem will perpetuate itself. Therefore, more must be done to isolate those infected, as we did during the Sars episode.

(A recent study found that a person infected with malaria is likelier to attract the malaria-carrying Anopheles mosquito. I wonder if a person infected with dengue could similarly attract the Aedes mosquito.)

Town councils, housing developers, cleaners and residents can do their part to prevent mosquitoes from breeding. The Government could also consider mandating that roof gutters (which are hard to maintain because of inaccessibility) be changed or improved to prevent water pooling, especially in older houses — just like it mandated that aluminium rivets in HDB flat windows be changed to steel rivets because they endanger lives!

At the macro level, the Ministry of Health has to focus on the management of infected patients and the long-term search for a vaccination. As this may take time, a shorter-term solution is needed. Here, my suggestion is to make use of our Sars experience to become dengue-free within six months or less.

We can do this by requiring all confirmed dengue cases to be quarantined at a designated "quarantine hospital" — an existing hospital or a hostel/hotel that is "fortified" against the Aedes mosquito.

Of course, there is an exposure window (between infection and diagnosis/quarantine) during which the infected person may be bitten, but with the shortening of the diagnostic period from about a week to a few hours with rapid-detection kits, such exposure can now be minimised.

Even better, if people are encouraged to go for such testing upon being bitten by mosquitoes (if the cost is prohibitive, the Government could consider some form of subsidy). As was the case with Sars, all doctors should be required to conduct dengue-testing on all fever patients and report all suspected cases for quarantine.

It is hoped the Government will not wait until dengue cases to escalate dramatically before implementing more drastic preventive measures, by which time irreparable damage may have been done (like tourists avoiding Singapore because it is classified "high risk").

Indeed, working towards a zero-infection rate would relieve the strain on resources that has led to less severe dengue cases being turned away at Tan Tock Seng Hospital because of insufficient beds.

posted by Dengue Alert In Singapore @ 4:57 AM