Tuesday, July 03, 2007

Dengue experience: ministers' shortcomings and to-do list - ST (3 July 2007) - Dengue cases hit epidemic level again

Date: Mon, 2 Jul 2007 21:07:59 -0700 (PDT)
From: Jeff Ho
Subject: Dengue experience: ministers' shortcomings and to-do list - ST (3 July 2007) - Dengue cases hit epidemic level again
To: mewr_yaacob_ibrahim@mewr.gov.sg, mah_bow_tan@mnd.gov.sg,
CC: lee_hsien_loong@pmo.gov.sg, reach@reach.gov.sg, amy_khor@mewr.gov.sg,
"HuiChieh@ Straits Times" ,
"Letters@ Today" , tnp@sph.com.sg, arti@sph.com.sg,
taniat@sph.com.sg, dawntan@sph.com.sg, "Radha@sph Basu" ,
"Chee Kong@Today Loh" , salma@sph.com.sg,
ST Forum

To: Ministers Khaw Boon Wan (MOH)/Yaacob Ibrahim (MEWR)/Mah Bow Tan (MND)
cc: Prime Minister Lee Hsien Loong
cc: Straits Times/Today/TNP

3 July 2007

Someone from my household had the misfortune to be down with dengue last week. But fortunately, she is now out of the CDC and recuperating at home. I understand from NEA there is another case across the road in my neighbourhood (Newton/Bukit Timah area) during the same period, so with these 2 cases occurring near each other, it would be updated as one of the many clusters although I note that the NEA website has yet to do so - refer link http://app.nea.gov.sg/cms/htdocs/category_sub.asp?cid=239 .

One good thing I learnt from almost first-hand experience is the observation that despite the last major outbreak in 2005, the lessons are still not learnt (or if learnt, not applied). Consequently, it is very easy for the outbreak to get out of hand again and again and again until and unless priorities are set and tackled by all concerned - households, NEA, MOH, MND, PUB, doctors, town councils, etc...

Let me share with you just 2 very basic but important observations which indicate major shortcomings that may have contributed to the recent outbreak. And since this involves inter-ministerial effort, and given the apparent ineffectiveness of the ministries working together (hence the current outbreak again), I shall set out to detail the To-do's for each minister how each should tackle the problem at his ministry:

AAA. "Preventive" measure:

In my condo, there have been many recent change of owners (due to the hot property market), as a result of which, some of the units were bought by foreigners hoping to re-sell them at a profit (just to highlight this point, one unit had barely changed hands before a "For Sale" sign was put up almost immediately. This was some 6 months ago but the unit is still vacant and unsold by the new buyer). Some months have passed but the units remain vacant - and since the owners are foreigners who do not reside here, they will remain vacant. Therefore, such vacant units are perfect for the Aedes mosquitoes - undisturbed for them to multiply manifold for many generations! And yet (despite my previous appeals for such "vacant" units to be the first to be inspected since any breeding inside these vacant units do not affect their owners (who do not stay there) or their families), the government (NEA?) is powerless as they wouldn't enter such premises without the owners' permission! (Just an example - NEA has not been able to enter one of the "identified" vacant units in my condo as they are unable to contact the owner since last week - by the time permission is granted (if ever it is granted), many generations of Aedes would have been hatched!).

Since there are confirmed cases in our estate, why isn't this a top priority?

I can foresee problems with this "missing link" where occupied houses (less likely to have breeding in the premises given the dangers posed to the occupants/loved ones) are subjected to inspection but the vacant units (more likely to have breeding since owners do not stay there) are not. This is exacerbated by the fact that more vacant units are coming up with the enbloc fever now, and the fact that many of the units are bought by foreigners (who do not stay here) for investment/speculation.

Moreover, Singapore regulations do not require these foreign owners to appoint local agents to "maintain" these units, unlike countries like Australia where I understand it is mandatory (correct me if I am wrong).

To-do's for Dr Ibrahim (MEWR) and Mr Mah (MND):

1. Make it mandatory for "vacant" units (unoccupied by owners or lessees) to be maintained by a local agent if the owner is a foreigner not residing here;
2. Mandate regulatory powers to enter households (forcibly) after 2 (or 3?) failed attempts to contact owners - especially for those in dengue clusters.
3. Thorough combing of houses and common areas in or around clusters (daily basis). I believe you have seen photos of clogged drains and filthy public areas, etc..., so I shall not belabour on this point but to add that I have always found it ridiculous that fingers have always been pointed to homeowners (be specific: homeowners of vacant units?) as the main culprits but evidence and reports have proven otherwise, with public areas like drains etc just as prone to breeding. (See my blog on dengue, www.denguealert.blogspot.com for more details).

BBB) For those infected with dengue:

1. My domestic helper first reported having fever on Saturday, 23 June while I was outstation. When the fever failed to go away, I brought her to a GP on Monday, 25 June upon my return to Singapore. GP's prognosis: unlikely to be dengue since (1) rashes only appearing on wrists and not the whole arms and legs; (2) temperature did not stay high at around 39 degree Celcius consistently throughout as her temperature fluctuated between 37 and 39 degrees. She was given anti-fever medicine. Believing the GP, I did not insist on blood test to confirm his prognosis.

2. Her condition improved intermittently but when the high fever returned on Thursday morning, I brought her to another 24-hour out-patient clinic at a nearby private hospital. The GP also said it was unlikely to be dengue as rashes appeared only on wrists and not on arms, legs and body. He however asked if I would like to have a blood test done on her to be absolutely sure, which I insisted since I suspected she might have the dengue. True enough, the blood test results an hour later confirmed my suspicion. She was later admitted to Tan Tock Seng Hospital (CDC).

3. So, for some 6 days (from Saturday, 23/6 to Thursday, 28/6) during her fever period, if any Aedes mosquito happened to have bitten her and then another person, the other person would have been infected, and the chain would go on, and on, and on....

4. The lesson learnt: Many people, including doctors, still do not know a lot about dengue, so despite all the assurances by the doctors about symptoms, the safest bet is still the blood test to confirm if dengue exists.

Given the gravity of the situation now, why isn't blood test for fever patients mandatory, or at least the first to be ordered? The blood test is pretty straight forward and fast (within an hour or so), so why not? The danger of not doing it is that someone with dengue may be missed out or wrongly disgnosed (like my maid - twice - until the blood test) and allowed to recuperate at home (most likely the source of the infection) with the high probability of her being bitten by an Aedes mosquito again for onward transmission to another healthy persson, and the transmission continues...

Despite all our painful dengue experience in 2005 and now, and the glorification of our Sars experience in 2003, such experience unfortunately is not put to good use.

To-do's for Mr Khaw, Health Minister:

1. All fever cases seen by private and public doctors must undergo a blood test to confirm dengue.
2. Report all such fever cases (potential and confirmed dengue) to a central database for tracking of clusters
3. Issue renewed advisory (with help from the local media?) about dengue symptoms since the public/doctors may have wrong ideas about such symptoms, which "may" include (extracted from Straits Times, 2 June 2007, "Dengue Strikes" - refer link, http://bp1.blogger.com/_zAPonigry-4/RmOD5A9cDiI/AAAAAAAAABM/GlEEugRozdo/s1600-h/st+(2+june+2007)+-+dengue+strikes+-+graphic.jpg :

a) Intermittent high fever (my maid had this symptom although not consistently);
b) body aches (my maid had this symptom);
c) exclude nausea (my maid did not have this symptom, so do not include this symptom, otherwise those without nausea may have the wrong impression they do not have dengue);
d) exclude diarrhoea (my maid did not have this symptom, so do not include).
e) rashes (on wrists and/or arms and/or legs and/or body but NOT ALL of these body parts as some doctors believe).

CCC. At the end of the day, minimising the spread of dengue should ideally involve both AAA and BBB above (eliminating breeding areas for the Aedes and preventing adult Aedes mosquitoes from biting an infected person), and the availability of a vaccine (still some years away), but since total elimination of all breeding areas (including forested areas and public areas) is almost impossible, what the government can zero in is to prevent adult Aedes from biting infected persons. (If you care to go through my blog www.denguealert.blogspot.com set up during the 2005 outbreak, I had proposed this too but the idea has not been taken up). How did my maid get infected? Most likely because she was unfortunate enough to be bitten by an infected mosquito after it had bitten an unsuspecting dengue patient (during the intervening "feverish" period before he/she is confirmed to be stricken with dengue via the blood test and/or while recuperating at home with fever - as in my maid's case).

MOH can easily achieve this by requiring all fever cases to see a doctor for a blood test to confirm if dengue exists, and if so, isolate them so that the chain can be broken (a valuable experience from the Sars days). At the same time, re-activate fever screening at all important points (immigration, public buildings, religious gatherings, etc... where masses are expected) to identify those with fever (another Sars invaluble experience) - such
heat-sensing machines are already in place in many areas).

Well, today's Straits Times report says it all - "Dengue cases hit epidemic level again", so do not wait for the situation to get worse (like in 2005) before taking appropriate action belatedly (reactively instead of pro-actively).

My maid remarked in disbelief, "Singapore is so clean (meaning "first world"?) when compared to her home town in Indonesia (meaning not-so-clean "third world"), but how could it happen here?"

When will the supposedly first-world Singapore government ever learn?


ST (3 July 2007) - Dengue cases hit epidemic level again


Dengue cases hit epidemic level again

By Arti Mulchand - Jul 3, 2007
The Straits Times
381 cases last week, crossing epidemic level for second time this year.

THE dengue situation has crossed into epidemic levels for the second time this year - the weekly number of cases here hit 381 last week.
That brings the number of people with dengue in the first 26 weeks of the year to 3,597. Three people have died.
Anything above 378 cases a week is considered an epidemic. The situation first crossed that line in the week of June 10, when it hit 401 cases.
There was a slight let-up last week, though Associate Professor Leo Yee Sin, clinical director of the Communicable Disease Centre and head of Tan Tock Seng Hospital's infectious disease department, had warned that it would be temporary.
She said: 'The number of cases is likely to fluctuate week by week, and it is likely that the level will remain high for the next few months.'
She is confident the figures will not match 2005, when there were 14,209 cases and 25 deaths, but only if 'all necessary measures' are put in place.
'All effort is needed to keep the numbers down,' she added.
The figures are expected to stay high until the usual mid-August or September peak. There were another 40 cases in the past two days alone.
There are now 78 areas where dengue is actively transmitted. In 15 of them, at least 10 people have been hit.
The situation remains bad in areas like Kim Keat, which has 31 cases, and where the dengue-spreading Aedes aegypti mosquito has been biting for close to a month.
It is also no better in the West Coast, where, between West Coast Road, West Coast Drive, West Coast Walk and Jalan Mas Puteh, there has been a combined 53 cases of dengue, and where the disease has been actively transmitted for more than 11/2 months.
Both the National Environment Agency (NEA) and the Ministry of Health (MOH) urge the public to be on even higher alert and to stay vigilant against mosquito breeding.
Those in known clusters should be extra careful, said the NEA. It advised spraying insecticide each morning in dark corners - for example, behind curtains and sofas - to get at mosquitos in hiding, and to apply mosquito repellent.
All clusters are listed on the Campaign Against Dengue website ( www.dengue.gov.sg )
MOH also reminds the public they should seek immediate medical attention if they have a fever. If diagnosed with dengue, they should use mosquito coils, nets and repellent to stop the disease being transmitted further.
'There should be no let-up in our efforts to break the chain of transmission. Continued vigilance is necessary,' said an MOH spokesman.



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