The Parliament's Approach in Turning Zikapore Back into Singapore

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There was a Ministerial Statement made in this week's parliament sitting by Health Minister Gan Kim Yong about Zika. We are posting his statement in full as opposed to the MSM's summarized versions to help give you, our readers, a clear idea on how the Health Ministry is responding to the Zika outbreak, free from the filter of a reporter's bias as you might read in the papers. 
Working Together to Address the Zika Outbreak - Ministerial Statement
Mr Alex Yam Ziming: To ask the Minister for Health (a) whether Ministry will consider setting up a National Zika Registry much like the Zika Active Pregnancy Surveillance System (ZAPSS) that was set up in the aftermath of the Puerto Rico Zika outbreak to track the effects of Zika on mothers and infants as well as otherwise healthy adults; (b) whether the Ministry will encourage screening of pregnant mothers; and (c) whether the Ministry will provide support to families with microcephalitic infants due to Zika.
Ms Tin Pei Ling: To ask the Minister for Health (a) whether free Zika screening can be offered to residents of affected areas; (b) what support will be given to pregnant women suspected of Zika infection; and (c) whether there are useful insights learnt from managing and communicating the latest Zika incident and, if so, what are they.
Mr Christopher de Souza: To ask the Minister for Health what steps have been taken to spread awareness among members of public of the effects of the Zika virus on pregnant women and what steps can be taken to reduce the risk of contracting the virus.
Assoc Prof Daniel Goh Pei Siong: To ask the Minister for Health given the need for better health management of workers staying in construction sites and dormitories close to residential areas to control the spread of dengue and Zika (a) whether daily temperature-taking and submission of records should be implemented for these sites and dormitories; and (b) whether the primary care system for the workers should be reviewed and improved upon.
Mr Png Eng Huat: To ask the Minister for Health whether the Ministry will consider putting out more information to the public on the Zika virus via traditional media like free-to-air broadcasts during prime time hours and newspapers to educate the public and to separate the myths from the truth about the virus.
Madam Speaker, on 27 August 2016, Singapore detected its first confirmed case of locally transmitted Zika virus infection.  As of noon yesterday (September 12th), 333 persons have tested positive for Zika, including 8 who are pregnant, and involving 7 clusters.  Most of the patients have recovered and are no longer symptomatic.  Although we had been expecting it, many Singaporeans were concerned when Zika cases first emerged in Singapore.  Their anxiety is understandable given that Zika is little known here.  We have learnt much over the last two weeks.  Allow me give the House an update on the situation.   
What is Zika?
First, what is Zika?  Zika is not a new disease.  The first documented case of Zika was in Africa in 1947.  The first reported large outbreak occurred in 2007, in Micronesia.  Zika was unknown in the Americas until last year when a number of cases were reported in north-eastern Brazil. 
By now, 72 countries and territories have reported evidence of Zika virus transmission.  On 1 February 2016, the World Health Organisation (WHO) declared that the recent cluster of microcephaly cases in Brazil, which are suspected to be linked to Zika, constituted a Public Health Emergency of International Concern.
Zika is transmitted via the Aedes mosquito, which can also carry the dengue and chikungunya viruses.  Zika can also be spread through sexual transmission in some cases. 
About four out of five infected with Zika virus will not have symptoms, that is, they are asymptomatic.  The rest mostly have mild symptoms, which include fever and rash, and other symptoms such as red eyes and joint pain.  On rare occasions, patients may also develop Guillain-Barré Syndrome, a disease that temporarily affects the nervous system. 
Zika is, however, of concern among pregnant women.  A small number of babies born to pregnant women with Zika infection may develop microcephaly, a congenital condition that affects the development of the brain.  Research is still ongoing to better understand the association between Zika and microcephaly. 
Zika in Singapore
We had expected Zika to come to Singapore sooner or later, given the large volume of travel in and out of Singapore.  When it did, we also expected to see local transmission, because of the presence of Aedes mosquitoes here.  Hence, we have put in place an action plan with a three pronged approach: first, preparing for Zika; second, responding to initial cases; and third, managing Zika in the long term.
Preparing for Zika
We prepared for Zika on a few fronts.
First, MOH worked with NEA’s Environmental Health Institute to put in place a sentinel surveillance programme for Zika two years ago.  We partnered about 200 clinics island-wide to collect blood samples from selected patients with symptoms associated with Zika, which are quite similar to dengue, and tested them for Zika virus.  From January this year, we stepped up surveillance and testing efforts, and increased the number of samples tested for Zika to more than 500 a month, a majority of them from people who had no travel history to Zika-affected areas.  Close to 4,000 samples were tested between February and August, before the first confirmed case happened.  All the test results then were negative.
At the same time, we strengthened our laboratory capabilities to facilitate the testing and management of patients. 
As a second layer of defense, we kept our doctors, especially our GPs, abreast of the developments on Zika.  Our GPs are the first line of care for most Singaporeans.  They have been helpful in alerting us to unusual disease patterns.  We have also made Zika a notifiable disease under the Infectious Diseases Act from January this year, so that MOH would immediately be alerted if any doctor or laboratory in Singapore detected a case of Zika. 
Third, we sought to reduce the risk of importation of Zika.  We issued travel advice to outbound travelers to Zika-affected areas and inbound travelers returning from affected areas. 
Fourth, we stepped up public education and issued health advisories.  In early February, we set up the Clinical Advisory Group (CAG) on Zika and Pregnancy, to develop a health advisory for pregnant women, and also to advise doctors on the clinical management of pregnant women with Zika.  An interim clinical guidance was issued in mid-April.
Fifth, we strengthened our operational readiness for an outbreak.  In January this year, MOH worked with partner agencies to prepare our operational plans in case of an outbreak.  In July, we conducted a multi-agency exercise where we simulated the import of an infectious disease into Singapore.  This involved a wide range of partner agencies, including MTI and MOM.
Meanwhile we continued to monitor global developments related to Zika closely, to obtain regular updates on the situation worldwide. 
Responding to Initial Cases: Containing the First Imported Case
Madam, on 12 May, a man was hospitalised after he fell ill upon returning from Brazil.  On 13 May, he tested positive for Zika and the patient was quickly isolated at the Communicable Diseases Centre (CDC) at Tan Tock Seng Hospital (TTSH). 
We screened the patient’s household members, and NEA deployed a large team of officers to conduct intensive vector control operations in the area around his home in Watten Estate. 
Residents in the area were given Zika information leaflets, and advised to seek medical attention should they develop symptoms of fever and rash.  We also asked the clinics in the vicinity to look out for Zika-like symptoms.
The man was discharged after he tested negative for the Zika virus and recovered.
 No other cases were subsequently linked to this case and the virus was successfully contained.
Responding to the First Locally Transmitted Case
Three months later, in the evening of 22 August, MOH was alerted by a GP from the Sims Drive Medical Clinic on an unusual increase in cases of fever, rash, and joint pain that had tested negative for dengue and chikungunya.  The next day, MOH arranged with the GP to refer new cases with similar symptoms to the CDC.  On 25 August, we approached the supervisor of a nearby construction site for records of workers who had recently been unwell, so that they can be investigated further.
The following day, a lady visited the same GP clinic with similar symptoms and was referred to the CDC, as was arranged with MOH.  She was confirmed as Zika-positive on 27 August.  Three other patients were preliminarily tested positive that day, pending confirmation tests. 
That very evening, MOH announced all four cases of locally transmitted Zika cases, one confirmed and three pending confirmation. 
Following this, we alerted the GPs in the Aljunied Crescent and Sims Drive area to specifically look out for patients with Zika-like symptoms, and advised residents in the area to see their doctor if they had such symptoms.  NEA also intensified vector control operations in the vicinity.
Actively Detecting Cases and Identifying Clusters
By now, MOH and NEA have moved beyond the surveillance phase, to actively detect cases and identify clusters to manage the spread of Zika.
To determine the extent and locations of the spread, we not only looked out for new cases, but also looked backwards in time to investigate past cases in the vicinity.  As a number of such cases were construction workers, we went back to the construction site on 27 August to trace and test workers who had recently recovered from fever, and also assessed and tested new patients.  We obtained most of the results by the next day and included them in our subsequent announcement. 
This active back-tracing was why the number of confirmed Zika cases increased from 1 reported on 27 August to 41 on 28 August.  This sudden jump was surprising to some people, who wondered if these cases had in fact been identified earlier but held back by MOH.  In reality, the number of confirmed new Zika-positive patients, and I repeat, new Zika positive patients, increased only to 5.  The other 36 were from our proactive back-tracing of workers at the construction site.  Many of them had already recovered by the sickness.
Through the back-tracing, we also checked the onset of symptoms for each case to determine the epidemiology of the outbreak.  The analysis showed that the earliest case had onset of symptoms on 31 July.  Some people misinterpreted this as MOH having known of the first Zika-positive case since 31 July.  This is not so.  As I explained,we only confirmed the first locally transmitted Zika case on 27 August, and we released the information the same evening.
We subsequently identified new clusters beyond Aljunied and Sims Drive and we provided updates daily. 
A/Prof Daniel Goh asked how we manage construction sites and dormitories.  MOM and NEA have stepped up the engagement of construction sites and dormitory operators to intensify their vector control efforts to prevent mosquito breeding. 
MOM has also reminded employers and dormitory operators to encourage workers to seek medical attention and notify their supervisors should they feel unwell.  Measures such as temperature taking have limited effect on Zika since a majority of infected individuals are asymptomatic, that is, they do not have temperature.  As Zika is a mosquito-borne disease, the key strategy is vector control.  I would also like to assure A/Prof Goh that our primary healthcare system are all accessible to foreign workers should they need to see a doctor.  The cost of their treatment will be borne by their employers.  
Managing Zika in the Long Term 
Let me now explain our approach towards Zika going forward and how we are preparing to manage Zika in the long-term.
Focusing on Vector Control
As more cases and clusters emerge, our efforts are focused on vector control.  Minister (MEWR) will speak on this later.
Isolation of patients has limited effect as 80% of those with Zika are asymptomatic, that is, without symptoms and there are mosquitoes in the community already carrying the virus. Hence, we now no longer isolate patients.
Hospitalisation of Zika patients is also not necessary as we find that most cases have mild symptoms.  Patients will be hospitalised only if it is clinically necessary. 
Facilitating Zika Testing
We had also reviewed our policy on testing of suspect cases.  Initially, we were focused on the clusters, to quickly assess the nature and extent of the outbreak so as to guide our strategy.  We therefore provided free testing for those with symptoms who lived, worked or studied in areas that are affected. 
As more cases were found in other parts of Singapore, we extended Zika testing beyond the clusters, and now provide a subsidy to all Singaporeans with Zika-like symptoms at the public healthcare institutions. 
Supporting Pregnant Women as a Special Group
Many pregnant women are understandably anxious about Zika.  We are paying particular attention to them, because of the possible risks to their fetuses if they are to be infected by Zika. 
The Clinical Advisory Group for Zika and Pregnancy had on 30 August updated its guidelines on the health advisory, testing and clinical management for pregnant women.  These were aligned with WHO guidelines, which advise that Zika testing for asymptomatic pregnant women is not routinely recommended.  However, WHO’s guidelines do recommend testing for symptomatic pregnant women and those whose male partners had tested positive for Zika.  Symptomatic pregnant women and those whose male partners had tested positive should seek the advice of their doctors.  They will be provided with free Zika tests at both public and private healthcare institutions if their doctors assess that testing is needed.
Pregnant women who are tested positive for Zika will be referred by their doctors to an obstetric or maternal-fetal medicine specialist for counseling and subsequent follow-up. 
Regular ultrasound scans will be carried out to monitor the development of the fetus.  Zika infection does not always result in abnormal fetal development.  It is therefore important that pregnant women be appropriately advised and monitored by the relevant specialists.  Babies born with microcephaly will be supported and cared for just as we do for babies with other congenital conditions.
People’s Association has also worked with NEA, and specially arranged for insect repellents to be available to pregnant women at community clubs island-wide since last Saturday.  We hope this is helpful.
Public Education
Mr Christopher de Souza and Mr Png Eng Huat asked how we could raise public awareness of Zika. Public awareness is one of the most critical elements in our fight against Zika, and we have undertaken multiple efforts on this front. 
Since January this year, we have kept the public updated on Zika developments through the media and the MOH website, providing information on precautions to take when travelling to Zika-affected areas.
Since the outbreak started on 27 August, we have shared information with the media and public on a daily basis.  I would like to thank the media for following the news closely, taking the effort to understand the issue, and presenting the news on Zika in a clear and accurate way. 
The Ministry of Communications and Information (MCI) has also set up a microsite on Zika with useful and easy-to read infographics and videos on ‘What is Zika’, providing advice to pregnant women, as well as the latest updates on the Zika situation in Singapore.  MCI has produced some interstitials on Zika, which have also been broadcast on free-to-air channels, starting from last week.
NEA has also set up a website with statistics on Zika infections and clusters.
NEA, in collaboration with the grassroots, has continued its outreach to the community through information leaflets and posters on Zika and dengue.  This has gone hand-in-hand with their vector control operations.
In Chua Chu Kang, for example, with the support of NEA, students from Pioneer JC and ITE College West, grassroots leaders and volunteers, we visited 134 blocks in the constituency on 4 September, to share with residents information on Zika and what they can do.  I am sure many other Members have done the same. 
Research Efforts
I have no doubt that we will be able to learn more about the Zika virus through global and local research efforts. 
The National Public Health Laboratory has worked with A*STAR’s Bioinformatics Institute to complete the sequencing of the Zika virus found in two patients here and shared their results publicly. 
We cannot tell at this moment whether the viruses found here cause more or less severe disease than those in South America.  Further research will be needed to shed light on this.
We can also expect more test kits to be on the market in future.  They will need to undergo field trials, be validated by laboratory professionals, and approved by regulators to ensure they are safe and results are reliable before they are available for use. 
Currently there is no specific anti-viral treatment or approved vaccine for Zika.  Early-stage human trials have commenced for experimental vaccines.  There are also ongoing research efforts in Singapore on Zika.  But testing and translating these to practical clinical use will take time. 
Mr Alex Yam asked about whether the Ministry will consider setting up a National Zika Registry. We will study this carefully.  Meanwhile, we are already tracking Zika, which is a notifiable disease.  Microcephaly has been tracked by the National Birth Defects Registry since January 1993. We will work with our doctors to monitor the outcomes of babies born to women with Zika over time.
Whole-of-Government and Whole-of-Society Strategy
Madam, Ms Tin Pei Ling asked if there are any useful insights learnt from managing and communicating the latest Zika incident.  I will share three learning points.
First, it is important to be transparent and timely in sharing accurate information.  This is why we released regular updates on Zika, in order to keep the public apprised of the situation.  This also prevents rumors and untruths from spreading, and creating confusion and suspicion. 
Second, a Whole-of-Government response is key.  MOH and MEWR are grateful that we have had strong support from our healthcare partners and professionals, government agencies such as NEA, MCI, MOM and PA, in responding to this outbreak. 
Lastly, and importantly, a Whole-of-Government approach is still not enough.  We need a Whole-of-Society approach.  I am grateful to many grassroots leaders and volunteers who helped to reach out to fellow residents on Zika.  I want to thank fellow Singaporeans for helping us on the ground to eliminate mosquito breeding sites.
Madam, there is still much to do, and all of us need to play our part in the fight against Zika. 
It is still early days to ascertain what the long-term trend of Zika infections will be.  We cannot afford to be complacent, even if we see day to day numbers coming down.
Even as NEA continues its vector control efforts, each one of us should do what we can to reduce the spread of Zika by taking personal precautions against mosquito and checking for mosquito breeding in our homes and our workplaces.  I urge all Singaporeans to continue to remain vigilant and do our part, to protect Singapore against Zika.
Madam, the journey in our fight against Zika is likely to be a long one, because of the presence of Aedes mosquitoes here.  Even if we can control the present outbreak, we will need to continue to guard against imported cases, as the Zika virus is still circulating among many countries, including several in this region. Therefore, as we tackle Zika, life must go on.  By working together, we can succeed in managing Zika in the long term.

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