1 Two weeks after WHO sounded the alert, the world has learnt a lot more about this A/H1N1 virus. We remain lucky, with no cases here in Singapore. This is partly because we have low human traffic with Mexico. Now that the virus is endemic in the US, it is a matter of time before we discover cases here, given the high volume of travelers between the US and Singapore.
2. The US has now the largest number of confirmed cases. A lot of useful scientific information has come out of the US, given their strong medical and scientific research infrastructure. Their data paint the following picture.
3. There is easy human-to-human transmission. Vast majority of the cases in the US have no travel history to Mexico. So it is now endemic there. There could have been many more patients not picked up and unreported as their symptoms are mild.
4. Transmission is thought to be via droplets, through respiratory or gastro-intestinal material, e.g. cough, sneeze, tears: hence our strong advice on cough and sneeze etiquette. All Singaporeans should wash their hands thoroughly and frequently.
5. The illness pattern ranges from self-limiting to severe pneumonia. Tamiflu and Relenza work for this virus. Most patients were able to recover with prompt treatment.
6. Fortunately, it is milder than originally feared. Of the 5 deaths outside of Mexico, most had some underlying health problems, such as asthma and heart disease. Seasonal flu is also more severe in such patients. However, compared to seasonal flu, the virus appears to have a more severe effect on young people, which is unusual. We have to wait for more data to see whether this is indeed a true characteristic of the virus. As H1N1 is a new virus, people are less likely to have immunity. So the number of cases may be higher, compared to seasonal flu.
7. Mexico is however baffling with an apparent case fatality rate of 2.7%, 56 deaths out of 2059 confirmed cases.
8. Elsewhere, the case fatality rate is only 0.16%. When the alert was first sounded, the Mexicans reported an even higher case fatality rate of 6%. However, as the virus strain appears identical with that found in the US, the Mexican actual case fatality rate may just simply be the same as elsewhere. The latest study from WHO estimates that up to 32,000 may have been infected in Mexico, and case fatality rate is estimated at 0.4% (with a range of 0.3% to 1.5%). The study also suggested that the virus may have been circulating there for quite some time already. We are consulting with the experts on this.
9. Meanwhile, we have lifted the visa requirement on Mexican citizens, given the reduced threat assessment.
10. The original intent of HQO on Mexican travelers without symptom, was to reduce the risk of transmission to our community, given the initial reports of high case fatality in Mexico. Now that the disease appears to be mild among cases that have travelled from Mexico, there is a case to review this policy and we are actively doing so.
11. But many questions still remain on the new virus. Experts remain worried that the virus may come back in a more lethal second wave. Some optimists think that a second wave may not happen. But many are pessimistic. WHO's flu expert, Dr Fukuda warned that one third of mankind, 2 billion people will be infected by it within a year. We will need a full year, to see how the virus evolves, as it does its tour of the globe from the northern to the southern hemisphere and back again to the north. We can then decide if we can relax.
12. Meanwhile, we should stay vigilant on code yellow. At our checkpoints, we will continue with temperature screening, and we will ask travelers who have come from North America to inform us if they have fever or any flu-like symptoms such as sore throat, cough or runny nose, so that we can screen them for H1N1. We will also continue to give all travelers coming into Singapore a Health Advisory Notice, asking them to monitor their own health if they have been to the affected areas. Hospital and clinics will also stay vigilant. However, the public can get on with normal life, but please do up the standard of personal hygiene, make it a way of our life.
13. Over the next few weeks and months, we will do three things.
14. First, we will replenish our stock of PPEs, Tamiflu and Relenza. I will strongly advise the private sector to do the same. The GPs and companies which did not stock-up these essential resources had to scramble when we moved to code orange two weeks ago. They would have learnt the hard lesson of being caught unprepared. Please follow the advice as documented in our flu pandemic preparation plan, supplemented by the refinements in our circulars. The supplies are now available and prices have also softened. Better consider going into the market soon. Companies should also take this opportunity to update their business continuity plans, procure other necessary equipment such as thermal scanners, etc, and make sure their plans are well-exercised and thought through. This way, we can all be better prepared when cases occur in the workplace and business continuity is less affected.
15. Second: we will post mortem our experiences, identify gaps in our plan and plug them. In particular, there is scope to improve the primary health care response. Post SARS we strengthened the hospital sector considerably, and hence they did very well this time round. H1N1 exposed some gaps in the primary healthcare sector; we will make sure that we will do much better when the virus eventually arrives on our shores or if a more serious second wave comes.
16. Third: we will learn from the affected countries, in particular North America. We will send teams of public health experts and scientists there to study their experience. After SARS, many countries sent delegations here to learn from our experience. We are lucky this time round but may not be as lucky next time round; better learn from others who have been battle-scarred.
17. In summary, evidence suggests that this virus is behaving in some ways like a seasonal flu virus, but with certain different characteristics, like more young people being affected. SARS came and swiftly disappeared. Strong containment measures were effective and appropriate.
18. It is likely that H1N1 is going to be here with us permanently; it may not simply disappear like SARS. Our control measures must therefore be designed for a long term sustainable operation, not for tackling a one-off acute episode. Given the ease of transmission, it will be endemic globally. It may simply become one of the various influenza strains circulating in the community. Many will be infected by it and if we go all out to look for them, we are bound to find many.
19. That is why every day, we hear of new confirmed cases being reported in Korea, Japan, Australia, China, and now Thailand. And no doubt about it, soon Singapore will be added to this list. This is particularly so, given the large volume of human traffic between Singapore and the US. Now that we better understand the nature of this virus, the public focus or anxiety should not be over the number of new cases or the number of new countries affected. Instead, the public health focus should be on the severity, if any, of the new cases: do the patients develop complications, pneumonia, severe respiratory failure? Who are those that are vulnerable to developing complications, so that we can focus on treating them early?
20. Based on the observations so far, the expectation is that almost all the new cases will be mild and will recover quickly. Some will need hospitalisation, 5% by US experience, and practically all will recover fully, if prompt medical attention is delivered, within the first 24 or 48 hours. Hence the priority should be to get new cases who feel unwell to seek medical attention immediately. With H1N1, there are effective treatments: Tamiflu, Relenza and good ICU facilities. They must not delay, brush aside the symptoms, only to regret later.
21. I spend some time on this, as we will encounter our first confirmed cases soon and as a society, we must know how to react to the first few cases. We need Singaporeans to understand our rationale, so that there is no misunderstanding or panic when cases do emerge.
22. When we encounter our first confirmed cases, we will still try to contain the outbreak here, treating the patients, quarantining the close contacts and health advisory for the other contacts. Our contact tracing capability is on standby for this purpose.
23. For example, if there is a confirmed case who is a student, we will isolate him in a hospital and treat him. We will screen all other students and staff in the school, but other than the close contacts, e.g. his close friends, classmates and their teacher, there is no need to close the school and quarantine all staff and students. But we will remind the students, parents and teachers to be alert to any flu-like symptoms and to let us know immediately.
24. We will take a similar tack if there is a worker who comes down with H1N1 in a work place, or if there is an affected traveler who is staying in a hotel. We will not close down the workplace or the hotel. But we will quarantine the close contacts and advise others in the workplace or hotel to closely monitor their own health and seek medical attention early, if they are unwell.
25. If there is a sick traveler on a plane, we will identify and quarantine those who were sitting near to him or those who have been part of his travelling party, and monitor them. For the other passengers, we will give them advice on monitoring their health and ask them to seek urgent medical attention if they become ill.
26. These initial responses will buy us some time to ascertain if indeed the cases are mild, as observed elsewhere. If the confirmed cases present with serious symptoms, despite not having other illnesses, and despite getting prompt attention, then we will have to review our approach.
27. There are however certain scenarios where we will have to close down a facility. This includes places where people are in close proximity to each other, for example, a childcare centre or a dormitory. If there is a case found in such a location, we may have to close the whole centre and quarantine everyone in it.
28. Last week, I did a house-to-house visit in Sembawang. I asked my residents whether they were worried about swine flu. All said that they were not worried; I asked why. They said we would be able to keep it out, because of our SARS experience.
29. While I appreciate the confidence of my residents, such a high expectation that we can keep out H1N1 is unrealistic. What is realistic, however is that we should be able to minimise deaths and severe complications due to the virus, provided (a) the patients seek treatment promptly; and (b) the patients have no other serious underlying medical condition. We should however expect some deaths due to H1N1 at some stage. Remember that every year, 600 Singaporeans die of seasonal flu. In fact, we are going to report more seasonal flu cases soon. Every year, seasonal flu cases in Singapore peak in the middle of the year, and again at year-end. The public should be mentally prepared for that, and not be alarmed when they see more people down with flu.
30. But while we remain vigilant, Singaporeans can continue their normal lives. The June holidays are coming up. Families can continue with life as per normal. But try to avoid vacations to affected countries - check the MOH website for the updated details, as this changes day by day. If you go on vacation, do take the usual common-sensical precautionary measures that you would exercise in Singapore as well. See a doctor if you don’t feel well, and avoid crowded places if possible, particularly if you are sick. Always keep up good hygiene, wash your hands frequently and thoroughly and don’t touch your eyes, nose, mouth.
