Zika in Singapore: Ministerial Statement by MOH, MEWR

Singapore's Zika efforts started two years ago
By Salma Khalik, Senior Health Correspondent, The Straits Times, 14 Sep 2016

For the past two years, well before the Zika virus came to its shores, Singapore has been preparing itself to fight it, Health Minister Gan Kim Yong told Parliament yesterday.

A surveillance programme for the virus was put in place two years ago, when the virus started hitting some parts of the world. Some 200 clinics began collecting blood samples from patients with Zika-like symptoms, Mr Gan said.



In January, Zika was made a notifiable infection so that the Ministry of Health (MOH) would be immediately alerted if any doctor or laboratory detected a case.

Close to 4,000 samples were tested between February and August - and all were negative until the first locally transmitted case was diagnosed on Aug 27.

Since then, 333 people have been infected, including eight pregnant women, and seven Zika clusters found. But for the first time since Aug 27, no new cases were announced yesterday.

Mr Gan said the jump in the number of cases - from one on Aug 27 to 41 the following day - had raised some questions."In reality, the number of confirmed new Zika-positive patients, and I repeat new cases, increased only to five," he said. The other 36 cases surfaced because of back-tracking efforts.

The focus now is on efforts to eradicate the Aedes mosquito.



Environment and Water Resources Minister Masagos Zulkifli said that between Aug 27 and Sept 11, more than 31,000 premises were inspected and more than 200 mosquito-breeding sites destroyed. The authorities have also broken into 24 premises to look for breeding sites.

Pregnant women, whose unborn foetus can be damaged by Zika, will still be treated as a special group. Those showing Zika symptoms will be tested free of charge. Those who have the virus will be monitored through their pregnancy.

Singapore still vulnerable to mozzie-borne infections
Climate, high population density among factors helping Aedes mosquitoes to flourish: Masagos
By Samantha Boh, The Straits Times, 14 Sep 2016

Singapore's warm and humid climate plus its high population density are a potent mix that has made the country an attractive place for the Zika-carrying mosquitoes to flourish.

In his ministerial statement on Zika yesterday, Minister for the Environment and Water Resources Masagos Zulkifli said such a climate allows the mosquitoes to breed all year round. It helps hasten as well the breeding and maturation cycles of mosquitoes.

A high population density is also "very helpful" to the breeding of the Zika-carrying Aedes aegypti, he added. This breed of mosquitoes has "adapted particularly well" to Singapore's urban environment, and likes to breed, mate and feed near human dwellings.

These were two of the five factors Mr Masagos cited to explain why Singapore remains vulnerable to dengue, Zika and other mosquito-borne infections despite widespread vector control efforts.

The other factors include the growing number of dengue cases globally, which according to the World Health Organisation stood at 3.2 million cases last year, a spike from 2.2 million in 2010.



He also told the House that being located in a dengue-endemic region, where there are four different dengue virus serotypes circulating at the same time, makes Singapore particularly susceptible to the scourge of dengue.

Another factor working against the Republic is that a large proportion of the population lack immunity to dengue and other mosquito- borne infections, as a result of "intensive mosquito control in the past decades".

Mr Masagos noted that in many other countries where dengue is endemic, those affected are often children.

While it is good that this is not the case in Singapore, successful vector control can have unintended consequences. "Our success has paradoxically lowered our herd immunity so that disease transmission occurs easily even with a very small mosquito population," he said.

At least 12 MPs raised questions on the Zika virus, such as whether the Government will further intensify efforts to curb its spread, and if more stringent measures could be put in place at construction sites.

Non-Constituency MP Dennis Tan asked when the Wolbachia technology - in which naturally occurring bacteria are used to make female mosquitoes lay sterile eggs - will be introduced on a larger scale.

Mr Masagos said the ministry will study the Wolbachia mosquitoes for six months from next month, to assess how high they can fly and how long they can survive.

If suitable, these mosquitoes will be put into action in a "field suppression trial" which, if successful, will see them eventually being rolled out to high-risk areas in 2020.

Not wise to do routine fogging outside clusters
By Samantha Boh, The Straits Times, 14 Sep 2016

While fogging is helpful in killing adult mosquitoes with the dengue or Zika virus, it "would not be wise to conduct fogging indiscriminately" outside clusters, said Minister for the Environment and Water Resources Masagos Zulkifli yesterday.

He said his ministry has heard calls for fogging to be conducted at various housing estates, but stressed that routine fogging should not be used as a preventive measure.

He gave three reasons in his ministerial statement on Zika.

First, the fogging chemical has to come into direct contact with the mosquitoes to kill them.

This means fogging has to be carried out repeatedly and frequently as new swarms of mosquitoes continue to emerge from breeding habitats that have not been removed.

"Routine fogging is not a sustainable vector control measure," he said in Parliament.

Second, the right chemical and sufficient number of fogging guns need to be used to "achieve an effective kill".

Fogging just a single area may also chase mosquitoes to another location. This is why it has to be properly planned.

Third, the overuse or indiscriminate use of chemical treatment may increase the resistance of the local mosquito population. Owing to overuse, some insecticides are no longer effective, he said.

"I know everyone likes fogging because it's very optical - everyone can see it and everyone feels better. But it does not solve the problem."

Mr Masagos was replying to Mr Christopher de Souza (Holland- Bukit Timah GRC), who asked if fogging could be carried out in more areas.

The minister also said fogging is done as an extra measure to quickly stop the transmission of dengue or Zika.

His ministry's key strategy for dengue and Zika control is source eradication, which is to detect and remove breeding habitats and larvae.

"Fogging should be used only when there are Zika or dengue clusters or when the adult mosquito population is observed to be high so that we can mitigate the situation, which, again I qualify, is effective only (when done) together with source eradication," he said.

Why detecting mosquito breeding spots is difficult
By Linette Lai, The Straits Times, 14 Sep 2016

Most mosquito-breeding spots are found in homes and not at construction sites.

This makes the job of detecting breeding spots harder because, unlike entering construction sites, the authorities cannot go into homes easily or frequently to check on them, said Minister for the Environment and Water Resources Masagos Zulkifli yesterday.

"This is why we have to emphasise repeatedly that every household must constantly do the necessary ground actions to remove potential breeding spots in their own homes," he said.

Mr Masagos was giving Parliament an update on mosquito control efforts in the light of the Zika outbreak last month.

He said the National Environment Agency did 748,000 inspections between January and July - 638,000 of them in homes and 4,400 at construction sites.



Half of the 10,000 or so mosquito-breeding habitats found were in homes, while only 5 per cent were at construction sites, he said in his reply to Dr Tan Wu Meng (Jurong GRC), Ms Foo Mee Har (West Coast GRC) and Non-Constituency MPs Dennis Tan and Daniel Goh.

Mr Masagos also said the authorities have stepped up enforcement action against errant contractors.

For instance, construction sites exceeding $50 million in project value have to employ full-time environmental control officers, while those with sites valued between $10 million and $50 million must employ such part-time officers.

The authorities have also issued stop-work orders and prosecuted repeat offenders in court.

"This combination of measures... has helped bring about a significant reduction in the percentage of inspected construction sites found with mosquito breeding - from 30 per cent in the 1990s to 11 per cent in 2013 to about 9 per cent today," Mr Masagos said.

He added that, between January and July, 2,200 households were fined after inspectors found breeding spots in their homes.

"Whether it is a home or a construction site, we must be as vigilant," Mr Masagos said.

"Everyone must do their part to make sure they do the five-step mozzie wipeout as a daily habit, to ensure that they don't give the mosquitoes a chance to breed."

Steps to contain potential economic impact
By Samantha Boh, The Straits Times, 14 Sep 2016

It is "premature" to determine the impact the Zika virus has had on travel to Singapore and the Republic's economy, Senior Minister of State for Trade and Industry Sim Ann said yesterday.

But the Government is taking "strong coordinated actions" to contain the Zika outbreak and any potential economic impact, she told Parliament.

She was responding to questions by Nominated MPs Randolph Tan and Thomas Chua, on the strategies the Ministry of Trade and Industry (MTI) is putting in place to limit the impact of the virus.

Ms Sim said the Singapore Tourism Board (STB), for example, is working closely with travel trade and tourism partners to address concerns from potential visitors, despite Zika's impact on visitor arrivals being "currently contained".

Staff at STB's Call Centre and Singapore Visitor Centre have also been monitoring daily visitor feedback and responding to queries on the Zika outbreak.

Ms Sim said it is too early to consider Zika-specific support measures for businesses, but said they can tap existing schemes if needed.

For example, small and medium-sized enterprises facing short- term cash flow issues can apply for loans of up to $300,000 under the Working Capital Loan programme administered by Spring Singapore.

Spring is also working with the Singapore Business Federation to help firms develop business continuity plans, to ensure they are able to adapt if operations are disrupted.

"MTI and its agencies will continue to closely monitor developments through the Ministry of Health and National Environment Agency, and are prepared to develop and activate further support for businesses should these prove necessary," said Ms Sim.

Battle against Zika likely to be a long one
Whole-of-government approach not enough - a whole-of-society effort needed in fight against Zika virus, says Health Minister
By Salma Khalik, Senior Health Correspondent, The Straits Times, 14 Sep 2016

The fight against Zika is likely to be a long one, Health Minister Gan Kim Yong told Parliament yesterday, and will require a concerted effort from not just the entire Government, but also society.

While the number of new cases being detected has fallen recently, it is still "early days" to ascertain what the long-term trend of Zika infections will be. "We cannot afford to be complacent," added Mr Gan in his ministerial statement to Parliament yesterday.

Addressing a question from MacPherson MP Tin Pei Ling whether there are any useful lessons learnt from the latest outbreak, Mr Gan said there were three.

"First, it is important to be transparent and timely in sharing accurate information. This is why we released regular updates on Zika... This also prevents rumours and untruths from spreading, and creating confusion and suspicion."

While the combined effort from government agencies, including the National Environment Agency (NEA) and Manpower Ministry, along with healthcare professionals, meant that Singapore was able to respond speedily, a whole-of-government approach is still not enough.

"We need a whole-of-society approach", Mr Gan stressed, urging everyone to reduce the spread of Zika by taking personal precautions against mosquito bites and checking for mosquito breeding in their homes and workplaces.



Another front in the fight against Zika is research.

The Ministry of Health's (MOH) National Public Health Laboratory and A*Star's Bioinformatics Institute have found that the Zika virus strains involved in at least two locally transmitted cases is similar to strains of the virus circulating in South-east Asia since the 1960s.

It was not recently imported from South America, where the virus has been linked with microcephaly. "We cannot tell at this moment whether the viruses found here cause more or less severe disease than those in South America," said Mr Gan. "Future research may help to shed light on this."

MOH also continues to exchange information regularly with international counterparts on managing the mosquito-borne virus.

"Public awareness is one of the most critical elements in our fight against Zika," said Mr Gan, pointing out that MOH will continue to keep people updated on the Zika situation. He highlighted how the Ministry of Communications and Information has set up a microsite on Zika, while the NEA carries statistics on Zika infections and clusters on its site.

"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 the region. Therefore, as we tackle Zika, life must go on," he said.

Financial help available for pregnant women with Zika
By Linette Lai, The Straits Times, 14 Sep 2016

Pregnant women who test positive for the Zika virus but cannot afford regular scans and follow-up treatment will not be left without help, said Health Minister Gan Kim Yong yesterday.

He assured them that, if necessary, additional aid is available from Medifund, a government scheme for those who cannot pay their medical bills after exhausting all other avenues.

"For treatment in our public healthcare institutions, they can always access our subsidy framework if they are subsidised patients," he said, when replying to Ms Tin Pei Ling (MacPherson) in Parliament.

"If they are unable to afford the costs, especially for the lower-income families, Medifund is available for them."

In his ministerial statement on Zika yesterday, Mr Gan acknowledged that pregnant women are "understandably anxious" about the outbreak of the mosquito- borne infection.

"We are paying particular attention to them because of the possible risks to their foetuses if they are infected by Zika," he said.

Currently, the Health Ministry is offering free testing to pregnant women with Zika symptoms or whose male partners are Zika-positive, as long as a doctor recommends that it is necessary.

The World Health Organisation does not recommend routine Zika testing for pregnant women without symptoms.

"Pregnant women who are tested positive for Zika will be referred by their doctors to an obstetric or maternal-foetal medicine specialist for counselling and subsequent follow-up," Mr Gan said.

Regular ultrasound scans will be carried out to monitor the development of the foetus, he added, stressing that the Zika infection does not necessarily mean the baby will have microcephaly.

Mr Alex Yam (Marsiling-Yew Tee GRC) asked if there have been other cases of microcephaly in Singapore.

Yes, Mr Gan said. "Over the last five years, we have an average of between five and 12 microcephaly cases per 10,000 live births in Singapore," he said.

"For the patients with microcephaly, we continue to provide support and manage them the same way as we manage children with congenital conditions."

From the gallery: When the House became one
By Janice Heng, The Straits Times, 14 Sep 2016

When new laws are introduced, or proposals made to change policies, these deserve thorough airing, scrutiny and debate in Parliament.

Then there are also issues which are less about the cut and thrust of debate, and more about legislators coming together because there is common cause and for which a unified solution is needed.

A national public health concern is one such instance.

And yesterday was one such occasion in Parliament, when two ministerial statements were made on the Zika outbreak in Singapore.

With Zika having the potential to be endemic islandwide, and already of particular concern to pregnant women, it would have been easy for MPs - whether from the ruling party or opposition - to engage in political posturing, or to pander to and stoke unfounded fears when discussing it in the House.

After all, when the news of local Zika transmission broke late last month, allegations of a government cover-up about what was known and when started to make the rounds online.

Much is still unclear about the potential effects of Zika and the exact nature of the local strain.

So it is commendable that all eight MPs who asked questions on Zika refrained from fuelling uncertainty, fear-mongering, and adding to the concerns that some individuals still have.

That is not to say that the MPs gave the office-holders - Health Minister Gan Kim Yong and Environment and Water Resources Minister Masagos Zulkifli - an easy time.

Ten questions on Zika had been filed ahead of yesterday's sitting, five for each ministry. This was in addition to two Zika-related questions for the Ministry of Trade and Industry on the impact on tourism and the economy, which were answered separately.

After Mr Gan and Mr Masagos delivered their statements, which also addressed the queries filed earlier, Ms Foo Mee Har (West Coast GRC) got the ball rolling with more questions.

She asked if the Government would consider additional measures: for instance, a new regulatory regime to require all construction contractors to get independent pest controllers to inspect their sites.

Mr Masagos replied that Singapore "should not go overboard" while also pointing out that most breeding spots are found in homes, not construction sites - a response Ms Foo accepted.

Questions from two Workers' Party Non-Constituency MPs were similarly focused on practical, factual issues.

Associate Professor Daniel Goh asked about the 36 construction workers found to have had Zika during the Health Ministry's back-testing of past cases. Did they visit a clinic, and if so, why did the clinic not detect Zika?

He also wanted to know about processes to ensure that contractors report multiple cases of illness, and whether the location of construction sites - not just their size - should be taken into consideration.

Mr Dennis Tan asked about the timeframe for the National Environment Agency's field study involving male Aedes mosquitoes bearing the Wolbachia bacteria. When such mosquitoes mate with female ones, the bacteria will cause the females to produce eggs that do not hatch.

These were practical questions devoid of political point-scoring.

Of course MPs, and arguably those in the opposition in particular, have a role in holding the Government to account, scrutinising policies, and raising questions when there is a need to.

But it would be dangerous if voters and MPs themselves take this to mean that they, and the process, must always be combative and confrontational.

Fortunately, as yesterday's session showed, MPs were not influenced by populist sentiments and focused instead on tackling the Zika issue together.

So, too, did MPs come together on another matter: Parliament's tribute to the late former president S R Nathan at the start of yesterday's sitting.

A total of nine MPs spoke, many of whom shared recollections that were personal.

Ms Sylvia Lim (Aljunied GRC) spoke about how her father, as one of the first batch of army officers, got to know Mr Nathan when he was at the then Ministry of Interior and Defence.

She also recalled how Mr Nathan made an effort to seek her out after she first entered Parliament as an NCMP in 2006.

Mr Murali Pillai (Bukit Batok), the newest member of the House, having been elected in May this year, recounted how Mr Nathan asked to meet him two months ago, even as the former president was in hospital. Over two hours, Mr Nathan spoke to him about issues facing the nation.

Even during his last days, Mr Nathan was always thinking about Singapore.

Mr Pritam Singh (Aljunied GRC) recalled how Mr Nathan noticed him and his wife at a football game, and invited them to sit with him. And one point he made to Mr Singh was: "You must always look after the interest of Singaporeans and Singapore."

It was fitting that a man so praised for his ability to unite people and his concern for everyone, regardless of station, brought MPs together yesterday.

When, in the coming months, Parliament debates the White Paper on changes to the elected presidency, there is no doubt that sparks will fly.

But as yesterday's session demonstrated, depending on the issue at hand, a session that is relatively free of the cut and thrust of debate is something also worth appreciating.