Cablegate: Singapore: Addressing Infectious Disease Concerns

DE RUEHGP #0925/01 2400941
R 270941Z AUG 08



E.O. 12958: N/A

REF: 2007 SINGAPORE 1241

1. (U) SUMMARY: The Regional Emerging Diseases Intervention
(REDI) Center (a joint USG-GOS initiative) and the Singapore
Ministry of Health (MOH) co-sponsored a regional forum on
HFMD August 21 and 22 to address the increasingly severe
outbreaks of HFMD in the Asia-Pacific region. More than 80
experts in disease surveillance and intervention attended.
In one presentation, the Deputy Director of the Surveillance
and Response Branch of the Singapore MOH outlined the
measures the GOS has instituted to slow the spread of the
disease, including closures of childcare centers. Incidence
of chikungunya (a mosquito-borne disease with dengue-like
symptoms) is rising significantly in Singapore, with 150
cases reported this year. Many cases appear to be the result
of local transmission, rather than the result of infections
contracted while traveling abroad. Dengue infections, which
surpassed MOH's epidemic threshold last year, have been much
lower thus far in 2008. END SUMMARY.

HFMD Regional Forum August 21-22

2. (U) The REDI Center and the Singapore MOH co-sponsored a
regional forum on HFMD August 21 and 22. More than 80
experts in disease surveillance and intervention attended the
two-day forum to share information and case studies on the
recent HFMD outbreaks in the Asia-Pacific region, including
those caused by a more severe strain known as enterovirus 71
(EV71). Several representatives from the Centers for Disease
Control and Prevention (CDC) mission in Bangkok attended
along with Singapore MOH officials. Other attendees included
health officials and practitioners from China, Taiwan,
Thailand, Brunei, Malaysia, Indonesia, and Australia.

3. (SBU) The Singapore MOH has reported approximately 18,000
HFMD cases this year, and approximately 1.6 percent of those
were caused by EV71, Steven Ooi, Deputy Director of the
Surveillance and Response Branch of the MOH explained in his
presentation at the forum. This month a three-year-old died
from an EV71 infection, the first HFMD death in Singapore
since a severe outbreak in 2000 and 2001. The GOS has
instituted measures to monitor and combat the spread of HFMD,
including requirements for hospitals, physicians, and public
childcare centers to notify MOH of any HFMD infections within
24 hours. The GOS forced some schools and childcare centers
to close for 10 days--a period that covers two incubation
cycles for the virus--to conduct thorough clean-ups when
there was a high incidence of HFMD. Physicians also have to
certify that an infected child has fully recovered before
returning to school, Dr. Ooi stated.

4. (SBU) The GOS is still struggling with how to handle the
socio-economic effect school closures and social isolation
can have on families with working parents. Dr. Ooi said
there are two groups of parents in Singapore: one demanding
immediate closures when HFMD is detected and another group
that relies heavily on the childcare centers and schools
because both mother and father are employed. There is no
hard evidence to suggest closures and social distancing
effectively stop the spread of the disease, since children
find ways to interact outside of these locations, Dr. Ooi
stated. Therefore, the GOS is also focused on educating
people about other critical HFMD control points and has
issued guidelines on proper hand-washing and food preparation
for children, parents, and childcare workers.

5. (SBU) One of the key questions raised during the HFMD
Forum is why the outbreaks in Asia, particularly China,
Taiwan, Hong Kong, and parts of Southeast Asia, are so much
more severe or even deadly than outbreaks elsewhere in the
world (Note: HFMD and EV71 are found worldwide.) There was
no easy answer to this question, and several attendees noted
the importance of regional forums to compare cases and
identify new ways to collaborate on research. A few
participants, including some from the CDC, raised the
possibility of genomic attributes in the population that may
require further study.

6. (SBU) The Asia-Pacific Enterovirus Surveillance Network
(APNET), has been researching EV71 outbreaks in Asia since
2000. APNET began as an informal collaboration among
clinicians and virologists working in Singapore, Malaysia,
and Australia to study the pathogenesis of the virus. It has
expanded to include research in Papua New Guinea and Vietnam.
Currently, the Wellcome Trust and the National Health and
Medical Research Council of Australia fund APNET, but the
funding ends in October 2009, Professor Peter McMinn, of the

SINGAPORE 00000925 002 OF 002

University of Sydney, explained in his presentation. Some
CDC representatives indicated they saw value in APNET's work
and might be interested in collaborating on research

Chikungunya Cases on the Rise

7. (U) The incidence of chikungunya in Singapore has
increased significantly over the summer months. As of June
2008, there were 28 cases reported in Singapore, but the
number has grown to about 150, according to MOH, and
approximately 80 of those cases were contracted locally.
When the disease initially appeared in January the MOH
believed the cases were isolated to people who had been
infected abroad. Now, locally acquired infections have been
linked to 18 different areas in Singapore. Public statements
from the MOH and the Ministry of the Environment and Water
Resources (MEWR) suggest the GOS believes the majority of
infections are still "imported" and that the disease has not
taken root here.

8. (SBU) To prevent the disease from spreading, the National
Environment Agency (NEA) has been conducting intensive
operations to find and eradicate mosquito breeding areas.
The NEA also studied the blood of infected Singaporeans and
found the virus strain was similar to that causing outbreaks
in Malaysia. The GOS has advised travelers to take
precautions such as wearing long sleeve shirts, long pants,
and using insect repellent when going to southern Malaysia.
There is sufficient interest in the increasing numbers of
chikungunya cases in Singapore that the REDI Center is
considering organizing a regional forum on the disease
similar to the one held on HFMD. We will continue to monitor
and report on relevant developments in chikungunya cases.

Dengue Fever Rates Down

9. (SBU) The NEA and MOH remain focused on dengue as a
long-term health problem for Singapore, but the rate of
infection in 2008 has been much lower than last year when
dengue reached MOH's epidemic threshold of 378 cases per week
(reftel). There have been 3673 dengue cases reported in
Singapore this year compared to 5507 cases in the same period
in 2007. The NEA remains vigilant in eradicating mosquito
breeding areas. Mosquitoes in Singapore continue to adapt to
the urban environment and are able to breed in ever smaller
amounts of water, such as the water collected in a leaf, Dr.
Lyn James, Director of the Communicable Diseases Division of
MOH, told Econoff at a meeting in May. Fewer Singaporeans
seem to have natural immunity to dengue strains and have
become more susceptible to infection even as the GOS has
become more effective in eradicating mosquitoes where they
breed, Dr. James also surmised. However, she has not seen an
obvious increase in infections among children, and many new
cases seem to be in young adults. Dr. James attributed that
to lifestyle more than immunity, noting smaller children and
older adults may spend more time indoors.

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