Friday, April 07, 2006

Is there cause for concern on resurgent TB in Singapore?

To: MOH - Attn Dr Balaji
cc: Andy Ho - Straits Times

7 Apr 2006

Dear Dr Balaji,

I refer to recent the recent article by Dr Andy Ho, "TB: No less a threat than bird flu" (ST, 1 Apr) and letter, "TB case: Why no contact tracing?" (ST 23 Mar).

I am sure there are many concerned Singaporeans waiting for answers and clarifications from the Ministry Of Health after reading these two articles. Therefore, it will be helpful if the MOH can advise the public on the following:

1. Is there a need to go for "booster" BCG jab (since most Singaporeans had this jab when they were young).
2. What are the action plans when known cases are detected (eg the letter writer asking if contact tracing is necessary, etc)?
3. Does MOH plan to educate the public on preventive measures, if any, and other "Good Practices" like it did during the Sars and dengue outbreaks?
4. At the government level, any "advisory" to outgoing travellers or measures for incoming travellers/tourists/workers given the borderless and globalised world (especially the travellers to and from countries with high number of known cases?)

I hope that with the lessons learnt during the recent Sars and dengue outbreaks, the MOH will take a proactive stance before TB gets out of hand here.


Straits Times (1 Apr 2006) - TB: No less a threat than bird flu

TB: No less a threat than bird flu

As the world frets over bird flu, scientists are warning of an old killer making a comeback. Tuberculosis

By Andy Ho
April 1, 2006
The Straits Times

THERE's that word again: Pandemic.
While scientists vexed over bird flu are still clucking their tongues, tuberculosis (TB) is making a comeback in a big way: The US Centres for Disease Control and Prevention (CDC) and the World Health Organisation (WHO) warned last week that there is a virtually incurable strain that may lead to a TB pandemic.
That strain probably surfaced around 2000. Here is what we now know: The TB germs in some 347 patient samples collected by WHO-affiliated laboratories worldwide from 2000 to 2004 were found to be resistant to isoniazid and rifampin, the two main TB drugs. As such, they were classified as 'multi-drug resistant' TB, a phenomenon first recognised some 15 years ago now.

The patients concerned not only did not recover after two years of daily doses of the two main drugs - patients are usually cured after a six-month course - but they were also found to be resistant to at least half of six 'second-line' drugs as well.
These germ samples, mainly from South Korea, Eastern Europe and western Asia, were then re-examined.
Some were found to be resistant to all of the more expensive and more toxic second-line drugs. These pa- tients, who succumbed to the disease, are now said to have contracted 'extensively drug-resistant' TB. This category is growing in numbers and geographical spread. The WHO estimates that, overall, at least a third of multi-drug resistant TB cases are actually extensively drug-resistant and will not respond to existing drugs. Singapore had a case last year, but one who was not a local.
In advanced countries like Australia, Canada, France, Germany, Japan, Britain and America, this kind of virtually untreatable TB made up just 3 per cent of their drug-resistant cases in 2000, but by 2004, it had risen to 11 per cent. To think that 20 years ago, TB was thought to have been all but eradicated in the developed world!
Looking back now, the emergence of multi-drug resistant TB some 15 years ago was a harbinger of a pandemic, the CDC said, so everything must be done to stop a global outbreak from becoming a reality this time around.
How in the world did we come to this?
The answer lies in geography, politics and economics.
First, while one in three people is already carrying the germ the world over, this TB is latent: Only a very small minority - mainly in some 22 developing nations like Indonesia and Bangladesh - go on to develop clinical illness or active TB. There are eight million new cases a year, with two million deaths.
Specifically, multi-drug resistant TB cases occur mainly in parts of the former Soviet Union, Central and Eastern Europe, and several Chinese provinces. Some 18 per cent of TB cases in Estonia and 12 per cent in Latvia, for example, are multi-drug resistant already.
In Eastern Europe, it was the transition to market-based economies which saw health-care systems including TB programmes collapse along with deteriorating living conditions that led to a rise in TB.
The lack of resources in some of these countries meant that patients could not be kept on the required drugs for the required six to eight months. In addition, the hospital stay and the very labour-intensive direct observation and constant monitoring of TB patients cost even more than the drugs used.
The result is under-treatment - and insufficiently treated TB patients remain infective.
Emigration from these countries - including many European Union accession countries - to Western Europe that has not had much of TB for decades means huge risks for the latter.
Secondly, HIV has been spreading in Africa. Because HIV suppresses the immune system, latent TB is easily activated, which then hastens the progression of HIV to Aids. In HIV-positive cases, also, many TB drugs interact with HIV drugs so they do not work well.
A recent WHO report said that Africa's HIV epidemic in Africa has caused the rapidly rising rates of TB there, with the Dark Continent now accounting for 20 per cent of the world's cases. In fact, the number of TB cases is actually quite stable or even falling in five out of six WHO regions, but growing at 0.6 per cent globally primarily because it is growing in Africa as a result of HIV. In Eastern Europe, the incidence peaked in 2001 and has begun falling.
But together, TB/HIV especially in Africa, and drug-resistant TB especially in Eastern Europe, are 'seriously hampering global control efforts to reduce the 1.7 million deaths caused by TB every year', the report said.
Thirdly, testing TB remains difficult. There is still no cheap, quick and reliable test to distinguish those who have been vaccinated from those who may have been infected.
Meanwhile, lab diagnosis remains the archaic way of visually establishing under the microscope the presence of TB germs in sputum, a method that may miss half the cases and certainly one that is not too useful in little kids who cannot cough up sputum.
Moreover, actual confirmation of diagnosis still requires that the TB germ be grown (cultured) in the lab, an old, inexpensive procedure but one that takes six to nine weeks. Even then, many developing countries simply do not have such labs.
Yes, there has been some effort to develop new TB tools, mainly by small life-science companies trying to leverage on advances in electronics and genomics. How- ever, only a couple of new TB tests have appeared on the market to date.
Fourthly, the markets have failed to bring in advances in TB drug therapy. While the demand exists, the bulk of drug resistant cases is likely to occur in the poorest countries that cannot afford new, full-priced TB drugs, so investing in TB drug R&D does not make commercial sense. The market for TB drugs in developed economies, the WHO estimates, is worth only US$113 million (S$183 million) annually, small beer compared to those for, say, hypertension and anti-cholesterol drugs that were worth more than US$25 billion each in 2004.
Meanwhile, only 5 per cent of the 16 million people currently ill with TB can pay for treatment. Their lack of buying power has dissuaded all top 20 drug makers except for GlaxoSmithKline, Novartis and Astra-Zeneca from having any ongoing TB drug development project.
Thus, no one has developed long-acting formulations of the old (off-patent) drugs that are actually still useful in 82 per cent of cases. Such formulations would mean a less frequent need to directly observe patients taking their drugs, thus significantly reducing treatment costs.
What would be even better are new drugs that can cure faster, a pipe dream, to be sure. All TB drugs around today were developed between 1944 and 1963. Because markets have failed, research into new TB drugs is largely being undertaken in the US public sector - the EU lags far behind in this respect - and by one non-profit group called The Global Alliance for TB Drug Development that is housed at the Geneva headquarters of the WHO.
Launched in 2001, the Alliance collaborates with small biotechnology firms, universities, public institutions and even an Indian generic manufacturer. But no big pharmas were involved until GlaxoSmithKline agreed last year to cooperate on a joint drug discovery programme, and Bayer to jointly field-test its existing antibiotic, moxifloxacin, to see if it could be used to shorten the standard six-month treatment protocol to, say, three months.
Finally, the markets have also failed to deliver new vaccines. The only available vaccine, BCG, a weakened form of a strain that infects cows, was introduced in 1923. Today, the protection it confers varies with location, depending on whether TB is endemic - for reasons scientists do not fully understand even today: Thus in Britain, where TB is uncommon, BCG can afford a 77 per cent protective cover, whereas in India, where it is endemic, BCG confers almost no protection.
If scientists understood better how the germ acts in humans at the molecular level - especially how it goes into dormancy and how it gets reactivated - vaccines better than BCG could be developed. But precious little research is going on in this area, so the testing of new vaccines - by non-profits - has largely been empirical exercises with little new science.
Even then, because there is no cheap, quick and reliable way of distinguishing the vaccinated from those with latent TB, it is difficult to ferret out the correct human subjects to test a new vaccine on. So, the WHO estimates, a new vaccine is unlikely for at least another decade.
In sum, difficulties in diagnosis and under-treatment, or lack of treatment, for all the reasons above mean that the incidence of multi-drug resistance has not been brought down as rapidly as possible when it first emerged. Over time, then, these strains became extensively resistant ones.
Still, there is a glimmer of hope.
The genome of the TB germ was decoded in 1998. Meanwhile, the TB Structural Genomics Consortium, comprising 134 labs in 15 nations, is now identifying TB genes that lead to the illness itself. Their data are placed in the public domain, which should eventually help in identifying new targets to develop TB drugs and vaccines against.
Also, in January this year, Microsoft founder Bill Gates pledged US$900 million in support of The Global Plan To Stop TB 2006-2015, a project developed by the Stop TB Partnership. Housed at the WHO headquarters in Geneva as well, the partnership is made up of governments, non-governmental groups and individuals. Still, the Gates funds are only about 2 per cent of the estimated US$56 billion the 10-year plan requires. The partnership hopes to introduce a new TB drug by 2010 and a new vaccine by 2015.

Straits Times (23 Mar 2006) - TB case: Why no contact tracing?,5562,379873,00.html?

March 23, 2006

TB case: Why no contact tracing?

RECENTLY, one of my colleagues was diagnosed with active tuberculosis (TB). As she was still working a few days before the diagnosis, I assumed that the Ministry of Health (MOH) would conduct some form of contact tracing to prevent the disease from spreading.
An article published by MOH, 'TB vigilance in schools: Full range of steps in place from detection to treatment', dated July 29, 2005 (, reinforced my assumption.
However, one week after the diagnosis, MOH has not conducted any form of contact tracing that I am aware of.
Some of my colleagues went to Sata for TB screening (Mantoux test) and a few of them tested positive (TB bacteria found in their bodies).
I would like to know under what circumstances contact tracing would be conducted.

Cheong Khai Meng

Tuesday, April 04, 2006

HFMD and dusty classrooms

From: Meiyi Ong <>
Date: 03-Apr-2006 14:24Subject:

Re: HFMD and dusty classrooms

To: Constance YIP <>Cc:, Corrina THER <>,,
My dear principal,

I visited the school in Mar and that is 3 months after the school started operations, the classrooms are still very dusty.
How long do you expect the cleaners to cleanup the classrooms?
In my email, I am suggesting that the school should use vacuum cleaners (instead of brooms) which will be more effective in sucking up the dust.

Did I in my email suggest that HFMD virus can be sucked by vaccum cleaner ?

My argument is that if the school cleaners cant even keep the dust out (which is visible to naked eyes), I have doubts in your ability to combat the invisible HFMD virus. I am sure the steam jet output from OSIM at 80 deg will definitely kill the HFMD virus.

Principal, I think you are losing touch with the ground.
Try walking around, see for yourself, talk to the teachers and students and see how effective the school cleaners are.

Also have an open mind and be open to suggestions.

Lastly, I hope that you will be able to combat the virus successfully.
By the way, are we into the 10th day of HFMD virus free day ?

Last but not least, pls dont mix religion in your official email.

bcc: Teachers of JPS.

Thursday, September 22, 2005

Malaysia sets up multi-agency task force to prevent bird flu

Channel News Asia
Posted: 21 September 2005 2311 hrs

Malaysia sets up multi-agency task force to prevent bird flu

PUTRAJAYA : Malaysia has set up a multi-agency task force to discuss precautionary measures to be taken to prevent the spread of avian influenza into the country from Indonesia or Thailand.

Agriculture and Agro-based Industry Minister Muhyiddin Yassin, who announced this on Wednesday, said the task force would comprise representatives of the Customs Department, Immigration Department, police and armed forces besides the Agriculture and Health departments. He said it would be jointly chaired by him and Health Minister Chua Soi Lek.

Speaking to reporters after his ministry's post-Cabinet meeting, Mr Muhyiddin said Malaysia was free of avian influenza and there was no need to undertake tests or any kind of preventive vaccination at farms.

He said the task force would hold its first meeting very soon to work on the contingency plans to prevent avian influenza from spreading into the country and the measures to be taken should an outbreak occur.

He said the government would bank on its experience in successfully containing the outbreak in Tumpat, Kelantan, last year.

Mr Muhyiddin said one important step to avoid the importation of avian influenza was to tighten checks at all entry points into the country, especially to prevent smuggling of live birds and chicken meat in raw or cooked form from neighbouring countries. - CNA/de

Saturday, September 17, 2005

Is Singapore taking proactive measures on Bird Flu before any outbreak here?

Sent to the Ministry of Health, Singapore:

I hope the relevant authorities are proactively looking into this potential threat before it gets out of hand like the current dengue outbreak. Thanks.

Jeff Ho

Today (16 Sept 2005):

New warning on bird flu

H5N1 may mutate, acquiring genes from human flu virus that will make it infectious: WHO chief

UNITED NATIONS — World Health Organisation (WHO) boss Lee Jong Wook issued a new warning about bird flu yesterday, reiterating that the virus, which has triggered a major health scare in South-east Asia, could mutate into a major killer.
At present, the H5N1 strain of bird flu, harboured by wild migrating birds and poultry flocks, is lethal for humans but is not very contagious, nor can it be easily transmitted from person to person.
"The existing H5N1 hasn't yet acquired its ability to transmit among the humans but when it acquires this ability — and there is some evidence that this will be the case — I hope this will be simply less toxic than the existing H5N1, which has killed half the people infected," Mr Lee told reporters.
The WHO director-general spoke at the fringes of a UN Summit where US President George W Bush launched what he called an "international partnership" aimed at preventing bird flu and other new strains from becoming the first new pandemic of the 21st century.
The WHO's biggest fear is that H5N1 may mutate, acquiring genes from the human influenza virus that will make it highly infectious as well as lethal.
"We cannot afford to face the pandemic unprepared," Mr Lee said after announcing that the WHO would join the US-led initiative, which is focussed on sharing samples of the virus among lab researchers.
The WHO last month said current production of anti-viral vaccines was insufficient to deal with a catastrophic flu epidemic like the one that struck in 1918 and killed some 40 million people around the world.
WHO already has a stockpile of medicine that could be used during a pandemic, Mr Lee said. The UN agency had access to 30 million doses of an anti-viral drug called Tamiflu, he said. "The 30 million capsules are reserved by a company. When we tell them to ship to certain countries, they will airlift it to the nearest airports, from where we will be responsible for this," he said. — AFP

Monday, September 12, 2005

Straits Times (12 Sept 2005) - ST Forum: Urgent need for S'pore to develop alternative energy resources

Sept 12, 2005
Urgent need for S'pore to develop alternative energy resources

As a Singaporean doing postgraduate studies in biofuels and green energy source research in Australia, may I offer another viewpoint on the issue with the rise in fuel prices.

We have seen proponents arguing for the environmental virtues of green energy sources and benefits for the individual.

The more cautious ones remind us of the high costs involved for a nation still adjusting to new competition in the world economy (ST Sept 8).

Singapore will never be isolated from the fierce and dynamic economic competition in a global community. If it were, it would be the financial ruin of our nation.

The past 10 years have shown us that economic-boom seasons are increasingly short-lived and our neighbours are increasingly able to compete in many of our once-dominant areas such as shipping, air travel, and IT industries.

What we may not realise is that our fuel refining and electricity industries that drive Singapore's electronics and financial sectors may not enjoy their heyday for much longer.

This is because of volatile politics and weather wrecking havoc in many fuel-producing countries, not to mention the finite crude reserves.

There is a need to find alternatives because of the high dependence of our economy on energy sources.

A conversion to green fuels and greater energy efficiency cannot happen overnight due to the high costs and complexity.

Singapore must therefore start investing now in research and infrastructure to ensure energy security.

We must do so while our economy is performing comfortably, not when it faces the squeeze with fuel woes adding to the trouble.

Yes it will be costly and the benefits may not be immediately visible, but to put it off is short-sightedness.

Raymond Tham Kon Weng
Adelaide, Australia

Wednesday, September 07, 2005

Welcome to Singapore Alert - Every Singaporean or resident can play a part to keep it safe and secure

This Blog is meant for every Singaporean or resident to take an active part in making Singapore the HOME he or she wants it to be. So if you see or feel anything that is wrong that may be life-threatening to Singapore (be it terrorism or war, public health hazards like dengue or bird flu, a dangerous spot or act even, road hazards, etc); or if you have suggestions relating to the above or other issues that may threaten the continuing existence of Singapore, for example, our over-dependence on imported essentials like water, oil or food (rice, meat, etc) or the increasing economic competition from China and India, please feel free to post your comments and suggestions (with photos where available).

Alternatively, you may wish to email details to me at or SMS me at (65) 98189123.

Thank you for your civic-mindedness and together, WE WILL ACHIEVE - THE NEXT LAP. Remember, every Singapore counts. And with your help, we can all achieve our collective vision to make Singapore safe and secure for this and future generations, a place where truly, every Singaporean matters.


6 Sept 2005