The national strategy against pandemic influenza essentially consists of 3 prongs: (i) effective surveillance, (ii) mitigation of the pandemic's impact, and (iii) render the population immune through vaccination. When the pandemic hits Singapore, the response plan aims to achieve the following 3 outcomes: (i) maintenance of essential services to limit social and economic disruption, (ii) reduction of morbidity and mortality through antiviral treatment, and (iii) slow and limit the spread of influenza to reduce the surge on healthcare services. The biggest challenge will come from managing the surge of demand on healthcare services. A high level of preparedness will help healthcare services better cope with the surge.
Antiviral Agents ; therapeutic use ; Communicable Disease Control ; Contact Tracing ; Disease Outbreaks ; prevention & control ; statistics & numerical data ; Global Health ; Humans ; Influenza Vaccines ; administration & dosage ; Influenza, Human ; drug therapy ; epidemiology ; Population Surveillance ; Quarantine ; Severe Acute Respiratory Syndrome ; epidemiology ; Singapore ; epidemiology

Anniversaries and Special Events ; Asia, Southeastern ; Biomedical Research ; Dengue ; Humans ; Singapore

Directly Observed Therapy ; Humans ; Medication Adherence ; Prejudice ; Prevalence ; Singapore ; epidemiology ; Tuberculosis, Multidrug-Resistant ; epidemiology

Adolescent ; Animals ; Birds ; Child ; Disease Outbreaks ; Humans ; Influenza A Virus, H5N1 Subtype ; genetics ; Influenza in Birds ; Influenza, Human ; genetics ; transmission ; Mutation ; Polymorphism, Genetic ; Singapore

Field epidemiology involves the implementation of quick and targeted public health interventions with the aid of epidemiological methods. In this article, we share our practical experiences in outbreak management and in safeguarding the population against novel diseases. Given that cities represent the financial nexuses of the global economy, global health security necessitates the safeguard of cities against epidemic diseases. Singapore's public health landscape has undergone a systemic and irreversible shift with global connectivity, rapid urbanization, ecological change, increased affluence, as well as shifting demographic patterns over the past two decades. Concomitantly, the threat of epidemics, ranging from severe acute respiratory syndrome and influenza A (H1N1) to the resurgence of vector-borne diseases as well as the rise of modern lifestyle-related outbreaks, have worsened difficulties in safeguarding public health amidst much elusiveness and unpredictability. One critical factor that has helped the country overcome these innate and man-made public health vulnerabilities is the development of a resilient field epidemiology service, which includes our enhancement of surveillance and response capacities for outbreak management, and investment in public health leadership. We offer herein the Singapore story as a case study in meeting the challenges of disease control in our modern built environment.
Disease Outbreaks/*prevention & control ; Ecology ; Environment ; Humans ; Life Style ; Pandemics/prevention & control ; Public Health Administration ; *Public Health Practice ; Singapore/epidemiology ; World Health

We describe the public health control measures implemented in Singapore to limit the spread of influenza A (H1N1-2009) and mitigate its social effects. We also discuss the key learning points from this experience. Singapore's public health control measures were broadly divided into 2 phases: containment and mitigation. Containment strategies included the triage of febrile patients at frontline healthcare settings, admission and isolation of confirmed cases, mandatory Quarantine Orders (QO) for close contacts, and temperature screening at border entry points. After sustained community transmission became established, containment shifted to mitigation. Hospitals only admitted H1N1-2009 cases based on clinical indications, not for isolation. Mild cases were managed in the community. Contact tracing and QOs tapered off, and border temperature screening ended. The 5 key lessons learnt were: (1) Be prepared, but retain flexibility in implementing control measures; (2) Surveillance, good scientific information and operational research can increase a system's ability to manage risk during a public health crisis; (3) Integrated systems-level responses are essential for a coherent public health response; (4) Effective handling of manpower surges requires creative strategies; and (5) Communication must be strategic, timely, concise and clear. Singapore's effective response to the H1N1-2009 pandemic, founded on experience in managing the 2003 SARS epidemic, was a whole-of-government approach towards pandemic preparedness planning. Documenting the measures taken and lessons learnt provides a learning opportunity for both doctors and policy makers, and can help fortify Singapore's ability to respond to future major disease outbreaks.
Communicable Disease Control ; organization & administration ; Contact Tracing ; Delivery of Health Care ; Disease Outbreaks ; prevention & control ; Focus Groups ; Humans ; Influenza A Virus, H1N1 Subtype ; Influenza, Human ; epidemiology ; prevention & control ; transmission ; Interviews as Topic ; Patient Isolation ; Public Health ; Singapore ; epidemiology ; Triage

INTRODUCTIONWe reviewed the epidemiological features of 1348 hospitalised cases of influenza A (H1N1-2009) [pandemic H1N1] infection in Singapore reported between 15 July and 28 September 2009.

MATERIALS AND METHODSData on the demographic and epidemiological characteristics of hospitalised patients with confirmed pandemic H1N1 infection were collected from all restructured and private hospitals in Singapore using a standard template and were analysed retrospectively.

RESULTSOf the 1348 cases, 92 were classified as severely ill (i.e. were admitted to an intensive care unit and/or who died). Of these severely ill cases, 50 (54.3%) required mechanical ventilation. While overall hospitalisation rates were highest in the 0 to 11 months age group, the incidence of severely ill cases was highest in patients aged 65 years and older. Fifty per cent of all hospitalised cases and 28% of all severely ill cases did not have any underlying medical conditions. The following factors were found to be independently associated with a higher likelihood of severe illness: older age and the presence of the following comorbidities: neuromuscular disorders, epilepsy and obesity.

CONCLUSIONBetween 15 July and 28 September 2009, pandemic H1N1 infection caused significant illness requiring hospitalisation, as well as intensive care and mechanical ventilation in some cases. There were 18 deaths from pandemic H1N1 during this period, which corresponded to a case-fatality rate of 7 deaths for every 100,000 cases of pandemic H1N1.

Adolescent ; Adult ; Aged ; Child ; Child, Preschool ; Disease Outbreaks ; Epidemiologic Studies ; Female ; Hospitalization ; statistics & numerical data ; trends ; Humans ; Infant ; Infant, Newborn ; Influenza A Virus, H1N1 Subtype ; isolation & purification ; Influenza, Human ; epidemiology ; Male ; Middle Aged ; Respiration, Artificial ; utilization ; Retrospective Studies ; Severity of Illness Index ; Singapore ; epidemiology ; Young Adult

INTRODUCTIONThe fi rst case of pandemic influenza A(H1N1) was detected in Singapore on 26 May 2009, 1 month after the fi rst cases of novel influenza A(H1N1) was reported in California and Texas in the United States. The World Health Organization declared the fi rst influenza pandemic of the 21st century on 11 June 2009.

MATERIALS AND METHODSConfirmed cases notified to the Ministry of Health between 27 May and 9 July 2009 were analysed. Various indicators of influenza activity were monitored throughout the study period. Estimates of the number of cases of H1N1-2009 were made using the number of polyclinic attendances for acute respiratory infection and influenza-like illness and the weekly prevalence of H1N1-2009.

RESULTSCases in Singapore affected mainly young adults, youths and children. By the end of September 2009, it was estimated that at least 270,000 persons had been infected by pandemic influenza A (H1N1) in Singapore. The peak number of cases occurred during E-week 30 (26 July-1 August) when an estimated 45,000 cases were seen in polyclinics and GP clinics. The hospitalisation, severe illness and mortality rates were estimated at 6 per 1000 cases, 0.3 per 1000 cases and 6.7 per 100,000 cases, respectively. The most common risk factors among hospitalised adult cases were asthma and diabetes. For hospitalised children, the most common risk factors were being under 5 years of age and asthma. The most common risk factors among persons with severe illness were diabetes in adults and epilepsy and being under 5 years of age in children. About half of cases with severe illness required mechanical ventilation. In addition, one-fifth of cases with severe illness had acute respiratory distress syndrome.

CONCLUSIONSThe fi rst wave of the influenza pandemic lasted about 10 weeks. Morbidity and mortality resulting from pandemic influenza were low.

Adolescent ; Adult ; Child ; Child, Preschool ; Comorbidity ; Disease Outbreaks ; Female ; Hospitalization ; Humans ; Infant ; Influenza A Virus, H1N1 Subtype ; isolation & purification ; Influenza, Human ; diagnosis ; epidemiology ; mortality ; Male ; Middle Aged ; Risk Factors ; Singapore ; epidemiology ; Young Adult

INTRODUCTIONWe undertook a study to evaluate the effectiveness of the National Childhood Immunisation Programme (NCIP) over the past 26 years by reviewing the epidemiological trends of the diseases protected, the immunisation coverage and the changing herd immunity of the population during the period of 1982 to 2007.

MATERIALS AND METHODSThe epidemiological data of all cases of diphtheria, pertussis, poliomyelitis, measles, mumps, rubella and acute hepatitis B notified to the Communicable Diseases Division, Ministry of Health (MOH) from 1982 to 2007 were collated and analysed. Data on tuberculosis (TB) cases were obtained from the TB Control Unit, Tan Tock Seng Hospital. Cases of neonatal tetanus and congenital rubella syndrome (CRS) among infants born in Singapore were identified from the Central Claims Processing System. The number of therapeutic abortions performed for rubella infections was retrieved from the national abortion registry. Coverage of the childhood immunisation programme was based on the immunisation data maintained by the National Immunisation Registry, Health Promotion Board. To assess the herd immunity of the population against the various vaccine-preventable diseases protected, the findings of several serological surveys conducted from 1982 to 2005 were reviewed.

RESULTSThe incidence of vaccine-preventable diseases covered under the NCIP had declined over the last 26 years with diphtheria, neonatal tetanus, poliomyelitis and congenital rubella virtually eliminated. The last case of childhood TB meningitis and the last case of acute hepatitis B in children below 15 years were reported in 2002 and 1996, respectively.

CONCLUSIONThe NCIP has been successfully implemented as evidenced by the disappearance of most childhood diseases, excellent immunisation coverage rate in infants, preschool and school children, and high level of herd immunity of the childhood population protected.

Adolescent ; Adult ; Child ; Child, Preschool ; Communicable Disease Control ; statistics & numerical data ; trends ; Communicable Diseases ; epidemiology ; Disease Notification ; statistics & numerical data ; Humans ; Immunity, Herd ; Immunization Programs ; statistics & numerical data ; Incidence ; Infant ; Population Surveillance ; Prevalence ; Singapore ; epidemiology