The global emergence of multidrugresistant (MDR) tuberculosis (TB) and extensively drug-resistant (XDR)-TB threatens to derail the efforts of TB control programmes worldwide. From 2000 to 2010, 161 pulmonary MDR-TB cases (including six XDR-TB cases) were reported in Singapore, and of these, 80% occurred among the foreign-born, with an increasing trend seen after 2004. Among new pulmonary TB cases, the highest incidence of MDR-TB occurred among patients from Myanmar (8%), followed by Vietnam (4.4%) and China (2.3%), while among those previously treated, the highest incidence was found in patients from Vietnam (50%), followed by Indonesia (33%) and Bangladesh (33%). Although the proportion of Singapore-born pulmonary TB cases with MDR-TB has remained comparatively low (0.2% and 1.3% in new and previously treated cases, respectively), there is no room for complacency. Top priority must be accorded toward the proper treatment of drug-susceptible TB cases under strict programme conditions so as to prevent the development of MDR-TB in the first place.
Antitubercular Agents ; therapeutic use ; Emigrants and Immigrants ; Extensively Drug-Resistant Tuberculosis ; epidemiology ; Humans ; Mycobacterium tuberculosis ; Singapore ; epidemiology ; Tuberculosis, Multidrug-Resistant ; drug therapy ; epidemiology ; transmission

The total number of new tuberculosis (TB) cases notified in Singapore among citizens, permanent residents and foreigners rose by 46% from 2004 to 2010. During this period, the proportion of foreigners increased from 29% to 47% of the total case burden. In 2008, the TB incidence rate among Singapore citizens and permanent residents increased for the first time in ten years, despite the on-going efforts of the Singapore TB Elimination Programme. Additional measures and resources are clearly needed to curb this rising trend. Pivotal to this is to address TB among foreigners. The political will to battle TB in Singapore must result in action to remove barriers to diagnosis, to enable all TB patients to undergo treatment under directly observed therapy (DOT), and to ensure that all healthcare providers who manage TB patients are responsible and accountable to the public health system.
Directly Observed Therapy ; Emigrants and Immigrants ; statistics & numerical data ; Humans ; Infection Control ; methods ; Singapore ; epidemiology ; Tuberculosis ; epidemiology ; ethnology ; prevention & control

Antitubercular Agents ; therapeutic use ; Directly Observed Therapy ; methods ; Humans ; Patient Compliance ; Tuberculosis ; drug therapy

Adult ; Antitubercular Agents ; therapeutic use ; Contact Tracing ; Counseling ; Female ; Humans ; Latent Tuberculosis ; drug therapy ; prevention & control ; Male ; Multivariate Analysis ; Odds Ratio ; Pamphlets ; Practice Patterns, Nurses' ; Prospective Studies ; Singapore ; Smoking Cessation ; methods

INTRODUCTIONExtensively drug-resistant tuberculosis (XDR-TB) is an emerging global health risk. We present the first case report of XDR-TB in Singapore.

CLINICAL PICTUREA 41-year-old Indonesian lady with previously treated pulmonary tuberculosis presented with chronic cough. Her sputum was strongly acid-fast bacilli positive and grew Mycobacterium tuberculosis complex resistant to first and second-line TB medications.

TREATMENTShe received 5 months of intensive multidrug treatment without sputum smear conversion. She then underwent resection of the diseased lung. The total cost incurred amounted to over S$100,000.

OUTCOMEShe achieved sputum smear/culture conversion post-surgery, but will require further medical therapy for at least 18 months.

CONCLUSIONXDRTB is poorly responsive to therapy and extremely expensive to manage. Its prevention by strict compliance to therapy is paramount.

Adult ; Antitubercular Agents ; therapeutic use ; Delirium ; drug therapy ; etiology ; Directly Observed Therapy ; Drug Resistance, Multiple, Bacterial ; drug effects ; Drug Therapy, Combination ; Extensively Drug-Resistant Tuberculosis ; drug therapy ; Female ; Humans ; Microbial Sensitivity Tests ; Mycobacterium tuberculosis ; drug effects ; isolation & purification ; Singapore ; Sputum ; microbiology ; Tuberculosis, Pulmonary ; drug therapy

Singapore has experienced a rise in the tuberculosis (TB) incidence rate among her local population since 2008, which we believe, is contributed in no small part to a recent increase in community transmission due to delayed diagnosis of infectious pulmonary TB cases. Data from the TB notification registry showed an increase from 2004 to 2008 in the number and proportion of sputum acid-fast bacilli smear-positive pulmonary TB cases with prolonged cough. Two surveys at the TB Control Unit showed that healthcare system delays exceeded patient delay in seeking medical consultation. There is thus an urgent need to heighten TB awareness among the public and the medical community in order to reduce the time taken to diagnose infectious TB cases in Singapore.
Delayed Diagnosis ; Humans ; Incidence ; Infection Control ; methods ; Lung ; diagnostic imaging ; Radiography ; Referral and Consultation ; Singapore ; epidemiology ; Tuberculosis, Pulmonary ; diagnosis ; epidemiology

INTRODUCTIONThe place of death of the elderly has implications on the overall healthcare delivery system. The aim of this study is to describe where deaths of elderly occur in Singapore and to determine the association of socio-demographic characteristics and the causes of death on dying at home.

MATERIALS AND METHODSData of 10,399 Singapore resident decedents aged 65 years and above in 2006 were obtained from the national Registry of Births and Deaths. Distributions of socio-demographic characteristics and causes of death by place of death were analysed, and associations between socio-demographic characteristics and home death for major causes of death were assessed by logistic regression models controlling for age, gender and ethnic group.

RESULTSMost elderly deaths occurred in hospitals (57%), followed by deaths at home (31%). The proportion of deaths at home increased with age while deaths in hospital declined with age. Significantly more elderly women died at home compared to men. Malay elderly had the highest proportion of home deaths (49%), and the lowest proportion of hospital deaths (47%). Elderly persons who died from stroke were most likely to die at home [odds ratio (OR) 2.8, 95% confidence interval (CI), 2.3-3.3] while those who died from lung and respiratory system diseases were less likely to die at home (OR, 0.7; 95% CI, 0.6-0.8).

CONCLUSIONElderly people in Singapore die mainly in hospitals. About a third of them die at home. The proportion of decedents dying at home increased with age. Home deaths among the elderly are most likely in those aged 85 years and above, females, Malays, and those who die of stroke.

Aged ; Aged, 80 and over ; Cause of Death ; Confidence Intervals ; Female ; Housing ; statistics & numerical data ; Humans ; Logistic Models ; Male ; Mortality ; trends ; Odds Ratio ; Registries ; Retrospective Studies ; Risk Assessment ; Risk Factors ; Singapore ; Socioeconomic Factors ; Statistics as Topic

COVID-19 ; Child ; Humans ; Internship and Residency ; Obstetrics/education* ; SARS-CoV-2 ; Singapore

The Ministry of Health (MOH) has developed the clinical practice guidelines on Prevention, Diagnosis and Management of Tuberculosis to provide doctors and patients in Singapore with evidence-based treatment for tuberculosis. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Prevention, Diagnosis and Management of Tuberculosis, for the information of SMJ readers. The chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.
Disease Management ; Evidence-Based Medicine ; methods ; Government ; Humans ; Morbidity ; trends ; Practice Guidelines as Topic ; Singapore ; epidemiology ; Tuberculosis ; diagnosis ; epidemiology ; prevention & control

INTRODUCTION: It is vital to diagnose and treat pulmonary tuberculosis (PTB) early, in the interests of the patient and public health. At the Singapore Tuberculosis Control Unit (TBCU), it was not uncommon to discover abnormal chest radiographs (CXRs) predating their PTB diagnosis by months to years in the electronic medical records (EMRs) of sputum acid-fast bacilli smear-positive patients. Our study explored this observation. METHODS: The EMRs of sputum smear-positive PTB patients treated at the TBCU from January to July 2014 were viewed for abnormal CXRs preceding their PTB diagnosis. Information in the EMRs pertaining to the indication for the CXRs, radiological reports (including whether the possibility of PTB was stated) and action taken was captured. RESULTS: Of the 254 sputum smear-positive patients, 108 had previous CXRs in their EMRs, of whom 39 (36.1%) had previous CXRs compatible with PTB. Most of these were performed in tertiary institutions and for reasons unrelated to PTB. No action was taken in response to these CXRs in 24 (61.5%) patients. 27 (69.2%) patients had abnormal CXRs dating back more than six months, with 12 (30.8%) dating back more than 30 months before the PTB diagnosis. Patients aged ≥ 55 years were significantly more likely to have previous CXRs that were compatible with PTB. CONCLUSION PTB patients may be asymptomatic or have chronic indolent disease and remain undiagnosed for years. There is a need for vigilance within our healthcare system to seize opportunities for early diagnosis and treatment to prevent the spread of this infectious disease in Singapore.