Debated in Parliament on 14 Jan 2019.
Order for Second Reading read.
Mr Deputy Speaker, on behalf of the Minister for Health, I beg to move, "That the Bill be now read a Second time."
Singapore has made significant progress in controlling infectious diseases since the early days of Independence. Improvements in public infrastructure, sanitation and hygiene have drastically reduced the rates of then common serious infectious diseases, such as cholera and typhoid.
Vaccination requirements, complemented by strong vaccination programmes, have resulted in high vaccination coverage against highly infectious diseases, such as measles and diphtheria.
Requirements for surveillance and reporting systems have also enabled the early detection of existing and new diseases, allowing for swift response to curtail disease spread.
However, we cannot let our guard down. Infectious pathogens and the environment in which we operate are continually changing, and we must regularly take stock of these changes and examine how we can better respond to them.
The Ministry of Health (MOH) recognises the following:
Firstly, Singapore is a densely-populated city-state, and a global travel and trade hub. We remain vulnerable to the importation of emerging and re-emerging infectious diseases. The Severe Acute Respiratory Syndrome (SARS) in 2003 is a stark reminder of how a new disease can wreak havoc on our healthcare system and socioeconomic fabric. We have also experienced the influenza H1N1 pandemic in 2009 and, most recently, Zika in 2016. Globally, ongoing outbreaks, which include Ebola in Africa and the Middle East Respiratory Syndrome (MERS) in the Middle East, remind us of the need to be vigilant and to be prepared for the emergence of new diseases.
Secondly, research and development (R&D), and technological advances have allowed us to rapidly increase our understanding of infectious diseases and develop better response measures. We cannot just rely on the old traditional methodologies and must make provisions to allow for more effective and efficient ways – through information technology (IT), R&D or the use of technology – to prevent and control infectious diseases.
Lastly, while the Government takes the lead in safeguarding public health, infectious diseases can happen and spread anywhere – in homes, schools, workplaces and from overseas destinations – and we will need the help of the community to safeguard Singapore against these threats.
The Infectious Diseases Act (IDA) was enacted in 1976 and was last amended in 2008. As part of our continual efforts to ensure that infectious disease prevention and control measures remain effective, this Infectious Diseases (Amendment) Bill seeks to amend the IDA in the three key areas of (a) enhancing infectious disease surveillance; (b) preventing the introduction of infectious diseases into Singapore; and lastly, (c) strengthening infectious disease control within Singapore.
Last year, my Ministry invited the public to provide their feedback on the proposed amendments over a six-week period. We received comments from members of the public, healthcare professionals, including infectious diseases specialists, academia and stakeholders from the telecommunications and transport sectors. Overall, respondents expressed support for the proposed amendments. There was also broad recognition that the amendments are intended to ensure that our legislative and regulatory measures to detect, prevent and control infectious diseases entering into and within Singapore, remain relevant and allow for the calibration of operations to manage the risk presented.
Mr Deputy Speaker, please allow me to highlight the major provisions in the Bill.
First, let me introduce the amendments to enhance infectious disease surveillance.
With better understanding of certain infectious diseases and advancements in IT, there could be new ways of monitoring the health status of persons who may have infectious diseases of concern, for example, through remote or indirect means. This reduces the burden and inconvenience to the person being monitored and allows for a more scalable surveillance system. Clause 2 of the Bill clarifies the definition of "surveillance" in the Act to indicate that it may be periodic or continuous and explicitly provides a definition for medical examinations, which among others, could be conducted remotely.
As it stands, both doctors and laboratories are required to notify my Ministry of the same set of infectious diseases when detected. With the understanding that some infectious diseases come with distinctive clinical signs and symptoms which can be identified by doctors, while others can only be confirmed through laboratory testing, clauses 4 and 27 of the Bill clarify section 6, to allow for doctors, laboratories and any other prescribed groups of persons to report different prescribed sets of diseases to the Ministry. This will allow us to streamline notification requirements and reduce duplication.
My Ministry undertakes public health surveillance where information and samples from healthcare facilities and laboratories are collected for testing and trend analysis. Strictly speaking, based on existing requirements, we must issue a new legal order each time we collect a sample, even though it may be an ongoing surveillance programme. Clause 5 of the Bill amends section 7 to allow my Ministry to state, through a one-time order, the frequency and time period for the submission of samples or information.
Next, allow me to introduce the amendments to prevent the introduction of infectious diseases into Singapore.
Under section 31, persons entering Singapore from specific areas must be required to be vaccinated against specified infectious diseases. To date, the only disease specified under this section, as guided by the International Health Regulations, is Yellow Fever, a serious viral infection. There is currently no cure for Yellow Fever, but it can be easily prevented through vaccination which protects the individual from acquiring the disease.
To prevent the import of the disease into Singapore, we currently require travellers coming into Singapore from Yellow Fever endemic areas to show that they have been vaccinated. The number of travellers without the required Yellow Fever vaccination has been small, at an average of 50 per year. For these people, the Infectious Diseases Act provides for my Ministry to implement isolation or surveillance measures, or require them to undergo vaccination, to mitigate the risk of importation and possible spread. Travellers who are non-citizens, may be refused entry into Singapore, if they do not comply with our measures.
While we can vaccinate and monitor small numbers of travellers, it would not be practicable to do so if the numbers increase to hundreds or even thousands, for example, if countries with high travel volume to Singapore are affected but fail to get their travellers vaccinated despite international advice. In such a circumstance, the entry of large numbers of unvaccinated travellers poses both a health and public security threat to our community. If necessary, we need to be able to protect ourselves against such threats. Clause 13 of the Bill, therefore, introduces additional flexibility to allow the refusal of entry of unvaccinated non-citizen travellers without needing to first provide vaccination, isolation or surveillance.
Vaccination verification is unique. Not all diseases are vaccine-preventable or serious enough for us to require all travellers from specific areas to show proof of vaccination. At a more general level, it is important to have measures for us to identify unwell travellers who may be potential carriers or cases of infectious diseases, to facilitate early public health measures, such as treatment or isolation. As an example, travellers arriving from countries with an ongoing risk of MERS currently undergo temperature screening on arrival.
In a similar vein, Singapore should likewise be able to take steps to prevent the export of infectious diseases through unwell travellers to other countries, should we experience a serious outbreak. This was the case during the SARS outbreak, where travellers leaving Singapore had to undergo temperature screening.
These infectious disease control measures at the borders are currently provided for under Regulation 3 of the Infectious Diseases (Measures to Prevent or Control the Spread of Infectious Diseases) Regulations 2004.
As we recognise that these are basic and important means of preventing and controlling infectious diseases, clause 15 of the Bill transfers this Regulation into the Act by inserting the new sections 45A and 45B, to allow the medical examination and surveillance of travellers entering or leaving Singapore. These help reduce the risk of the introduction and spread of infectious diseases into the community in Singapore and the international spread of diseases from Singapore.
Lastly, I will introduce the amendments to strengthen infectious disease control within Singapore.
Regulation 4 of the Infectious Diseases (Measures to Prevent or Control the Spread of Infectious Diseases) Regulations 2004 provides for MOH to require workplaces and dormitories to conduct contact tracing and surveillance for specific diseases. This is to facilitate the identification and management of infected persons or contacts, to prevent disease spread.
The threat of infectious diseases is, however, not restricted to workplaces or dormitories alone. During the SARS outbreak, MOH put in place temperature monitoring of staff and students in schools, as a form of surveillance to identify and treat any infected persons, and prevent disease spread. More recently, in 2016, the detection of a cluster of tuberculosis cases in a block of flats in Ang Mo Kio was followed by the setup of onsite screening and contact tracing services to identify any other undiagnosed cases for follow-up treatment and monitoring.
While MOH had worked collaboratively with the relevant Government agencies, such as the Ministry of Education and the Housing Development Board to institute the respective measures, the experiences surfaced the potential need for legislative levers to require persons in charge of different types of premises to put in place surveillance or contact tracing measures to mitigate the spread of infectious diseases.
Clause 7 of the Bill inserts a new section 19A to incorporate the current Regulation 4 of the Infectious Diseases (Measures to Prevent or Control the Spread of Infectious Diseases) Regulations 2004 into the Act and expands its scope to include premises beyond workplaces and dormitories.
Following the detection of infectious diseases, a person may be restricted from his occupation under section 21, if the conduct of his occupation poses a risk of spread to others. For example, food handlers tested positive for diseases that spread through food would be required to stop work. This stop-work requirement is a blanket one and does not facilitate allowing a worker to conduct other tasks, such as backend administration or cashiering that do not involve contact with food and, hence, would not spread the disease. Clause 8 of the Bill calibrates section 21 to allow persons of a lower risk of transmission to perform specific occupational activities assessed to be acceptable from the disease transmission perspective.
Likewise, clause 9 of the Bill amends section 21A to allow my Ministry to calibrate the restriction of movement placed on persons of lower risk of transmission, such as certain contacts of an infectious disease, to allow them some liberty to be at specified places, subject to conditions that would minimise the risk of disease exposure and transmission to others, instead of being disallowed in all public or common places outside of their homes. For example, a low-risk contact may be allowed to go to his or her workplace via a specified mode of transport, such as a private car, for a certain period of time.
I had spoken about the importance for my Ministry and other stakeholders to conduct surveillance and collect the necessary information to prevent disease spread. In the event of an outbreak or potential disease spread, it is also of utmost importance that we have the means to push out critical information to the public such that they may take the necessary steps to protect their health. Besides information shared through mass media, there may be instances where targeted sharing to generate awareness among specific population groups is necessary. For example, there would be value for persons travelling to or returning from a country affected by an outbreak to receive information concerning the disease and precautions to observe.
During the 2013 outbreak of H7N9 avian influenza in various parts of China, collaborative arrangements were made between my Ministry, the Civil Aviation Authority of Singapore (CAAS), Immigration and Checkpoints Authority, Changi Airport Group and the relevant airlines, to distribute health advisory notices to travellers returning from affected areas.
Clause 10 of the Bill inserts a new section 21B, to provide the legal basis to tap on the capability, infrastructure and expertise of operators, to disseminate health advisories to persons specified in an order, such as persons travelling to or returning from overseas areas affected by an outbreak, or persons within or likely to enter any place within Singapore affected by or likely to be affected by an outbreak. This provision also provides the legal backing to operators required to disseminate information in different formats, including electronic ones. Examples of operators include mobile operators, land, air and sea transport operators providing local and cross-border services, port and transport facility operators, persons who control or manage premises and event organisers.
Section 21B also allows my Ministry to require operators to provide information of relevant persons to facilitate the dissemination of advisories. For example, if a case of measles or infectious tuberculosis is discovered on an airplane, we would need to obtain the airplane's passenger manifest, to provide passengers seated around the infectious person with information on the disease and mitigating actions to be taken.
When consulted, operators asked whether they would be in contravention of privacy laws, such as the Personal Data Protection Act (PDPA). In this regard, clause 25 of the Bill inserts a new section 67A, which confers immunity against legal liability under other laws, to persons disclosing or providing any information required under the IDA, in good faith and with reasonable care in accordance with any requirement under the Act.
Even in our efforts to work with high-risk persons to prevent disease spread through necessary public health measures, a small minority may refuse to comply. For example, an infectious person served an isolation order may abscond, totally disregarding the risk to others. Section 56 currently allows such non-compliant persons to be arrested without warrant and to be punished, on conviction, with a penalty of a fine or jail term. However, an arrest does not directly mitigate the immediate public health risk of disease transmission to others.
Clause 20 of the Bill amends section 56 to allow health officers to take necessary measures, including the use of physical means, to enforce a legal order served under the Act, for example, by bringing an absconder back to the place of isolation, in lieu of arrest. It also makes explicit that persons under legal orders that restrict their movement in Singapore, would not be allowed to leave Singapore, unless otherwise permitted.
These provisions allow my Ministry to take steps to enforce the restrictions which are put in place on individuals. We are mindful that these powers should be exercised carefully and will put in place a framework for the assessment of cases, and safeguards, such as limiting the exercise of powers to specific situations, for example, where the immediate isolation of a highly infectious person is necessary.
Finally, in facilitating prevention measures and improving preparedness against infectious diseases, we will be strengthening provisions relating to the disclosure of information for the prevention of disease spread and outbreak, and national public health research.
First, the disclosure of information for prevention of disease outbreak or spread. To protect against the spread of infectious diseases, it is critical that entities responsible for carrying out disease prevention and control measures rapidly share information with one another. Currently, section 57A of the Act requires, in certain circumstances, the Minister of Health's approval for the disclosure of information on infectious disease cases, carriers or contacts, from my Ministry to third parties for the purpose of preventing disease spread. To facilitate expedient information sharing, clause 21 of the Bill amends section 57A to empower the Director of Medical Services to do so, without the Minister's approval.
To provide for the direct sharing of such information among healthcare providers, as authorised by the Director of Medical Services, clause 22 inserts a new section 57B. I give the example of infection by multi-drug resistant organisms, which can be transmitted through contact with a carrier. A carrier of such organisms may seek care from different hospitals in different regional clusters. In this case, the sharing of information among hospitals is important, so that the necessary isolation measures can be taken to prevent the transmission of the disease to other patients. Information shared may include the identifiers of the person and these should only be shared or used to the extent that allows the necessary measures to be taken to prevent disease spread.
We recognise that the use and disclosure of information should be conducted strictly on a need-to-know basis. The healthcare services to which this new provision relates, and the conditions to be adhered to by the disclosing and receiving parties, will be specified.
Second, national public health research. National public health research is an important tool to understand diseases and is necessary for the evaluation of current operations and identification of more efficient ways to manage or prevent outbreaks. Research outcomes include the development of preparedness plans and prevention and control policies, for the benefit of public health and to facilitate the optimal deployment of resources during an outbreak.
We should not be doing research only when we are close to an emergency or already in one. It is well-recognised that public health research needs to be conducted well in advance of any possible outbreak during peacetime, to ensure that Singapore's defences against any new or re-emerging infectious disease remain relevant and strong, so that we can effectively respond during an actual outbreak. Clause 23 of the Bill, therefore, clarifies that section 59A allows national public health research to be conducted even when there is no imminent risk or crisis.
Clause 23 also amends section 59A, to allow the use of information or samples obtained through other sections of the Act for research, for example, surveillance or disease notification data, as well as to facilitate the use by my Ministry and sharing of individually-identifiable information or samples with third party researchers, where research can only be carried out using identifiable information or samples, for example, in tracing the transmission pathways and patterns of spread of a rare or new disease.
We recognise the importance of protecting the confidentiality of persons and preventing potential misuse of data. I would like to assure the House that data protection remains paramount to us. In using identifiable data, we will assess that it will benefit the greater public health interests of Singapore and there are no other reasonable alternative means to conduct the research. Also, persons authorised to access identifiable data will be limited and must comply with conditions to ensure confidentiality.
There are also other amendments to the Act which facilitate its administration. These include alignment of nomenclature, firstly, for "Human Immunodeficiency Virus (HIV) infection" and removal of "Acquired Immunodeficiency Syndrome (AIDS)", a late stage subset of HIV; secondly, clarifying the responsibility of the Minister for Health and the Minister responsible for health and sanitary measures in relation to vessels, aircraft, vehicles and persons entering or leaving Singapore; thirdly, enabling the seizure of books, documents or records for investigation of offences, and the disposal of seized items; and lastly, the adoption of standard provisions on how liability for offences by corporations and other types of entities is to be determined.
As I come to the close of my speech, let me once again highlight my Ministry’s commitment to continue building on the good work which had been put into developing Singapore’s capabilities to prevent and control infectious diseases.
Last year, Singapore was evaluated by the World Health Organization (WHO) on our capabilities in health security as stipulated through WHO's International Health Regulations. I am happy to share that Singapore was assessed, and I quote, to "[have] demonstrated strong leadership and a highly developed capacity to detect and respond to potential public health emergencies".
My Ministry recognises that we must not and cannot afford to be complacent. The IDA is an important legal instrument that enables Singapore to prevent, protect against, control and respond to the spread of infectious diseases. This round of amendments to the Act was proposed following a detailed review of our existing levers and approaches.
The proposed amendments are intended to achieve two key objectives. First, to strengthen the Act based on the current infectious disease landscape and our operational experience. Second, to put in place risk-stratified approaches in managing outbreaks, and infected and at-risk persons, given our improved understanding of disease spread.
To sum up, the Infectious Diseases (Amendment) Bill is premised on the need to remain continually vigilant and maintain a high degree of preparedness against evolving infectious diseases. I ask for the support of all Members for this Bill. Mr Deputy Speaker, I beg to move.
Question proposed.
Mr Deputy Speaker: Dr Chia Shi-Lu.
Mr Deputy Speaker, Sir, I was born in the 1970s, when advances in antimicrobial therapy and vaccination were so blindingly impressive that they led many experts to foretell the end of infectious diseases and epidemics as health threats. How wrong they were.
Although here in Singapore we remain rightly focused on the control of chronic diseases, such as diabetes, as they pose the greatest burden on our ageing population, we must never let our guard down on the threat that infectious diseases pose to a small, densely-populated country like ours. The spectre of SARS, barely 15 years ago, remains fresh in many of our minds, and since then, many serious epidemics have occurred in many parts of the world, often spreading with frightening speed, both within the affected country and beyond its borders.
WHO has published guidelines on how disease epidemics should be managed, but certainly, a key focus for any society would be, first, to prevent the spread of disease into the country, and, of course, later, following a disease outbreak, on how to contain its spread both within the country and beyond its borders. The amendments to this Bill are, therefore, timely as they seek to strengthen powers directed towards both epidemic prevention and containment.
As the Senior Minister of State has just pointed out, presently, non-citizen visitors to Singapore travelling from a location with active transmission of a serious communicable disease, such as Yellow Fever, and who are unvaccinated and thus potential carriers of the disease, cannot be refused entry without first offering them monitoring, disease prophylaxis or isolation. I agree with the Ministry that this can be impractical, particularly if the numbers of visitors arriving are large, and many countries already reserve the right to turn away unvaccinated travellers.
I would like to ask the Minister to clarify whether these new powers also apply to emerging infectious diseases of a serious nature, for which perhaps there may be no known preventive or therapeutic measure. If one recalls the Ebola outbreaks in the not too distant past, we debated the measures that were available to safeguard Singapore by controlling the entry of travellers from the affected countries. This had to be achieved via a rather circuitous route whereby travellers from countries with active and significant Ebola transmission had to obtain a temporary entry visa before travelling into Singapore. The new sections 45A and 45B refer to monitoring activities. But what if there is no accurate or practical means of screening travellers from hot zones?
Second, the amended section 21 now allows for risk stratification of disease cases and carriers, so that they may perform limited vocational duties, or make limited travel outside their homes. For cases and carriers, I would like to ask what is the mechanism by which they can appeal for or against that particular risk classification.
Finally, I also welcome the amendments which facilitate infectious disease, public health research even when there is no imminent danger of an infectious disease crisis. I would like to ask the Ministry to clarify what is the precise mechanism through which a decision is made to allow such public health research in normal times, whereby, for example, clinical samples may need to be sent to third party collaborators or laboratories, or when research on individually-identifiable specimens can be conducted. What is the process of review and who are the entities that conduct such a review? I look forward to the Minister's clarifications on these points and support the amendments to the Bill.
Mr Deputy Speaker: Er Dr Lee Bee Wah.
Mr Deputy Speaker, Sir, I rise to support the Bill. Millions of tourists pass through our shores by air, land and sea. Hence, we need to take steps to closely monitor and implement measures on how infectious diseases can be controlled to protect the health of our local population.
I note that there are various requirements for doctors and those who run laboratories carrying out various medical tests to report to MOH when infectious diseases are detected. I think what we need to look into is how the frontline staff at the clinics and laboratory technicians are protected. What training is given to them to keep them abreast of preventive measures to be taken?
This is the group that is vulnerable and they can be a source for spread of infectious diseases if they are not properly trained and protected. Also, we have seen from the outbreak of SARS how the frontline medical staff at the Government hospitals fell victim.
While we know the Government healthcare institutions are very vigilant and they conduct regular disease outbreak exercises to prepare their staff for such eventualities, unfortunately, I am not sure whether the same is true for non-Government hospitals and medical centres. What is the MOH doing to ensure that their frontline staff also receive adequate protection? How stringent are checks at privately-run clinical laboratories to ensure that the technicians and all those working there observe the necessary safety rules? How often does MOH conduct audits of these laboratories where they handle blood, urine and other samples?
Secondly, I note that the Government healthcare institutions offer free vaccinations for their medical staff against infectious diseases, such as seasonal flu. Will the Government make this mandatory for all hospital staff so that they do not become carriers because of the nature of their work in the hospital setting? I believe, at present, it is not compulsory for all the staff, especially non-medical staff, like the receptionists, cleaners and so forth.
Next, I would like to ask the Minister what is the process in place if someone has visited a person or patient who is suffering from an infectious disease while overseas? Is this person required to declare upon embarking in Singapore? Is there not a risk that this person could become a carrier though he or she may not have symptoms until after the gestation period? Is there any public education that MOH will carry out to warn Singaporeans and others who travel abroad to visit a sick person?
I believe, in the setting of a public healthcare institution, staff are reminded if they return from, say, the Middle East, and have fever, they should report to the infectious disease control clinic for a check. But what about those in private healthcare? What about those who are not even in a healthcare setting? How do we help educate them about their social responsibility towards the community?
I am pleased to note that MOH, under a new section 21B, the Minister can seek the assistance of mobile operators as well as various transport operators to disseminate health advisories. I feel that MOH may also tap on the Ministry of Foreign Affairs' (MFA's) website and app to disseminate such health measures to be taken for Singaporeans who register with MFA before they travel abroad, especially to high health-risk countries.
I note that section 31 allows the Port Health Officer to return a person, who is not a Singapore citizen, who arrives in Singapore without having undergone a vaccination or prophylaxis. May I also ask what is the process in place for an aircraft to be disinfected if a passenger travelling on board is found to suffer from a highly infectious disease? For that matter, on the ground, what about the taxi that transports the person to the hospital? I am also concerned about how taxi drivers are protected against infectious diseases, especially against the avian flu.
I would also like to raise this point about the plastic trays used at airport checkpoints around the globe and touched by millions of passengers as they drop shoes, laptops, luggage and other items to clear X-ray scanners. In September this year, there were reports pointing out that studies have found that these trays carry a variety of germs, including the ones responsible for the common cold, according to researchers in Europe.
Scientists from the University of Nottingham in England and the Finnish National Institute for Health and Welfare swabbed frequently touched surfaces at Helsinki Airport in Finland during and after peak hours in the winter of 2016 and picked up traces of rhinovirus, the source of the common cold, and of the influenza A virus, reported the New York Times article. Did MOH do any such audit of the trays at our airport and other checkpoints?
It is important for us to remember that the spread of infectious diseases is not to be taken lightly and there must not be any compromise in this regard. It is unfortunate that while modern medicine has eradicated many diseases, new ones are evolving and these are, at times, even more lethal. We need to reboot our vigilance and go back to basics and remind everyone, children to adults, such good habit as the importance of keeping our hands clean every time, all the time. Mr Deputy Speaker, Sir, in Mandarin, please.
(In Mandarin): [Please refer to Vernacular Speech.] The spread of infectious diseases cannot be underestimated. Hence, I fully support this amendment. I have a few clarifications.
First, in public hospitals, measures to prevent infectious diseases are very stringent. I would like to know how MOH ensures that private hospitals and laboratories also comply with the same stringent steps.
Second, doctors and nurses can enjoy free vaccinations against common infectious diseases. Do other staff from the hospital, such as the canteen staff and cleaners, enjoy the same benefits as well?
Third, for infectious diseases from overseas, MOH will make use of mobile phones and transport operators’ network to inform our people. This is a good move. I hope that MOH can educate more Singaporeans.
Although it is good that patients with infectious diseases can be deported, the various places he has been in contact with, such as the aircraft cabin, the security screen trays and the taxis, should also be disinfected accordingly to prevent the spread of viruses. How shall we do it? Are our taxi drivers properly protected?
(In English): Sir, I support the Bill.
Mr Deputy Speaker: Ms Irene Quay.
Mr Deputy Speaker, Sir, thank you for the opportunity to speak on the amendment of the Infectious Diseases (Amendment) Bill.
First of all, I would like to declare my interest as the President of the Pharmaceutical Society of Singapore. I understand that the recently amended Bill has been focused on strengthening contact tracing, surveillance, communication and the disclosure of information for infectious diseases.
However, it is to my surprise that there is not much mention regarding the legalisation to curb the global and national issue of antibiotic resistance. To provide some background information, antibiotic or antimicrobial resistance occurs when microbials or micro-organisms, such as bacteria, viruses, fungi and parasites, change in ways that render the medications used to cure the infections they cause ineffective. When the micro-organisms become resistant to most antimicrobials, they are often referred to as "superbugs".
This resistance occurs naturally but is facilitated by the inappropriate use of medicines, for example, using antibiotics for viral infections, such as cold or flu, sharing antibiotics or excessive inappropriate use of antibiotics in animals. I shall henceforth refer to antimicrobial resistance as AMR.
On 30 March 2017, a new Bill 1840 was brought before the United States (US) Congress to provide tax incentives to "reinvigorate" antibiotic research due to the grave nature of AMR. The growing resistance of human infections to antimicrobial agents has emerged as one of the most pressing health problems in Singapore and the world. I understand that the National Research Foundation (NRF) announced the launch of a new Antimicrobial Resistance Interdisciplinary Research Group in January 2018 in conjunction with the Singapore National Strategic Plan on Antimicrobial Resistance, hopefully, to better understand how microbial resistance happens and to develop new antibiotics to curb these "superbugs".
A study from the Singapore-Massachusetts Institute of Technology (MIT) Alliance for Research and Technology shows that AMR currently results in about 700,000 deaths per year worldwide, with recent studies predicting an increase to 10 million deaths per year by 2050, outpacing the mortality of cancer. The economic burden will follow a similar trend as a result. In the US alone, "AMR bacteria infect two million people every year at a healthcare cost of S$27 billion. On a global scale, AMR is predicted to cost up to S$130 trillion by 2050." These statistics are very distressing and not at all encouraging.
According to a WHO report, only 11 antibiotics in clinical development could address pathogens considered critical threats, and three in four of the antibiotics under development belong to existing classes of antibiotics, against which microbials resistance has already been observed or could easily develop, due to the innovative nature of these "superbugs" in evading our current controls.
So, at this rate, the world, including Singapore, will run out of antibiotics before long, and we might possibly go back to the era where even simple skin infections or urinary tract infections could kill us. The severity of this threat should not be underestimated, and I urge that we deal with this issue critically and swiftly.
Tackling the AMR problem would require a multi-pronged and multifaceted approach. I acknowledge with relief that MOH has set up the National Strategic Action Plan on Antimicrobial Resistance, engaging various Ministries and agencies, such as the Agri-Food and Veterinary Authority (AVA), National Environment Agency, Public Utilities Board and so on, to evaluate various core strategies from public and healthcare professional education, surveillance and risk assessment, research, prevention and control of infection to the optimisation of antimicrobial use, and I applaud MOH for their tremendous effort in tackling this pressing threat.
While a lot of surveillance and engagement work has been focused on hospitals since 2009, much more salient efforts have to be applied to get to the root of the problem. This includes how we can further enhance our AMR surveillance to grasp the utilisation rate of diagnostic toolkits which can be used to differentiate viral and bacterial infections, as well as where and how much antibiotics are being sold, prescribed and dispensed in each hospital, general practitioner clinic, retail pharmacy and for animal use. It is then necessary to extract such detailed information and apply data analysis or audits to identify specific abusive users and establish a feedback mechanism for better accountability.
As such, I would like to propose measures that are imperative in resolving and lessening the impact of AMR in Singapore. Currently, we have systems in public hospitals to curb the misuse and overuse of antibiotics, but we will require a similar framework in the community where 80% of the primary healthcare is provided by private practices.
I would, therefore, like to advocate an AMR taskforce to discuss and recommend strategies to ensure appropriate use of antibiotics in a community setting, such as the reviewing and streamlining of an antibiotics formulary available for perusal within the community and exploring prescribing-dispensing separations, where possible.
It is also essential to urgently come up with clinical practice guidelines on the use of antibiotics, the appropriate course duration of use, as well as the conducting of audits on the appropriateness of antibiotics utilisation, especially for broad spectrum antibiotics like quinolones, in the community setting.
Educational programmes for healthcare providers in the United Kingdom (UK) have shown considerable effectiveness in reducing the prescription of antibiotics in primary care, and maybe similar programmes should be enacted in Singapore.
Flu vaccinations are currently claimable by MediSave for specific population groups. This coverage should be extended nationwide and offered at a subsidised rate to our Pioneer Generation under the Community Health Assist Scheme (CHAS). Flu vaccinations should also be introduced into the national childhood immunisation programme to ensure that school children benefit from this and, at the same time, increasing the overall national take-up rate.
A 2017 systematic review published in the Journal of Epidemiology and Community Health looked at studies that calculated the return on investment for public health interventions. The researchers identified 52 studies that looked at interventions at local and national levels. Health protection interventions, which would include vaccinations that match the actual influenza type, have saved $34 for every $1 spent on them, according to the review. Such a high return occurs because of all the disease and death prevented.
In light of this review, a national public awareness programme should be incepted to educate the general public on the potential side effects and infections from the uninformed use of antibiotics. Citizens should be warned to refrain from asking for antibiotic prescriptions from their doctors. I understand that the Health Promotion Board (HPB) is already working on this, but more aggressive and intense public education campaigns must be carried out to raise urgent attention.
Clostridium difficile, a bacterium which infects the bowels and causes diarrhoea, is one such example of an infection usually related to antibiotic use, particularly in hospitals. It has been responsible for an estimated 14,000 deaths annually in the US. Other potentially deadly side effects due to drug allergies include anaphylaxis, a life-threatening allergic reaction, or fatal skin reactions like the Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN), fungal infections which lead to severe itching from vaginal yeast infections or burning mouth sores from oral thrush, and antibiotics-associated diarrhoea.
There is a compelling need to empower patients to speak up and discuss risks versus benefits of imbibing antibiotics with their doctors to help them take ownership of their own health. Emphasis on the importance of hand hygiene and infection preventive measures in the community should not be understated. Similarly, the importance of flu vaccination and the fact that getting vaccinated protects loved ones around you, such as those more vulnerable to serious flu illnesses like babies and young children, as well as older people and people with certain chronic health conditions. This is possible through the vaccine herd effect or herd immunity, which makes a disease hard to spread because there are very few people who are susceptible.
To facilitate these actions, the use of rapid diagnostic health devices should be promoted and distributed widely at a highly subsidised rate. This will make it more cost-effective to use these devices compared to paying for a course of antibiotics.
AMR is a major worldwide complication that has persisted and will continue to persist. It is something that we simply cannot afford to disregard in the slightest if we are not to invite disastrous consequences.
It requires the synergistic coordination and collaboration of everyone in Singapore to combat and safeguard against. The cooperation of citizens, operators, healthcare professionals, diagnostic and pharmaceutical industries, educators, researchers, various Government Ministries and policymakers should be sought out in order to fend off this dire situation.
Globally, many countries struggle with this deplorable predicament. I firmly believe that Singapore, being a country of first-world infrastructure and data management, armed with capabilities of a Smart nation, can and should employ data analytics and her pool of highly educated citizens to weather this storm. I am certain that we can proclaim to the world that it is, indeed, possible to come out on top and rein in AMR. Notwithstanding my proposal and concerns above, I stand to support the amendment Bill.
Mr Deputy Speaker: Prof Fatimah Lateef.
Sir, let me, first, declare my interest as a frontline medical specialist who is involved in decision-making and also management of patients with infectious diseases.
The Infectious Diseases Bill was first enacted in 1977 and last amended in 2008. Thus, indeed, it is timely to have it updated and reviewed, looking also at the current state of affairs of the world with the spectrum of new, emerging and re-emerging infectious diseases. In doing this, Singapore must continue to stand guided by global bodies, such as WHO and the Communicable Diseases Centre (CDC). I have a few clarifications for the Minister.
One, in light of an infectious disease outbreak or suspected outbreak in Singapore, what is the chain of command that we practise? At the institution level, all our restructured hospitals have got an action plan and also a response plan. Do we also wait for MOH, WHO and CDC advisories? What is the coordination like on a bigger scale at the global or even regional levels? Is there a direct chain of communications and correspondence for Singapore that has been established?
Second, in the event of cross-border outbreak or spread, how and what will be our model of working and communications with our closest neighbours, for example, Malaysia? Do the environmental and health organisations of both countries have a modus operandi in place?
Third, temperature scanners these days are not commonly seen at our borders as compared to the period during the SARS outbreak. Does this mean that we rely entirely on people and travellers declaring that they are ill at our points of entry? Can the Minister please just comment on this as well?
Fourth, in dealing with infectious diseases and notification, there is a need to report particulars and details. Thus, disclosures and consent become compulsory and are given significant weightage. In this day and age of the PDPA and handling information and particulars with utmost confidentiality, we will definitely have to strike a balance between this and upholding public health policies and principles. Therefore, would MOH be embarking on more public awareness and education programmes to help the frontline medical personnel when we are having issues with outbreaks and handling infectious diseases, including antibiotic resistance as well? I notice that HPB has already started an educational campaign on that matter.
Fifth, what about persons on flights enroute to Singapore who are suspected or are diagnosed with certain infectious diseases? What is our framework with CAAS and also other airlines? How fast can contact tracing and ringfencing be done? And this is critical because our borders are really very open these days. With these clarifications, Sir, I support the Bill.
Mr Deputy Speaker: Mr Murali Pillai.
Deputy Speaker, Sir, I rise in support of the Bill. As mentioned by the hon Members of Parliament who spoke before me, in particular, Er Dr Lee Bee Wah, Singapore is an international travel hub. About 7,200 flights land or depart from Changi Airport each week. As at November last year, approximately 60 million passengers passed through Changi Airport in 2018. These travellers come from all over the world.
Greater travel connectivity and movement of people come with the attendant risk of the spread of diseases, something that the hon Senior Minister of State Dr Lam Pin Min highlighted. These proposed amendments to the IDA allow the Government to enhance infectious disease surveillance and equip us to better prevent the spread of infectious diseases both within Singapore and from outside Singapore into Singapore.
I would like to commend the Ministry for its efforts to consult stakeholders over a six-week period before finalising the Bill which is before Parliament today. I seek two clarifications on two areas.
Section 21 of the Act is proposed to be amended to allow the Government to take a more calibrated approach to address the risk of the spread of infectious diseases by persons who are carrying infectious diseases.
Instead of a blanket ban against carrying on any occupation, trade or business, which is presently the case, the amendments allow the authorities to make an assessment of the extent of risk in the circumstances, and make appropriate orders as necessary to prevent the transmission of infectious diseases, which may not need to be a complete cessation of trade or business. And the learned Senior Minister of State mentioned food handlers as an example. This calibrated approach will be less disruptive to businesses and traders. I welcome it.
The amendments, however, do not provide direct assistance to a person who has been ordered by the Director to cease business to prevent the spread of infectious diseases. To illustrate, if a person is a carrier of an infectious disease, such as dengue or measles, is afflicted and he is asked to be quarantined, for certain occupations, such as self-employed persons like taxi drivers, they may still have to honour their contractual arrangements with their counterparties, for example, the taxi companies, for the period they should be quarantined, so that they will not infect their passengers. It is commonly provided in agreements between taxi companies and their drivers that they have to pay rent for the hire of the taxi if they have a medical certificate (MC) for longer than a defined period, for example, seven days. This creates a potential conundrum for the self-employed person who may be caught between a rock and a hard place. If they abide by the Director's orders, they may be exposed to liability vis-a-vis the counterparties.
This is not a theoretical musing. I met a gentleman at a funeral wake of his relative. He related to me that he was given 14 days' MC for his infectious disease. However, he was required to pay rent after an initial seven-day period. He was unable to secure cover because of the suddenness of the situation. He had no choice but to pay rent even though he was quarantined at home on his doctor's orders.
In contrast, section 20 of the UK Public Health (Control of Disease) Act 1984, provides for local authorities to, by notice in writing, request any person to discontinue work. And, in such instances, the local authorities may have to compensate the person if he has suffered any loss in complying with such a request. Section 20 of the UK Act has since been repealed and replaced with regulation 8 of the UK Health Protection (Local Authority Powers) Regulations 2010 which continues to enable the local authorities to offer compensation.
Apart from a written request in writing to stop work, section 45H of the Public Health (Control of Diseases) Act also allows for local authorities to apply to a Justice of the Peace for an order to impose restrictions or requirements to protect human health. The order made may order the payment of compensation or expenses in connection with the taking of measures pursuant to the order.
The point is that the UK provisions contemplate the authorities giving compensation where a worker's work or trade has been affected by a measure taken in protection of public health, such a stop-work order.
In Singapore, we do not have that, which means that the risks may lie entirely with the trader or worker concerned. Even if we do not go so far as to compensate people in respect of stop-work directions given, perhaps we can at least consider having a statutory basis for people to be relieved or held harmless from liability for their contractual business or trade obligations for the period that they are directed by the Director to do an act which renders them unable to perform their work obligations.
Next, section 6 of the Act is proposed to be amended to require certain persons who are aware or suspects that another person is suffering from, or is a carrier of, a prescribed infectious disease, to notify the Director of Medical Services of those facts. The section previously made reference to "infectious disease", which is specified in the First Schedule of the Act, instead of "prescribed infectious disease". The amendments also provide that what amounts to "prescribed infectious disease" will be set out in Regulations.
Given that the Act already spells out what amounts to infectious disease in the First Schedule, and also separately spells out what is dangerous infectious disease in the Second Schedule, may I please ask what will be covered under the new defined term of "prescribed infectious disease"?
How will the list of prescribed infectious disease be drawn up? Will there be any interplay between the infectious diseases set out in the First Schedule and the list of prescribed infectious diseases? Or is it contemplated that the application of the prescribed infectious diseases list is only in respect of section 6 of the Act, since no other sections of the Act refers to prescribed infectious diseases?
Sir, before I sit down, I would like to make reference to a point made by the learned Senior Minister of State. He mentioned that MOH received plaudits from WHO for its ability to successfully detect and prevent the spread of infectious diseases. This is a hard-earned reputation and, frankly, whatever we pass today in the House, it is the capability of MOH and its professionals that would make a decisive difference in the fight against the spread of infectious diseases. And in that regard, we should never forget the heroes, such as Nurse Hamidah Ismail and Dr Alex Chao, who lost their lives in helping Singaporeans during the SARS incident, and they always would deserve our eternal debt of gratitude. Thank you.
Mr Deputy Speaker: Mr Louis Ng.
Sir, I stand in support of this Bill that will increase our responsiveness to infectious diseases. The most effective responses to infectious diseases are steps that are taken pre-emptively to curb the risk of any emerging threats.
The Bill provides the stakeholders with the necessary powers to respond ahead of time of any outbreaks, and quickly, should an outbreak actually occur. However, I also believe that all powers should be accompanied by checks and balances and I would like to seek some clarifications on the broad powers the Bill provides.
Under section 21(1), the Director may give directions to any individual to cease or to change how they carry out any occupation, trade or business. I note that section 21(2)(a) states that the Director will specify the "period of time" that the individual will have to cease their occupation, trade or business. Can the Minister confirm that the Director will not have the blanket power to order a person to cease their occupation, trade or business for an indefinite period? Will the decision be made by just one person or a committee?
Will it be subject to time limits? For instance, section 17A, which allows the Minister to declare a public health emergency and designate restricted zones, is subject to a 14-day time limit. There is no similar time limit for the Director’s powers under section 21(1). Can the Minister confirm whether any time period specified will at least be limited by the requirement of reasonableness? Can the Minister also provide the assurance that reasonable periods, subject to regular reviews, will be preferred over long bans?
Next, under section 57B(1), a healthcare provider may disclose information identifying a person as an individual affected or suspected to be affected by an infectious disease. The healthcare provider must be authorised by the Director to do so. Can the Minister clarify whether the affected person will be notified of the disclosure? Under section 57B(3) the specified recipient of information may further disclose that information to another person providing a prescribed healthcare service. The disclosure is only to the extent necessary to prevent the spread or outbreak of the infectious disease.
Can the Minister elaborate on whether the extent necessary is at the sole judgement of the specified recipient, and whether the Director's authorisation or affected person’s consent would be required?
Section 57B(6) defines "healthcare provider" and "specified recipient" as any person that provides a prescribed healthcare service which will be prescribed in subsequent regulations.
In addition to section 57B, section 59A(5A) also allows individually-identifiable information to be disclosed for the purpose of national public health research. There are no express provisions for both section 57B and section 59A on safeguards that may be imposed on the recipient of such information. Rather, section 57B(2) and section 59A(5)(c) allow the Director to impose conditions. I assume that these conditions will require the recipient of the information to take steps to prevent further disclosure. Will the subsidiary legislation or guidelines further elaborate on the safeguards that recipients must put in place?
Lastly, I would like to commend MOH on the six-week public consultation that was conducted in mid-2018 on the proposed amendments to the IDA. However, unlike the draft Healthcare Services Bill, there was no direct response from the Ministry to the public consultation feedback. Sir, notwithstanding my clarifications, I stand in support of this Bill.
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