Government's Action Plan for Ebola

Dr Chia Shi-Lu asked the Minister for Health in view of the worsening Ebola outbreak in West Africa and its spread to other countries, whether the Ministry will consider imposing a travel ban on the affected nations in Africa until the epidemic is brought under better control.

Mr Gerald Giam Yean Song asked the Minister for Health (a) whether the current Ebola screening measures at Changi Airport are effective in detecting the virus given that its symptoms may appear up to 21 days after exposure to Ebola and that it is difficult to verify travellers' self-declarations of their exposure to Ebola; (b) whether there are plans to use rapid diagnostic test kits to diagnose Ebola; and (c) what lessons have been learnt from the cases of Ebola transmission in Texas, US and Spain to prevent the same mistakes from occurring in Singapore should an Ebola-infected traveller get through our border checkpoints.

Mr Gerald Giam Yean Song asked the Minister for Health (a) what is the quantum and nature of assistance that Singapore has provided to countries in West and Central Africa to combat the spread of Ebola and treat patients infected with the virus; and (b) what further assistance Singapore plans to provide to the affected countries should the Ebola situation worsen.

As of 31 October 2014, the World Health Organization (WHO) reported a total of 13,567 cases of Ebola, including 4,951 deaths. There continues to be widespread and intense transmission of Ebola in Guinea, Liberia and Sierra Leone. Nigeria, Senegal, Spain, the US and Mali have reported imported cases, some with limited transmission. WHO has

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since declared Nigeria and Senegal to be free of Ebola. In addition, a separate Ebola outbreak is ongoing in the remote areas of the Democratic Republic of the Congo (DRC) involving 66 cases and 49 deaths. No new cases of Ebola have been reported in DRC since 4 October. WHO has stated that DRC will be declared free of Ebola on 21 November, if there are no further cases.

Since 7 August 2014, MOH has instituted several border control measures. Travellers are provided with a Health Advisory on Ebola through the deployment of Health Advisory Posters and the distribution of Health Advisory Notices (HANs) to nationals from Ebola-affected African countries at all air, land and sea checkpoints, as well as other travellers who self-declare their history of travel to Ebola-affected countries. The Advisory tells them about Ebola symptoms and advises them to seek medical attention immediately and inform the medical staff of their travel history if they develop such symptoms.

MOH has stepped up screening measures against Ebola at our checkpoints. Nationals and travellers from countries with significant or potentially significant Ebola transmission – currently seen in Guinea, Liberia, Sierra Leone, DRC and Mali – arriving at our air checkpoints will be directed to a screening station where they will be screened for fever, requested to complete a Health Declaration Card which will include their contact details in Singapore and assessed for the risk of exposure to Ebola through a questionnaire.

Travellers who are found to have a fever will be sent to Tan Tock Seng Hospital (TTSH) for further assessment and testing. Those who are well but assessed to have a risk of exposure to Ebola will be kept under phone surveillance or quarantined for up to 21 days, depending on the nature of their potential exposure. Screening of travellers from countries with significant Ebola transmission is also conducted at land and sea checkpoints using Health Declaration Cards and questionnaire assessment.

The border health measures are part of a multi-layer defence against Ebola. While they alone will not be able to identify persons who are still in the incubation period and are not symptomatic or are not truthful in answering the screening questionnaire, they complement our overall efforts in looking out for travellers who may have Ebola infection.

MOH is concerned by the widespread and intense community transmission of Ebola in West Africa. As such, MOH is working with MFA, MHA, the Immigration & Checkpoints Authority (ICA) and the Civil Aviation Authority of Singapore (CAAS) to impose temporary visa requirements for nationals from Guinea, Liberia and Sierra Leone for entry into Singapore, starting from 5 November. This move will allow for better oversight and control of entry of nationals from these countries and facilitate possible contact tracing. MOH will

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continue to monitor the Ebola situation closely and calibrate our preparedness measures.

To keep our healthcare institutions in a high state of vigilance, we have given regular updates to all hospitals, polyclinics and primary care doctors on the Ebola situation. We have also provided them with guidance and protocols on the criteria for identifying suspected Ebola cases, how to refer such cases for further assessment and the subsequent management of suspected and confirmed cases of Ebola. MOH has also conducted preparedness exercises and visited our public hospitals to ensure that they are well-prepared and adequately resourced to manage cases of Ebola.

Suspected and confirmed cases of Ebola will be centrally managed in TTSH, which has been designated as the national disease outbreak centre. Meanwhile, Ebola virus testing will be centrally conducted by the National Public Health Laboratory's designated testing facilities at Defence Science Organisation (DSO) National Laboratories.

Currently, testing for the Ebola virus is done using the polymerase chain reaction (PCR) method. This is the most sensitive method and the mainstay of diagnosis in all reference laboratories. Rapid diagnostic test kits to diagnose Ebola are being developed and tested but none has yet been approved for use. MOH will evaluate the performance of such rapid kits to determine their suitability for use in our environment when they become available.

The standard treatment for Ebola is supportive therapy. While there are experimental treatments and vaccines being developed and tested, none has been proven to be clinically safe or effective. MOH will continue to monitor developments in these areas.

Of the five Ebola cases that were diagnosed in Spain and the US, three involved healthcare workers who had provided care to patients who were infected with Ebola in West Africa. Investigations of these cases suggested possible breaches in infection control measures, such as improper removal of Personal Protective Equipment (PPE).

Although our hospitals and healthcare workers have been trained on the proper use of PPE, we have not been complacent. Our hospitals have been reminded on the need for strict infection control measures and adherence to stringent protocols when managing suspected and confirmed cases of Ebola. Even with proper equipment, protocols and training, human error can occur, as was observed in the cases of secondary transmission in Spain and the US. MOH will continue to work with the National Infection Prevention and Control Committee (NIPC) and other experts to review our guidelines and protocols to ensure a high degree of competency and preparedness in our hospitals.

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In response to appeals for aid, Singapore has contributed an aid package consisting of medicines, medical supplies and personal protective equipment to WHO. In addition, Singapore also contributed US$150,000 in cash to the WHO to support the WHO Ebola Response Roadmap. Singapore will continue to work with WHO on how to further assist in the global effort against the Ebola outbreak in Africa based on our capability and available resources, including the possibility of seconding one of our experts to assist WHO Headquarters in Geneva in their relief effort.

Mdm Speaker, three supplementary questions, please. May I ask the Minister of State whether MOH can step up information dissemination on the Ebola virus, especially on its epidemiology scientific data which had been available for almost four decades? Does the Minister of State agree that the better informed the healthcare workers and the population are, the better will be the success on the control of the Ebola virus, especially on awareness and prevention and early detection treatment? Therefore, will the Minister of State adopt and promote actively on the policy of choosing facts over fear for everyone? May I also ask the Minister of State how adequate is our protocol to vigorously train healthcare workers to handle Ebola patients and, lastly, what are the contingency plans for contact-tracing and the control of the spread of the Ebola virus here?

I would like to thank the Member for the many supplementary questions.

First, I would like to reassure the Member as well as Members of the House that MOH takes the training of our healthcare workers in the handling of Ebola very seriously. We have done regular audits and checks on the training as well as the preparedness of our healthcare workers, especially those in the frontline, for example, in the Emergency Department. We make sure they adopt and practise the right protocols and procedures that have been stipulated by the National Infection Prevention and Control Committee.

At the same time, we do send circulars to all our healthcare professionals, including private general practitioners, to update them on the situation of Ebola in affected countries, as well as the measures that we are taking in Singapore. In that aspect, I would like to reassure the Member that we are doing all we can to prevent a possible imported case to Singapore.

Nonetheless, we understand that it is impossible to prevent subsequent cases that may appear on our doorstep. The important thing is that we have to be well-prepared for that eventuality.

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With regard to the possibility of fear-mongering among the people, it is important that MOH continue to update the public on the epidemiology, the situation in West Africa and also to educate people that Ebola, although it is a fatal disease, is not easily spread from one person to another person because of the way that the disease is. It is spread through close contact with people who are infected with the disease and it is not through the respiratory route.

I thank the Member for those supplementary questions. We will continue to monitor the situation very closely and to step up our preparedness as well as necessary measures, as and when necessary.

Mdm Speaker, I would like to thank the Minister of State for his reply. I am sure the Minister of State would agree that the greatest threat to us now would be the import of an Ebola case. I am heartened by the announcement that there are some new visa requirements. Two supplementary questions from me.

First, with regard to the just-announced visa requirements, I know it is a bit early, but I would like the Minister of State to comment on what he feels is the efficacy of such a move and whether a more comprehensive travel ban might be a better move. Maybe a total travel ban from the affected countries, at least until the so-called backbone of the epidemic has been broken.

My second supplementary question refers to whether or not there is any consideration for a travel ban for Singaporean nationals travelling to affected countries for non-essential reasons.

I would like to thank Dr Chia for the supplementary questions. That is a very relevant question, with regard to the imposition of a travel ban. I would like to highlight to Members of the House that the decision to impose travel restrictions cannot be taken lightly. It is based on certain principles: (a) the extent of the epidemic in the affected countries, that is, whether there has been widespread and intense community transmission as seen in the three West African countries; (b) the state of the healthcare and public health infrastructure in those affected countries; (c) the ability of the affected country to contain further spread; and last but not least (d) the recommendations from the World Health Organization, as well as expert inputs from our local agencies, including the National Infection Prevention and Control Committee.

Imposing a visa requirement, which we are doing from 5 November, will allow us to have better oversight of these travellers entering Singapore. We will be able to collect information, such as local contact details, local sponsor as well as their exact dates of travel,

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and this will facilitate the process of contact tracing, should the need later arise.

In addition, it will also allow Singapore to inform the applicants at the point of visa issuance about our Ebola health advisory and the actions that they should take should they develop symptoms while enroute to and during their stay in Singapore. So, currently, we will not be imposing any travel ban on the affected countries in West Africa and this is also in line with WHO’s recommendation that there should not be any travel ban imposed on these countries. However, I understand that the situation is very dynamic and we will continue to review our measures as the Ebola situation evolves.

Thank you, Madam. One area of risk is the transmission that could take place onboard the planes that are bound for Singapore. My question is: do the authorities work with airports and public health authorities in other countries to ensure that passengers who board Singapore-bound planes are screened for infectious diseases, including Ebola?

I understand that the US Department of Transportation has a rule which permits airlines to deny boarding to air travellers with contagious diseases, and this rule also applies to flights by foreign airlines into the US. Does Singapore have such a regulation? At the minimum, does Singapore Airlines screen its passengers before its flights to Singapore?

I would like to thank the Member for the supplementary questions. From what I understand, we do share information with other civil aviation authorities from the different countries on some of the protocols and measures they have taken. In fact, even in the affected countries in West Africa, they do have exit screening of travellers out of the country to make sure that they are asymptomatic before they are allowed to board the plane.

What is important is that Singapore has actually taken a more discriminate, stratified kind of approach to monitor the health of arrivals from affected West African countries. We divide them into both symptomatic as well as asymptomatic travellers. If they are found to be symptomatic when they arrive in Singapore, then they will be managed accordingly by being brought to TTSH for further assessment. But if they are asymptomatic, then we will have to probe further with regard to the risk of exposure.

If they have high-risk exposure, meaning they have been managing patients who are affected by the Ebola virus without any personal protection, then they will be put on very close surveillance, either being quarantined in Government quarantine facilities or even in home quarantine. But if the exposure is assessed to be low-risk, then we will put them on phone surveillance for 21 days to make sure that they are asymptomatic during this period

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before they are allowed to continue with their unrestricted activities.