Impact of New Bird Flu Strain (H7N9) on Singapore

Er Dr Lee Bee Wah asked the Minister for Health with the outbreak of the new strain of bird flu and the imminent school holidays in June (a) what is the Ministry's advice for those who are planning trips to China; and (b) how prepared are our hospitals to meet any epidemic outbreak of bird flu.

Mr Zainal Sapari asked the Minister for Health (a) what is the risk assessment of the H7N9 strain of bird flu spreading to Singapore; (b) what are the measures taken to minimise the potential threat posed by the spread of this strain of bird flu; and (c) what is the worst-case scenario that Singapore has to be prepared for.

Dr Lam Pin Min asked the Minister for Health (a) if he will provide an update on the novel coronavirus and H7N9 influenza outbreak; and (b) what are the surveillance measures and management strategies in place to handle any index case in Singapore.

Madam, since the first reports from China on 31 March this year, there have been a total of 132 confirmed cases of avian influenza A (H7N9) infection, including 33 deaths. Affected areas in China include eight provinces and two municipalities: Zhejiang, Shanghai, Jiangsu, Anhui, Henan, Beijing, Shandong, Jiangxu, Fuijian and Hunan. Taiwan also reported one confirmed case who was likely to have been infected in Jiangsu, China.

Infected poultry and contaminated live poultry markets are the most likely source of infection. Many of the cases had such exposure, and the virus has been isolated in chickens, ducks, pigeons and environmental samples from live poultry markets. Closure of the poultry markets in Shanghai has significantly reduced the number of cases there.

There is no evidence of sustained person-to-person transmission so far. Despite close monitoring of more than 2,000 contacts, only three small family clusters have been identified so far, but these could be due to either common exposure to an animal source or limited person-to-person transmission.

Besides the threat of H7N9, MOH is also closely monitoring another emerging infectious disease – the novel coronavirus infection first reported by the World Health Organization (WHO) in September last year. To date, there are a total of 34 confirmed cases of novel coronavirus worldwide, with 18 deaths. Countries which have reported cases include Jordan, Qatar, Saudi Arabia, the United Arab Emirates, the United Kingdom (UK) and France. The source of the novel coronavirus remains unclear. There have been several clusters suggestive of limited human-to-human transmission between close contacts, but there is no evidence of sustained human-to-human transmission of the infection so far. However, we are monitoring the progress of investigations into the latest Saudi Arabian cluster closely.

Madam, so long as there is no sustained human-to-human transmission for H7N9 or novel coronavirus, the risk of an outbreak in Singapore will remain low.

Singapore does not import live poultry, birds or fresh frozen poultry meat from China. AVA has a comprehensive inspection and testing programme for imported poultry and birds to ensure that they are free from H7N9. The local chicken farms are under strict biosecurity and AVA conducts regular inspections at all pet shops that sell birds. AVA has a surveillance programme in place for chickens and birds in Singapore, including birds in the wetlands reserves and public parks, such as the Singapore Botanic Gardens. The H7 avian influenza virus has not been detected in tests on local and imported birds.

A potential concern is transmission of H7N9 to Singapore via migratory birds carrying the virus. However, as the current H7N9 virus has not been detected in migratory birds in China, the risk of such transmission is currently low. AVA is vigilant against this possibility, and has stepped up surveillance testing on birds in Singapore, including migratory birds.

Nevertheless, we need to be vigilant against the possibility of cases in travellers coming to Singapore. MOH has alerted all hospitals and doctors to look out for suspect cases with symptoms such as fever, cough and signs of pneumonia, and a travel history to affected areas for H7N9 and novel coronavirus. Suspect cases will be isolated and tested for H7N9 or novel coronavirus infection. To date, MOH has been notified of 11 cases who have been investigated for H7N9, and 24 who were investigated for novel coronavirus. None have been positive.

Our hospitals have put in place procedures to manage suspected cases of H7N9 and novel coronavirus. These include infection control measures for management of respiratory infections, and triaging and separating of suspect cases at emergency departments from non-suspect cases to minimise risk of transmission.

When a confirmed index case is detected in Singapore, we stand ready to undertake contact tracing and phone surveillance of close contacts as an added precautionary measure, even in the absence of sustained human-to-human transmission. ICU isolation beds are available to manage severely ill patients.

WHO, currently, does not advise special screening at points of entry, nor does it recommend any travel or trade restrictions for both H7N9 and novel coronavirus.

MOH has advised travellers to affected areas on general precautions, such as practising frequent hand washing with soap and water, avoiding crowded areas and maintaining a high level of personal hygiene. In addition, H7N9-specific precautionary measures include avoiding direct contact with poultry, birds and their droppings, and consuming poultry and eggs that are thoroughly cooked.

We have put up health advisory posters and issued health advisory notices to travellers at our airports to remind inbound travellers who have been in the affected areas to seek medical attention if they become unwell with fever and cough, and to inform their doctors of their travel history. As the June school holidays are approaching, we expect that Singaporeans will be making plans for overseas travel. We would like to remind them to be alert to the latest global disease situations for H7N9 and novel coronavirus, as well as updates to MOH's travel advisory.

We continue to monitor the situation for evidence of community transmission of H7N9 or novel coronavirus.

MOH has actively engaged other Government agencies to coordinate whole-of-Government measures to be ready for such a scenario. We have worked with hospitals and clinics to ensure that there is adequate surge capacity in healthcare infrastructure and beds. At the national level, we have sufficient personal protective equipment and antiviral stockpiles, which can be deployed, should the need arises. Possible control measures include isolation of cases, quarantine of close contacts, and social distancing measures to reduce community transmission, if necessary.

We will continue to engage the WHO and our overseas counterparts to keep abreast of the most updated information. We are monitoring the situation closely as it evolves to ensure that public health is safeguarded. As of now, there is no indication that more drastic measures are required.

Mdm Speaker, I would like to thank the Minister for the comprehensive answer. A lot of the residents are concerned about this mainly because they think that there may not be sufficient hospital beds, should the need arises. Based on their experience currently, they say that when they go to hospitals, sometimes they have to wait for the hospital beds. They are thinking, in case we need more hospital beds, how prepared are we and how fast can we react?

Madam, I thank the Member for the question; it is a very important one. Our hospitals have been working together with MOH to look at how we can expand hospital capacity at short notice if there is a surge in demand. Some of this capacity could be temporary in nature in response to emergency cases due to, for example, the coronavirus or H7N9 should they land in Singapore.

The hospitals are ready. One of the possible measures, for example, is to defer some of the elective surgery so that we can free up beds for emergency cases that come in. Another possible measure that we are looking at is to facilitate discharge of the medically stable patients, either to stepdown care or help them to be discharged home. We can provide home support for these patients so that additional beds can be freed up when necessary.

Mdm Speaker, according to the latest WHO report, the novel coronavirus that has killed at least 18 people in Europe and the Middle East could be transmitted from human to human, albeit after prolonged contact. With this latest information, would the Minister agree that air passengers travelling and confined in an aircraft cabin with an infected person for flight duration of about seven to eight hours typically from the Middle East countries, can pose a significant risk of transmission of the disease? Can the Minister comment on the surveillance measures that are currently available at points of entry and whether these are sufficient to identify these high-risk groups? I would also appreciate it if Minister could explain to the House what sustained human-to-human infection means.

Madam, up to today, the knowledge of the actual transmission mechanism of novel coronavirus is still very limited. We are watching and monitoring very closely. Reports are coming out from WHO on the knowledge that they have gained in the investigation into the various cases. So far, WHO has not recommended any travel restrictions because from their investigations, transmission is limited to very close and prolonged contact, primarily, within the same family or where they are housed together within the same hospital ward. We would follow the advice from WHO in terms of travel advisory.

For us in Singapore, we have introduced several measures including notices to our travellers who are arriving in Singapore, that should they develop symptoms or fall ill and if they have the travel history to affected areas, we encourage them to see our doctors immediately so that we can provide the necessary treatment as well as, if necessary, to isolate them. For the outbound travellers, we have given general travel advice to encourage them to stay away from crowded areas, and to exercise and maintain a high level of personal hygiene. These measures will help to mitigate the potential risks.

Finally, on sustained transmission: when we look at the current cases of transmission, transmission tends to be between one or two persons when they are in close contact. Transmission after the second person tends to be attenuated. Sustained transmission means there is a sustained transmission beyond the immediate contact. From WHO's contact tracing, out of the 2,000 that they have followed up on, very few of them have developed these symptoms, other than the clusters I mentioned in my reply.

Mdm Speaker, I would like to ask the Minister a supplementary question. Given the threat of H7N9 and novel coronavirus, how much more is Singapore prepared today, as compared to the SARS outbreak in 2003 to deal with the pandemic in Singapore?

Madam, I want to thank the Member for another very important question. In fact, with our experience in SARS, we are now much better prepared than 10 years ago. However, with each new infectious disease, it will bring in new experiences, new challenges, new threats. It is a continuing journey of learning so our healthcare professionals and institutions are working together, preparing ourselves for the possibility of the arrival of H7N9 or novel coronavirus patients in Singapore. Our institutions are ready and we will be able to manage them.

Mdm Speaker, I thank the Minister for the information and the explanations. Given that there is no real need to press the panic button for either H7N9 or novel coronavirus right now, is it a good time now for us to look at how we can create greater civic-minded or community-driven measures to deal with such diseases? This aspect of the way we deal with endemic diseases like dengue most recently, can the Ministry do more now that there is no need to panic, to start this going?

Mdm Speaker, in fact. MOH has been working with the various Government agencies, including our own Health Promotion Board (HPB), National Environment Agency (NEA), as well as AVA, on outreach and public education. We want to raise the awareness of the threat of infectious diseases. During peace time, or without the immediate threat of infectious diseases, our focus has been on non-communicable diseases associated mainly with ageing and so on. But we are very much aware that infectious diseases continue to be a threat, given today's globalised world.

There is now a much higher volume of international travellers and infectious diseases will continue to be a threat to many countries in the world. This is an area that MOH will continue to work on with our various organisations and agencies to reach out to not just our residents at the community level but also the professionals, such as doctors and the healthcare institutions, so as to raise their awareness and to enhance their preparedness should a crisis arise.