7th Mar 2024
A. Introduction and enhancements for efficiency during PHT and PHE
1. Madam Deputy Speaker, as mentioned by the Minister for Health, a key intent behind the amendments to the IDA is to introduce powers that provide for a gradation of measures that can be taken during a public health threat (PHT) and public health emergency (PHE).
2. Besides the Minister’s powers to make regulations during a PHT or PHE, the following amendments are also being introduced to enhance operational and enforcement efficiency during a PHT or PHE:
i. One, the Minister may direct all persons or any class of persons in charge of premises, such as the owners of shopping malls, to implement contact tracing or surveillance measures.
ii. Two, oral directions may be given by authorised Health Officers to require persons to comply with the relevant PHT or PHE regulations in force. For example, if there is a regulation that imposes limits on the size of gatherings and a Health Officer comes across a gathering that exceeds this limit, the Health Officer may give an oral direction to the group requiring them to disperse.
iii. Three, a higher maximum penalty can be provided for repeat offenders who do not comply with PHT or PHE regulations. The effectiveness of disease containment efforts is contingent on the public’s cooperation in taking public health measures seriously. Non-compliance does not only put oneself at risk of disease, but also others in the community, and can set our national efforts back significantly.
iv. Four, to focus our resources on the pandemic response, statutory appeals to the Minister will be temporarily suspended during a PHT or PHE. Members of the public will still be able to reach out to the Ministry of Health (MOH) to seek exceptional handling on a case-by-case basis, and MOH will attend to these quickly and administratively.
3. These amendments will allow the expeditious implementation of public health measures during a PHT or PHE.
B. Introduction of amendments to enhance future disease outbreak response
4. Besides incorporating the relevant powers under Part 7 of the CTMA and providing a gradation of responses under the IDA, MOH has also taken this opportunity to review and update the IDA in its entirety.
5. The COVID-19 pandemic has required us to adopt new ways to prevent, mitigate and manage infectious disease outbreaks. Advancements in scientific technology and ever-growing international connectivity have demonstrated the need for a new paradigm of infectious disease management measures to fit the modern times.
I. Expanding group of persons that can be appointed as Health Officers
6. Let me start with the appointment of officers who need to carry out the public health actions. Public health actions under the IDA are mainly carried out by Health Officers appointed by the Director-General of Health, the Director-General of Public Health, or the Director-General, Food Administration. As the powers exercisable under the IDA may potentially be intrusive, only public officers, officers of statutory bodies and employees of prescribed institutions, may currently be appointed as Health Officers.
7. However, manpower from the public service forms a relatively smaller portion of the local workforce. When faced with a pandemic, there is often the need to tap on the rest of the workforce to supplement the national response. With diverse partnerships or working arrangements, less intrusive functions can be performed by other parties in partnership with the public service.
8. Clause 4 of the Bill thus expands the pool of people who can be appointed as Health Officers to implement and enforce the IDA. The first new group of persons are employees of prescribed entities and institutions. These will include employees of private healthcare providers and MOH-linked entities such as MOH Holdings and the Agency for Integrated Care. The second new group are employees of prescribed service providers that the Government or statutory bodies have engaged. These could include call centres engaged to do contact tracing. The third group are auxiliary police officers. These three groups were in fact closest to the action during the COVID-19 pandemic, and will be the first sources of manpower MOH will tap on, especially during an escalating outbreak.
9. As public sector resources will be stretched further during a PHT or PHE, there may be a need to bring together additional manpower to supplement and support these Health Officers. Clause 22 introduces a new section 21I of the Bill, which will allow persons who are deemed suitable to be appointed as adjunct Health Officers during a PHT or PHE, to perform the functions of a Health Officer. These persons could include volunteers, such as former nurses, who have stepped forward to help with contact tracing and surveillance.
10. To ensure proper oversight over these Health Officers and adjunct Health Officers, they will need to be appointed and authorised with powers on an as-needed basis. They will also be informed of the scope of their powers and the validity period of their appointments, and receive appropriate training before being tasked to carry out their functions under the IDA.
11. The IDA also provides for specific situations where the arrest of offenders may be carried out by authorised Health Officers without a warrant, such as the arrest of persons who breach isolation orders. MOH recognises that the power of arrest is a serious one which should only be exercised by persons who are trained to do so. Accordingly, clauses 14 and 36, and the new section 21H of the Bill, insert an additional safeguard where only Health Officers who are public officers, officers of statutory bodies or auxiliary police officers can be authorised to arrest persons without a warrant. In addition, these officers must also be separately authorised by the Minister to exercise such powers of arrest.
II. Strengthening levers to prevent importation and exportation of infectious diseases
12. We also will be strengthening our levers to safeguard our population against the importation of disease. Global connectivity in modern times can facilitate the spread and migration of diseases. Outbreaks in one country can spread rapidly to the rest of the world. We saw that for COVID-19 and SARS. Given that Singapore is an international trade and travel hub, we remain vulnerable to the importation of emerging infectious diseases and must take the necessary precautions.
13. Many would be familiar with the concept of pre-departure testing and mask-wearing on international flights implemented during the COVID-19 pandemic. These measures were implemented through sectoral levers. As circumstances may differ in future outbreaks, clause 27 of the Bill introduces new provisions to empower the Minister to specify pre-departure or onboard health requirements which persons travelling to Singapore are required to comply with. Upon arrival, travellers may also be required to produce proof of their compliance with any pre-departure health requirement. Non-compliance with any of these requirements can give rise to an offence. Clause 27 of the Bill will provide us with the ability to impose such requirements uniformly and to take firm action against incoming travellers who do not comply with them.
14. Currently, section 31 of the IDA requires persons arriving in Singapore by air or sea to fulfil specified vaccination requirements and show proof of such vaccination. In line with the World Health Organization’s recommendations, this provision is currently applied in respect of yellow fever vaccinations for travellers from certain African and South American countries that are endemic for yellow fever. This is intended to protect Singapore against the risk of importation of the disease. To guard against new diseases and to capture all possible modalities of travel into Singapore, clause 28 of the Bill will expand section 31 to include travellers entering Singapore by land.
15. Besides strengthening our levers to prevent the importation of diseases into Singapore, Singapore should also be responsible in preventing the exportation of diseases if we are experiencing an outbreak. Therefore, clause 32 of the Bill removes the prerequisite under section 45B of the IDA for a PHE to be declared before the Minister can require persons to undergo medical examinations before leaving Singapore. Such medical examinations – also known as ‘exit-screening’ – are implemented in advance of a PHT or PHE as a key measure to prevent the cross-border spread of an infectious disease. Such measures are also line with the World Health Organization’s recommendations under the International Health Regulations.
III. Strengthening levers to prevent spread of infectious diseases within Singapore
16. Singapore is a densely populated country, and this can accelerate the spread of an infectious disease within the population. Therefore, additionally, we will be strengthening our levers to prevent disease transmission within our communities.
17. Currently, the IDA recognises three categories of persons in relation to an infectious disease - (1) actual infected ‘cases’ who have the disease; (2) ‘carriers’ who are harbouring, likely to or suspected of harbouring the disease; and (3) ‘contacts’ who have been exposed to the risk of infection from the disease. The COVID-19 pandemic showed that there may be situations where we will need to take public health measures pre-emptively for persons who do not fall within any of these three categories, but are still at higher risk of exposure to infection and onward transmission of the disease due to their unique circumstances and the nature of that particular disease.
18. Hence, clause 2 of the Bill supplements these three categories by introducing the concept of an ‘at-risk individual’. An ‘at-risk individual’ includes an individual who is or appears to the Director-General of Health or a Health Officer to be a contact or carrier of an infectious disease. Examples of such individuals include those who live in high-risk living arrangements or work in high-risk occupations where prolonged close contact with others may be unavoidable. An ‘at-risk individual’ would also include individuals entering Singapore from a country during a period when there is an outbreak or suspected outbreak in that country. Individuals who have undergone a medical examination in connection with an infectious disease but have not received a conclusive test result are also ‘at-risk individuals’. The recognition of ‘at-risk individuals’ and the application of the powers under the IDA to such individuals allow public health measures, such as testing or isolation, to be carried out at an early stage to stem the spread of an infectious disease.
19. During the COVID-19 pandemic, there were instances where persons who were served with isolation orders went about running errands or having meals, before heading home to be isolated. Such actions have heightened the risk of disease transmission. Clause 12 of the Bill introduces a new provision that makes it an offence if such persons, without reasonable cause, fail to proceed to the place of isolation as soon as possible, if the isolation order does not specify a time to do so.
20. Currently, section 21A of the IDA requires persons who know or have reason to suspect that they are a case, carrier or contact of a dangerous infectious disease to not expose others to the risk of infection in places outside of their homes. Household members inherently face higher transmission risk, and the current provision assumes that they are willing to accept such risks due to their close relationship or living arrangements with one another. However, the COVID-19 pandemic showed us that there can be varied living arrangements in Singapore where the assumption may not apply. These include co-tenants or employer-employee living arrangements. Additionally, there may also be cases where a person behaves irresponsibly inside their home to the detriment of the other household members. Hence, clause 20 of the Bill amends section 21A by additionally making it an offence to deliberately or recklessly put another person in one’s own place of residence at risk of infection by one’s own conduct. This would allow us to act against infected persons who refuse to isolate in their rooms or continue to use communal areas without taking reasonable precautions.
IV. Refinements to meet operational needs and the exercise of powers
21. Various provisions in the IDA will also be refined to meet our operational needs in managing the outbreak of infectious diseases.
22. Clause 3 of the Bill introduces a new section 2A, which provides that (1) parents or guardians of minors and (2) guardians of persons with any intellectual disability or lacking in mental capacity, may be notified of any requirement, direction, notice or order that has been issued to the person under their care. Upon receipt of such notice, the parent or guardian will be personally required to ensure that the person under their care complies with the requirement, direction, notice or order, as the case may be.
23. Currently, section 17 of the IDA requires the declaration of an isolation area to be published in the Gazette before it can take effect. Clause 14 of the Bill amends section 17 to provide that the declaration of an isolation area takes effect once it is brought to the notice of all persons who need to be aware of the declaration. This amendment will allow for the effective and timely isolation of persons within a particular area to prevent the spread of disease. For public awareness, MOH will continue to publish the declaration of an isolation area in the Gazette.
24. The IDA will also be updated to account for the latest modalities and approaches to disease management. For example, the definition of ‘medical examination’ in section 2 of the IDA will be expanded to include self-administered examinations such as antigen-rapid tests. Separately, for clarity, the service of orders and notices under the IDA using electronic means such as email and SMS will also be explicitly recognised.
25. The powers under the IDA that involve public health assessment will now reside with the Director-General of Health, instead of the Minister for Health. These amendments are in recognition that such decisions would be better suited to the professional expertise of the Director-General. These powers include imposing requirements on healthcare professionals or institutions for the purposes of investigating or preventing the spread of an infectious disease; the declaration of isolation areas; and orders to disseminate health advisories.
26. Finally, in addition to the amendments relating to outbreak response, we have also updated other sections of the IDA. MOH will be removing the requirement which circumscribes the group of persons who can perform vaccinations. The provision of vaccination, including the persons who may perform vaccinations, will be regulated under relevant levers that govern healthcare service delivery and the conduct of practitioners, such as the Healthcare Services Act 2020 and the Medical Registration Act 1997.
C. Amendment of the HIV disclosure obligation to encourage responsible testing and treatment adherence
27. Let me now discuss the proposed amendment concerning HIV. Section 23(1) of the IDA was introduced in 1992 as one of the public health measures to control and curb HIV transmission. It requires persons living with HIV to inform their sexual partners, prior to sexual activity, of the risk of contracting HIV from them and to obtain the partner’s consent to accept the risk of transmission. This allows the sexual partner to make an informed decision on whether to proceed with the sexual activity and take necessary precautions to minimise the risk of contracting HIV. In practice, doctors regularly inform patients about this legal obligation at the point of HIV diagnosis.
28. The intention of this disclosure requirement was to control the spread of HIV and deter the irresponsible behaviour of those that put others at risk of contracting HIV. The disclosure requirement remains relevant as a public health safeguard to protect the sexual partners of persons living with HIV.
29. Section 23(2) of the IDA similarly requires persons who do not know that they have HIV but have reason to believe that they may have HIV, to inform their sexual partners of the risk of infection. These safeguards remain and will continue to deter irresponsible behaviour, including from those who attempt to hide behind the ignorance of their HIV status.
30. While the safeguards are in place to deter irresponsible behaviour, it is important also for our HIV legislation to be aligned with medical advancements in HIV treatment, in order to encourage early detection and treatment of HIV. HIV remains incurable. However, with medical advancements in HIV treatment, persons living with HIV who adhere to their HIV treatment as prescribed by their doctors are now able to reduce the amount of HIV in their bodies to an undetectable level. This is referred to as having an undetectable viral load. A person who maintains a stable undetectable viral load over time, as a result of a consistent adherence to their treatment, cannot transmit HIV to their sexual partner. The sexual partner therefore is not at risk of contracting HIV from these individuals.
31. The amendment Bill introduces a provision which excludes persons living with HIV from the disclosure requirement under section 23(1), if the person has maintained an undetectable viral load for a certain period of time preceding the sexual activity in question. A person is presumed to have done so if certain conditions are met. These conditions are that the person living with HIV adhere to treatment, have stable and consistent undetectable viral load test results from a licensed laboratory in Singapore, and have an undetectable viral load test result within a specified period prior to sexual activity. More details will be set out in subsidiary legislation. This amendment aligns with medical advancements and our public health objective to curb transmission by shifting greater responsibility to individuals to get tested and treated for HIV in order to achieve and maintain a stable undetectable viral load.
32. The objectives of the amendments are to encourage individuals who are at higher risk of getting HIV to be tested regularly for HIV, and if positive, to get treated early, so that they can achieve undetectable viral load as early as possible. We urge persons living with HIV to adhere to HIV treatment and monitor their viral load closely with their doctors. In doing so, we aim to reduce the risk of HIV transmission. Singapore is not the first or only country to amend the law on this. Other jurisdictions such as Sweden, Taiwan, United States have removed the disclosure requirement for persons living with HIV who have no risk of transmitting HIV. I would like to emphasise that in proposing the amendments, we are not relaxing the public health safeguards against HIV transmission, but encouraging infected persons to come forward to be tested and treated, thereby better protecting their sexual partners. Irresponsible behaviour that can lead to the transmission of HIV remains an offence in Singapore, and appropriate enforcement action will be taken as required.
D. Conclusion
33. To conclude, I return to the primary aim behind the amendment Bill. We have sought to enhance the IDA to enable the swift prevention and control of infectious diseases, and the flexibility to calibrate our response according to the public health situation. We have ported over relevant provisions under CTMA Part 7 which served us well and updated the existing IDA provisions.
34. As experts have cautioned, the likelihood of another pathogen with even deadlier potential than COVID-19 remains. The intent behind these amendments is to better equip MOH and Singapore to tackle future outbreaks and pandemics, safeguard the lives of our people and the functioning of our healthcare system.
35. I ask for the support of all Members for this Bill. Madam Deputy Speaker, I beg to move.