H1N1 Charges

20 Jul 2009

Question No:  76  

Question

Name of the Person: Mdm Cynthia Phua

To ask the Minister for Health in light of the current outbreak of Influenza A (H1N1-2009) (a) what is the charge for calling the designated ambulance service 993; (b) what can the Ministry do to lower the related charges including the cost of testing for Influenza A (H1N1-2009) and the cost of Tamiflu; (c) whether the Ministry has a recommended guideline for fees charged by neighbourhood Pandemic Preparedness Clinics; and (d) how can the Ministry help lower income families affected by Influenza A (H1N1-2009)

Reply

Reply From MOH

1. Mdm Cynthia Phua has posed four specific questions on H1N1.  As this is the first time we are discussing the H1N1 pandemic in this House, I shall give a comprehensive reply on this subject. 

2. On Apr 24, the WHO sounded the alert on a new novel virus then circulating in Mexico and initially referred to as “the swine flu” by the media.  As pig farmers raised their objection, the new virus picked on different names, including “the Mexican flu”, “the North American flu” before the WHO settled on naming it “Influenza A (H1N1)”.  While ground zero was Mexico, the virus quickly became a global pandemic and WHO declared it as such on Jun 11.  This was of historical significance, as there were only 3 declared pandemics in the last century.

3. The initial reaction by the world was one of grave concern.  The data coming out of Mexico were serious.  They reported a very high case fatality rate of some 6.2% during the initial period.  Contrast this to the normal case fatality rate of less than 0.1% for seasonal flu.  Moreover, the casualties in Mexico were largely coming from the young adult population, including pregnant women.

4. Three months after the WHO alert, the world has learnt a lot more about this novel virus and how to cope with it.  While some serious issues remain, experts have generally come to the conclusion that this virus is behaving more like the seasonal flu: it can spread easily but the vast majority of the patients can recover fully, even without hospitalisation.  WHO has classified this disease as one with “moderate risk”.  By now, all countries have shifted their strategy from “containment”, i.e. trying to contain the spread and minimising the number of infected patients, to “mitigation”, i.e. treating the high-risk patients and minimising the number of deaths.  In line with this approach, WHO has stopped counting the number of patients and doctors are now treating the patients clinically rather than subjecting every suspect case to H1N1 laboratory testing.  Moreover, most patients are now being treated by GPs as outpatients.  Only the high-risk patients are referred to hospitals and hospitalisation is now the exception, rather than the norm.  Likewise, travel advisory, temperature screening at airports, contact tracing and home quarantine measures have by now been largely stepped down.     

5. In Singapore, we have moved our outbreak alert level from green to yellow, then briefly to orange before we moved it back to yellow.  Singaporeans have done well in this battle against the first wave of the H1N1 outbreak.  Our media have done a good job of keeping everyone informed.  There was no hysteria or panic, neither was there any complacency.  Singaporeans take the pandemic seriously, but also carry on their lives normally, going on June holidays and joining in the Great Singapore Sale.  Schools re-opened in July uneventfully and we had a successful hosting of the first Asian Youth Games, without any major incident. 

6. I want to thank all our front line staff- at the borders, in hospitals and clinics, in the laboratories, in schools, childcare centres, Aloha and Pasir Ris holiday chalets, in 993 and 995 ambulances, in hotline call centres- for their dedication and diligence.  They do their jobs seriously and put up with the discomfort of wearing N95s and surgical gowns.  Many had their own travel plans cancelled and many worked long hours, putting on extra shifts to cope with the sudden surge in number of suspect cases and patient load.

7. I want to thank Singaporeans for their sense of social responsibility.  Temperature scanners at the borders picked up 25% of the returned travellers with H1N1.  The other 75% slipped through the borders because they had no symptoms at arrival, but promptly came forward to be tested when symptoms emerged.  Many had to suffer long, agonising and uncomfortable waiting under the tent outside the hospital Emergency Department while their laboratory tests were being processed.  I thank them for their patience and tolerance.

8. After Mexico, US and Canada went into community spread of the virus almost immediately.  They had to move straight into the mitigation phase.  In Asia, some countries went into community spread after a month, despite very strong containment measures.  Singapore was into community spread after 7 weeks.  We were lucky but the efforts jointly put in by all Singaporeans must have contributed to this outcome.

9. The 7-week lag was valuable.  It allowed us to better prepare our people psychologically for the eventual community outbreak.  It allowed us to gear up our Pandemic Preparedness Clinics (PPCs) and our hospitals to free up isolation and ICU beds to treat the more complicated cases.   

10. We are now in the last leg of our battle against the first wave of the H1N1 outbreak.  But the war is not over yet.  The enemy is still out there.  Going by the experience elsewhere, more Singaporeans will get infected, reaching a peak before the numbers start to decline, as in New York where the wave peaked in May – June and has been declining since.  Experts refer to this phenomenon as the community acquiring “herd immunity”.

11. We track this development by a robust surveillance system of sampling patients with flu-like symptoms and determining the precise cause of their symptoms.  Prior to community spread, none of the samples revealed any patient with positive H1N1.  Four weeks ago, the surveillance system showed that 13% of the samples were found to be H1N1 positive.  The figure moved up to 30% two weeks ago.  The latest data showed that 53% of patients with flu-like symptoms had been infected with H1N1.  This number will continue to grow as the H1N1 strain displaces the other influenza strains and becomes the dominant strain for this season.

12. As the current virus strain is mild, this development is largely benign as almost all patients will fully recover.  But there will be complications among some high risk patients and even deaths.  The overall risk of death is similar to normal seasonal flu, but the risk groups are slightly different.  In normal flu, those over 65 years old are at highest risk along with the very young, under 2.  But in this flu, younger adults are at higher risk than those over 65, if they have underlying medical problems, such as chronic problems with breathing, gross obesity, low immunity or are pregnant.

13. That is why we are still in yellow alert.  Over the past few days, we have stepped down many control measures, at the borders, at mass events, in factories and in offices.  Temperature taking remains in schools and army camps.  The influenza surveillance data suggest that H1N1 prevalence should peak within a week or two and we can expect to step down temperature taking in schools from Aug 1.  For SAF camps, they will step down their control measures appropriately, in accordance with their specific operational needs.  However, our hospitals remain on high vigilance and we continue to discourage visitation and remind all to practice infection control measures.

14. During this phase of the outbreak, there are three priorities.  First, we are focusing on the high-risk patients and helping them enhance their chance of a full recovery.  These are patients with underlying medical conditions, where the experience elsewhere suggests that they may face complications, including deaths.  We have a few cases already. They had to be admitted to ICU for intensive care.  With effective treatment, a couple have fully recovered.  But one with a severe heart disease had succumbed to heart attack, with H1N1 infection as well. We need patients to come forward promptly, and not wait until their symptoms have become too serious to reverse. 

15. Second, we are reviewing our control measures in the past 3 months.  There are valuable lessons to extract from this experience and we must plug any gaps and deficiency.

16. Third, we are preparing Singapore for the next wave of H1N1.  Experts believe that the next wave may come when winter returns to the northern hemisphere and worry that the virus may be more deadly then.  This is not a certainty, as viruses mutate all the time and they often attenuate and become less deadly.  While we hope for the best, we must always prepare for the worst. 

17. An important aspect of the preparation is to ensure we have access to an adequate supply of a safe and effective vaccine.  None exists today though there are many claims by vaccine manufacturers of such a supply before year end.  We have an ongoing contract with an established vaccine manufacturer for a pandemic vaccine sufficient for our population.  We are supplementing this contract with an order for 1 million doses from the vaccine manufacturer who can promise the quickest delivery. 

18. But we should not put all our eggs in the vaccine basket.  Any vaccine based on the current mild strain may not be effective if the virus turns more deadly.  And if the virus remains mild, there may be little demand for such a vaccine.

19. Instead, the most basic strategy against an influenza pandemic is a high standard of personal hygiene by all Singaporeans.  This can be learnt by all and incorporated into our daily life.  Singaporeans must also learn the sound habit of staying at home and away from crowds when unwell and have a runny nose, fever or cough.  It is no fun falling sick and we must not inflict this on others around us.  And if you must go out, please put on a surgical mask.

20. Let me now address the specific queries by Mdm Cynthia Phua.  Calls to 993 ambulance service were not charged.  As the demand for 993 has shrunk considerably, we will be winding up the service. 

[Note: The winding up is scheduled for 21 July.  Callers will hear an automated message telling them to visit their nearest GP or PPC in the symptoms are mild, or to call 995 if they have severe symptoms.]

21. The laboratory testing of H1N1 is costly, at about $250 per test, but MOH absorbs the cost in full.  Tamiflu is affordable, at $45 for a standard treatment cycle, and is chargeable, in line with our philosophy of co-payment. 

22. We do not regulate the charges by PPCs but generally our GPs are price competitive and their fees are largely affordable.  Those who need subsidised care can get it at polyclinics. Let me assure Members that the lower-income families with H1N1, or for that matter, any other disease, will all be helped, if they have difficulty paying their medical bills.  Medisave, MediShield and Medifund are designed for this purpose.