Causative Agents TYPHUS Rickettsia typhi (murine typhus) and Orientia tsutsugamushi (scrub typhus). Causative Agents IncubationRickettsia typhi Period (murine typhus) and Orientia tsutsugamushi (scrub typhus). 1 to 3 weeks Incubation Period Infectious1 to 3 weeks Period Zoonoses with no human-to-human transmission. Infectious Period TransmissionZoonoses with no human-to-human transmission. Scrub typhus: Bite of grass mites (larval trombiculid mites) MurineTransmission typhus: Bite of rat fleas (also cat and mice fleas) RodentsScrub typhus: are the Bite preferred of grass and mites normal (larval hosts. trombiculid mites) Murine typhus: Bite of rat fleas (also cat and mice fleas) EpidemiologyRodents are the preferred and normal hosts. Distributed throughout the Asia-Pacific rim and is a common cause of pyrexia of unknownEpidemiology origin throughout SE Asia. Occupational contact with rats (e.g. construDistributedction throughout workers in the makeAsia-Pshiftacific container rim and isfacilities, a common shop cause owners, of pyrexia granary of workers,unknown and origin garbage throughout collectors) SE or Asia. exposure Occupational to mite habitat contacts in lonwithg grass rats (e.g. hikersconstru andction so ldiers) workers are inrisk make factors.-shift container facilities, shop owners, granary workers, and garbage collectors) or exposure to mite habitats in long grass (e.g. hikersIn Singapore, and soldiers) a total are ofrisk 13 factors. laboratory confirmed cases of murine typhus were r eported in 2008. The majority of cases were foreign workers. In Singapore, a total of 13 laboratory confirmed cases of murine typhus were Clinicalreported Featuresin 2008. The majority of cases were foreign workers. Fever Clinical Headache Features (prominent) MyalgiaFever ConjunctiHeadache val(prominent) suffusion MaculopapularMyalgia rash Conjunctival suffusion Scrub Maculopapular typhus may alsorash have: relative bradycardia, eschar (80%), painful regional adenopathy, hepatosplenomegaly, meningoencephalitis and renal failure. Scrub typhus may also have: relative bradycardia, eschar (80%), painful regional Murineadenopathy, typhus hepatosplenomegaly, is generally a mild meningoencephalitisinfection. Untreated andscrub renal typhus failure. has appreciable mortality. Murine typhus is generally a mild infection. Untreated scrub typhus has appreciable Investigationsmortality. White cell count is usually normal (may be leucopoenic). Investigations Thrombocytopenia is common. LiverWhite function cell count tests is usuallymay show normal mild (may elevation be leucopoenic). of transaminases. Thrombocytopenia is common. Liver function tests may show mild elevation of transaminases.
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Mild hyponatraemia. Rickettsial-specific serological diagnosis is available. Ideally, blood is collected Mildas early hyponatraemia. in the course of disease as possible and a second sample collected after 1Rickettsial-2 weeks -(diagnosticspecific serological titres are diagnosispresent in is approximately available. Ideally, 50% bloodof murine is collected typhus aspatients early inwithin the course 1st week of anddisease almost as possible all patients and within a second 15 sampledays of collectedonset of after 1il-l2ness). weeks (diagnostic titres are present in approximately 50% of murine typhus Thepatients Weil within-Felix 1 testst week depends and almost on similarity all patients between within antigens15 days of of onsetRickettsia of and Proteusillness). spp. and is not recommended as Rickettsia-specific tests are now avaiThe lable. Weil -TheFelix OX19 test depends(at a cut on-off similarity of 1/160) betweenis fairly antigensspecific for of murineRickettsia typhus and butProteus not asspp. sensitive and is as not EIA. recommended The OXK (scrub as Rickettsia typhus)-specific in local tests experience are now is avaiparticlable.ularly The prone OX19 to cross (at a- reactionscut-off of with 1/160) other is diseasesfairly specific like dengue. for murine typhus but not as sensitive as EIA. The OXK (scrub typhus) in local experience is Notificationparticularly prone to cross-reactions with other diseases like dengue. Not a notifiable disease. Inform Ministry of Health (Form MD131 or electronically Notificationvia CD-LENS) if outbreak suspected. Not a notifiable disease. Inform Ministry of Health (Form MD131 or electronically Managementvia CD-LENS) if outbreak suspected. Doxycycline 100 mg bd x 5-10 days or for > 3 days after defervescence occurs Management(fever should usually resolve within 72 hours of treatment initiation). (Alternative)Doxycycline 100 Ciprofloxacin mg bd x 5 -10 500mg days or bd forx >5 -310 days days after or defervescence for > 3 days occurs after defe(feverrvescence should usually occurs .resolve within 72 hours of treatment initiation). Pregnant(Alternative) women Ciprofloxacin or allergy/intolerance 500mg bd to xdoxycycline: 5-10 days PO or azithromycin for > 3 days 500mg after asdefe a rsinglevescence dose occurs. . Pregnant women or allergy/intolerance to doxycycline: PO azithromycin 500mg Preventionas a single and dose Control. Urban and domestic rat control. Prevention Protective and clothing Control from occupational exposure to rat fleas or mites in long grUrbanass. and domestic rat control. InsectProtective repellents clothing and frommiticides occupational i.e. N,N -diethyl exposure-3- methylbenzamide to rat fleas or mites (DEET) in long are effectivegrass. when applied to both clothing and skin. Insect repellents and miticides i.e. N,N-diethyl-3-methylbenzamide (DEET) are Referenceseffective when applied to both clothing and skin. 1. Ong AK, Tambyah PA, Ooi S et al. Endemic typhus in Singapore—a re-emerging infectious Referencesdisease? Singapore Med J. 2001; 42:549-52 2. Chen MI, Chua JK, Lee CC et al. Epidemiological, clinical and laboratory characteristics of 19 1. Ong AK, Tambyah PA, Ooi S et al. Endemic typhus in Singapore—a re-emerging infectious serologically confirmed rickettsial disease in Singapore. Singapore Med J. 2001; 42:553-8 disease? Singapore Med J. 2001; 42:549-52 3. Civen R, Ngo V. Murine typhus: An unrecognised suburban vector borne disease. Clin Infect Dis. 2. Chen MI, Chua JK, Lee CC et al. Epidemiological, clinical and laboratory characteristics of 19 2008;46:913-8. serologically confirmed rickettsial disease in Singapore. Singapore Med J. 2001; 42:553-8 4. Kim YS, Lee HJ, Chang M et al. Scrub typhus during pregnancy and its treatment: a case series and 3. Civen R, Ngo V. Murine typhus: An unrecognised suburban vector borne disease. Clin Infect Dis. review of the literature. Am J Trop Med Hyg 2006;75:955-9 2008;46:913-8. 4. Kim YS, Lee HJ, Chang M et al. Scrub typhus during pregnancy and its treatment: a case series and review of the literature. Am J Trop Med Hyg 2006;75:955-9
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VIRAL HEPATITIS
Causative Agent VIRAL HEPATITIS Hepatovirus (hepatitis A), orthohepadnavirus (hepatitis B), hepacivirus (hepatitis CCausative), deltavirus Agent (hepatitis D) and hepevirus (hepatitis E). Hepatovirus (hepatitis A), orthohepadnavirus (hepatitis B), hepacivirus (hepatitis IncubationC), deltavirus Period (hepatitis D) and hepevirus (hepatitis E). See Table. Incubation Period InfectiousSee Table. Period See Table. Infectious Period TransmissionSee Table. See Table. Transmission Epidemiology See Table. Hepatitis A, B, C and E are endemic in Singapore. Epidemiology AHepatitis total of A, 253 B, casesC and ofE areserologically endemic in confirmed Singapore. acute viral hepatitis were reported in 2009. Of these, 111 (44%) were imported. There were 89 cases of hepatitis A (35%),A total 69of 253cases cases of hepatitis of serologically B (27%), confirmed 5 cases of acute hepatitis viral C hepatitis (2%) and were 90 reportedcases of hepatitisin 2009. EOf (36%). these, No111 deaths (44%) were were reported. imported. There were 89 cases of hepatitis A (35%), 69 cases of hepatitis B (27%), 5 cases of hepatitis C (2%) and 90 cases of Clinicalhepatitis FeaturesE (36%). No deaths were reported.
Fever Clinical Anorexia, Features nausea, vomiting RightFever hypochondrial pain JaundiceAnorexia, nausea, vomiting DarkRight urine,hypochondrial pale stools pain HepatomegalyJaundice Dark urine, pale stools See TableHepatomegaly for description of sequelae.
InvestigationsSee Table for description of sequelae. Common biochemical abnormalities shared by the viral hepatitides: Investigations Leucopenia Common Urine biochemical urobilin, urobilinogen abnormalities shared by the viral hepatitides: RaisedLeucopenia serum bilirubin and transaminase levels (ALT > AST) RaisedUrine urobilin, gamma- urobilinogenGT Raised serum bilirubin and transaminase levels (ALT > AST) Raised gamma-GT
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Investigations (See Table) . Hepatitis A: IgM antibodies become detectable when jaundice develops Investigationsand persist (Seefor approximately Table) 3 months. . Hepatitis B: A: In IgM acute antibodies hepatitis becomeB, HBsAg detectable is present when in serum. jaundice However, develop its isand also persist present for approximately in long-term 3 carriersmonths. of HBV. The diagnosis of acute . diHepatitissease is B: confirmed In acute hepatitisby demonstrating B, HBsAg IgM is presentanti-HBc in serum.antibody However, in serum. it Thisis also appears present 2 weeksin long after-term HBsAg carriers and of disappears HBV. The a diagnosis few months of acute after diuncoseasemplicated is confirmed infection. by demonstrating IgM anti-HBc antibody in serum. . HCV:This appears Diagnosis 2 weeks depends after on HBsAg the detection and disappears of antibodies a few to months recombinant after antigensuncomplicated and detection infection. of viral RNA (e.g. by PCR techniques). . HCV: Diagnosis depends on the detection of antibodies to recombinant Notificationantigens and detection of viral RNA (e.g. by PCR techniques). A legally notifiable disease in Singapore. Notify Ministry of Health (Form MD 131 orNotification electronically via CD-LENS) not later than 72 hours from the time of diagnosis. A legally notifiable disease in Singapore. Notify Ministry of Health (Form MD 131 or electronically via CD-LENS) not later than 72 hours from the time of diagnosis. Management There is no specific anti-viral therapy indicated for acute viral hepatitis. ManagManagementement is symptomatic and supportive. Treatment is available for chronic carriersThere isof hepatitis no specific B and anti C. -Considerviral therapy referral indicated to a hepatologist. for acute viral hepatitis. Management is symptomatic and supportive. Treatment is available for chronic Infectioncarriers of Controlhepatitis B and C. Consider referral to a hepatologist. Contact precautions should be observed for hepatitis A and E. UniversalInfection Controlprecautions should be observed for hepatitis B, C and D. Contact precautions should be observed for hepatitis A and E. PreventionUniversal precautions and Control should be observed for hepatitis B, C and D. Hepatitis A Prevention. andAll Controlsusceptible persons travelling to or working in countries that have Hepatitis highA or intermediate hepatitis A endemicity should be vaccinated. . AllOne susceptible dose of monovalent persons travelling vaccine (HAVRIXto or working 0.5mL in countries for 1-18 thatyears have old highand 1.0mL or intermediate for ≥ 19 yearshepatitis old) A should endemicity be administered should be vaccinated.any time before . departureOne dose of (ideally monovalent with vaccine IG if given (HAVRIX ≤ 2 0.5mL weeks for for 1- older18 years adults, old immunocompromisedand 1.0mL for ≥ 19 years persons old) should and personsbe administered with chronic any time medical before conddepartureition). (ideally with IG if given ≤ 2 weeks for older adults, . Completionimmunocompromised of vaccination persons (2nd dose and at persons 6-12 months) with chronic is necessary medical for condlong itermtion). protection. nd . CompletionTravellers who of vaccination are less than (2 12dose months at 6-12 of months) age, are is necessary allergic to for a valongccine term component, protection. or who otherwise elect not to receive vaccine . Travellersshould receive who a are single less thandose 12 of IGmonths (0.02mL/kg), of age, are which allergic provides to a vaeffectiveccine component,protection agains or whot HAV otherwise infection elect for up not to to 3 months. receive vaccine . shouldBoiling receiveor cooking a single food and dose beverage of IG (0.02mL/kg),for at least 1 whichminute providesto 85°C effectiveinactivates protection HAV. against HAV infection for up to 3 months. . Boiling or cooking food and beverage for at least 1 minute to 85°C inactivates HAV.
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Contact tracing of the source of infection and the mode of transmission will be carried out for acute cases. In common source outbreaks of hepatitis A, special Contactattention tracing will be of given the sourceto contaminated of infection food, and especially the mode importedof transmission shellfish. will be carried out for acute cases. In common source outbreaks of hepatitis A, special Hepatitisattention willB be given to contaminated food, especially imported shellfish. . Vaccination against Hepatitis B is routinely given to all newborns Hepatitis (seeB Childhood Immunisation Programme in Appendix 2), healthcare . Vaccinationpersonnel and against other population Hepatitis Bgroups is routinely at risk. given Seronegative to all newborns contacts (seeof acute Childhood hepatitis Immunisation B cases and carriersProgramme should in alsoAppendix be vaccinated. 2), healthcare . Anpersonne acceleratedl and other vaccine population schedule groups could atbe risk.used Seronegativefor those travelling contacts to endemicof acute hepatitisareas at Bshort cases notice and carriersand facing should imminent also be exposurvaccinated.e because . Anof behavioural accelerated risksvaccine or to schedule emergency could responders be used forto disaster those travelling areas. The to endemicmonovalent areas hepatitis at short B notice vaccine and canfacing be usedimminent at 0, exposur 7, and e 14because days. Pofa tientbehavioural should receiverisks or ato booster emergency at least responders 6 months to after disaster the areas.start of The the vaccinationmonovalent series. hepatitis B vaccine can be used at 0, 7, and 14 days. . PPreventionatient should of hepatitisreceive a Bbooster requires at leastthe use 6 months of disposable after the needles start of andthe vaccinationsyringes and series. use of sterile equipment for parenteral injections, . Preventionacupuncture, of tattooing hepatitis andB requires other procedures the use of where disposable skin is needles punctured. and syringesObserving and universal use of precautions sterile equipment is the cornerstone for parenteral of prevention injections, in theacu puncture,healthcare tattooing setting. and other procedures where skin is punctured. TransfusionObserving hepatitis universal B and C are precautions prevented is by the screening cornerstone of blood of prevention donors. in Post-Exposurethe healthcare Management setting. (See Table). NotifyTransfusion all childhood hepatitis B hepatitis and C are B prevented vaccinations by screening to the National of blood Immunisation donors. Registry,Post-Exposure Health Management Promotion (See Board, Table). and post-vaccination adverse reactions to theNotify Pharmacovigilance all childhood hepatitis Branch, Health B vaccinations Sciences toAuthority the National. Immunisation Registry, Health Promotion Board, and post-vaccination adverse reactions to the Pharmacovigilance Branch, Health Sciences Authority.
References 1. CDC. Prevention of hepatitis A through active or passive immunization: Recommendations of the ReferencesAdvisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1. CDC.2006;55(RR07):1 Prevention -of23. hepatitis A through active or passive immunization: Recommendations of the 2. AdvisoryMinistry of Health. Committee Hepatitis on B Immunizationimmunisation: long Practices-term immunogenicity (ACIP). MMWR of low dose Recomm yeast- derived Rep. recombinant2006;55(RR07):1 hepatitis-23. B vaccine. Epidemiol News Bull 2010;36:46-52. 3.2. ChowMinistry WC,Tien of Health. SL, Hepatitis Tan CK etB al.immunisation: Treatment of long chronic-term hepatit immunogenicityis C in patients of low with dose end yeast-stage-derived renal recombinantdisease and haemophilia hepatitis B vaccine.- the Singapore Epidemiol experience. News Bull Intervirology 2010;36:46 2006;-52. 49: 107-11. 3.4. ChowWinslow WC,Tien M, Subramaniam SL, Tan CK M, et Ngal. TreatmentWL et al. Seroprevalence of chronic hepatit of ishepatitis C in patients C in intravenous with end-stage opioid renal diseaseusers presenting and haemophilia in early phase- the Singapore of injectin experience.g drug use inIntervirology Singapore. Sing2006; Med 49: J107 2007;48:504-11. -8. 5.4. HongWinslow WW, M, Ang Subramaniam LW,Cutter M, J et Ng al. WL Changing et al. Seroprevalence seroprevalence of of hepatitis hepatitis C B in virus intravenous markers opioidof adults inusers Singapore presenting. Ann in Acaearlyd Medphase Singapore of injectin 2010;39:591g drug use in-8. Singapore. Sing Med J 2007;48:504-8. 5. Hong WW, Ang LW,Cutter J et al. Changing seroprevalence of hepatitis B virus markers of adults in Singapore. Ann Acad Med Singapore 2010;39:591-8.
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CLINICALCLINICAL FEATURES FEATURES OF COMMON OF COMMON VIRAL VIRAL HEPATITIS HEPATITIS
IncubationIncubation Infectious Infectious LaboratoryLaboratory HepatitisHepatitis Period Period PeriodPeriod ClinicalClinical Sequelae Sequelae TransmissionTransmission Route Route DiagnosisDia gnosis RemarksRemarks A A 15 - 5015 days - 50 days2 - 3 weeks2 - 3 weeksNo chronicNo chronic sequelae. sequelae. Food andFood water and bornewater borne Anti-HAVAnti -IgMHAV + IgMPEP/vaccine + PEP/vaccine before beforeand 1 and 1 availableavailable week afterweek after onset ofonset of jaundicejau ndice B B 45 - 16045 days - 160 daysMany weeksMany weeksSequelae Sequelae of chronic of chronic HBV HBV Blood Bloodand body and fluids, body fluids, HBsAgHBsAg +, +, PEP/vaccinePEP/vaccine before beforeonset ofonset infe of ctioninfe includesction includes liver cirrhosis, liver cirrhosis, parenteral, parenteral, perinatal, perinatal, sexual sexualHBeAg HBeAg +/-, +/-, availableavailable symptomssymptoms to tochronic chronic active activehepatitis hepatitis (CAH), (CAH), Anti-HBcAnti IgM-HBc + IgM + monthsmonths or or chronicchronic persistent persistent hepatitis hepatitis (CAH,(CAH, CPH CPH
136 136 years afteryears after (CPH)(CPH) and hepatocellular and hepatocellular diagnoseddiagnosed by by jaundicejaundice in in carcinomacarc i(HCC)noma (HCC) as well as as well as liver biopsy)liver biopsy)
chronicchronic carriers carriers hepatitis hepatitis D superinfection. D superinfection. HBV DNAHBV PCRDNA PCR + + C C 2 - 15 weeks2 - 15 weeksAs in HBVAs in HBVSequelae Sequelae of chr onicof chr HCVonic HCV Blood Bloodand body and fluids, body fluids, Anti-HCVAnti -IgGHCV + IgGNo + PEP/ No vaccine PEP/ vaccine infectioninfe includesction includes HCC, CAH,HCC, CAH,pa renteral,parenteral, perinatal perinatal HCV PCRHCV + PCR + availableavailable CPH andCPH liver and cirrhosis. liver cirrhosis. (uncommon),(uncommon), sexual sexual(not well (not well defined)defined) D D 2 - 8 weeks2 - 8 weeksAs in HBVAs in HBVSimultaneous Simultaneous infection infection with with As in HBV;As in HBV;co-infection co-infection with withAnti -HDVAnti -IgM+HDV IgM+Vaccine Vaccine to to HBV anHBVd HDV and mayHDV lead may to lead to HBV orHBV super or- infectionsuper-infection in a in anda IgG+and IgG+ preventprevent HBV HBV severe severeor fulminant or fulminant hepatitis. hepatitis. chronic chronic HBV carrier. HBV carrier. infectioninfe ction E E 4 - 8 weeks4 - 8 weeksAs in HAVAs in HAVNo chronicNo chronic sequelae. sequelae. Higher Higher Mainly Mainly water- bornewater- borne Anti-HEVAnti -IgHEV M + Ig NoM +PEP/vaccine No PEP/vaccine incidenceincidence of fulm ofinant fulm diseaseinant disease availableavailable than hepatitisthan hepatitis A. High A. mortality High mortality in pregnantin pregnant women. women. HAV -HAV Hepatitis - Hepatitis A virus A virus HCV -HCV Hepatitis - Hepatitis C virus C virus HEV -HEV Hepatitis - Hepatitis E virus E virus HBV -HBV Hepatitis - Hepatitis B virus B virus HDV -HDV Hepatitis - Hepatitis D virus D virus PEP - PEPPost - -Exposure Post-Exposure Prophylaxis Prophylaxis RECOMMENDATIONSRECOMMENDATIONS FOR FORHEPATITIS HEPATITIS B PROPHYLAXIS B PROPHYLAXIS FOR FORHCW HCW FOLLOWING FOLLOWING PERCUTANEOUS PERCUTANEOUS EXPOSUREEXPOSURE
WhenWhen source source is found is foundto be :to be : ExposedExposed HCW HCW HBsAgHBsAg + + HBsAgHBsAg UnknownUnknown UnvaccinatedUnvaccinated AdministerAdminister HBIGx HBIGx1 and 1initiate and initiate Initiate Initiate HB vacc HBin vacce inInitiatee Initiate HB vacc HBine vacc ine HB vaccHBine vacc ine PreviouslyPreviously vaccinated vaccinated Test exposedTest exposed person person for anti for-HBs anti -HBs . Known. Known responder responder 1. Adequate,1. Adequate, no prophylaxis no prophylaxis No prophylaxisNo prophylaxis No prophylaxisNo prophylaxis 2. Inadequate,2. Inadequate, HB vacc HBine vacc ine boosterbooster dose dose 137 137 . Known. Known non- non- RevaccinateRevaccinate If highIf- riskhigh source,-risk source, may treat may as treat if as if
responderresponder HBIGHBIG plus 1 plus dose 1 of dose HB of vacc HBine vacc ine sourcesource were HBsAgwere HBsAg + + to startto new start course new course of HB of HB vaccinationvaccination RevaccinateRevaccinate Test exposedTest exposed person pers foron anti for-HBs anti -HBs . Response. Response unknown unknown 1. Adequate,1. Adequate, no prophylaxis no prophylaxis Test exposedTest exposed person person for anti for-HBs anti -HBs 2. Inadequate,2. Inadequate, HB vacc HBine vacc ine 1. Adequate,1. Adequate, no prophylaxis no prophylaxis boosterbooster dose dose 2. Inadequate,2. Inadequate, HBIG HBIG plus HB plus HB vaccinevacc boosterine booster dose dose
HBIGHBIG - Hepatitis - Hepatitis B Immune B Immune Globulin Globulin dose 0.06 dose ml/Kg 0.06 ml/Kg intramuscularly intramuscularly AdequateAdequate anti-HBs anti is-HBs > 10 is mIU > 10/ml mIU /ml RecommendedRecommended for HCW for HCWis > 100 is >mIU 100/ml mIU /ml BoosterBooster is recommended is recommended if < 100 if
YELLOW FEVER AND OTHER VIRAL HAEMORRHAGIC FEVERS
YELLOW FEVER
YELLOW FEVER Causative Agent Yellow Fever Virus (YFV) Causative Agent YellowIncubation Fever Period Virus (YFV) 3 - 6 days Incubation Period Infectious3 - 6 days Period Initial 5 days of illness. Infectious Period InitialTransmission 5 days of illness. Vector-borne transmission occurs via bite of an infected mosquito, primarily Aedes Transmissionor Haemogogus spp. Nonhuman and human primates are the main reservoirs of the Vectorvirus; anthroponotic-borne transmission (human occurs-to-vector via -bitto-ehuman) of an infected transmission mosqui occurs.to, primarily Aedes or Haemogogus spp. Nonhuman and human primates are the main reservoirs of the Threevirus; anthroponoticmain transmission (human cycles:-to-vector -to-human) transmission occurs. . The sylvatic (jungle) cycle involves transmission of the virus between non- Three mainhuman transmission primates cycles:and mosquito species found in the forest canopy and . suThebsequent sylvatic transmission (jungle) cycle to involveshumans whentransmission they encroach of the virusinto the between jungle non - humanduring occupationalprimates and andmosquito recreational species activities. found in the forest canopy and . Thesubsequent intermediate transmission (savannah) to humans cycle in when Africa they involves encroach transmission into the jungle of YFV fromduring monkeys occupational to hole and-breeding recreational Aedes activities. spp to humans working or living in . Thejungle intermediate border areas. (savannah) cycle in Africa involves transmission of YFV . fromThe urban monkeys cycle to involves hole-breeding transmission Aedes sppof the to virushumans between working humans or living and in jungleurban mosquitoes,border areas. primarily Ae. aegypti. . The urban cycle involves transmission of the virus between humans and Humans urbaninfected mosquitoes, by YFV experienprimarilyce Ae. high aegypti levels. of viraemia making blood-borne transmission possible (via transfusion, needle stick, and intravenous drug abuse) Humans infected by YFV experience high levels of viraemia making blood-borne transmissionEpidemiology possible (via transfusion, needle stick, and intravenous drug abuse) Yellow fever occurs in sub-Saharan Africa and tropical South America, where it is endemicEpidemiology with intermittent epidemics. In Africa, natural immunity increases with age,Yellow thus fever infants occurs and childrenin sub-Saharan are at greatest Africa andrisk tropicalfor disease. South America, where it is endemic with intermittent epidemics. In Africa, natural immunity increases with age,The incidencethus infants world and -childrenwide has are increased at greatest due risk to recurrentfor disease. epidemics in several West African cities. The incidence world-wide has increased due to recurrent epidemics in several West African cities.
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Clinical Features Suspect in a febrile traveller who has been to a YF endemic country during the Clinicalpreceding Features 6 days and has not been vaccinated against the disease. TheSuspect clinical in a febrile spectrum trav ofeller yellow who feverhas been includes to a YF subclinical endemic infection;country during abortive the precedingnon-specific 6 days febrile and illness has not without been vaccinated jaundice; against and life the threatening disease. illness with fever,The clinical jaundice, spectrum renal failure of yellow and hemorrhage. fever includes subclinical infection; abortive Aboutnon-specific 1 in 5 febrile- 20 infections illness withoutresult in jaundice; clinical disease and life with threatening jaundice, illnessthe rest with are abortivefever, jaundice, or subclinical. renal failure and hemorrhage. ThreeAbout phases1 in 5 -of 20 disease infections: result in clinical disease with jaundice, the rest are abortive1. Early or phasesubclinical. - Viremic stage characterised by fever, chills, headache, Threebac phaseskache, of myalgia, disease: prostration with bradycardia, conjunctival injection and 1. coatedEarly phasetongue. - Viremic stage characterised by fever, chills, headache, 2. Periodbackache, of myalgia, “remission” prostration occurring with over bradycardia, next several conjunctival days with injection transient and recoverycoated tongue. and remission of fever lasting up to 48 hours. Patients with 2. aboPeriodrtive of infections “remission” recover occurring at this over stage. next Approximately several days 15with percent transient of individrecoveryuals and infected remission with YFV of fever enter lasting the third up stage to 48 of hours.the disease. Patients with 3. Periodabortive of infections“intoxication” recover begins at thison the stage. 3rd to Approximately the 6th day of 15infection percent with of individuals infected with YFV enter the third stage of the disease. increasing systemic symptoms, jaundice,rd albuth minuria, oliguria, 3. haemoPeriod rofrhagic “intoxication” complications begins (black on thevomit), 3 to delirium, the 6 day stupor, of infection acidosis withand increasingshock. systemic symptoms, jaundice, albuminuria, oliguria, Casehaemo-fatalityrrhagic rate is complications 20 - 50 % between (black the vomit), 7th and delirium, 10th day after stupor, onset. acidosis and shock. The differential diagnoses are varied; viralth hepatitis,th leptospirosis, malaria, Casetyphoid-fatality and other rate isviral 20 -haemorrhagic 50 % between fevers the 7 need and to 10 be dayexcluded. after onset. The differential diagnoses are varied; viral hepatitis, leptospirosis, malaria, Investigationstyphoid and other viral haemorrhagic fevers need to be excluded. Leucopoenia, thrombocytopenia Investigations Elevated direct bilirubin, transaminases, urea, creatinine HypoglycaemiaLeucopoenia, thrombocytopenia SpecificElevated diagnosisdirect bilirubin, by: transaminases, urea, creatinine Hypoglycaemia. viral isolation from blood or tissue specimens. Specific. identification diagnosis ofby: viral antigen or nucleic acid in tissues (including liver) . uviralsing isolation immunohistochemistry from blood or tissue (IHC), specimens. enzyme- linked immunosorbent assay . ide(ELISA)ntification antigen of capture, viral antigen or polymerase or nucleic chain acid reaction in tissues tests. (including liver) . serologicalusing immunohistochemistry diagnosis by IgM(IHC), antibodyenzyme- linked capture immunosorbent (ELISA), histoassay- immunochemistry(ELISA) antigen capture, or complement or polymerase fixation chain tests reaction (CFT). tests. . serological diagnosis by IgM antibody capture (ELISA), histo- Locally, aimmunochemistry complement fixation or complement test to the flavivirusesfixation tests group (CFT). can be done. Positive results in the appropriate clinical setting may be suggestive but not confirmatory. Locally, a complement fixation test to the flaviviruses group can be done. Positive results in the appropriate clinical setting may be suggestive but not confirmatory.
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Notification A legally notifiable disease in Singapore. Notify Ministry of Health (Form MD 131 orNotification electronically via CD-LENS) not later than 24 hours from the time of diagnosis. ACall legall MOHy notifiable Communicable disease Diseases in Singapore. Surveillance Notify Ministryteam at :of 98171463 Health (Form as soon MD as 131 the diagnosisor electronically is suspecte via d.CD -LENS) not later than 24 hours from the time of diagnosis. Call MOH Communicable Diseases Surveillance team at : 98171463 as soon as the Managementdiagnosis is suspecte d. Suspected patients will be isolated at CDC. Treatment is symptomatic and Managementsupportive and directed at the management of the complications of YF. ThereSuspected is no patients specific will anti be-viral isolated therapy. at CDC. Treatment is symptomatic and supportive and directed at the management of the complications of YF. Prevention There is and no specificControl anti -viral therapy. YF vaccine consists of a live attenuated virus preparation. A single Preventionsubcutaneous and Control injection of 0.5 ml of reconstituted vaccine offers protection forYF vaccine up to 10 consists years. of The a live International attenuated Health virus preparation. Regulations A require single subcrevaccinationutaneous injection at intervals of 0.5 of ml 10 of years. reconstituted Recommended vaccine onlyoffers for protection persons olderfor up tha n to 9 months 10 years. of age. The It offers International > 95% protection. Health Regulations require Anyrevaccination disembarking at intervals passenger of suspected 10 years. to Recommended be infected will only be fortransferred persons immediatelyolder than 9 monthsto the CDC of age. for It isolation. offers > 95% protection. DuringAny disembarking the acute phase passenger of the suspected infection, to the be patientinfected should will be be transferred protected fromimmediately mosquito to the bites CDC to for avoisolation.id spread of the infection. Universal Duringprecautions the against acute phase blood/body of the fluids infection, and sharps the patient should should be in place. be protected Epidemicfrom mosquito control bitesmeasures to include avoid spreadmosquito of control the infection. with special Universalattention givenprecau totions airports, against hospitals blood/body and fluids the homes and sharps and vicinityshould be of in the place. confirmed aEpidemicnd suspected control cases. measures All contactsinclude mosquito and health control personnel with special will need attention to be vaccinatedgiven to airports, and kept hospitals under surveillance. and the homes and vicinity of the confirmed Theand suspected public and cases. the World All contacts Health Organisationand health personnel will be informedwill need of to allbe suvaccinatedspected and and confirmed kept under cases. surveillance. The public and the World Health Organisation will be informed of all su spected and confirmed cases. References 1. CDC Health Information for International Travel 2010. The Yellow Book: Available at Referenceshttp://wwwnc.cdc.gov/travel/yellowbook/2010/table -of-contents.aspx. Accessed Dec 2010. 2. WHO Yellow Fever Fact Sheet. Available at 1. CDC Health Information for International Travel 2010. The Yellow Book: Available at http://wwwnc.cdc.gov/travel/yellowbook/2010/tablehttp://www.who.int/mediacentre/factsheets/fs100/en/-.ofAccessed-contents. Decaspx 2010.. Accessed Dec 2010. 3. International Travel & Health. WHO, Geneva 2010. Available at http://www.who.int/ith/en. 2. WHO Yellow Fever Fact Sheet. Available at Accessed Dec 2010. http://www.who.int/mediacentre/factsheets/fs100/en/ .Accessed Dec 2010. 4. Barnett, ED. Yellow fever: epidemiology and prevention. Clin Infect Dis 2007; 44:850 3. International Travel & Health. WHO, Geneva 2010. Available at http://www.who.int/ith/en. Accessed Dec 2010. 4. Barnett, ED. Yellow fever: epidemiology and prevention. Clin Infect Dis 2007; 44:850
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YellowYellow Fever Fever “Endemic” “Endemic” Countries Countries
AfricaAfrica South/CentralSouth/Central America America and Caribbean and Caribbean . Angola. A ngola . Equatorial. Equatorial Guinea Guinea . Nigeria . Nigeria . Argentina. Argentina . Benin. Benin . Gabon. Gabon . Rwanda. Rwanda . Bolivia. Bolivia . Burkina. B urkinaFaso Faso . Gambia. Gambia, The , The . São Tomé. São &Tomé Príncipe & Príncipe . Brazil . Brazil . Burundi. Burundi . Ghana. Ghana . Senegal. Senegal . Colombia. Colombia . Cameroon. Cameroon . Guinea. Guinea . Sierra. SierraLeone Leone . Ecuador. Ecuador . Chad. Chad . Guinea. Guinea-Bissau-B issau. Somalia. Somalia . French. French Guiana Guiana . Central. Central African African Republic Republic . Kenya. Kenya . Sudan. Sudan . Guyana. Guyana . Congo. Congo . Liberia. Liberia . Tanzania. Tanzania . Panama. Panama . Côte .d'Ivoire Côte d'Ivoire . Mali . Mali . Togo. Togo . Paraguay. Paraguay . Democratic. Democratic Republic Republic of the Congoof the Congo . Mauritania . Mauritania . Uganda. Uganda . Peru . Peru 141 141 . Ethiopia. Ethiopia . Niger. Niger . Suriname. Suriname
. Trinidad. Trinidad & Tobago & Tobago . Venezuela. Venezuela
Source:Source: CDC Travel CDC InformationTravel Information 2010 Yellow 2010 YellowBook Book
Note: Note: 1. Singapore1. Singapore requires requires a yellow a yellowfever vaccination fever vaccination certificate certificate from travellers from travellers over one over year one of yearage who,of age within who, thewithin preceding the preceding 6 days 6have days been have in been or have in or have passed throughpassed through any of theany countries of the countries partly or partly wholly or whollyendemic endemic for yellow for yellowfever. fever. 2. Yellow2. Yellowfever vaccinat fever vaccination mustion be must administered be administered at a WHO at a- approvedWHO-approved yellow yellowfever vaccination fever vaccination centre. centre. 3. After3. immunisation,After immunisation, an International an International Certificate Certificate of Vaccination of Vaccination is issued is andissued is validand is 10 valid days 10 after days vaccination after vaccination to meet to entry meet and entry exit and requirements exit requirements for all countries.for all countries. 4. A4. country A country-by-country-by-country listing oflisting Yellow of YellowFever Vaccination Fever Vaccination Requirements Requirements is provided is provided in: (1) thein: US(1) theCenters US Centers for Disease for Disease Control Control & Prevention & Prevention (CDC) (CDC) documentdocument “Comprehensive “Comprehensive Yellow YellowFever VaccinationFever Vaccination Requirements” Requirements” under CDCunder Travel CDC TravelInformation Information and; (2) and the; (2)WHO the InternationalWHO International Travel Tandravel and Heatlh (Heatlhhttp://www.who.int/ith/ITH2010countrylist.pdf (http://www.who.int/ith/ITH2010countrylist.pdf). ).
OTHER OTHERVIRAL HAEMORRHVIRAL HAEMORRHAGIC FEVERSAGIC FEVERS (VHF) (VHF) CausativeCausative Agents Agents FilovirusesFiloviruses (including (including Ebola an dEbola Marburg and Marburgviruses) viruses) ArenavirusesArenaviruses (including (including Lassa fever) Lassa fever) BunyavirusesBunyaviruses (including (including Rift Valley Rift fever, Valley Cri fever,mean -CriCongomean haemorr-Congohagic haemorr fever,hagic and fever, hantaviruses) and hantaviruses) FlavivirusesFlaviviruses (including (including dengue, yellowdengue, fever) yellow fever)
COMPARISONCOMPARISON OF VIRAL OF HAEMORRHAGIC VIRAL HAEMORRHAGIC FEVERS FEVERS Type TypeIncubatio IncubatioOccurrenceOccurrence Mode of ModeSpecific of clinicalSpecific features clinical Investigation features Investigation Management Management Prevention Prevention n period transmission n period transmission Lassa Fever 6-21 days Rural West Africa, Direct contact with Inflammation of throat Serology, Supportive Control of rodents, Lassa Fever 6-21 days Rural West Africa, Direct contact with Inflammation of throat Serology, Supportive Control of rodents, Sierra Leone, Guinea, infected rodents; (with white exudates) viral +/- ribavirin barrier nursing & Sierra Leone, Guinea, infected rodents; (with white exudates) viral +/- ribavirin barrier nursing & Liberia, Nigeria person-to-person; and eye, encephalopathy, isolation surveillance of Liberia, Nigeria person-to-person; and eye, encephalopathy, isolation surveillance of inhalation of aerosol deafness, loss of contacts inhalation of aerosol deafness, loss of contacts from rodent urine coordination
142 from rodent urine coordination
142 Rift Valley 2-6 days Sub-Saharan Africa, Bites from infected Encephalitis, ocular Serology, Supportive Animal vaccination, Rift Valley 2-6 days Sub-Saharan Africa, Bites from infected Encephalitis, ocular Serology, Supportive Animal vaccination,
Fever Egypt, Madagascar, arthropods; direct disease viral +/- ribavirin protection &
Fever and Mauritania,Egypt, Kenya, Madagascar, contact witharthropods; infected direct disease isolation, viral +/-pr ribavirinevention ofprotection & Somalia, Tanzaniaand Mauritania, and animals; Kenya, aerosols contact with infected PCR isolation, mosquito bites,pre vention of Yemen. Somalia, Tanzania and animals; aerosols PCR barrier nursingmosquito bites, Ebola and 5-21 days Republic ofYemen. Congo, Direct contact with Maculopapular rash, Serology, Supportive Barrier nursingbarrier nursing Marburg Ebola and 5Côte-21 days d'Ivoire, Republic of Congo,infected blood,Direct contactjau nwithdice, multiMaculopapular-organ viral rash, Serology, Supportive Barrier nursing Fever Marburg DemocraticCôte Republic d'Ivoire, secretions andinf ected blood,failure jaundice, multiisol-organation, viral Fever of Congo, AngolaDemoc raticand Republicorgans; personsecretions-to- and failure PCR isolation, possibly Zimbabweof Congo, Angolaperson and organs; person-to- PCR possibly Zimbabwe person Crimean-Congo 1-13 days Endemic in many Bites of infected Tachycardia, Serology, Supportive, Personal protective HaemorrhagicCrimean -Congo 1cou-13n daystries inEndemic Africa, in manyticks; directBites contact of infectedhepatomegaly, Tachycardia, viral Serology,+/- ribavirin Supportive,measures againstPersonal protective Fever Haemorrhagic Europe andcou Asia,ntries and in Africa,with infected ticks; directlymphad contact enopathy,hepatomegaly, multi- isolation, viral +/-tick ribavirin bites & infectedmeasures against Fever during 2001,Europe cases andor Asia,live stockand with infectedorgan failurelymphad enopathy,antigen multi - isolation, livestock, barriertick bites & infected outbreaks haveduring been 2001, cases or livestock organ failure detection, antigen nursing livestock, barrier recorded inoutbreaks Kosovo, have been PCR detection, nursing Albania, Iran,recorded Pakistan, in Kosovo, PCR and South Africa.Albania, Iran, Pakistan, and South Africa. AppendixAppendix 1 1 POST-EXPOSUREPOST-EXPOSURE PROPHYLAXIS PROPHYLAXIS (PEP) (PEP)
InfectionInfection IndicationsIndications for PEP for PEP PEP PEP Contra-Indications/RemarksContra-Indications/Remarks
Measles MeaslesInfants
ChickenpoxChickenpox Susceptible Susceptible persons where persons risk where of risk ofVZIG shouldVZIG be s houldadministered be administered as soon as as possible, soon as possible,though though complicationscomplications is high e.g. is high e.g. may be effectivemay be effectiveup to 96 hoursup to 96after hours exposure. after exposure. immunocoimmunocompromisedmpromised patients, patients, Dose of 125U/Dose of 10 125U/ kg BW 10 (min kg BW dose (min 125U dose - max 125U of - max of neonates neonatesof mothers of infectedmothers upinfected to 5 up to625U). 5 625U). days beforedays and before 2 days and after 2 days delivery. after delivery.
SusceptibleSusceptible persons without persons contra without- contraVaricella- Varicella vaccination vaccination can prevent can or prevent ameliorate or ameliorate disease if disease Varicella if Va vaccinericella should vaccine not should be not be indicationsindications who have who been have exposed. been exposed.given withingiven 72 within hours 72of exposure.hours of exposure. given to immunocompromisedgiven to immunocompromised individuals,individuals, patients withpatients history with of history of anaphylaxisanaphylaxis to neomycin, to neomycin, severe severe illness, andillness, pregnant and pregnantfemales. females. Rubella RubellaPregnant Pregnantfemales exposedfemales toexposed rubella to rubellaIG may beIG given may be(0.55 given ml/kg (0.55 IM) ml/kg within IM) 72 within hours 72of hours ofMay reduceMay but reduce will not but eliminatewill not eliminate who refusewho to refusehave an to abortionhave an abortionif if rubella exposurerubella exposure the risk forthe rubella. risk for rubella. rubella develops.rubella develops.
InfectionInfection IndicationsIndications for PEP for PEP PEP PEP Contra-Indications/RemarksContra-Indications/Remarks
HepatitisHepatitis A Household A Household and homosexual and homosexual /sexual /sexualIG at doseIG of at 0.02dose ml/kg of 0.02 (IM) ml/kg within (IM) 2 withinweeks 2 weeksThe vaccineThe mayvaccine be usedmay concombe used itantlyconcom withitantly with contacts.contacts. of exposureof exposure will ameliorate will ameliorate or prevent or disease.prevent disease. IG in a postIG in-exposure a post-exposure situation situation but must but be must be During outbDuringreaks outb in reaksday-care in day -care Late administrationLate administration of IG will of still IG willattenuate still attenuate given at givendifferent at different sites. sites. centres orce hospitalsntres or hospitals when there when may there disease.may disease. be exposurebe exposure to faeces to faeces HepatitisHepatitis B Occupational B Occupational exposures exposures (bites, NSI, (bites, NSI,If never Ifvaccinated never vaccinated or non-immune or non- immune(anti-HBs (anti -HBsIdeally, shouldIdeally, document should document evidence evidence for for splash). splash). < 10mIU),< 10mIU), give HBIG give at HBIG dose of at 0.06dose ml/kg of 0.06 ml/kgim munityim aftermunity completion after completion of primary of primaryHB HB and initiateand HB initiate vac series.HB vac series. vaccination.vaccination. For HCWs, For shouldHCWs, keep should anti keep- anti- If previousIf previously vaccinatedly vaccinated and anti -andHBs anti < 100-HBs < 100HBs >100HBs mIU. >100 mIU. 144 144 mIU, givemIU, one give booster one dosebooster of HBV.dose of HBV.
HIV HIV IndividualsIndividuals exposed exposedto discrete to discrete 2-3 antiretroviral2-3 antiretroviral drug regimen drug rforegimen 4 weeks for 4 weeksEvaluate Evaluate type of exposure type of exposure and source and patient source patient NSI/splaNSI/splash/mucoussh/mucous contact, contactideally , ideallydepending depending on type ofon exposure, type of exposure, index patient’s index patient’s if HIV statusif HIV unknown. status unknown. Specialist Specialist advice advice within 4within hours ,4 of hours exposure., of exposure. stage of stagedisease of anddisease experience and experience with anti with- anti- should beshould sought. be sought. retroviralretroviral treatment treatment. . InfluenzaInfluenza Antiviral Antiviral drugs considered drugs considered for the for theTreatment Treatment should be should started be within started 48 within hours 48 of hoursZanamivir of Zanamivir may cause may bronchoconstriction. cause bronchoconstriction. chemoprophylaxischemoprophylaxis of unvaccinated of unvaccinated illness onsetillness and onset continue and continue for 5 days. for 5 days. high-riskhigh persons-risk agedpersons > 1 aged year >in 1 year in communitycommunity influenza influenza outbreaks outbreaks and O andseltamivir, Oseltamivir, zanamivir. zanamivir. influenzainfluenza outbreaks outbreaks in other settingsin other settings unvaccinatunvaccinated healthed care health workers care workers who havewho close have contact close withcontact with influenzainfl-infecteduenza- infectedpatients. patients.
InfectionInfection IndicatiIndications forons PEP for PEP PEP PEP ContraContra-Indications/Remarks-Indications/Remarks
RabiesRabies Both immunisedBoth immunised and non and- non- If completedIf completed pre-exposure pre-exposure vaccination, vaccination, give two give two BesidesBesides rabies PEPrabies treatment, PEP treatment, immunisedimmunised individuals individuals with with boostersboosters at days at 0 daysand 30 of and HDCV 3 of HDCV IM (deltoid) IM (deltoid). No . Nowound wound management management with with suspectedsus pectedor confirmed or confirmed contact. contact. HRIG needed.HRIG needed. cleansing,cleansing, antibiotics antibiotics and tetanus and tetanus If unimmuIf unimmunised, startnised, 5 -startdose 5HDCV-dose HDCV and HRIG. and HRIG. immunisationimmunisation may be may required. be required. HRIG shouldHRIG shouldbe infiltrated be infiltrated into wound into wound and remainder and remainder into glutealinto gluteal area area MeningococcalMeningococcal HCWs HCWs involved involved in resuscitation, in resuscitation, RifampRifampicin 10icin mg/kg 10 mg/kg(max 600 (max mg) 600 bd mg) (children bd (children < 145 145 before beforeonset of onset illness of illness(house -(house- CeftriaxoneCeftriaxone 250 mg 250 (children mg (children <15yr- <15yr 125mg)- 125mg) X 1 IM X 1 IMVa ccinationVaccination has been has used been in used in mates, mates,day-care day contacts,-care contacts, cell- cell- dose whendose other when antibiotics other antibiotics contraindicated contraindicated conjunctionconjunction with with mates).mates). chemoprophchemoprophylaxis inylaxis PEP in but PEP but value unknown.value unknown. HaemophilusHaemophilus Household Household or day -orcare day contacts-care contacts RifampicinRifampicin 20mg/kg 20mg/kg once-dail oncey -(maxdaily 600mg) (max 600mg) x 4 x 4 ContraindicatedContraindicated in pregnancy in pregnancy influenzaeinfluenzae B B residingresiding with index with caseindex > case4 hours > 4 hoursdoses doses meningitismeningitis for 5-7for days 5- 7before days beforeonset of onset illness of illness TuberculosisTuberculosis IndividualsIndividuals exposed exposed to a confirmed to a confirmed After excludingAfter excluding active TB,active isoniazid TB, isoniazid for 6 months for 6 months-1 -1Risk factorsRisk factors for hepatotoxicity for hepatotoxicity case case year year have tohave be considered. to be considered. Consult Consult ID/TBCUID/TBCU for MDR for- TBMDR -TB PEP = PEPPost -=exposure Post-exposure prophylaxis prophylaxis IG = ImmIG =unoglobulin Immunoglobulin VZIG =VZIG Varicella = Varicella zoster immunezoster immune globulin globulin MDR -TBMDR = Multi-TB =- drugMulti resistant-drug resistant tuberculosis tuberculosis HB vacHB = Hepatitisvac = Hepatitis B vaccine B vaccine HDCVHDCV = Human = Human diploid diploid cell vaccine cell vaccine NSI = NeedlestickNSI = Needlestick injury injury HIV = HIVHuman = Human immunodeficiency immunodeficiency virus viruHRIGs =HRIG Human = Human rabies immunoglobulinrabies immunoglobulin HCWs HCWs = Health = -Healthcare workers-care workers AppendixAppendix 2 2 NationalNational Childhood Childhood and Adolescent and Adolescent Immunisation Immunisation Schedule, Schedule, Singapore Singapore for persons for persons aged 0 toaged <18 0 yearsto <18 years 6-7 106--711 10-11 VaccinationVaccination against againstBirth 1 Birthmonth 1 month3 months 3 months4 months 4 months5 months 5 months6 months 6 months12 month 12s month18 monthss 18 months24 months 24 months years^ years^^years^ years^^ TuberculosisTuberculosis BCG BCG HepB HepB HepB HepB# HepB# Hepatitis B*Hepatitis B* (D1) (D2)(D1) (D2) (D3) (D3) Diphtheria,Diphtheria, Tetanus, Tetanus, DTaP DTaPDTaP DTaPDTaP DTaP DTaP DTaP Td## Td## Pertussis Pertussis (D1) (D1)(D2) (D2)(D3) (D3) (B1) (B1) (B2) (B2) OPV OPVOPV OPVOPV OPV OPV OPV OPV OPVOPV OPV PoliovirusPoliovirus (D1) (D1)(D2) (D2)(D3) (D3) (B1) (B1) (B2) (B2)(B3) (B3) Measles, Mumps,Measles, Mumps, MMR MMR MMR MMR Rubella Rubella (D1) (D1) (D2) (D2) PneumococcalPneumococcal PCV PCV PCV PCV PCV PCV 146 146 Disease**Di sease** (D1) (D1) (D2) (D2) (B1) (B1) Human Human RecommendedRecommended for females for 9 females to 26 years 9 to; 26three years doses; three are dosesrequired are atrequired intervals at ofintervals 0, 2, 6 monthsof 0, 2, 6 months PapillomavPapillomavirus irus Influenza Influenza RecommendedRecommended for all children for all agedchildren 6 months aged 6to months <5 years to and<5 years children and agedchildren 6 months aged 6to months <18 years to <18 in high years-risk in highgroups***-risk groups*** Notes: Notes: BCG BCGBacillus CalmetteBacillus-Guérin Calmette -Guérin # Dose# 3 of HepatitisDose 3 Bof vaccinationHepatitis B canvaccination be given can with be the given 3rd dosewith theof DTaP3rd dose and of OPV DTaP for and OPV for HepB HepBHepatitis B vaccineHepatitis B vaccine the conveniencethe convenience of parents. of parents. DTaP DTaPPaediatric diphtheriaPaediatric and diphtheria tetanus andtoxoids tetanus and acellulartoxoids and pertussis acellular vaccine pertussis vaccine## Can## use either:Can use either: Td TdTetanus toxoidTetanus and reduced toxoid and diphtheria reduced toxoid diphtheria-containing toxoid vaccine-containing vaccine - tetanus- toxoidtetanus and reduced toxoid and diphtheria reduced toxoid diphtheria vaccine; toxoid or vaccine; or MMR MMRMeasles, mumps,Measles, and mumps, rubella vaccineand rubella vaccine - tetanus- toxoid,tetanus reduced toxoid, diphth reducederia toxoid diphth anderia acellular toxoid and pertussis acellular vaccine pertussis vaccine OPV OPVOral polio vaccineOral polio vaccine * Refer* to ‘OtherRefer Recommendations’ to ‘Other Recommendations’ below for guidelines below for on guidelines infants born on infantsto hepatitis born Bto hepatitis B PCV PCVPneumococcal Pneumococcal conjugate vaccine conjugate vaccine carrier motherscarrier mothers D1/D2/D3 D1/D2/D3Dose 1, doseDose 2, dose 1, dose 3 2, dose 3 ** Refer** to ‘OtherRefer Recommendations’ to ‘Other Recommendations’ below for guidelines below for on guidelines catch-up on vaccination catch-up vaccination B1/B2/B3 B1/B2/B3Booster 1, boosterBooster 2, 1, boo boosterster 3 2, booster 3 schedule andsche vaccinationdule and forvaccination high-risk forgroups high -risk groups ^ ^ Primary 1 Primary 1 *** Refer*** to ‘OtherRefer Recommendations’ to ‘Other Recommendations’ below for more below details for more on guidelines details on for guidelines influenza for influenza ^^ ^^Primary 5 Primary 5 vaccination vaccination Medisave300 Use of Medisave is allowed for Hepatitis B vaccine, pneumococcal conjugate Medisave300 vaccine, and HPV vaccine under Medisave300 for up to $300 per Medisave account Use of Medisave is allowed for Hepatitis B vaccine, pneumococcal conjugate per calendar year. All vaccinations under the NCIP should be routinely offered to vaccine, and HPV vaccine under Medisave300 for up to $300 per Medisave account parents who bring their infants and children for immunisation or whenever per calendar year. All vaccinations under the NCIP should be routinely offered to opportunities arise, as a standard of care. Needy parents with insufficient Medisave parents who bring their infants and children for immunisation or whenever balance can seek special assistance at polyclinics on a means-tested basis. opportunities arise, as a standard of care. Needy parents with insufficient Medisave Babybalance Bonus can seek special assistance at polyclinics on a means-tested basis. Parents can also pay for the vaccination using their child's Baby Bonus cash gift Baby Bonus and/or savings in his/her Child Development Account (CDA) at Baby Bonus- Parents can also pay for the vaccination using their child's Baby Bonus cash gift approved healthcare institutions. More information on the Baby Bonus and its and/or savings in his/her Child Development Account (CDA) at Baby Bonus- approved healthcare institutions can be found at http://www.babybonus.gov.sg. The approved healthcare institutions. More information on the Baby Bonus and its Baby Bonus and CDA can also be used to pay for siblings’ vaccinations. approved healthcare institutions can be found at http://www.babybonus.gov.sg. The NotificationBaby Bonus andof vaccination CDA can also [For be medicalused to paypractitioners] for siblings’ vaccinations. Please notify all immunisations to the National Immunisation Registry (NIR), Notification of vaccination [For medical practitioners] Health Promotion Board. NIR can be accessed via www.hpp.moh.gov.sg. Please notify all immunisations to the National Immunisation Registry (NIR), Notification forms 550A can be requested from NIR via email [email protected]. Health Promotion Board. NIR can be accessed via www.hpp.moh.gov.sg. OtherNotific Recommendationsation forms 550A can be requested from NIR via email [email protected]. HepatitisOther Recommendations B1 All infants born1 to mothers who are hepatitis B carriers (HBsAg positive), regardless Hepatitis B of their ‘e’ Ag status, should receive the hepatitis B vaccine and hepatitis B All infants born to mothers who are hepatitis B carriers (HBsAg positive), regardless immunoglobulin (HBIG) (0.5mls) within 12 hours of birth, administered at different of their ‘e’ Ag status, should receive the hepatitis B vaccine and hepatitis B injection sites. immunoglobulin (HBIG) (0.5mls) within 12 hours of birth, administered at different Infantsinjection born sites. to mothers whose hepatitis B status is unknown should receive the first dose of the hepatitis B vaccine within 12 hours of birth and the mother should have Infants born to mothers whose hepatitis B status is unknown should receive the first her blood drawn as soon as possible to determine her hepatitis B status. If she is dose of the hepatitis B vaccine within 12 hours of birth and the mother should have found to be a hepatitis B carrier (HBsAg positive), the infant should receive the her blood drawn as soon as possible to determine her hepatitis B status. If she is HBIG as soon as possible but no later than seven days after birth. found to be a hepatitis B carrier (HBsAg positive), the infant should receive the AllHBIG infants as soon born as topossible women but who no arelater hepatitis than seven B carriers days after (HBsAg birth. positive) should be tested for seroconversion following the primary course of hepatitis B vaccination, All infants born to women who are hepatitis B carriers (HBsAg positive) should be preferably three months after completion of the course. The primary course of tested for seroconversion following the primary course of hepatitis B vaccination, hepatitis B vaccination, comprising 3 doses of hepatitis B vaccine, should be preferably three months after completion of the course. The primary course of administered at birth, followed by dose 2 at one month and dose 3 at 5-6 months. hepatitis B vaccination, comprising 3 doses of hepatitis B vaccine, should be adminiInfluenzastered vaccination at birth, followed2 by dose 2 at one month and dose 3 at 5-6 months. Annual seasonal influenza2 vaccination is recommended for the following groups: Influenza vaccination Annual All childrenseasonal aged influenza 6 months vaccination to <5 years; is recommended for the following groups: AllChildren children aged aged 6 months 6 months to <18to <5 years years; who have chronic disorders of the lungs or heart, including asthma; Children aged 6 months to <18 years who have chronic disorders of the lungs or heart, including asthma; 147 147 Children aged 6 months to <18 years who have required regular medical follow- up or hospitalisation during the preceding year because of chronic metabolic Childrendisease (includingaged 6 months diabetes to <18 mellitus), years who kidney have orrequired blood regu disorders,lar medical or loweredfollow- immup oru nity hospitalisation caused by medications during the or preceding by HIV; year because of chronic metabolic disease (including diabetes mellitus), kidney or blood disorders, or lowered Children aged 6 months to <18 years who are receiving long-term aspirin immunity caused by medications or by HIV; therapy. Previously Children unvaccinated aged 6 months children to under <18 yearsthe age who of 9 a yearsre receiving will require long 2-term doses aspirin given at leastther apy.one month apart. Children 9 years and above will require a single dose of the vaccine.Previously unvaccinated children under the age of 9 years will require 2 doses given at least one month apart. Children 9 years and above will require a single dose of the vaccine.Pneumococcal vaccination Catch-up vaccination3 CatchPneumococcal-up vaccination vaccination is recommended for all children under 5 years of age who are 3 previouslyCatch-up v unimmunised.accination Catch-up vaccination is recommended for all children under 5 years of age who are previously Previously unimmunised. unimmunised children below 12 months of age, 2 doses for the primary series and 1 booster dose (at aged 12-24 months) should be given. The Prereviouslycommended unimmunised interval between children the belowfirst and 12 second months dose of is age, eight 2 weeks, doses forwith the a primaryminimum series interval and of 1 4booster weeks. dose The (atminimum aged 12 interval-24 months) between should the second be given. dose The of therec ommendedprimary series interval and thebetween booster the dose first is andeight second weeks. dose is eight weeks, with a minimum interval of 4 weeks. The minimum interval between the second dose of Previously unimmunised children between 12 to 23 months of age, 2 doses of the primary series and the booster dose is eight weeks. PCV should be given with a minimum interval of 8 weeks between doses. Previously unimmunised children between 12 to 23 months of age, 2 doses of Previously unimmunised children between 24-59 months of age who have PCV should be given with a minimum interval of 8 weeks between doses. asplenia or splenic dysfunction, or who are immunocompromised and may have Pa reviously sub-optimal unimmunised response to childrenthe first dose between of vaccine, 24-59 months2 doses of PCV age whoshould have be agivensplenia, with or splenican interval dysfunction, of 8 weeks or between who are doses. immunocompromised and may have a sub-optimal response to the first dose of vaccine, 2 doses of PCV should be All other previously unimmunised children between 24-59 months of age, a given, with an interval of 8 weeks between doses. single dose of PCV should be administered. All other previously unimmunised4 children between 24-59 months of age, a Vaccinatisingle ondose for of high PCV-risk should groups be administered. A single dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) should 4 beVaccinati administered,on for highin addition-risk groups to PCV, to persons aged 2 to <18 years at high risk of developingA single dose severe of 23 pneumococcal-valent pneumococcal disease: polysaccharide vaccine (PPSV23) should be administered, in addition to PCV, to persons aged 2 to <18 years at high risk of developing Persons severewith chronic pneumococcal illnesses: disease: . Chronic respiratory diseasea b Persons. Chronic with heart chronic disease illness es: a . Chronic respiratoryrenal disease diseasec b . Chronic heartliver diseasediseased c . ChronicDiabetes renal disease d Cochlear. Chronic implants; liver disease . Diabetes Cerebrospinal fluid leaks; Cochlear implants; Cerebrospinal fluid leaks; 148 148 Persons who have anatomic or functional asplenia (including conditions such as homozygousPersons who sicklehave anatomic cell disease or functional and coeliac asplenia syndrome (including that may conditions lead to suchsplenic as dysfunction);homozygous sickle cell disease and coeliac syndrome that may lead to splenic Immunocompromiseddysfunction); patientse. e Children Immunocompromised aged 2 to <5 years patients in high. risk groups should receive a single dose of PPSV23,Children aged in addition 2 to <5 to years PCV. in The high interval risk groups between should doses receive of PPSV23 a single and dose PCV of shoPPSV23,uld be at in least addition two months. to PCV. The interval between doses of PPSV23 and PCV Boostershould be doses at least of PPSV23two months. are not recommended routinely. However, booster doses areBooster recommended doses of PPSV23every five are years not inrecommended individuals withroutinely. no spleen, However, splenic booster dysfunction doses andare recommendedchronic renal disease. every five years in individuals with no spleen, splenic dysfunction Medisaveand chronic can renal be used disease. to pay for the cost of PPSV23 in children under the age of 5 yearsMedisave for whom can be the used vaccine to pay is for clinically the cost indicated. of PPSV23 Medisave in children cannot under be theused age to ofpay 5 foryears the for cost whom of PPSV23 the vaccine in persons is clinically aged 5 indicated. years and Medisave older. cannot be used to pay for the cost of PPSV23 in persons aged 5 years and older. a Including chronic obstructive pulmonary disease (COPD), including chronic a bronchitisIncluding and chronic emphysema; obstructive and pulmonarysuch conditions disease as bronchiectasis, (COPD), including cystic fibrosis, chronic interstitialbronchitis and lung emphysema; fibrosis, pneumoconiosisand such conditions and as bronchopulmonarybronchiectasis, cystic dysplasia fibrosis, (BPD).interstitial Children lung fibrosis, with respiratory pneumoconiosis conditions and caused bronchopulmonary by aspiration, dysplasia or a neur(BPD).omuscular Children disease with (e.g. respiratory cerebral palsy) conditions with a risk caused of aspiration. by aspiration, or a b Includingneuromuscular those disease requiring (e.g. regularcerebral medication palsy) with and/ora risk of follow aspiration.-up for ischaemic b heartIncluding disease, those congenital requiring heart regular disease, medication hypertension and/or with follow cardiac-up complications, for ischaemic andheart chronic disease, heart congenital failure heart disease, hypertension with cardiac complications, c Includingand chronic nephr heartotic failure syndrome, chronic renal failure and renal transplantation dc Including biliarynephrotic atresia, syndrome, cirrhosis chronic and chronic renal failure hepatitis and renal transplantation ed Immunosuppression,Including biliary atresia, due cirrhosisto disease and or chronictreatment, hepatitis including HIV infection at all e stages,Immunosuppression, asplenia or splenic due to dysfunction, disease or treatment, patients un includingdergoing HIVchemotherapy infection at all leastages,ding aspleniato immunosuppression, or splenic dysfunction, individuals patient on sor un likelydergoing to be chemotherapy on systemic steroidsleading tofor immunosuppression, more than a month at individuals a dose equivalent on or likely to prednisolone to be on systemic at ≥ 20mg persteroids day (anyfor more age), than or for a monthchildren at undera dose 20kg, equivalent a dose to of prednisolone ≥1mg per kg at per ≥ 20mg day. Referencesper day (any age), or for children under 20kg, a dose of ≥1mg per kg per day. 1.References MOH Circular 10A/2007. Administration of hepatitis B immunoglobulin to babies born to hepatitis B carrier mothers. 16 May 2007. 2.1. MOH Circular 10/2010.10A/2007. Update Administration on influenza of hepatitissituation Band immunoglobulin recommendations to babies on the born use ofto seasonalhepatitis influenzaB carrier mothersand influenz. 16 Maya A (H1N1 2007. -2009) vaccines. 1 April 2010 3.2. MOH Circular 1/20110/2010.1. Update Updated recommendationson influenza situation on pneumococcal and recommendations vaccination. on the13 Januaryuse of seasonal 2011 4. Ministryinfluenza ofand Health, influenz Singapore.a A (H1N1 Vaccination-2009) vaccines. against 1 April pneumococcal 2010 disease. Epidemiol News Bull 3. 2010;MOH 36:7Circular-15 1/2011. Updated recommendations on pneumococcal vaccination. 13 January 2011 4.This MinistrySchedule ofis cur Health,rent as Singapore. of February Vaccination 2011. For againstupdated pneumococcalinformation, please disease. visit Epidemiol the HPB website News Bullat: 2010; 36:7-15 http://www.nir.hpb.gov.sg/ (under Immunisation Schedule) This Schedule is current as of February 2011. For updated information, please visit the HPB website at: http://www.nir.hpb.gov.sg/ (under Immunisation Schedule) 149 149 Appendix 3 LIST OF OTHER VACCINES Appendix 3 (Reproduced and modified from: International Travel and Health. WHO, Geneva, 2010) LIST OF OTHER VACCINES Interval (ReproducedPrimary and modified from: InternationalLower TravelEffective and Health. BoosterWHO, Geneva, 2010) Type between Remarks series age limit after: interval Intervaldoses Primary Lower Effective Booster Type between Remarks series age limit after: interval 2 (oral minimumdoses 2 years 7 days after 6-12 Risk of cholera in inactivated) 7 days 2nd dose months travellers is very Cholera 2 (oral minimum 2 years 7 days after 6-12 Risksmall; of does cholera not in inact ivated) 7 days 2nd dose months travellersprotect against is very Cholera 1 (live oral) - 2 years 8 days after 6-12 small;Vibrio doescholerae not single dose months prO139.otect against 1 (live oral) - 2 years 8 days after 6-12 Vibrio cholerae single dose months O139. 1 (immuno- - 1 year immediately 3-6 months Preventive Hepatitis A globulin immunoglobulin 1 (immuno - - 1 year immediately 3-6 months Preventivetherapy is effective Hepatitis A globulin immthoughunoglobulin of limited 2 (injectable 6 – 24 None 4 weeks 10 years duration and st therapy is effective inactivated months after 1 thoughhepatitis of A limited vaccine 2 vaccine) (injectable 6 – 24 None 4 doseweeks 10 years durationis preferred and when inactivated months after 1st hepatitisavailable. A vaccine vaccine) dose isIndicated preferred for when travel avaito developinglable. Indicatedcountries. for travel to developing countries. Japanese 2-3 7 – 14 1 year 10 -14 days 1 – 4 years Indicated for encephalitis (inacti vated) day s children extended stay Japanese 2-3 7 – 14 1 1 year-3 10 -14 days 1 – 4 years I(>2weeks)ndicated for in rural encephalitis (inactivated) days childrenyears extendedareas of endemic stay 1should-3 (>2weeks)countries. in rural yearsreceive areas of endemic shouldhalf a countries. receivedose). half a Meningococcal 1 (type A+C); - dose).2 years 15 days 3-5 years Indicated for meningitis 1 (quad- people travelling Meningoco ccal 1rivalent) (type A+C); - 2 years 15 days 3-5 years Indicatedin epidemic for areas. meningitis 1(A/C/Y/W (quad- - peopleDoes not travelling prevent rivalent)135) intransmission epidemic areas. by (A/C/Y/W - Doescarrier. not To pr eensurevent 135) transmissionlong-lasting by carrier.immunity, To a ensure longbooster-lasting dose may immbe requiredunity, a in boosteryoung child doseren. may be required in young children. 150 150 Interval Primary Lower Effective Booster Type between Remarks series age limit after: interval doses Interval Primary Lower Effective Booster Type between Remarks Rabies 3 (injectableseries 7 days for 12age months limit 3after:rd dose Firstinterval after Indicated for high- doses (pre-exposure) inactivated) 2nd dose, 12 months, risk occupations 28 days then every and situations in Rabies 3 (injectable 7 days for 12 months 3rd dose First after Indicated for high- for 3rd 2-3 years endemic areas. (pre-exposure) inactivated) 2nd dose, 12 months, risk occupations dose Serum should be 28 days then every and situations in checked for for 3rd 2-3 years endemic areas. antibody level 1 dose Serum should be month after 3rd checked for dose. Additional antibody level 1 booster dose(s) month after 3rd should be given in dose. Additional case of exposure booster dose(s) to a rabid or should be given in suspect animal. case of exposure to a rabid or suspect animal. Typhoid 3 (oral live 2 days 2 years 5 days after 1 year Either vaccine is attenuated last dose recommended for people travelling Typhoid 3 (oral live 2 days 2 years 5 days after 1 year Either vaccine is 1 (injectable - 2 years 10 days 3 years to conditions of attenuated last dose recommended for Vi vaccine) doubtful hygiene. people travelling 1 (injectable - 2 years 10 days 3 years to conditions of Vi vaccine) doubtful hygiene. Yellow fever 1 (live - 6 months 10 days 10 years Validity of the attenuated) international certificate of Yellow fever 1 (live - 6 months 10 days 10 years Validity of the vaccination begins attenuated) international 10 days after certificate of vaccination. vaccination begins 10 days after vaccination. 151 151 Appendix 4 Appendix 4 COMMUNICABLE DISEASE SURVEILLANCE IN SINGAPORE COMMUNICABLE DISEASE SURVEILLANCE IN SINGAPORE Introduction Medical practitioners play a vital role in the surveillance of communicable diseases. Introduction A clinician’s anecdotal reporting of a cluster of gastroenteritis cases, a physician’s Medical practitioners play a vital role in the surveillance of communicable diseases. notification of a case of dengue fever and a virologist’s confirmation of a positive A clinician’s anecdotal reporting of a cluster of gastroenteritis cases, a physician’s influenza A isolate all provide important information for national surveillance of notification of a case of dengue fever and a virologist’s confirmation of a positive communicable diseases, as well as early detection and timely response towards influenza A isolate all provide important information for national surveillance of disease outbreaks. communicable diseases, as well as early detection and timely response towards disease outbreaks. This chapter outlines Ministry of Health (MOH)’s national communicable disease surveillance and notification system and highlights the important role that all This chapter outlines Ministry of Health (MOH)’s national communicable disease medical practitioners in Singapore have in the protection of public health. surveillance and notification system and highlights the important role that all medical practitioners in Singapore have in the protection of public health. Local Surveillance The incidence of infectious diseases in Singapore is monitored systematically Local Surveillance through various surveillance systems. In addition to the surveillance of human cases The incidence of infectious diseases in Singapore is monitored systematically of infectious diseases, animal surveillance for infectious and zoonotic diseases, through various surveillance systems. In addition to the surveillance of human cases environmental surveillance for mosquito breeding and rodent infestation, as well as of infectious diseases, animal surveillance for infectious and zoonotic diseases, food surveillance for food-borne pathogens, all contribute towards the overall environmental surveillance for mosquito breeding and rodent infestation, as well as national infectious disease surveillance framework. Whilst the Agri-Food and food surveillance for food-borne pathogens, all contribute towards the overall Veterinary Authority (AVA) is responsible for animal and food surveillance, the national infectious disease surveillance framework. Whilst the Agri-Food and National Environment Agency (NEA) takes on the role of environmental Veterinary Authority (AVA) is responsible for animal and food surveillance, the surveillance. National Environment Agency (NEA) takes on the role of environmental surveillance. With the support of medical practitioners, MOH monitors the local incidence of human infectious diseases via: With the support of medical practitioners, MOH monitors the local incidence of human infectious diseases via: 1) Mandatory notifications 2) Sentinel polyclinics 1) Mandatory notifications 3) Anecdotal reporting 2) Sentinel polyclinics 4) Virological surveillance 3) Anecdotal reporting 5) Seroepidemiological surveillance 4) Virological surveillance 5) Seroepidemiological surveillance Mandatory Notifications Information on the national incidence of infectious diseases of public health Mandatory Notifications importance is obtained from notifications by registered medical practitioners. Information on the national incidence of infectious diseases of public health All medical practitioners and clinical laboratories are legally required to notify importance is obtained from notifications by registered medical practitioners. All medical practitioners and clinical laboratories are legally required to notify 152 152 cases of infectious diseases, as stipulated under the First Schedule of the Infectious Diseases Act. The infectious diseases are listed in Appendix 5. cases of infectious diseases, as stipulated under the First Schedule of the InfeTo enhancectious Diseases this component Act. The of infectious the surveillance diseases system, are listed medical in Appendix practitioners 5. are required to notify the incidence of certain time-sensitive infectious diseases Towithin enhance 24 hours,this component and others of the within surveillance 72 hours. system, This m edical is to practitioners enable prompt are requiredepidemiological to notify investigations the incidence to be of carried certain out time and-sensitive timely interventions infectious diseases to halt withinfurther transmission24 hours, and of aothers disease. within All notifications72 hours. This have is to to be enable made viaprompt the epidemCommuniologicalicable Diseasesinvestigations Live andto be Enhanced carried out Surveillance and timely Systeminterventions (CD- LENS)to halt furtherhttp://www.cdlens.moh.gov.sg transmission of a disease. or by All fax. notifications have to be made via the Communicable Diseases Live and Enhanced Surveillance System (CD-LENS) Sentinelhttp://www.cdlens.moh.gov.sg Polyclinics or by fax. In addition, outpatient attendances for acute respiratory infection, conjunctivitis Sentineland diarrhoeal Polyclinics illness are also monitored. The 18 polyclinics distributed Inthroughout addition, theoutpatient country attendances form our sentinels, for acute providing respiratory us infection,with weekly conjunctivitis returns on andthe number diarrhoeal of patients illness who are havealso been monitored. treated Theat their 18 healthcarepolyclinics facilities distributed for throughoutthese infectious the country syndromes. form our sentinels, providing us with weekly returns on the number of patients who have been treated at their healthcare facilities for theseOutpatient infectious attendances syndromes. for the syndromes are obtained from the computerised system which collates data on the clinical diagnoses of all patients treated at Outpatientpolyclinics. attendances for the syndromes are obtained from the computerised system which collates data on the clinical diagnoses of all patients treated at polyclinics.Anecdotal Reporting Medical practitioners have also been providing useful information on infectious diseases.Anecdotal They Reporting often inform MOH when they encounter an unusually high nuMedicalmber ofpractitione patients withrs have a particular also been infectious providing syndrome useful information or disease. on infectious diseases. They often inform MOH when they encounter an unusually high nuVirologicalmber of patients Surveillance with a particular infectious syndrome or disease. Virological surveillance, through laboratory tests, is also routinely carried out Virologicalfor: Surveillance Virological. influenza surveillance, types isolated thro fromugh respiratory laboratory specimens tests, is also taken routinely from hospitalised carried out for: patients and those presenting with influenza-like symptoms at polyclinics . influenzaand sentinel types GP isolated clinics; from respiratory specimens taken from hospitalised . patientsenteroviruses and those isolated presenting from throa witht swabsinfluenza taken-like from symptoms hospitalised at polyclinics/A&E andHFMD sentinel patients GP inclinics; KKH and NUH and those presenting with HFMD . enterovirusessymptoms at sentinelisolated GPfrom clinics; throa t swabs taken from hospitalised/A&E . HFMDdengue viruspatients serotypes in KKH isolated and NUH from and blood those specimens presenting taken with from HFMD cases symwithp suspectedtoms at sentinel dengue GP virus clinics; infection; . chikundenguegunya virus serotypes virus detection isolated from from blood specimens specimens taken tested from negative cases for withdengue suspected in TTSH, dengue NUH virus and sentinel infection; GP clinics; . chikunad-hoc gunya Malaria virus screening detection of from workers blood at specimens Malaria testedreceptive negative areas for in dengueSingapore in TTSH,and molecular NUH and typingsentinel of GP all clinics; malaria positive samples by the . adNational-hoc MalariaPublic H ealth screening laboratory of workers ; at Malaria receptive areas in Singapore and molecular typing of all malaria positive samples by the National Public Health laboratory ; 153 153 . enterovirus isolated from stools of cases presenting with acute flaccid . paralysisenterovirus as isolatedwell as patientsfrom stools diagnosed of cases with presenting associated with conditions acute flaccid (e.g. encephalitis,paralysis as well transverse as patients myelitis), diagnosed and with associated conditions (e.g. . detectionencephalitis, of new transverse strains myelitis),of viruses. and . detection of new strains of viruses. Sero epidemiological Surveillance SeroPeriodicepidemiological serosurveys Surveillance are carried out to assess the herd immunity of the populPeriodication serosurveys against various are infectious carried out diseases, to assess and to the evaluate herd immunity the effectiveness of the ofpopul thea tion national against childhood various infectious immunisation diseases, programme. and to evaluate The coveragethe effectiveness of the natof ional the national childhood childhood immunisation immunisation programme programme. is monitored The via coverage a notification of the systemnational maintained childhood at immunisation the National Immunisation programme is Registry. monitored via a notification system maintained at the National Immunisation Registry. A ccessing Communicable Disease Information A ccessing Communicable Disease Information Medical practitioners, who are major partners in the national communicable disease surveillanceMedical practitioners, effort, provide who are information major partners on infectious in the national diseases communicable which are collateddisease andsurveillance analysed effort, together provide with information information on from infectious animal, diseases food and which environmental are collated suandrveillance. analysed Various together communication with information platforms from have animal, been foodestablished and environmentalfor sharing of communicablesurveillance. Various disease communication information withplatforms medical have practitioners, been established depending for sharing on the of urgencycommunicable and type disease of information information to be with disseminated. medical practitioners, depending on the urgency and type of information to be disseminated. During infectious disease outbreaks, the MedAlert System enables the rapid diDuringssemination infectious of information disease outbreaks, to all medical the practitioners, MedAlert System via SMS, enables email the and rapid fax. diMedicalssemination practitioners of information receive to timely all medical updates practitioners, on the outbreak via SMS, situation email and via fax.this syMedicalstem. practitioners receive timely updates on the outbreak situation via this sy stem. The MOH Weekly Infectious Disease Bulletin publishes detailed information onThe the MOH weekly Weekly incidences Infectious of infectious Disease diseases Bulletin including publishes graphs detailed demo informationnstrating ontrends the weekly and comparisons incidences of with infectious the preceding diseases including year. The graphs weekly demo bulletinnstrating is accesstrends ible and online comparisons at: with the preceding year. The weekly bulletin is access. i ble http://www.moh.gov.sg/mohcorp/statisticsweeklybulletins.aspx online at: or . http://http://www.moh.gov.sg/mohcorp/statisticsweeklybulletins.aspxwww.cdlens.moh.gov.sg (hyperlink from CD-LENS). or . http://www.cdlens.moh.gov.sg (hyperlink from CD-LENS). The Quarterly Epidemiological News Bulletin and Annual Report feature Theepidemiological Quarterly Epidemiological analyses of infectiousNews Bulletin diseases, and Annual detailed Report reports feature on investigationepidemiological findings analyses of diseases of infectiousoutbreaks and diseases, control measures detailed ta reportsken, public on healthinvestigation related findings research of findings diseases and outbreaks information and controlon multi measures-agency collaborationtaken, public inhealth public related health research achievements. findings The and bulletin information can be on accessed multi-agency online at:collaboration in public. http://www.moh.g health achievements.ov.sg/mohcorp/publicationsnewsbulletins.aspx The bulletin can be accessed online at: or . http://www.cdlens.moh.gov.sghttp://www.moh.gov.sg/mohcorp/publicationsnewsbulletins.aspx (hyperlink from CD-LENS). or . http://www.cdlens.moh.gov.sg (hyperlink from CD-LENS). 154 154 New and better communication channels are being developed for more timely and effective sharing of communicable disease information with medical practitioners, Newwith and the better aim of communication early detection channels of infectious are being diseases developed and for prompt more response timely and to effectiveoutbreaks. sharing of communicable disease information with medical practitioners, with the aim of early detection of infectious diseases and prompt response to outbreaks. I nfectious Disease Notifications and Anecdotal Reporting IMedicalnfectious practitioners Disease N otificationsplay a vital androle Ainnecdotal the surveillance Reporting of communicable diseases. Timely and complete notifications of infectious diseases and anecdotal reporting of clustersMedical practitioners of infectious play syndromes a vital role are in importantthe surveillance for early of communicable detection of diseases. disease ouTimelytbreaks and and complete rapid response notifications for disease of infectious control. diseases and anecdotal reporting of clusters of infectious syndromes are important for early detection of disease ou tbreaksNotification and rapid of responseInfectious for Diseases disease control. Medical practitioners are reminded to notify all infectious diseases on MD131 FormNotification via: of Infectious Diseases Medi. Electroniccal practitioners Notification are reminded System to (CD notify-LENS) all infectious @ http://www.cdlens.moh.gov.sg diseases on MD131 FormOR via: . FaxElectronic -Fax No. Notification 6254 1616 System (for HIV, (CD AIDS)-LENS) @ http://www.cdlens.moh.gov.sg OR -Fax No. 6252 4051 (for tuberculosis via MD532) . Fax - Fax-Fax N No.o. 6299 6254 4335 1616 (for (for sexually HIV, AIDS)-transmitted infections) -Fax No. 629943356252 4051 (for (for leprosy) tuberculosis via MD532) -Fax No.No. 62216299 55284335 or(for 6221 sexually 5538- transmitted(for all other infections) infectious diseases) -Fax No. 62994335 (for leprosy) Anecdotal -Fax Reporting No. 6221 5528 or 6221 5538 (for all other infectious diseases) If you notice a cluster of infectious syndrome (e.g. a family cluster of gastroeAnecdotalnteritis Reporting or a cluster hand-foot-mouth disease cases in a child care centre) orIf an you unusual notice occurrence a cluster of of an infectious infectious syndrome disease in (e.g.excess a of family normal cluster (e.g. an of unusgastroeuallynteritis large or numbera cluster ofhand dengue-foot -mouth fever casesdisease seen cases at in the a child practice), care centre) please informor an unusual MOH Communicable occurrence of anDis infectiouseases Surveillance disease inteam excess at : of normal (e.g. an unus. Tollually free large line: number 1800-325 of 8451 dengue fever cases seen at the practice), please inform MOH Communicable Diseases Surveillance team at : For. reportingToll free line: of mosquito 1800-325 breeding 8451 sites, unhygienic food establishments and other environmental concerns, please call NEA at: For. reportingToll free line: of mosquito 1800-225 breeding 5632 sites, unhygienic food establishments and other environmental concerns, please call NEA at: . Toll free line: 1800-225 5632 155 155 Appendix 5 Appendix 5 LIST OF INFECTIOUS DISEASES LEGALLY NOTIFIABLELIST OF UNDER INFECTIOUS THE INFECTIOUS DISEASES DISEASES ACT LEGALLY______NOTIFIABLE UNDER THE INFECTIOUS DISEASES ACT ______ Diseases and deaths to be notified within 24 hours from time of diagnosis to Director, Communicable Diseases Division, MOH (Fax 62215528/62215538) Diseases and deaths to be notified within 24 hours from time of diagnosis to 1. Director,Avian influenza Communicable Diseases Division, MOH (Fax 62215528/62215538) 2. Campylobacteriosis 1.3. AvianChikungunya influenza fever 2.4. CampylobacteriosisCholera 3.5. ChikungunyaDengue fever fever 4.6. CholeraDengue haemorrhagic fever 5.7. DengueEncephalitis, fever viral 6.8. DengueHand, foot haemorrhagic and mouth diseasefever 7.9. Encephalitis,Legionellosis viral 8.10. Hand,Malaria foot and mouth disease 9.11. LegionellosisMelioidosis 12.10. MeningococcalMalaria disease 13.11. NipahMelioidosis virus infection 14.12. ParatyphoidMeningococcal disease 13.15. NipahPlague virus infection 14.16. ParatyphoidSalmonellosis 15.17. PlSevereague acute respiratory syndrome (SARS) 16.18. SalmonellosisTyphoid 17.19. SevereYellow feveracute respiratory syndrome (SARS) 18. Typhoid 19. Yellow fever Diseases to be notified within 72 hours from time of diagnosis to Director, Communicable Diseases Division, MOH ((Fax 62215528/62215538) Diseases to be notified within 72 hours from time of diagnosis to Director, 20. CommunicableDiphtheria Diseases Division, MOH ((Fax 62215528/62215538) 21. Haemophilus influenza type B (Hib) disease 22.20. HepatitisDiphtheria (acute), viral 23.21. MeaslesHaemophilus influenza type B (Hib) disease 24.22. MumpsHepatitis (acute), viral 25.23. PertussisMeasles 26.24. PneumococcalMumps disease (invasive) 27.25. PoliomyelitisPertussis 28.26. RubellaPneumococcal disease (invasive) 27. Poliomyelitis 28. Rubella 156 156 Diseases to be notified within 72 hours from time of diagnosis to Head, National Public Health Unit, MOH (Fax 62541616) Diseases to be notified within 72 hours from time of diagnosis to Head, 29. NationalAcquired immunePublic Health deficiency Unit syndrome, MOH (Fax(AIDS) 62541616) 30. Human immunodeficiency virus (HIV) infection (non-AIDS) 29. Acquired immune deficiency syndrome (AIDS) 30. Human immunodeficiency virus (HIV) infection (non-AIDS) Disease to be notified within 72 hours from time of diagnosis to Director, Tuberculosis Control Unit, STEP Registry (Fax 62524051) via MD532 Disease to be notified within 72 hours from time of diagnosis to Director, 31. Tuberculosis Control Unit, STEP Registry (Fax 62524051) via MD532 31. DiseaseTuberculosiss to be notified within 72 hours from time of diagnosis to Head, Department of STI Control Clinic (Fax 62994335) Disease s to be notified within 72 hours from time of diagnosis to Head, Department of STI Control Clinic (Fax 62994335) 32. Chlamydial genital infection (only laboratories required to notify) 33. Genital herpes (first episode, or recurrent) 32.34. ChlamydialGonorrhoea genital infection (only laboratories required to notify) 35.33. NonGenital-gonococcal herpes (first urethritis episode, or recurrent) 36.34. SyGonorrhoeaphilis (non -infectious - latent/tertiary; infectious - primary/secondary; congenital) 35. Non-gonococcal urethritis 36. DiseaseSyphilis (nonto be-infectious notified within- latent/tertiary; 72 hours infectious from time - primary/secondary; of diagnosis to Director, congenital) National Skin Centre, Leprosy Registry (Fax 62994335) Disease to be notified within 72 hours from time of diagnosis to Director, 37. LeprosyNational Skin Centre, Leprosy Registry (Fax 62994335) 37. Leprosy 157 157 Notification Forms Appendix 6 INFECTIOUS DISEASES ACT MD 131 (CHAPTER 137) Notification Forms Regulation 3Appendix 6 INFECTIOUS DISEASES (NOTIFICATION OF INFECTIOUS DISEASES) REGULATIONS INFECTIOUS DISEASES ACT NOTIFICATION OF INFECTIOUS DISEASES UNDER SECTION 6 MD 131 (CHAPTER 137) PARTICULARS OF PATIENT (Please appropriate box where applicable) Regulation 3 Name of Patient (BLOCK LETTERS)INFECTIOUS DISEASES (NOTIFICATION OF INFECTIOUSNRIC No./PassportDISEASES) REGULATIONS No./Foreign Identification Number (FIN) NOTIFICATION OF INFECTIOUS DISEASES UNDER SECTION 6 PARTICULARS OF PATIENT (Please appropriate box where applicable) Name of Patient (BLOCK LETTERS) NRIC No./Passport No./Foreign Identification Number (FIN) Gender Date of Birth (dd/mm/yyyy) Ethnic Group Residential Status Occupation Male Chinese Indian Resident Female Malay Others Non-Resident Gender Date of Birth (dd/mm/yyyy) Ethnic Group Residential Status Occupation Residential Address Postal Code Male Chinese Indian Resident Telephone No. Home PlaceFemale of Work/School/Child Care Centre/Kindergarten Malay Others Non-ResidentPostal Code Office/HP/PG Residential Address Postal Code Telephone No. DISEASE DIAGNOSED (CLINICAL OR LABORATORY DIAGNOSIS) Home Place of Work/School/Child Care Centre/Kindergarten Postal Code @ TO CDD NOT LATER THAN 24 HOURS FROM TIME OF DIAGNOSIS. FAX NO. 62215528Office/HP/PG OR 62215538 DISEASE1. Avian DIAGNOSED Influenza (CLINICAL OR LABORATORY8. Hand, Foot & MouthDIAGNOSIS) Disease 15. Plague TO CDD2. Campylobacteriosis@ NOT LATER THAN 24 HOURS FROM9. TIMELegionellosis OF DIAGNOSIS. FAX NO.16. 62215528Salmonellosis OR 62215538 3. Chikungunya Fever 10. Malaria 17. SARS 4.1. CholeraAvian Influenza 11.8. Hand,Melioidosis Foot & Mouth Disease 15.18. Plague Typhoid 5.2. DengueCampylobacteriosis Fever 12.9. LegionellosisMeningococcal Disease 19.16. SalmonellosisYellow fever 6.3. DengueChikungunya Haemorrhagic Fever Fever 13.10. NipahMalaria Virus Infection 17.20. SARSOthers(specify)______7.4. Encephalitis,Cholera Viral 14.11. ParatyphoidMelioidosis 18. Typhoid 5. Dengue Fever 12. Meningococcal Disease 19. Yellow fever For any disease not appearing in this form,which may be of an infectious nature and result in an epidemic. If name of disease is not known, please specify symptoms. TO CDD6. Dengue@ NOT Haemorrhagic LATER THAN Fever 72 HOURS FROM13. TIME Nipah OFVirus DIAGNOSIS. Infection FAX NO.20. Others(specify)______62215528 OR 62215538 7.#21. Encephalitis, Diphtheria Viral 14.#24. Paratyphoid Hepatitis B, acute #28. Mumps For any#22. disease Haemophilus not appearing influenzae in this form,whichtype may b be of an infectious25. nature Hepatitis and result C, in acutean epidemic. If name of disease is not known,#29. pleasePertussis specify symptoms. @ TO CDD (Hib)NOT Disease LATER THAN 72 HOURS FROM 26.TIME Hepatitis OF DIAGNOSIS. E, acute FAX#30. NO. Pneumococcal 62215528 OR Disease 62215538 (Invasive) #23.#21. HepatitisDiphtheria A, acute #27.#24. HepatitisMeasles B, acute #28.#31. MumpsPoliomyelitis # For#22. notifiable Haemophilus diseases influenzae marked #,type please b provide vaccination25. Hepatitis history C, acute: #32.#29. RubellaPertussis (Hib) Disease 26. Hepatitis E, acute #30. Pneumococcal Disease (Invasive) Yes - If yes, Date of vaccination (dd/mm/yyyy) No #23. Hepatitis A, acute #27. Measles #31. Poliomyelitis ¶ TO# ForNPHU notifiableNOT diseases LATER marked THAN #, 72 please HOURS provideFROM vaccination TIME OF history DIAGNOSIS.: FAX#32. NO. Rubella 62541616 33. Yes AIDS - If yes, Date of vaccination (dd/mm/yyyy)34. HIV Infection (non-AIDS) No TO NSCNPHU¶NOTNOT LATER LATER THAN THAN 72 72 HOURS HOURSFROMFROM TIME TIME OF OF DIAGNOSIS. DIAGNOSIS. FAX FAX NO. NO. 62994335 62541616 *35.33. Chlamydia AIDS Genital Infection 34. *38. HIV Non Infection-Infectious (non Syphilis-AIDS) (latent/tertiary) *41. Genital Herpes (first episode) *36. Gonorrhoea *39. Infectious Syphilis (primary/secondary) *42. Genital Herpes (recurrent) TO NSC NOT LATER THAN 72 HOURS FROM TIME OF DIAGNOSIS. FAX NO. 62994335 *37. Non-Gonococcal Urethritis *40. Congenital Syphilis 43. Leprosy *35. Chlamydia Genital Infection *38. Non-Infectious Syphilis (latent/tertiary) *41. Genital Herpes (first episode) * For sexually transmitted infections marked *, full name, NRIC/Passport No./FIN, address and telephone number need not be completed. *36.Initials, Gonorrhoea date of birth, ethnic group and residential*39. Infectiousstatus of the Syphilis patient (primary/secondary) should be given. *42. Genital Herpes (recurrent) Circle*37. Non as -appropriateGonococcal Urethritis *40. Congenital Syphilis 43. Leprosy FOR* For TB sexuallyPlease transmitted use Notification infections of Tuberculosis marked *, full Form name, (MD532) NRIC/Passport to notify No./FIN,TBCU (FAX address No. 62524051)and telephone not numberlater than need 72 hoursnot befromcompleted. Initials, date of birth, ethnic group and residential status of the patient should be given. the time of diagnosis. Circle as appropriate Diagnosis Date of onset of illness Follow-up of patient FORClinical TB Please Confirmed use Notification by laboratory of Tuberculosis tests (dd/mm/yyyy, Form (MD532) for tolaboratory notify TBCU (FAX No.Treated 62524051) as outpatient not later than 72 hours from Date presentthe diagnosis time of diagnosis was made/. suspected notification, please provide the Referred to Communicable Disease Centre For laboratory notification, please provide the date of receipt of sample) Referred to DSC / TBCU dateDiagnosis of test of positive sample Date of onset of illness Follow-up of patient Clinical Confirmed by laboratory tests (dd/mm/yyyy, for laboratory Hospitalised DeathTreated as outpatient Date present diagnosis was made/(dd/mm/yyyy) suspected notification, please provide the OthersReferred (specify) to Communicable ……………………... Disease Centre For laboratory notification, please provide the date of receipt of sample) Travel history over the past one month Referred to DSC / TBCU date of test of positive sample Hospitalised From (dd/mm/yyyy) (dd/mm/yyyy) to DeathCountries visited : ………………………..……….. Others (specify) ……………………... PARTICULARSTravel history over OFthe pastINFORMANT one month FromName (dd/mm/yyyy) of Medical Practitioner/Scientist (BLOCK LETTERS) to Signature andCountries Date visited : Phy………………………..………..sician Code (MCR No.) PARTICULARS OF INFORMANT Name ofand Medical Address Practitioner/Scientist of Clinic/Hospital/Institution/Laboratory (BLOCK LETTERS) Signature Postal and Date Code PhyTelephonsician eCode Number (MCR No.) Remarks : Name and Address of Clinic/Hospital/Institution/Laboratory Postal Code Telephone Number Remarks : 158 158 EXPLANATORY NOTES @ CDD : Director, Communicable Diseases Division, Ministry of Health, 16 College Road, EXPLANATORY Singapore NOTES 169854, Tel: 1800-3258451 (Toll free line), 63258357, 63258358, Fax:62215528 / 62215538 @ CDD : Director, Communicable Diseases Division, Ministry of Health, 16 College Road, ¶ NPHU Singapore: Head, National 169854, Public Tel: 1800Health-3258451 Unit, c/o (Toll 142 freeMoulmein line), 63258357, Road, Singapore 63258358 308087,, Fax:62215528 Tel: 62568123, / 62215538 Fax:62541616 ¶ NPHUTBCU c/o: Head, STEP National Registry Public : Director, Health TB Unit, Control c/o 142 Unit Moulmein c/o STEP Road, Registry, Singapore 142 Moulmein 308087, Road,Tel: 62568123, Singapore Fax:62541616 308087, Tel:62584369, Fax:62524051 TBCU c/o STEP Registry : Director, TB Control Unit c/o STEP Registry, 142 Moulmein Road, Singapore 308087, NSC : For diseases (35) to Tel:62584369, (42), to Head, Fax:62524051Department of STI Control, Blk 31 Kelantan Lane #01-16, Singapore 200031, Tel: 62939648, Fax:62994335 NSC : For diseases (35) to (42), to Head, Department For of (44) STI Leprosy, Control, to Blk Director, 31 Kelantan National Lane Skin #01 Centre,-16, Singapore c/o Leprosy 200031, Registry, Blk 31 Kelantan Lane #01-16, Singapore 200031, Tel: 62939648, Fax:62994335 ForTel: (44)62939648, Leprosy, Fax:62994335 to Director, National Skin Centre, c/o Leprosy Registry, Blk 31 1.Ke Notificationlantan Lane is#01 required-16, Singapore in accordance 200031, with section 6 of the Infectious Diseases Act. 2. This notification form should be used whenever a notifiable Tel: 62939648, infectious Fax:62994335 disease is diagnosed or suspected in a clinic, hospital or laboratory. 1. Notification is required in accordance with section 6 of the Infectious Diseases Act. 2. This notification form should be used whenever a notifiable infectious disease is diagnosed or suspected in a clinic, hospital or l aboratory.01.11.2010 01.11.2010 159 159 160 160 161 161 162 163 164 165 166 167 168 169 170 171 USEFUL CONTACT NUMBERS USEFUL CONTACT NUMBERS Communicable Disease Centre (CDC), Tan Tock Seng Hospital Operator: 62566011 / Fax: 62524056 Communicable Disease Centre (CDC), Tan Tock Seng Hospital Operator:Infectious 62566011Diseases physician / Fax: 62524056 on call, CDC/TTSH Operator: 62566011 Infectious Diseases physician on call, CDC/TTSH MinistryOperator: of 62566011 Health (MOH) Singapore Tel: 63259220 / Fax: 62241677 Ministry of Health (MOH) Singapore Tel:MOH 63259220 Communicable / Fax: 62241677 Diseases Surveillance Tel: 1800-325 8451 MOH Communicable Diseases Surveillance Tel:NEA 1800 Call- 325Centre 8451 Hotline 1800-CALL NEA (1800-2255 632) Fax:NEA 62352611 Call Centre Hotline 1800-CALL NEA (1800-2255 632) Fax:Department 62352611 of STI Control Tel: 62939648 Department of STI Control Tel: 62939648 Infectious diseases on the World Wide Web: GeneralInfectious and diseases emerging on infectious the World diseases Wide Web: websites: http://www.cdc.gov/ (CDC Atlanta website) General and emerging infectious diseases websites: http://www.cdc.gov/mmwrhttp://www.cdc.gov/ (CDC (Morbidity Atlanta website) and Mortality Weekly Report) http://www.who.int/en/http://www.cdc.gov/mmwr (WHO (Morbidity website) and Mortality Weekly Report) hthttp://www.who.int/en/tp://www.promedmail.org (WHO (International website) Society for Infectious Diseases) http://www.moh.gov.sghttp://www.promedmail.org ( Ministry (International of Health, Society Singapore) for Infectious Diseases) http://www.cdlens.mohhttp://www.moh.gov.sg.gov.sg ( Ministry (CDLENS of Health, Electronic Singapore) Notifi cation System, MOH) http://app.nea.gov.sghttp://www.cdlens.moh (National.gov.sg (CDLENS Environment Electronic Agency Notifi, Singapore)cation System, MOH) http://app.nea.gov.sg (National Environment Agency, Singapore) Travel-related and tropical medicine websites: Travel http://www.cdc.gov/travel/-related and tropical medicine (Travellers websites: Health, NCID) http://www.who.int/ith/http://www.cdc.gov/travel/ (International (Travellers Travel Health, and NCID) Health, WHO) www.vaccines.comhttp://www.who.int/ith/ (Suitable (International for both Travelpublic andand healthHealth, professionals) WHO) www.vaccines.com (Suitable for both public and health professionals) 172 172