THESMANEWS Vol 30 NO 4 Aril 1998

Our challenge going forward is to balance the pursuit

Iof medical excellence and affordability of healthcare to individuals, their families and the community.

■ SPEECH BY DPM LEE HSIEN LOONG AT OFFICIAL OPENING OF CHANGI GENERAL HOSPITAL

Ladies and Gentlemen, Institute, or the National Cancer Centre. These three levels 1. I am happy to be here this morning to declare the of the hospital system serve different segments of the opening on the new Changi General Hospital. patient population according to different medical needs. CONTENTS Together, they enable patients to enjoy the best care President's Forum 2 2. Changi General Hospital is the first of our new- Commentary possible at the best value. 3 generation regional hospitals. Developed at a cost of $380 Reflections 4 Materia-Non-Medica 6 million, it replaces two of our old hospitals, Changi Letter to the Editor 8 Hospital which was built in the 1930s, and Toa Payoh Regional Hospitals Medical Students' Column 9 Hospital which has been operating for 37 years. It will Classified Ads 10 6. Regional hospitals like Changi General are the main provide high quality medical care across a wide range of providers of hospital care in the acute hospital network. specialities, wider than what Toa Payoh Hospital and the We envisage three regional hospitals in Singapore: Changi EDITORIAL BOARD old Changi Hospital used to provide. The types of medical Editor General in the east; Tan -lock Seng Hospital serving the care provided include general medicine, general surgery, A/Prof Goh Lee Gan central sector; and eventually a new hospital serving the orthopaedic surgery, geriatrics, rehabilitation medicine and Assistant Editor west. They have the appropriate levels and mix of medical, psychiatry, ENT and eye, plus two sub-specialities: gastro- Dr Wong Chiang Yin nursing and paramedical personnel. They are equipped with enterology and urology. Members modern facilities and equipment. They have the resources Dr Au Kah Kay 3. Changi General Hospital is part of the Ministry of and the professional capability to manage most patients Dr Chan Kah Pone A/Prof Chee Yam Chang Health's master-plan to build a modern hospital network efficiently and effectively. Dr Goh Jin Hian of developed-country standards, to meet the needs of 7.For most medical conditions, Singaporeans should regard Dr Jon Goh the Singaporean population for the 21st century. In the the regional hospital nearest them as the hospital of their Dr Tan Hooi Hwa past decade, the Health Ministry has built or redeveloped first choice. For all but the most complex problems, regional Ex-officio 5 hospitals, 4 national centres and 8 polyclinics. The Dr Wong Chiang Yin hospitals will provide good quality and affordable care. upgrading programme will continue. The Government is Dr Cheong Pak Yean Should they need to be referred to a tertiary hospital or a committed to provide Singaporeans with excellent and Executive Secretary national centre because of their medical condition, the affordable health care. This is part of our vision of Our Ms Chua Gek Eng regional hospital will do so. Regional hospitals, tertiary Best Home for Singaporeans. Editorial Assistants hospitals and national centres will cooperate closely to Ms Tan Hwee Ping Ms Hazel Goh 4. Changi General will be the main hospital serving the handle referrals smoothly. They share the goal of quality eastern part of Singapore. We have decided to rename it service. Changi General Hospital rather than New Changi Hospital. The views and opinions expressed in 8. The Government encourages each regional hospital to all the articles are those of the The new name better reflects its role as a regional hospital authors. These are not the views of excel in one or two specialities or sub-specialities. This offering a broad range of services, and also the main the Editorial Board nor the SMA will enhance the professional standing and public reputation Council unless specifically stated so provider of hospital services for the 750,000 Singaporeans of the hospitals. It will help them to attract and retain in writing. The contents of the living east of Kallang Basin. Newsletter are not to be printed in good staff. It will also encourage Singaporeans living in whole or in part without prior written approval of the Editor. the vicinity to use regional hospitals as the hospital of Published by the Acute Hospital Network their choice. For example, Changi General Hospital has Singapore Medical Association, Level 2, Alumni Medical Centre, 5. The national network of acute hospitals comprises of capabilities in gastro-enterology and urology. The 2 College Road, Singapore 169850 regional hospitals such as Changi General Hospital, Government will also consider allowing Changi General to Telephone 223 1264 Facsimile 224 7827 tertiary hospitals such as Singapore General Hospital and develop other clinical services, if there is high demand from Email [email protected] National University Hospital, and national centres such the catchment population of the hospital, and if it can URL httpt//www.sma.org.sg as the National Heart Centre, the National Neuroscience successfully do so. ► N5 President's Forum Commentary

THE TASKS AHEAD AGM NEWS The Last Whistle EXCELLENT, AFFORDABLE HEALTHCARE THE 38TH SMA COUNCIL When peer pressure fails This is my third term as President of SMA and by The 38th Annual General Meeting of the SMA was Excellent, affordable healthcare is dependent on necessary towards excellent, affordable meaningful role in the patient management. He constitution, this will be my last consecutive year held on Sunday, 19 April 1998. The following were What remains? several elements. Defined delivery systems and a healthcare. One is the patient. 130 Lee has also must know enough doctors in that hospital to be as President. The AGM has returned al the elected as office bearers for the 39th Council for The letter of the law prevailing ethos of cooperation .are two of such alluded to this. The patient needs to be discerning able to receive help and support professionally candidates that I know will provide the leadership 1998/1999. The rhetoric of ethics elements. These are reflected in BG Lee Hsien Loong's and to use the various elements of the health at the time he needs that. and the continuity ahead. President Dr Cheong Pak Yean And the whistle from our hearts address on the occasion of the opening of the Changi care delivery system appropriately. He or she Many hospitals have seen the merits of My first task in the third term is to list the 1st Vice President A/Prof Goh Lee Gan General Hospital. The text of his address forms should make use of the regional hospitals instead developing the doctors in their drainage areas. tasks that some committees would tackle. 2nd Vice President Dr Lim Teck Beng We whistled loud of tertiary hospitals where appropriate. Similarly, Honorary Secretary Dr Wong Chiang Yin the lead article in this issue of the Newsletter. Perhaps, more primary care doctors should avail We fought on We have over the years developed a good if the patient would make use of his primary care themselves of such linkages. Notwithstanding 1.MEMBERSHIP COMMITTEE Hon Asst Secretary Dr Goh Jin Hian healthcare infrastructure. This is however, not doctor, then the workload in the A & E and these linkages, there are still problems in the We have to look at the declining percentages of Honorary Treasurer Dr Tan Sze Wee Is our cause forlorn? enough. There is a need for regional hospitals, hospital walk-in clinic will be much reduced. The shared care programmes. Many patients in the SMA membership in private practice over the Is our calling now. drowned The other newly-elected members of the 39th tertiary hospitals and national centres to co- queue will be shorter and the service will be faster. shared care programmes return to hospital care past few years. Though we have not done by the clang of cash registers? SMA Council are Dr Ang Peng Tiam, Dr Vivian operate closely to handle referrals smoothly. Each All it needs is for every citizen to use it only for because the primary care doctor can never detailed analyses, we suspect that the sectors Balakrishnan, Dr Chow Wan Cheng, Dr Chong Yeh must do what one is good at and appropriate for real emergencies. provide the medicines at the cost that the least represented are either general practitioners Woei and Dr Yue Wai Mun. But now the last whistle his level of care. For this to happen, we need a The other area of cooperation is between hospital can. The hospital is able to get cheaper practising alone or assistants working in group Dr Cheong Pak Year, Dr Lim Teck Beng, Dr Tan Has reverberated change of mindset. There is a need of a mental the hospital and the primary care clinics. Doctors medicines because of quantity purchase. Perhaps, practice. Kok Soo, Dr Wong Chiang Yin, Dr Lee Pheng Soo, Through HDB and regal corridors revolution to value working with one another. The in the government polyclinics and private clinics this advantage could be shared with the We also need to look at the question of A/Prof Low Cheng Hock, Dr T Thirumoorthy and The albatross now hangs credo of institutions have to change to what is can play a bigger role if their services are put to participating primary care doctors. spouse membership again. The constitutional Dr Wong Wang Hong, who were elected to the their role in patient care, research and optimal use. The primary care doctor should be Excellent, affordable health care is possible amendment made last year to reduce the 38th SMA Council, will continue to serve their on our necks and more professional development of doctors. The linked to the regional hospital of his district in in Singapore, if we seek out avenues to see how subscription for this group have not achieve any second year on the 39th SMA Council. organisation of seminars for GPs and public talks more than one sense. He should be linked through we can cooperate and enable each of us to do a result. Also, lady doctors are under-represented Should we all bother should not be for more market share. They should patient care, through referrals and also in his better job. And this applies to the patient too. at all levels. We are quite fortunate to have a C/Prof Chao Tzee Cheng and Dr When doctors can only prosper be aimed at reinforcing the notion of working professional development. He must have the After all, he or she is the most important factor lady council member this year after a hiatus of Wong Heck Sing elected as SMA By trading patients like fodder? together for good, affordable medical care. confidence he will get his patient whom he has in the health care provision equation. Food for at least 5 years. Maybe this council would be Honorary Members And whistle blowers should beware Two other areas of cooperation are referred back to him again. He must have a thought. ■ able to increase participation by lady doctors. The Singapore Medical Association is honoured that during the 38th SMA AGM held on 19th April 1998, Pounds of flesh prepare A/PROF G OH LEE GAN 2.ETHICS COMMITTEE C/Prof Chao Tzee Cheng and Dr Wong Heck Sing The Ethics Committee has steadily made were elected to Honorary Membership in recognition Will this last whistle progress. This year, the committee ambit would of their services to the medical profession and the Be the clarion of a new bidding community. The official conferment of the be further enlarged and this would be reflected Or the knell of medicine's calling? in the appointment of 3 vice-chairmen, one for Honorary Membership will be held on 25 April ■ Will this whistle each of the areas in ethical policy, special case 1998, at the SMA Annual Dinner. Be the last of our pleading? Glaxo Wellcome plc management and publications.

The committee would look into pro-active Medical Advisory Board IMPORTANT NOTIFICATION RELATING TO INTELLECTUAL PROPERTY case management and mediation in certain cases. Mount Elizabeth Hospital WHISTLE BLOWERS PROTECTION ON RANITIDINE AND RANITIDINNE HYDROCHLORIDE The ethical policy group would be looking into CARDIOLOGY, THORACIC & Glaxo Wellcome's ranitidine products for the treatment of ulcers and other gastrointestinal disorders are sold in Singapore by Glaxo Wellcome the issue of media interviews and publications CARDIOVASCULAR SURGERY Singapore Pte Ltd under the registered trademark by doctors. More important, the Ethics and SPECIALTY GROUP Practice Manual would be published before the TALK ZANTAC end of this council's term. Thursday, 28 May 1998 1.00 pm to 2.00 pm These products continue to be an important part of Glaxo Wellcome's portfolio of healthcare products in Singapore and elsewhere. 3.PRIVATE PRACTICE COMMITTEE The specific polymorphic form of ranitidine hydrochloride known as Form 2, which is the active constituent in Zantac• products, is the The subject of the clinic dispensary was discusssed TOPIC subject of Singapore Patent Registration No. 522/85, which remains in force until 1 October 2001. at the AGM. A task force within an enlarged private Current Issues in Cardiovascular Medicine 38TH SMA COUNCIL practice committee would study the subject in SPEAKER President Dr Cheong Pak Yean Glaxo Wellcome also holds patents and other intellectual property rights in Singapore relating, inter alia, to processes for making ranitidine Dr Michael Lim depth and initiate necessary actions. The guideline 1st Vice President Dr Lim Took Bong hydrochloride and certain intermediates, and to specific formulations and presentations, all of which remain in force until at least 2003. CASE PRESENTATION 2nd Vice President Dr Tan Kok Soo for charges for medicine would also be published It has come to the attention of Glaxo Wellcome that certain parties in Singapore have been involved in importing, offering for sale, selling and "Limb Salvage" — Dr C Sivathasan Honorary Secretary Dr Wong Chiang Yin distributing "Urantac" 150mg tablets which are not manufactured by or with the consent of Glaxo Wellcome, and which contain Form 2 by the end of this council's term. CHAIRMAN Hon Asst Secretary Dr Tan Sze Wee Dr Lim Chin Hock Honorary Treasurer Dr Goh Jin Hian ranitidine hydrochloride, which is protected by the aforementioned Singapore Patent Registration No. 522/85. Council Members Dr Lee Pheng Soon, 4. INVITATION TO PARTICIPATE VENUE Consumers and members of the public Ile advised that all genuine Glaxo Wellcome products are sold in Singapore under the Zantac Seminar Room 1, Education Centre A/P Low Cheng Hock, We are enclosing the names and contacts Mount Elizabeth Hospital #02-01 Dr Low Lip Ping, trademark by Glaxo Wellcome's Sole Distributor, Inchcape Healthcare. Purchases of such products should only be made from the Sole numbers of the chairmen/vice-chairmen Singapore 228510 Dr W R Rasanayagam, Distributor or from authorised dealers appointed by the Sole Distributor. appointed to the various committees in an Dr Tan Yew Ghee, Lunch is sponsored by Mount Elizabeth Hospital Dr T Thirumoorthy, TAKE NOTICE that Glaxo Wellcome will vigorously enforce its intellectual property rights in respect of ranitidine and ranitidine hydrochloride enclosure. Please response to indicate the area and will be served at 12.00 pm Dr Wong Tien Yin, by commencing legal proceedings and seeking remedies including injunctions, delivery up of infringing products, damages and legal costs, as you are interested in. ■ Dr Wong Weng Hong, well as commencing criminal prosecution if necessary, in the event of infringement by authorised development sale, offer for sale, manufacture, This talk has been accredited Dr Jason S K Yap, with one CME point importation, or stock-piling of ranitidine hydrochloride. Dr Yue Wai Mun DR CHEONG PAK YEAN All doctors are welcome

N2 N3 1 Reflection] Food For Thought ccnt'd from N1 "SPEECH BY OPM LEE AT OFFICIAL OPENING OF THE CHANGI GENERAL HOSPITAL"

Should we accept it as the sign of the times? Or should THE PROFIT GUARANTEE: JOURNAL SAYS AMERICANS 9. Regional hospitals can build closeness to the Tertiary Hospitals and National we remind doctors of their promise to society - to THE GOVERNMENT'S LOSING FAITH IN DOCTORS communities they serve, and can reach out more Centres I to the communities than a national-level 13.Tertiary hospitals manage patients with more relieve suffering - as their manna and regard making POSITION institution can. Since moving into these new complex problems across a broad range of money as a secondary concern? The Journal of the American College of Physicians, warned on Tuesday, 14 April 1998, that US society facilities, Changi General has been conducting specialties. The two tertiary hospitals — SGH and The Government's position on profit guarantee was losing confidence in the ability of physicians health education talks, health screenings for • NUH — have the specialised expertise and was reported by the Straits Times and the to curb their appetite for money. The Annals of common diseases, and training for residents in facilities required to care for such patients properly: KK Women's and Children's Hospital is Business Times on 21 April 1998. The subject was Internal Medicine, which the doctors' group CPR and first aid. You have been running patient • THE PROFIT GUARANTEE_LA_SIGN OF THE TIMES? support groups and helping patients to learn self- a specialist hospital, catering to the special needs tabled by Mr Choo Wee Khiang, MP for Jalan publishes, said in its latest issue that a public care skills after being discharged from hospital .of women and children. Besar GRC on 20 April 1998 at the Parliament. loss of faith in medical ethics could be seen in for conditions such as diabetes, stroke and Doctors are aware of the meaning of caring for Dr A's letter to SMA He wanted to know how profit guarantee would efforts by the Congress and the Clinton 14. We have 5 national centres of excellence: for incontinence. You have also been working closely the patient. They are also aware of the constant affect the standard of medical practice here. This Administration to crack down on physician fraud. skin, eye, heart, cancer and neuroscience. These 14 April 1998 with other caregivers like general practitioners, tussle between patient interest and self interest. follows the recent Business Times report on the cover the most important specialised areas to meet Dear President, and plan to establish links with nearby nursing The world has become commercialised. Money deal struck in February between AsiaMatrix and our present and future healthcare needs. Three of I refer to your letter regarding the "profit homes and community hospitals, including offering is increasingly seen as a symbol of success. The the centres — National Heart Centre, Singapore guarantee", dated 11 April 1998. After all have been four specialists in private practice. The doctors "I hope that we them training and assistance. I commend the latest commercial arrangement to hit the National Eye Centre and National Skin Centre are said, what are you going to do about it? guaranteed AsiaMatrix a $4.36 million share of staff of Changi General on your efforts to make profession is the profit guarantee. Is this a sign in Singapore do well established. The National Cancer Centre and. Is the SMA going to recommend to the SMC to the profits annually for five years beginning on this the hospital of first choice for residents of of the times? recommend to the government to pass laws to the not end up in the National Neuroscience Institute will open in 1999. Jan 1, in exchange for it acquiring majority stakes the eastern part of Singapore. The gut feeling among many doctors is this effect that doctors cannot take part in profit making in their businesses. same boat..:' 15. I understand that the regional hospitals are has gone out-of-bounds of what is acceptable for themselves or for the health care organisations? 10.Regional hospitals allow Singaporeans to enjoy In reply, the Health Minister, Mr Yeo Cheow Professor SY Tan, concerned that the tertiary hospitals will take to the medical profession. We are seduced by Unless this is done, the resolution will just remain a good quality medical care at affordable prices. They Professor of Medicine patients away from them, and the tertiary hospitals resolution without any teeth, and nobody will be Tong said that "the Health Ministry supports the should avoid competing head-on with tertiary the charm of the so-called "free market forces" and Adjunct Professor are similarly worried about the national centres. bothered and everybody will continue in their own strong stand taken by the Singapore Medical hospitals and national centres. Their value lies in without balancing this with the long tradition of happy ways. In fact, in a very short time, all will be of Law They should not worry. The regional and tertiary Association (SMA) on the issue of doctors giving precisely that they can provide at lower cost the medical ethics that has been the guiding light to forgotten and more doctors will jump onto the of University of Hawaii hospitals will continue to manage the majority of best care for a large proportion of medical needs, the profession. "Free market" is seen as a bandwagon. What wants to be left behind? Who is profit guarantee". "These", said Mr Yeo, "will put patients within their capabilities, and refer only the by referring the minority of cases needing more panacea. We have forgotten where our values to be faulted? them at greater risk of unethical behaviour as difficult cases to the national centres. The different "That society should see a need for laws to expensive facilities and complex treatment to tertiary should be anchored. It will be a very sad day indeed for the medical they are working under purely financial types of hospitals are meant to collaborate with profession. protect patients from their physicians is hospitals and national centres. At the same time, What is doctoring? Is it the age-old promise imperatives imposed by a third party." The SMA's and complement one another. Specialists with the Is there any way to halt this onslaught on the disheartening:' an editorial in the journal by Dr tertiary hospitals and national centres should not and commitment to the patient and the resolution was also supported by the Singapore appropriate qualifications, expertise and experience, medical profession when more and more numbers of expand into those areas which are better met by community that the doctor will use his healing M Gregg Bloche, a medical doctor and legal no matter where they may be practising, should the medical community see no way out but join in Medical Council. regional hospitals. hand to reduce suffering? Or is it a means to expert at the Georgetown University Law the fray? Mr Yeo said that the four specialists "do not participate actively in clinical service, training and increase earning capacity? Center in Washington said, "Physicians should 11.On their part, Singaporeans needing medical research activities at the national centres. Be that as it may, I like to give my whole hearted contravene any existing laws, and the parties do The changing climate of medical practice has support to the resolution passed. As least SMA has heed the sobering message the laws send — services should use the level of care appropriate Specialists in the relevant departments in the public not require the ministry's approval." But he added evoked different emotions. To some there is taken a stand and I am in total agreement that ethical that Americans have lost faith in their physicians' to their needs. If they make unnecessary or hospitals will be offered concurrent appointments that the Ministry is "very concerned with any despair and a sense of helplessness. See Dr A's standards must be maintained. How to go about it ability to restrain themselves when tempted by excessive use of specialist services in the tertiary to the national centres. Those in the private sector other than through the Singapore Medical Council is letter to the SMA President. Some get angry and commercial transaction... which can lead to a money." hospitals and national centres, they will drive up will be invited to participate on a part-time basis. always the problem facing the SMA. resign from the SMA. See letter from B. lowering of our high professional and ethical The American College of Physicians, which medical costs, It will also mean longer waiting The SMA Council has decided that the profit Yours faithfully, standards of medical practice." "We must times for appointments and hospital beds, represents more than 100,000 doctors, has joined Conclusion Dr A remember that the doctor-patient relationship is physical overcrowding and long queues in these guarantee puts the doctor at risk of unethical the American Medical Association and other 16. We already have a first class healthcare (Editor's note: For purpose of confidentiality, the tertiary centres. Many patients now managed in behaviour and discourages doctors from being a different from other consumer-provider groups to seek new ways to root out abuse and system. Singaporeans have ready access to a doctor's name will not be revealed) the tertiary hospitals and national centres can party to such commercial arrangements. Some transactions, where the consumer has sufficient punish fraud while reducing unnecessary burdens wide range of preventive, curative and be just as well managed in regional hospitals, doctors who are waiting to jump on the knowledge of the service or product to make an on doctors. rehabilitative health programmes. We enjoy high and at lower cost. bandwagon may get angry and view this as informed choice. It is therefore vital... that the The College Journal's Editorial also called on quality medical care at affordable prices. We whistle blowing. It is encouraging that the doctor remains professionally independent to do the medical community to recommit itself to the 12. it is understandable that Singaporeans who have managed to achieve this by complementing Singapore Medical Council has supported the Dr B's letter to SMA what he believes is best for the patient." Hippocratic Oath, which embodies the essence need medical treatment want the best treatment Government subsidies with our philosophy of resolution passed by the SMA Council. 14 January 1998 possible. But if everyone looks for a specialist to He added that the Ministry of Health will of medical ethics. "Restoration of people's promoting personal responsibility for one's own To the doctor As and Bs in our medical do an MRI scan every time he has a headache, we health, and requiring co-payment of at least part Dear Sir, conduct more intensive audits on medical confidence in the medical profession's willingness profession, we need to move beyond despair and I have watched with dismay and will never have enough specialists or MRI machines, of the medical expenses when one falls ill. establishments at greater risk of compromise of to keep faith at the bedside should be a higher anger. These are emotions of futility. We need to disappointment the inability of the SMA to stem nor are we able to afford them. I urge Singaporeans priority for physicians than criticism of the fraud 17 Our challenge going forward is to balance encourage every thinking person in the medical the winds of change, from the practice of medicine professional or ethical standards, and will not to use these expensive facilities only for complex and abuse laws." it said. • the pursuit of medical excellence and affordability profession, in the public, and in our Goverment to to the marketing. of medicine. hesitate to act decisively to bring errant doctors medical conditions that cannot be adequately of healthcare to individuals, their families, and reflect on the increasing commercialisation of I do not wish to be a member of the SMA. before the Singapore Medical Council when treated elsewhere. In many developed countries, the community. We need to optimise the use of medical practice. Should we accept it as the sign Yours faithfully, needed. Source: David Morgan from Reuters, 14 April 1998 patients must be referred by a general practitioner the acute hospital network. The regional of the times? Or should we remind doctors of Dr B "Doctors who enter into business before they can see a specialist. Fortunately we do hospitals will play a crucial role in providing high their promise to society — to relieve suffering — (Editor's note: For purpose of confidentiality, the not need to do that yet. If we can convince arrangements must be circumspect and avoid any quality care to the large majority of patients. Editor's note: as their manna and regard making money as a doctor's name will not be revealed. The Secretary has situation or arrangement, which would potentially Singaporeans that regional hospitals provide as good accepted the member's letter of resignation hut hopes The Editor wishes to thank Professor SY Tan for care as the tertiary hospitals, that should help reduce 18. It is now my pleasure to declare the Changi secondary concern? • compromise their professional independence and that he will continue to exert efforts on his own to sending this piece of news from Reuters the problem. General Hospital open. • A/PROF GOH LEE GAN stem the winds of change. their patients' interests.", said the Minister. •

N4 N5 Materia-non-medica

"Endless, the distant hills IBlue upon blue, peak upon peak!'

■ GUNUNG TAHAN AND A HEALTHY LIFE-STYLE

Gunung Tahan, 2187 M, is the highest peak in the easiest. Then, a difficult stretch along a high Day 4 : 5.5.92 We pitched our tents on the grass at Padang higher and higher up the ridge and we were at Peninsular Malaysia. Situated on the main range river embankment before arriving at Kern Teku, Each day the scenery changed, like someone and, because of strong winds, secured the fly- the top! in Taman Negara (Malaysia's national park), its 168M, at 5.30pm. It has taken us 27 hills, one changed the prop on stage. Departing Wray Kern sheets firmly for our 2 nights stay. Our packs On top of Gunung Tahan, 2187 M at 1.30pm challenge "lies not so much in its height nor the mountain, 8 river crossings and 2 days to arrive at 9 am, we climbed an hour and reached Gunung were hung on trees because rats were around (a party from Kuala Lumpur arrived there before steepness of its sides, but rather in its at the foothills of Gunung Tahan and still the Pankin, 1400 M, and after another 45 minutes, the campsite at night. Bathed and collected water us) — the spot marked by a metal pylon with remoteness and inaccessibility." The round trip mountain peak was out of sight. its upper reaches at 1463 M. We were now at the nearby stream whilst Bob cooked dinner name-plates left behind by previous climbers. We from the park HO to the summit and back, a Erected tents, cooked rice, bathed by the above the clouds and there were excellent views in the rain, Bob always quietly cooking our meals. took photos, hoisted the Singapore flag and the Seletar Hash pennant enacted the climb on video, distance of about 110 Km, can be accomplished river, followed by "happy hour" and all our of the valleys below. The temperature was 16 degrees C in the and the rains came. by the fastest trekkers in 5 days. tiredness vanished. We continued our uphill climb and reached evening, dropping to 12 degrees C at night. The "No great deal!" was the general sentiment, Gunung Tangga 15, 1539 M, at noon, where we Southern Cross showed the way whence we had now that we had reached the top. But every Someone once said that adventure is hardship Day 3 : 4.5.92 stopped for a brief rest and resumed climbing. come. The Plough pointed at Tahan, which was mountain is its own, high or low, and to be reckoned recalled in the comforts of your sitting room. Thus, A late rising, and after a breakfast of porridge The terrain was steep and upwards almost all still out of sight, to the north. Then the mists On top of Tahan with. I shall never complain about Bukit Timah hill I tell my story. and tinned meats (energy needed for the climb) the way. The trail then ran along the top of a came and blotted out the sky. again. To each his own mountain. There was nothing Two months of "training" carrying 25 K packs we broke camp and departed at 10 am. We also narrow ridge with breathtaking views (like from more to do now other than to return. up and down an HDB highrise block with week- Three-quarters way across the Malang Hills carried a cooked lunch of rice, sausage and dried an aeroplane) on both sides. Day 5 : 6.5.92 end climbs on Bukit Timah hill and, mentally, we — a waterless ridge of 27 peaks between 300 — prawns (our constant ration) because there was We scaled up and down Gunung Reskit by It takes 3 hours from the Padang campsite to Day 6 : 75.92 were ready. 500 M high — we arrived at Kern Tengah, 379 M, no water on the way. ropes and paused for a dry lunch of biscuits in the top of Gunung Tahan. This was the day! We Coming down is always easier and this was the A chartered minivan from Johor Bahru took at 6pm and camped for the night. At a hidden the rain. "Eat, for energy!", urged William, our left at 10 am carrying only water, cooked lunch, fun part. One step retrieved meant one step us on an overnight ride to Jerantut, the town spring, 5 minutes down a steep slope, we drew leader, who was as shagged as anyone else. I medical kit (William's previous party was stung nearer home, one less obstacle to go, and so we nearest to the ferry point for the national park, water, precious living water, to wash ourselves "No great deal!" laid on the ground. The whole world was my grave. by hornets), the video and cameras. made it down-hill (equal to our 2 days uphill climb) but the 3 hour ferry ride in a 12 seater narrow and to cook rice for dinner, then settling down to was the general More vertical cliffs and rope-assisted climbs The trail to the summit (minus the guide) was to Kern Tuku in about 8 hours. motor-boat up the picturesque Sungei Tembeling a "happy hour" of brandy and retiring at Ilpm. sentiment, now and, finally we made the shoulder of Gunung easy to follow. Over the Padang plateau, up along found us catching up with lost sleep. that we had Gedong, which allowed a panoramic view of the the dried-up river beds of quartz rocks, orchids, Day 7 : 8.5.92 Day 2 : 3.5.92 Padang campsite below. pitcher plants and stunted vegetation all around, The return stretch from Kern Tuku to Kem Melantai Day 1 : 2.5.92 A sleepless night — I always have difficulty trying reached the top. (recovering the river crossings, Gunung Rajah and The Wildlife Department's office is situated in to sleep in strange places, even in a 5-star hotel But every the 27 hills) was our longest, departing at 9 am and Kuala Tahan at the park HO. After obtaining our — and it was dry and comfortable within our two mountain is its not arriving until after dark, in the rain, with torches, permits and declaring all tinned cans taken along large 6-man tents. All were aroused by a "morning own, high or low, at 750 pm. It was only on the return journey that (the empty tins had to be brought back at the call" at 6.30 am and after breakfast we broke and to be we could appreciate how far we had come. Like a risk of a penalty), we met Mohammed bin Hj camp at 8.30 am. reverse play on the cine, it was only now that I Ibrahim, the guide assigned to us, and discussed We continued up the Malang Hills, climbing reckoned with. dared to look beyond my footsteps to realise the our itinerary. William, our leader, had made a continuously, and in an hour reached Gunung To each his own long stretches we had covered. "secret" climb without a guide 5 years previously, Rajah, 576 M, the last and highest peak on the mountain. but a guide was now compulsory. ridge. "Rajah is nothing!" Psychologically, we had Day 8 : 9.5.92 Starting off at 8.45 am with myself (the triumphed. This last day was the easiest. Departing Kern slowest and oldest) to set the pace, we trekked Downhill all the way, we reached Kern Puteh, Uphill and uphill, "take 5", "take 10" at every Melantai at 9.45 am we made our way swiftly 4 hours across undulating lowland jungle with where we rested and cooked lunch from 11.15 am half-hour, and we reached Pondok Dua ("Two on flat terrain back to the park HO by .1 pm, many small streams and leeches a-plenty to reach to 1.30 pm and again hid our food for the return Humps"), or Wray's Camp, 1100 M, by 3 pm, where chilled beers (prepared by our advanced party) and a shower at the HO awaited us. Time Kem Melantai, where we cooked lunch by the journey. The scenery changed now from jungle where we settled for the night. Water was to throw away the dirty T-shirt I had worn for river and buried our food for the return journey. treks to river crossings, and we crossed the available 10 minutes down a steep track, where those 8 days and to inspect my two big toes, The jungle protected us from the fierce sun. From Sungei Tahan — a fast flowing, thigh-deep river — we bathed and collected water in bottles tied minus the nails, and the blisters over the heels. Melantai, it was uphill all the way. For me, it was 8 times, with the assistance of a stout stick, in around our necks, to cook rice and for the next Our return to Singapore was uneventful. We not the ultimate summit, but every step along the strong current. The guide assisted me by day's journey. were now ready for our "National Big Walk", the way, each step complete in itself, and every holding my outstretched hand, to which Henry We could have reached the next campsite scheduled for 24.5.92. Shall we try? ■ each moment, that made the journey. And as I made a rude remark — something about "giving further up, where there was prospect of a DR LIM KUANG HUI began to experience our every movement, I began away the bride". "beautiful sunrise", but there was no water up OPHTHALMOLOGIST IN PRIVATE PRACTICE Tel: 734 6666 Fax 734 6667 to enjoy the climb. The sixth river crossing, on a tree trunk, was. there. River crossing

N6 N7 Letter to the Editor Medical Students' Column

19 March 1998 advice from pharmacists and their doctors as safe- Pharmaceutics (physical pharmacy, pharmaceutical Letter from Oxford: Medical In my opinion, gaining entry to the clinical school aspects of your life. I am fortuitous in that I can guards. Pharmacists are ethically bound to regard technology, dosage form design) = 6 modules, Interviews is akin to a lottery. How does a 10 — 15 minute count myself among the few who were offered a Editor the health of their patients as their first Pharmacy Practice (pharmacy law, Miss Michelle Teo is a fourth year medical student interview allow one to judge if you are a suitable place without an interview. Perhaps ail that time The SMA News consideration. Section A (3) of the Code of Ethics pharmacotherapy, therapeutic drug monitoring) = 9 in Oxford University. She was involved in helping candidate to become a doctor? spent on a basketball court and an athletics track Singapore Medical Journal states that "A pharmacist should not encourage a modules, and Medical Sciences (taught by the the SMA collate a community service directory. For major corporations, interviewing job accomplishes much more than just self-fulfilment. member of the public to purchase or obtain more Faculty of Medicine — anatomy, physiology, candidates is an intense and rigorous experience, The interview serves as a means by which your Dear Sir, of a medicinal product than he may reasonably pathology and pharmacology), 7 modules. Doctors The Oxford medical course is clearly delineated into consisting of two interviews and an assessment future clinical tutors assess whether they would I refer to Dr Lee Pheng Soon's article titled "Do require". Therefore pharmacists have to exorcise and pharmaceutical practitioners are invited to give a pre-clinical and a clinical phase. Entry into the centre, with aptitude tests, personality inventories, like to work with you. You have to know more about doctors and pharmacists understand and trust each their professional discretion in dealing with some of the lectures in the modules mentioned. pre-clinical course requires at least 1 interview report writing, practical tasks and exercises, group yourself, than about various rare clinical syndromes. other enough?" published in the February 1998 issue purchases of health products made by members of Upon graduation, pharmacy graduates have to though two interviews are the norm for foreign tasks, and giving presentations. By investing one They look for honesty and personality, not just of the Singapore Medical Journal. the public. I am certain that doctors fears that satisfactorily complete a one year pre-registration students. It is well known that there is a quota of to two days in this extremely thorough process, candidates who are cardboard copies of an ideal I would like to commend Dr Lee Pheng Soon for patients are more likely to try and self-medicate training (similar to housemanship for doctors) at 3 foreign medical students each year. Usually one the companies attempt to ascertain your suitability prospect. One student was asked: "Which preclinical bringing up cogent issues that affect the doctor- with health products if they were sent to a an approved training centre (usually in a community Singapore applicant is accepted though there are for the job on offer. Then again, they are not always subject do you think will be most useful in your pharmacist relationship. It would be beneficial for pharmacy is unfounded given the fact that such or hospital pharmacy) under the supervision of a some years no Singaporean is accepted. correct. clinical years?". Instead of giving a textbook answer, the Pharmaceutical Society of Singapore (PSS) to products are available in health food shops, registered pharmacist based on an approved Entry to study pre-clinical medicine here does I have previously experienced a mock, but he quipped: "I guess that I will find that out only clarify established and perceived misconceptions supermarkets and even the grocers, places which training syllabus before they can register as a not automatically secure a place in the John intense, assessment centre with Shell. We worked when I begin clinical school:' He is currently a and assumptions with regards to pharmacists roles, the public is more likely to frequent. The answer to pharmacist. During the one year period, pre- Radcliffe Hospital in Oxford for the clinical years. our way through real-life scenarios, and were given successful Oxford student. responsibilities and training. the issue about health products lie in public education registration pharmacists also have to attend a Instead other applicants for example with B.A. or 40 minutes to prepare a 15-Minute talk. The talk One of the factors which interviewees cannot and informed choices. As a public watch dog, the series of compulsory lectures organised by the B.Sc. degrees are also enticed to join the keen was assessed on a one-to-one basis with a senior overcome is the prejudice which the interviewers 1. On the question of dispensing exactly according Consumers Association of Singapore (CASE) can play Pharmaceutical Society of Singapore for example: competition. However, all applicants have to pass member of the corporation. During that time, I am may hold. The latter will always have a conception to prescription, pharmacists are professionally and a more pro-active role. Members of the public should communication & presentation skills, community, the first part of the B.M. examination. This does positive that they elicited more about my of what a medical student should look like, and ethically obliged to do so. This is clearly stated in complain to CASE if they come across dubious hospital and industrial pharmacy, first aid, and not exclude non-pre-clinical students from studying personality and cognitive skills compared to a how a medical student should act. If one doesn't fit the Code of Ethics For Pharmacists Section D(2) claims being made on health products. The therapeutic sessions. These lectures are delivered Medicine. I know law graduates, who proceed to medical interview. into this profile, hard luck. which states "A pharmacist who has accepted a Advertising Standards Authority of Singapore by pharmacy practitioners and doctors. At certain do pre-clinical medicine for 2 years and then join in What are medical schools looking for when Mistakes will always be made because the prescription for dispensing will dispense the (ASAS) is another body that can actively look at training sites, pre-registration pharmacists are the rush for clinical school places. they evaluate candidates? According to Dr John selection process is not 100% accurate. 1 have prescription exactly in accordance with the dubious claims and advertisements. The attached to a GP clinic for interaction. Presently, numerous applicants for the Clinical Sear, head of the Oxford Clinical School, if one has some very good medic friends whose company I prescribers wishes and, in particular will not (except Pharmaceutical Society of Singapore's stand on After registration, there are continuing pharmacy School are readying themselves for a panel interview consistently obtained distinctions preclinically, but enjoy, but I know that I will never approach them with approval of the prescriber or in an emergency) health products is that the consumer should be given education (CPE) opportunities just as there are CME with 6 doctors. Needless to say, they are all fairly has done nothing else but study, entry into the clinical for a medical consult. For all I know, there are substitute any other product for a specifically all relevant and unbiased information including opportunities. The Pharmaceutical Society of anxious, realising that success at the interview school is not guaranteed. Most candidates are very friends out there who will avoid me at all costs named product even if the therapeutic effect and scientific data (if any) about the products. The Singapore has a CPE accreditation scheme which is would enable them to train with some of the best similar when judged academically, therefore when I graduate. • quality of the other product are identical." Hence pharmacist should advice the consumer and make doctors and surgeons in the world. considerable emphasis is placed on the non-medical voluntary. Pharmacists can choose to attend MICHELLE TED fears that doctors may have with regards to the relevant recommendations, including not to lectures which are accredited by the Society. therapeutic substitution are unfounded. Generic purchase a certain product (where applicable), drugs are cheaper than branded ones. Therefore putting the health of the consumer as his first 4. On the issue of patients being able to request the question of generic substitution needs to be consideration. prescriptions from doctors, it is very encouraging Parkway Group Healthcare Pte Ltd addressed by both doctors and pharmacists to note that the SMA encourages its members to • East Shore Hospital • Gleneagles Hospital • Mount Elizabeth Hospital • collaboratively in order to alleviate the economic 3. With regards to the undergraduate and oblige their patients if requested. It would be helpful (1_00pm to 2.00pm) burden on patients and reducing healthcare costs professional training of pharmacists, they are well to patients and lay public if SMA can make a public CME Monthly Calendar — May 1998 in the long run. equipped to take on the complementary role as statement on this collaboratively through CASE or E DATE TOPIC SPEAKER/CHAIRMAN members of the healthcare team. even with PSS. Most patients do not know they S 7th Localising Lesion with Eye Signs Drs Yeow Yew Kim/Yea Poh Took 2. On the question of unregulated health products The pharmacy undergraduate course offered can request for such prescriptions. H 21st Eye Trauma Drs Marc Tay/S M Tahir and herbal remedies being stocked in the pharmacies, at the National University of Singapore is a 3-year In light of what has been said, as responsible Venue Health Education Centre, Level 3, East Shore Medical Centre the offer far sale of such products should not be Bachelor of Science (Pharmacy) and a 4-year health professionals, there should be greater C Person Ng Chieh Yun, 340 8750/736 3538 construed as unethical. The main problem lies in the Bachelor of Science (Pharmacy) with Honours (3 collaboration between doctors and pharmacists fact that these products are not medicines and years B Sc. Pharmacy + 1 year Honours) degree at all levels which can only lead to better G therefore are not regulated except as food items. course. Starting from the present academic year understanding, co-operation and respect between DATE TOPIC SPEAKER/CHAIRMAN The other issue is the promotion of these health (1997/1998), it will move to a full 4-year structure the two professions. Doctor's and pharmacist's 6th Hospital-Acquired Pneumonia — Fact vs Fiction Drs Amy Stebbings/Tan Tiong Har L products and quasi-medicinal products as health- with most students graduating with a B Sc roles are complementary and we need to work as 13th Erectile Dysfunction — New Treatments, including Viagra Ors I Swaminathan/Tan Hun Hoe 20th Update on the Management of Seronegative Spondyloarthropathy Drs Koh Wei Howe/Leong Keng Hong giving by the manufacturer. Medical advertisement (Pharmacy) Honours. a team for the ultimate benefit of patients. The 27th Photoaging Die Tan Kong Chong/Tham Siew Nee on the label and insert of a quasi-medicinal product The objectives of the pharmacy undergraduate goal must be to collaboratively provide a high Venue Lecture Theatre, Level 3, Gleneagles Hospital are controlled under the Sale of Drugs Act. Medical curriculum are two-fold: firstly, to establish a strong standard of healthcare that is affordable to all Sharon Yap, 470 5650/736 3538 advertisements in general are regulated under the foundation in the pharmaceutical sciences and Singaporeans through more interprofessional C Person Medicines (Medical Advertisements) Regulations of secondly focus on competencies in patient-oriented dialogues and collaboration. • the Medicines Act. Consumers, doctors and skills, based on the medical sciences, clinical • DATE TOPIC SPEAKER/CHAIRMAN Broadening of Therapeutic Options for Asthma: Ant-leukotrienes Therapy pharmacists should report to the Ministry of Health pharmacy and pharmacy practice. Thank you. E 8th Drs Sally Wenzel (U of Colorado)/Cheong Tuck Hong Towards a Pain-Free Surgery — An Update an Post Operative Pain Relief if they find any quasi-medicinal product making There are 29 essential modules and 10 elective H 15th Drs Boey Wah Keong/George Lim unwarranted medical claims. Pharmacists are also modules in the course. One module is equivalent to 22nd Genetic Counselling in Obstetric Practice Drs Ivy Ng (KK Women & Children H)/Yeoh Swee Choo Yours sincerely, critical of products that have not been properly 50 hours of instruction (lecturers, tutorials, 29th Effects of Radiocontrast on the Kidney: How Real is the Problem? Drs Akira Wu/ Pwee Hock Swee tested. In the same way consumers practise self- practical). The essential modules are distributed as MR WU TUCK SEND Venue Doctors' Dining Room/Seminar Room 1, Education Centre, Level 2, Mt Elizabeth Medical Centre medication, the purchase of health products must follows: Pharmaceutical Chemistry (medicinal President be carried out responsibly with information and chemistry and pharmaceutical analysis) = 7 modules, Pharmaceutical Society of Singapore C Person Angela Tay, 731 2079

N8 N9 NATIONAL UNIVERSITY HOSPITAL SNIA Classif ied Ads SINGAPORE A. B. JOHN Ear, Nose & Throat (ENT Clinic & Surgery) Ak1 Excellence: Our Mission, A Commitment GOH K. S. SKIN CLINIC Mount Elizabeth Medical Centre ■ FOR SALE/RENTAL 3 Mount Elizabeth #15-10, Singapore 2288510 Mount Elizabeth Medical Centre Clinic to share with present occupant. A surgeon or The National University Hospital is a 900-bed multi-specialty teaching anaesthetist preferred. Please call Mylene at Tel 734 3749. hospital. An opportunity exists td share in our mission of achieving Clinic space available for sharing in Gleneagles Medical Centre comprising Dear Colleagues, A.B. JOHN EAR, NOSE & THROAT (ENT) excellence in patient care, medical education and research through the personal office space of 220 square feet and common reception/waiting area. provision of quality patient care with state-of-the-art medical technology. CLINIC & SURGERY PTE LTD Available immediately. Please call 474 4677 I would like to inform you that I have resigned as a Consultant Dermatologist from the National Skin Centre. REGISTRAR IN GASTROENTEROLOGY . Clinic space for rent at Mount Elizabeth Medical Clinic. Area approx. 1,100 sq feet. Dear Colleagues, Contact 940 44016. My new practice is at: Applicants must hold a basic medical degree registrable with the Singapore Medical Council and must possess an M Med (Int Med), MRCP (UK) or ARIM Clinic room available at Mt Elizabeth Medical Centre. Common reception, waiting Gob K.S. Skin Clinic I have resigned my post as Head of the Ear, Nose & Throat Department qualification or their equivalent and a good grounding in general medicine. area and OT to be shared. Please call Irene at 732 2334. 9 Penang Road at Tan Tock Song Hospital, with immediate effect. #07-12 Park Mall Commencing salary will be competitive depending on qualifications and Clinic in Hounanq for taking over. Good returns. Interested parties please page 9312 experience. Tel : 333 5626 My new clinic is located at: 8032. Assistant doctor also required. Those interested please page 9312 8032. Fax : 333 5623 3 Mount Elizabeth #15-10 Mount Elizabeth Medical Centre You have the opportunity to participate actively in the care patients with general medical, gastroenterological and liver-related (including liver Thank you for all your support in the past and I hope to be of service to Singapore 228510 transplantation) problems. Research is strongly encouraged. Commencing ■ POSITIONS AVAILABLE you and your patients in the future, Tel :735 9654 salary will be competitive depending on qualifications and experience. Full-time associate required for clinic in Kembangan Plaza. Please contact Rudolf at Fax :737 5912 With warmest regards, 9668 9242. e-mail : [email protected] Please give full personal particulars, professional qualifications, career Female doctor required by clinic in HOB estate in Jurong East. Good remuneration history and expected salary together with medical testimonials, certificate and working hours. Fax 463 0541 of Tel 463 0540. Sincerely, of registration, recent photograph and telephone number to: Chairman, Medical Board Young full-time Assistant Doctor needed in HDB practice at Chua Chu Kang. I Medical Affairs Department About 40-42 hour week only, including several evenings and weekends. orvi,4„1„...1,1 National University Hospital DR GOH KIM SOON Interested please write personally with full resume, expected salary & recent 5 Lower Kent Ridge Road photo to: The Advertiser, 14 Jalan Ria, Singapore 359070. Consultant Dermatologist Singapore 119074 M.D., FAMS (Dermatology) Consultant, ENT Surgeon American Board of Dermatology MBBS (Singapore), FRCS (Glasgow), FAMS (Singapore) Fax: (65) 775 6757 Tel: (65) 772 5920/22 Website: http://www.nuh.com.sg Enquiries: leesmanuh.com.sg Closing date: 4 May 1998

TEOH Colon, Rectum & General SURGERY

DR TEOH TIONG ANN MBBS (S'pore), FRCS (Fain), FAMS M.Med (Surgery) (Spore), FICS Dear Colleagues, Consultant Colorectal Surgeon ,Qs a*) Agape ray Consultant General Surgeon & Ultrasound Centre I wish to inform you that I have resigned from TanTock Seng Hospital as Dear Colleagues, Dear Colleagues, 60 Albert Street. 003-11 Atari Complex, Singapore 18096g. Ter, 339 9718 Fax: 339 1355 Consultant Rheumatologist. I have started my private practice at Mount I would like to inform you that I have commenced private practice in Mt 1.11.919999d Of. Mtn: MON - : 9.00 ant - FOP 1.00 -.3.00 Elizabeth Medical Centre. Elizabeth Medical Centre specialising in Colorectal Surgery, General Surgery DP NO NWEEhla 1.19.138 PFICA SAnJ000Y: 9 Mani -I Cap nt. We wish to inform you that we have relocated from Specialist and Laparoscopic Surgery. Besides my special interest in the management of rheumatoid arthritis Shopping Centre, Our new practice is at: I was previously Consultant Colorectal and General Surgeon at Tan Took and seronegative spondyloarthropathy/ankylosing spondylitis, I am also Dear Colleagues, Seng Hospital, where I am now a Visiting Consultant. Besides being a trained keen to treat other rheumatological conditions such as difficult gout, and accredited General Surgeon, my subspecialty training is in Colorectal Surgery. osteoarthritis, psoriatic arthritis, soft tissue rheumatism, immune diseases I wish to thank you for your kind support for the past 6 years while at I was a Fellow in Colorectal Surgery at the Cleveland Clinic Florida, USA. my eg. systemic lupus erythematosus, and osteoporosis. Mien, A. 41m ettftic specialty experience includes the surgical treatment of Colorectal Cancer, Radiologic Clinic. especially Sphincter-Preserving Surgery for Low Rectal Cancers (Reducing I can be contacted at: I will be commencing practice in April at Agape Imaging at #03-11, 1, GRANGE ROAD, #10-03, ORCHARD BUILDING unnecessary Colostomies), Surgery for Inflammatory Bowel Disease, Koh Wei Howe Arthritis & Rheumatism Medical Clinic SINGAPORE 239693 TEL : 2353280 (3 Lines) FAX: 7358319 Albert Complex (opposite Sim Lim Square). We will be performing daily Reconnstructive Anal and Rectal Surgery and Proctology including the treatment 3 Mount Elizabeth #07-05 contrast (Barium and IVU) examinations, ultrasound, mammography Mount Elizabeth Medical Centre of Hemorrhoids, Fistulae, Anal Problems, Fecal incontinence and Constipation. as well as plain film facilities. I will also practice the full range of General Surgery. Singapore 228510 Telephone 737 5255 My other subspecialty interest is in Laparoscopic Surgery and this include We look forward to your kind support and to be of assistance to you Facsimile 732 5066 Thank you for your support. procedures like Laparoscopic Appendicetomy, Cholecystectomy and also and your patients. Advanced Laparoscopic Procedures like Needlescopic Cholecystectomy and Answering service 9802 5555 Pager 9535 8075 Laparoscopic Colorectal Surgery. Thank you. My clinic address is: TEOH Colon, Rectum and General SURGERY DR KHEW KHOON SHIN Sincerely, MBBS, AM, FICS, FRCOG (London) Suite 05-04, Mt Elizabeth Medical Center Tel: 738 9133 Fax: 738 7889 Warmest regards, DR THOMAS UM WEE HWA 24-hr Answering Service: 535 8833 or 9802 5555 MBBS, (Syd) AM, FRCOG (London) Please feel free to contact me if I can offer any assistance to your patients' DR KOH WEI HOWE surgical problems. I would also be most happy to accept referrals for Emergency Consultant Rheumatologist and Physician Consultations and am available 24-hours via the answering service. Visiting Consultant, Tan Tock Seng Hospital DR NG HWEENA I look forward to being of service to you and your patients. MBBS, MRCP (UK), FAMS (Rheumatology)

DR TEOH TIONG ANN N10 N 11 9020301 chickenpox of 87% in unvaccinated individuals? Transmission in children who received the vaccine by the subcutaneous been reported following the use of salicylates during natural Pregnancy VARIVAXTh route.22 Although no placebo-controlled trial was carried out with In the placebo-controlled trial, transmission of vaccine virus Persistence of antibody and efficacy in those receiving varicella infection (see CLINICAL PHARMACOLOGY, Reye's Pregnancy Category Cr Animal reproduction studies have [Varicella Virus Vaccine Live (Oka/Merck)] VARIVAX using the current vaccine, a placebo-controlled trial was assessed in household settings (during the 8-week intramuscular injections have not been defined. Syndrome). not been conducted with VARIVAX. It is also not known whether The safety and efficacy of VARIVAX have not been VARIVAX can cause fetal harm when administered to a pregnant DESCRIPTION was conducted using a formulation containing 17,000 PFU per postvaccination period) in 416 susceptible placebo recipients INDICATIONS AND USAGE established in children and young adults who are known to be woman or can affect reproduction capacity. Therefore, VARIVAX VARIVAX * [Varicella Virus Vaccine Live (Oka/Merck)] is a dose.4.5 In this trial, a single dose of VARIVAX protected who were household contacts of 445 vaccine recipients. Of infected with human immunodeficiency viruses with and without preparation of the Oka/Merck strain of live, attenuated varicella 96-100% of children against chickenpox over a two-year the 416 placebo recipients, three developed chickenpox and VARIVAX is indicated for vaccination against varicella in should not be administered to pregnant females; furthermore, virus. The virus was initially obtained from a child with natural period. The study enrolled healthy individuals 1 to 14 years of seroconverted, nine reported a varicella-like rash and did not individuals 12 months of age and older. evidence of immurtosuppression (see also pregnancy should be avoided for three months following CONTRAINDICATIONS). vaccination (see CONTRAINDICATIONS). varicella, then introduced into human embryonic lung cell age (n=491 vaccine, n=465 placebo). In the first year, 8.5% of seroconvert, and six had no rash but seroconverted. If vaccine Revaccination Care is to be taken by the health care provider for safe and cultures, adapted to and propagated in embryonic guinea pig placebo recipients contracted chickenpox, while no vaccine virus transmission occurred, it did so at a very low rate and effective use of VARIVAX. Nursing Mothers cell cultures and finally propagated in human diploid cell recipient did, for a calculated protection rate of 100% during possibly without recognizable clinical disease in contacts. The duration of protection of VARIVAX is unknown at present The health care provider should question the patient, parent, It is not known whether varicella vaccine virus is secreted in cultures (WI-38). Further passage of the virus for varicella the first varicella season. In the second year, when only a subset These cases may represent either natural varicella from and the need for booster doses is not defined. However, a boost or guardian about reactions to a previous dose of VARIVAX or vaccine was performed at Merck Research Laboratories (MRL) of individuals agreed to remain in the blinded study (n=163 community contacts or a low incidence of transmission of in antibody levels has been observed in vaccinees following human milk. Therefore, because some viruses are secreted in a similar product. in human diploid cell cultures (MRC-5) that were free of vaccine, n=161 placebo), 96% protective efficacy was vaccine virus from vaccinated contacts (see PRECAUTIONS, exposure to natural varicella as well as following a booster dose human milk, caution should be exercised if VARIVAX is adventitious agents. This live, attenuated varicella vaccine is a calculated for the vaccine group as compared to placebo. Transmission).4.16 Post-marketing experience suggests that of VARIVAX administered four to six years postvaccination.s The health care provider should obtain the previous administered to a nursing woman. In a highly vaccinated population, immunity for some lyophilized preparation containing sucrose, phosphate, There are insufficient data to assess the rate of protection transmission of vaccine virus may occur rarely between healthy immunization history of the vaccinee. individuals may wane due to lack of exposure to natural varicella glutamate, and processed gelatin as stabilizers. against the complications of chickenpox (e.g., encephalitis, vaccinees who develop a varicella-like rash and healthy VARIVAX should not be injected into a blood vessel. Pediatric Use as a result of shifting epidemiology. Post-Marketing surveillance Vaccination should be deferred in patients with a family VARIVAX, when reconstituted as directed, is a sterile hepatitis, pneumonia) in children. susceptible contacts. Transmission of vaccine virus from No clinical data are available on safety or efficacy of VARIVAX studies are ongoing to evaluate the need and timing for booster preparation for subcutaneous administration. Each 0.5 rnL dose vaccinees without a varicella-like rash has been reported but history of congenital or hereditary immunodeficiency until the in children less than one year of age and administration to vaccination. patient's own immune system has been evaluated. infants under twelve months of age is not recommended. contains the following: a minimum of 1350 PFU (plaque forming Clinical Data in Adolescents and Adults has not been confirmed. Vaccination with VARIVAX may not muffin protection of all units) of Oka/Merck varicella virus when reconstituted and Although no placebo-controlled trial was carried out in A separate sterile needle and syringe should be used for healthy, susceptible children, adolescents, and adults (see administration of each dose of VARIVAX to prevent transfer of ADVERSE REACTIONS stored at room temperature for 30 minutes, approximately 25 adolescents and adults, efficacy was determined by evaluation Herpes Zoster CLINICAL PHARMACOLOGY). infectious diseases. In clinical trials, mg of sucrose, 12.5 mg hydrolyzed gelatin, 3.2 mg sodium of protection when vaccinees received 2 doses of VARIVAX 4 Overall, 9454 healthy children (12 months to 12 years of 4.5.9-15 VARIVAX was administered to 11,102 chloride, 0.5 mg monosodium L-glutamate, 0.45 mg of sodium or 8 weeks apart and were subsequently exposed to age) and 1648 adolescents and adults (13 years of age and Needles should be disposed of properly and should not be healthy children, adolescents, and adults. VARIVAX was CONTRAINDICATIONS recapped. generally well tolerated. phosphate dibasic, 0.08 mg of potassium phosphate chickenpox in a household setting.5 In up to two years of active older) have been vaccinated with Oka/Merck live attenuated A history of hypersensitivity to any component of the monobasic, 0.08 mg of potassium chloride; residual follow-up, 17 of 64 (27%) vaccinees reported breakthrough varicella vaccine in clinical trials. Eight cases of herpes zoster In a double-blind placebo controlled study among 914 vaccine, including gelatin. Transmission components of MRC-5 cells including DNA and protein; and chickenpox following household exposure; of the 17 cases, 12 have been reported in children during 42,556 person years of healthy children and adolescents who were serologically trace quantities of sodium phosphate monobasic, EDTA, (71 %) reported <50 lesions, 5 reported 50-300 lesions, and follow-up in clinical trials, resulting in a calculated incidence of A history of anaphylactoid reaction to neomycin (each dose Post-marketing experience suggests that transmission of confirmed to be susceptible to varicella, the only adverse of reconstituted vaccine contains trace quantities of neomycin). vaccine virus may occur rarely between healthy vaccinees who neomycin, and fetal bovine serum. The product contains no none reported >306 lesions with an oral temperature above at least 18.8 cases per 100,000 person years. The reactions that occurred at a significantly (p<0.05) greater rate preservative. 100°F. In combined clinical studies of adolescents and adults completeness of this reporting has not been determined. One Individuals with blood dyscrasias, leukemia, lymphomas of any develop a varicella-like rash and healthy susceptible contacts. in vaccine recipients than in placebo recipients were pain and type, or other malignant neoplasms affecting the bone marrow Transmission of vaccine virus from vaccinees without a redness at the injection site. To maintain potency, the lyophilized vaccine must be kept (n=1019) who received two doses of VARIVAX and later case of herpes zoster has been reported in the adolescent and 4 or lymphatic systems. frozen at an average temperature of -15°C (+5°F) or colder developed breakthrough chickenpox and reported numbers of adult age group during 5410 person years of follow-up in clinical varicella-like rash has been reported but has not been and must be used before the expiration date (see HOW lesions (42 011019), 25 of 42 (60%) reported <50 lesions, 16 of trials resulting in a calculated incidence of 18.5 cases per Individuals receiving immunosuppressive therapy. confirmed. Children 1 to 12 Years of Age Individuals who are on immunosuppressant drugs are more SUPPLIED, Stability and Storage). Storage in any frost-free 42 (38%) reported 50-300 lesions, and 1 of 42 (2%) reported 100,000 person years.5 Therefore, vaccine recipients should attempt to avoid, In clinical trials involving healthy children monitored for up susceptible to infections than healthy individuals. Vaccination freezer (e.g. chest, frost-free) that reliably maintains with an >300 lesions and an oral temperature above 100°F.5 All nine cases were mild and without sequelae. Two cultures wherever possible, close association with susceptible high risk to 42 days after a single dose of VARIVAX, the frequency of with live attenuated varicella vaccine can result in a more average temperature of -15°C (+5°F) or colder and has a The attack rate of unvaccinated adults exposed to a single (one child and one adult) obtained from vesicles were positive individuals for up to six weeks. In circumstances where contact fever, injection-site complaints, or rashes were reported as extensive vaccine-associated rash or disseminated disease in separate sealed freezer door is acceptable. contact in a household has not been previously studied. When for wild-type varicella zoster virus as confirmed by restriction with high-risk individuals is unavoidable, the potential risk of follows: compared to the previously reported attack rate of natural endonuclease analysis.5.17 The long-term effect of VARIVAX on individuals on immunosuppressant doses of corticosteroids. transmission of vaccine virus should be weighed against the Individuals with primary and acquired immunodeficiency CLINICAL PHARMACOLOGY varicella of 87% following household exposure among the incidence of herpes zoster, particularly in those vaccinees risk of acquiring and transmitting natural varicella virus. Table I states, including those who are immunosuppressed in Varicella is a highly communicable disease in children, unvaccinated children, this represents an approximate 70% exposed to natural varicella, is unknown at present. Susceptible high risk individuals include: Fever, Local Reactions, or Rashes (%) in Children association with AIDS or other clinical manifestations of adolescents, and adults caused by the varicella-zoster virus. reduction in the expected number of cases in the household In children, the reported rate of zoster in vaccine recipients • immunocompromised individuals 0 to 42 Days Postvactination infection with human immunodeficiency virus; The disease usually consists of 300 to 500 maculopapular and/ setting,2 appears not to exceed that previously determined in a 23 cellular immune • pregnant women without documented history of deficiencies; and hypogammaglobulinemic and Reaction or vesicular lesions accompanied by a fever (oral temperature There are insufficient data to assess the rate of protection population-based study of healthy children who had chickenpox or laboratory evidence of prior infection N Post Dose 1 Peak Occurrence in dysgammaglobulinemic states. >100°F) in up to 70% of individuals.1,2 Approximately 3.5 million of VARIVAX against the serious complications of chickenpox experienced natural varicella:5,181g The incidence of zoster in • newborn infants of mothers without documented history Postvaccinaton Days A family history of congenital or hereditary cases of varicella occurred annually from 1980-1994 in the in adults (e.g., encephalitis, hepatitis, pneumonitis) and during adults who have had natural varicella infection is higher than of chickenpox or laboratory evidence of prior infection Foyer 2102T (39°C) Oral 8827 14.7% 0-42 immunodeficiency, unless the immune competence of the United States with the peak incidence occurring in children pregnancy (congenital varicella syndrome). that in children 20 potential vaccine recipient is demonstrated. five to nine years of age.3 The incidence rate of chickenpox is Information for Patients Injection-site complaints 8915 19.3% 0-2 Active untreated tuberculosis. 8.3-9.1% per year in children 1-9 years of age.4 The attack lmmunogenicity of VARIVAX Reye's Syndrome The health care provider should inform the patient, parent (pain/soreness, swelling Any febrile respiratory illness or other active febrile infection. rate of natural varicella following household exposure among Clinical trials with several formulations of the vaccine Reye's Syndrome has occurred in children and adolescents or guardian of the benefits and risks of VARIVAX. and/or erythema, rash, Pregnancy; the possible effects of the vaccine on fetal Patients, parents, or guardians should be instructed to report healthy susceptible children was shown to be 87%.2 Although containing attenuated virus ranging from 1000 to 17,000 PFU following natural varicella infection, the majority of whom had pwritus, hematoma, development are unknown at this time. However, natural it is generally a benign, self-limiting disease, varicella may be per dose have demonstrated that VARIVAX induces detectable received salicylates.21 In clinical studies in healthy children and any adverse reactions to their health care provider. induration, stiffness) varicella is known to sometimes cause fetal harm. If vaccination associated with serious complications (e.g., bacterial immune responses in a high proportion of individuals and is adolescents in the United States, physicians advised varicella Pregnancy should be avoided for three months following of postpubertal females is undertaken, pregnancy should be vaccination. superinfoction, pneumonia, encephalitis, Reye's Syndrome), generally well tolerated in healthy individuals ranging from 12 vaccine recipients. not to use salicylates for six weeks after Varicella-like rash 8916 3.4% 8-19 avoided for three months following vaccination. (See and/or death. months to 55 years of age.4.5.5-25 vaccination. There were no reports of Reye's Syndrome in (injection site) Seroconversion as defined by the acquisition of any varicella vaccine recipients during these studies. PRECAUTIONS, Pregnancy). Drug Interactions Median number of lesions 2 Evaluation of Clinical Efficacy Afforded by VARIVAX detectable varicella antibodies (gpELISA >0.3, a highly sensitive See PRECAUTIONS, General, regarding the administration PRECAUTIONS Clinical Data in Children assay which is not commercially available) was observed in Studies with Other Vaccines of immune globulins, salicylates, and transfusions. Varicella-like rash 8916 3.8% 5.26 In combined clinical trials5 of VARIVAX at doses ranging 97% of vaccinees at approximately 4-6 weeks postvaccination In combined clinical studies involving 1080 children 12 to (generalized) General from 1,000-17,000 PFU, the majority of subjects who received in 6889 susceptible children 12 months to 12 years of age. 36 months of age, 653 received VARIVAX and M-M-R*11 Drug Interactions, Use with Other Vaccines Median number of lesions 5 Adequate treatment provisions, including epinephrine VARIVAX and were exposed to wild-type virus were either Rates of breakthrough disease were significantly lower among (Measles, Mumps, and Rubella Virus Vaccine Live) Results from clinical studies indicate that VARIVAX can be injection (1;1000), should be available for immediate use should completely protected from chickenpox or developed a milder children with varicella antibody titers >5 compared to children concomitantly at separate sites and 427 received the vaccines administered concomitantly with M-M-R II (Measles, Mumps, an anaphylactoid reaction occur. form (for clinical description see below) of the disease. The with titers <5. Titers >5 were induced in approximately 76% of six weeks apart. Seroconversion rates and antibody revels were and Rubella Virus Vaccine Live). In addition, the most frequently (">1%) reported adverse The duration of protection from varicella infection after protective efficacy of VARIVAX was evaluated in three different children vaccinated with a single dose of vaccine at comparable between the two groups at approximately six Limited data from an experimental product containing experiences, without regard to causality, are listed in decreasing vaccination with VARIVAX is unknown. varicella vaccine suggest that VARIVAX can be administered ways: 1) by comparing chickenpox rates in vaccinees versus 1000-17,000 PFU per dose. In a multicenter study involving weeks post-vaccination to each of the virus vaccine order of frequency: upper respiratory illness, cough, irritability/ It is not known whether VARIVAX given immediately after concomitantly with DTaP (diphtheria, tetanus, acellular historical controls, 2) by assessment of protection from disease susceptible adolescents and adults 13 years of age and older, components. No differences were noted in adverse reactions nervousness, fatigue, disturbed sleep, diarrhea, loss of appetite, exposure to natural varicella virus will prevent illness. following household exposure, and 3) by a placebo-controlled, two doses of VARIVAX administered four to eight weeks apart reported in those who received VARIVAX concomitantly with pertussis) and PedvaxHlB using separate sites and syringes vomiting, otitis, diaper rash/contact rash, headache, teething, Vaccination should be deferred for at least 5 months (see CLINICAL PHARMACOLOGY, double-blind clinical trial. induced a seroconversion rate (gpELISA >0.3) of approximately M-M-R II (Measles, Mumps, and Rubella Virus Vaccine Live) at Studies with Other malaise, abdominal pain, other rash, nausea, eye complaints, following blood or plasma transfusions, or administration of Vaccines).5 However, there are no data relating to simultaneous In early clinical trials,5 a total of 4142 children received 75% in 539 Individuals four weeks after the first dose and of separate sites and those who received VARIVAX and M-M-R II chills, lymphadenopathy, myalgia, lower respiratory illness, immune globulin or varicella zoster immune globulin (VZIG).24 administration of VARIVAX with DTP or OPV. 1000-1625 PFU of attenuated virus per dose of VARIVAX and 99% in 479 individuals four weeks after the second dose. The (Measles, Mumps, and Rubella Virus Vaccine Live) at different allergic reactions (including allergic rash, hives), stiff neck, heat Following administration of VARIVAX, any immune globulin have been followed for up to six years post single-dose average antibody response in vaccinees who received the times (see PRECAUTIONS, Drug Interactions, Use with Other rash/prickly heat, arthralgia, eczema/dry skin/dermatitis, including VZIG should not be given for 2 months thereafter Carcinogenesrs, Mutagenesis, Impairment of Fertility vaccination. In this group there was considerable variation in second dose eight weeks after the first dose was higher than Vaccines).5 constipation, itching. unless its use outweighs the benefits of vaccination.24 VARIVAX has not been evaluated for its carcinogenic or chickenpox rates among studies and study sites, and much of that in those, who received the second dose four weeks after In a clinical study involving 318 children 12 months to 42 Pneumonitis has been reported rarely (<1%) in children Vaccine recipients should avoid use of salicylates for 6 mutagenic potential, or its potential to impair fertility. the reported data were acquired by passive follow-up. It was the first dose. In another multicenter study involving adolescents months of ago, 160 received an investigational vaccine (a vaccinated with VARIVAX; a causal relationship has not been weeks after vaccination with VARIVAX as Reye's Syndrome has observed that 2.1%-3.6% of vaccinees per year reported and adults, two doses of VARIVAX administered eight weeks formulation combining measles, mumps, rubella, and varicella established. chickenpox (called breakthrough cases). This represents an apart induced a seroconversion rate (gpELISA >0.3) of 94% in in one syringe) concomitantly with booster doses of DTaP approximate 67% (57-77%) decrease from the total number 142 individuals six weeks after the first dose and 99% in 122 (diphtheria, tetanus, acellular pertussis) and OPV (oral poliovirus of cases expected based on attack rates in children aged 1-9 individuals six weeks after the second dose.5 vaccine) while 144 received M-M-R II (Measles, Mumps, and over this same period (8.3-9.1%).4.6 In those who developed VARIVAX also induces cell-mediated immune responses in Rubella Virus Vaccine Live) concomitantly with booster doses REPLY BY FAX: 296 0005 breakthrough chickenpox postvaccination, the majority vaccinees. The relative contributions of humoral immunity and of DTaP and OPV followed by VARIVAX 6 weeks later. At six experienced mild disease (median number of lesions <50). In cell-mediated immunity to protection from chickenpox are weeks postvaccination, seroconversion rates for measles, one study, a total of 47% (27/58) of breakthrough cases had unknown. mumps, rubella, and varicella and the percentage of vaccinees <50 lesions compared with 8% (7/92) in unvaccinated whose titers were boosted for diphtheria, tetanus, pertussis, YES! I am interested in receiving more information on Varicella Virus and VARIVAXTM individuals, and 7% (4/58) of breakthrough cases had >300 Persistence of Immune Response and polio were comparable between the two groups, but anti- lesions compared with 50% (46/92) in unvaccinated Studies in vaccinees examining chickenpox breakthrough varicella levels were decreased when the investigational vaccine individuals./ In studies of vaccinated children who contracted rates over 5 years showed the lowest rates {0.2-2,9%) in the containing varicella was administered concomitantly with DTaP. YES! 1 would like a MSD medical representative to visit me chickenpox after a household exposure, 57% (31/54) of the first two years postvaccination, with somewhat higher but stable No clinically significant differences were noted in adverse cases reported <50 lesions, while 1.9% {1/54) reported >300 rates in the third through fifth year. The severity of reported reactions between the two groups.5 lesions with an oral temperature above 100°F. breakthrough chickenpox, as measured by number of lesions In another clinical study involving 307 children 12 to 18 In later clinical trialss with the current vaccine, a total of 1164 and maximum temperature, appeared not to increase with time months of age, 150 received an investigational vaccine (a children received 2900-9000 PFU of attenuated virus per dose since vaccination .5 formulation combining measles, mumps, rubella, and varicella Name: of VARIVAX and have been followed for up to three years post In clinical studies involving healthy children who received 1 in one syringe) concomitantly with a booster dose of single-dose vaccination. It was observed that 0.2%-1.0% of dose of vaccine, detectable varicella antibodies (gpELISA >0.3) PedvaxHlB` [Haemophilus b Conjugate Vaccine vaccinees per year reported breakthrough chickenpox for up were present in 98.8% (3775/3822) at 1 year, 98.9% (1057/ (Meningococcal Protein Conjugate)] while 130 received M-M-R Title: a to three years post single-dose vaccination. This represents 1069) at 2 years, 97.5% (548/562) at 3 years, and 99.5% (220/ II (Measles, Mumps, and Rubella Virus Vaccine Live) an approximate 93% decrease from the total number of cases 221) at 4 years postvaccination. Antibody levels were present concomitantly with a booster dose of PedvaxHlB followed by expected based on attack rates in children aged 1-9 over this at least one year in 97.2% (423/435) of healthy adolescents VARIVAX 6 weeks later. At six weeks postvaccination, Address: same period (8.3%-9.1%).2.25 In those who developed and adults who received two doses of live varicella vaccine seroconversion rates for measles, mumps, rubella, and varicella, breakthrough chickenpox postvaccination, the majority separated by 4 to 8 weeks. A boost in antibody levels has been and geometric mean titers for PedvaxHlB were comparable experienced mild disease. observed in vaccinees following exposure to natural varicella between the two groups, but anti-varicella levels were Among a subset of vaccinees who were actively followed, which could account for the apparent long-term persistence decreased when the investigational vaccine containing varicella Singapore: Tel: Fax: 259 were exposed to an individual with chickenpox in a of antibody levels after vaccination in these studies. The was administered concomitantly with PedvaxHlB. No clinically household setting. There were no reports of breakthrough duration of protection from varicella obtained using VARIVAX significant differences in adverse reactions were seen between chickenpox in 80% of exposed children; 20% reported a mild in the absence of wild-type boosting is unknown. VARIVAX also the two groups.5 ,0Tradenlark of Merck & Co., inc. Copyright Merck & Co., inc. 1996 Whitehouse Station, NJ, USA. All rights reserved. induces cell-mediated immune responses in vaccinees. The VARIVAX is recommended for subcutaneous administration. form of chickenpox .5 This represents a 77% reduction in the MSD MERCK SHARP & DOHME (I.A.) CORP. expected number of cases when compared to the historical relative contributions of hurioral immunity and cell-mediated However, during clinical trials, some children received VARIVAX attack rate of varicella following household exposure to immunity to protection from chickenpox are unknown. intramuscularly resulting in seroconversion rates similar to those Singapore Branch 300 Beach Road #13-02 The Concourse Singapore 199555 Tel: (65) 296 7772 Fax: (65) 296 0005

Febrile seizures have occurred rarely (<0.1%} in children Adolescents and adults 13 years of age and older should freezer door is acceptable for storing VARIVAX. vaccinated with VARIVAX; a causal relationship has not been receive a VARIVAX may be stored at refrigerator temperature (2-8°C, established. 0.5 mL dose administered subcutaneously at elected date and 36-46°F) for up to 72 continuous hours prior to reconstitution. a second 0.5 mL dose 4 to 8 weeks later. Vaccine stored at 2-8°C which is not used within 72 hours of THE HEPATITIS A VACCINE WHICH DEMONSTRATED Adolescents and Adults 13 Years of Age and Older VARIVAX is for subcutaneous administration. The outer removal from -15°C storage should be discarded. In clinical trials involving healthy adolescents and adults, aspect of the upper arm (deltoid) is the preferred site of injection. Before reconstitution, protect from light. the majority of whom received two doses of VARIVAX and were VARIVAX SHOULD BE STORED FROZEN at an average The diluent should be stored separately at room temperature 1 100% PROTECTION IN A LANDMARK STUDY' monitored for up to 42 days after any dose, the frequency of temperature of -15°C (+5°F) or colder until it is reconstituted (20-25°C, 68-77°F), or in the refrigerator. fever, injection-site complaints, or rashes were reported as for injection (see HOW SUPPLIED, Storage). Any freezer (e.g., follows: chest, frost-free) that reliably maintains an average temperature REFERENCES of -15°C and has a separate sealed freezer door is acceptable 1.Balfour, H.H.; eiai.:Acyciovirheatment of varicella in otherwise healthy Table 2 for storing VARIVAX. The diluent should be stored separately children, Pediatr., 116: 633-639,1990. Fever Local Reactions or Rashes (%) in Adolescents and Adulls at room temperature or in the refrigerator. To reconstitute the. 2. Ross, A1-1.i. Modification of chickenpox in family contacts by 9 to 42. D ars Posivaccination vaccine, first withdraw 0.7 mL of diluent into the syringe to be administration of gamma globulin, N. Engl. J. Med. 267: 369-376,1962. used for reconstitution. Inject all the diluent in the syringe into 3. Preblud, &R.: Varicella: Complications and Costs, Pediatrics, 78(4 Reaction N Post Peak N Post Peak the vial of lyophilized vaccine and gently agitate to mix Pt 2): 728-735,1985. 4. Weibel, R.E.; et al: Live Attenuated Varicella Virus Vaccine, N. Engl. Dose Occurrence in Dose Occurrence in thoroughly. Withdraw the entire contents into a syringe, change TMt J. Med. 310(22): 1409-1415,1984. 1 Postvaccination 2 Postvaccinaton the needle, and inject the total volume (about 0.5 mL) of Days Days 5. Unpublished data; tiles of Merck Research Laboratories. reconstituted vaccine subcutaneously, preferably into the outer 6. Wharton, M.; et al.: Health Impact of Varicella in the 1980's. Thirtieth aspect of the upper arm (deltoid) or the anterolateral thigh. IT Interscience Conference on Antimicrobial Agents and Chemotherapy, (hepatitis A vaccine, Fever 100'F 1584 102% 14-27 956 9.5% 0.42 IS RECOMMENDED THAT THE VACCINE BE (37.7°C) Oral (Abstract #1138),1990. ADMINISTERED IMMEDIATELY AFTER RECONSTITUTION, 7. Bernstein, H.R.; et al.: Clinical Survey of Natural Varicella Compared TO MINIMIZE LOSS OF POTENCY. DISCARD IF Injection-gee 1605 24.4% 0.2 955 32.5% 0-2 with Breakthrough Varicella After Immunization with Uve Attenuated Oka/ purified inactivated, MSD) complaints RECONSTITUTED VACCINE IS NOT USED WITHIN 30 Merck Varicella Vaccine. Pediatrics 92: 833-837, 1993. (soreness, erythema, MINUTES. 8. Kuter, B,J.; et al.: Oka/Merck Varicella Vaccine in Healthy Children: sailing, rash, CAUTION: A sterile syringe free of preservatives, antiseptics, Final Report of a 2-Year Efficacy Study and 7-Year Follow-up Studies, PROTECTION PURE AND SIMP pruritus, pyrexia, and detergents should be used for each injection and/or Vaccine, 9: 643-647, 1991. heinatoma, reconstitution of VARIVAX because these substances may 9. Arbeter, A.M.; et al.; Varicella Vaccine Trials in Healthy Children, A induration, numbness) inactivate the vaccine virus. Summary of Comparative and Follow-up Studies, AJDC 138: 434-438,1984. It is important to use a separate sterile syringe and needle 10.Weibel, R.E.; Cl al.: Live Oka/Merck Varicella Vaccine in Healthy Children, JAMA 259(17): 2435-2439,1985. Varicella-like rash 1600 3% 6-20 955 1% 0-5 for each patient to prevent transmission of infectious agents (injection site) 11.Chartrand, D.M.; et al.: New Varicella Vaccine Production Lots in from one individual to another. Healthy Children and Adolescents, Abstracts of the 1988 Inter-Science Median ouster of To reconstitute the vaccine, use only the diluent supplied, Demonstrated 100% protection against hepatitis A after a single dose in 519 lesions 2 2 Conference Antimicrobial Agents and Chemotherapy: 237(Abstract #731). since it is free of preservatives or other anti-viral substances 12Johnscn, et al.: Live Attenuated Vaccine in Healthy 12 to 24 which might inactivate the vaccine virus. month old Children, Pediatrics 81: 512-516,1988. susceptible children (ages 2-16) in a landmark protective efficacy trial (p<0.001)'' Varicella-like rash 1606 5.5% 7.21 955 0.9% 0.23 Do not freeze reconstituted vaccine. (generalized) 13.Gershon, A,A.; et al.: Immunization of Healthy Adults with Live Median number of Do not give immune globulin including Varicella Zoster Attenuated Varicella Vaccine, Journal of Infectious Dseases, /58(11: 132-137, lesions 5 5.5 Immune Globulin concurrently with VARIVAX (see also 1988. Highly immunogenic* after a single dose in healthy adults and children (95% - 97%)2 PRECAUTIONS). 14.Gershon, A.A.; et al.: Live Attenuated Varicella Vaccine: Protection in Healthy Adults Compared with Leukemic Children, Journal of Infectious In addition, the most frequently (31%) reported adverse Parenteral drug products should be inspected visually tor particulate matter and discoloration prior to administration, Diseases, 161: 661-666,1990. experiences, without regard to causality, are listed in decreasing 15.White, CU.; et al.: Varicella Vaccine (VARIVAX) in Healthy Children Generally well tolerated' order of frequency: upper respiratory illness, headache, fatigue, whenever solution and container permit. VARIVAX when reconstituted is a clear, colorless to pale yellow liquid. and Adolescents: Results From Clinical Trials, 1987 to 1989, Pediatrics, cough, rnyalgia, disturbed sleep, nausea, malaise, diarrhea, 87(5): 604-610,1991. stiff neck, irritability/nervousness, lymphadenopathy, chills, eye 16.Asano, Y.; et al.: Contact Infection from Live Varicella Vaccine complaints, abdominal pain, loss of appetite, arthralgia, otitis, HOW SUPPLIED Recipients, Lancet 1(7966): 965, 1976. Indicated for both children (>_2 years) and adults - One primary and one booster' itching, vomiting, other rashes, constipation, lower respiratory No. 4826/4309 - VARIVAX is supplied as follows: (1) a 17.Harnmerschlag, M.R.; et al.: Herpes Zoster in an Adult Recipient of illness, allergic reactions (including allergic rash, hives), contact single-dose vial of lyophilized vaccine, NDC 0006-4826-00 Live Attenuated Varicella Vaccine, J Met Dis 160(3); 535-537,1989. rash, cold/canker sore. (package A); and (2) a box of 10 vials of diluent (package B). 16.White, C.J.: Letters to the Editor, Pediatrics 318: 354, 1992. • A high level of vaccine purity2 As with any vaccine, there is the possibility that broad use No. 4827/4309 - VARIVAX is supplied as follows: (1) a box 19.Guess, RA.; et al.: Epidemiology of Herpes Zoster in Children and of the vaccine could reveal adverse reactions not observed in of 10 single-dose vials of lyophilized vaccine (package A), NDC Adolescents: A Population Based Study, Pediatrics 76(4): 512-517,1985. clinical trials. 0006-4827-00; and (2) a box of 10 vials of diluent (package B) 20.11agozzino, M.; et al.: Population-Based Study of Herpes Zoster and Its Sequelae, Medicine The following additional adverse reactions have been (6505-01-413-1331, Ten Pack). 61(5): 310-316,1982. 21.Morbidity and Mortality Weekly Report 34(1): 13-16, Jan 11, 1985. reported since the vaccine has been marketed: Stability 22.Dennehy, P.R.; et al.: Immunogenicity 01 Subcutaneous Versus Intramuscular Okailvlerck Varicella Vaccination in Healthy Children, Pediatrics Uniquely practical prefilled syringes Body As A Whole VARIVAX retains a potency level of 1500 PFU or higher per dose for at least 16 months in a frost-free freezer with an 88(3): 604-607, 1991. Anaphylaxis. 23.Center for Disease Control: Immunization of Children Infected with streamline administration and record keeping Hemic and Lymphatic System average temperature of -15°C (+5°F) or colder. VARIVAX has a minimum potency level of approximately Human T-Lymphotropic Virus Type Ill/Lymphadenopathy - Associated Virus, Thrombocytopenia. Annals of Internal Medicine, 106: 75-78, 1987. 1350 PFU 30 minutes after reconstitution at room temperature Nervous/Psychiatric 24.Recommendations of the Advisory Committee on Immunization (20-25°C, 68-77°F). Peel-off label for patient charts makes Extra-long syringe barrel (1.5 ml) Encephalitis; Bell's palsy; ataxia. Practices (ACIP); General Recommendations on Immunization, MMWR vaccination record keeping easier makes aspiration easy Respiratory Prior to reconstitution, VARIVAX retains potency when stored 43(No.RR-1): 15-18, January 28, 1994. Pharyngitis. for up to 72 continuous hours at refrigerator temperature (2-8°C, 25.Vaccine Adverse Event Reporting System - United States, MMWR 36-46°F). 39(41): 730-733, 1990. Skin " "`""' "A` Stevens-Johnson syndrome; erythema multiforme; herpes PEINORK/ADOLESUNT FORIYIURTION zoster. Storage 03 rnl, 1--25511 During shipment, to ensure that there is no loss of potency, Manufactured by: DOSAGE AND ADMINISTRATION the vaccine must be maintained at a temperature of -20°C 401 MERCK & CO (-4°F) or colder. MSD 'Trademark of MERCK & CO., Inc. Whitehouse Station, NJ, USA FOR SUBCUTANEOUS ADMINISTRATION Before reconstitution, store the lyophilized vaccine in a Do not inject intravenously freezer at an average temperature of -15°C (+5°F) or colder. COPYRIGHT MERCK & CO., Inc., 1995 Any freezer (e.g., chest, frost-free) that reliably maintains Children 12 months to 12 years of age should receive a All rights reserved single 0.5 mL dose administered subcutaneously. an average temperature 01-15°C and has a separate sealed ADULT PORMIltATI

Affix Stamp Color-coded plunger rod Rigid needle shield minimizes the Here reduces the chance of Prefilled syringe reduces risk of accidental needlesticks product misidentification administration time and avoids needle blunting

MERCK SHARP & DOHME (I.A.) CORP. References 1.Werzberger, A. et al.: A controlled trial of a formalin-inactivated hepatitis A vaccine in healthy children, N. Engl. J. Med. 327(7):453-457, August 13, 1992. Singapore Branch 300 Beach Road 2. Data on file, MSD Singapore #13-02 The Concourse Singapore 199555 # A double-blind, placebo-controlled triaLin an American community with recurrent outbreaks of hepatitis A (n.1037). Efficacy was evaluated 50 days or more (primary end point) and as early as 30 days (secondary end point)2 after vaccination Tel: (65) 296 7772 Fax: (65) 296 0005 In all studies conducted by Merck & Co., Inc., the minimum anti-HAV titer required for seroconversion using the "modified HAVAB" assay was >10 mill/mi. HAVAB is a registered trademark of Abbott Laboratories SG J-

Before prescribing, please consult the prescribing information on page 143 7002-

tTrademark of MERCK & CO., INC., Whitehouse Station, N.J., U.S.A. HK- 98- MSD Family of Vaccines MERCK SHARP & DOHME (I.A.) CORP. Singapore Branch 300 Beach Road #13-02 The Concourse Singapore 199555 Tel: (65) 296 7772 Fax: (65) 296 0005 99 VAQ- 4-