Opening address by Prof K Satku, Director of Medical Services, At World TB Day / STEP 15th Anniversary Symposia, Saturday 24th March 2012

Distinguished Guests, Colleagues, Ladies and Gentlemen - Good Afternoon. 

Introduction

Let me begin by extending a warm welcome to all, to this symposium which has been specially organised to commemorate World Tuberculosis Day. This year also marks 15 years of the Singapore Tuberculosis Elimination Programme or STEP.  I am pleased that we are joined today by two special distinguished speakers from the United States, Professor Lee Reichman and  Dr Paula Fujiwara. They played a critical role in helping us set up STEP.  

On this occasion, as we reflect on the achievements of STEP, we should also address how the programme can be strengthened, so that we may achieve the ultimate goal of eliminating TB from our community.

Singapore’s TB situation

The first ten years of STEP were encouraging. From 1997-2006, TB incidence rates went down from 55 cases to 35 cases per 100,000.  The fall in incidence coincided with the implementation of various measures under STEP such as enhanced detection, treatment and monitoring of TB cases. Directly Observed Therapy (or DOT), was also introduced.  Despite our early success, our TB rates have rebounded. Last year, a total of 1533 new cases were notified from amongst our resident population. This gives an incidence rate of about 41 cases per 100,000 population. 

The reasons behind the increase in TB incidence are multi-factorial. Our ageing population, increased mobility and migration, and the emergence of drugresistant forms of TB add to the list of challenges that threaten to derail our current efforts. What then can we do to curb the rising trend in TB incidence in Singapore?  

I would now like to share what my ministry is exploring in the three fundamental areas; prevention, detection and treatment. 

Ensuring treatment compliance and effectiveness

Let’s start with treatment. We will work towards increasing the proportion of patients who comply with treatment by lowering our threshold for DOT and initiating out-reach DOT.  Countries which have shown strong commitment towards DOT, for example the United States, Japan, Taiwan and Hong Kong have made positive headway towards controlling their TB situation.  

Currently, almost 80% of TB patients seen at the TB Control Unit are already on DOT. However this translates to an overall national DOT rate of just over 50%. Although this is an improvement from the 10% DOT coverage before STEP was introduced, more must be done to improve its acceptance amongst patients.  

Although MOH has the legal power to compel treatment under DOT, legal actions should be the last resort. We will address barriers which affect compliance to DOT. We need to educate patients on the importance of compliance to treatment, and how non compliance will affect their health and that of their family and friends and the community. 

Patients who face dire and urgent social or financial problems may default DOT due to these pressing circumstances. Increasing accessibility by reducing barriers to DOT could make the treatment regimen less onerous for such patients to comply with. We will also work with our community partners to enhance financial assistance for patients in need. 

For patients who are unable to attend polyclinics for DOT, one possibility is for nurses to visit their homes. Outreach DOT will achieve the same aims of ensuring treatment compliance as traditional DOT, but with added flexibility to cater to patients who are elderly or with social or health problems which prevent them from complying with traditional DOT. 

DOT is currently offered to patients only in the public treatment programme at TBCU. We are exploring the implementation of routine DOT to other patients seen outside of TB Control Unit. This way, the inherent benefits of DOT can be extended to all patients irrespective of where they are being managed. 

Reducing delays in diagnosis

Next we must reduce delays in diagnosis and protect the community from unnecessary disease transmission. Our surveillance data shows that about a third of infectious pulmonary TB patients in Singapore were  diagnosed after having had cough symptoms for longer than 8 weeks. Last year, among infectious patients, the median duration of cough before diagnosis was 6 weeks. This is not acceptable and we must shorten the time it takes for patients to be diagnosed. In this regard, the healthcare professional must remain vigilant so that patients with symptoms of TB can undergo investigations without delay.  

I would like to urge doctors to work closely with MOH and the TB Control Unit to enhance detection at the community level.  All persons with a productive cough lasting 3 weeks or more should be evaluated for possible TB. Sputum specimens should  be submitted for microbiological examination and patients should be  referred for further evaluation and management at TBCU. When chest x-rays show signs suggestive of TB, doctors should refer such patients for further evaluation even if they have no symptoms.   

Doctors will also need to provide prompt and accurate information of cases for TB surveillance. Under the Infectious Diseases Act, doctors are required to notify MOH of any confirmed or suspected case of TB within 72 hours.  This arrangement is critical in activating downstream public health actions, such as contact tracing and screening.  

To assist our doctors MOH will work with TB Control Unit to publish clinical guidelines for tuberculosis. 

We will also work with our partner, the Health Promotion Board, to raise public awareness about tuberculosis, including its symptoms and the importance of completing treatment. This will enable members of the public to seek early treatment or support friends and family members to seek medical attention or complete  treatment.  

Treating latent TB infection in the community 

Finally and just as importantly, we need to strengthen our prevention strategy by managing individuals with latent TB infection effectively so that the likelihood of them progressing to active disease is decreased. Every infectious TB case will generate close contacts that become infected. While a few of these contacts may have symptoms, the vast majority of infected contacts are asymptomatic. Diagnosis will require screening for latent TB infection.  Currently, the TB Control Unit routinely carries out contact investigation for all infectious TB cases. Over 70% of index cases are successfully interviewed and their contacts obtained for follow-up. We should aspire to extend the coverage of contact tracing and investigation to all infectious patients in Singapore. 

All contacts with latent TB infection should be offered preventive treatment, and be counselled to seek medical advice early if they exhibit signs and symptoms suggestive of TB. 

Conclusion

In closing I would like to pay tribute to Professor Sonny Wang for his tireless dedication to TB control in Singapore. Together with Dr Cynthia Chee and the rest of the team at TB Control Unit, Professor Wang has made invaluable contributions to STEP and ensured that we have in place a robust and effective system for TB control in Singapore.  

This symposium provides an excellent opportunity for doctors to understand more about the progress and challenges of local TB  control. I would also like congratulate the organising committee, led by Professor Wang and Dr Chee, on putting together an excellent programme covering a wide range of topics related to TB control and epidemiology in Singapore and overseas. 

I wish you a pleasant and enriching afternoon.  

Thank you.