Public health measures are not compromised

29 Jan 2008, Today

Question

Name of the Person: Loh Chee Kong

As eyebrows rise over the under-reporting of dengue deaths, MOH pledges to plug loophole

A NEWS report clarifying that the country had 20 dengue deaths last year, instead of eight as originally reported, would not have looked out of place in a newspaper from a Third World country — where the healthcare system and overall communications are bogged down by inefficiencies.

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But when the under-reporting of deaths relating to a dengue epidemic occurred in Singapore, more than a few eyebrows were raised, even as the Ministry of Health (MOH) pledged to act swiftly to plug the loophole in the Infectious Diseases Act (IDA).

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Incidentally, the news of the much higher dengue deaths, which was reported earlier this month, came less than two months after the MOH completed a public consultation process on amending the Act.

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The planned amendments to the 31-year-old law, which is jointly administered by the MOH and the National Environment Agency, are aimed at strengthening Singapore's capabilities to respond effectively to outbreaks.

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But with the dengue virus being no stranger to our public health agencies — they have been grappling with it for the past two decades — the under-reporting poses a question mark over Singapore's readiness to deal with an endemic outbreak.

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For the record, last year's 20 dengue deaths were just five fewer than in 2005, when Singapore saw its worst dengue outbreak in recent memory.

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How did it happen? The MOH had explained that the additional dengue deaths turned up only after it had "obtained inputs from the Registry of Births and Deaths".

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Dengue — along with 28 other diseases including Sars, cholera and nipah — is gazetted under the Infectious Diseases Act, which makes it compulsory under the law for medical practitioners to inform the MOH when they are aware or suspect a patient "is suffering or has died from or is a carrier of an infectious disease".

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But in response to media queries, the MOH explained that the law had one loophole — there was "no requirement for medical practitioners to report deaths from these infectious diseases".

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This means that doctors are required by law to notify — by fax, post or via an online notification system — the ministry when they come across infected cases but not when such patients die subsequently. However, it is compulsory for doctors to notify the MOH when a patient, who was not previously identified as a dengue carrier, dies from dengue.

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"To ensure more complete and timely information on dengue deaths, MOH will soon be revising the Infectious Diseases Regulations to make deaths from infectious diseases specified under the IDA notifiable," the ministry said.

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While the legal loophole explains how the authorities got it all wrong, doctors who spoke to Today said that such a lapse should not have occurred. They believe that doctors have a duty to inform the health authorities on any dengue deaths even if the law, as it exists, does not require them to do so.

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One of them, Dr Wong Sin Yew, told Today that he makes it a point to immediately notify the Health Ministry upon the death of any of his dengue patients.

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As an infectious disease expert at Gleneagles Medical Centre, Dr Wong has been treating patients in advanced stages of dengue.

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Said Dr Wong: "It's quite clear and important for me to make the ministry aware of such cases. I don't do things only based on whether it's compulsory to do so by law."

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Dr Wong also pointed to the existence of forms which are used by doctors to notify the MOH of cases of infectious diseases, or to jot down any other diseases or illnesses that they suspect the patient to be suffering from. These forms, he said, are an important channel of communication to alert the MOH of any potential outbreaks of diseases though it is based only on doctors' suspicions and preliminary diagnosis.

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Said Dr Wong: "The information that doctors give to the ministry should be information relevant to the ministry, whether it's required by law or not."

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For Member of Parliament, Mdm Halimah Yacob, common sense should prevail in cases where the law might be found wanting.

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"Even if the law is not explicit enough, common sense would tell us that such instances should be reported," said Mdm Halimah, who heads the Government Parliamentary Committee on Health.

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She was "surprised" at the magnitude of the under-reporting but as this was the first time she has heard of such a lapse, the issue of under-reporting "does not appear to be widespread".

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Still, Mdm Halimah noted that the World Health Organisation has already identified infectious diseases as a global security threat.

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And at a time when the Government is putting together a more robust National Registry of Diseases, accurate and up-to-date data are critical for national planning, she reiterated.

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"It is important that these loopholes have to be addressed. Otherwise, we may get the impression that the problem is less serious than what it actually is," Mdm Halimah added.

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As Dr Yeo Chor Tzien — a general practitioner — put it, such errors are uncharacteristic for a country like Singapore, which prides itself for its efficiency and transparency. "If this had happened in a Third World country, I would not be surprised," he said.

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First World or otherwise, the lapse in the reporting system serves as a red flag to Singapore's reputable public health system.

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If nothing else, the erroneous reporting of dengue deaths drives home the point that there's no room for complacency throughout the ranks — especially when lives are at stake.

Reply

Reply from MOH  

Loh Chee Kong questioned "Why the (dengue deaths) Numbers Went Missing", (TODAY, Jan 26 08) and asked if this would compromise Singapore's ability to respond effectively to disease outbreaks.  The answer is no.

All doctors are required by law to notify MOH as soon as they come across any dengue or suspected dengue patients.  Upon receipt of any such notification, MOH and NEA will commence public health measures and vector control operations immediately.  This is how we manage dengue outbreaks.

In all the 20 dengue deaths reported for 2007, public health action was never compromised as all the cases had been notified to MOH within 24 hours of diagnosis.