When the flu bug ran amok

SINGAPORE - The Ministry of Health (MOH) announced last week that it is freeing up the use of Medisave for childhood vaccines.

Up to $400 a year can be used from the Medisave accounts of either the children or their parents for vaccines on the National Childhood Immunisation Schedule, which protects children from ailments such as diptheria, mumps, measles and rubella and polio.

The change is part of an ongoing review of health-care financing undertaken by the ministry. Each Singaporean has his or her own Medisave account, with funds built up from Central Provident Fund contributions deducted from their salaries and from employers' contributions. Medisave use is severely curtailed: It is mainly for hospitalisation bills and limited outpatient uses such as chemotherapy and dialysis, and also for chronic ailments such as hypertension and diabetes, subject to caps.

Many MPs in the Budget debate last week called on MOH to allow the use of Medisave for diagnostic tests, health screening and other outpatient purposes.

At first glance, allowing greater use of Medisave for vaccines appears to be a great move.

It helps those who find the costs of such jabs prohibitive. It also sends the signal that the MOH considers these so useful that it's allowing use of the closely guarded Medisave money.

But there is something innately wrong with this move as it sends the signal that vaccines are important (hence the freeing up of Medisave) - but only for children.

Yet that is blatantly untrue. Children are not the only ones who can benefit from vaccines. Everyone can. Besides the very young, the very old and those with compromised health should protect themselves with vaccines whenever medically indicated.

Yet the vaccine uptake in Singapore is very low, except where children are concerned. Parents vaccinate their kids based on the immunisation schedule.

Unlike in many developed countries, Singapore doesn't have a similar programme for youth, adults and the elderly.

It's time to review this.

The case for vaccines

As is well-known, vaccines help to prevent illness for all. Many vaccines are clinically proven to be effective. Getting vaccinated can save much illness, hospital stays and even lives.

After all, even the simple influenza kills.

In the United States, in spite of annual recommendations to vaccinate, between 3,000 and 50,000 people die of this viral infection each year. Without millions getting vaccinated annually, the number of deaths would be even higher.

Although Singapore does not have a clear flu season, it is not immune to morbidity and deaths from this common ailment.

For 19 days in July last year, the flu bug ran amok in a nursing home in Singapore, infecting 61 of the home's 137 residents and 11 of its 79 employees. Of these 72 who fell ill, 11 had to be hospitalised and one died.

In all, one out of every three persons in the home caught the bug, and where residents were concerned, almost half fell ill.

The saddest thing about the whole episode is that the viral strain they caught was one of the three found in flu vaccines.

None of the 72 who got sick had had a flu vaccine in the previous 12 months. Flu vaccines need to be taken annually, as flu viruses mutate quickly and people need protection from the latest strains, and immunity, even for the same strain, goes down over time.

An article on the outbreak in the latest Epidemiological News Bulletin published by MOH quoted local experts as saying: "This outbreak may have been prevented had the residents and staff been routinely vaccinated as the outbreak causing strain of the influenza virus matched the prevailing influenza vaccine strain at that time."

Flu and pneumonia

Another article in the latest 4th Quarter 2012 issue of the Bulletin looked at the impact of influenza and pneumonia on public hospitals over the past five years.

It showed a strong link between the flu and pneumonia, especially in the elderly.

At its peak, over just one week in 2009, 639 patients with flu or pneumonia turned up at public hospitals' emergency departments. Also in just one week, 459 people with such ailments were hospitalised.

That article also pointed out that patients with pneumonia account for between 2.3 and 2.6 per cent of all public hospital patients - or roughly 8,000 a year.

If more people got vaccinated and that reduced even a mere 10 per cent of hospitalisation from flu or pneumonia, it would free up a lot of hospital beds and significantly ease the current bed crunch. It might also prevent some unnecessary deaths.

What hospitals see is the tip of the iceberg. Many more sick patients turn up at GP clinics or polyclinics.

The article by the MOH's public health group concluded: "The impact of acute respiratory infections and pneumonia on health- care utilisation at primary and tertiary care level is of significance.

"The National Expert Committee on Immunisation has recommended annual influenza vaccination for elderly Singaporeans and for persons at high risk of having complications from influenza."

Outside Singapore, experts are saying the same thing.

The American Lung Association promotes vaccination against both pneumonia and flu. It says: "One of the best ways to prevent pneumonia is to vaccinate against it. In addition, an annual flu shot can provide protection due to the close relationship between influenza and pneumonia."

Singapore should take heed of this, since pneumonia is the third-biggest cause of death here - after cancer and heart disease - and some of it is preventable.

The US Centres for Disease Control and Prevention recommends a list of vaccines for everyone, like the flu vaccine to be taken every year, and those for specific groups, such as cervical cancer vaccine for young adults.

What Singapore should do

Singapore should do the same by getting its experts to draw up a list of recommended vaccines relevant to the tropics.

Next, it should allow Medisave use for these vaccines - since this would imply government endorsement of vaccination.

Vaccines can be expensive, ranging from under $30 to a couple of hundred dollars, so allowing Medisave use would help those who are financially strapped, but would like to protect themselves or their family.

And, for some of the more important and more costly vaccines, the Government should consider providing subsidies, or even offering them free the way it does for essential vaccines for children.

In Australia, for example, citizens aged 65 and above get free pneumococcal and flu vaccines.

MOH should be guided by infectious diseases experts on what vaccines to offer, which to subsidise and for what groups of people.

For a start, MOH should provide such vaccines to residents of all nursing homes - free, at a subsidised rate or at cost.

These residents are particularly vulnerable. They are in a nursing home because they are ill, and therefore have lower immunity. Living together in a home makes it easier for bugs to spread. Witness the spread of the flu bug to almost half the residents in one home last year.

Many studies around the world have shown time and again that it is cheaper to vaccinate the population than treat those who get sick for the lack of vaccine.

Health Minister Gan Kim Yong has been talking about moving "upstream", that is, doing more to prevent, detect and treat early.

Encouraging vaccinations is one good way of doing this.

It is true of course that vaccines rarely provide 100 per cent protection. But reducing the rate of illness is good, not just for people but also for the health-care system. Even a small drop in the number of people who need to see a doctor or stay in hospital will ease the crunch on the highly stretched facilities. And that would certainly make Mr Gan's job as Health Minister easier.


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