DISEASES IN SINGAPORE

As in most developed countries, the major causes of death are heart disease, cancer, and strokes, pneumonia, and cerebrovascular diseases. About 10 percent of population has diabetes. Across the population, nearly 17 percent of Singaporeans have neurotic disorders such as anxiety and depression, double the number of 20 years ago.

Singapore has traditionally been regarded as a potential breeding ground for diseases. It has a hot equatorial climate where mosquitos can breed year round. And its status as a major international port and transportation hub mean that travelers can bring in diseases and disperse them.

The major causes of death in 1986 were heart disease, accounting for 24 percent of all deaths; cancer, 23 percent; cerebrovascular disease, (stroke) 11 percent; and pneumonia, 8 percent. In 1988 two minor outbreaks of dengue fever took place but were halted through prompt control of arthropod-borne microorganisms, and a minor cholera epidemic broke out among the inmates of a mental institution. In 1982 the World Health Organization (WHO) declared Singapore malaria-free, and 161 of the 165 cases of malaria reported in 1987 were determined to be imported. In 1987 the most serious epidemic disease was hepatitis; 752 cases of acute viral hepatitis and 11 deaths were reported. [Source: Library of Congress, 1989*]

In the 1980s, Noise-induced deafness and industrial-related skin disease the major occupational diseases; there was also some concern over exposure of workers to toxic and carcinogenic substances and to asbestos. The health authorities paid special attention to patients with kidney failure, a condition that which killed some 200 people a year. The number of deaths reflected inadequate dialysis facilities and a shortage of organ donors. The 1987 Human Organ Transplant Law gave doctors the right to remove the kidneys of those killed in accidents unless the victim had objected in writing or was a Muslim. *

Fighting Disease in Singapore

In the 1960s, Singapore had one of the highest rates of tuberculosis in the world and was plagued by diseases like malaria, cholera, typhoid, hepatitis and leprosy. It was able to virtually eliminate these diseases through improved medicine and sanitation and organized disease-fighting effort by the government. Things have improved so much that some worry Singapore is so clean that its citizens have a reduced tolerance to disease.

Singapore follows a disease-fighting strategy similar to that advocated by the Center for Disease Control in the United States. It relies on doctors to quickly relay information about diseases so outbreaks can be located, isolated and contained. But Singapore goes further, it has strict laws, namely the Infectious Diseases Act, to back up this strategy and has medical and law-enforcement task forces that are prepared to act quickly in the case of a medical emergency. The government has the power to impose quarantines, something it did quite effectively in the battle against SARS.

In 1964, there was a serious dengue fever epidemic .Efforts by the government resulted in there being far fewer victims than there could have been. Short term efforts included offering assistance to victims and taking measures to prevent the disease. Singapore also embarked on a long-term plan to get rid of dengue-fever- and malaria-carrying mosquitos that included the Destruction of Disease-Bearing Insects Act, which allowed health inspectors to enter a house without a warrant to look for mosquito breeding spots (namely pools of water) and impose stiff fines and prison terms on violators. By the early 1980s, malaria mosquitos had been eradicated enough for the WHO to declare Singapore malaria free.

Wayne Arnold wrote in the New York Times, “Singapore has a siege mentality about disease, much as it does about other security issues, because it exists in a microbiologically turbulent region. A crowded port 1 degree above the equator, Singapore is an ideal habitat for pathogens. Mosquitoes can breed year-round here, and travelers bring in a steady supply of bugs new and old. "The thing that tends to be different in Singapore is that rules imposed tend to be stricter than other places," said Dr Gurinder Shahi, a local biotech entrepreneur and former official at the International Vaccine Institute. Authorities have also been given the power to intrude to fight other diseases. Because lepers tended to hide from public view, for example, a leprosy law gave officials the power to enter suspected dwellings without warning and remove the people for treatment. Leprosy was virtually eliminated by 1992, and the law was rescinded.[Source: Wayne Arnold, New York Times, June 11, 2003 //\]

“In 1970, Singapore passed what Dr Goh considers one of the most significant pieces of health legislation, the Environmental Public Health Act. “Among many other things, the law drove the ubiquitous street vendors indoors. Until then, hawkers were considered intrinsic to Singapore life, peddling curry, meat and noodles from pushcarts, using filthy water and dumping waste in the sewers. "Getting them off the street was a big deal," said Dr Shahi. The effort helped reduce the incidence of cholera, salmonella, hepatitis and typhoid. //\

“Public health regulation has also affected Singapore's taste for pork, a staple of the local Chinese diet. Pigs were once raised locally and sold fresh in wet markets, but the government phased out pig farming in the late 1980's. That virtually eliminated the incidence of Japanese encephalitis, a disease that passes from pigs to humans via mosquito. Most pork, after that point, was imported from neighboring Malaysia. //\

“Then there is what Dr Goh calls the paradox of dengue. Incidence of the disease has risen in Singapore despite efforts to eliminate places the dengue mosquito breeds. Unlike the malaria mosquito, which breeds outdoors, the dengue mosquito is an indoor breeder. As new buildings and homes replaced the swampy areas and construction sites where malaria had been fought, the dengue mosquito made itself at home. Dr. Goh said strict health controls had led to public complacency: most people trust the government to keep bugs at bay. In the end, the only answer to dengue, Dr Goh said, is a vaccine. "Law enforcement is a last resort," he said. "It's a deterrent."

Success of Singapore’s Disease-Fighting Efforts

Wayne Arnold wrote in the New York Times, “The results are compelling. The average life expectancy in Singapore in 1965 was 66 years, on par with Argentina. Singapore had one of the world's highest rates of tuberculosis. Malaria was widespread. Just 38 years later, Singapore's life expectancy is higher than the United States'. Singapore is so clean that public health officials worry that its citizens have low resistance to even mild outbreaks.[Source: Wayne Arnold, New York Times, June 11, 2003 //\]

“In 1968, Singapore gave teeth to anti-malaria efforts with a law allowing health inspectors to enter premises without a warrant to look for mosquito breeding spots. Failure to eliminate the problems can now cost violators up to $50,000 in fines and six months in jail. Under these anti-mosquito laws, the authorities can fumigate homes and can force residents to submit blood samples and be treated. //\

“By 1982, these efforts, combined with urbanization, had wiped out most of the malaria mosquito population and the World Health Organization declared Singapore malaria-free. Travelers occasionally reintroduce the parasite, however, so authorities continue to control the population of mosquitoes. As a result, people often rush to close windows to block clouds of pesticide that rise when workers fumigate city shrubbery. //\

Rules and Fighting Disease

Singapore’s anti-spitting laws were enacted in part to help the city-state reduce tuberculosis because it was believed that spitting helped spread disease. A campaign against spitting was resurrected to battle SARS in the early 2000s, which was spread through droplets from the nose and mouth. At that time. Eleven men accused of spitting in public were paraded front of camera and fined $300 each.

Singapore resident Steven Wrage wrote in Atlantic Monthly that police visited his apartment after neighbors turned him in for over watering his houseplant. The police told him, "You are subjecting the neighborhood to the danger od dengue hemorrhagic fever...Standing water is precisely what female mosquitos are searching for."

After he removed the saucers under his plant pots that were collected the incriminating standing water, the police told him, "I'm glad you understand...We all need to work together to do our part to make Singapore safe and secure and healthy for all.’ Heaven forbid if a potted plant falls off a balcony. The Housing Development Board launches a thorough search for the “killer litterbug.”

In 1964, there was a serious dengue fever epidemic .Efforts by the government resulted in there being far fewer victims than there could have bee. Short term efforts included offering assistance to victims and taking measures to prevent the disease. Singapore also embarked on a long-term plan to get rid of dengue-fever- and malaria-carrying mosquitos that included the Destruction of Disease-Bearing Insects Act, which allowed health inspectors to enter a house without a warrant to look for mosquito breeding spots (namely pools of water) and impose stiff fines and prison terms on violators. By the early 1980s, malaria mosquitos had been eradicated enough for the WHO to declare Singapore malaria free.

Hand, Foot and Mouth Disease (HFMD)

In 2000, there was a serious outbreak of the relatively rare and deadly form of hand, foot and mouth disease. In a two week period more than 1,700 people, most of them children under five , came down with the disease. At least three died, including two children in the same family who died within three hours of one another. Many schools were closed down. After the disease stuck around for a while, The MOH said HFMD is an endemic childhood disease in Singapore, with yearly seasonal outbreaks typically in March-May and September-November.

In 2013, Kok Xing Hui wrote in Today, “The latest weekly number of Hand, Foot and Mouth Disease (HFMD) cases is down significantly from a year ago — at 701 cases compared to 1,685 last year — although the figure is the highest recorded so far this year. Only one childcare centre, Jamiyah Child Care Centre, is on the Ministry of Health’s (MOH) watch list for reporting more than 10 HFMD cases or an attack rate greater than 13 percent, and a transmission period of more than 16 days. [Source: Kok Xing Hui, Today, May 24, 2013 +++]

“There have been 7,440 cases reported this year as of last week, compared to 19,638 a year ago. And numbers are likely to go down further with pre-schools heading for a month-long break after the next week, said Mrs Elsie Tan, Principal of Living Sanctuary Kindergarten. Educators TODAY spoke to said that they have been using the same measures this year as they had in previous years: Sanitising the environment and toys, making sure the children stick to good hygiene habits and taking daily temperatures. +++

“The drop in the number of cases could be due to more conscious effort on everybody’s part to prevent the spread of HFMD, they said. Mrs Tan highlighted an example at her pre-school — which had only three HFMD cases this year — where the parent of an infected pre-nursery child also kept his elder sibling in Kindergarten 2 from attending school. “There is a lot more parent cooperation this year compared to previous years. I think dengue and HFMD reports on the news have raised awareness,” she said. +++

“Some pre-schools, like Character Montessori Pasir Ris, have been taking daily temperatures of students and sending those with a fever home, even if it is a mild temperature and the children are not exhibiting rashes. The school has had zero cases of HFMD this year compared to 10 last year, said supervisor Nor Hazizah. To encourage vigilance, the school sends regular reminders to parents explaining precautionary measures that parents should take, and gives out pamphlets sent from the MOH regarding HFMD.” +++

Dengue Fever

Dengue fever is a nasty, viral disease transmitted by the Aedes mosquito, usually the Aedes aegypti , the same mosquito that often carries yellow fever. Sometimes called "breakbone fever" or "break-heart" because of the intense pain it can produce, the disease is characterized by sudden onset of fever; intense pounding, frontal headaches; aching bones and joints; nausea and vomiting; and a feeling of being too sick to eat anything. Other symptoms include severe sweats, symptoms: eye pain, rash, chills, and excruciating chest pains. Tests foe dengue rely on the presence of antibodies, which can take up to a week to develop.

Dengue fever is found in 100 countries and kills about 20,000 people annually. Nine out of 10 people who get dengue fever don’t even feel it or get a mild case in which they feel something akin to a slight flu. People who get full-blown dengue fever are sick for a week or more. Many patients have a rash, which appears 3 to 5 days after the onset of the disease, and experience severe emotional and mental depression during the recovery period. Most cases of the disease are benign and self-limiting although convalescence may take a long time.

A few people with dengue fever suffer gastrointestinal bleeding. Fewer still suffer brain hemorrhages. In about 1 percent of cases dengue fever can cause a severe and often fatal hemorrhagic disease called dengue hemorrhagic fever (DHF) that occurs when capillaries leak and the circulatory system collapses.. Those that die of dengue fever often get DHF hemorrhaging in the final stage of the sickness. Failing to realize they are infected, they go don’t get treatment soon enough and lose blood plasma and go into shock after the initial fever passes. Some victims die within 10 hours of developing serious symptoms if they don’t get appropriate treatment.

Dengue Fever Outbreak in 2005

Singapore’s worst dengue outbreak in recent years was in 2005, when over 14,000 cases and 27 deaths were reported. The government earmarked S$30 million (US$18 million) to fight the disease that focused on a "search and destroy" campaign against potential breeding areas.

According to a study by led by B.K Koh of Singapore’s Ministry of Health: In 2005, there were a total of 14,006 cases of dengue fever (DF)/dengue haemorrhagic fever (DHF) comprising 13,625 cases of DF and 381 cases of DHF, including 27 deaths, giving an incidence rate of 322.6 per 100,000 and a case-fatality rate of 0.19 percent. The median age of the cases and deaths were 32 and 59.5 years, respectively. The incidence rate of those living in compound houses was more than twice that of residents living in public and private apartments. The distribution of DF/DHF cases was more closely associated with Aedes aegypti compared to Aedes albopictus breeding sites and the overall Aedes premises index was 1.15 percent (2.28 percent in compound houses and 0.33 percent to 0.8 percent in public and private apartments). The predominant dengue serotype was DEN-1. A significant correlation between weekly mean temperature and cases was noted. The correlation was strongest when the increase in temperature preceded rise in cases by a period of 18 weeks. [Source: The 2005 dengue epidemic in Singapore: epidemiology, prevention and control. Koh BK, Ng LC, Kita Y, Tang CS, Ang LW, Wong KY, James L, Goh KT. Hospital Services Division, Ministry of Health, College of Medicine, Singapore]

The resurgence occurred in a highly densely populated city-state in the presence of low Aedes mosquito population. Factors contributing to this resurgence included lower herd immunity and change in dominant dengue serotype from DEN-2 to DEN-1. There was no evidence from gene sequencing of the dengue viruses that the epidemic was precipitated by the introduction of a new virulent strain. The current epidemiological situation is highly conducive to periodic dengue recurrences. A high degree of vigilance and active community participation in source reduction should be maintained. [Ibid]

The National Environment Agency said that the dengue fever problem may be worsening because of higher temperatures and changes in viral strains. The mean temperature has risen to 28.2 ̊C (82.8 ̊F) from 27.8 ̊C in 2003. In the second week of September, more than 100 new cases were reported daily and many were admitted to public hospitals. Health Minister Khaw Boon Wan said that one of the concerns is that more Singaporeans are infected with Dengue Type 3, which is a new strain of the dengue virus. Some experts, such as Dr Paul Reitner, Professor of Entomology at the Pasteur Institute in France, suggested that Singapore's success in suppressing the dengue has partly contributed to this year sudden increase in dengue cases. The population born over the last two decades has a low herd immunity and therefore more susceptible to the virus. [Source: Wikipedia]

Preventive Measures Used in the Dengue Fever Outbreak in 2005

Singapore launched a number of measures to contain the dengue outbreak, including public awareness campaigns and regular fogging with insecticides. 4,200 volunteers, 970 environmental control officers hired by construction sites, 350 so-called "mozzie busters" made up of girl guides and scouts, have participated in the preventive efforts. [Source: Wikipedia +]

The Ministry of Health stepped up its monitoring of common mosquito breeding sites and launched an online map listing "hotspots" for the insects. Residents who allow mosquitoes to breed in their homes can be fined between S$100 to S$200, and heavier penalties may be issued for construction sites found with standing water. The number of officers conducting such checks have tripled since the start of the year to 360, and may increase to 510 by December. The National Environment Agency has allocated an additional S$7.5 million on top of its existing S$2.5 million budget to clear drains of stagnant water where mosquitoes breed. Singapore Land Authority has also stepped up its checks on vacant state properties. +

On 10 September, National Environment Agency started collecting blood samples from residents of Sims Avenue, a dengue hotspot, to help track the infection. The residents were asked to provide voluntarily 5 millilitres of blood sample and a swab of saliva for the study. The samples were to be analysed for antibodies against dengue infection in the last 2 months.

The National Parks Board (NParks) considered removing broad-leafed plants which may breed mosquitoes. These plants like palm trees or any plants with axils capable of trapping water, are potential breeding sites. Holes in tree trunks were also a concern, and NParks workers filled these holes with sand. NParks engaged 16 pest companies to stop mosquito breeding in the parks it manages. Due to the dengue threat, some schools cancelled excursions to the parks.

Health Minister Khaw Boon Wan urged the public to help in the fight against the disease. As households are common breeding grounds for mosquitos and are less accessible for fogging, residents were told to check for stagnant water in their households and neighbourhoods and ensure there as no blockage of drains. Due to the short life cycle of Aedes aegypti mosquitos (7 to 10 days), frequent checks were necessary to eradicate dengue. These checks only took several minutes. Singapore residents also armed themselves with anti-mosquito products including insecticides, repellents and electronic mosquito traps. For repellents, experts recommend those with DEET which provides more effective and lasting protection. Some residents bought a potted plant called Citronella. The perennial grass plant, imported from Cameron Highlands, gives off a strong lemon-like fragrance which repels mosquitoes. To prevent the spread of the virus, those who were already infected with dengue were encouraged to use mosquito repellents, wear long-sleeved clothing and sleep under mosquito nets to prevent mosquitoes from biting them again and spreading the virus to others.

Singapore Put on Alert in 2013 after Dengue Fever Cases Rise

More than 9,000 people contracted dengue fever, with two deaths, in Singapore in the first five months of 2013. The government responded by issuing an alert. Associated Press reported: “ Doctors in Singapore are being urged to be more vigilant after a huge rise in the number of people struck down by dengue fever this year. There have been more than twice as many cases in 2013 than during the whole of 2012. The health ministry said it has alerted clinics in areas where dengue cases have spiked and has advised all medical practitioners about the early diagnosis and close monitoring of patients. [Source: AP, June 11, 2013 ]

“Part of the reason for this year’s increase is that the dengue virus seems to be showing more strength and resistance, Asok Kurup, a doctor at Mount Elizabeth Hospital’s infectious diseases care centre, said. Officials have urged Singaporeans to take precautions and clear stagnant water where mosquitoes breed, but some residents say the main responsibility lies with the healthcare system. “With so many cases occurring, shouldn’t the vigilance fall on our doctors instead?” said Audrey Quek, whose teenage son had dengue two years ago. She said the doctor initially mistook his fever and joint pains for flu symptoms.

“Authorities say they are taking other measures such as increasing insecticide fumigation and sending officers to inspect locations where mosquitoes might breed. Public-awareness campaigns are also being planned, including an online reality show focusing on environmental officers on anti-dengue patrols. Singapore imposes tough penalties on residents whose homes are found to be mosquito breeding areas. Offenders can be fined and jailed for three months.

Singapore’s Dengue Alert

The National Environment Agency (NEA) launched the “Do the Mozzie Wipeout” on 28 April 2013. This campaign calls on everyone in the community to do their part to prevent dengue. With numbers of dengue cases hitting the 400 mark in the last few weeks, the NEA forecasts that the situation could get worse as the typical dengue peak season approaches. The campaign comes at a moment when community support is critical to stop the chain of dengue transmission. The campaign aims to promote awareness on the dengue situation, inspire action to prevent dengue, and encourage advocacy through social media and word of mouth. [Source: Singapore government, National Environment Agency, 2013]

NEA has focused its inspections and operations to tackle Den-1 and Den-3 clusters in particular, since the start 2013. In high risk areas, it started its intensive source reduction exercises to remove actual and potential breeding habitats to reduce the risk of dengue transmission. NEA is also coordinating with other public agencies within the Inter-Agency Dengue Taskforce to prevent mosquito breeding within their facilities and land. Singapore cannot fight dengue without the community’s action to remove mosquito breeding in their homes. The Aedes mosquito breeds in artificial containers mainly found in homes, and its life-cycle averages seven days. Hence it is imperative for all to do the Mozzie Wipeout together to break the breeding cycle. Do the The 5-Step Mozzie Wipeout regularly.

NEA's key strategy in dengue control is to tackle the root of the problem, which is to deny Aedes mosquitoes the place to breed (i.e. source reduction). This approach has been endorsed by WHO . NEA adopts a multi-pronged approach to control dengue. The main thrusts in our approach are: a. preventive surveillance and control; b. public education & community involvement; c. enforcement; and d. research.

Preventive Surveillance and control Through data gathered during field surveillance and with the aid of the Geographical Information System, NEA conducts daily mosquito surveillance operations. The information enables NEA to move quickly into areas to do source reduction (i.e. remove/destroy breeding grounds found). These are important steps to prevent possible dengue transmission.

NEA's operations strategies are: a. Active surveillance in areas prone to dengue and/or where there is high mosquito population. b. Breaking the source of transmission as quickly as possible when cases (both suspected and confirmed) and clusters of cases emerge. Currently NEA has 850 officers carrying out dengue inspection on full time basis. Dedicated teams have been formed to carry out regular auditing, inspections and enforcement in each of the 87 constituencies. These teams, being familiar with the areas under their charge, are able to identify and pre-empt potential problematic areas quicker and more effectively.

The PCOs will carry out audits on common areas such as common corridors, linkways, gutters, bus shelters, bin centres and roof tops of HDB blocks as part of preventive surveillance. If there is active transmission of dengue cases in a particular location, the PCOs will thermal fog the area, including corridors of all floors of HDB blocks and surrounding ground areas to kill all possible infective adult mosquitoes. As an additional precautionary measure, the PCOs will help NEA check places where there are heavy concentration of people, e.g. town centres with bus interchanges/MRT stations. This will reduce any possible breeding in such heavily populated areas. In this way, Aedes mosquitoes cannot have breeding spots to populate and infect new generations to further transmit the virus. A dengue cluster is formed when 2 or more dengue cases occur within 14 days and the homes of the dengue victims are within the distance of 150m. For map of cluster boundary, please click on the cluster locality.

Alert Level indicates the severity of a dengue cluster. Each alert level is associated with a list of preventive actions that the public can take to protect against dengue. There are 3 alert levels: Red: High-risk area with 10 or more cases; Yellow: High-risk area with less than 10 cases Green: No new cases, under surveillance for the next 21 days.

NEA has observed an increase in the number of dengue cases, especially the less common dengue serotype1 (DEN-1) virus which the community has lower immunity against. To protect yourself from dengue do take preventive steps such as the 10-minute 5-Step mozzie wipeout regularly. These preventive measures will help to reduce the number of mosquito breeding habitats.

Singapore Too Successful Combating Dengue Fever?

In the midst of the 2005 dengue fever outbreak, AFP reported: Singapore’s “dengue crisis is partly the result of the city-state's previous efforts in combating the disease, resulting in a population highly susceptible to the virus, a government-appointed panel of dengue said. According to the panel the city-state's high hygiene standards had lowered residents' immunity to the mosquito-borne disease. "It's a paradox. Because (Singapore) has been so successful (in suppressing the disease), the population that was born in the last 20 years has a very low herd immunity," panel member Paul Reiter, an entomology professor from the France-based Pasteur Institute, told reporters. "The (Aedes) mosquito has become more effective, so you've got to go that extra mile to suppress this new level of transmission." [Source: Agence France Presse, October 1, 2005 /^/]

“The city-state's dense human population has also contributed to the possibility of an epidemic breaking out, said Duana Gubler, director of the Asia-Pacific Institute for Tropical Medicine and Infectious Diseases. "When a virus is introduced, in such a dense population that has a very low herd immunity..., you increase the possibility of secondary transmission," Gubler said. /^/

“Unlike previous media reports attributing private residences as the main mosquito breeding grounds, the panel noted that more than half of dengue infections occur elsewhere, such as commercial buildings and public parks. Gubler emphasised the need to implement active laboratory-based disease surveillance programmes to limit the possibility of future outbreaks. "What we have to do in Singapore right now is to have the mosquito control operations guided by research... to find out where people are being infected," Gubler said. /^/

Singapore Precautionary Measures Help It Avoid Bird Flu

Singapore largely avoided the bird flu outbreak that hit Southeast Asia in 2004. Some healthy chickens were killed as a precaution. There were no reported human cases of the diseases. In February 2004, AFP reported: “Singapore authorities declared the city-state was operationally prepared to deal with an outbreak of bird flu after a successful practice cull of 5000 chickens. More than 40 trained personnel from the Agri-Food and Veterinary Authority (AVA) carried out the eight-hour culling exercise at a privately owned farm located in the western part of the island. The chickens — healthy hens which can no longer lay eggs — were stuffed in heavy-duty bags and suffocated with carbon dioxide before later being disposed of in an incinerator. "The main objectives of the exercise were met," AVA chief executive Ngiam Tong Tau said at a news briefing. [Source: Agence France Presse, February 16, 2004 \~/]

"Our logistics system was generally efficient with minor disruptions. The exercise confirmed that all relevant agencies are operationally ready to deal with a bird flu outbreak." Ngiam said in the event of an avian influenza outbreak in Singapore, "we will be able to act swiftly to contain and eradicate the disease with minimal public health risks. It would take between one to two weeks for the country's 2.1 million chickens to be culled.\~/

“Ngiam said however the exercise showed some of the cullers did not have the stamina to endure the slaughter, while others took off their masks and goggles. To solve these flaws, the AVA will have a reserve pool of cullers and carry out additional training of personnel on safety protection during the culling. The exercise was the largest ever slaughter of chickens undertaken in Singapore, where the government has vowed to take tough meaures to keep the island free of the bird flu that has struck at least 10 of its Asian neighbours. One of the measures is the setting up of a high level task force to keep the island free of bird flu. \~/

"There is no avian flu in Singapore," the Ministry of Home Affairs spokesman said in a statement e-mailed to AFP. "Nevertheless, the government has taken proactive action to form groups to work out plans and pre-emptive measures." Singapore, which won international praise for imposing some of the toughest measures to contain SARS, has vowed a similar response to the bird flu. The government removed all live poultry in homes and small backyard farms in an islet off the mainland and has banned the import of poultry products from countries hit by the bird flu.” \~/

Image Sources:

Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, Lonely Planet Guides, Library of Congress, Singapore Tourism Board, Compton’s Encyclopedia, The Guardian, National Geographic, Smithsonian magazine, The New Yorker, Time, Newsweek, Reuters, AP, AFP, Wall Street Journal, The Atlantic Monthly, The Economist, Foreign Policy, Wikipedia, BBC, CNN, and various books, websites and other publications.

Last updated June 2015