Air-/Droplet- Vector-Borne/ Food-/Water- Blood-Borne Environmental-

Environment- HIV/AIDS, STIs, Childhood

Borne Zoonotic Borne Diseases
Disease Related Tuberculosis Immunisation
Diseases Diseases Diseases Diseases
Disease & Leprosy

Encephalitis

Murine Typhus
• Murine Typhus
Leptospirosis
• Leptospirosis
• Japanese
• Dengue

Malaria
• Malaria
24
 Communicable Diseases Surveillance in Singapore 2005

II
VECTOR-BORNE DISEASES

Vector-borne and zoonotic diseases are diseases
transmitted to humans by insects or animals. Vectors
may transmit infectious diseases to humans through
the blood-feeding arthropods such as mosquitoes and
ticks or through contaminated urine, tissues or bites of
infected animals such as rats or dogs. The causative
organism may be viral, bacterial, fungal or protozoan
and the transmission could be via direct contact, food
and water.

DENGUE FEVER/DENGUE HAEMORRHAGIC FEVER (DF/DHF)

Dengue fever is an acute febrile viral disease
characterised by sudden onset of fever for 3 – 5 days,
intense headache, myalgia, arthralgia, retro-orbital
pain, anorexia, gastrointestinal disturbances and rash.
Early generalised erythema may occur in some cases.
The infectious agents are flaviviruses comprising four
serotypes (dengue-1, 2, 3 and 4) and are transmitted
by the Aedes mosquito. In some cases, dengue
haemorrhagic fever - a potentially fatal complication
characterised by high fever, thrombocytopaenia,
haemorrhagic manifestations, and evidence of plasma
leakage – may develop.
A total of 14,209 laboratory confirmed cases of DF/DHF
[comprising 13,816 cases of dengue fever (DF) and
393 cases of dengue haemorrhagic fever (DHF)] were
reported in 2005, an increase of 50.2% from the 9,459
dengue cases reported in 2004. Of these, 14,046 were
local residents with 14 imported and 14,032 indigenous
cases. The remaining 163 cases were foreigners not
residing in Singapore and who reportedly acquired
the infection overseas; majority of whom had come to
Singapore for medical treatment. There were 27 reported
dengue deaths, consisting of 25 indigenous cases, one
imported case and one foreigner from overseas who
sought medical treatment in Singapore.
The year began with a high incidence rate which had
continued from the previous year, before a decline was
observed in late February. It remained relatively low in
March and April, before the number of cases began to
increase in May. This was followed by a sharp surge,
showing a bimodal pattern. After the second peak
in September, the incidence declined sharply and it
continued to decrease for the remainder of the year
(Figure 2.1).

Figure 2.1
E-weekly distribution of DF/DHF cases, 2004 – 2005
800

700

600

500
No. of cases

400

300

200

100

0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

2004 2005 Week

The incidence rate among indigenous cases was high- groups, Chinese had the highest incidence rate, followed
est in the 15 - 24 years age group with a male to female by Malays and Indians. Foreigners comprised 23.5% of
ratio of 1.4:1 (Table 2.1). Among the three major ethnic the indigenous cases (Table 2.2).

25
 Table 2.1
Age-gender distribution and age-specific incidence rates of indigenous# DF/DHF cases, 2005
Incidence rate per
Age (Yrs) Male Female Total (%)
100,000 population*
0–4 101 83 184 ( 1.3) 88.4
5 – 14 941 808 1,749 ( 12.5) 329.8
15 – 24 1,834 1,244 3,078 ( 21.9) 469.6
25 – 34 2,030 1,223 3,253 ( 23.2) 369.9
35 – 44 1,690 1,072 2,762 ( 19.7) 353.2
45 – 54 818 769 1,587 ( 11.3) 256.5
55+ 664 755 1,419 ( 10.1) 209.5
Total 8,078 5,954 14,032 (100.0) 322.5
#
Cases acquired locally among Singaporeans, permanent and temporary residents.
*Rates are based on 2005 estimated mid-year population.
(Source: Singapore Department of Statistics)

Table 2.2
Ethnic-gender distribution and ethnic-specific incidence rates of
indigenous# DF/DHF cases, 2005
Incidence rate per
Male Female Total (%)
100,000 population*
Singapore Resident
Chinese 4,560 3,907 8,467 ( 60.3) 315.4
Malay 777 665 1,442 ( 10.3) 297.6
Indian 306 213 519 ( 3.7) 167.8
Others 155 153 308 ( 2.2) 412.3
Foreigner 2,280 1,016 3,296 ( 23.5) 413.1

Total 8,078 5,954 14,032(100.0) 322.5

#
Cases acquired locally among Singaporeans, permanent and temporary residents.
*Rates are based on 2005 estimated mid-year population.
(Source: Singapore Department of Statistics)

There were 14 (0.1%) imported cases, defined as local from Southeast Asian countries: 11 from Indonesia, two
residents with a history of travel to endemic areas seven from Malaysia and one from Thailand (Table 2.3).
days prior to the onset of illness. All of these cases were

26
 Communicable Diseases Surveillance in Singapore 2005

Table 2.3
Imported DF/DHF cases, 2001 – 2005
Year
2001 2002 2003 2004 2005
Southeast Asia
Brunei 2 0 0 0 0
Cambodia 8 4 8 4 0
East Timor 1 0 0 0 0
Indonesia 142 155 93 17 11
Malaysia 77 139 100 22 2
Myanmar 8 2 1 1 0
Philippines 5 6 2 1 0
Thailand 32 43 18 3 1
Viet Nam 0 0 2 0 0
South Asia
Bangladesh 8 3 1 1 0
India 19 14 14 7 0
Nepal 0 0 1 0 0
Pakistan 1 1 1 0 0
Sri Lanka 3 9 3 2 0
Other Regions 2 9 2 3 0
Total 308 385 246 61 14

Residents in Housing & Development Board (HDB) However, the incidence rate of residents of compound
flats, compound houses and condominiums constituted houses (710.7 per 100,000) was over twice that of
75.2%, 16.6% and 6.1% of the cases, respectively. residents in HDB flats (332.1 per 100,000) (Table 2.4).

Table 2.4
Incidence rates of reported indigenous DF/DHF cases by housing type, 2005
Incidence rate per
Housing Type No. %
100,000 population*
Compound houses (including shophouses) 2,333 16.6 710.7
HDB Flats 10,545 75.2 332.1
Condominiums 860 6.1 289.8
Others 294 2.1 53.4

Total 14,032 100.0 322.5

*Rates are based on census of population 2000.

(Source: Singapore Department of Statistics)

Though cases were concentrated in the central (29.1%) boundary demarcated by the Community Development
and south-eastern (21.1%) parts of Singapore, cases Council / National Environment Agency (NEA) Regional
were reported from around the island [according to the Office] (Figure 2.2).

27
 Figure 2.2
Geographical distribution of dengue cases in Singapore, 2005

Dengue cases

A total of 1,190 clusters involving 5,362 epidemiologically median duration of transmission was five days (range 1
linked cases were identified. The median number of to 54) (Table 2.5). The number of clusters increased by
cases in each cluster was three (range 2 to 75) and the more than two-fold compared to the previous year.

Table 2.5
Dengue clusters identified, 1990 – 2005
Median
No. of No. of cases in No. of clusters Median no.
No. of duration of
Year indigenous cluster area with > 10 cases of cases
cluster* transmission
cases (% total cases) (% total clusters) per cluster
(days)
1990 1,640 40 270 (16.5) 11 ( 27.5) 4.5 10
1991 2,062 74 414 (20.1) 9 ( 12.2) 3.5 6
1992 2,741 134 733 (26.7) 13 ( 9.7) 3 5
1993 794 33 183 (23.0) 4 ( 12.1) 3 8
1994 1,084 75 424 (39.1) 8 ( 10.7) 3 7
1995 1,756 118 679 (38.7) 16 ( 13.6) 3 7
1996 2,877 143 1,088 (37.8) 27 ( 18.9) 3 6
1997 4,039 198 1,124 (27.8) 24 ( 12.1) 3 5
1998 5,105 239 1,197 (23.4) 23 ( 9.6) 3 7
1999 1,138 54 230 (20.2) 6 ( 11.1) 3 11
2000 402 9 40 (10.0) 1 ( 11.1) 4 15
2001 2,064 93 531 (25.7) 15 (16.1) 3 8
2002 3,560 73 725 (20.4) 30 (41.1) 7 20
2003 4,542 180 1,405 (30.9) 38 (21.1) 4.5 12
2004 9,297 559 2,434 (26.2) 34 ( 6.1) 3 4
2005 14,032 1,190 5,362 (38.2) 93 ( 7.8) 3 5

*A cluster is defined as two or more cases epidemiologically linked by place [within 150m (200m till 2002)] and time (within 14 days)

28
 Communicable Diseases Surveillance in Singapore 2005

Of the 1,190 clusters identified, there were 93 clusters and the median duration of transmission was 23 days
(7.8%) having 10 cases or more. The median number (range 7 to 54). Those clusters with 20 cases or more
of cases in these 93 clusters was 15 (range 10 to 75) are listed in Table 2.6.

Table 2.6
Dengue clusters identified, 2005 (20 or more cases)

S/No Location No. of cases Month

1 Yishun Street 72 75 Aug - Oct
2 Marsiling Crescent 54 Aug - Sep
3 Upper Boon Keng Road 50 Jun - Jul
4 Lorong 7 / Lorong 8 Toa Payoh 47 Aug - Oct
5 Kang Ching Road 45 Oct - Nov
6 Woodlands Avenue 9 43 Aug - Sep
7 Yishun Street 11 42 Aug - Oct
8 Woodlands Street 13 34 Aug - Oct
9 Ang Mo Kio Avenue 3 / Street 11 32 Jun - Jul
10 Upper Boon Keng Road / Lorong 1 Geylang 30 Jun
11 Hougang Avenue 1 29 Aug - Sep
12 Kovan Road 29 Aug - Sep
13 Woodlands Street 13 27 Mar - Apr
14 Potong Pasir Avenue 3 27 Sep - Oct
15 Woodlands Avenue 3 26 Sep - Oct
16 Pending Road 26 Sep
17 Shunfu Road 26 Sep - Oct
18 Shunfu Road 24 Aug - Sep
19 Jurong West Avenue 1 / Street 42 24 Sep - Oct
20 Jurong West Street 41 24 Sep - Oct
21 Sims Avenue 23 Aug
22 Bishan Street 12 23 Aug - Sep
23 Jurong West Street 41 23 Sep - Oct
24 Woodlands Street 41 22 May
25 Yishun Street 61 22 Jun - Jul
26 Yishun Ring Road 22 Jun - Jul
27 Jurong East Street 32 22 Aug - Sep
28 Boon Lay Drive 22 Nov
29 Hougang Street 11 21 Aug - Sep
30 Yishun Ring Road 21 Aug - Sep
31 Bukit Batok Central 21 Sep
32 Cashew Road / Petir Road 20 Sep - Oct

29
DHF Deaths
A total of 27 fatal cases of DF/DHF, comprising three DF
and 24 DHF cases were reported in 2005. Of these, 25
cases were indigenous infections among local residents.
The remaining two cases consisted of an imported case
involving a local resident, and a non-resident foreigner
who sought treatment in Singapore; both had acquired
the infection overseas.

Laboratory Surveillance
All reported cases of DF/DHF were confirmed by one General Hospital, and the Environmental Health Institute,
or more laboratory tests; viz. anti-dengue IgM antibody, National Environment Agency.
enzyme linked immunosorbent assay (ELISA), and
polymerase chain reactions (PCR). All four dengue serotypes were detected, comprising
DEN-1 (67.4%), DEN-2 (8.7%), DEN-3 (17.9%) and
A total of 1,171 blood samples obtained from both DEN-4 (0.6%). 5.4% was indeterminate (Figures 2.3
inpatients and outpatients tested positive for dengue & 2.4).
virus by Polymerase Chain Reactions (PCR) at the
Department of Pathology and Laboratory Medicine, DEN-1 continued to be the predominant circulating
Tan Tock Seng Hospital, National University Hospital’s serotype in 2005, although an increase in DEN-3 was
Laboratory, the Department of Pathology, Singapore also observed (Figure 2.4).

Figure 2.3
Surveillance of dengue virus serotypes, 2005
350

300

250
N o . o f p o s itiv e s a m p le s

200

150

100

50

0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Mont h
DEN-1 DEN-2 DEN-3 DEN-4

(Source: Singapore General Hospital Department of Pathology, Environmental Health Institute,

Tan Tock Seng Hospital Department of Pathology and Laboratory Medicine, and
National University Hospital Laboratory)

30
 Communicable Diseases Surveillance in Singapore 2005

Figure 2.4
Surveillance of dengue virus serotypes, 1992 – 2005
100%

90%

80%
% of positive samples

70%

60%

50%

40%

30%

20%

10%

0%
May 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
1992
DEN-1 DEN-2 DEN-3 DEN-4 Year

(Source: Singapore General Hospital Department of Pathology, Environmental Health Institute,

Tan Tock Seng Hospital Department of Pathology and Laboratory Medicine, National University
Hospital Laboratory, and Kandang Kerbau Hospital Laboratory)

Aedes Surveillance and Control

Aedes surveillance and source reduction are routinely
carried out daily by NEA officers. The focus is primarily
on areas that had historically high rates of dengue
infection. In 2005, an average of 77,000 residential
premises and 4,000 non-residential premises were
inspected every month. A geographical information
system (GIS) was used for clustering and analysis of
mosquito breeding sites and dengue cases. In addition,
5,000 ovitraps were placed around Singapore for Aedes
surveillance (Figure 2.5).
The distribution of dengue cases was more closely
associated with Aedes aegypti than Aedes albopictus
(Figure 2.6). The overall Aedes premises index was
around 1.15%, with the highest percentage detected
in compound houses (Figure 2.7). The top five
breeding habitats for Aedes aegypti were domestic
containers (26%), ornamental containers (24%),
discarded receptacles (7%), flower pot plates (4%), and
roof gutters (3%) (Figure 2.8). In the case of Aedes
albopictus, the most common breeding habitats were
discarded receptacles (21%), domestic containers
(10%), ornamental containers (10%), gully traps (5%),
and canvas/plastic sheets (5%) (Figure 2.9).
During the dengue outbreak in September, a carpet
combing exercise was initiated. NEA mobilised additional
manpower with the help of government agencies,
volunteers and Town Councils (TC) to thoroughly search
and destroy mosquito breeding grounds in all residential
estates. A total of six weeks of carpet combing operation
was carried out, involving some 6,000 volunteers. In
total, over 10,000 public housing apartment blocks and
its surroundings, as well as private estates were covered.
Over 1,000 mosquito breeding habitats were found and
destroyed and another 8,400 potential breeding sites
were removed.
An Inter-agency Task Force was formed in September
2005 to enhance the communication and coordination
on dengue control efforts among various agencies.
Since then, the mosquito control regimes of the various
government agencies had been strengthened.
As a first step, the agencies and private organisations
undertook a thorough sweep of all their infrastructure,
properties and development sites under their charge.
The mosquito control programmes and audit systems
by each agency also underwent a review to ensure
more source reduction efforts on the ground rather
than just focusing on fogging. Permanent solutions to
eliminate potential sources of stagnant water like repairs

31
to infrastructure, sealing up of cracks, backfilling of land
and removal of roof-gutters were carried out.
The formation of this task force has helped to make
communication and coordination on dengue control
efforts among these agencies and private organisations
more effective. NEA can now liaise directly with the
person in charge and implement measures more swiftly
especially when there is a major dengue cluster.
Breeding in common areas under TCs had risen in
2005, constituting about 28% of the total breeding sites
found. To reduce the number of breeding sites found in
TC-maintained areas, NEA had provided financial and
technical assistance to help TCs introduce dedicated
programmes for more effective mosquito control. To
date, 15 out of 16 TCs had implemented the programme.
NEA had also trained 80 officers in 15 TCs to be Estate
Environmental Officers (EEO) in vector management
so that they could supervise the performance of the
dedicated pest control operators engaged for mosquito
control.
Support from the community in dengue prevention was
equally important. Some 10,000 volunteers from the
grassroots spent their weekends distributing the “10-
minute Mozzie Wipe Out” pamphlets to around 880,000
homes. Other organisations such as construction sites,
factories, child-care centres, etc, were also reminded to
practice proper mosquito control measures.

Figure 2.5
Locations of 5,000 ovitraps used for Aedes surveillance

(Source: National Environment Agency)

32
 Communicable Diseases Surveillance in Singapore 2005

Figure 2.6
Geographical distribution of Aedes albopictus, Aedes aegypti and dengue cases, 2005

(Source: National Environment Agency)

Figure 2.7
Percentage of premises breeding Aedes mosquitoes, 1998 – 2005

5
% of premises breeding

0
1998 1999 2000 2001 2002 2003 2004 2005

HDB flats Condominiums Compound houses Year

(Source: National Environment Agency)

33
 Figure 2.8
Distribution of Aedes aegpyti by top five breeding habitats, 2005

26 %

36 %
Domestic containers

Ornamental containers

Discarded receptacles

Flower pot plates

Roof gutters

Others

3%
24 %
4%
7%

(Source: National Environment Agency)

Figure 2.9
Distribution of Aedes albopictus by top five breeding habitats, 2005

21%

Discarded receptacles

Domestic containers

Ornamental containers
49%
Gully traps
10%
Canvas / plastic sheets

Others

10%

5%
5%

(Source: National Environment Agency)

34
 Communicable Diseases Surveillance in Singapore 2005

Outbreaks of dengue
Some case studies of how the dengue outbreak was
managed are discussed below.

Yishun Street 72
On 16th August 2005, the Ministry of Health was notified
of a case of dengue fever involving a student residing at
Yishun Street 72. Within one week, another three cases
involving residents in the same area were reported.
Epidemiological investigations were immediately carried
out.
A total of 74 serologically confirmed cases were identified
in the outbreak. All of them had onset of illness between
9 August and 10 October 2005. 56 (75.7%) of the cases
required hospitalisation.
The epidemic curve is shown in Figure 2.10.

Figure 2.10
Time distribution of 74 DF/DHF cases at Yishun Street 72,
August – October 2005
7
Search and destroy

Outdoor fogging
6
Indoor fogging

5
No. of cases

4
Cluster
identified
3
First case
notified

0
7-Aug 14-Aug 21-Aug 28-Aug 4-Sep 11-Sep 18-Sep 25-Sep 2-Oct

Date of onset

The cases comprised 31 working adults, 22 students,
nine housewives, three retirees and two unemployed
persons. The occupations of seven cases were
undetermined. The majority of cases were in the 15 - 24
years and 34 - 45 years age groups (25.7% and 24.3%,
respectively). The male to female ratio was 1:1.
All of the cases could be clustered by residential/
workplace address within a 250-metre radius from the
initial focus of transmission (Figure 2.11). As part of
vector control operations, Aedes mosquito breeding
habitats were identified in 11 (0.6%) of the 1,836
premises inspected. More than half (54.5%) of the
breeding habitats were found in domestic containers
such as dish trays, pails etc. Profuse breeding was
detected within a locked apartment at Blk 756. Aedes
aegypti and Aedes albopictus accounted for 90.9% and
9.1% of the breedings, respectively.

35
 Figure 2.11
Geographical distribution of 74 DF/DHF cases at Yishun Street 72,
August – October 2005

Marsiling Crescent Blk 212, 213

On 18 August 2005, the Ministry of Health was notified
of a case of dengue fever involving a technician
residing in Marsiling Crescent. Within the next five
days, another five cases were reported from the same
area. Epidemiological investigations were immediately
instituted.
A total of 52 serologically confirmed cases were reported.
All of them had onset of illness between 10 August and
16 September 2005. 50 (96.1%) of the cases required
hospitalisation.
The epidemic curve is shown in Figure 2.12.

Figure 2.12
Time distribution of 52 DF/DHF cases at Marsiling Crescent, August – September 2005
7
Search and destroy

Outdoor fogging
6
Indoor fogging

5
First case
notified
No. of cases

4 Cluster
identified

10-Aug 17-Aug 24-Aug 31-Aug 7-Sep 14-Sep

Date of onset

36

The cases comprised 19 students, 10 working adults,
nine housewives and one retiree. The occupations of
13 cases were undetermined. The majority of the cases
were in the 15 - 24 years age group (34.6%) with an
equal number of males and females affected.
All cases were clustered by residential/workplace
Figure 2.13
Geographical distribution of 52 DF/DHF cases at Marsiling Crescent, August - September 2005
JAPANESE ENCEPHALITIS
Japanese encephalitis is an arthropod-borne disease,
characterised by sudden onset of high fever, chills,
severe headache, meningismus, photophobia, nausea,
abdominal pain, drowsiness and obtundation. The
infectious agent is the Japanese encephalitis virus (a
Flavivirus), which the mosquitoes acquired mainly from
domestic pigs and wild birds. The mode of transmission
is through the bite of infective mosquitoes from the Culex
tritaeniorhynchus group.
There was one case of Japanese encephalitis reported
in 2005. He was a 51 years old Chinese man residing at
Bukit Batok West Avenue 4 who worked as a life guard
37
Communicable Diseases Surveillance in Singapore 2005
addresses within a 250-metre radius from the initial focus
of transmission (Figure 2.13). Of a total of 781 premises
checked, 16 were found to be breeding mosquitoes.
The main breeding habitats were domestic containers
(25.0%) and ornamental containers (25.0%). Aedes
aegypti and Aedes albopictus accounted for 75.0% and
25.0% of the breedings respectively.
at Jurong swimming pool and had no history of travel
and contact with pig farms. Family members were well
with no similar symptoms of illness. He presented with
fever, chills, rigor and myalgia for three days starting on
30 April 2005. On admission to the Singapore General
Hospital, the patient was confused with positive Kernig’s
sign, terminal neck stiffness and tremors of both upper
limbs. He was initially diagnosed as suspected dengue
fever and meningoencephalitis. Dengue serology was
negative. The diagnosis of Japanese encephalitis was
made based on positive PCR detected in his cerebral
spinal fluid and MRI brain showing leptomeningeal
enhancement.
LEPTOSPIROSIS
Leptospirosis is a zoonotic bacterial disease of variable
clinical manifestations. The common presenting
features are fever, headache, chills, severe myalgia
and conjunctival suffusion. The etiologic agent,
Leptospires, is a spiral organism and a member of the
order Spirochaetales found mainly in infected wild and
domestic animals. The mode of transmission is through
direct contact of the skin (especially if broken) or mucous
membranes with the urine or tissues of infected animals.
Soil or vegetation contaminated by infected animals may
also cause infection. Occasionally leptospirosis has
occurred following the ingestion of food contaminated
by the urine of infected rats.
In 2005, a total of 32 laboratory-confirmed cases of lep-
tospirosis were reported, compared with 9 in 2004. Of
these 30 were local residents, comprising 11 imported
and 19 indigenous cases. The remaining two cases were
foreigners who came to Singapore for medical treatment
(Table 2.7 and 2.8).

Table 2.7
Age-gender distribution and age-specific incidence rates of
reported letospirosis cases^, 2005
Incidence rate per
Age (Yrs) Male Female Total (%)
100,000 population*
0–4 0 0 0( 0.0) 0.0
5 – 14 0 0 0( 0.0) 0.0
15 – 24 4 4 8 ( 26.7) 1.2
25 – 34 10 1 11 ( 36.7) 1.3
35 – 44 5 1 6 ( 20.0) 0.8
45 – 54 1 0 1( 3.3) 0.2
55+ 4 0 4 ( 13.3) 0.6
Total 24 6 30 (100.0) 0.7

^Excluding two foreigners seeking medical treatment in Singapore.

*Rates are based on 2005 estimated mid-year population.
(Source: Singapore Department of Statistics)

Table 2.8
Ethnic-gender distribution and ethnic-specific incidence rates of
reported leptospirosis cases^, 2005
Incidence rate per
Male Female Total (%)
100,000 population*
Singapore Resident
Chinese 10 2 12 ( 40.0) 0.4
Malay 5 2 7 ( 23.3) 1.4
Indian 0 0 0( 0.0) 0.0
Others 0 0 0( 0.0) 0.0
Foreigner 9 2 11 ( 36.7) 1.4
Total 24 6 30 (100.0) 0.7

^Excluding two foreigners seeking medical treatment in Singapore.

*Rates are based on 2005 estimated mid-year population.
(Source: Singapore Department of Statistics)

38
 Communicable Diseases Surveillance in Singapore 2005

MALARIA
Malaria is a parasitic disease characterised by fever
and chills. Most serious malarial infections may
present with cough, diarrhoea, respiratory distress and
headache. The infectious agent is a protozoan parasite,
Plasmodium, and there are four different species namely,
P. vivax, P. malariae, P. faciparum and P. ovale. The
mode of transmission is via a bite of an infective female
Anopheles mosquito.
In 2005, a total of 166 laboratory-confirmed cases
were reported, an increase of 9.2% from the 152 cases
reported in 2004 (Figure 2.14). However, 165 (99.4%)
cases were reportedly acquired overseas. Among the
124 local residents affected, 123 were classified as
imported cases and one was classified as cryptic. The
remaining were tourists (19) and foreigners seeking
medical treatment in Singapore (23).

Figure 2.14
E-weekly distribution of reported malaria cases, 2004 – 2005

22
20
18
16
14
No. of cases

12
10
8
6
4
2
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Week
2004 2005

Among the 124 reported cases of malaria in local was 5.9:1 (Table 2.9). Among the three major ethnic
residents, the age-specific incidence rate was highest in groups, the incidence rate was highest for Malays,
the 15 - 24 years age group. The male to female ratio followed by Indians and Chinese (Table 2.10).

Table 2.9
Age-gender distribution and age-specific incidence rates of
reported malaria cases^, 2005
Incidence rate per
Age (Yrs) Male Female Total (%)
100,000 population*
0–4 1 0 1( 0.8) 0.5
5 – 14 5 1 6( 4.8) 1.1
15 – 24 36 2 38 ( 30.6) 5.8
25 – 34 36 7 43 ( 34.7) 4.9
35 – 44 11 4 15 ( 12.1) 1.9
45 – 54 10 1 11 ( 8.9) 1.8
55+ 7 3 10 ( 8.1) 1.5
Total 106 18 124 (100.0) 2.8

^Excluding 23 foreigners seeking medical treatment in Singapore and 19 tourists.

*Rates are based on 2005 estimated mid-year population.
(Source: Singapore Department of Statistics)

39
 Table 2.10
Ethnic-gender distribution and ethnic-specific incidence rates of
reported malaria cases^, 2005
Incidence rate per
Male Female Total (%)
100,000 population*
Singapore Resident
Chinese 8 2 10 ( 8.1) 0.4
Malay 16 3 19 ( 15.3) 3.9
Indian 8 3 11 ( 8.9) 3.6
Others 3 3 6( 4.8) 8.0
Foreigner 71 7 78 ( 62.9) 9.8

Total 106 18 124 (100.0) 2.8

^Excluding 23 foreigners seeking medical treatment in Singapore and 19 tourists.

*Rates are based on 2005 estimated mid-year population.
(Source: Singapore Department of Statistics)

Malaria parasite species

The distribution of the cases by parasite species was P. and mixed infection (1.8%) (Table 2.11).
vivax (64.5%), P. falciparum (32.5%), P. malariae (1.2%)

Table 2.11
Classification of reported malaria cases by parasite species, 2005
Parasite species
Classification Mixed Mixed Total (%)
P.v. P.f. P.m.
(P.v. & P.f.) (P.v. & P.m.)
Imported* 107 53 3 0 2 165 ( 99.4)
Introduced 0 0 0 0 0 0( 0.0)
Indigenous 0 0 0 0 0 0( 0.0)
Cryptic 0 1 0 0 0 1( 0.6)
Induced 0 0 0 0 0 0( 0.0)
Total 107 54 3 0 2 166 (100.0)

P.v. - Plasmodium vivax P.f. - Plasmodium falciparum P.m. - Plasmodium malariae

*Including relapsed and induced cases that were imported.

Overseas-acquired malaria
The majority of the malaria cases acquired overseas P. vivax accounted for 87.9% of the infections acquired
were infected in India (40.0%) and Indonesia (34.5%). in India (Table 2.12).

40
 Communicable Diseases Surveillance in Singapore 2005

Table 2.12
Imported malaria cases by country of origin and by parasite species, 2005
Mixed Mixed
Countries P.v. P.f. P.m. Total %
(P.v. & P.f.) (P.v. & P.m.)
Southeast Asia
Indonesia 35 18 3 0 1 57 34.5
Malaysia 5 2 0 0 0 7 4.2
Myanmar 3 1 0 0 0 4 2.4
South Asia
Bangladesh 1 0 0 0 0 1 0.6
India 58 7 0 0 1 66 40.0
Other Asian countries
Papua New Guinea 1 1 0 0 0 2 1.2
Africa
Ghana 0 1 0 0 0 1 0.6
Nigeria 1 23 0 0 0 24 14.5
Americas
Guyana 3 0 0 0 0 3 1.8
Total 107 53 3 0 2 165 100.0

P.v. - Plasmodium vivax P.f. - Plasmodium falciparum P.m. - Plasmodium malariae

Most of the cases (75.8%) had onset of fever within three malaria, 21.2% did not develop symptoms until more
weeks of entry into Singapore (Table 2.13). For P. vivax than six weeks after entry.

Table 2.13
Imported malaria cases by interval between period of entry and onset of illness and
by parasite species, 2005
Parasite species
Interval in
weeks Mixed Mixed
P.v. P.f. P.m. Total (%)
(P.v. & P.f.) (P.v. & P.m.)
<2 55 33 3 0 1 92 ( 55.8)
2–3 13 20 0 0 0 33 ( 20.0)
4–5 4 0 0 0 0 4( 2.4)
6–7 4 0 0 0 0 4( 2.4)
8–9 2 0 0 0 0 2( 1.2)
10 – 11 0 0 0 0 0 0( 0.0)
12 – 13 3 0 0 0 0 3( 1.8)
14 – 15 2 0 0 0 0 2( 1.2)
16 – 17 2 0 0 0 0 2( 1.2)
18 – 19 0 0 0 0 1 1( 0.6)
20 – 23 5 0 0 0 0 5( 3.0)
24 – 27 7 0 0 0 0 7( 4.2)
28 – 31 5 0 0 0 0 5( 3.0)
32 – 35 2 0 0 0 0 2( 1.2)
36 – 39 0 0 0 0 0 0( 0.0)
40+ 3 0 0 0 0 3( 1.8)
Total 107 53 3 0 2 165 (100.0)

P.v. - Plasmodium vivax P.f. - Plasmodium falciparum P.m. - Plasmodium malariae

41
The overseas-acquired cases comprised 46 Singapore other foreigners (5.5%), 23 foreigners seeking medical
residents (27.9%), 46 work permit/employment pass treatment in Singapore (13.9%) and 19 tourists (11.5%)
holders ( 27.9%), 22 student pass holders (13.3%), 9 (Table 2.14).

Table 2.14
Classification of imported malaria cases by population group, 2004 – 2005
2004 2005
Classification
Cases % Cases %
Local Residents
Singapore residents 43 28.6 46 27.9
Work permit/Employment pass holders 36 24.0 46 27.9
Student pass holders 1 0.7 22 13.3
Other foreigners 10 6.7 9 5.5
Foreigners seeking medical treatment 45 30.0 23 13.9
Tourists 15 10.0 19 11.5
Total 150 100.0 165 100.0

The majority of Singapore residents who contracted chemoprophylaxis except one who took an inadequate
malaria whilst travelling overseas were on social dosage (Table 2.15 and 2.16).
visits or holidays. All admitted that they did not take

Table 2.15
Purpose of travel for local residents who contracted malaria overseas, 2001 – 2005

2001 2002 2003 2004 2005

Purpose of Travel
Social visits/holidays 47 37 30 34 35
Business 8 13 7 8 11
Military service 0 1 1 1 0
Total 55 51 38 43 46

Table 2.16
History of chemoprophylaxis for local residents who contracted malaria overseas,
2001 – 2005

2001 2002 2003 2004 2005

Chemoprophylaxis
Took complete chemoprophylaxis 0 1 0 1 0
No chemoprophylaxis 51 47 35 40 45
Irregular/incomplete chemoprophylaxis 4 3 3 2 1
Total 55 51 38 43 46

A cluster of imported falciparum malaria

In September 2005, the Ministry of Health (MOH)
identified a cluster of falciparum malaria cases involving
Nigerian students who had recently arrived in Singapore.
The index patient was a 23 years old female student
who arrived on 5 September and developed fever the
following day. Subsequently, another seven students,
all males aged 20 - 25 years, developed fever between
13 September and 16 September 2005.
The onset chart is shown in Figure 2.15.

42

Figure 2.15
Time distribution of nine malaria cases involving Nigerian students, September 2005
4
Students arriving
to Singapore
3
No. of cases
2 screening
0
4-Sep 6-Sep 8-Sep 10-Sep 12-Sep 14-Sep 16-Sep 18-Sep 20-Sep 22-Sep 24-Sep 26-Sep 28-Sep 30-Sep
Epidemiological investigations showed that the patients
were part of a cohort of young Nigerians drawn from
various parts of Jigawa State in Nigeria to be trained
in Singapore for two years. Prior to their arrival, whilst
in Nigeria, they had lodged at a hostel in Kazaure for
about two weeks before moving to Lagos. From there,
they flew in batches via Dubai to Singapore from 5 - 8
September 2005.
In Singapore, the Nigerian students stayed at a private
hostel in Tanjong Katong. Health officers immediately
carried out fever surveys and active case finding among
the students of the hostel and residents in the vicinity.
None of them were symptomatic at the time. The
management of the hostel was further instructed to
monitor their residents and seek medical consultation
to exclude malaria for any persons developing
symptoms.
Comments
Although declared free of indigenous transmission
of malaria by the World Health Organization in 1982,
Singapore remains vulnerable to the threat of malaria
via the introduction of cases from endemic countries
around the region. Moreover, Singapore is receptive
to malaria transmission due to the presence of the
Anopheles mosquitoes.
The incubation period for P. falciparum is 9 - 14 days,
43
Communicable Diseases Surveillance in Singapore 2005
Nine
students Four students
picked up picked up and
and referred referred to
to SGH 2nd ESH
screening
Blood of all 3rd
students screening
of of all
students students
Case picked up
from screening
Date of onse t
Blood screening of the Nigerian students for malarial
parasites was also conducted and 13 of the students
tested positive for the presence of Plasmodium
falciparum. 12 of them were asymptomatic while one
developed fever on 25 September 2005. They were
referred to hospital for treatment and isolation. All the
cases recovered following medical treatment.
Inspection of the premises found the housekeeping to be
satisfactory. There were no habitats within the premises
that were conducive for the breeding of the Anopheles
mosquitoes. The nearby drains were subjected to tidal
influence. There was also no major construction activity
or foreign workers' quarter in the vicinity. Nonetheless,
as a precautionary measure, the hostel management
activated their pest control operators to carry out night
thermal fogging.
while the extrinsic incubation period (time needed for the
malarial parasites to undergo development within the
mosquito vector before they are infectious to humans) is
10 - 21 days. Working backwards on the likely source of
infection based on the dates of onset of the patients from
6 - 16 September 2005 and the known incubation period
of 9 - 14 days, a common source exposure to infective
mosquitoes would have likely occurred between 28
August and 2 September 2005. This strongly implicated
Kazaure in Nigeria as the place where transmission reintroduction of malaria into Singapore and the need
occurred. Further investigation revealed that there was to remain vigilant.
an outbreak of malaria occurring in Kazaure at the time
that the students were staying there.
This cluster reminds us of the ever-present threat of

Blood film examination for malaria parasites

A total of 1,555 blood films were collected during routine parasites. None of the blood films tested positive for
epidemiological investigations and examined for malaria malaria parasite (Table 2.17).

Table 2.17
Malaria Surveillance, 2005

Locality No. of blood films examined

Bukit Batok East Avenue 2 35
Springside Avenue 104
Upper Bukit Timah Road 76
Mandai Lake Road Site 1 123
Mandai Lake Road (SAF contractors) 5
Mandai Lake Road Site 2 6
Woodlands Avenue 4 44
Singapore Zoological Gardens 192
Bukit Batok West Avenue 2/Central 152
Soon Lee Road (SCAL Dormitory) 67
Compassvale Bow/Link Junction Site 1 205
Compassvale Link/Bow Junction Site 2 121
Admiralty Road West, Sembawang Shipyard 254
Tuas Avenue 11 117
Tuas Avenue 9 54
Total 1,555

MURINE TYPHUS
Murine typhus is a rickettsial disease whose course
resembles that of louse-borne typhus. The infectious
agents are Rickettsia typhi (Rickettsia mooseri) and
Rickettsia felis. Mode of transmission is by infective rat
fleas that defecate ricketsiae while sucking blood from
its host. This contaminates the bite site and other fresh
skin wounds. Occasionally cases occur following the
inhalation of dried infective flea faeces.
In 2005, a total of 27 laboratory confirmed cases of
murine typhus were reported, identical to 2004. Four
(14.8%) were Singapore residents and 23 (85.2%) were
foreign workers. The majority of cases were male. Four
cases were imported and 23 were indigenous. The
incidence rate was highest for foreigners in the 25 - 34
years age group (Tables 2.18 and 2.19).

44
 Communicable Diseases Surveillance in Singapore 2005

Table 2.18
Age-gender distribution and age-specific incidence rates of
reported murine typhus cases, 2005
Incidence rate per
Age (Yrs) Male Female Total (%)
100,000 population*
0–4 0 0 0( 0.0) 0.0
5 – 14 0 0 0( 0.0) 0.0
15 – 24 2 0 2( 7.4) 0.3
25 – 34 13 1 14 ( 51.9) 1.6
35 – 44 8 0 8 ( 29.6) 1.0
45 – 54 1 0 1( 3.7) 0.2
55+ 2 0 2( 7.4) 0.3
Total 26 1 27 (100.0) 0.6

*Rates are based on 2005 estimated mid-year population.

(Source: Singapore Department of Statistics)

Table 2.19
Ethnic-gender distribution and ethnic-specific incidence rates of
reported murine typhus cases, 2005
Incidence rate per
Male Female Total (%)
100,000 population*
Singapore Resident
Chinese 4 0 4 ( 14.8) 0.1
Malay 0 0 0( 0.0) 0.0
Indian 0 0 0( 0.0) 0.0
Others 0 0 0( 0.0) 0.0
Foreigner 22 1 23 ( 85.2) 2.9

Total 26 1 27 (100.0) 0.6

*Rates are based on 2005 estimated mid-year population.

(Source: Singapore Department of Statistics)

Rodent surveillance
Rodent surveillance and control are regularly carried
out by NEA officers. Food establishments are routinely
inspected for rodent infestation. In addition, wet markets,
food centres and bin centres in Town Council estates
are assessed on a six-monthly basis. Feedbacks and
complaints from public are also used to identify locations
infested with rodents. When burrows are detected, they
are treated with rodenticide and subsequently sealed
up after all the rodents are eradicated. In addition,
respective agencies managing the area are advised
to step up on cleansing maintenance and improve
on housekeeping and refuse management to deprive
rodents of food and habitats.
In 2005, a total of 808 sites were inspected. Rodent
burrows were detected in 226 sites (28%) (Figure 2.16).
Of the infested sites, 64% had low level of infestation
(< 6 burrows), 22% had medium level of infestation (6
- 10 burrows) and the remaining 14% had high level of
infestation (> 10 burrows) (Figure 2.17). The common
habitats were: planted turf areas in Town Council areas,
around bin centres/bin chutes, and cracks and crevices
along roadside drains. The common causes identified
for these infestations were: uncovered refuse bins, refuse
spillage, unkempt bin centres and defective structures.

45
 Figure 2.16
Geographical distribution of rodent burrows detected, 2005

• Rodent burrows

(Source: National Environment Agency)

Figure 2.17
Rodent infestation levels in premises inspected, 2005

14%

22%

64%

Low (<6 burrows ) Medium (6-10 burrows ) High (>10 burrows)

(Source: National Environment Agency)

46

Rat Attack programme
With the emergence of rodent-borne diseases worldwide,
NEA has introduced a structured rodent surveillance
and control programme with the aim of achieving zero
rodent infestation. In April 2005, NEA launched the
Rat Attack Plus programme, a two-year programme to
help Town Councils (TCs) set-up a sustainable rodent
control programme in public housing estates island-wide.
The programme involved the active participation of all
stakeholders in the community.
The Rat Attack Plus programme consists of two phases,
namely, attack phase and maintenance phase. In
the attack phase that lasts for three months, the pest
management companies (PMCs) are required to carry
out a baseline survey to:
• Assess current level of infestation; and
• Identify irregularities in environmental sanitation
and refuse management at the sites that are
contributing to the infestation.
The rodent population, determined from the baseline
survey, is then reduced through intensive rat baiting
as well as implementation of measures to improve
the overall sanitation of the housing estates. This is
followed by the maintenance phase lasting for the next
18 months whereby the TCs are to maintain the sites in
a rodent-free state.
47
Communicable Diseases Surveillance in Singapore 2005
To help the TCs kick-start the project, NEA provides
funding support to all TCs for six months of the
programme. To date, 13 of 16 TCs have embarked on
this project and NEA will encourage the remaining two
TCs to come on board. NEA has also received positive
feedback on the improvement in rodent management and
in the level of sanitation within housing estates.
In addition, a Rat Attack Task Force, led by the General
Manager of each TC has also been set up to oversee the
implementation of the Rat Attack programme in the town
council estates. The members of the Task Force comprise
representatives from the TCs, NEA and PMCs. The
Task Force works closely with the various stakeholders,
namely, trade operators, Hawkers Association, Shop
Merchants Association, Coffeeshop Association, public
waste collectors, cleaning contractors, grassroots
organisations, such as the Citizens Consultative
Committees and Constituency SOK Task Force, and
residents to improve refuse management systems and
adopt better housekeeping to eliminate any food supply
and deny rodents the opportunity to nest.
NEA will continue to monitor the rat situation closely
to ensure that Singapore maintains a low rodent
population.