Opening Remarks by Minister for Health Mr Ong Ye Kung At the MOH Press Conference to Update On the Public Health Preparedness Measures for Mpox Clade I On 4 September 2024

We are here to talk about mpox Clade I. Mpox Clade II has been in Singapore for over a year, and is largely not a public health threat. But what we are concerned now is mpox Clade I, that has broken out in many African countries. At some point, we should expect it to spread beyond Africa, and then at some point it will arrive in Singapore.

2. We have received many media queries over the last week. Thank you for your interest. They are all very relevant questions and we thought it is much better that we have a press conference, so that everybody can be briefed on our response plan.

3. This plan is based on what we know about the virus. The virus has not spread to many countries yet, so we do not have full information on the characteristics of this virus, but we have good information on how it behaves and the key characteristics, which allows us to develop the response plan.

4. Things can change as we understand the virus better, and as the situation evolves. Hence, our plans may have to adapt over time, but as of now, I think we have quite a comprehensive plan.

5. I would say that the bottom line is this: We think we were right to be worried about mpox Clade I, and the World Health Organization was right to have declared it as a Public Health Emergency of International Concern. But we think this is likely to be a troublesome virus that we can manage. It will very unlikely lead to the kind of disruptions that happened during COVID-19.

6. As I explained earlier in Parliament, when we passed the amendments to the Infectious Diseases Act, we provided for four levels of alert for Singapore - Peacetime, Outbreak Management, Threat (COVID-19 was a Threat), and Emergency, which we have not declared before.

7. Typically, we toggle between Peacetime and Outbreak Management. We moved to Outbreak Management when there was an incident such as the tuberculosis outbreak in Jalan Bukit Merah at the ABC Brickworks Hawker Centre, or when mpox Clade II first arrived and we did not know much about it, and we were in Outbreak Management level. Typically, we toggle between these two levels and the public does not even know.

8. We do not think there is a reason to elevate the level of alert beyond Outbreak Management for mpox Clade I.

9. That said, we should not be complacent. We have been developing many contingency plans since the COVID-19 pandemic. It is time for us to dust off these plans, put some of them into action and implement them. We must continue to monitor the situation, and be prepared to respond, adapt, and even decisively implement certain measures, should it be necessary.

Response Measures

10. The first important rule is to recognise that every virus is different. They have different characteristics, and we must respond accordingly based on those characteristics. Never fall into the trap of fighting the last war, that just because we did that in the last pandemic, we must now do the same. It all depends on the characteristics of the virus and what are we dealing with. Let me summarise the key characteristics of mpox Clade I

11. First, the transmission mode is mainly through close physical contact with infected persons. This includes sexual contact, mouth-to-mouth, skin-to-mouth, and skin-to-skin contact. What makes Clade I different from Clade II is that the global outbreak of Clade II is mostly amongst men who have sexual relations with men. However, Clade I in the DRC does not spread primarily through just sexual networks, but also through family members living in the same household, where there will be some close and physical contact.

12. A question which scientists are looking at is whether it is spread via air, just like respiratory illnesses and diseases. It cannot be ruled out, but this will be clear in the coming months. What is clear is that it does not transmit far and wide like COVID-19, where one singer can transmit to many members of the audience. This is very unlikely the case for mpox Clade I.

13. The second characteristic we should look at is infectiousness, which is measured by the reproduction number, otherwise known as "R". As of now, mpox Clade I virus has a known R of about 1.3. This means that for every 10 infected persons, they can spread to 13 persons. Compared to COVID-19, mpox Clade I is far less infectious, and because of the high level of transmission, we required all kinds of safe management measures and even the circuit breaker in order to slow down the transmission. We are not seeing that in mpox Clade I. This is a decisive factor as we develop the response plan.

14. The third characteristic we look at is severity. Out of every 100 infected cases in the Democratic Republic of the Congo, there were about three to four who died, which is actually quite a high number, and the majority are actually young people below the age of 15.

15. The actual statistics in Europe and developed countries like in Singapore will most likely be significantly lower for two reasons. Number one is that in Africa and the DRC, the denominator is probably underestimated, because many infected cases are not detected or notified. So with a bigger denominator, the severity rate should actually be lower than three to four. Secondly, there will be better access to quality medical care in Europe or Singapore, which will lower the severity rate significantly.

16. The fourth characteristic is the specific groups that will be especially affected by mpox Clade I. The first group is, of course, the vulnerable, meaning the old, sick or people who are immunocompromised. The second group is possibly the young, because, as mentioned, a large proportion of cases and deaths in the DRC are children below the age of 15. There are other factors and reasons for the higher severity observed in children in the DRC. For example, there is a high prevalence of malnutrition in the DRC, and the children may also be infected with other diseases. Third, they may not have access to good quality healthcare. All three factors are critically important to children when they are infected with a disease like mpox Clade I.

17. We believe that the clinical outcomes will be different outside of the DRC, and certainly better in Singapore. That said, this is a risk we need to pay close attention to, and to protect these vulnerable groups. We should not resort to draconian and very disruptive measures. No country is doing that now. The best way to suppress the spread of the virus, provide proper treatment to those who are infected and have a very effective vaccine strategy.

18. This brings me to our response plan. There are a few key aspects the response plan.

19. First - border measures. Since COVID-19, we have never gotten rid of the Electronic Health Declaration when you arrive in Singapore, and it is precisely for a situation like this. Don't step it down and then having to step up again. We just kept it simple - just two questions - in order to have some border surveillance of people coming in, including Singaporeans coming back.

20. We have enhanced the Electronic Health Declaration Card through the SG Arrival Card. Travellers are now required to declare mpox-related symptoms such as rash, and travel history to affected areas. We have put in place temperature and visual screening for symptoms for persons arriving from higher risk areas, at both air and sea checkpoints. Symptomatic travellers will be assessed by doctors at the borders and if necessary, transferred to hospitals for further assessment and testing.

21. The second area will be in contact tracing and quarantine. Mpox has a fairly long incubation period, up to 21 days and so cases may not be picked up at the borders, even if someone is infected, so chances are they will develop after they enter the border. Our clinics have been notified and will be on alert to spot such cases and immediately report to MOH whenever they detect symptoms which they suspect might be mpox Clade I in particular.

22. Should they detect a case, existing contact tracing and quarantine protocols will kick in. All suspect mpox Clade I cases will be conveyed to designated hospitals for further assessment and testing. If tested positive, these patients will be treated and isolated until they are no longer infectious. Contact tracing will be conducted for all confirmed cases of mpox. This is a very effective way to limit transmission and drive the R number lower.

23. The National Environment Agency will oversee environmental cleaning and disinfect all the key areas that the infected persons have been to in recent days.

24. Quarantine of close contacts of confirmed cases will then also be activated. It will be in a designated government quarantine facility. The duration will be set at 21 days for now, because that is the incubation period that we know, but it starts from the last day of exposure. So, for the great majority of people quarantined, it is not likely they will serve the full 21 days. Persons under quarantine will be offered vaccination to reduce the risk of infection.

25. The third area is the migrant workers' dormitories. We have been working with the Ministry of Manpower to develop various contingency plans since the COVID-19 pandemic and some of the measures have been activated in the foreign workers' dormitories. These include: One, wastewater testing. This is being conducted at 120 dormitories currently and also at the Onboard Centre. It can be a useful way to give us an early warning. Two, temperature and visual screening for newly arrived work permit holders at the Onboard Centre. And third, triggering existing protocols which will track, trace, and isolate workers in the dormitories, and support workers in their recovery. This is actually a very important system that has been put in place since COVID-19, where infected workers have spaces available within the dormitories to isolate infected workers so that it does not spread further within the dormitories.

26. The fourth area of response is preschools and schools. We have also been working closely with the Ministry of Education and the Early Childhood Development Agency to put in place contingency plans since the COVID-19 pandemic. Schools have quite effective existing protocols to manage outbreaks, such as hand, foot and mouth disease, and they are relevant in countering mpox Clade I. This includes ensuring good hygiene practices among the students, and screening them for symptoms. If there is an infected case, the student will be isolated, the premises will be cleaned, contact tracing will be triggered and if necessary, the class, level or school may be temporarily closed to prevent further transmission. These are all in place to manage, say, hand, foot and mouth disease, and they will be relevant for mpox Clade I as well.

27. As mentioned earlier, given the characteristics of mpox Clade I, the most effective way to protect our children is to have a good response plan that will suppress the transmission of mpox Clade I, through sensible community measures, contact tracing, and isolation.

28. The fifth area - masking. As I mentioned earlier, based on what we know now, Clade I mpox is spread mainly through close physical contact with infected individuals. Is there transmission through the air? This is a question that is uncertain. We cannot rule that out, but it is quite likely that it is not the primary mode of transmission.

29. If that is the case, people who are well do not need to wear a mask. It is not necessary for MOH to impose a masking requirement on people who are well. However, should there be evidence of significant respiratory transmission, such as beyond the households into, say, public areas, then we need to re-evaluate this policy. One step we can consider then is to require masking on public transport, or indoor crowded spaces. I think more evidence will emerge in the coming weeks and months.

30. Our current mask stockpiles and local manufacturing capabilities will assure us of adequate supply.

Closing

31. In closing, we think this is a troublesome virus, but something we can manage. We will likely learn more about it in the coming weeks and months, and we should be prepared to adapt our response plan as we understand the disease better.