Tuberculosis in Singapore

Tuberculosis, commonly known as TB, is an infectious disease caused by the Mycobacterium tuberculosis bacterium. It spreads from person to person via airborne respiratory droplets from an infected person, and primarily affects the lungs.In the 19th century, Singapore’s flourishing entrepot trade attracted large numbers of emigrants from China and India. As Singapore’s migrant population grew, it brought along an increased incidence of tuberculosis, the spread of which was attributed to the overcrowded, poorly ventilated and insanitary housing of migrants living in the municipal area.2 TB has since been endemic in Singapore. The Ministry of Health launched the Singapore Tuberculosis Elimination Programme (STEP) in 1997 to curb the spread of the disease, which resulted in a decline in the incidence rate of tuberculosis in Singapore in recent years.3

Tuberculosis Committee and the Singapore Improvement Trust
Tuberculosis was first emphasised as a public health threat in Singapore in the 1918 report by the Housing Commission which highlighted that the poor living conditions in the slums had caused the spread of the disease.4 In May 1920, W. Dawson was appointed as Tuberculosis Officer and he opened a tuberculosis clinic in the following year. However, the clinic closed down after just a few months due to the lack of patients despite providing free treatment.5 In 1923, an expert committee was established to look into the tuberculosis problem. The committee recommended three measures for control of the disease: improvement in housing conditions in crowded areas; provision of hospital accommodation for advanced cases; and provision of treatment for early cases.6 The report also emphasised housing as the most crucial preventive measure.7


As part of the tuberculosis response, the Singapore Improvement Trust was formed in 1927 to improve the housing situation and “establish healthy residential areas”. The trust was given $10 million to clear the slums.8

Tuberculosis policy
Difficult living conditions and the lack of medical care and supplies contributed to the rise in the incidence and death rates of tuberculosis during the war.9 After being excluded in the previous edition of the Medical Plan, tuberculosis control was finally included in 1948 as part of the colonial government’s 10-year Medical Plan.10 The tuberculosis policy, drawn up by W. J. Vickers, Director of Medical Services, outlined the priorities in combatting the disease: “housing, adequate nutrition, the establishment of a tuberculosis hospital-sanatorium to serve as a centre for specialist treatment with a first class clinic for outpatients, preventive inoculation, adequate relief schemes, subsidiary sanatoria”.11


Singapore Anti-Tuberculosis Association (SATA)
Tuberculosis was the leading cause of death in Singapore in the postwar years,12 but there was inadequate medical facilities to combat and contain the spread of the disease.13 Eventually, a group of businessmen, community leaders and doctors came together to establish the Singapore Anti-Tuberculosis Association (SATA) on 23 August 1947 to fight the disease. SATA focused on public education and providing outpatient diagnostic and treatment services for the community. While the association was approved by the government, it did not receive funding. Hence, SATA relied on voluntary contributions and fundraising campaigns.14


In 1949, a temporary TB treatment unit, located next to St Andrew’s Mission Hospital, was opened. Three years later, the Royal Singapore Tuberculosis Clinic was set up in Shenton Way. The clinic was more spacious, with separate wings for X-rays, laboratory tests, treatment and rehabilitation. A mobile treatment service was also rolled out in 1955 to offer treatment to those who could not afford to make a trip to the clinics.15

SATA embarked on various projects to cater to those suffering from the disease. Many tuberculosis patients who had recovered from the disease faced difficulties in finding employment due to discrimination, although they were certified fit to work. Thus, SATA launched the Rehabilitation Centre, which aimed to reskill cured patients to boost their employability. Some of the skills taught included tailoring, bookbinding, weaving and box-making, gardening and carpentry. SATA also provided free food rations and TB treatment allowances for patients who required financial or other forms of assistance.16

Bacille Calmette-Guérin (BCG) vaccination
Vaccination is an important preventive measure to create immunity. The alarming prevalence of the disease among young children after the war led SATA and the government to focus on inoculating young people.17


SATA launched the BCG vaccination programme in June 1949 for those aged 18 and below.18 In the mid-1950s, mass BCG vaccination was implemented and became part of the national childhood immunisation programme. Under this programme, BCG vaccination was administered at birth, and revaccination carried out at ages 12 or 16. BCG revaccination was discontinued on 1 July 2001 as there was no scientific evidence on the protective effectiveness of revaccination.19

Tuberculosis Treatment Allowance Scheme
The Tuberculosis Treatment Allowance Scheme, administered by the Social Welfare Department, started in April 1949. The scheme sought to help TB patients who had a chance of recovery by supporting their family or dependents while undergoing treatment.20 By the end of 1949, more than $440,000 of relief funds had been paid out.21 In November 1953, it was announced that tuberculosis patients who had been left jobless due to the disease would be eligible for a special treatment allowance to support himself and his family.22


National Tuberculosis Programme and Singapore Tuberculosis Elimination Programme
Singapore’s National Tuberculosis Programme was kickstarted in 1957 with the establishment of the Tuberculosis Control Unit. The National Tuberculosis Register was set up the following year. The incidence rate of the disease started to decline sharply with the launch of the programme. However, the incidence rate plateaued from 1987 to 1996, which prompted the enhancement of the National Tuberculosis Programme into the Singapore Tuberculosis Elimination Programme (STEP).23


The Ministry of Health rolled out STEP in April 1997. Its goals are to “eliminate tuberculosis from Singapore by detecting and diagnosing all infectious (sputum-positive) cases in the community; curing all cases; detecting and treating all infected tuberculosis contacts; and preventing the emergence of multidrug-resistant tuberculosis”.24

STEP comprises two components. The first is STEP Registry, which administers the National Tuberculosis Notification Registry and the National Treatment Surveillance Module. The second is the Tuberculosis Control Unit, which functions as the clinical arm of STEP and the national centre for contact investigation, preventive therapy, management of tuberculosis patients as well as the training and education of healthcare workers and the public.25

Following the launch of STEP, the incidence of tuberculosis in Singapore declined to 33.9 cases per 100,000 resident populations in 2020, compared to 49–57 per 100,000 resident populations between 1987 to 1998.26



Author
Asrina Tanuri




References
1. Ministry of Health. (2016, March). Prevention, diagnosis and management of tuberculosis, p. 14. Retrieved from Ministry of Health website: https://www.moh.gov.sg/docs/librariesprovider4/guidelines/moh-tb-cpg-full-version-for-website.pdf
2. Loh, K. S. (2020). Tuberculosis – the Singapore experience, 1867–2018: Disease, society and the stateNew York: Routledge, p. 2. (Call no.: RSING 616.995095957 LOH); Tuberculosis in the settlements. (1931, September 4). The Straits Times, p. 19. Retrieved from NewspaperSG.
3. Ministry of Health. (2016, March). Prevention, diagnosis and management of tuberculosis, pp. 19–20. Retrieved from Ministry of Health website: https://www.moh.gov.sg/docs/librariesprovider4/guidelines/moh-tb-cpg-full-version-for-website.pdf
4. Tuberculosis in the Settlements. (1931, September 4). The Straits Times, p. 19. Retrieved from NewspaperSG.
5. Tuberculosis in the Settlements. (1931, September 4). The Straits Times, p. 19; Overcrowding in Singapore is increasing. (1940, March 18). The Singapore Free Press and Mercantile Advertiser, p. 5. Retrieved from NewspaperSG; Loh, K. S. (2020). Tuberculosis – the Singapore experience, 1867–2018: Disease, society and the stateNew York: Routledge, p. 37. (Call no.: RSING 616.995095957 LOH) 
6. Tuberculosis in the Settlements. (1931, September 4). The Straits Times, p. 19; Tuberculosis in Singapore. (1923, November 3). The Straits Times, p. 10. Retrieved from NewspaperSG.
7. Loh, K. S. (2020). Tuberculosis – the Singapore experience, 1867–2018: Disease, society and the stateNew York: Routledge, p. 37. (Call no.: RSING 616.995095957 LOH)
8. Loh, K. S. (2020). Tuberculosis – the Singapore experience, 1867–2018: Disease, society and the stateNew York: Routledge, pp. 36, 44, 46. (Call no.: RSING 616.995095957 LOH)
9. Loh, K. S. (2020). Tuberculosis – the Singapore experience, 1867–2018: Disease, society and the stateNew York: Routledge, p. 59. (Call no.: RSING 616.995095957 LOH)
10. S’pore scheme to fight T.B. menace. (1948, August 19). The Malaya Tribune, p. 5. Retrieved from NewspaperSG; Loh, K. S. (2020). Tuberculosis – the Singapore experience, 1867–2018: Disease, society and the stateNew York: Routledge, pp. 67–68. (Call no.: RSING 616.995095957 LOH)
11. Vickers, W. J. (1948). Tuberculosis policy, Singapore. Singapore: Singapore Government. (Call no.: RCLOS 614.542 SIN); S’pore scheme to fight T.B. menace. (1948, August 19). The Malaya Tribune, p. 5. Retrieved from NewspaperSG.
12. Singapore Anti-Tuberculosis Association. (1997). Fighting TB: The SATA story, 1947–1997Singapore: Singapore Anti-Tuberculosis Association, p. 18. (Call no.: RSING 614.542095957 SIN)
13. SATA CommHealth. (2020). The SATA story. Retrieved from SATA CommHealth website: https://www.sata.com.sg/wp-content/uploads/2020/10/SATA-Story-Booklet-web-version.pdf
14. Singapore Anti-Tuberculosis Association. (1997). Fighting TB: The SATA story, 1947–1997Singapore: Singapore Anti-Tuberculosis Association, pp. 18–19. (Call no.: RSING 614.542095957 SIN); SATA CommHealth. (2020). The SATA story. Retrieved from SATA CommHealth website: https://www.sata.com.sg/wp-content/uploads/2020/10/SATA-Story-Booklet-web-version.pdf
15. Singapore Anti-Tuberculosis Association. (1997). Fighting TB: The SATA story, 1947–1997Singapore: Singapore Anti-Tuberculosis Association, pp. 19–20, 24. (Call no.: RSING 614.542095957 SIN)
16. The sick and the workless. (1955, July 14). The Straits Times, p. 6. Retrieved from NewspaperSG; ‘Let them have a chance’ – Doctor. (1954, November 4). Singapore Standard, p. 4. Retrieved from NewspaperSG; Singapore Anti-Tuberculosis Association. (1997). Fighting TB: The SATA story, 1947–1997Singapore: Singapore Anti-Tuberculosis Association, pp. 21, 25. (Call no.: RSING 614.542095957 SIN)
17. Singapore Anti-Tuberculosis Association. (1997). Fighting TB: The SATA story, 1947–1997Singapore: Singapore Anti-Tuberculosis Association, p. 20. (Call no.: RSING 614.542095957 SIN)
18. TB immunisation of children begins. (1949, June 29). The Straits Times, p. 7. Retrieved from NewspaperSG.
19. Ministry of Health. (2016, March). Prevention, diagnosis and management of tuberculosis, p. 19. Retrieved from Ministry of Health website: https://www.moh.gov.sg/docs/librariesprovider4/guidelines/moh-tb-cpg-full-version-for-website.pdf
20. Allowances for T.B. victims being paid. (1949, April 29). The Straits Times, p. 5. Retrieved from NewspaperSG.
21. $443,993 paid out in relief funds. (1949, December 28). The Straits Times, p. 4. Retrieved from NewspaperSG.
22. All jobless T.B. patients aided. (1953, November 28). The Straits Times, p. 2. Retrieved from NewspaperSG.
23. Ministry of Health. (2016, March). Prevention, diagnosis and management of tuberculosis, pp. 19–20. Retrieved from Ministry of Health website: https://www.moh.gov.sg/docs/librariesprovider4/guidelines/moh-tb-cpg-full-version-for-website.pdf
24. National Centre for Infectious Diseases. (2021). National tuberculosis programme. Retrieved from National Centre for Infectious Diseases website: https://www.ncid.sg/About-NCID/OurDepartments/Pages/National-Tuberculosis-Programme.aspx; Chee, C. B. E., & James, L. (2003). The Singapore Tuberculosis Elimination Programme: The first five years. Bulletin of the World Health Organization, 81 (3), 217–221. Retrieved from ProQuest Central via NLB’s eResources website: https://eresources.nlb.gov.sg/
25. National Centre for Infectious Diseases. (2021). National tuberculosis programme. Retrieved from National Centre for Infectious Diseases website: https://www.ncid.sg/About-NCID/OurDepartments/Pages/National-Tuberculosis-Programme.aspx; Chee, C. B. E., & James, L. (2003). The Singapore Tuberculosis Elimination Programme: The first five years. Bulletin of the World Health Organization, 81 (3), 217–221. Retrieved from ProQuest Central via NLB’s eResources website: https://eresources.nlb.gov.sg/
26. Ministry of Health. (2016, March). Prevention, diagnosis and management of tuberculosis, p. 14. Retrieved from Ministry of Health website:  https://www.moh.gov.sg/docs/librariesprovider4/guidelines/moh-tb-cpg-full-version-for-website.pdf; Ministry of Health. (2021, March 24). Update on tuberculosis situation in Singapore. Retrieved from Ministry of Health website: https://safe.menlosecurity.com/https://www.moh.gov.sg/news-highlights/details/update-on-tuberculosis-situation-in-singapore-2021



The information in this article is valid as at January 2021 and correct as far as we are able to ascertain from our sources. It is not intended to be an exhaustive or complete history of the subject. Please contact the Library for further reading materials on the topic.

 

 

Subject
Public health
Tuberculosis--Singapore--History
Communicable disease control
Tuberculosis--Singapore--Prevention
Tuberculosis--Vaccination--Singapore

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