Academic journal article Bulletin of the World Health Organization

The Singapore Tuberculosis Elimination Programme: The First Five Years. (Policy and Practice)

Academic journal article Bulletin of the World Health Organization

The Singapore Tuberculosis Elimination Programme: The First Five Years. (Policy and Practice)

Article excerpt


Singapore is an island city-state with a total population of about 4 million, of whom 3.26 million are resident, and 0.74 million non-residents on long-term employment, student or social visit passes. Ethnically the resident population is 77% Chinese, 14% Malay, and 8% Indian, with 1% being of other ethnicities. The proportion of people aged over 60 years is 11%; it is projected that 27% will be in this age group by 2030 (1).

Since 1965 Singapore has made striking social and economic progress. The incidence of tuberculosis declined from 300 per 100 000 in the 1960s to 55 per 100 000 in 1987 as a result of substantial improvements in environmental hygiene, housing and sanitation, the provision of medical services, the advent of short-course tuberculosis chemotherapy, and the national tuberculosis programme. Mortality from tuberculosis declined from 12% of all deaths in 1950 to less than 1% in the 1990s. However, the tuberculosis notification rate remained between 49 and 56 per 100 000 population from 1987 to 1997 (Table 1, Fig. 1) (2).


Pulmonary tuberculosis accounts for around 90% of notified cases. Mycobacteriological culture and sensitivity testing have been consistently performed on over 90% of these cases, and the rate of positive cultures has been in the range 6070%. The incidence of primary multidrug-resistant tuberculosis has been below 1%. Over the past decade or so the disease has predominantly affected older men: 50-60% of cases have been men aged over 50 years and approximately twice as many males as females have contracted tuberculosis (Fig. 2) (2).


Non-residents entering Singapore for long-term stays are required to undergo chest radiograph screening for active disease. Tuberculosis notifications among non-residents constituted 31% of all notified cases in 2000 (3). The corresponding proportion was 38% in 1997, when the Singapore Tuberculosis Elimination Programme (STEP) was introduced (2).

The low incidence of tuberculosis in childhood and early adulthood and the steep rise in incidence with age suggest a low level of transmission in the community. Endogenous reactivation in an aging population appears to be a major factor contributing to the leveling off of tuberculosis rates. The possibility of increased transmission among older people, however, should not be ignored. The impact of infection with human immunodeficiency virus (HIV) on the tuberculosis rate is not believed to be significant, as Singapore has a relatively low HIV rate of 71 per million population and under 10% of HIV-infected patients have tuberculosis (2).

The Ministry of Health conducted a review of the national tuberculosis programme in response to the decade-long stagnation in the tuberculosis rate and the growing global epidemics of tuberculosis and HIV. STEP was launched with a mission 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 (4).

Organizational structure of the Singapore Tuberculosis Elimination Programme

STEP is overseen and directed by a committee appointed by the Ministry of Health. An international advisory panel comprising four tuberculosis experts from Canada, the USA, and International Union Against Tuberculosis and Lung Disease provides advice and assistance. It is led by the Programme's national tuberculosis adviser, Professor Lee B. Reichman, Executive Director, New Jersey Medical School National Tuberculosis Center.

Components of the Programme

The two main arms of STEP are the epidemiological component under the Department of Clinical Epidemiology and the clinical component under the Tuberculosis Control Unit, Tan Tock Seng Hospital. The epidemiological component is essentially a surveillance system comprising the revamped National Tuberculosis Notification Registry, the treatment surveillance module and the registry for contact investigation. …

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