MRSA infection rates in Singapore hospitals

TODAY newspaper published a nice article on the efforts made by hospitals to control MRSA infections. The overall infection rates (over 6 public hospitals) have fallen from from 0.4/1000 patient days in 2007 to 0.3/1000 in 2009. Whoohoo...!!

errrmmmm....

Need to look at this in a bit more detail....

Here are the figures across 6 hospitals (2007-2009):

Year 2007 2008 2009

Overall: 0.4 0.4 0.3

AH 0.2 0.3 0.2

NUH 0.4 0.3 0.1

TTSH 0.5 0.5 0.3

CGH 0.2 0.3 0.2

KKWCH 0.1 0.1 0.1

SGH 0.6 0.6 0.4

Seems like not a clear pattern here. Yes, 3 hospitals showed a drop especially between 2008 and 2009. But a couple of hospitals had numbers bouncing around. And it is unclear if the overall improvement was heavily biased by NUH's spectacular drop in 2009. (I am actually quite appalled that our SGH is the dirtiest....

Actually part of the problem looking at these numbers is the lack of clarity in the definitions used in the collection of data. An earlier report by Straits Times had pointed this out, i.e. if the bug is on the skin when patient is admitted, and an infection occurs, it is not counted as an infection....

I looked at a MOH report by Dr Helen Goh in 2007. She had then defined the rate as being based on the CDC-NNIS methodology:

"The National Nosocomial Infections Surveillance (NNIS) system defines a nosocomial infection as a localized or systemic condition that a) results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and b) was not present or incubating at the time of admission to the hospital. For most bacterial nosocomial infections, this means that the infection usually becomes evident 48 hours (i.e., the typical incubation period) or more after admission5. The diagnosis of nosocomial infection is thus a combination of clinical findings and results of laboratory and other tests."

Assuming the definitions haven't changed and are consistent across all hospitals (of which I am doubful) ....... we should be able to splice her data with TODAY's info:

Year 2002 2003 2004 2005 2006 2007 2008 2009

Overall: 0.6 0.5 0.5 0.5 0.5 0.4 0.4 0.3

AH 0.3 0.3 0.3 0.2 0.3 0.2 0.3 0.2

NUH 0.8 0.8 0.9 0.8 0.7 0.4 0.3 0.1

TTSH 0.6 0.6 0.6 0.6 0.5 0.5 0.5 0.3

CGH 0.1 0.1 0.1 0.1 0.1 0.2 0.3 0.2

KKWCH 0.1 0.03 0.1 0.1 0.1 0.1 0.1 0.1

SGH 1.0 0.9 0.7 0.8 0.7 0.6 0.6 0.4

Yes, overall the improvement is to be applauded. SGH still looks incredibly filthy. KKWCH looks too good to be true, and CGH actually getting worse.

Lapses in audit? Suggest they check if MOE's budget for medical education has been appropriately used.

The Public Accounts Committee released its report on the MDA, MTI, MOE and Mindef showings lapses in the audit books.

It's all very interesting, but seems like chicken feed to me.

From where I am sitting, it always seems to me that whatever has been budgeted for medical education always seems like not enough. I have always wondered if the MOE budget for training of medical undergraduates, which I understand is based on number of graduating doctors, has been appropriately spent by the medical school. The number of students per graduating class has increased, so the total budget (MOE budget and school fees) must have gone up. The number of students per lecture theatre has gone up so the classroom cost per student must have gone down. The number of labs have been slashed, so the costs of providing labs must have gone down. The problem based learning platform that they migrated to some years ago utilizes 'non-expert tutors (facilitators)'....so the cost of tutoring must have gone down.

So if the budget has gone up and teaching costs gone down....how come the shortfall appears going up?

To what extent is the increasing costs due to non-teaching expenditure, such as research related ventures. I wonder if the Public Accounts Committee had looked into this?

Watch out for the next round of student fee increase.

Worker's safety: Fluorescent safety vests - what's the point?

It is wonderful to see a greater number of workers routinely put on those high visibility vests in the work place. Now that there is so much construct around the Bukit Timah area, I see them all the time. I think it is mandated by the Worker's Health and Safety Act, but I can't seem to access the MOM website and download the Act.

But what seems obvious to me is that the construction sites, and their managers appear only to be concerned with the appearance of being 'safety conscious' without actually being 'safe'.

What's the point of making the workers dress up in all those fluorescent green high visibility vests, when most of them are so faded and dirty that they are no more visible than a dirty t-shirt.

General requirements for a high visibility safety best can be found at this eHow site. According to the site, "The American Traffic Safety Services Association estimates that safety vests worn on a daily basis have a service life expectancy of approximately 6 months. Apparel that isn't worn daily may last as long as 3 years. Vests worn for very dirty work, work in hot climates or work at high altitudes may be more subject to fading and soiling and may not last as long. Any garment that is not visible from at least 1,000 feet away, both day and night, should be replaced."

Somehow i don't think our construction sites care. Perhaps the MOM should look into this.

Singapore population growth

This year is census year, and we should soon have some exciting demographic info to think about....

Statistical information about Singapore is often patchy and incomplete, though not necessarily unavailable. We know for example how fast the population is growing, but to try and figure out how much of this growth is natural, i.e. born here, as compared to immigrants requires a bit of detective work.

Here are some interesting ideas. Bear in mind I am neither a statistician or demographer....rather a kaypoh as usual... :

in 2000, when the last census was done, we had a population of 3.210822 million, out of which, 2.647393 were born in Singapore. So that can serve as a convenient starting point for us. Since population growth every year is birth rate - death rate + immigration rate, we can calculate natural population growth by just using birth rate - death rates. These rates (annually since 2000) have been conveniently provided for us here (birth rate), and here (death rate).

Plugging these into my outdated Excel spreadsheet allows me to chart the natural growth of our population since 2000. (Probably only an approximation since the birth/death rates are for whole population rather than just for Singapore born folks. But it gives us an idea.)

Year 1000s

2000 2,647

2001 2,656

2002 2,665

2003 2,673

2004 2,681

2005 2,687

2006 2,692

2007 2,697

2008 2,702

2009 2,707

Accordingly, if we had gown naturally we should have had a population of 2.707 million in 2009.

By contrast, our 2009 population is 4.988 million, out of which 3.734 million are 'residents' (citizens and PRs), i.e. approximately 1 million residents in Singapore were not born locally. Interestingly, as our current citizens are 3.201 million, it implies that about 0.5 million citizens were not born in Singapore since 2000. Also our total population is almost twice as numerous (4.988/2.707) as those Singaporeans who were born locally.

Interesting. I can't wait for the 2010 census data.

Ethics of prophylaxis

Recently the issue of the fluoridation of our drinking water was raised in parliament, to which Minister of Health Khaw gave a written defence.

We have had fluoride in our drinking water since 1954, and it is without doubt the most effective way to protect growing teeth against caries. But it's been more than 50 years, and we are now no more a backward rural third world community with poor dental hygiene. Do we still need that paternalistic hand of protection shovellings fluoride down our throats?

It just made me wonder about what the ethical issues are with respect to governments forcing public health prophylaxis upon citizens. De we have a choice or say in the matter?

No doubt the government has a responsibility to impose public health measures on the population for the public good. I can think of compulsory seat belt laws, or crash helmet laws.... but then these are to protect against serious potentially fatal risks. Compulsory vaccinations at birth.... but these may be defended because they protect the vaccinated and people around them against serious diseases.

Fluoridation does not much more than protect against dental cavities.... an almost trivial concern by comparison. Plus, there are alternative ways to protect the teeth.... good hygiene, fluoride in toothpastes, etc. The public does have a choice in the matter.

How about fortification of milk or beverages with all sorts of vitamins and good-for-you kind of stuff, you say? These are not mandated by law.

So how ethical is it for a government to spike the drinking water with fluoride and force its citizens to consume excessive fluoride? I wonder.

Good leader, or a bad follower....?

Dr Goh Keng Swee's passing made me ponder a bit about what set him apart so clearly from his contemporaries, and identified him, for me at least, as one of the truly great leaders of his time.

I think it was for me, his clarity of vision and firmness of conviction, and his ability to translate that into down to earth policies that were able to galvanize his followership into achieving wonders for our small island state.

And I think of so much of what's happening in the medical community and our main medical school that disappoints because so much of our 'leadership' appear unable to see beyond blindly following an 'American model'. Where is the vision and self belief that can galvanize our community into achieving true greatness? Instead, the lemming-like dash towards an US residency system continues to baffle everyone about what it is supposed to be achieving. The medical school has been similarly impressive with respect to its pig-headed commitment to policies and pedagogical fads that now is threatening to unravel the very core of medical training.

So here I am wishing instead, that a true leader like Dr Goh can step forward within the medical leadership (MOH or NUS or MOE, or whatever...) and remove the blinkers from their eyes and see the destruction their poor followership has been wreaking on the medical community.

Dr Goh Keng Swee - Requiscat in pace

Dr Goh Keng Swee, Robert, 吴庆瑞

6 October 1918 – 14 May 2010

The passing of a great Singapore leader. Requiscat in Pace, Sir.