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Singapore comprises three ethnic groups: Chinese (76.7%), Malays (14%), and Asian-Indians (7.9%). Overall, Singaporeans experience coronary heart disease rates similar to those found in the United States. However, there is a dramatic interethnic gradient, with Asian-Indians having significantly higher risk than Chinese and Malays. These differences are associated with HDL cholesterol levels and cannot be solely explained by environmental exposure, and may be driven by genetic factors. The gene encoding apolipoprotein A-V ( APOA5 ) has been located on chromosome 11, and it is emerging as an important candidate gene for lipoprotein metabolism. We investigated associations between APOA5 polymorphisms and plasma lipids in 3,971 Singaporeans to establish whether they accounted for some of the ethnic differences in plasma lipids. We found significant associations between the minor alleles at each of four common polymorphisms and higher plasma triglycerides (TGs) across ethnic groups. Haplotype analyses showed significant associations with TGs, explaining 6.9%, 5.2%, and 2.7% of the TG variance in Malays, Asian-Indians, and Chinese, respectively. Conversely, we observed significant inverse associations between the minor alleles and HDL cholesterol concentrations for Chinese and Malays. These data suggest that APOA5 plays a role in the ethnic differences observed for plasma TG and HDL cholesterol concentrations. -Lai, C-Q., E-S. Tai Singapore is a highly developed country in Southeast Asia, populated by ‫ف‬ 4.5 million people living in a mostly urbanized area of ‫ف‬ 700 km 2 and representing three ethnic groups (Chinese 76.7%, Malay 14%, and Indian 7.9%, with other minor ethnicities making up the other 1.4%). Despite their ethnic and cultural differences from Western populations, Singaporeans suffer from high cardiovascular disease (CVD) rates similar to those found in the United States and Australia (1). Most interestingly, the effects of urbanization have not affected all three major ethnic groups equally. Asian-Indians have the highest rate of CVD, followed at a significant distance by Malays and Chinese (1-4). In addition, the ethnic difference is further reflected by the diverse lipid profile among these ethnic groups. In particular, HDL cholesterol levels mirror CVD rates, with Asian-Indians having the lowest, followed by the Malays, and with the Chinese displaying the highest concentrations. Conversely, plasma triglyceride (TG) concentration is the highest in Malays and Asian-Indians and the lowest in Chinese. These differences occur despite the high socioeconomic status and the consumption of diets that have similar biochemical and nutritional compositions regardless of the ethnic origin (2,5). This provides an ideal situation in which to examine the contribution of genetic factors to disease risk heterogeneity and to study the interaction between genetic and environmental factors.High TG and LDL cholesterol and low HDL cholesterol concentrations are independent risk factors for CVD (6, 7). Identifying ...

BackgroundDengue resurged in Singapore during 2013-14, causing an outbreak with unprecedented number of cases in the country. In the present study, we summarise the epidemiological, virological and entomological findings gathered through the dengue surveillance programme and highlight the drivers of the epidemic. We also describe how the surveillance system facilitated the preparedness to moderate epidemic transmission of dengue in the country.MethodsThe case surveillance was based on a mandatory notification system that requires all medical practitioners to report clinically-suspected and laboratory-confirmed cases within 24 hours. The circulating Dengue virus (DENV) populations were monitored through an island wide virus surveillance programme aimed at determining the serotypes and genotypes of circulating virus strains. Entomological surveillance included adult Aedes surveillance as well as premise checks for larval breeding.ResultsA switch in the dominant serotype from DENV-2 to DENV-1 in March 2013 signalled a potential spike in cases, and the alert was corroborated by an increase in average Aedes house index. The alert triggered preparedness and early response to moderate the impending outbreak. The two-year outbreak led to 22,170 cases in 2013 and 18,338 in 2014, corresponding to an incidence rate of 410.6 and 335.0 per 100,000 population, respectively. DENV-1 was the dominant serotype in 2013 (61.7 %, n = 5,071) and 2014 (79.2 %, n = 5,226), contributed largely by a newly-introduced DENV-1 genotype III strain. The percentage of houses with Ae. aegypti breeding increased significantly (p < 0.001) from 2012 (annual average of 0.07 %) to 2013 (annual average of 0.14 %), followed by a drop in 2014 (annual average of 0.10 %). Aedes breeding data further showed a wide spread distribution of Ae. aegypti in the country that corresponded with the dengue case distribution pattern in 2013 and 2014. The adult Aedes data from 34 gravitrap sentinel sites revealed that approximately 1/3 of the monitored sites remained at high risk of DENV transmission in 2013.ConclusionsThe culmination of the latest epidemic is likely to be due to a number of demographic, social, virological, entomological, immunological, climatic and ecological factors that contribute to DENV transmission. A multi-pronged approach backed by the epidemiological, virological and entomological understanding paved way to moderate the case burden through an integrated vector management approach.

IntroductionDetermining the optimal time to vaccinate is important for influenza vaccination programmes. Here, we assessed the temporal characteristics of influenza epidemics in the Northern and Southern hemispheres and in the tropics, and discuss their implications for vaccination programmes.MethodsThis was a retrospective analysis of surveillance data between 2000 and 2014 from the Global Influenza B Study database. The seasonal peak of influenza was defined as the week with the most reported cases (overall, A, and B) in the season. The duration of seasonal activity was assessed using the maximum proportion of influenza cases during three consecutive months and the minimum number of months with ≥80% of cases in the season. We also assessed whether co-circulation of A and B virus types affected the duration of influenza epidemics.Results212 influenza seasons and 571,907 cases were included from 30 countries. In tropical countries, the seasonal influenza activity lasted longer and the peaks of influenza A and B coincided less frequently than in temperate countries. Temporal characteristics of influenza epidemics were heterogeneous in the tropics, with distinct seasonal epidemics observed only in some countries. Seasons with co-circulation of influenza A and B were longer than influenza A seasons, especially in the tropics.DiscussionOur findings show that influenza seasonality is less well defined in the tropics than in temperate regions. This has important implications for vaccination programmes in these countries. High-quality influenza surveillance systems are needed in the tropics to enable decisions about when to vaccinate.

Abstract.Singapore has experienced periodic dengue epidemics despite maintaining a low Aedes house index. Each epidemic was associated with a switch in the predominant serotype. We investigated the temporal dynamics of dengue fever and dengue virus (DENV) and analyzed the epidemiological and entomological patterns of dengue in Singapore from 2004 to 2016. The case surveillance is based on a mandatory notification system that requires all medical practitioners to report clinically suspected and laboratory-confirmed cases. Circulating (DENV) serotypes are monitored through a virus surveillance program. Entomological surveillance involves inspections for larval breeding and monitoring of adults using gravitraps. Singapore experienced a similar epidemic pattern during 2004–2007 and 2013–2016. The pattern involved a 2-year DENV-1 epidemic occurring after a switch in the predominant serotype from DENV-2 to DENV-1, followed by a “lull” year. Thereafter, the predominant serotype switched back to DENV-2, tailed by a small-scale epidemic. Across the years, the highest incidence group was in the 25–44 years age group. The incidence rate of those aged ≥ 55 years was about half of that of the 15–24 years age group during DENV-1 predominant years. However, it was almost equal to the younger age group in DENV-2 predominant years. Types of Aedes aegypti breeding habitats remained similar. Dengue incidence was significantly higher in areas with high breeding percentage (BP) than areas with low BP (P < 0.05). In conclusion, the oscillation of DENV-1 and DENV-2, throughout the 13-year period, led to a cyclical epidemic pattern and older adults were more affected by DENV-2 than DENV-1.

OBJECTIVE -To determine the effect of lowering the fasting plasma glucose (FPG) criterion for impaired fasting glucose (IFG) on the prevalence of IFG, the risks of diabetes, and cardiovascular disease (CVD) associated with IFG. RESEARCH DESIGN AND METHODS-Three studies were used: 1) the 1998 National Health Survey (NHS98), a randomly selected cross-sectional sample of 4,723 subjects; 2) the Singapore Impaired Glucose Tolerance (IGT) Follow-up Study, a cohort study comprising 295 IGT and 292 normal glucose tolerance subjects (frequency matched for age, sex, and ethnic group) followed up from 1992 to 2000; and 3) the Singapore CVD Cohort Study, comprising 5,920 subjects from three cross-sectional studies in whom the first ischemic heart disease (IHD) event was identified through linkage to registry databases. Risk of diabetes (Singapore IGT Follow-up study) was estimated using logistic regression adjusted for age, sex, and ethnicity. Risk of IHD (Singapore CVD cohort) was estimated using stratified (by study, from which data were derived) Cox's proportional hazards models adjusted for age, sex, and ethnicity.RESULTS -Lowering the criterion for diagnosing IFG to 5.6 mmol/l increased the prevalence of IFG from 9.5 to 32.3% in the NHS98. The lower cutoff identified more subjects at risk of diabetes and IHD, but the relative risk was lower than that for IGT.CONCLUSIONS -Greater efforts to identify those with IGT, or a group at similar risk of diabetes and CVD, may be a more efficient public health measure than lowering the FPG criterion for diagnosing IFG. Diabetes Care 27:1728 -1734, 2004T he American Diabetes Association had previously recommended (1) the recognition of impaired fasting glucose (IFG) as a category of glucose tolerance analogous to impaired glucose tolerance (IGT). It was recommended that IFG be diagnosed in those with fasting plasma glucose (FPG) between 6.1 and 6.9 mmol/l. Since then, many analyses have examined the equivalence of FPG and 2-h postchallenge glucose (2-h PG) in predicting both diabetes and cardiovascular disease (CVD). Several key findings have emerged from these studies. First, the association between IGT and CVD events and mortality is stronger than that for IFG (2,3). Second, although IFG and IGT identify some of the same individuals, the degree of overlap is variable (4,5). As a consequence of the recommendations to use FPG rather than 2-h PG for the diagnosis of diabetes, many subjects with IGT, who are at risk of future CVD events, would not be identified.On the basis of the aforementioned findings, the American Diabetes Association has recently recommended (6) that the lower limit for the diagnosis of IFG be changed from 6.1 to 5.6 mmol/l. However, the need for this change has been questioned by others (7,8). Singapore is a small country in Asia with a high prevalence of diabetes and IGT. As in Europe and the U.S., we have found that IFG and IGT often identify different individuals. Only 26% of subjects with IGT had IFG (as defined by the older criteria of FPG 6.1-6.9 mmol/l),...

We have previously reported an interaction between -514C>T polymorphism at the hepatic lipase (HL) gene and dietary fat on high-density lipoprotein-cholesterol (HDL-C) metabolism in a representative sample of white subjects participating in the Framingham Heart Study. Replication of these findings in other populations will provide proof for the relevance and consistency of this marker as a tool for risk assessment and more personalized cardiovascular disease prevention. Therefore, we examined this gene-nutrient interaction in a representative sample of Singaporeans (1324 Chinese, 471 Malays and 375 Asian Indians) whose dietary fat intake was recorded by a validated questionnaire. When no stratification by fat intake was considered, the T allele was associated with higher plasma HDL-C concentrations (P = 0.001), higher triglyceride (TG) concentrations (P = 0.001) and higher HDL-C/TG ratios (P = 0.041). We found a highly significant interaction (P = 0.001) between polymorphism and fat intake in determining TG concentration and the HDL-C/TG ratio (P = 0.001) in the overall sample even after adjustment for potential confounders. Thus, TT subjects showed higher TG concentrations only when fat intake supplied >30% of total energy. This interaction was also found when fat intake was considered as continuous (P = 0.035). Moreover, in the upper tertile of fat intake, TT subjects had 45% more TG than CC individuals (P < 0.01). For HDL-C concentration, the gene-diet interaction was significant (P = 0.015) only in subjects of Indian origin. In conclusion, our results indicate that there are differences in the association of -514C>T polymorphism with plasma lipids according to dietary intake and ethnic background. Specifically, the TT genotype is associated with a more atherogenic lipid profile when subjects consume diets with a fat content > 30%.

Pandemic preparedness plans must include cities that are global trading hubs.