Read below for travel health advice on Singapore from the MDtravelhealth channel on Red Planet Travel.
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Summary of recommendations
Most travelers to Singapore will need vaccination for hepatitis A and medications for travelers' diarrhea. Other immunizations may be necessary depending upon the circumstances of the trip and the medical history of the traveler, as discussed below. All travelers should visit either a travel health clinic or their personal physician 4-8 weeks before departure.
|Hepatitis A||Recommended for all travelers|
|Yellow fever||Required for all travelers greater than one year of age arriving from or transiting through a yellow-fever-infected area in Africa or the Americas. Not recommended otherwise.|
|Japanese encephalitis||For travelers who may spend a month or more in rural areas and for short-term travelers who may spend substantial time outdoors in rural areas, especially after dusk|
|Hepatitis B||Recommended for all travelers|
|Measles, mumps, rubella (MMR)||Two doses recommended for all travelers born after 1956, if not previously given|
|Tetanus-diphtheria||Revaccination recommended every 10 years|
Travelers' diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.
Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.
If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.
Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.
The following are the recommended vaccinations for Singapore:
Hepatitis A vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available in the United States: VAQTA (Merck and Co., Inc.) (PDF) and Havrix (GlaxoSmithKline) (PDF). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.
Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see hepatitis A for dosage) in the place of vaccine.
Japanese encephalitis vaccine is recommended for those who expect to spend a month or more in rural areas and for short-term travelers who may spend substantial time outdoors or engage in extensive outdoor activities in rural or agricultural areas, especially in the evening. Japanese encephalitis is rarely reported from Singapore. The recommended vaccine is IXIARO , given 0.5 cc intramuscularly, followed by a second dose 28 days later. The series should be completed at least one week before travel. The most common side effects are headaches, muscle aches, and pain and tenderness at the injection site. Safety has not been established in pregnant women, nursing mothers, or children under the age of two months. In addition to vaccination, strict attention to insect protection measures is essential for anyone at risk.
Hepatitis B vaccine is recommended for all travelers if not previously vaccinated. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) (PDF) and Engerix-B (GlaxoSmithKline) (PDF). A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.
Measles-mumps-rubella vaccine: two doses are recommended (if not previously given) for all travelers born after 1956, unless blood tests show immunity. Many adults born after 1956 and before 1970 received only one vaccination against measles, mumps, and rubella as children and should be given a second dose before travel. MMR vaccine should not be given to pregnant or severely immunocompromised individuals.
Typhoid vaccine is not recommended. Typhoid is virtually absent from Singapore.
Polio vaccine is not recommended for any adult traveler who completed the recommended childhood immunizations. In October 2000, the World Health Organization certified that polio had been eradicated from the Western Pacific region, including Singapore.
Cholera vaccine is not recommended. Cholera is not reported from Singapore.
Yellow fever vaccine is required for all travelers over one year of age arriving from a yellow-fever-infected country in Africa or the Americas and for travelers who within the preceding 6 days have been in transit more than 12 hours in an airport located in a country with risk of yellow fever transmission. The vaccine is not recommended or required otherwise. Yellow fever vaccine is not recommended or required otherwise. The vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. Yellow fever vaccine should not in general be given to those younger than nine months of age, pregnant, immunocompromised, or allergic to eggs.
Outbreaks of hand, foot, and mouth disease are regularly reported from Singapore, most recently in April 2006, April 2007, April 2008, April 2009, and April 2012 (see ProMED-mail, April 24, 2007, April 27, 2008, and May 7, 2012). More than 13,000 cases had been reported for the year as of the end of April, 2012. The outbreaks in 2006 and 2007 were caused by coxsackievirus A16, whereas most of the infections in 2008 were caused by enterovirus 71, which causes a more severe form of the disease. The cases in the 2012 outbreak have been mild and do not appear to be due to enterovirus 71.
Hand, foot, and mouth disease is characterized by fever, oral blisters, and a rash or blisters on the palms and soles, usually occurring in young children. Most cases resolve uneventfully. Infections caused by enterovirus 71, unlike coxsackievirus A16, are sometimes complicated by encephalitis (inflammation of the brain), myocarditis (inflammation of the heart muscle), or pulmonary edema (fluid in the lungs). In September-October 2000, an epidemic of hand, foot, and mouth disease caused by enterovirus 71 caused 3790 cases and five deaths (see Emerging Infectious Diseases). The viruses which cause hand, foot, and mouth disease are transmitted by exposure to fecal material from infected individuals. There is no vaccine. The key to prevention is good personal hygiene and scrupulous hand-washing, especially after defecation and before handling food.
The first local cases of chikungunya fever, a mosquito-borne illness characterized by fever and incapacitating joint pains, were reported from Singapore in January 2008. The number of cases began to rise in July 2008, resulting in a total of 388 locally acquired cases by December. The outbreak began in the southeastern part of the city-state (Little India) and spread to Kranji Way (a popular recreational area in the north), Lim Chu Kang (directly east of Kranji Way), Pasir Panjang Wholesale Centre (PPWC) (a southwestern district), and Sungei Kadut (see the Singapore Ministry of Health and ProMED-mail). Two cases were reported in travelers: an American who had visited Singapore in January 2009 and a French woman who had visited for two days in March 2009. The number of cases declined to 3-6 annually for the next several years. However, in the first five months of 2013, more than one hundred cases were reported.
Symptoms of chikungunya fever include fever, joint pains, muscle aches, headache, and rash. The disease is almost never fatal, but may be complicated by protracted fatigue and malaise. Rarely, the infection is complicated by meningoencephalitis, which is usually seen in newborns and those with pre-existing medical conditions. Insect protection measures are strongly recommended, as described below. Because of the risk of mother-to-child transmission, pregnant women need to take special care to protect themselves from mosquito bites. For background information, go to the Chikungunya Fever Fact Sheet on the CDC website.
Outbreaks of dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, are reported regularly from Singapore, most recently in April 2013, causing more than 5000 cases. A total of 4490 cases of dengue fever were reported nationwide for the first nine months of 2011. A dengue outbreak was reported in April 2008, causing 6424 cases by the end of the year. A total of 8607 cases were reported for the year 2007 (see ProMED-mail, May 21 and June 12, 2007; April 14 and December 29, 2008; and August 20, 2011). A major dengue outbreak began in July 2005, causing more than 13,000 cases and 19 deaths before the disease was controlled in early 2006. A large outbreak also occurred in 1998.
Dengue is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. Transmission usually peaks from June through November, though the disease occurs year-round. See ProMED-mail and the World Health Organization for further information. No vaccine is available at this time. Insect protection measures are advised, as outlined below.
Three cases of dengue fever were acquired by blood transfusion in Singapore in 2007. Blood donors in Singapore are not screened for dengue fever.
An outbreak of severe acute respiratory syndrome (SARS) was reported in March 2003, resulting in 206 cases and 31 deaths by the time the outbreak had ended in May. In September 2003, a single additional case of SARS was reported in a postgraduate medical student who most likely acquired the infection as the result of accidental contamination in a laboratory. In December 2003, a single case of SARS, also laboratory-acquired, was reported in a Taiwanese research scientist who had traveled to Singapore shortly before becoming ill. No additional cases have been reported. No travel restrictions are recommended for Singapore at this time.
The outbreak was linked to three people who became ill after visiting Hong Kong, where a SARS outbreak was in progress. In Singapore, the overwhelming majority of cases occurred in health care workers or in family members or other close contacts of those with the disease. A small cluster of cases was connected to a large wholesale fruit and vegetable market. The outbreak was terminated by an aggressive program of contact identification and quarantine. For a summary of the outbreak in Singpore, go to the World Health Organization.
The disease appears to be caused by a previously unknown virus belonging to the coronavirus family. The incubation period usually ranges from two-to-seven days, but may be as long as ten days. The first symptom is usually fever, often accompanied by chills, headache, body aches, and malaise. This is typically followed by dry cough and difficulty breathing, at times severe enough to require intubation and mechanical ventilation. For further information, go to the World Health Organization, the Singapore Ministry of Health, and the Centers for Disease Control.
An increased number of cases of melioidosis, which may cause pneumonia or sepsis, was reported in 2004. The infection may be life-threatening, especially in those with limited immune defenses, such as the elderly and diabetics. Melioidosis is caused by a bacteria called Burkholderia pseudomallei, which lives in soil and surface water, especially in rice paddies. Most cases are related to direct contact with mud or water. The rise in cases appeared to be related to flooding. For further information, go to ProMED-mail (April 9 and September 17, 2004).
An outbreak of encephalitis caused by Nipah virus was reported among abatttoir workers in March 1999, leading to eleven cases and one fatality. Nipah virus infections occur in those with occupational exposure to pigs. There is no evidence of human-to-human transmission and no evidence of any risk associated with eating cooked pork. For further information, go to the World Health Organization.
Leptospirosis may occur in Singapore.
Marine hazards include corals, jellyfish, sharks, sea urchins, and sea snakes. Avoid unmarked, unpatrolled beaches.
HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.
Food and water precautions
Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, sea bass, and a large number of tropical reef fish.
All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include ciprofloxacin (Cipro), levofloxacin (Levaquin), rifaximin (Xifaxan), or azithromycin (Zithromax). Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.
Insect and Tick Protection
Wear long sleeves, long pants, hats and shoes (rather than sandals). Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accommodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night.
Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity.Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet.
Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.
Pack a personal medical kit, customized for your trip (see description). Take appropriate measures to prevent motion sickness and jet lag, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent blood clots in the legs. For those at high risk for blood clots, consider wearing compression stockings.
Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.
Ambulance and Emergency Services
For an ambulance in Singapore, call 995.
Good medical care is widely available. For a broad array of travel medicine services, you can go to the Traveller's Health and Vaccination Centre at Tan Tock Seng Hospital (11 Jalan Tan Tock Seng; ph. (65) 6357 2222; website http://www.ttsh.com.sg/). The International Medical Clinic, which is affiliated with the Australian-based Travel Doctor (TMVC) Group, is dedicated to the care of expatriates (see their website at http://www.imc-healthcare.com/ for locations and phone numbers). For specialty care, travelers are usually referred to Gleneagles Hospital (6A Napier Road, Singapore 258 500; ph. (65) 6473 7222; website http://www.gleneagles.com.sg/) or Mount Elizabeth Hospital (3 Mount Elizabeth, Singapore 228 510; ph. (65) 6737 2666; http://www.mountelizabeth.com.sg/). Both are accredited by the Joint Commission International and both are members of the international networks of the Massachusetts General Hospital and the New York-Presbyterian Hospital, two leading U.S. hospitals.
For an online guide to other physicians and hospitals in Singapore, go to the Singapore Ministry of Health. Most doctors and hospitals will expect immediate payment by cash or credit card, regardless of whether you have travel health insurance. Be aware that Ministry of Health auditors may be granted access to medical records without the patient's consent.
For an overview of health care in Singapore, go to the World Health Organization - Western Pacific Region.
Pharmacies are well-supplied and pharmacists are fully trained. The pharmacies operated by the National Healthcare Group (website http://www.pharmacy.nhg.com.sg/index.asp), located at their polyclinics at Ang Mo Kio, Bukit Batok, Choa Chu Kang, Clementi, Hougang, Jurong, Toa Payoh, Woodlands and Yishun, offer a wide selection of pharmaceuticals and other products.
Traveling with children
Before you leave, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency medical care if needed (see "Physicians and hospitals" above).
All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule).
When traveling with young children, be particularly careful about what you allow them to eat and drink (see food and water precautions), because diarrhea can be especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever, which are transmitted by contaminated food and water, are not approved for children under age two. Baby foods and cows' milk may not be available in developing nations. Only commercially bottled milk with a printed expiration date should be used. Young children should be kept well-hydrated and protected from the sun at all times.
Be sure to pack a medical kit when traveling with children. In addition to the items listed for adults, bring along plenty of disposable diapers, cream for diaper rash, oral replacement salts, and appropriate antibiotics for common childhood infections, such as middle ear infections.
Travel and pregnancy
International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.
Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary (see "Physicians and hospitals" above). In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy.
Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential.
Helpful maps are available in the University of Texas Perry-Castaneda Map Collection and the United Nations map library. If you have the name of the town or city you'll be visiting and need to know which state or province it's in, you might find your answer in the Getty Thesaurus of Geographic Names.
(reproduced from the U.S. State Dept. Consular Information Sheet)
Americans living in or visiting Singapore are encouraged to register at the Consular Section of the U.S. Embassy in Singapore, which has updated information on travel and security within Singapore. The Embassy is located at 27 Napier Road, Singapore 258508, tel.  6476-9100, fax  6476-9340, home page web address: http://singapore.usembassy.gov. In case of emergencies after working hours, the duty officer at the Embassy may be contacted by calling tel.  6476-9100.
For information on safety and security, go to the U.S. Department of State, United Kingdom Foreign and Commonwealth Office, Foreign Affairs Canada, and the Australian Department of Foreign Affairs and Trade.
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