Bio-Terrorism Key Facts on Plague, Botulism, Smallpox and Anthrax In the aftermath of the September 11 attacks by terrorists on the World Trade Center in New York and the Pentagon in Washington, the term biological warfare has become known to people all over the world. Biological warfare, popularly known as bio-terrorism, is the intentional use of organisms to harm or kill people. High on the list of organisms that may be used by terrorists are those causing infectious diseases, as they would easily spread among people and cause panic and fear. Among these organisms, anthrax and smallpox pose the biggest threats. Other organisms and diseases including Yersinia Pestis (bubonic plague), Clostridium Botulinum (botulism), Tularemia and Tuberculosis could pose a threat too. However, they are not as hardy as anthrax, and difficult to manufacture and distribute. The recent incidents in the United States have demonstrated the vulnerability of man to the threat from these agents. Although the cases of anthrax exposure and infection were not many, the confusion and fear among the public was widespread one of the aims of the terrorists. Gas masks, gloves and antibiotics were in great demand. The US government is seriously considering the option of vaccinating all its citizens against smallpox, something that has not been done since the disease was eradicated 20 years ago. This issue of HealthNews looks at 4 diseases in greater detail plague, botulism, smallpox and anthrax. Clinical features, prophylaxis and treatment of each of these diseases are discussed.
Cover Story Plague By Dr Kwan Yew Seng Plague, caused by Yersinia pestis (Y pestis), is one of the most serious diseases that could cause death in sufficient numbers to cripple a city or region. Y pestis is relatively easily available, it can be mass produced and be disseminated by aerosol method. The difficulty in preventing such activities makes its potential use as a biological weapon of great concern. History There has been 3 plague pandemic recorded in history so far. The latest began in China in 1855, spread to all inhabited continents, and ultimately killed more than 12 milion people in India and China alone. Advances in living conditions, public health, and antibiotic therapy make future pandemics unlikely. However, plague outbreaks following use of a biological weapon are a possible threat. Naturally occurring plague Human plague most commonly occurs when plague-infected fleas bite humans who then develop bubonic plague. As a prelude to human epidemics, rats frequently die in large numbers, causing the movement of the flea population from its natural rat reservoir to humans. Plague remains an infection in animal communities, usually rats, ground squirrels, prairie dogs and other rodents. Plague following use of a biological weapon Intentional dissemination of plague would most probably occur via an aerosol of Y pestis. A pneumonic plague outbreak would result. Symptoms would begin to occur 1 to 6 days following exposure. The first sign of illness would be fever with cough and dyspnoea, sometimes with the production of sputum. Other common symptoms include nausea, vomitting, abdominal pain and diarrhoea. Diagnosis may be confirmed by identifying or growing the bacteria in sputum or blood. Is there a vaccine available? To date, there is still no vaccine available for plague. Research is ongoing in the pursuit of a vaccine that protects against primary pneumonic plague. Recommended treatment Antibiotics are available for treatment of plague. In a mass casualty setting, oral therapy with either doxycycline or ciprofloxacin is effective. Prevention of transmission Person-to-person transmission of pneumonic plague occurs via respiratory droplets. Experts recommend the use of disposable surgical masks to prevent the transmission of pneumonic plague. Infected persons should be isolated during the first 48 hours of antibiotic therapy. Botulinum Toxin Botulinum toxin is produced by the bacteria Clostridium botulinum. It poses a major bioweapon threat because of its extreme potency and lethality. It is also easy to produce, transport and misuse. It is the most poisonous substance known. One gram, evenly dispersed and inhaled, would kill more than 1 million people. Botulinum toxin is also the first biological toxin to become licensed for treatment of human diseases like muscular disorders and even for cosmetic improvement. History Attempts have been made by terrorists to use botulinum toxin as a bioweapon. Aerosols were dispersed at multiple sites in Tokyo, and at US military installations in Japan on at least 3 occasions between 1990 and 1995 by the Japanese cult Aum Shinrikyo. However, these were unsuccessful. After the 1991 Persian Gulf War, Iraq admitted to having produced 19,000 litres of concentrated botulinum toxin, which is approximately 3 times the amount needed to kill the entire human population by inhalation. Use of botulinum toxin as a biological weapon When botulinum toxin is aerosolized, inhalational botulism results. So far, inhalational botulism has only occurred accidentally in humans. The symptoms occurred around the third day after exposure with mucus in throat, difficulty in swallowing solid food and dizziness. Other symptoms that follow include difficulty in moving eyes, indistinct speech, unsteady gait and extreme weakness. Treatment Therapy for botulism consists of supportive care and passive immunization with antitoxin. Antitoxin should be administered as soon as possible after clinical diagnosis. Antibiotics are not effective against botulinum toxin. Is there a vaccine available? At present, vaccination is not available to the general population. 2 Raffles Healthnews Issue 1/2002
Smallpox - eradicated in 1980 Smallpox Cover Story By Dr Madeleine Chew Smallpox is a disease caused by Variola virus. The only known reservoir for the virus was humans. The most frequent mode of transmission was person-to-person, spread through face-to-face contact with an infectious person. Indirect spread through fine-particle aerosols or a fomite containing the virus was less common. During the smallpox era, overall mortality rates were approximately 30%. Symptoms of smallpox begin 7 to 17 days after exposure. It usually starts with an initial prodrome of high fever, malaise, and prostration with severe headache and backache. This is followed by the appearance of a rash that progresses. The rash appears first on the head and forearms before spreading to the trunk and legs. As the skin lesions heal, the scabs separate and pitted scarring gradually develops (as shown in Figure 1). Smallpox patients are most infectious during the first week of the rash. A patient is no longer infectious after all scabs have separated (i.e., 3 to 4 weeks after the onset of the rash). Our Success Story Dryvax, the vaccinia (smallpox) vaccine currently licensed in the United States, is a live-virus preparation of infectious vaccinia virus which does not contain smallpox (variola) virus. This vaccine is highly effective which enables the global eradication of smallpox. The last naturally occurring case of smallpox occurred in Somalia in 1977. In May 1980, the World Health Assembly certified that the world was free of naturally occurring smallpox. Smallpox as a Weapon Although use of biological agents is an increasing threat, use of conventional weapons (for example, explosives) is still considered more likely in terrorism scenarios. Moreover, use of smallpox virus as a biological weapon might be less likely than other biological agents because of its restricted availability. However, the world must be prepared for any form of bio-terrorism. As such, the United States Centre of Disease Prevention and Control has developed a set of guidelines with respect to vaccination against smallpox terrorist attack. Figure 1: Progression of smallpox lesions from, left to right, pustules to scabs to scars. Prerelease Vaccination As the risk for smallpox occurring as a result of a deliberate release by terrorists is considered low, preexposure vaccination is not recommended for any group other than laboratory or medical personnel working with Orthopoxviruses. Postrelease Vaccination If an intentional release of smallpox (variola) virus does occur, vaccinia vaccine will be recommended. Smallpox vaccine can prevent or decrease the severity of disease, even if it is given 3 to 4 days after exposure to the smallpox virus. Raffles Healthnews Issue 1/2002 3
Cover Story Anthrax By Dr Madeleine Chew Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. This bacteria derives its name from the Greek word for coal, anthracis, because of its ability to cause black, coal-like skin scars called eschars. Anthrax is a disease acquired following contact with infected animals or contaminated animal products or following the intentional release of anthrax spores as a biological weapon. Clinical Human anthrax has three major clinical forms: cutaneous (skin), inhalation (lung), and gastrointestinal (stomach and intestines). If left untreated, anthrax in all forms can lead to septicemia and death. Symptoms of disease vary depending on how the disease was contracted, but symptoms usually occur within 7 days. Cutaneous anthrax is the most common naturally occurring type of infection (>95%). The incubation period ranges from 1 to 12 days. Most (about 95%) anthrax infections occur when the bacterium enters a cut or abrasion on the skin. Skin infection begins as a raised bump that resembles a spider bite, but within 1 to 2 days it develops into a vesicle and then a painless ulcer, usually 1 to 3 cm in diameter, with a characteristic black necrotic (dying) area in the centre. Lymph glands in the adjacent area may swell. Patients may have fever, malaise and headache. About 20% of untreated cases of cutaneous anthrax will result in death. Deaths are rare if patients are given appropriate antibiotics. Inhalational anthrax is the most lethal form of anthrax. Anthrax spores must be aerosolized in order to cause inhalational anthrax. The number of spores that cause human infection is unknown. The incubation period of inhalational anthrax among humans is unclear, but it is reported to range from 1 to 7 days, possibly ranging up to 60 days. It resembles a viral respiratory illness and initial symptoms include sore throat, mild fever, muscle aches and malaise. These symptoms may progress to respiratory failure and shock with meningitis frequently developing. Although case-fatality estimates for inhalational anthrax are based on incomplete information, the rate is extremely high, approximately 75%, even with all possible supportive care including appropriate antibiotics. Gastrointestinal anthrax usually follows the consumption of raw or undercooked contaminated meat and has an incubation period of 1 to 7 days. It is associated with severe abdominal distress followed by fever and signs of septicemia. The disease can take an oropharyngeal or abdominal form. Involvement of the pharynx is usually characterized by lesions at the base of the tongue, sore throat, dysphagia, fever, and lymph glands in the adjacent area may swell. Patients may have nausea, loss of appetite, vomitting and fever, followed by abdominal pain, vomitting blood, and bloody diarrhoea. The case-fatality rate is estimated to be 25% to 60% and the effect of early antibiotic treatment on that case-fatality rate is not defined. Anthrax as a weapon Over the last 60 years, anthrax has been developed as one of the biological weapons by several countries, including the Soviet Union and the United States. The number of nations believed to have biological weapons programs has steadily risen from 10 in 1989 to 17 in 1995, but how many are working with anthrax is uncertain. 4 Raffles Healthnews Issue 1/2002
Cover Story The current wave of interest in anthrax was started soon after the September 11 terrorist act with few cases of inhalational anthrax associated with death in the United States. This is not the first time in which specter of autonomous groups with ill intentions are using anthrax in acts of terrorism. The Aum Shinrikyo religious sect, infamous for releasing sarin gas in a Tokyo subway station in 1995, developed a number of biological weapons, including anthrax. The worst case scenario would be the release of a lethal cloud of anthrax spores from an aircraft in flight. Given the right weather conditions, the cloud could extend beyond 20 kilometers downwind. The aerosol cloud would be colourless, odourless and invisible following its release. Given the small size of the spores, people indoors would receive the same amount of exposure as those on the street. There are currently no atmospheric warning systems to detect an aerosol cloud of anthrax spores. The first sign of a bio-terrorist attack would most likely be patients presenting with symptoms of inhalation anthrax. FAQ Should I purchase a gas mask as protection from any chemical agent release such as anthrax? This is not recommended as the likelihood that you would be involved in a chemical attack is low. Purchasing a gas mask causes a false sense of security because masks that are not used properly or that do not fit well will not give you adequate protection. If the patient is suspected of being exposed to anthrax, should he/she be quarantined or should other family members be tested? Direct person-to-person spread of anthrax is extremely unlikely and anthrax is not contagious. Therefore, there is no need to quarantine individuals suspected of being exposed to anthrax or to immunize or treat contacts of persons ill with anthrax, such as household contacts, friends, or co-workers, unless they were also exposed to the same source of infection. Are there quick ways to test for anthrax? Yes, hand-held assays (sometimes referred to as Smart Tickets ) are sold commercially for the rapid detection of Bacillus anthracis. However, these assays are intended only for the screening of environmental samples. Can someone get anthrax from contaminated mail, equipment or clothing? In the mail handling processing sites, Bacillus anthracis spores may be aerosolized during the operation and maintenance of highspeed, mail sorting machines. In addition, these spores could get into heating, ventilating, or air conditioning (HVAC) systems. Will antibiotics protect me from a bio-terrorist event? Should I stockpile them? It is not recommended to start antibiotics unless a specific disease has been identified. There are several different agents that could be used for bio-terrorism, such as bacteria, viruses, and toxins. Not a single antibiotic (or vaccine) works for all of these agents. Antibiotics only kill bacteria, not viruses or other agents that could also be used in a bio-terrorist event. Antibiotics can also cause serious side effects and drug interactions. What is cipro (ciprofloxacin)? Ciprofloxacin, or commonly known as cipro, is a broad-spectrum, synthetic antimicrobial agent active against several microorganisms. The use of ciprofloxacin should be prescribed by your doctors. Is there a vaccination for anthrax? A protective vaccine has been developed for anthrax; however, it is primarily given to military personnel. Vaccination is recommended only for those at high risk, such as workers in research laboratories that handle anthrax bacteria routinely. What should be done with clothing contaminated with anthrax? Clothing can be decontaminated using soap and water, and 0.5% hypochlorite solution (one part household bleach to 9 parts water). Raffles Healthnews Issue 1/2002 5
Health & U Screening for Precancerous Conditions of the Cervix and Cancer of the Cervix What is cancer of the cervix (cervical cancer)? The cervix is the neck of the womb and is the part of the womb that can be seen via the vagina. Cancer of the cervix starts at the neck of the womb and if it is not detected early and treated, it will spread to the tissues at By Dr Lee I Wuen the side of the womb, the vagina and the bladder. At the advanced stage, it can spread to the liver, bone and lungs. Cancer of the cervix is the fourth commonest cancer among females and the most common cancer of the female genital tract in Singapore. What are the risk factors for cervical cancer? Almost all women carry some risk of developing cervical cancer. The risk is increased if certain risk factors are present: Early age of first sexual intercourse Multiple sexual partners Cigarette smoking Genital warts and the presence of certain specific types of the human papillomavirus (HPV) HIV infection However, cervical cancer can occur in the absence of the above risk factors, and all women are encouraged to undergo regular Pap smear screening from the time they are sexually active. Is cervical cancer preventable? Yes, it is potentially preventable. Reducing or avoiding the risk factors can reduce the risk of cervical cancer. In addition, cervical cancer has a precancerous or preinvasive stage known as cervical intraepithelial neoplasia (CIN) which can be detected by the Pap smear. Detection of CIN and appropriate treatment of the CIN can prevent cervical cancer in more than 90% of cases. What is Pap smear screening? go for screening to detect these conditions. The Pap smear aims to detect the preinvasive or CIN stage before the overt cancer stage when it is still asymptomatic and easily treatable. How is the Pap smear done? The Pap smear is a quick and simple procedure done in the outpatient clinic. The doctor gently inserts an instrument called a speculum into the vagina to expose the cervix. The cervix is then cleansed with a mild salt solution, and a vinegar-like solution is applied. This solution causes any abnormal areas on the cervix to appear white when viewed through the colposcope. A small brush or spatula is gently wiped across the cervix to obtain a sample of cells from the cervix. These cells are then smeared onto a glass slide and the slide is fixed with alcohol before it is despatched to the laboratory for examination under a microscope. This procedure is known as colposcopy whereby Preinvasive and very early invasive disease of the cervix are completely asymptomatic and therefore it is important that women 6 Raffles Healthnews Issue 1/2002
Health & U the cervix is examined under magnification with a binocular microscope called a colposcope. Abnormal areas and abnormal blood vessels on the cervix can be clearly seen with the colposcope. When you make an appointment for a Pap smear test, it is best scheduled in the middle of the menstrual cycle (ie about halfway between one period and the next). The whole procedure takes less than 5 minutes and it is not painful, though there may be some slight discomfort during the insertion of the speculum. If any abnormal areas are seen, the doctor will take a small piece of tissue from the abnormal areas (a biopsy), which will be sent to the laboratory for examination under a microscope. The doctor will then see you again when the biopsy result is ready for discussion and decide whether any treatment is necessary. Who should go for Pap smear screening? All women who have ever had sexual intercourse should go for Pap smear screening. Women are advised to have their first Pap smear by the age of 25, or when they become sexually active. Women who have never had sexual intercourse need not have Pap smear screening. However, if these women have any symptoms such as abnormal vaginal discharge, bleeding in between menses or bleeding after the menopause, they must consult a doctor. Where can I get a Pap smear done? Pap smear screening is available at: Your family doctor (GP) The Polyclinic (Well Woman Clinic) Singapore Cancer Society Gynaecologists at the restructured or the private hospitals What if my Pap smear is abnormal? The Pap smear picks up any changes in the cells obtained from the cervix. An abnormal Pap smear can mean anything from a very mild abnormality to something more severe. It can be due to infection, precancerous disease of the cervix or cancer of the cervix. Your doctor will contact you regarding the results. If it is due to infection, you will be treated for the infection and the Pap smear repeated at a time interval recommended by your doctor. If CIN is suspected, your doctor will refer you for a colposcopy for further assessment of the cervix. How is CIN treated? CIN is graded into 3 grades: CIN 1, CIN 2 and CIN 3. CIN 1 need not always be treated as a certain percentage may regress on its own. However, the woman must go for follow-up treatment of CIN 1 if it remains persistent. CIN 2 and CIN 3 should always be treated. Treatment of CIN can be by laser vaporization, electrocautery, loop electrosurgical excisional procedure (LEEP) or cone biopsy of the cervix. The gynaecologist will choose the most appropriate mode of treatment depending on the severity and extent of the lesion. What is the cure rate of CIN? Cervical cancer is a cancer which has an asymptomatic precancerous stage which can be detected by the Pap smear. Treatment of this precancerous stage is simple and effective in preventing cervical cancer. With appropriate treatment, CIN will be cured in more than 90% of the cases. However, a woman who has been treated for CIN is at increased risk of the CIN recurring and must continue her follow-up. In conclusion Pap smear screening has been shown to reduce the incidence of cervical cancer and death from it. Cervical cancer is a cancer which has an asymptomatic precancerous stage which can be detected by the Pap smear. Treatment of this precancerous stage is simple and effective in preventing cervical cancer. Raffles Healthnews Issue 1/2002 7
Medical Myths... About Kidstuff - MYTH Fat children are cute... after all, it s only puppy fat which will go away and won t affect the child in any way! MYTH Diabetes, Arthritis, Kidney problems... these are diseases of the aged, kids don t get it! How could my 6-year old daughter be suffering from diabetes? MYTH My 7-month old baby is having fever... he must just be teething. MYTH My child is having high fever... if I swaddle and cover him with sweaters and blankets, it will make him sweat it out and bring the fever down faster! The Facts Behind Them By Dr Bina Kurup FACT Studies have shown that obesity alone can cause a risk of severe narrowing of arteries in very young children. This impairment was similar to that found in the elderly and heavy smokers! This is due to the fact that the function of the inner lining of the blood vessel is affected in obese children, and this predisposes to the artery narrowing and its attendant complications of heart attacks and strokes later on. However, regular exercise and proper diet can reduce this risk which can be seen within 6 weeks of adopting the healthy lifestyle. Hence, one is never too young to be on a healthy diet and to maintain ideal body weight. As parents, a lot depends on us to ensure our children s future health. FACT Although these conditions are more common in the adult and elderly, children are not exempt from these diseases, though they may present in different forms. Diabetes in children tend to have a more acute onset with the child being rather ill, drowsy and even comatose at times. Diabetic children usually require life-long insulin treatment. With proper education and care, these children can live a near normal life. Joint and bone pains can occur in children and are not all due to an overactive child with frequent bumps and falls nor are they just growing pains. Other more serious causes, like Juvenile Rheumatoid Arthritis, Bone Tumors and even Leukemias need to be excluded. FACT Though teething infants may have slight fever, it is never very high. Furthermore, other causes of the fever should first be excluded by your Family Doctor. Infants who are teething tend to have sore gums which causes them to be more fretful and occasionally refuse feeds. Using chilled teething rings often helps relieve their discomfort. FACT On the contrary, when your child is having fever, it is best for him to wear cool light clothing and be in a room with cool ambient temperature. Further sponging him with tap water (not ice water, which, if it causes shivering, can increase the body temperature further) and the anti-fever medication will help. It is important to control the fever in children, especially between the ages of 6 months to 6 years, as children in this age-group run the risk of febrile fits. Editorial Board Dr Teo Sek Khee, Dr Bina Kurup, Moiz Tyebally, Ng Siao Sze & Celine Ong The information contained in this publication should not be regarded as a substitute for detailed medical advice in individual cases. Please address all correspondence to The Editor, Raffles Healthnews, Fax no. 311 2383. Raffles Healthnews is published by Raffles Medical Group Ltd, 585 North Bridge Road, Raffles Hospital #11-00, Singapore 188770. 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Raffles Heart Centre eart disease is responsible for 1 in 4 deaths in Singapore. The most common forms of H the disease are blocked arteries, slow or fast heart rate, high blood pressure and high cholesterol levels. Prevention, early detection and accurate diagnosis make a big difference in treatment and complete recovery. At Raffles Hospital, we recognise that in addition to accurate diagnosis and appropriate treatment, comfort and convenience are also of importance. We have thus set up a one-stop specialist centre Raffles Heart Centre to cater to the needs of our patients. Here, our cardiologists work as a team with their colleagues to ensure timely and coordinated care. We have the facilities to perform a wide range of diagnostic tests to check the function of the heart and its arteries and valves. Corporate Scene Specialists at Raffles Heart Centre: Dr Ng Wai Lin MBBS (Adelaide, Aust), FRACP, FAMS Dr Chee Tek Siong MBBS (Mal), M.Med (Int Med) (S pore), FAMS These include: electrocardiogram (ECG), Treadmill Exercise Stress Test, 2D Echocardiogram, Dobutamin Stress Echocardiography and Angiogram. If diagnosed of a heart condition, do take heart. There are now many viable and tested treatments that have proved effective in the combat against heart disease. For more information or to make an appointment, please call our 24-hour Specialist Appointments Hotline at (65) 311 1222. Women Empower Yourself Take Charge of Your Health have created a comfortable and private space at Raffles Hospital for women to We consult with our obstetricians and gynaecologists on all matters of women s health. In addition to screening, prevention, diagnosis and treatment, we also offer education and medical advice on women s health issues as part of a holistic approach to your well-being. 4 Well Women Programmes are currently available at our Women s Centre: Breast Health Programme focuses on breast health and breast care. In addition to mammography and ultrasound of your breasts, you will also be instructed on self breast examination. Gynae Check-Up Programme is a comprehensive gynaecological assessment which includes breast and pelvic examinations as well as a Pap smear. There is also an option of mammography and ultrasound of the breasts. Comprehensive Wellness Programme combines a full physical assessment and investigations such as mammogram and breast ultrasound, ultrasound of pelvis, Pap smear and urine analysis. Preconception Programme is an assessment in preparation for pregnancy. In addition to comprehensive investigations and examinations, our specialist will also give advice on matters related to conception. Specialists at Raffles Hospital s Women s Centre Dr Tan Yew Ghee MBBS (S pore), M.Med (O&G) (S pore), MRCOG (Lond), FAMS Dr Joan Thong Pao-Wen (Ms) MBBS (S pore), M.Med (O&G) (S pore), MRCOG (Lond) Dr Lee I Wuen (Ms) MBBS (S pore), M.Med (O&G) (S pore), MRCOG (Lond), FAMS Dr Koh Gim Hwee MBBS (S pore), M.Med (O&G) (S pore), MRACOG (Aust), MRCOG (Lond), FAMS For more information or to make an appointment, please contact the Women s Centre at (65) 311 1230 or our 24-hour Specialist Appointments Hotline at (65) 311 1222. Raffles Healthnews Issue 1/2002
Clinic Announcement Corporate Scene On The Move Opening of New In-House Clinic Our GP clinic at Marina Bayfront moved in October 2000 to Marina Square. The new address is: 6 Raffles Boulevard #01-205 Marina Square Singapore 039594 Tel : (65) 339 6644 Fax : (65) 339 6698 Our dental clinic at Marina Bayfront has moved to Millenia Walk. The new address is: The new in-house clinic at SPH Toa Payoh opened in December 2000. The new address is: 1000 Toa Payoh North Singapore Press Holdings 7th Storey Annex Block Singapore 318994 Tel : (65) 319 2400 Fax : (65) 352 9725 9 Raffles Boulevard #02-24B Millenia Walk Singapore 039596 Tel : (65) 337 6000 Fax : (65) 334 8607 Have Your Baby at Raffles affles Hospital combines the space, comfort and ambience of a 5 star hotel with the professional care of a tertiary hospital. R The delivery suites are designed and equipped not only for the mother s comfort but the father s as well. For those in early labour, there is also a lovely landscaped courtyard just outside the maternity ward. There is a range of maternity packages to choose from. Mothers-to-be are welcome to call us at (65) 311 1666 for a tour of the hospital. During the tour, we will be pleased to introduce you to our labour ward staff, answer your questions and show you our delivery suites, nursery and ward rooms for your stay after delivery. Do You Know... Nestled within Raffles Women s Centre is The Breast Clinic where our breast specialists provide diagnosis and treatment of benign and malignant breast diseases. Where needed, we will co-ordinate with our plastic surgeons for breast reconstruction, or our oncologist for complementary care. Raffles Healthnews Issue 1/2002