I received the Ministry of Health Clinical Practice Guidelines (CPG) for tuberculosis a couple of weeks ago. The full version is also available on the MOH website here.

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Mixed feelings. There is always a bit of pride at having contributed to such things. Having sat in on the meetings, I am also aware of the effort put in by my colleagues – especially those from the MOH secretariat and esteemed clinicians like Prof Sonny Wang (longstanding director of the Tuberculosis Control Unit) and Dr Cynthia Chee – most of whom are not paid to come up with this work.

There is also no doubt that tuberculosis continues to be a very important infectious disease globally and in Singapore, although it is somewhat under the radar and lacks the necessary broad community recognition and support required for successful control even here. Rapidly spreading infectious diseases like MERS, Ebola, Dengue and now Zika continue to hog the limelight, commanding public attention and resources despite the fact that year on year, they have collectively caused less mortality and socioeconomic costs relative to tuberculosis. It is therefore good to have local guidelines that promote a certain level of clinical practice and that may lead to less cases of delayed diagnosis (one of the primary reasons for the continued spread of this otherwise slow disease).

Yet I have always wondered about the effectiveness of the MOH CPGs (and previous incarnations) series. There has never been any medicolegal framework that surrounds and supports them, although this is a really controversial area – guidelines are not laws to be enforced, and by nature are behind the curve of clinical advancement; what is good for a population may also not be good for an individual, etc. 

More importantly, there has never been a real effort to communicate (or market, if you like) them effectively, and in this day and age, having hardcopies and web-based PDF downloads is antiquated. Look at this superb effort (not MOH supported) from the Singapore Cancer Network to see what can be done (although they still lack an app!) even with fairly limited funding. 

Some thought can and should also be put into continuity – this may perhaps work best if there are strong professional societies with at least partial ownership of guidelines development. The Infectious Diseases Society of America (IDSA) has a rough calendar for updating guidelines, which it does of its own accord – and most of us here in Singapore do refer to their practice guidelines when it comes to clinical management.

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