A whimsical piece below, with the caveat that different major outbreaks pose different investigative challenges and scientific questions. Good to have the opinions and thoughts of others.

I have been involved in a few major outbreaks in Singapore over the past decade-and-half, and have often wondered whether it is better to organise and write up the investigations and/or research as a single major academic piece of work (with subsequent follow-up manuscripts in specific disciplines) or to have a more “laissez-faire” approach.

The benefits of the former appear apparent:

  • One can get a more comprehensive and detailed (in almost all ways) picture of a major outbreak (in Singapore from the late 1990s, those that have captured the public eye include Nipah virus, SARS, GBS, influenza H1N1-2009, and Zika), if efforts are coordinated rather than fragmented.
  • There would be a (more or less) convenient and objective scientific public record of these outbreaks available for future perusal.
  • For the academics/researchers, there is an increased likelihood of publishing the work in a “higher impact publication”, which rightly or wrongly is linked to promotion and bonus prospects.

The challenges for attempting the former are many and can be daunting. Some of these challenges are:

  • The coordination of the research is non-trivial, and increases as more disciplines, investigators and institutions are involved. In any typical large outbreak, for example, the work could involve clinicians, epidemiologists, public health officials, molecular and laboratory experts
  • The financial cost of outbreak investigation and research also increases as more sophisticated molecular tools and laboratory tests are brought into play.
  • There is often a considerable delay in completing all the work and investigations, relative to single institution research or those where fewer research disciplines are involved. The risk then is that such a work could be partially “scooped”, resulting in reduced novelty and therefore interest from the major scientific journals.
  • For a major outbreak involving multiple institutions, it is often impossible to include all parties or institutions, and also to include all aspects of an outbreak investigation into a single paper. This contributes to the problem of being partially “scooped” as listed above.
  • Competition for “first” and “corresponding” author positions – because these are deemed to be more “valuable” in the academic setting, can be intense and need to be carefully negotiated.

During the SARS outbreak of 2003, all the elements of scientific and inter-institutional competition were in play in Singapore, and the result was multiple publications from various hospitals and institutions with minimal efforts attempted at coordinating the outbreak research. One would have to read through the multiple publications in multiple journals from that time to get a clear picture of the scientific and outbreak investigation work that was done in Singapore. We were also clearly slower than the Hong Kong people and Canadians at getting the research going (biomedical research was not quite a priority in Singapore at that time).

I was not involved in the research surrounding the influenza H1N1-2009 outbreaks in Singapore (part of the influenza pandemic). Again, there were multiple publications, and my subjective impression was that the signal research achievement originated from the Singapore Armed Forces, who showed the success of ring tamiflu prophylaxis at limiting the spread of the virus in army camps. The SAF investigators involved in this pragmatic and useful operational research had worked with multiple government and research groups in Singapore, and succeeded in publishing their work in the prestigious New England Journal of Medicine. What was also different this time was that the flagship journal of the Academy of Medicine Singapore published a special issue on pandemic influenza in Singapore. The many papers within this issue (April 2010) provide a good picture of the outbreak research in Singapore during the first few months of the pandemic in 2009, despite the fact that several investigators provided what was their “second best” work (owing to the relatively low impact factor of the journal).

In 2015, Singapore was hit by an unusual outbreak involving severe Group B streptococcus infections after consumption of raw freshwater fish. I was involved in coordinating some of the outbreak research efforts, and experienced many of the challenges listed above. It was an enlightening experience, and the work (with still a significant number of unanswered questions) has just been published, as described in an earlier blog post. The almost 2-year delay between the outbreak and publication of the work is disappointing, and there were at least 3 other academic papers on smaller/limited aspects of the outbreak that were published before this paper became publicly available.

During the 2016 Zika outbreak in Singapore, there was an effort made to coordinate the outbreak research, driven primarily by public health officials from the Ministry of Health.  Although many of the same challenges described above were again experienced, the coordination was much smoother this time, and the work has just been published in Lancet Infectious Diseases, just nine months after the local outbreak was first observed. Still, there were some four more limited publications describing the Zika outbreak and cases in Singapore prior to the release of this major publication.

As first mentioned, each outbreak poses unique research and investigative challenges, and therefore none of the events mentioned above are directly comparable. Taking a long-term perspective, it is clear that outbreak research in Singapore is getting better conducted and coordinated over the years. The original question remains: is it is better to organise and write up major outbreak investigations and/or research as a single major academic piece of work (with subsequent follow-up manuscripts in specific disciplines) or to have a more “laissez-faire” approach resulting in multiple more limited publications?

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Infectious diseases, Outbreak, Public Health, Singapore


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