Coronavirus: Singapore looks well placed to further ease restrictions, say experts

Although Covid-19 cases in the community have crept up since the country exited its circuit breaker last week, this is not cause for alarm, because the numbers reflect aggressive testing and "hidden reservoirs" of infection, rather than an increase in cases due to the easing of measures.

Ten days since Singapore began reopening schools, and some economic activities and services resumed, the situation remains in check, said Professor Teo Yik Ying, dean of the National University of Singapore's Saw Swee Hock School of Public Health.

"I do not see anything that is out of the norm, and (the data) reflects a situation that remains under control," he said.

At this rate, Singapore is well placed to move from phase one to phase two of its reopening, which would mean a further easing of restrictions to allow even more businesses and social activities to resume, said Prof Teo and other experts interviewed.

They stressed, though, that people should not let their guard down because the battle is far from over.

The number of new cases in the community has increased to an average of eight per day in the past week, from six per day the week before. This has been mainly due to active screening of groups such as front-line workers and those with acute respiratory infection symptoms, Prof Teo explained.

The same can be said for unlinked community cases, which has increased to an average of four per day in the past week, from just one case per day in the week before that. "We always knew there are hidden reservoirs in the community, and many of these may be asymptomatic or with very mild symptoms.

"Active screening will pick up these cases, and some of them may already have gotten over the infection - meaning they are no longer shedding viruses," he said.

Ten to 14 days post-circuit breaker is a good time to take stock of the situation, the experts said. They noted that this is the time it takes for two cycles of transmission of the virus; the time needed for the disease to spread from one infected person to the next, and for the second person to infect another.

So if a lot of infections began happening when the circuit breaker ended on June 1, they would start showing up some time now.

"So far, the situation looks quite promising," said Associate Professor Alex Cook, an epidemiologist at the NUS Saw Swee Hock School of Public Health.

"We haven't seen a huge resurgence of cases in the general community", he added. His prognosis: "So far, so good."

WHAT THE DATA SHOWS

While the number of community cases is an indication of the trend of infections here, other factors are equally important, the experts said.

These include hospital capacity and how cases are picked up.

With 227 confirmed cases who are still in hospital, and two in intensive care, hospitals have adequate capacity to deal with cases.

This is a vast reduction from a high of 32 patients in the ICU recorded on April 10. The number of patients in hospitals hovered around 1,500 at the end of April.

The number of elderly folk getting the disease must also be monitored, as their conditions are more likely to worsen.

Said infectious diseases expert Leong Hoe Nam: "Eradicating Covid-19 is a pipe dream in the absence of a vaccine.

"The focus thus should be to keep (patient) numbers as small as possible, and ensure that they receive the best care, resulting in the fewest deaths possible."

On how cases are picked up, the experts said it would be worrying if too many patients turn up at clinics with no clear indication of where the infection originated from.

Therefore, it is important to keep an eye on unlinked cases, bearing in mind that some time is necessary for links to be uncovered.

A high number of unlinked cases indicates a possible larger, hidden reservoir of cases which has not yet been uncovered.

On the other hand, if cases are picked up through contact tracing, this means that the authorities have a handle on who has been infected and how the disease is spreading, and can take steps to stem transmission.

Another indicator is how long cases are at large before being picked up.

The longer cases are symptomatic and not isolated, the more new infections they can lead to.

Here, the data is encouraging, the experts added.

In early February, it took an average of about eight days from the time an unlinked community case started to display symptoms to the time of isolation. This has now dropped to four to five days.

"Looking at how quickly cases are picked up tells us how the epidemic is playing out," said Prof Cook.

With testing and contact tracing being ramped up as more people go out to work and school, the absolute figures may well go up, he added.

"As more testing capacity becomes available, we find cases that we previously would not have, and that makes the situation look worse (than it really is)."

OPENING UP

The Government is carefully monitoring the effects of increased activity in phase one, and if the community infection rates remain low and stable, phase two could happen before the end of the month.

Then, almost the entire economy will reopen, and more activities will resume, the task force handling the coronavirus pandemic has said.

But further reopening must be done safely, with group sizes and capacity limits in place. These would apply to retail, dine-in, personal health and wellness, as well as home-based services.

Sports and other public facilities including stadiums and swimming pools will be opened too, the task force chaired by Health Minister Gan Kim Yong and National Development Minister Lawrence Wong has said.

While masks will remain a must when one heads out, small gatherings of up to five people will be allowed.

Seniors will still be encouraged to stay home, but more services and programmes for seniors will resume.

Schools will fully reopen from the end of the month, while institutes of higher learning will gradually allow more students back on campus at any one time for face-to-face learning.

At this point, testing and contact tracing efforts are crucial, and they are being ramped up significantly.

Singapore is able to conduct about 13,000 tests a day currently, and it is on track to reach 40,000 tests daily in the coming months.

In addition, contact tracing has been expanded to include personnel from the police and Singapore Armed Forces. Technology has also been employed, such as the SafeEntry check-in/check-out system, the TraceTogether app as well as wearable Bluetooth devices that are being developed.

Everyone must also remain vigilant, the authorities have said.

With an estimated one in two cases believed to be asymptomatic, an infected person may be unaware that he has the disease.

Professor Dale Fisher, senior consultant in the infectious diseases division at the National University Hospital, added: "As we start realising that asymptomatic spread is real, we need interventions targeting this, such as mask wearing and limiting social contact."

Associate Professor Josip Car, director of the Centre of Population Health Sciences at Nanyang Technological University's Lee Kong Chian School of Medicine, said that so far, the nation's track record with Covid-19 has been quite exemplary.

But moving into phase two is by no means a signal that the danger is over, he stressed.

"I'd just like people to remember that there's still a real health crisis going on, one for which we're nowhere near a permanent solution.

"That's why individual social responsibility will be paramount."

He added: "We need to maintain the same level of commitment towards maintaining high standards of hygiene, continuing to practise safe distancing whenever we can, and being mindful of our physical well-being.

"For the most part, Singaporeans have shown that they are ready to take on this social responsibility."

And as the nation takes careful steps towards reopening, there is no rulebook to follow.

Prof Teo noted that Singapore would have learnt from other countries on possible weak links, as well as the different plans and exit strategies.

"In many ways, the Government adopts a cautious and evidence-based approach towards easing the circuit breaker, and this is not hurried or pressured by the actions of other countries around us," he said.

Said Prof Fisher: "I completely support the conservative approach being taken and fear other countries will have to reverse the easing of restrictions if they acted too hastily."

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ON TRACK TO MOVE TO PHASE TWO

I do not see anything that is out of the norm, and reflects a situation that remains under control... If this trend continues, we will be on track to move to phase two, perhaps in less than three weeks.

PROFESSOR TEO YIK YING, dean of National University of Singapore's Saw Swee Hock School of Public Health.

WHY MORE CASES ARE BEING PICKED UP

We need not be overly concerned about the slight rise in community cases on certain days, as the ramping up of testing capacity means we are picking up cases we wouldn't have before.

ASSOCIATE PROFESSOR ALEX COOK, vice-dean of research and an epidemiologist at the NUS Saw Swee Hock School of Public Health.

INDIVIDUAL SOCIAL RESPONSIBILITY VITAL

We need to be aware that moving to phase two is not a signal that the danger of Covid-19 is over... Individual social responsibility will be paramount moving forward.

ASSOCIATE PROFESSOR JOSIP CAR, director of the Centre for Population Health Sciences at Nanyang Technological University's Lee Kong Chian School of Medicine.

AREAS TO FOCUS ON

Eradicating Covid-19 is a pipe dream with the absence of a vaccine... The focus should be on keeping infection numbers as small as possible... (ensuring) patients receive the best care and keeping fatality rates low.

DR LEONG HOE NAM, an infectious diseases expert at Mount Elizabeth Novena Hospital.

SINGAPORE'S APPROACH THE RIGHT ONE

I completely support the conservative approach being taken by Singapore and fear other countries will have to reverse the easing of restrictions if they acted too hastily.

PROFESSOR DALE FISHER, a senior consultant in the infectious diseases division at the National University Hospital.

This article was first published in The Straits Times. Permission required for reproduction.

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