Covid-19 in Singapore

Personal Thoughts by Kenneth Lyen

INTRODUCTION

On the 23rd January 2020, the first case of a novel coronavirus in Singapore was announced (1). This was a 66-year-old Chinese National who came from Wuhan and was staying at the Shangri-La's Rasa Sentosa Resort. The next day, two more cases of this illness were diagnosed, the 37-year-old son of the first case, and a 53-year-old female, both also from Wuhan. Initially we dubbed the illness Wuhan fever or Wuhan flu, but there were objections in laying the blame on one city or place, and so it was later renamed Covid-19 referring to the coronavirus and the year in which the respiratory illness was discovered.

The Chinese authorities first announced that dozens of people were treated in Wuhan for pneumonia from an unknown source on 31 December 2019 (2).

Earlier, ophthalmologist Dr Li Wenliang blew the whistle by sounding the alarm that he had found seven cases of pneumonia that looked like the SARS virus. But he was silenced and punished for “spreading rumours”; he later died from the Covid-19 virus (3).

In Singapore, the public reaction was quite frenzied. Suddenly, there was panic buying in the shops, and there were long lines queuing up for toilet paper, tissue paper, rice, instant noodles and bottled water.

I watched people loading entire trolleys of these items, and by the next day, the shops were depleted of them (4). I went to the Guardian Pharmacy to buy some surgical masks and hand-sanitising solutions, but they were also all gone. This has sprouted a number of smaller shops to engage in profiteering by price gouging and scalping (5). I regularly pass by one particular store that sells hand-sanitising solution and surgical masks for exorbitant sums, and am astonished by the queues of people who will allow themselves to be exploited.

OVERSEAS TRAVEL

We had booked a family holiday trip to Taiwan traveling in February, but a 55-year old female who worked in Wuhan and traveled to Taiwan, was diagnosed to have the novel coronavirus on 20 January in Taipei (6). We therefore immediately canceled our family holiday, and we got a partial refund from the airlines and the hotels. I have since heard from a number of my friends who were barred by the Singapore government from traveling to South Korea and North Italy but did not get refunds for their air tickets.

The Singapore Ministry of Health started monitoring the temperatures of all travelers from Wuhan from 21 January. They banned all non-Singaporean travelers from Hubei province where Wuhan is located, on 23 January, and they implemented a mandatory 14-day quarantine for all Singaporeans returning from Hubei, on 29 January 2020 (7).

DISEASE OUTBREAK RESPONSE SYSTEM CONDITION (DORSCON)

Initially we were unduly over-optimistic in thinking that Singapore cases of Covid-19 were only those who traveled to Wuhan. Unfortunately, on 4 February, four Singaporeans who had not traveled to China but had been in contact with people who recently arrived from China, contracted Covid-19 (8).

Following the finding that Covid-19 can be transmitted from person-to-person, on February 7, the Minister of Health raised the Disease Outbreak Response System Condition (DORSCON) level from yellow to orange (9). Some of the implications are outlined below.

Currently in Singapore there have been several thousand cases of Covid-19 originating from other countries, and increasing numbers of locally transmitted diseases originating from clusters that include religious meetings, large dinner meetings, hotels, schools (10), and foreign workers dormitories.

IMPACT ON BUSINESS

Business is down. Weddings have been canceled or postponed, or if they carry on, many of the guests fail to turn up. Chinese New Year dinners have also been canceled and many restaurants have reduced diners. Because of travel restrictions, hotels and airline businesses are down.

On 26 March, all bars, clubs, theatres and cinemas will be closed for one month. All overseas travelers coming to Singapore, including students returning home, will be on a 14-day stay home notice (SHN). Social distancing is being strongly encouraged, which includes keeping 1 metre distance when queueing up for shopping, and eating in food courts and restaurants.

Retail shops are quite empty, hawker stalls and eating places look empty because customers are not allowed to sit down to eat, and only takeaway food is sold. Indeed the government is giving hawkers some rental waiver. Tenants in Changi Airport, especially the newly opened Jewel, are getting some rental rebate. Attendance at live shows, cinemas, the Chingay Parade, the Singapore Airshow, and other events dropped. And now, all live entertainment and cinemas have been shut down. Businesses flourishing during this crisis include manufacturers of toilet paper, surgical masks, and hand-washing solutions, and e-commerce online selling. The impact of Covid-19 on Singapore’s economy is already exceeding SARS, and the Government predicts that we might be heading towards a recession (11).

SINGAPORE HEALTHCARE

All healthcare workers have been affected by the outbreak, including doctors. In my practice, the number of patients has fallen, and my medical and surgical colleagues also report a significant drop in their cases. Visitors to the medical centres and hospitals have to fill in a declaratory form which includes whether or not they have traveled to China. All our continuing education meetings are suspended, our dinner meetings and celebrations are canceled. With a few exceptions, we are not allowed to practice in more than one hospital or healthcare centre. I was asked to see a suspected Covid-19 case in the Accident and Emergency department. I had to wear special Personal Protective Equipment (PPE) gowns and masks. I was hot and soaking in sweat. Fortunately the child turned out not to have the disease. Telemedicine, where you can consult a doctor via a handphone, is flourishing, because patients cannot catch those infections that might be lurking in a doctor’s office (12).

SINGAPORE MEDICAL SCHOOLS

Medical students at all three medical schools in Singapore are barred from going to the wards, and their lectures are also canceled. They receive distant learning, watching lectures online. Even their final graduation exams no longer need to examine patients. No need to palpate masses, listen to heart murmurs, or do a neurological examination. It makes me wonder whether this will affect the quality of these newly graduating doctors? As for selecting medical students, the Yong Loo Lin School of Medicine and the Lee Kong Chian School of Medicine are not conducting face-to-face interviews this year, but they are using the new technology of Zoom, so student and examiner can see and hear each other. Multi-mini interviews (MMI) are being conducted in this distance way too. Back in the good old days we had one or two sets of interviewers that we can interact with physically, and we can see and hear the more subtle expressions and body language. Things have changed!

CONTACT TRACING

What the Ministry of Health has been efficient in executing is rapid contact tracing. Every person diagnosed with Covid-19 is asked who he has been in close contact with, and they have been traced. This is a massive effort, and each of the close contacts are tested for Covid-19 virus (13).

NEWS MEDIA

The media has been feeding us every day with details of new cases of Covid-19, and how other countries are coping or failing to cope with the rapidly spreading infection. Everywhere we are constantly reminded to wash hands, and wear surgical masks if unwell. I am an obedient Singaporean and I wash my hands 20 times a day (I counted), so that an observer might think I suffer from obsessive compulsive disorder. My WhatsApp group friends and other chat groups update me several times a day on Covid-19.

DIAGNOSTIC TESTS

Covid-19 has given our bioscience industry a boost. There are several ways of diagnosis Covid-19 including Chest Xrays and MRI scans, but these tests do not actually identify the virus. Singapore has developed a new test, which is also based on the reverse transcriptase polymerase chain reaction. This test is currently used when travelers are found to be febrile, and they are taken to at travel check points where a nose or throat swab is taken. It Is 99% accurate, and the results takes about 3 hours to come back (17). A new test kit made by Biolidics where blood antibodies to Covid-19 is tested. It is 95% accurate, the results coming back within 10 minutes, and it has been launched in April 2020. However, the problem is that it is not very sensitive in the early stage of Covid-19, and is more useful after 2 weeks of illness.

SARS WAKEUP CALL

In 2003, Singapore encountered the Severe Acute Respiratory Syndrome (SARS) where 238 people were infected, and 33 died, including vascular surgeon Dr Alexandre Chao, a friend of mine (picture above). We were unprepared for this disease, and it woke us up (18).

Infectious diseases became a priority for Singapore, and it led to the foundation of the National Centre for Infectious Diseases (NCID) with a beautiful new building at Tan Tock Seng Hospital (19). Healthcare workers are in the frontline of fighting this invisible virus. They put their lives at risk, and they work long hours to protect us. We owe them an immense debt of gratitude.

In contrast to SARS, as of 30 December 2021, Covid-19 has infected around 300 cases per day, totalling over 279,000 cases in Singapore and there have been 828 deaths: the majority were unvaccinated, and nearly all suffered from chronic diseases. Compared to many other countries, Singapore took the early warning from Wuhan very seriously. Our government started stocking up on masks, hand sanitizers, thermometers, respirators, upgrading diagnostic (reverse transcriptase polymerase chain reaction) tests, activating contact tracing and prevention strategies, etc, were implemented. This preparedness won praise from the World Health Organization. However, the number of diagnosed cases and deaths have been creeping up, in part because we did not close schools and shops early enough, and in part because we did not address our foreign workers, who stay in overcrowded dormitories. And now the rapid spread is due to the Delta and Omicron variants which are far more infective than the previous strains.

CURRENT PROBLEMS

VARIANTS

New variants of the SARS-CoV-2 virus were first reported in the UK in January 2021. Significant variants are the Delta variant, which was first identified in India in late 2020 although it did not get named until 31 May 2021. The Delta variant causes the most severe illness including respiratory difficulties requiring ventilation, and it has the highest mortality.

The Omicron variant was first reported on 26 November 2021 in South Africa, but it has been suspected that this variant has been around much longer. The Omicron variant is the most infectious, doubling in numbers in a few days. However, it does not cause so severe an illness compared to the other variants, and many infected patients are looked after in their own homes.

These new variants are due to viral mutations, and they differ from the original SARS-CoV-2 virus in that they are spread more rapidly. The delta and the Mu variants are much more contagious, and although there is no evidence that they cause more serious illnesses, the far larger number of new Covid-19 cases jam up hospitals and intensive care units. Current vaccines are said to be effective against these variants.

Another worry is the detection of side effects, including blood clots following vaccination. The AstraZeneca and the Johnson & Johnson vaccines have been reported to be associated with blood clots, but the number of cases of blood clots is quite rare following vaccination, and several medical bodies, including the World Health Organisation have announced that the vaccines are safe and recommend continuation with the vaccination programs. The BioNTec-Pfizer and the Moderna vaccines are associated with a very small number of younger patients experiencing heart inflammation (myositis). This complication is also found in patients who have the actual Covid-19 infection. Unfortunately news of these side effects have raised vaccine hesitancy in many countries, and has led a surge in new Covid-19 cases in the unvaccinated.

An older problem is in diagnosing Covid-19 in the early stages. The initial symptoms of cough, fever, and muscle aches, overlap with several other infections including influenza and the common cold. It used to be thought that Covid-19 patients are less likely to have runny nose, phlegm and sore throat. But nothing in medicine is absolute, so there are cases of Covid-19 that have a slight runny nose and sore throat. It is estimated that about 80% of people who have Covid-19 may have mild symptoms, and some are even asymptomatic. Hence most cases are missed. The virus is transmitted from person to person by respiratory droplets produced by coughing or sneezing. The droplets can travel up to 6 feet away.

Prevention of spread include wearing surgical masks as these prevent water droplet spread. N95 masks are good for very small particles of around 3 microns diameter. Although it may be possible to transmit the virus by touching contaminated surfaces with one's hand and then touching one's own mouth, nose or eyes, this is probably not the main mode of spread. Handwashing with soap and water or using an alcohol sanitiser are suggested for prevention of spread if one has coughed into one's hands. Social distancing is also recommended, so people are asked to stand 1 meter away when queueing up, and to sit further away in restaurants and waiting rooms. Shaking hands is discouraged, and the "elbow-shake" is being introduced!

The median incubation period of the Delta variant is 3-5 days, while the Omicron variant incubation is 3 days. Hence the suggested quarantine period of around 5-7 days.

In Singapore, restrictions are named "Circuit Breakers". Everyone is asked to stay at home. Schools are closed, and with a few exceptions, most shops are closed. Gatherings outdoors and meetings greater than 10 people are no longer approved, and if one loiters in public, they may be fined.

To date a few antiviral antibiotics have been partially successful. These include remdesivir, bamlanivimab and etesevimab. Unconventional medicines, like the antimalarial hydroxychloroquine, have been assessed, and the results show that they do not work. In 2003, SARS petered out just under six months. However, the Covid-19 infection appears destined to last for much longer. Several vaccines have been release in early 2021, and the developed countries are rapidly getting their population vaccinated.

GLOBAL PERSPECTIVES

China announced its first case of the novel coronavirus on 31 December 2019. It had ravaged Wuhan and the province of Hubei like wildfire, causing thousands of deaths. Only a few countries, like Singapore, took this early warning seriously. Stocking up masks, hand sanitizers, thermometers, respirators, upgrading diagnostic (reverse transcriptase polymerase chain reaction) tests, activating contact tracing and prevention strategies, etc, were implemented. Unfortunately many rich developed countries ignored this devastating pandemic until it had claimed thousands of lives and brought the economy to a standstill.

Covid-19 has been spreading unrelentingly into 220 countries in the world, including most developed countries, in Asia, Middle East, Europe and North America. Overall there are 287 million cases with 5.43 million deaths (21-25). In fact the United States has surpassed China in the number of people infected. Governments have tried to curb the dissemination of this virus, ranging from stay home notices (SHN), to 14-day quarantine either at home or in a special boarding house, to a lockdown of an entire city or stage. The measures include the temporary closure of schools, universities, cinemas, theatres, nightclubs, restricting travel both locally and overseas, closure of offices, factories, and banning large public meetings. These measures have caused an economic freeze, resulting in unemployment and potential bankruptcies. Only food supplies and groceries are allowed to remain open during the lockdown. Countries that have adopted these stringent lockdown measures have succeeded in containing the coronavirus.

Currently, China has the most stringent restriction measures and higher vaccination rates, and this has kept the infection rate down to 102,000 cases with 426 deaths in total. In contrast, the United States has a more relaxed attitude towards lockdown, socialising, wearing of masks, and the vaccination rate is much lower. They have the highest number of infections in the world. To date, the USA has over 54 million cases of Covid-19, and over 823,000 deaths.

The worry now are the new mutant strains, especially the delta and the Mu variants. They spread more easily and they have a shorter incubation period. The delta variant, especially is causing problems worldwide. In Singapore, for the earlier part of 2021, we kept the number of new cases down to double digits. But from the end of July onwards it shot up to triple digits, and this part month we are experiencing over 500 new cases daily, despite 80% of the adult population being fully vaccinated, and the stringent lockdown measures. The delta variant plays a big part in the recent surge.

What about the poorer developing countries? They will be hit harder than the rich developed countries. Foreign investors have already started to pull out of these countries, and these countries do not have a safety net to withstand this economic withdrawal. Demand for their commodities have collapsed, as has their tourist industry. Many of these poorer nations do not have piped water, good roads, and their health services are already overstretched. The distribution of vaccines currently favor the richer countries. When the pandemic invades these countries, the death rate could be cataclysmic.

CONCLUSIONS

Covid-19 is a global affliction that has affected the health, economy, and geopolitics of the world. It seems to have generated some cases of xenophobia and racist assault. I hope this will abate. Let us thank our frontline healthcare workers who have courageously and tirelessly been working to protect us from this epidemic. We need to join hands to fight this adversary. Together we can overcome!

Written by Kenneth Lyen

19 June 2020; Updated 31 December 2021