#16,216
Three months ago Singapore made headlines by announcing plans to treat COVID much as they treat influenza (see Singapore preparing road map for living with Covid-19); no longer as a pandemic, but as an endemic virus.
With daily cases consistently in the low-to-mid double digits for months, they believed restrictions on gatherings - particularly for those fully vaccinated - could be eased over the month of August. Lockdowns would become a thing of the past, and life - and the economy - could return to `normal'.
The Delta variant, however, had other plans (see chart below), with Singapore yesterday reporting their highest one-day total of cases (n=1939) since the pandemic began. Of note, cases began their upward trajectory in mid-August, when restrictions on indoor dining, and group sizes, were eased.
As a result, today Singapore's MOH announced a 1 month `Stabilization Phase' - to run from today through October 24th - with increased restrictions on social gatherings put back in place, in order to keep their current outbreak from getting completely out of hand.
As part of this plan, in order to reduce the growing burden on local healthcare delivery services, the MOH is advising that most people can safely recover at home, and that only those with serious illness will be hospitalized.
Some excerpts from a much longer statement from the MOH, followed by a graphic reflecting the changes follow. I'll have a brief postscript after the break.
STABILISING OUR COVID-19 SITUATION AND PROTECTING OUR OVERALL HEALTHCARE CAPACITY
24TH SEP 2021
Singapore entered the Preparatory Stage of our transition journey to a COVID-19 resilient nation on 19 August 2021. We ramped up our healthcare and response capacity as daily cases increased. We also introduced Home Recovery, as most of the cases, especially younger or vaccinated individuals, have mild symptoms or are asymptomatic and can stay at home to recover.
2. However, daily cases started to rise exponentially from end of August 2021. While the number of COVID-positive individuals who become severely ill – i.e., requiring oxygen supplementation and intensive care unit (ICU) – remains within expectations, the number of individuals with mild symptoms has increased very rapidly. This has put a strain on our overall healthcare and response system and on our healthcare workers, as many COVID-positive individuals with mild symptoms are seeking medical attention at our hospitals when it might not be necessary.
3. While we have been advising individuals with mild COVID-19 symptoms that it is appropriate to recover at home, we understand the anxiety of some individuals to want to seek medical attention at hospitals. The protocols and processes for home recovery are also new, and we are still improving the system as people are adjusting to them. There have also been service lapses as the numbers on Home Recovery increased, which added to their anxiety. We are ironing out the teething issues with the Home Recovery programme, and in the coming few weeks, will further ramp up our care facilities to handle more cases.
4. Most infection cases are mild in symptoms or asymptomatic and home recovery is the most appropriate care protocol for them. But if the overall number of cases continues to rise rapidly, we are also likely to see a growing number of infected persons, especially among the elderly, who do need hospital care. Hence, there is a need to slow down community transmission. We will thus be tightening our community safe management measures until our overall healthcare and response capacity has been appropriately augmented.
Updates on Local COVID-19 Situation
5. The large majority (98%) of cases were asymptomatic or had mild symptoms. This is due to our high vaccination coverage, which is now at 82% of the population who have completed their full regimen. Of the 254 cases with severe illness in the last two weeks, a disproportionate 48% were unvaccinated with the remainder being vaccinated individuals with co-morbidities. This ratio needs to be understood in the context of more than 80% of our population being fully vaccinated, indicating a vaccine efficacy against severe illnesses that is still around 80% to 90%, with the elderly and individuals with co-morbidities among the vaccinated making up the 10% to 20% who remain susceptible despite vaccination.
6. The number of persons requiring ICU is rising at the same rate as our overall case numbers, albeit with a lag. We had 21 new cases in ICU in the past week, as compared to 9 in the preceding week.
Right-siting Patients for Appropriate Care
7. The most appropriate care management protocol for fully vaccinated individuals aged 12 to 69 years will continue to be recovery at home[1]. These individuals are less likely to fall severely ill and there is no need for them to be cared for in our hospitals. Similarly, parents with infected children aged 2 to 11 years who choose to home recovery may also do so after their children have been assessed in our hospitals for suitability to do so.
8. To make best use of our hospital facilities and beds, and allow our hospitals to care for both their COVID-19 patients as well as the many other non-COVID patients requiring hospital care, we will be admitting those who are stable but do require closer monitoring to appropriate intermediate care facilities where their care and close monitoring needs will be met.
9. Patients with co-morbidities, with a risk of potentially developing severe illness, but who are otherwise asymptomatic or mildly symptomatic will be closely monitored at Community Treatment Facilities (CTFs), which are being set up progressively islandwide. These CTFs will be closely partnered with our hospitals so that there will be seamless escalation protocols for such patients to be conveyed from the CTF to an acute hospital expeditiously for further treatment when necessary. This is similar to the existing protocol for Community Care Facilities (CCFs), but with a higher level of medical care at the CTFs to ensure that these patients who are stable but at higher risk of serious illness are cared for with the appropriate level of medical manning and supporting equipment.
Safe Management Measures for Stabilisation Phase
10. If the infection continues at its current trajectory, we can expect to reach a daily count of 3,200 and beyond within the next 2 weeks. Beyond that, there is a range of possibilities, but we cannot rule out cases doubling further. To minimise the strain on our overall healthcare capacity, we will have to tighten measures before that happens. We would like to thank Singaporeans for reducing their level of activity and interactions in the past two weeks. We do not need to return to a Heightened Alert. But we have to do more to scale back social interactions further in order to slow down community transmissions and allow for better stability. The following measures will take effect from 27 September 2021 through 24 October 2021. We will review the measures two weeks after implementation and adjust these based on the community situation then. Please refer to Annex A for details.
Permissible Group Sizes
11. Permissible group sizes for social gatherings will be reduced from a maximum of 5 persons to a maximum of 2 persons. Correspondingly, the maximum number of unique visitors per household will be reduced to 2 per day. Individuals should continue to limit their overall number of social gatherings to not more than 1 per day, whether to another household, or meeting with friends and family members in a public place.
Singapore has one of the highest vaccination rates in the world (> 80%), which is why COVID deaths so far (n=78) have been remarkably low. Deaths, however, are a lagging indicator, and are expected to rise substantially over the next few weeks.
In mid-September Singapore began offering COVID booster shots to seniors, which they hope will help stem the tide of rising infections.
While this setback will hopefully be a temporary one for Singapore, it is another reminder that edicts notwithstanding, the Coronavirus is still calling the shots.
