As each country charts its own path through the coronavirus pandemic, Singapore has often been held up as an example of where diligent contact tracing, isolation of cases and quarantining of contacts has allowed control of clusters and outbreaks without the need for widespread extreme social distancing measures, but there is more to it than that.
The post below, from researchers at Singapore University of Technology and design, provides on-the-ground insights into Singapore’s multi-faceted strategy to control the spread of the virus, bringing its willing population along for the ride.
In another salutary lesson as Australia celebrates its own efforts to “flatten the curve,” things have changed somewhat in Singapore in the past week, with substantial clusters among the country’s many guest workers, causing a challenging increase in cases and a need to double down on efforts.
Nonetheless, there are many lessons here for Australia’s response.
Brigid Trenerry, Jocelin Lam and Samuel Chng write:
Seventeen years ago, a young woman returned to Singapore after a holiday in Hong Kong, and was admitted to hospital with a pneumonia-like illness. Little did anyone know that she was carrying a deadly flu-like virus that first originated in China, later identified as Severe Acute Respiratory Syndrome, or SARS.
While the young woman went on to recover, several family members who had visited her died. Healthcare workers also made up a large proportion of persons infected and killed by SARS during the global outbreak in 2003, mostly due to a lack of personal protective equipment during the early stages of the outbreak, and exhaustion.
Nearly two decades on, the painful memory of SARS has been forever etched into the public memory in Singapore, as well as other hard hit countries in Asia, such as Hong Kong.
When news came from China of a new viral outbreak – SARS-CoV-2 – on 31 December 2019, Singapore was well prepared, having already established a purpose-built center for infectious disease following SARS. The country also moved quickly to set up a multi-ministry taskforce and conducted early testing, contact tracing and quarantine for at-risk individuals.
Though Singapore’s battle against COVID-19 is far from over, we summarise three aspects of Singapore’s response that may have implications for other countries, such as Australia. These include (1) aggressive contact tracing, isolation and quarantine; (2) protecting frontline health care workers; and (3) building public trust.
While not exhaustive, and recognising Australia’s own commendable efforts in acting quickly and decisively to curb the spread of COVID-19, our aim is share knowledge and offer potential policy implications.
Aggressive contact tracing, isolation and quarantine
In Singapore, early testing and contact tracing have been crucial to allow health authorities, together with the military, police and custom agencies, to quickly identify COVID-19 cases and trace close contacts. The goal is to adopt aggressive but targeted isolation.
The process of contact tracing is painstaking and labour-intensive. Taking advantage of Singapore’s high mobile phone penetration rate, the government technology agency introduced TraceTogether in March, a community-driven contact tracing app that leverages short-distance Bluetooth signals between phones to detect users in close proximity.
The Defence Science and Technology Agency also developed tools and algorithms to uncover possible links between cases, and discover potential new clusters.
Once confirmed, cases of COVID-19 are either hospitalised or isolated in community isolation facilities if symptoms are mild. As Professor Dale Fischer, Chair of Infection Control at the National University of Singapore recently wrote, this differentiates Singapore’s approach from other countries Even mild cases are not left to self-isolate at home.
The rationale is that quarantine can be difficult to enforce. There are reports that some people fail to self-isolate, and there is potential for the virus to spread to entire families. Moreover, initially mild patients who become worse quickly can be left without access to urgent medical treatment.
Other isolation and quarantine measures in Singapore include placing citizens, residents and visitors from affected areas in 14 day quarantines in designed facilities, such as hotels whose occupancy rates are affected by declining tourism. Australia has recently adopted a similar response, where returning citizens and overseas visitors will serve a mandatory quarantine in allocated hotels.
Protecting frontline health care workers
As with SARS, overworked health care workers are particularly vulnerable to infectious diseases such as COVID-19. In China more than 3330 health-care workers were infected by the disease, while many died. For other countries, such as Italy, Spain, France, the UK and the US, even more healthcare workers have been infected. In Italy, the latest reports show that 94 medics have died in the outbreak so far, many in hard-hit Lombardy.
The supply of adequate personal protection equipment (PPE) is a global concern, where some health professionals have resorted to fashioning their own gowns, masks and shields. Even in Australia, there is growing alarm about inadequate supply, particularly in rural and remote areas, alongside concerns that current garments are not protective enough.
In China, the initial high infection rate eventually led all doctors and nurses dealing with COVID-19 patients to wear full-body protective gear, including goggles, head coverings, N95 particle-filtering masks, and hazmat suits. Incredibly, these measures helped to prevent a further 42,000 doctors and nurses who were brought into the epicenter in Wuhan from being infected.
In the absence of adequate PPE, such as occurs when patients are not known to be infected with COVID-19, the standard protective measures used in Singapore may well be adequate.
In a case study in Singapore, it was reported that 41 health care workers were exposed during an aerosolised procedure, to a patient who was later confirmed to have COVID-19. None were infected, although 85% were using only surgical masks, hand hygiene, and other standard procedures.
In Singapore, both N95 masks and surgical masks are part of the country’s pandemic preparedness stockpile, along with other protective gear. Due to higher global demand in PPE during COVID-19, authorities have also moved to diversify current supplies, including locally made face shields.
Finally, masks have been distributed to all households in Singapore to ensure residents have access to them and that the country’s stockpile of masks remains sufficient for front-line healthcare workers.
Primary care providers, such as GPs, have also been given adequate supplies of masks, gowns and gloves.
Building public trust through clear and transparent communication
Singapore has the benefit of being a city-state, with a stable government and an established multi-ministry task force to coordinate an effective response on an unprecedented crisis like COVID-19.
This task force was tested and refined through the 2009 H1N1 pandemic and 2016 Zika virus outbreak. Early recognition of the threat of COVID-19, combined with open and transparent communication have been pivotal in garnering public trust and the cooperation of residents.
The Singapore Government provides clear and consistent updates about the outbreak’s development. Nevertheless, fake news was still rampant, creating fear and panic among residents.
Authorities quickly consolidated all official communications under the trusted gov.sg channel on Whatsapp, a widely-used communication app in Singapore. This proved to be a key vehicle for providing accessible and verified daily updates, and for debunking fake news, reassuring residents and further strengthening trust.
Implications for Australia
There are no easy answers in responding to the threat of COVID-19, a global pandemic that has stretched health care systems to the very limit and led to the loss of loved ones, including healthcare workers, alongside substantial economic and social effects.
As a city-state, Singapore has been able to coordinate a rapid national response, while also benefiting from its prior experience in dealing with respiratory infectious disease such as SARS.
This allowed Singapore to maintain a sense of normality and continuity in the first few months, however with rising local infections, the country has now shifted to a month-long shutdown to act as a ‘circuit-breaker’.
Australia has also acted swiftly and decisively to curb the spread of infection, through extensive lock-downs and social distancing. These measures appear to be slowing the rate of new infection, however the government has warned of an explosive resurgence of cases if these measures are relaxed anytime soon.
Nonetheless, challenges for both countries remain. This includes how to adequately isolate COVID-19 patients and other high-risk individuals from the rest of the community. As we have discussed, an approach that has worked well in Singapore is to completely isolate the sick from the well, tapping on temporary facilities from the private sector.
While this approach may not be possible in countries with a large number of cases, even China eventually moved to isolate around 50,000 infected COVID-19 patients in two rapidly-built large temporary hospitals.
Given Australia is still dealing with a smaller number of patients relative to other countries, this approach could similarly be adopted so as to avoid the potential dangers of letting people isolate at home. The advice to quarantine even people with mild symptoms from COVID-19 away from their usual households was recently given by a group of Chinese experts visiting Italy.
Another urgent issue for Australia and elsewhere is to ensure that healthcare workers are adequately protected. Recent estimates from Australian medical workers and academics indicate that the volume of PPE required to deal with COVID-19 patients is staggering.
While Australian governments and manufacturing industries have already moved to mass local production of masks and shields, drawing on insights from Singapore and China, we also recommend the urgent production of full-body protective gear and training, to keep health care workers safe.
Furthermore, asymptomatic health workers may be unknowingly spreading COVID-19 to other staff and patients, so everyone benefits with well protected healthcare professionals.
The use of technology is another measure that Singapore is both experimenting with and adopting, including the use of big data and Artificial Intelligence for contact tracing and quarantine enforcement.
Singapore’s Personal Data Protection Commission has relaxed its consent terms to allow the collection, use and disclosure of personal data to support contact tracing and quarantine measures.
This does raise concerns over surveillance and privacy, although the government has reassured the public that data will only be stored for a limited timeframe. Looking ahead, governments should be cautious and mindful on the ethical and appropriate use of technologies, even as they show great potential in our fight against COVID-19.
Every country has taken different approaches in the COVID-19 pandemic, specific to their unique contexts. We hope that the sharing of three policy measures from the Singapore approach may be helpful for Australia’s, or even the global fight against COVID-19. It will take a global effort in this unprecedented time.
Dr Brigid Trenerry, Ms Jocelin Lam and Dr Samuel Chng are from the Lee Kuan Yew Centre for Innovative Cities at Singapore University of Technology and Design. Dr Trenerry is a multi-disciplinary researcher and is experienced in working in applied policy and industry contexts in both Australia and Singapore. Ms Lam is a health communication and public health researcher whose interest is in preventive health behaviors. Dr Chng is an applied social and environmental psychologist working in decision-making and behaviour change research.