Commentary: Why home isolation is key to Singapore’s transition to endemic living
In this new phase of the pandemic, Singapore must target healthcare resources appropriately, says the NUS Saw Swee Hock School of Public Health’s Alex Cook.
SINGAPORE: The Ministry of Health’s announcement on Friday (Sep 10) that Singapore will push ahead with home isolation of milder COVID-19 cases marks an important step in the country’s journey towards the endemic era.
Fully vaccinated young people with no underlying illnesses will recover at home rather than at the hospital by default from Wednesday onwards, after a pilot programme saw encouraging results.
The arrangement will be progressively extended to those aged 50 or below with no significant illnesses – a group that accounts for half of all infected cases now, according to Health Minister Ong Ye Kung.
A NEW PHASE OF THE PANDEMIC FOR SINGAPORE
Indeed, Singapore has moved into a new phase of the pandemic.
High vaccination rates have enabled this shift by substantially reducing the severity and risk of death of “breakthrough infections” involving the fully vaccinated, even with the emergence of the Delta variant.
MOH data for cases identified over the past month shows that for every 1,000 breakthrough infections, only seven were sick enough to require oxygen supplementation with none dead or needing intensive care.
Seen from the lens of severe disease, the current situation is not as bad as it appears from record-high community cases. There are seven in intensive care as of Sunday (Sep 12).
At the last peak, a month ago, that corresponding figure was 11. In the first big wave of community infections over March and April last year, there were 32.
Most infections today are mild or asymptomatic, with viral loads that fall much faster than infections in unvaccinated, unprotected people, according to the National Centre for Infectious Diseases. This is why hospitals can safely discharge patients earlier if their viral load is undetectable.
Separately, Singapore has expanded and ramped up testing, making it a regular routine for workers returning to workplaces. Households have also been given antigen rapid test kits and urged to self-test regularly.
Combined with the high vaccine coverage, this means Singapore will see many times more mild and fully vaccinated cases at very low risk of developing severe disease.
We should remain vigilant but not get alarmed. People are worried when they compare total infection figures to those that led to Singapore pulling a circuit breaker. But we did not have the same capacity to contact trace and test so many people then.
A TIERED APPROACH NEEDED
To meet the coming wave of infections, however, Singapore does need a new national approach that differentiates the treatment of mild or asymptomatic cases from the severe ones.
We must focus acute care resources towards treating the most impacted. We know outcomes for the unvaccinated are poorer than those who have been vaccinated. For every 1,000 infections, 45 needed oxygen and eight were admitted to ICU or died, according to recent MOH data.
The Singapore healthcare system is in good shape for now. Despite record community infections detected, the current number needing intensive care is far below the 1,000 current and reserve intensive care beds Singapore has.
But the numbers in hospital are ticking up. If we indiscriminately isolate all cases there or in dedicated healthcare facilities, by the time we hit the projected high of 2,000 new cases a day mentioned by Minister Lawrence Wong, tens of thousands of beds could be taken up by mostly well people who do not require them.
We do not want to be in a position where the healthcare system is unnecessarily burdened, necessitating tighter measures.
We also need to encourage socially responsible behaviour. From an individual’s perspective, if you’re vaccinated and have only mild or no symptoms, and your family is also vaccinated, it seems excessive to have to move to a facility to isolate.
Worse, the threat of long isolation from family for more than a week may actually reduce compliance to testing practices.
With greater use of voluntary, rapid testing to reduce onward transmission and slow the spread, the last thing we want is for people to be deterred, especially when we know regular testing in the migrant worker dormitories has kept transmission in check.
How close is Singapore to being able to live normally with an endemic COVID-19? Two infectious disease experts give their view: on CNA's Heart of the Matter
BOOSTERS TO KEEP INFECTIONS MILD CAN HELP
Boosting the protection of seniors through another round of vaccination can help counter any waning of the vaccine efficacy against infection and severe disease and keep these cases out of the hospital.
But there are uncertainties like how much additional protection such shots offer, for how long and whether Singapore will roll out boosters to the wider population – when few countries have started using boosters.
Additionally, this policy provides no additional protection to the one in 10 elders not vaccinated at all.
While about one in every 100 unvaccinated cases die or are admitted to ICU, those deaths are not spread evenly across everyone who is unvaccinated but concentrated in the oldest cases.
This means getting as high a vaccination rate as possible for seniors must remain a critical effort.
WHAT NEXT: ENDEMIC LIVING ALSO NEEDS SOCIALLY RESPONSIBLE BEHAVIOURS
Case isolation in a hospital or another facility has been a cornerstone of Singapore’s successes to date.
Earlier in the pandemic I had argued in The Lancet that other countries should adopt the Singapore approach to mitigate epidemic growth and buy time for vaccination. Europe and the US show how infections can get out of control if home recovery is offered prematurely.
However, with over 80 per cent of the population now vaccinated, Singapore must shift gears because institutional isolation will place an undue burden on the healthcare system once cases surge and is a disincentive to getting tested.
We know from our recent experience of Phase 2 Heightened Alert that cases will come down if restrictions are tightened but the cost is large — both economically, to affected businesses, and socially, to a pandemic-fatigued nation in desperate need of normal human engagement.
To ward off that possibility, we must take both regular testing and home isolation seriously as we move into this next phase of the pandemic.
Alex R Cook in an associate professor who leads the Biostatistics and Modelling Domain and serves as the vice dean of research at the NUS Saw Swee Hock School of Public Health.