Commentary: Why Singapore is better prepared to handle COVID-19 than SARS
Lessons learnt from SARS and investments in science, research, and technology have provided game-changers for Singapore, says NHG’s Chief Research Officer Dr Benjamin Seet.
SINGAPORE: On Mar 1, 2003, SARS hit Singapore. Over the next four months, we witnessed its spread through public hospitals and the community, infecting 238 people with 33 succumbing to the virus.
I lost a close friend, Alex, whom I had known since primary one. A visit by an overseas scientist further led to my being issued a Home Quarantine Order, and with that, the obligatory daily reporting before a CISCO video surveillance camera.
DEALING WITH SARS
Singapore’s biomedical scene was fledgling then - the first buildings in Biopolis were newly constructed.
Notwithstanding, scientists at the Agency for Science, Technology and Research (A*STAR) became one of the first globally to sequence and genetically map the SARS virus as well as develop a commercial test kit (with Roche Diagnostics).
We witnessed the mobilisation of the Singapore Armed Forces (SAF) to support contact tracing, electronic tagging of quarantine breakers and the conversion of military thermal sights to the now pervasive fever scanners. Novel research, clever engineering, good old-fashioned public health measures and the Singapore brand of public policy ensured that we beat the virus.
Singapore was declared SARS-free by the World Health Organization (WHO) on May 30, 2003 – three months after the virus had arrived on the island.
Seventeen years on, we face a global pandemic. As of March 15, 2020, over 169,000 cases and 6,500 deaths from COVID-19 have been reported, with 226 cases in Singapore.
While the situation in China and South Korea shows some respite, large outbreaks continue to evolve in Italy and Iran, with growing hotspots across every continent. Mathematical models indicate that the epidemic is only just beginning. Containment efforts have bought us precious time to understand what we have to deal with and to ready our health institutions for an anticipated surge.
What has changed this time is that Singapore is now ranked as one of the top biotech and innovation locations globally – and that we are pulling above our weight to make a difference. We are also more prepared than before to deal with this outbreak.
DETECTING THE VIRUS
The Bioinformatics Institute at A*STAR supports the GISAID (Global Initiative on Sharing All Influenza Data) database, where genetic sequences of the COVID-19 virus are uploaded and shared.
This permits analysis of how the virus mutates as it spreads geographically and over time, providing molecular clues as to how best to deal with it, as well as a precision tool to augment contact tracing.
Working closely with the National Centre for Infectious Diseases (NCID), scientists at Duke-NUS Medical School successfully cultured the COVID-19 virus just one week after it landed in Singapore on Jan 23, 2020.
This group went on to become the first globally to develop a serological test for COVID-19, which detects antibodies produced by the body’s immune response against the virus, setting the stage for rapid testing and population surveillance.
The National Public Health Laboratory, together with the public hospitals, developed and ramped up a diagnostic test for the virus in January 2020 that has allowed the Ministry of Health (MOH) to carry out more than 21,000 tests thus far, boosting our ability to detect infected cases.
Research laboratories across the island also joined the international race to develop diagnostic kits for laboratory use.
An A*STAR kit, jointly developed with Tan Tock Seng Hospital (TTSH), was deployed in public hospitals by early February, while 10,000 tests were shipped to support efforts in China.
Local biotech firms, Veredus and Acumen Research Laboratories announced their prototypes within weeks of the outbreak. The Veredus kit received its provisional licence just one month later, and was deployed by the Home Team in its laboratories to support screening at border checkpoints by early March.
A reliable diagnostic test is critical for outbreak and patient management.
The challenge remains that current tests are laboratory-based, which take time and entail additional logistics. Ideally, we want a point-of-care test with rapid turn-around time - somewhat like a pregnancy test kit.
This will enable doctors at the frontline to diagnose COVID-19 in their clinics without having to send samples to hospital laboratories. One technical barrier is that such a test demands high sensitivity, so that we do not miss positive cases.
COMING UP WITH A CURE
The COVID-19 virus is a novel one. About 20 per cent of patients develop serious illness and complications, and case fatality ranges from less than 1 per cent to as high as 4 per cent.
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A distant cousin of other coronaviruses like SARS and MERS, there is currently no proven treatment or vaccine for COVID-19. Given the high standards of care in our hospitals, as well as the tight network of public and university labs, Singapore offers advantages for companies to conduct drug development here.
US biotech firm, Gilead Sciences, announced that it would be widening clinical trials here for its anti-viral drug, called remdesivir, for the treatment of COVID-19. This trial involves the NCID and other public hospitals, providing patients here with early access to the drug.
NCID will also support a leading biotech company’s push to develop an antibody treatment against the virus. Duke-NUS Medical School has announced that it will work with the Coalition for Epidemic Preparedness Innovations, and with US biotech company, Arcturus Therapeutics, to develop vaccines for COVID-19.
ON THE DIGITAL FRONT
The fight against COVID-19 extends to the digital arena. Over at the integrated TTSH Operations Command Centre, data is continually streamed from different hospital systems, providing real-time situational awareness of its overall operations.
This has enabled local health authorities and TTSH to better plan and coordinate for the surge demand at NCID, deploying over 1,000 staff to support frontline screening and treatment in the outbreak wards, while still providing regular hospital care for patients.
The new Real Time Location System, a tracking system, further strengthens the process of contact tracing.
Doctors at TTSH are also working with A*STAR to potentially employ computer vision and deep learning to detect lung infection on chest x-rays. This would enhance screening at NCID, and potentially in primary care, in the event of widespread community transmission of COVID-19.
Another innovation is the design and rapid prototyping of face shields to replace goggles used by staff managing COVID-19 cases. Wearing goggles for prolonged periods can lead to discomfort and facial imprints. This led a team from TTSH and NCID to leverage on 3D printing to develop cost-effective face shields for better protection, fit and comfort.
On a wider scale, we now face an information pandemic, comprising health advisories, scientific communications and a social media maelstrom generously peppered with fake news.
One Chinese website has drawn close to three billion views, providing almost real-time count of infection numbers in every province and city, as well as countries across the globe.
Official updates from MOH now come through both traditional and social media, while educational content from our universities are available online. All of these help counter the disinformation that digital channels may otherwise help proliferate.
Chinese netizens have commented that Singapore’s handling of COVID-19 has been “zen”.
Singapore’s approach has garnered praise from the WHO and international experts.
I would put forth the view that SARS taught us the important lesson of needing to be prepared, and that our investments in science, research, and technology have provided game-changers which have made a difference.
Dr Benjamin Seet is the Group Chief Research Officer at the National Healthcare Group in Singapore. He was formerly Executive Director of the Biomedical Research Council at A*STAR.