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Why Singapore is still in a transition stage towards endemic living: Infectious disease experts explain

Singapore’s slew of measures to slow the spread of COVID-19 amid rising community cases raises questions over what living with endemic COVID-19 means and how far the country is from that. Two infectious diseases experts break it down in CNA’s Heart of the Matter podcast.

Why Singapore is still in a transition stage towards endemic living: Infectious disease experts explain

People walk past rows of restaurant along Boat Quay in Singapore on Sep 15, 2020. (Photo: AFP/Roslan Rahman)

SINGAPORE: On Monday (Sep 6), multi-ministry task force co-chair Lawrence Wong announced new measures to stem the spread of infections, including more testing and a ban on workplace social interactions.

The news raised questions over Singapore’s plans to live normally with an endemic COVID-19 and how far the country is from that.

In June, Health Minister Ong Ye Kung said Singapore’s build-up of contact tracing, testing and quarantine capabilities will enable the country to “put circuit breaker behind us”.  

Yet Mr Wong mentioned on Monday that a circuit breaker could not be ruled out at this point.

Daily infections have ticked up since late-August – the Ministry of Health reported 450 locally transmitted cases on Thursday (Sep 9). Unlinked cases have also crept up, with several clusters involving a key essential service – bus interchanges.

Infectious disease experts interviewed on CNA’s Heart of the Matter say Singapore is still in a “transition stage” and this is where we may be for some time yet.

Dr Lim Poh Lian, member of the expert committee for COVID-19 vaccination, said the science is still evolving, and this means figuring out how and when to move forward isn’t straightforward.

Dr Lim added that if one looks at the approach taken by other countries that have opened up quickly and then been hit by infection waves that led to deaths and overwhelmed hospitals, Singapore’s slow, careful approach has been validated.

“Every death is one death too many ... we are still trying to minimise that as much as possible.” 

Singapore’s testing and reducing infections as much as it can has made the difference in keeping a lot of people safe and alive, she said.

The other difficulty is if Singapore opens up too quickly and more people are infected, there could be wider implications. “Other countries would potentially not want to have us visit,’’ she said.

TOO CAUTIOUS?

Dr Ooi Eng Eong, Professor at the Programme in Emerging Infectious Diseases at Duke-NUS Medical School, who was also on the podcast, offered a different view, saying it all boils down to risk appetite and what society is willing to accept.

“Either we bite the bullet and say, okay, this is normal from now on. That we will never be able to gather as a family if the family is larger than five, we will never be able to … celebrate weddings with our families and friends. Are we going to accept that? I am not sure that society is quite prepared for that,’’ he said.

Against the backdrop of high vaccination rates and the ability to carry out rapid testing and contact-tracing, Dr Ooi said: “At some point we have to accept we are chasing our own tail. We (can) go back to our normal lives and expect there will be some severe cases. But that’s a decision for society to make.’’

Dr Lim, however, pointed out that Singapore’s cautious approach has kept it safe so far and while this is a “two steps forward, one step back” dance, going slow is the best thing to do.

But is the cost to people and businesses too high?

The pandemic has been very hard on most people who need a clearer idea of what will happen in a few weeks or months, said Dr Lim. For instance, people want to know if they can plan a holiday in December.

Unfortunately for everyone, the changing nature of the pandemic means “it is not always possible to try and force certainty when there is no certainty to be had. This is one of those times … it’s like playing five or 10-dimensional chess, the virus is changing, the vaccines are changing.’’

“We’re in the transition phase … We are not yet at endemic living …everyone wants to reopen and go back to normal but we have to get there safely,’’ she said.

People are seen at Raffles Place in Singapore on Jan 11, 2021. (Photo: AFP/Roslan Rahman)

DELTA VARIANT

Referring to Mr Wong’s announced measures and explaining why there was a need to “tap on the brakes”, Dr Lim said the Delta variant has been a “game-changer”.

“Delta changed everything … so the goalposts shift, partly because the virus itself is changing,” said Dr Lim.

It’s a tighter race between the virus and immune system, which takes four days for cells to mount a defence, Dr Ooi, pointed out.

But the Delta variant takes only three days to cause fever and illness, a much faster rate compared to the original strain’s five days.

Lab results showed this variant is “very fit”, he said. “Everything that has come out so far has been suppressed by Delta. Even if there is a new variant, it’s hard to see it being fitter,” he said

The World Health Organization (WHO) reported that the Delta strain has been recorded in 124 territories. In Singapore, it accounted for 99.6 per cent of infections sequenced between April and August according to the National Centre for Infectious Diseases (NCID).

The Delta variant’s high transmissibility is a cause for concern. “Asymptomatic people can still be infectious and that makes a difference. You could be sitting next to your colleague at work who could be two months pregnant. Or attend a dinner with 10 people who are exposed.’’

Listen to CNA's conversation with Dr Lim Poh Lian and Dr Ooi Eng Eong on CNA's Heart of the Matter podcast:

VACCINES NOT A SILVER BULLET

But with cases rising despite the vast majority of Singapore vaccinated against COVID-19, does this mean that vaccines cannot offer the protective shield they were touted to?

Vaccines were never meant to be a silver bullet, said Dr Lim. “But it is silly to throw away a good intervention like vaccinations just because it is not 100 per cent,’’ she said, adding that infectious diseases cannot be eradicated without vaccines.

Most importantly, vaccinations also clearly prevent severe illness – well within the 90 per cent, Dr Ooi pointed out.

While the main objective of vaccination is to prevent severity and death, Dr Lim said the number of infections still matter as early warning indicators that tougher measures might be needed.

“We have always said that we control COVID-19 with a combination of measures, including masks, contact tracing for exposed persons, isolation of infectious cases and border control measures. So, when we see a rise of cases, we have to sort of tap on the brakes lightly.’’

Dr Ooi however offered a different view on whether one should “get nervous” about the high infection numbers, when proactive polymerase chain reaction (PCR) tests can pick up mild and asymptomatic cases compared to at the start of the pandemic.

“Now, because we have the tools to be able to go and screen and detect the virus very sensitively, we are picking up a lot. Part of this 200, 300 cases we are seeing now, unfortunately mixes in asymptomatic infection … so by counting this into the group, the numbers are a lot bigger,” he said.

His view is that there isn’t a need to “worry too much” especially when Singapore has antiviral and antibody treatments like remdesivir, dexamethasone and molnupiravir, that could eventually be given in a primary care setting without the need to go to the hospital.

But Dr Lim countered that these drugs remained expensive and if people reached a stage where such treatments were needed, it was best to administer them in a hospital setting where they can be observed.

“There are fires burning around us. If we open up, we have to do it very carefully. We can begin to try to approximate endemic living but it’s going to be a lot of stepping forward and stepping back because we are not there yet,’’ concluded Dr Lim.

Source: CNA/sl

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