Tracking COVID-19 outbreak in SG: The past, present, and future

On Jan 23, Singaporeans woke up to the news of a first imported case of COVID-19. The man in question: a 66 year-old Chinese tourist from Wuhan.

Hot on the heels of the first case, two more cases were confirmed the following day and another the day after.

Contact tracing began soon after the first confirmed case. The government acted swiftly to contain the spread. Various measures, including border controls were put in place — banning visitors with a recent travel history to Hubei, which later expanded to include China, from entering the city-state. 

The infiltration of the COVID-19 virus did not stop either. Undeterred, the virus marched right into the heartland in the following days. On Feb 4 came news that four locals who had not recently travelled to China were infected. All four were linked to Yong Thai Hang, a complementary health product shop which mainly serves Chinese tourists. The spread, clearly, was no longer confined to imported cases. 

On the ground, fear was starting to take a grip on people. The demand for face masks skyrocketed — supply was wiped off the shelves as soon as they were filled in pharmacies. Hand sanitizers and disinfectant cleaning products were not spared as well. This, however, marks only the beginning of what was to come on Feb 7.

DORSCON orange

Following the emergence of several local confirmed cases with no links to previous cases and no recent travel history to China, the government raised the risk assessment for the outbreak from yellow to orange on Feb 7.

DORSCON, an acronym for “Disease Outbreak Response System Condition”, is a colour-coded pandemic preparedness framework to guide Singapore’s response in face of a disease outbreak. Different colour codes, from green at the lowest to red at the highest, indicate different risk levels of the current disease situation. Each level up calls for additional measures in response to the outbreak.

The system was set up after Singapore’s experience from the SARS* outbreak in 2003. The only time the alert has been raised to code orange was for the H1N1 outbreak in 2009, and now, for COVID-19.

Code orange implies that the outbreak is considered to have moderate to high impact on public health — meaning the disease is severe and transmits easily, but still contained. Additional precautionary measures will be implemented to limit the risk of further community transmission. 

Under the orange alert, nonessential large-scale events should be suspended, schools are to cancel inter-school and external activities, daily temperature taking is instituted at workplaces, and the number of visitors to preschools and eldercare premises is restricted to protect vulnerable groups.

More measures have since been rolled out in the following days, such as reactivation of Public Health Preparedness Clinics islandwide and advice to extend medical certificates to 5 days for patients with respiratory symptoms.

In fact, many of the measures have already been in place and, with the heightened alert to DORSCON orange, are being stepped up. To curb the spread of the virus, the government has implemented measures such as quarantine of close contacts of confirmed cases and a mandatory 14-day leave of absence from workplaces for those returning from China since January. At schools, recess times were staggered and assemblies suspended since the first local transmission cases surfaced on Feb 4.

Also, the government has started handing out four surgical masks each to 1.37 million households in Singapore from Feb 1 to quell the public’s insatiable hunger for masks. At the same time, it also made clear that only those unwell need to wear a mask.

At the flick of code orange on Feb 7, masks, it seems, were not the only commodity facing a feverish demand from the ground. 

Panic strikes

On Feb 7, shoppers at the local supermarkets were greeted with shelves upon shelves of empty space for what used to be stacked with rice, meat, toilet rolls, and cleaning products.

The shopping frenzy for essential items has gone into full swing with the rise of the DORSCON code. Fearful that the situation might worsen — technically rendering frequent grocery shopping impractical — people began stockpiling for a rainy day.

The drama continued through to the next day, despite reassurance that there are sufficient supplies for essential items. The government decided that something had to be done to stem the panic buying. 

By the evening of Feb 8, Singapore Prime Minister Lee Hsien Loong called on the nation to remain calm amid the heightened alert on the COVID-19 situation. Singapore is much better prepared to cope with the virus this time, he said, after its experience from SARS outbreak 17 years ago.

“We have ample supplies, so there is no need to stock up with [these essential items],” he reassured in a video telecast, which has since gathered more than 440,000 views on online platform alone.

People took heed — the long queues in supermarkets disappeared overnight. Some calm, it seemed, was restored.

“Whatever the situation, we can each do our part,” urged the Prime Minister, citing personal hygiene, compliance to daily temperature taking, and avoiding crowded places if unwell as examples. “These simple steps … will go a long way towards containing the spread of the virus.”

What lies ahead?

“The situation is still evolving. Every day brings new developments, and we have to respond promptly and dynamically,” the Prime Minister said. “If the numbers keep growing, at some point we will have to reconsider our strategy.”

The number of confirmed cases now hits 110, as of Mar 3. To date, six local transmission clusters have been identified: Yong Thai Hang, a private business meeting at Grand Hyatt Singapore, the Seletar Aerospace Heights construction site, Wizlearn Technologies Pte Ltd, The Life Church and Missions, and the Grace Assembly of God. On the bright side, 78 have since been discharged.

In view of the evolving COVID-19 situation, there are several critical issues that require concerted attention and action, according to a panel of three experts led by Professor John Wong Eu-Li of the National University of Singapore, Singapore in an opinion paper published in JAMA. [JAMA 2020;doi:10.1001/jama.2020.2467]

“Better understanding is needed regarding the modes of transmission of this new virus, and in particular, whether affected individuals are infectious while asymptomatic and the degree to which this contributes to spread,” they wrote.

As the early signs and symptoms of COVID-19 is typically nonspecific such as sore throat, dry cough, and low-grade fever, these pose a challenge to early detection of the disease.

“Because acute respiratory infections are very common, there is a pressing requirement for a rapid, sensitive, affordable point-of-care screening test in the primary care setting to identify suspected cases as early as possible to reduce community spread,” pointed out Wong and co-authors.

Development of an effective vaccine is imperative and will confer the greatest benefit in managing the disease, they added.

“Singapore would like to contribute to the global effort, led by organizations like Coalition of Epidemic Preparedness Innovations (CEPI), to develop and test a vaccine that is hoped will enter clinical trials by the second quarter of this year,” they continued. “Even then, it is likely that it would be at least a year or more before any vaccine is readily available for global use.”

Unlike the era of SARS, the age of information explosion now — enabled by social media — can be a double-edged sword. While this opens the door for keeping the public abreast of the latest updates, it also makes way for propagation of fake news, noted Wong and colleagues.

“The medical community needs to collectively find better ways to communicate and engage the public in the social media era,” they stated.

“We should take courage and see through this stressful time together,” emphasized the Prime Minister during his Feb 8 national address. “The real test is to our social cohesion and psychological resilience … Fear can [only] do more harm than the virus itself.”

“Let us stay united and resolute in this new coronavirus outbreak. Take sensible precautions, help one another, stay calm, and carry on with our lives,” he said.