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04 May 2020

4th May 2020

Update on Transmission Trends

1.            Mr Speaker, Sir, thank you for allowing me to update members again on the COVID-19 situation and address some of their questions.

2.            When I spoke in March 2020, we were seeing the centre of the pandemic shift away from China, and a rapid increase in cases globally. Close to 80% of our cases then were imported, mainly from returning Singaporeans. We tightened our border controls and our import cases have drastically reduced. In the past week, we had no imported cases, down from around 16 a day on average in March.

3.            At the same time, we have seen a rise in community cases from 9 a day in March to 31 a day on average in the week before circuit breaker, with an increasing proportion of unlinked cases, suggesting that there is underlying community transmission. We decided to do the hard thing, to impose circuit breaker measures from 7 April 2020, and introduced stricter measures following that on 21 April 2020. We also extended the circuit breaker measures to 1 June 2020.

4.            There are signs that our circuit breaker measures are working. The average number of new community cases had fallen from 31 in the week before the circuit breaker, to 11 last week. The average number of new unlinked community cases a day had similarly reduced from 12 to 5 over the same period. This suggests that our circuit breaker measures are effective. Let me take this chance to acknowledge the many sacrifices of our people, workers and businesses during these past few weeks of the circuit breaker. It has not been easy, but you have all played a part in bringing these numbers down and I want to express my heartfelt gratitude. But we are not out of the woods yet.

5.            While the community cases are coming under control, we have seen a rise in migrant worker cases, particularly in the dormitories. We moved in quickly, set up medical posts in all the purpose built dormitories and provided mobile medical support for the factory converted dormitories. The Ministry of Health (MOH) worked with the Interagency Task Force led by the Ministry of Manpower (MOM) to ensure the medical needs and welfare of the workers are taken care of.  We are grateful for the assistance of the Task Force members including the Singapore Armed Forces (SAF) and Singapore Police Force (SPF) and our healthcare workers from our public healthcare institutions as well as from the private sector. We are making progress, and will continue to do our best to care for our migrant workers. Minister Teo will elaborate on this in her statement.

6.            Notwithstanding stringent precautions, there have also been cases at our Nursing Homes and at one Welfare Home. As these facilities serve the elderly who are a vulnerable group, we take such cases very seriously. MOH has ramped up more aggressive testing for staff and residents at these Homes, working jointly with the Ministry of Social and Family Development (MSF). This is to protect our vulnerable seniors, by quickly picking out hidden cases if any, to isolate them and care for them, and thus protect the rest of the Homes’ residents and staff. We have started this, but it will take some time to complete. Meanwhile, we may see cases picked up at these Homes as a result of the active screening. In addition, we are also arranging lodging for staff who interact with residents at designated accommodation facilities on-site or at hotels, to reduce their exposure to the community during this circuit breaker period. Both these steps complement existing safe distancing and infection control measures, so as to enhance protection to our seniors in these homes.

7.            Overall, despite our high case numbers, we have managed to keep death rates low so far. This is partly because most of our patients are younger and partly due to the tireless efforts of our healthcare workers providing good and timely medical care for all our COVID-infected patients. We must continue to do all we can to save patients who become gravely ill, and keep fatalities as low as possible.

8.            In preparation for the expected increase in the number of cases, especially from the dormitories, we have rapidly expanded our healthcare capacity.  This includes both medical facilities, as well as healthcare manpower.

9.            We have seen countries whose healthcare systems were overwhelmed, and this quickly led to high numbers of death among patients. Ms. Irene Quay has asked if we have an ethical framework to allocate use of healthcare resources. We are working hard to avoid getting to this point. We have planned ahead, created and ramped up many different types of healthcare facilities to support the specific needs of COVID-19 patients. In addition, our healthcare system has the flexibility to stretch our capacity to respond to increasing demand. Let me elaborate.

10.          Hospital and intensive care unit (ICU) beds. To ensure that there is available hospital capacity to care for COVID-19 patients, public hospitals have postponed non-urgent elective procedures, and discharged medically stable long-stayers to step-down care facilities. Public hospitals have also repurposed and converted existing wards into isolation rooms, and progressively opened more wards for COVID-19 patients. Our number of isolation beds has increased from around 550 in January this year, to close to 1,500 as of 2 May 2020. The National Centre for Infectious Diseases (NCID) has also increased their capacity from about 100 to more than 500 negative pressure isolation beds in the same period.

11.          Currently, 22 COVID-19 patients are in our ICU, as the majority of the cases are mild. We have about 150 vacant ICU beds, and can quickly bring another 300 online. But we are not taking any chances as we must preserve our buffer capacity.  Mr. Leon Perera had asked about our ability to further ramp up. The public hospitals have put in place plans to ensure that their infrastructure, equipment, medications and manpower are in place to add another 450 ICU beds by mid-May if needed. We have also ensured a sufficient supply of ventilators and other ICU accessories to support the care of ICU patients.

12.          Community Care Facilities. The majority of our COVID-19 cases have only mild symptoms. Hence, we have expanded our medical facilities to care for patients with mild symptoms and those who are on a recovery path and no longer need extensive medical support. These facilities allow the hospitals to focus resources on providing care to those who require emergency and intensive care. The Community Care Facility (CCF) is one such facility for patients with milder symptoms. At the CCFs, patients continue to be monitored and have access to appropriate medical care when needed.

13.          Currently, we have more than 10,000 bed spaces in CCFs for our patients. These include places such as the D’Resort at Paris Ris, Singapore Expo Halls 1 to 6, and part of Changi Exhibition Centre. Another 10,000 are being set up. Building up our CCF capacity called for a multi-agency effort comprising government agencies and the private sector. Many teams had worked round the clock to make this possible, and I want to extend my gratitude to all of them. For example, for the first hall in EXPO, this was made possible through the hard work of individuals from Temasek Holdings, Singapore Expo, Surbana Jurong, the Integrated Health Information Systems, Resorts World Sentosa as the managing agent, PSA, ST Engineering, Certis Cisco, Parkway Pantai, the Woodlands Health Campus as well as the SAF. The list is very long, but this gives us a sense of the complexity of the operations and how closely everyone had to work together. Through the efforts of everyone involved, we managed to set up the first hall in a week. This is truly an exemplary example of a Whole-Of-Society effort.

14.          We have also set up Community Recovery Facilities (CRFs), which is a step-down facility for recovering patients. Based on epidemiological evidence and research by local and international infectious disease experts, patients who remain well at day 14 of their illness are past the critical stage and are unlikely to need further medical care. However, they still have to be isolated to reduce the risk of transmission. Hence, patients past day 14 of their illness can be safely transferred to the CRFs before they are assessed for discharge.

15.          We currently have around 2,000 CRF bed spaces, with some of them within our dormitories, and others in selected SAF camps. We will be expanding CRF capacity to more than 10,000 beds by end June. As our CRF facilities increase, we can also free up spaces at the CCFs.

16.          With this layered set of healthcare facilities, customised to patient needs, we will be able to provide appropriate care for patients while also ensuring sufficient healthcare capacity to meet our needs. All these efforts require close coordination among multiple agencies, as the example of CCF @ Singapore Expo illustrates, to ensure operations are optimised, facilities are well-managed, patient flows are facilitated and tracked, while keeping watch on the capacity utilisation overall.  MOH has set up a Medical Operations Task Force (MOTF) with the support of the SAF to oversee and coordinate our efforts on the ground. I want to thank our partners, and SAF in particular, for their support and efforts.

17.          Looking ahead, while we take heart in the progress made, especially in the community cases, we should not be complacent. There are still unlinked cases, and cases picked up from our surveillance programme, indicating the presence of hidden cases in the community. Globally, the number of cases also continues to increase. Even countries and regions with low daily numbers, such as China, Hong Kong, South Korea and New Zealand, are watching out anxiously for a second wave of infection that may result in another prolonged outbreak.

18.          Hence we must continue to do what we can to keep our cases low, to keep the lid tight even as we gradually roll back some of our circuit breaker measures. We are now at the end of the two weeks of tighter circuit breaker measures. Last Saturday, the Multi-Ministerial Taskforce announced the gradual resumption of selected activities and services in the coming weeks, subject to the necessary safe management measures being in place. The rest of the circuit breaker measures will continue to apply till 1 June.

 

Roadmap Ahead

19.          If we work together, by 1 June, we hope our situation will have improved further, with community cases remaining low or coming down further.  Migrant worker cases in the dormitories will hopefully by then be clearly under control. We can then consider further opening up. This is important to enable our people to start going back to work. It is also important for Singapore to protect our strategic position in the global supply chains as the global economy recovers from COVID-19.

20.          We will still need to open up in a phased and calibrated manner, to avoid a second wave of outbreak. There will likely still be cases of infection in the community, as the virus is very difficult to eradicate. What is key is to keep the number of cases small and reduce the risk of big clusters, through various safeguards and enablers. It will take a while before the COVID-19 outbreak subsides globally, or before a vaccine is available. Thus we will have to adapt to a new way of life and social interactions.

 

Indicators for Phased Opening

21.          Ms. Sylvia Lim asked what indicators we would look at in considering lifting the circuit breaker measures. We would consider a variety of factors.

22.          First, numbers are important but they are not the only thing. We need to be assured that community transmission locally is stemmed, or very low. Community cases should ideally fall to zero or single-digits daily, with very low numbers of unlinked cases, and not just for one day, but sustained over a period of time. We also need to see a decrease in migrant worker cases. These cases are high today, partly due to proactive case-finding in some settings. While we have been able to keep local community cases low despite high number of cases among migrant workers, it is equally important to reduce the migrant worker cases over time, though it will take a while longer. Otherwise we will continue to be at risk of a spillover from the dormitories into the wider population.

23.          Second, we need to make an assessment of the situation globally and for individual countries, to inform the extent and approach on reopening our borders. We would review the rate of transmissions in other countries, as well as what they have done to contain the spread. For any re-opening of our borders, we are likely to start small and selectively, and to continue to impose a mix of isolation and test requirements, to protect ourselves from new imported cases leading to community spread.

24.          Third, we must put in place a system to allow us to open up safely. When we allow more business and social activities to resume, there will be more interactions, and higher risk of virus transmission at the workplace and in the community. Therefore we need to step up our capability and capacity to test and detect cases early, contact trace quickly, ringfence close contacts promptly, and establish the original source of the infection to stop other undetected transmission chains if any. These are the key enablers which will give us confidence to re-open.

 

Testing Strategy and Capacity

25.          Let me start with testing as the first key enabler. To date, we have conducted over 140,000 tests for COVID-19, or 2,500 tests per hundred thousand people in Singapore.[1] This is among the highest testing rates in the world. But we plan to do more, and will continue to expand our testing capacity, and to strategically deploy them to yield the greatest impact.

26.          Members have asked about different tests and their uses. Today, we use mainly the polymerase chain reaction, or PCR tests, to detect confirmed COVID-19 cases. The PCR works by detecting the virus RNA from a nose or throat swab, and is the gold standard for detecting current infection. To the question by Ms. Sylvia Lim, we use PCR testing for three key purposes – one, to diagnose suspect cases to provide early treatment and isolate close contacts; two, to do screening and active case finding of individuals at risk, such as migrant workers decanted from their dormitories before they return to work; and three, to do surveillance to monitor undetected cases in the community. Currently, we have the capacity to conduct more than 8,000 PCR tests a day in total across our community and migrant workers in the dormitories, up from 2,900 a day in early April. We are working with various private and public sector partners to progressively increase our testing capacity further to up to 40,000 a day.

27.          With this increase, we will widen the net that we cast for diagnostic testing for symptomatic cases, active case finding, screening and surveillance testing in our community and among workers, including migrant workers. We will also do more testing and monitoring to pick out asymptomatic and pre-symptomatic cases among priority groups such as nursing home residents and staff, to prevent clusters from developing. Testing is crucial as risk of infection will increase when we allow more economic and social activities to resume.

28.          Ms. Sylvia Lim and Ms. Foo Mee Har had asked about another type of test called serology testing. This works by detecting antibodies produced by the body to fight against the virus from a blood sample. Based on our local studies, the effectiveness of such tests is very low in the first 10 days of illness as it takes time for the immune system to develop antibodies. Therefore, unlike the PCR testing, serology tests are useful to indicate past infection but it is not very useful for early diagnosis because of the time lag. Many such tests in the market are also still under review and validation.

29.          Notwithstanding this, NCID has begun to use serology testing to study the level of infections among various groups, including healthcare workers, close contacts of COVID-19 patients, and the general population. Their study was published last week, and found that among the close to 2,000 samples from our healthcare worker volunteers and the general population, none had antibodies pointing to a past infection. This shows that the infection rate among our healthcare workers and general population is low. The study also showed that among close contacts around 2.5% had antibodies, despite not having had symptoms during their quarantine.  That means they had been infected earlier but recovered, and remained well without any symptoms. This points to the need to continue our efforts to quickly isolate close contacts of confirmed cases. We will continue to do more of these studies, to help us understand the extent of spread and immunity in the community.  I should add that scientific evidence on protective immunity is still under intensive study currently.

30.          There have been some suggestions to do asymptomatic testing for the entire population. We will study this. As there is no widespread community transmission here, the yield will be very low if asymptomatic testing is done indiscriminately for the whole population. To be effective, it may also need to be done repeatedly as it does not reflect immunity and those tested can be infected after the test.  It may not be best way to use our testing resources.

31.          Instead, we will and have started doing asymptomatic testing selectively, for priority groups. For example, we currently test asymptomatic young children, if they are in the same household as COVID-19 patients, since they may not be able to articulate their symptoms well. In addition, a key priority is to protect vulnerable groups. This includes seniors, particularly nursing home residents. As mentioned, we have started to test staff and residents at MOH and MSF homes with a high proportion of seniors, such as Nursing Homes and Welfare Homes. Such tests complement existing precautionary measures, such as good infection control practices and close monitoring for symptoms in staff and residents.  They will allow us to intervene early where needed to protect the elderly residents.  As more businesses reopen, we may also do more tests for essential services workers. At our borders, we can also deploy tests for arrivals to reduce the risk of local transmission from imported cases.

32.          In all, as we build up our testing capacity, we will be able to test more and for more purposes. This will be important as we start to open up, so that we can pre-emptively detect and break any potential transmission chains.

 

Contact Tracing with Technology

33.          The second enabler is our contact tracing capacity. After we have confirmed a COVID-19 case, we will need to contact trace and isolate high-risk close contacts, to limit the spread in the community. This needs to be done fast, has to be scalable and thorough to be effective. This will allow us to quickly ringfence and prevent further spread.  We have set up 50 contact tracing teams, up from 20 since my last update in March.  But we must scale up quickly if there are more cases or large clusters, and to discover less obvious links. To do so manually will be very difficult.

34.          Many countries have leveraged on technology to help them contact trace effectively and efficiently. We will also explore how we can tap on SafeEntry and TraceTogether as well as other technological solutions.

 

Supporting Our Healthcare Workers

35.          Even as we build our capability and capacity for testing, contact tracing and healthcare infrastructure, we need the support of our healthcare workers. They are at the core of our fight against this COVID-19 outbreak. We deeply appreciate their sacrifices, long hours as well as personal and professional commitment to care for each patient. This will be a long campaign, and we will need the support of our healthcare workers and we will need to support them and take care of their needs.

36.          Many MPs have asked about the well-being of our healthcare workers. I would like to reaffirm our commitment to take care of them in every way. Our key priority is in keeping them safe and healthy by ensuring adequate supply of Personal Protective Equipment to protect our healthcare workers, and provide them training on the proper usage.

37.          I thank Dr Chia Shi-Lu for his concern on the infection rate among our healthcare workers. As of 26 Apr 2020, there were 66 cases of confirmed COVID-19 infection among healthcare workers. 46 cases were from healthcare workers whose work involve direct contact with patients. Based on the investigations thus far, there are no established epidemiological links of a healthcare worker being infected in the line of duty for caring for their patients, except for one case in a private healthcare institution where we are unable to rule out a possible link between the doctor and a COVID-19 patient. Our healthcare workers have taken an extra level of care at their workplaces to protect themselves and their families. The recent National Centre for Infectious Diseases (NCID) study also did not detect any past infection among a sample of healthcare workers. Nevertheless, we cannot be complacent. We have reminded our healthcare workers constantly that they should take adequate precaution during their work to protect themselves, their patients as well as their family members. In the event that our healthcare workers fall ill, we will ensure that they are well taken care of and our healthcare institutions will provide them with the necessary support.

38.          It is also important for us to take care of the mental well-being of our healthcare workers. Even before the COVID-19 pandemic, the healthcare clusters had measures in place, such as counselling clinics, helplines, and peer support programmes. We have since stepped up our efforts. For example, our institutions have rostered breaks and staff rotations to ensure that healthcare workers have sufficient rest periods in between work days. The clusters have also been actively working with the NTUC, and in particular the Healthcare Services Employees’ Union (HSEU), with initiatives such as the distribution of care packages, the launch of GrabCare to provide transport for our frontline workers, and collaboration with Mindfi, a mindfulness app.

39.          The many gifts and words of encouragement from members of the public to our healthcare workers mean a lot to them and have helped to keep up their morale. Members of the public have been writing thank you messages and buying breakfast for our healthcare workers. As part of the SG United initiative, close to 9,000 messages for our healthcare workers were collected from Appreciation Zones across Singapore. On behalf of our healthcare workers, let me thank you for your continued support.

40.          Compensation is another important area, which Ms. Cheryl Chan Wei Ling had asked about. We recognise the invaluable contributions of our workers, and will ensure that they receive due recognition for stepping up during this challenging period. DPM had previously announced a special bonus for our public healthcare workers working on the frontline. Healthcare workers are also paid shift or overtime allowances if they take on longer or more shifts during this outbreak.

41.          However, we recognise that no monetary compensation is ever enough. I want to again acknowledge and thank our healthcare workers for their hard work and dedication. One great example is Ms Tovelle Loh, an assistant nurse clinician from NCID. Ms Loh supports training of staff to ensure that they are updated on infection control policies and recommendations, and also helps to review infection control workflows at NCID and other settings. Despite the heavy work load, she remains spirited and committed to do the best for her patients, and it helps that her husband has been very supportive. Examples like Ms Loh abound, among our frontline workers, support staff, and also researchers in our testing and research labs.

42.          Another key part of our strategy is to augment the healthcare workforce, which Mr Murali Pillai had asked about. While our public healthcare sector currently has sufficient healthcare professionals, they are stretched, and there is a need to rotate and refresh staff periodically, as the fight against COVID-19 is likely to be a long one.

43.          To address these sustainability concerns, MOH has given the public healthcare institutions some flexibility to deploy staff across institutions to meet pressing operational needs on the ground and to support one another as one public healthcare system, with strict infection control protocols in place.

44.          MOH has also looked to external sources to augment our public healthcare workforce. This includes tapping on healthcare professionals in the private sector and encouraging retired and non-practising staff to return to public practice through the newly launched SG Healthcare Corps. We have expanded the scope to include those without prior healthcare experience, whom we will train to take on supporting roles, such as performing swab procedures and basic care roles. As of 3 May, we received more than 11,000 sign-ups altogether. I am heartened by this overwhelming response from Singaporeans. So far, we have matched about 800 Corps members to various needs on the ground, and they are being progressively deployed, and we will do more. Members of the SG Healthcare Corps will be remunerated for their time and contribution when they are deployed to work alongside our healthcare workers on the ground.

45.          Third, we also use technology as a force multiplier, to deliver the same or enhanced outcomes, with less time and resources. For example, in the CCFs, round-the-clock care is made possible through the use of medical kiosks and teleconsultations. Devices such as pulse oximeters and health apps are also used to monitor patient well-being. Healthcare institutions have also started teleconsultation services for follow-up on their patients.

46.          Through all these initiatives, we aim to ensure that our public healthcare services remain available to those in need, and our healthcare workers are well-taken care of during this challenging period. This enables us to have a sustainable healthcare workforce in this long-term fight.

 

Health Promotion

47.          Even as we fight COVID-19, we need to continue to address longer-term health issues. I am glad that Prof Lim Sun Sun has asked about this. Let me share what we have been doing in this area.

48.          We have temporarily deferred launching any new initiatives to allow staff to be re-deployed to more critical areas of COVID-19 work. But for selected programmes, such as measures on sugar sweetened beverages, banning partially-hydrogenated oils, and standardised packaging for tobacco products, we will continue to push ahead.

49.          To support our safe distancing measures, we have already suspended all on-ground activities such as general health screening, but we will continue to encourage Singapore residents to practise healthy habits and fight diabetes through less resource-intensive alternative platforms. For example, the Health Promotion Board (HPB) continues to provide on HealthHub bite-sized videos and articles on practising good personal hygiene, healthy eating, physical activity, and mental well-being.

50.          We must also never let our guard down on dengue. The total number of dengue cases in 2020 has exceeded 6,000 – more than double that over the same period in 2019.  With the traditional dengue peak season approaching, National Environment Agency (NEA) officers are on the ground conducting dengue inspections at common areas and construction sites, where construction site operators continue to be responsible for vector control measures, even during the circuit breaker period.  A worrying trend that NEA observed was a 50 per cent increase in Aedes mosquito breeding in homes over the past three years, compared to the preceding three years. Minister Masagos has asked me to urge everyone at home to be vigilant and do the Mozzie Wipeout to remove potential mosquito breeding habitats. NEA also brought forward the National Dengue Prevention campaign to 22 March to rally all members of the community. Our efforts on all these fronts continue even as we battle the COVID-19 outbreak, to keep Singaporeans healthy.

 

Conclusion

51.          Let me conclude. In this fight against the COVID-19 pandemic, everyone can play a role, during and after the circuit breaker period.

52.          We acknowledge that the circuit breaker measures are difficult, and we appreciate everyone’s support and sacrifice to stay home and adhere to the measures. For our frontline officers, including those in healthcare, and dormitories operations, we stand behind you, and want to express our enormous gratitude to your efforts. Our collective efforts are not in vain, and we have seen a decrease in our community numbers.

53.          We are looking ahead, and making preparations for post-1 June. We must make calibrated moves to prevent a resurgence of cases and clusters.  We must put in place key enablers and safeguards to allow us to contain the spread and care for future cases, even as we roll back our circuit breaker measures and re-open.

54.          We must remain vigilant and must not let our guards down. If we all do our part, we can overcome and emerge stronger. Let us work together, and move forward together, as one SG United.

 

[1] As of 27 Apr 2020.




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