Friday, 21 February 2020

World Health Organisation very impressed with Singapore's COVID-19 response

Republic's efforts in tackling cases and approach in communicating to public win experts' praise
The Straits Times, 20 Feb 2020

Singapore's efforts in tackling coronavirus cases and its approach in communicating to the public have won plaudits from experts and observers from around the world.

World Health Organisation (WHO) chief Tedros Adhanom Ghebreyesus said he had spoken on Monday to Singapore Health Minister Gan Kim Yong.

"We are very impressed with the efforts they are making to find every case, follow up with contacts and stop transmission," said Dr Tedros.

"Singapore is leaving no stone unturned, testing every case of influenza-like illness and pneumonia and, so far, they have not found evidence of community transmission."

Singapore first detected a case of coronavirus on Jan 23 and two weeks later, the Government raised its risk assessment (DORSCON) of the outbreak from yellow to orange.

As of 19 February, the Republic had 84 confirmed coronavirus cases, while a total of 34 patients have been discharged.

Mr Gan said earlier this month that although Singapore has registered "limited transmission" of the virus, it does not constitute widespread community transmission.

According to a Harvard study to identify which locations may potentially have undetected internationally imported cases based on air travel volume estimates from Wuhan, Singapore was found to have identified more imported cases than expected, compared with other locations such as Thailand and Indonesia.

"Singapore lies above the 95 per cent prediction interval (PI), with 12... more reported import cases than expected under our model," said the paper, which has not been peer-reviewed and has been uploaded on medRxiv, an online platform for unpublished health sciences manuscripts.

The researchers said that Thailand has a relatively high air travel volume as compared with all other locations, yet it lies below the 95 per cent PI. "Based on our model, locations whose case counts exceed the 95 per cent PI could be interpreted as having higher case-detection capacity and/or more connection with Wuhan than that captured by available daily air travel volume, such as land transportation," said the Feb 11 report.

Singapore-based Australian journalist Stephen Dziedzic contrasted the Republic's "immense and sophisticated campaign" to contain the coronavirus against some other South-east Asian nations that have struggled to handle the threat.

"When the epidemic first hit, the vast machine of Singapore's public service roared smoothly into life, and it's still running at full throttle," he wrote in The Strategist, the commentary and analysis site of think-tank Australian Strategic Policy Institute, while listing the various efforts put in place by the Republic to limit the spread of the virus.

"Even if the bout of panic buying suggests the city-state is slightly more brittle than portrayed in national mythologies, this crisis has still been a powerful reminder of Singapore's formidable capacities."

Singapore leaders, led by Prime Minister Lee Hsien Loong, have taken the lead to allay concerns over the spread of the epidemic.

PM Lee posted a video in three languages on his Facebook page on Feb 8 urging Singaporeans to stay united and resolute, adding that the nation is much better prepared to deal with the situation than it was 17 years ago with the severe acute respiratory syndrome (Sars). His speech was also televised.

He also said the Government would change its approach if the virus became widespread to avoid overwhelming hospitals, adding that he would keep the public "informed every step of the way".

The speech won plaudits from the Philippines' largest entertainment and media conglomerate, ABS-CBN, which praised the 68-year-old for portraying "a picture of eloquent, soothing calm".

"He didn't only urge his citizens to do their part, but acknowledged those already doing theirs," it said.

Coronavirus detection in Singapore 'gold standard' for case detection: Harvard study
By Rei Kurohi, The Straits Times, 18 Feb 2020

Singapore's approach to the coronavirus outbreak is the "gold standard" for case detection, according to a new study at Harvard University, with researchers using Singapore as a benchmark for other countries.

The study concluded that the global number of cases of COVID-19, as the disease has been called, would be 2.8 times more than it is currently if every other country had the same detection capacity as Singapore.

"We consider the detection of 18 cases by Feb 4, 2020 in Singapore to be a gold standard of near-perfect detection," wrote four epidemiologists at Harvard's T. H. Chan School of Public Health.

The researchers include epidemiology professor Marc Lipsitch, postdoctoral research fellows Aimee Taylor and Pablo Martinez de Salazar Munoz, and research associate Rene Niehus.

"We estimated that detection of exported cases from Wuhan worldwide is 38 per cent as sensitive as it has been in Singapore," they wrote.

Among what the study calls "high surveillance" countries, the number was 40 per cent. The study said detection ability among "low surveillance" countries, was just 11 per cent of Singapore's.

High surveillance countries were defined as those that scored the highest on the Global Health Security Index (GHSI), which ranks countries on their disease prevention, detection, reporting and response capabilities, among other things.

The researchers also referred to a previous study from the school which highlighted Singapore as a statistical anomaly when it tried to estimate how many cases each country should have based on travel volume from China.

The researchers had examined aggregated data from a Feb 4 World Health Organisation report on the number of cases imported by travellers with known travel history to China to 191 countries and regions. The study excluded Hong Kong, Macau and Taiwan.

The researchers then used historical data from the International Air Travel Association and other sources to estimate the number of daily air travel passengers from Wuhan, where the virus originated, to locations outside of China.

"Among countries with substantial travel volume, Singapore showed the highest ratio of detected imported cases to daily travel volume, a ratio of one case per five daily travellers," the study's authors wrote.

"Singapore is historically known for exceptionally sensitive detection of cases, for example in Sars (severe acute respiratory syndrome), and has had extremely detailed case reporting during the COVID-19 outbreak."

One implication of the latest study is that the virus could have remained undetected after being exported from Wuhan to various locations worldwide before the city was locked down on Jan 23, the authors noted.

The Harvard study was uploaded to a free online health sciences archive called medRxiv on Friday as an unpublished manuscript.

The report is complete but the website notes that such manuscripts, or preprints, are "preliminary reports of work that have not been peer reviewed" that should not be relied on to guide clinical practice or health-related behaviour.

Singapore-made test helps solve virus mystery linked to mega cluster
How a breakthrough lab test and expert contact tracing solved the mystery behind Singapore’s largest COVID-19 cluster
Discovery is good news as it gives assurance spread is within control: Health Minister Gan Kim Yong
By Timothy Goh, The Straits Times, 26 Feb 2020

A new test that can detect coronavirus infections even in recovered patients has been used to link Singapore's biggest virus cluster at the Grace Assembly of God church and the cluster at The Life Church and Missions.

In what is likely a world first, contact tracers used serological tests - which are done on blood samples - to identify a married couple as the missing link between the clusters.

The couple - cases 83 and 91 - had attended a Chinese New Year gathering in Mei Hwan Drive on Jan 25.

The Health Ministry (MOH) yesterday said it determined the primary case in the Grace Assembly of God cluster was case 66, a 28-year-old Singaporean who works at the church and lives in Mei Hwan Drive.

Case 66 reported the onset of symptoms on Jan 29 - the earliest in the cluster of 23 cases, and went to work at the church while symptomatic.

Investigations showed that he had attended the same Chinese New Year gathering on Jan 25 as cases 83 and 91.

Contract tracers found that the married couple had gone to the Life Church and Missions on Jan 19, the same day as cases 8 and 9 - Chinese nationals from Wuhan who tested positive for Covid-19 in late January.

Cases 83 and 91 were well and had no symptoms during recent investigations, but records showed both had earlier sought medical treatment, the ministry said.

Case 83, a 54-year-old Singaporean, had visited a general practitioner clinic repeatedly.

Meanwhile, case 91 reported the onset of symptoms on Jan 23 - before the Jan 25 gathering. The 58-year-old Singaporean went to Sengkang General Hospital on Jan 26, but was not tested for Covid-19 as she did not meet the definition for suspect cases at the time.

Both case 83 and 91 were referred to the National Centre for Infectious Diseases for tests on Feb 18.

Case 83 tested positive on Feb 19, and was warded at the centre.

The lab tests currently used to confirm infections, known as polymerase chain reaction tests, detect the presence of viral genetic material in biological samples obtained from a patient, such as a saliva swab. Thus, these will not work if the patient has recovered.

As case 91 had recovered from the virus and was well, she took the serological test developed by Singapore's Duke-NUS Medical School.

The new test works by detecting antibodies the body produces in response to an infection. These antibodies can stay in the body for several years, making it possible for the test to find out if someone was infected with the virus previously - even if she has already recovered.

After case 91 tested positive for Covid-19 on Feb 22, the ministry managed to draw the missing link between the two church clusters.

"This meant that cases 83 and 91 likely got infected from cases 8 and 9, and went on to pass the infection to case 66 at the Chinese New Year gathering on Jan 25," said MOH.

"Case 66 subsequently passed the infection to his colleagues at Grace Assembly of God."

The discovery of case 91 as the missing link between the two clusters is good news, Health Minister Gan Kim Yong said yesterday.

"If we are not able to determine the source (of an infection), there is a risk that it is still in the community and we may have other clusters as a result of it. Now that we are able to determine that the source came from the Life Church cluster... there is a greater assurance that these two clusters are within our control."

In a Facebook post last night, Prime Minister Lee Hsien Loong said the breakthrough would not have been possible without close cooperation among MOH, the police and Duke-NUS Medical School researchers.

Additional reporting by Rei Kurohi


Ministry of Health - Updates on COVID-19 (Coronavirus Disease 2019) Local Situation 2019 - COVID-19 (Coronavirus Disease 2019) situation in Singapore

2019 Novel Coronavirus: Ministerial Statement on Whole-of-Government Response

Wuhan virus: Singapore confirms first case of novel coronavirus infection on 23 January 2020

Wuhan virus: Singapore has to stay vigilant, but has every reason to be confident, says PM Lee Hsien Loong

Wuhan virus: Each Singapore household to get 4 free masks for contingencies; collection starts on 1 Feb till 9 Feb 2020

2019-nCoV: Singapore reports first cases of local coronavirus transmission on 4 February 2020

2019-nCoV: Singapore employers will receive $100 a day for each worker serving the 14-day Leave of Absence (LOA)

DORSCON Orange: Singapore raises coronavirus outbreak alert on 7 February 2020; Singaporeans clear supermarket shelves in panic buying of essentials

Fear and panic can do more harm than coronavirus: PM Lee Hsien Loong

Singapore to work closely with China to battle novel coronavirus threat: Deputy Prime Minister Heng Swee Keat

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