S'pore's Covid-19 'endemic' road map: Time for a frank conversation

When Singapore embarks on the endemic Covid-19 road map, the risk of serious illness and death among unvaccinated seniors will rise to its highest level since the start of the pandemic

Seniors under observation at a vaccination centre after getting their vaccine shots late last month. ST PHOTO: ALPHONSUS CHERN

Two contrasting opinions greeted the announcement that Singapore is soon to embark on the road map to endemic Covid-19.

The first can be summarised as a relieved, "It's about time". Singapore is on a solid footing to fully vaccinate four-fifths of the population by end-August. Also, the repeated on-off imposition of restrictions has caused considerable social and economic hardship for individuals and businesses.

The second opinion amounts to a concerned, "Is this the right time?"

After all, Singapore registered the highest number of active clusters on Tuesday - of 131 - and still continues to report a high number of unlinked cases every day.

And, half a year after it was first offered to them, more than 80,000 seniors above 70 years remain unvaccinated, as are all children under 12 as they are ineligible for vaccination.

Not to mention that Singapore just saw six Covid-19 deaths in less than 10 days - a frequency that was never seen even at the height of the outbreak last year.

Plans for reopening also look jarring, coming amid reports of new lockdowns in many parts of the Asia-Pacific.

Is Singapore truly ready to embark on an endemic Covid-19 road map, one that involves the easing of safe management measures in risk-calibrated transition stages? Also, what should we expect in terms of hospitalisations and deaths when we do so?

Timing matters

For a start, it is worth emphasising that Singapore is expected to begin the first transition stage next month. It is now only in the preparatory stage, with differentiated public health measures to buy us additional time to vaccinate more people, and to preserve our healthcare capacity to look after the sicker cases.

What makes September a feasible date to commence the road map is that by then 80 per cent of Singapore's population would have received both doses of vaccines that protect against serious illness and deaths from Covid-19, even by the deadlier Delta variant.

And even then, measures will be lifted in phases to allow for policy fine-tuning, rather than in a sudden rush towards complete freedom.

Unvaccinated young children

Although we are still missing details on what the different stages will look like and when they are scheduled for, we should be mindful of those under 12, who are ineligible for vaccination.

However, clinical trials are under way to understand the safety and efficacy of the mRNA vaccines used in Singapore for these children, with results expected in the fourth quarter of this year.

It has taken longer to generate data for them because traditionally there are ethical hurdles to clear when recruiting young children into clinical research, and not because of any safety concerns.

When there is clear and irrefutable evidence that vaccination can be extended to children below 12 with little risk, I expect Singapore will embark on an efficient campaign to vaccinate them quickly and safely.

The question of vaccinating young children arises because while they are less likely to be infected than adults, there is still a chance of infection and when Singapore begins to relax safe management measures, paediatric cases of Covid-19 may increase.

The good news here is that over 99 per cent of infected young children, even when unvaccinated, are expected to experience only mild symptoms, with no long-term impact on their health.

The bad news is, just like adults, a child with underlying conditions such as asthma or an immuno- compromised condition may experience serious illness when infected, despite these occurrences being considerably rare.

Parents of children with such comorbidities may want to consider taking the same precautions as if they are unvaccinated seniors, before they can be vaccinated.

Unvaccinated seniors

The six deaths reported most recently were all unvaccinated, and four were seniors above 60.

Despite the numerous concessions and vaccination campaigns that specifically target the elderly, there are still about 150,000 seniors above the age of 60 yet to be vaccinated.

When Singapore embarks on the endemic Covid-19 road map, the risk of serious illness and death among these seniors will rise to its highest level since the start of the pandemic.

Mathematical models by Professor Hannah Clapham and her team at the School of Public Health estimates a cumulative ICU admission in 2022 of almost 2,100 cases in this age group, of whom 480 may die.

The vast majority of these cases will involve the unvaccinated.

Pushing the vaccination uptake in seniors above 60 years old by another 5 percentage points can dramatically reduce the number of deaths in this age group by nearly 60 per cent.

Precisely because these are preventable deaths and the benefits of vaccination magnify across the community to protect others in addition to oneself, the Government and public health experts have been exhorting everyone to come forward to be vaccinated.

Many of these unvaccinated seniors actively chose not to be vaccinated, whether from a sense of indifference or from personal beliefs against Covid-19 vaccines.

However, there is another sizeable group comprising very old or frail seniors who are mentally incapable of making a choice, and instead it is their well-intentioned children who oppose having their parents getting the jab for fear of subjecting them to side effects such as fever and muscle aches.

We should respect the choice that these families have taken, especially if the adult children themselves recognised the importance of vaccination and have vaccinated themselves in order to protect their frail elderly parents.

Yet, these families need to recognise the risk the endemic Covid-19 road map will bring to their unvaccinated seniors, even if home-bound.

In fact, people who regularly interact with an unvaccinated senior must continue to curtail their own social and public activities, regardless of the extent Singapore eases its safe management measures. They may even want to undertake the self-administered antigen rapid test (ART) regularly to ensure they remain free from infection.

Maintaining such a "social bubble" of protection is necessary for all members in a household who have an unvaccinated senior, although a frank discussion must happen within the household on the ability to adopt this stance indefinitely.

Vaccinated family members can be infected but remain completely unaware of their infection status, because they have no or only mild symptoms, and could end up inadvertently passing on the virus to their vulnerable unvaccinated senior.

This is not a theoretical possibility, but something that is likely to happen across the country many times over in the months ahead, resulting in the hospitalisation and deaths of some of these seniors.

Vaccine-differentiated measures, alongside a continued mandate on mask wearing, can do only so much to blunt the numbers of hospitalisations and deaths.

Simply put, vaccination can be a matter of life and death for seniors.

Death despite vaccination

It is only a matter of time before Singapore experiences its first death of a fully vaccinated person.

We have already seen this occur in other countries, including those with advanced healthcare infrastructure comparable to what we have in Singapore.

But just because it happens does not mean the vaccine is ineffective.

To understand why, imagine a population where everyone is fully vaccinated. Endemic Covid-19 means there will still be people who are infected, who develop serious illness, require hospital care, are admitted to ICU, and who die from complications related to Covid-19.

On average, Singapore experiences about 800 deaths a year as a result of influenza. Many of the victims are elderly or have underlying medical conditions.

This is what we will see in endemic Covid-19, where at any point in time, there will be people who may be hospitalised or may die from Covid-19, although the majority can avoid this with vaccination and some vital safe management measures, including mask wearing.

The road ahead

We need to recognise that the "road" ahead with an endemic Covid-19 road map is still fraught with uncertainty.

The protection conferred by vaccines may wane with time, especially in people at the highest risk of poor outcomes. New variants of concern beyond Delta may also emerge to challenge present vaccines.

While none of these risks undermines the importance of vaccination, Singapore must continue to monitor the evolving situation and be ready to consider the need for vaccine boosters, in order to keep the road map relevant.

And precisely because unknowns and uncertainties exist, frank conversations about the risk of hospitalisation and death must continue to happen, so people are prepared and can make the best decision to protect lives and livelihoods.

  • Professor Teo Yik Ying is dean of the Saw Swee Hock School of Public Health at the National University of Singapore.

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