SINGAPORE - Understanding whether people who have Covid-19 are infectious while asymptomatic and how significant this is are among the seven critical issues that require coordinated attention and action in the fight to contain the outbreak, said local experts in an opinion piece.

The article published last Thursday (Feb 20) in the Journal of the American Medical Association (Jama) was written by Professor John Eu-Li Wong, senior vice-president (health innovation & translation) at the National University of Singapore and former chief executive of the National University Health System; Professor Leo Yee Sin, executive director of the National Centre for Infectious Diseases; and Professor Tan Chorh Chuan, Singapore's first chief health scientist at the Ministry of Health.

Last Wednesday, Singapore had 84 lab-confirmed Covid-19 cases.There are now 90 cases here, of which 53 have been discharged and 37 remain hospitalised, including seven in critical condition in the intensive care unit. There have been no deaths to date.

The seven issues listed in the article titled "Covid-19 In Singapore -Current Experience: Critical Global Issues That Require Attention And Action" are:

1. A better understanding of the modes of transmission of this new virus, in particular whether affected individuals are infectious while asymptomatic, and the degree to which this contributes to the spread of the disease, is needed.

Another important question is whether infected children and adolescents, who appear to have relatively mild symptoms, are infectious and contribute significantly to the spread of the disease, they wrote.

Local situation: In Singapore, symptomatic infections in children are rare, and in the three confirmed cases involving the very young - aged six months, one year and two years - the symptoms were very mild, they wrote. This is similar to a recent report from China.

2. It is easy to miss the disease in the early stage of the infection, as acute respiratory infections are very common.

There is thus 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.

It is critical that clinicians take a detailed travel and exposure history during this epidemic, the authors said.

Local situation: They said "the early presentation of Covid-19 infection is typically non-specific".

Many patients who sought help at primary care clinics had common and mild symptoms such as dry cough, sore throat, low-grade fever or malaise, before their symptoms worsened several days later to the point that they had to be attended at hospital emergency departments.

3. Covid-19 has a wide spectrum of severity, ranging from asymptomatic to mildly symptomatic to severe illness that requires mechanical ventilation.

Given this, clinical criteria and biomarkers that can help differentiate individuals more likely to progress to severe illness are needed.

Local situation: Although published reports to date have identified pre-existing chronic noncommunicable diseases as being a risk factor for clinical deterioration, the experience to date in Singapore is that patients without significant comorbid conditions can also develop severe illness, the authors said.

4. Randomised trials of lopinavir/ritonavir - drugs approved for the treatment of HIV infection, and remdesivir, originally developed to treat Ebola, are ongoing in China and may provide valuable information on the effectiveness of these agents.

Information is needed to identify which patients might most benefit from such treatments as well as the optimal timing of administration, early in the course of the disease or only at deterioration.

Local situation: No mention of this in the paper, but the HIV drugs have been used here.

5. As the public is understandably anxious about Covid-19 - given how rapidly the epidemic has spread, with 10 to 20 per cent of hospitalised patients becoming severely ill - the medical community needs to collectively find better ways to communicate and engage the public in the social media era.

The author said that a major difference from the Sars (severe acute respiratory syndrome) epidemic is the remarkable extent and speed of information flow, enabled by social media, in this outbreak.

This, together with how easily fake news spreads, creates major challenges for public health officials.

"Clear, accurate, and timely transmission of information from trusted sources is critical during an epidemic, but the traditional communication channels are inadequate."

Local situation: Singapore has been utilising print, broadcast, websites, and social messaging platforms such as WhatsApp, Twitter, Telegram and Facebook on a daily basis since the first imported case was identified on Jan 23 to keep the population informed and advised about how to reduce the risk of infection.

There is also active engagement of many specific groups, ranging from healthcare professionals to taxi drivers through conventional approaches, as well as through social media and townhall meetings.

6. Those who work in healthcare facilities caring for patients with Covid-19 are under tremendous stress, and this stress may be compounded when they are shunned because of fear that they may transmit infection.

"Working with PPE (personal protective equipment) is cumbersome and uncomfortable, especially if procedures are required," they said.

"Knowing the risks of contracting the illness, coupled with caring for affected colleagues, is something all staff who experienced the Sars epidemic will never forget."

Local situation: Singapore is actively addressing this, with Prime Minister Lee Hsien Loong and members of the Cabinet making special efforts to visit staff who are providing front-line services to personally hear the challenges they encounter and to offer support.

7. Having an effective vaccine will have the greatest benefit in managing this disease, though it is likely that it would be at least a year or more before any vaccine is readily available for global use.

In the meantime, public health containment measures must continue and efforts be redoubled to find answers to the critical questions that will help to better fight this disease outbreak.

Local situation: Singapore would like to contribute to the global effort, led by organisations such as the 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.