Time for Singapore to firm up Covid-19 exit strategy: Experts

Experts say there is little to be gained by delaying exit measures beyond this month.ST PHOTO: LIM YAOHUI

SINGAPORE - Singapore should implement its exit strategy from Covid-19 restrictions soon, given that the number of people stepping up to be vaccinated has tailed off. These days, only about 8,000 are coming forward daily for their first dose.

As at Aug 3, 4.33 million people had received at least one dose of the vaccine against Covid-19. It is only fair to give these people time to get their second dose, and the two weeks needed for their immunity to build up for maximum protection.

Senior Minister of State for Health Janil Puthucheary's announcement that Singapore is looking into vaccinations for the 50,000 short-term pass holders here would plug another gap of possible infection and spread.

Start easing measures

With more than 77 per cent of the population having received at least one dose of the vaccine, experts told The Straits Times there is little to be gained by delaying exit measures beyond this month.

Professor Paul Tambyah, a senior infectious diseases consultant at the National University Hospital (NUH), said: "The number of deaths is so low right now that it is unlikely that further prolonging the restrictions will have a significant impact."

Since Covid-19 hit Singapore in January last year, a total of 39 people have died. There are now seven people requiring intensive care - a far cry from the hundreds feared when this wave of infections started.

In announcing the current phase two (heightened alert) last month, Health Minister Ong Ye Kung said 1,000 intensive care unit (ICU) beds have been set aside for Covid-19 patients.

Although there was only one patient in ICU on July 16, he feared "in one week, it will be 50". "One more week, 100. One more week, 200. One more week, about 500. Fifth week, 1,000. System collapses."

Fortunately, this has not happened. A lot of credit for this goes to the doctors and nurses caring for these Covid-19 patients, who are able to keep the vast majority from becoming severely ill.

Professor Dale Fisher, also a senior infectious diseases consultant at the NUH, said: "While people are still rushing to get vaccinated, I think we should mostly wait. There are almost 900,000 people with only one jab and they are therefore still vulnerable. They will be fully protected by the end of the month."

Two doses of the Covid-19 vaccine are needed for maximum protection.

Professor Ooi Eng Eong, who does viral research at Duke-NUS Medical School, suggested Singapore set a date on when it plans to ease restrictions as "a firm decision on when measures will change or be relaxed will provide a clear signal for all to act accordingly, as many who procrastinate or are undecided will be mobilised by deadlines".

He said the principle is to ensure that the benefits of disease control outweigh its cost to society. He said: "As the cases that truly need hospitalised management are now well within the limits of our healthcare resources, the cost of the current measures to the rest of society in Singapore, who are now mostly vaccinated, has inflated sizeably."

Now, people who have been vaccinated, whose livelihoods have been affected, whose plans for weddings and other social activities have been put on hold, are just waiting for the laggards to get vaccinated.

Associate Professor Alex Cook, vice-dean of research at the NUS Saw Swee Hock School of Public Health, added: "Stragglers who have been putting off getting vaccinated cannot in good conscience expect everyone to wait for them to make up their minds… or overcome their fear of needles."

Prof Ooi is all for an early date to ease curbs since "cases have not abated despite the phase two (heightened alert) measures".

Pointing to the low impact of the lockdown in Sydney, Prof Ooi said such measures are less effective against the Delta variant than they were against the original wild strain.

"Its transmission is much harder to prevent using conventional physical measures, such as social distancing. However, there is ample evidence that Delta can nonetheless be effectively prevented by current vaccines," he said.

Prof Fisher agreed that easing of restrictions is important "because of the economic impact on small and large businesses and the country". He said: "There is also a huge social impact on weddings, funerals and family get-togethers."

Professor Teo Yik Ying, dean of the NUS Saw Swee Hock School of Public Health, said easing of measures can start now if done in a calibrated and phased manner.

What measures to ease

Prof Teo suggested some differentiation to protect the unvaccinated.

"For example, dining in for vaccinated people can be permitted, perhaps in even larger group sizes of up to five. For unvaccinated people, dining in should still be restricted, maybe to one person or at most two."

The same principle should apply to social and fitness activities, he said, adding that "the differentiation is to protect the unvaccinated people, rather than to discriminate against them".


Some eateries such as McDonald’s had imposed a blanket rule of allowing only up to two people per table for dining in, before it was announced that Singapore would return to phase two (heightened alert). PHOTO: ST FILE

Prof Fisher added that there should be some guidance for unvaccinated people, as well as the vulnerable vaccinated (these include people with compromised immune systems for whom the vaccine is less effective). They should wear masks, avoid groups and show up early for testing and treatment, if they have symptoms of Covid-19.

Like Prof Teo, Prof Fisher said: "We have to let our hawkers and restaurateurs get back to work."

He, too, is in favour of allowing larger groups to gather if everyone within them is vaccinated, and to drop the wearing of masks outdoors if people are able to social distance.

He also thinks contract tracing should be reduced or even stopped. "If this continues as restrictions ease, we will simply be putting more people in quarantine. Currently, there are 18,000 who cannot go to work or go to school. A halfway measure could be to identify only close contacts and therefore quarantine fewer."

Prof Fisher added that testing for Covid-19 should also be limited to unvaccinated close contacts and patients admitted to hospitals.

Prof Tambyah said while those who are vaccinated can get infected and pass the disease on, the risk is far lower as their viral load falls much more quickly than in people who have not been vaccinated. "The implication is that vaccinated people are less likely to spread the virus to anyone."

Prof Fisher said this is another reason for letting vaccinated people who are infected to recuperate at home.

Prof Tambyah too sees no need for them to be hospitalised. While the healthcare system is coping well, he said "it could cope even better if we could straightaway send people to community care facilities or home isolation unless they meet normal criteria for admission for people with other respiratory viruses such as influenza".

Will more people die?

Unfortunately, the answer is yes - with the unvaccinated elderly at the highest risk of serious illness and deaths once Singapore eases restrictions.

Said Prof Teo: "As Singapore starts to ease restrictions, I expect asymptomatic and mild infections to start going up, and this will invariably spread to the unvaccinated people, particularly the elderly.

"The Delta variant has made Covid-19 much more transmissible, and potentially more virulent to those who are infected. As such, the risk to unvaccinated people is genuinely higher.

"However, waiting for a higher vaccination uptake will mean continued economic hardship for many individuals and businesses."

He said families with unvaccinated elderly have to be careful to prevent household transmissions to them, especially since someone who has been vaccinated may have mild or even no symptoms, but can still spread the disease.


Families with unvaccinated elderly have to be careful to prevent household transmissions to them. ST PHOTO: GIN TAY

Prof Cook said he was particularly worried that unvaccinated elderly think that because they do not go out much, they will not be at risk. "That is not the case, even if the family members are vaccinated, they could still bring infection back into the household."

Depending on the vaccination rate here, deaths from Covid-19 could range from a few hundred a year to over a thousand.

Prof Cook, an expert in disease modelling, said the key is the number of elderly who are vaccinated. "If it remains at 80 per cent in this age group, then 1,000 deaths in the next year is quite plausible, mostly among those who declined to be vaccinated."

"If we can get the vaccination rate up to 95 per cent, then potentially a few hundred deaths might result, again primarily in the unvaccinated."

Prof Tambyah added: "I think that we will be able to accept around 100 to 200 deaths a year which would be an improvement from the more than 500 deaths a year we used to see with influenza."

From May 2020 till June this year, Singapore has not had a single case of laboratory-confirmed influenza. There was one case last month.

A Ministry of Health (MOH) study published in 2006 found that close to 600 people died of influenza-associated deaths here each year, with the elderly facing more than 11 times the risk of death.

There has been little panic over flu deaths, although these can be prevented through vaccines too. Covid-19, however, has become a rather emotional issue for many.

To further protect the population, Dr Asok Kurup, who chairs the Academy of Medicine's Chapter of Infectious Disease Physicians, said Singapore should require all visitors to be vaccinated before arrival.

Vaccines are currently being tested in children under the age of 12 and will likely be available for them before the end of this year. But children who get infected rarely get severely ill.

Said Prof Cook: "Vaccinating younger children would reduce the number of deaths primarily by reducing the risk of unvaccinated elderly acquiring infection from them. This is much less efficient than vaccinating the elderly directly."

He added that children here have made huge sacrifices over the past year, such as having their schooling disrupted, to protect the elderly from infection.

"It should be a matter of urgency to reduce the burden on children of pandemic-control measures, whose beneficiaries are the elderly who have been eligible for vaccination for half a year already."