SINGAPORE - Singapore recently crossed a milestone, having fully vaccinated more than 80 per cent of its population.

This was the target the multi-ministry task force (MTF) had set as a precondition for easing restrictions further as Singapore moves towards treating Covid-19 as an endemic disease.

Unfortunately, the way things have panned out, reaching this target no longer spells the end of pandemic woes.

Instead, the MTF wants to introduce more testing and people to have fewer social interactions - with none at the workplace.

This appears to be a backward step since the MTF had said a month back that we have to prepare to accept that Covid-19 is endemic and the spread of the coronavirus in the population is to be expected.

It had said the answer to living with Covid-19 is vaccination, because that significantly prevents serious illness or death.

But now that more than 90 per cent of the eligible population is fully vaccinated, the MTF, instead of opening up, has decided to prolong the current regime by a couple of weeks and is putting even more measures in place. Why?

It is true that over the past fortnight, the number of new locally transmitted cases crossed 100 on most days, and often went above 200. But this comes as no surprise, and the numbers are expected to keep rising.

Associate Professor Alex Cook, vice-dean of research at the National University of Singapore Saw Swee Hock School of Public Health, said that at the current rate of infection, with no easing or tightening of measures, Singapore could be seeing 1,000 cases a day in two to three weeks.

Does this mean our high vaccination rate is not delivering the anticipated results? Is there anything that will? Or will the world remain in a state of constant lockdowns, or face high numbers of serious illness and deaths?

The truth of the matter is that the Covid-19 landscape is not static. If the world were still facing the original virus that emerged from Wuhan in December 2019, the vaccines would have worked well in suppressing the disease.

But the Delta variant that is dominant in the world today is far more transmissible than the original strain that emerged in Wuhan.

Where the original virus spreads, on average, from one person to 2.5 others, the Delta strain spreads to five or more people.

If Delta had emerged one year back, instead of appearing only around April this year, the fallout would have been catastrophic.

With a base population of 5.7 million unvaccinated people and starting with one case of each variant, at the end of a month, the original virus would have spread to 1,525 people. In contrast, one case of the Delta variant would have infected 366,572 people.

Prof Cook said: "I am confident that if Delta had not showed up, we would have next to no community cases right now."

But Delta did show up, and its higher transmission rate is the reason that the number of infections and unlinked cases remains high despite measures in place. The Delta variant also increases the chances of people getting severely ill.

The current vaccines were produced based on the original virus and are generally less effective against the Delta variant.

Most studies put mRNA vaccine efficacy against Delta in the 64 per cent to 88 per cent range - against the 95 per cent efficacy from the clinical trials. This also means that more people are likely to suffer from serious illness and death if infected.

An article in The Lancet Infectious Diseases on a Public Health England study published on Aug 27 found that patients with the Delta variant had more than two times the risk of hospital admission compared with patients with an earlier Alpha variant.

Given that Delta is the main variant in the world today, none of the options available today is ideal or without risks.

Professor Paul Tambyah, a senior infectious diseases consultant at the National University Hospital (NUH), said: "This is a policy question and not a medical question."

He added: "Policies which need to balance economic versus perceived public health benefits need to be decided upon by the leaders based on considerations that are important to them."

Close to one in five people here are yet to be fully vaccinated.

About half of them are children under the age of 12 years, for whom there is currently no approved vaccine. While their risk of getting infected is there and they can pass the disease on to others, the children themselves are far less likely to fall seriously ill.

But the other unvaccinated people face significant risk of serious illness and death.

The risk of infection among vaccinated people falls by two-thirds and they are far less likely to suffer prolonged symptoms, according to an article in the Lancet journal last Wednesday.

The study concluded: "Almost all symptoms were reported less frequently in infected vaccinated individuals than in infected unvaccinated individuals, and vaccinated participants were more likely to be completely asymptomatic, especially if they were 60 years or older."

So, people who have been vaccinated have significant protection against severe illness and death - which is the primary purpose of vaccination.

These reports are borne out by cases here. The Ministry of Health (MOH) said on Monday: "Over the last 28 days, the percentage of unvaccinated (people) who became severely ill or died is 6.6 per cent, while that for the fully vaccinated is 0.9 per cent."

Relaxing measures and opening up borders may cause a surge in infections, as barriers to the spread of the virus will be removed.

However, MOH said that among infected people who have been fully vaccinated, more than 99 per cent were asymptomatic or only mildly ill.

Eventually, the spread of the disease in the population is inevitable. But this may not be a bad thing, said Professor Ooi Eng Eong, who co-directs the Viral Research and Experimental Medicine Centre at the SingHealth Duke-NUS Academic Medical Centre.

He said: "If one then gets asymptomatically infected, then it is the best thing that can happen for immunity - we will then develop immune response to the rest of the virus, and not just to the spike gene.

But he admitted: "Letting the virus spread will take a lot of guts. Obviously, this is harder to control and is easier to conceptualise theoretically than to implement."

The MTF is also concerned about the healthcare system getting overwhelmed, as has happened in some countries.

But Professor Dale Fisher, also a senior infectious diseases consultant at NUH, said: "Singapore's health system is very robust. While it is always a concern, one cannot forget the price being paid for the ongoing restrictions in terms of those with businesses being affected and loved ones they can't see."

According to the MOH statement on Monday, there are 637 people with Covid-19 infections who are hospitalised, though "most are well and under observation".

It added: "There are currently 21 cases of serious illness requiring oxygen supplementation, and six in critical condition in the intensive care unit (ICU)."

Health Minister Ong Ye Kung previously indicated that Singapore had set aside 1,000 ICU beds for Covid-19 patients. Currently, only six are in use.

The Government has done its best to protect citizens by providing free vaccination to all. It can add to this with booster shots if these prove beneficial and necessary. The MTF has announced plans to provide booster shots.

While experts are not convinced about the benefits of a third shot for those who are not immunocompromised, it remains a valid option for people who may be at higher risk.

Beyond this, there is not really very much more that can be done. Covid-19 is here to stay, and we need to learn to live with it.

Prof Fisher said: "Caution is good but we can open up faster and allow people to socialise and travel again. This is also critical to the economy."

Locking up the country has never been a long-term solution. It has cost thousands of people their livelihood and taken its toll on the mental health of many people.

Further delays in reverting to life as normal serve little purpose.

As Prof Cook put it: "Stalling the reopening is a means to buy time.

"But unless whatever we are buying time for will change the fundamentals of the epidemiology of the virus, we will find ourselves back in the same situation once we stop stalling and resume reopening."

Associate Professor Hsu Li Yang, an infectious diseases expert at the NUS Saw Swee Hock School of Public Health, said the current moves "are a series of heavy-handed nudges compared to the legal prohibitions of the heightened alerts".

"What remains unfortunately unclear are concrete targets and outcomes by which restrictions may be lifted or added, giving a negative impression of shifting goal posts."

More important is to decide what the new normal needs to be.

It should at least include protecting the vulnerable, such as patients in hospitals and the elderly in care facilities; the wearing of masks in crowded public places and the MRT and buses; and checking the Covid-19 status of people entering the country.

One should also be ready for any sudden surge in hospitalisations.

With the more transmissible and deadly Delta variant in play, none of the options now available to Singapore is ideal, and none is without cost.

Waiting for the unvaccinated to get jabbed makes no sense.

As Prof Cook said: "It seems we are unwilling to make vaccination compulsory, but are willing to impose continued restrictions on those who got vaccinated to protect those who declined to be vaccinated."

Since the choice is left to individuals, one must accept the consequences and acknowledge there will be deaths - already 15 last month - and severe illness.

But after its big push for people to get vaccinated so life can return to normal, the Government, too, should deliver on that promise, as nothing unanticipated has occurred. So, let's choose the least bad option, and start opening up.