Singapore

As coronavirus cases surge, can Singapore's health care system handle the pressure?


As Singapore experiences a drastic spike in Covid-19 cases – which grew tenfold over March to hit 1,000 on April 1, then rose almost sixfold to 5,992 as of Saturday – the authorities are on alert to ensure the health care system can withstand this growing pressure.

Experts such as infectious diseases specialist Leong Hoe Nam say hospitals can cope for now, but they are concerned about admissions outpacing the number of discharged patients.

As of Saturday, there were 2,563 coronavirus patients in hospitals and another 2,678 in newly converted community isolation facilities, with 740 having made a full recovery.

Singapore had 11,321 acute care beds in public and private hospitals as of last year.

Official data for last month shows eight public hospitals were at least three-quarters full, but at the time, there were only 802 coronavirus cases and a quarter of these patients had recovered, with some in isolation facilities and 420 in hospitals.

Singapore’s public hospitals were filling up, said Professor Teo Yik Ying, dean of the Saw Swee Hock School of Public Health at the National University of Singapore (NUS).

Associate Professor Jeremy Lim, from the same school, said last week when there were almost 2,000 cases in hospitals that these represented “more than 15 per cent of all the hospital beds”.

The concern now is how many more infections there are within the migrant worker community, 323,000 of whom live in 43 mega-dormitories and 1,200 smaller ones across the island and do low-wage jobs shunned by Singaporeans.

About 4,162 of these workers are infected with the virus, forming close to 70 per cent of the country’s positive cases.

The spread has been fuelled by the crowded dormitories these workers live in, with 12 to 20 men in each room.

The government is now aggressively testing workers, having tested about 5,000 in the past few days.

Teo said some pressure on public hospitals was relieved by private hospitals taking in milder cases, and new isolation facilities providing step-down care for those recovering well.

“There is a daily process that is centrally managed to decant mild and recovering patients from the public hospitals to these additional facilities to free up capacity,” he said.

The D’Resort NTUC in Pasir Ris was converted to a community isolation facility with capacity for 500 patients who are well but still tested positive for Covid-19.

Two halls at the Singapore Expo Convention and Exhibition Centre were also converted to care for 950 patients, with a third hall opening soon.

Community facility Bright Vision Hospital also transferred its patients to other facilities so it could receive about 200 Covid-19 patients.

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Health Minister Gan Kim Yong on Tuesday admitted that the recent rise in infections had “stretched” health care resources, but offered the reassurance that “we are still able to cope”.

Ying-Ru Lo, Head of Mission and World Health Organisation (WHO) representative to Malaysia, Brunei Darussalam and Singapore, said the city state’s public health response was deemed successful because the aim should be to “ultimately prevent deaths from infections”.

11 people have died of complications from Covid-19 in Singapore.

Beyond bed space

Still, experts interviewed last week said bed capacity was not the only limiting factor in fighting the outbreak.

In fact, Singapore had “a lot of built-in buffer” for bed spaces from the private sector and from cancelling and postponing elective operations, said Paul Tambyah, president of the Asia-Pacific Society of Clinical Microbiology and Infection.

“I think we have some way to go before maxing out,” he said.

Associate Professor Hsu Li Yang, the programme leader for infectious diseases at the NUS Saw Swee Hock School of Public Health, said depending on the strategy, other limiting factors can include reagents for polymerase chain reaction tests and laboratory facilities, ventilators, and trained health care workers.

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The bigger threat was if more vulnerable members of society fell ill, said Tambyah, adding that cases from nursing homes involving senior citizens would require more medical care and could not be at isolation facilities.

Leong, who is at Mount Elizabeth Hospital, said those who would require intensive care would need ventilators and critical care beds – things that were hard to scale up, compared to bed space for patients with milder symptoms.

Even the number of health care workers, to an extent, can be increased.

On April 8, the health ministry asked former nurses, doctors and other health care professionals in private practice or who had retired to support the current workforce.

In just one day, 1,100 had signed up.

Asok Kurup, an infectious diseases physician at Mount Elizabeth Hospital, said Singapore had response plans in place for ventilators, with a capacity of “beyond several hundreds”.

“This has been planned several weeks or months beforehand so we are not seeing that kind of epidemiology like in New York or in Italy,” he said, referring to how both have had to lobby for donations as supplies of equipment run low.

The shortages Singapore could face are in medication for patients and protective gear for health care workers.

Like many countries, Singapore uses combination drugs to treat severe cases, such as Lopinavir and Ritonavir, typically used for HIV patients.

Kurup said even though there were “still some supplies”, he feared a shortage if the situation spiralled. Doctors are also now “very cognisant” of who should receive treatment, following a set of guidelines issued by the authorities.

Some patients who are critically ill could also enter clinical trials led by American biopharmaceutical company Gilead, where they would be given antiviral medication Remdesivir under “compassionate use”.

But Kurup said there were strict requirements patients had to fulfil, such as being on ventilator support. “We can’t just buy [these drugs] off the shelves,” he said.

The global shortage of personal protective equipment was also highlighted in an April report by the Asian Development Bank, noting production backlogs of up to six months.

China is the world’s largest exporter of masks, gowns, protective suits and goggles, according to the report, while Malaysia is the top exporter of surgical gloves.

It cited how export bans on masks as well as transport and shipping constraints have caused the supply chain bottleneck.

Matt Zafra, a principal in health and life sciences at the Asia-Pacific arm of consulting firm Oliver Wyman, said as the number of infections climbed globally, the risk of an equipment supply shortage would increase correspondingly.

“This is why the health care system needs to continue to ‘flatten the epidemic curve’ to buy time to find alternative sources,” he said.

This includes ramping up domestic production or repurposing other manufacturers to make gowns, masks and gloves.

 

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However, Teo, the dean of Saw Swee Hock School of Public Health, said Singapore was prepared. “I understand a series of negotiations have allowed a diversified supply chain into the country, and local manufacturers have stepped up to produce some of these resources,” he said.

This Week in Asia understands that some protective gear is manufactured in Singapore, with health care products group MedTecs and American mask manufacturer 3M, for example, churning out hospital gowns and masks, while face shields and goggles are supplied by US-headquartered Honeywell as well as PPM Medical and manufacturing firm Quebee.

On top of that, Singapore’s Defence Science and Technology Agency recently developed an alternative face protector for frontline workers.

‘Treat as many as there will be’

The experts This Week in Asia spoke to did not want to speculate on when Singapore’s health care system would hit breaking point, but said if there were widespread transmissions causing sustained spikes, the government’s strategy would have to change.

“Then it is reasonable for the national strategy to evolve from containment to a mix of containment to manage down the number of cases and mitigation to protect the most vulnerable, including seniors and those with chronic conditions,” said Lim.

Tambyah said “we might reach a stage where we tell people with very mild disease to stay home with careful monitoring – Singapore has excellent tele-health capacity”. The focus, then, can be on the most vulnerable, such as the elderly who are more likely to be severely affected by the disease.

“That will ensure that the health care system remains functioning for those who have heart attacks, fractures, etc, which do not stop just because there is a pandemic,” he said.

Hsu said Singapore would need to look at how to keep increasing health care capacity and isolation facilities to treat “as many as there will be… just as other countries such as China have done, even while limiting the spread through stricter interventions to achieve physical distancing, quarantine and contact tracing”.

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For now, the authorities are taking heart that those in the largest infection cluster – migrant workers – are younger and generally in better shape, meaning they are less likely to develop serious complications from Covid-19 that require long hospital stays.

All of the 43 mega-dormitories have been quarantined which means workers cannot leave the compound, have staggered shower times, and are not allowed to mingle between floors, while 16 dorms are under a full lockdown so workers cannot leave their rooms at all to mingle with others.

This had reduced the chance of the virus spreading within the larger community, Health Minister Gan said.

Indeed, community spread looks to have levelled off, with daily numbers in the past week averaging 50.

Lim said mask-wearing, which was made compulsory on April 14, and safe-distancing measures would help stem further community spread.

“I am confident the health care system won’t be overwhelmed,” he added.

For the latest updates on the coronavirus, visit here.

This article was first published in South China Morning Post.



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