AsianScientist (Feb. 28, 2020) – It has been nearly three months into the COVID-19 epidemic, and the virus shows no signs of stopping. While most of the 82,000-plus cases and roughly 2,700 deaths are confined to China, a recent spike in cases in South Korea and even Iran has magnified fears that a pandemic may be imminent.
In the global battle against COVID-19, Singapore has received international praise for its meticulous approach. Since the 2002-3 severe acute respiratory syndrome (SARS) crisis, the Lion City has systematically strengthened its capacity to manage similar outbreaks.
Over the past decade and a half, for instance, the city-state has set up the National Centre for Infectious Diseases (NCID) and the National Public Health Laboratory (NPHL), built more isolation rooms in hospitals and biocontainment laboratories, amassed stockpiles of masks and other protective gear as well as significantly invested in infectious disease research.
And yet, with 96 confirmed cases as of February 28, Singapore has the highest number of COVID-19 cases in Southeast Asia. With this in mind, three veterans of Singapore’s medical scene, namely the National University of Singapore’s Professor John Wong, the NCID’s Professor Leo Yee Sin and the Ministry of Health’s Chief Health Scientist Tan Chorh Chuan, recently identified seven critical issues regarding the outbreak requiring urgent action in a viewpoint in the medical journal JAMA, summarized below.
1. Map COVID-19’s transmission routes
Similar to other respiratory illnesses like the common flu, COVID-19 is thought to spread primarily via droplets that are expelled when an infected person coughs or sneezes. Recent studies, however, suggest that the virus likely has multiple transmission routes—including through stool, as indicated in this paper from the Chinese Center for Disease Control and Prevention.
Conventional wisdom also holds that respiratory viruses are most infectious when patients are at the peak of their illness. But as the authors state, confirmed cases in Singapore were observed to have higher numbers of viral particles, or viral load, in the early parts of their illnesses. More research is therefore needed to confirm if the viral load correlates to how infectious a person is, especially in light of anecdotal evidence that COVID-19 can be spread by affected but asymptomatic individuals.
2. Develop rapid and reliable diagnostics
Further compounding COVID-19’s spread is the fact that its initial symptoms are indistinguishable from that of the common cold: dry cough, sore throat, mild fever—hardly cause for concern. Many cases were discovered only when patients presented themselves at hospital emergency departments, triggered by a worsening of symptoms.
Given this, the authors highlight the urgent need for a rapid, sensitive and affordable screening test that can be deployed in primary care settings to quickly identify suspected cases as early as possible and reduce the risk of COVID-19 spreading into the community. To their credit, scientists from the Agency for Science, Technology and Research (A*STAR) were able to develop a COVID-19 diagnostic kit as early as February 9. However, production still needs to be scaled up so that the kits can be deployed nationwide.
3. Establish clinical criteria to classify patients
Though no deaths have been reported in Singapore so far, COVID-19 deaths in other afflicted countries have been linked to either old age or pre-existing medical conditions. However, the authors share that in Singapore, even relatively healthy patients have progressed to severe illness.
Due to the wide spectrum of symptoms, ranging from none at all to requiring mechanical ventilation for breathing, the authors stress that clinical criteria and biomarkers are needed to help identify the patients most likely to later become severe cases.
4. Clarify clinical treatments
In China, randomized clinical trials of drugs repurposed for COVID-19 are currently ongoing. Drugs being assessed at these trials include a cocktail of HIV drugs lopinavir and ritonavir, which target enzymes crucial for COVID-19 replication, as well as Gilead Sciences’ remdesivir, which was originally meant to treat Ebola.
While more time is needed to assess the effectiveness of these drugs, the authors state that the patients who will benefit the most from the drugs must be identified and the optimal timing of treatment—whether early on or only upon deterioration—clearly defined.
5. Communicate proactively on social media
When the SARS outbreak hit in 2002-3, the concept of portable, handheld, perennially-connected computers (aka smartphones) didn’t exist in public imagination. Back then, the flow of information was much more straightforward, taking place through traditional media channels like print, radio, and television.
Fast forward to 2020 and not only is the world facing an epidemic, but also an “infodemic” fueled by the rise of social media. Fake news and rumors regarding COVID-19 are now far more publicly accessible, exacerbating the challenges faced by public health officials. Thus, the authors emphasize the importance of transmitting clear, accurate and timely information via all possible means.
Since the first imported case was identified in Singapore, official updates and advisories have been disseminated through traditional channels, in addition to newer social media platforms like WhatsApp, Telegram, Twitter and Facebook. Recognizing the importance of engaging beyond the screen, town hall meetings have also taken place with various professional and civic society groups.
6. Extend a helping hand to healthcare workers
With all eyes on the confirmed COVID-19 cases, the struggles of healthcare workers have taken a backseat. On top of the demands of screening, diagnosing and treating the patients, the authors point out that medical personnel are also likely undergoing tremendous psychological stress.
After all, frontline staff treating the patients are among the most likely to contract the illness. Indeed, several prominent medical professionals have already succumbed to the virus—most notably Li Wenliang, one of the first doctors to raise the alarm over the coronavirus outbreak.
The need to care for affected colleagues can also add to the stress, as well as the stigma they may face from the community due to fears of transmitting the infection. Therefore, the Singaporean government is actively reaching out and offering support to those on the frontlines.
7. Get started on developing a vaccine
Ultimately, deploying an effective vaccine is the best way to manage COVID-19, the authors say. With COVID-19’s genetic sequence publicly available, scientists worldwide have been moving at unprecedented speed to work towards this goal. Singapore’s own Duke-NUS Medical School, for example, has been collaborating with the Norway-headquartered Coalition for Epidemic Preparedness Innovations (CEPI) to roll out vaccine trials as early as three months from now.
Still, the authors caution that it will take time to confirm the efficacy and safety of any vaccine candidate. In fact, according to the authors, it would likely take at least a year or more before any vaccine would be readily available for global use.
As the virus continues its relentless spread, it is now more important than ever to rely on tried-and-tested public health containment measures and redouble efforts to address the aforementioned issues. Clearly, COVID-19 is an outbreak unlike any other; overcoming it therefore requires an extraordinary response and collective effort, in the spirit of global health.
Copyright: Asian Scientist Magazine; Illustration: Shelly Liew/Asian Scientist Magazine.
Disclaimer: This article does not necessarily reflect the views of AsianScientist or its staff.