When the Coronavirus first started making its way across the globe and found its way into Singapore, the small island city was lauded by experts in the World Health Organization (WHO) for its efforts in combatting the transmission of the virus within the community, its rigorous contact tracing measures being one of them. Yet as we have seen, Singapore has experienced a huge surge of new COVID-19 cases, the vast majority of which coming from migrant workers living in foreign worker dormitories. As of May 7 2020, Singapore has recorded 20,939 cases of COVID-19 with 20 related deaths. With hundreds of new cases each day, questions are being raised regarding why this is the case.
While there seems to be almost no end in sight, perhaps we should turn our attention to the beacon of hope that is shining upon us — Singapore’s nationwide testing strategy.
Testing allows us to gain a deeper insight into the extent of which infections are occurring within the population. As the saying goes, how we look determines what we see. Thus, Singapore’s high levels of testing can in part be attributed to the numbers we are seeing today.
Singapore’s Minister for National Development Mr. Lawrence Wong has recently announced that the country is in the midst of developing a more enhanced community surveillance plan as part of a nationwide COVID-19 testing strategy. He noted that Singapore will be ramping up its testing capacity and level of testing to better detect any cases of COVID-19 in the community, particularly among the most vulnerable in the population who present the highest risk, such as its healthcare workers and residents and employees of welfare homes, before expanding to the rest of the essential workforce and the community at large.
Why is testing so important for Singapore?
Testing accomplishes several crucial functions. It helps to diagnose patients infected with the virus and to provide timely and appropriate treatment for them. It also aids in contract tracing efforts to limit the extent of community spread.
It acts as a complement to the existing circuit breaker measures put in place in Singapore. The current circuit breaker no doubt reduces the level of social interactions that are made on a daily basis, which decreases the opportunities available for community transmission. While community spread among locals have indeed decreased, for all we know, the virus could be lying dormant right now in society, but who is to say that it will continue to lay dormant when June 1 rolls around the corner and circuit breaker measures are lifted?
Testing is so important precisely because it helps Singapore to look at the bigger healthcare picture, especially when it comes to enhancing its existing preventive measures. It provides much needed insight on how contagious the virus really is, the extent of spread within the community, and which population groups are proving to be the most vulnerable to the virus, and thus, require more support. This greatly enables policymakers to make better public policy decisions when it comes to public healthcare, which would translate into a safer society for Singaporeans. It could hopefully light up a path towards a COVID-19 free Singapore.
This is especially pertinent at a time when the Singapore government is looking to gradually reopen its economy. If the rigour of testing is not maintained or even increased to a much greater extent, the lifting of circuit breaker measures could potentially spell a disaster as Singapore may experience a spike in COVID-19 cases in what could be a second wave of infections.
How many people are we testing right now?
Currently, Singapore carries out around 8,000 tests for COVID-19 daily. These tests are predominantly carried out in polyclinics, general practitioners, hospitals, and foreign worker dormitories, where more than 143,000 of such tests have been conducted in total. While Singapore’s high testing rate shows a lot of promise, it still lags behind countries such as Germany, New Zealand, and Denmark, which highlights the need for Singapore to continue stepping up its testing rates as well as its testing capacity that will allow it to do so.
Right now, Singapore’s positive rate of COVID-19 testing is around 14.6%. Simply put, this means that for every 100 Singaporeans that are tested for the virus, approximately 15 people test positive. Ashish Jha, the director of the Harvard Global Health, posits that when a country presents a very high positive rate, it suggests that there is likely a decent number of people within the community who are infected with the virus but have yet to be tested.
To provide a benchmark, the U.S. has a positive rate of around 20%, a rate that these researchers claim to be too high. Hence, when looking at Singapore’s 14.6%, there seems to be a sigh of relief that it is lower than that of the U.S., but this should not give us a false sense of complacency. Much still needs to be done, particularly increased testing, to lower Singapore’s positive rate to around 10%, which has been indicated as the target rate for countries.
Who exactly are we currently testing?
For starters, Singapore’s migrant workers form the segment of the population with the highest rates of COVID-19 infection in Singapore. Therefore, Singapore has taken a rather aggressive approach to conduct testing on its migrant worker population residing in foreign worker dormitories, which it has identified as a high-risk group.
Health Minister Mr. Gan Kim Yong expressed on April 27, 2020, that the country currently tests around 3,000 of its migrant workers on a daily basis, an increase from 2,900 at the beginning of April. He further mentioned that a total of 21,000 migrant workers residing in our foreign worker dormitories have undergone testing since the beginning of the viral outbreak, so much so that 1 in every 15 migrant workers have been tested thus far. As Singapore’s testing capacities rise, so will the level of testing that is being conducted among migrant workers.
The Singapore government is also actively testing other population groups that possess a high-risk level for infection, such as its frontline healthcare workers as well as residents and working staff of nursing and welfare homes.
There is also sentinel surveillance, where random blood samples of patients are tested for various infectious diseases like measles. Singapore has had this program in place in polyclinics since 2007, where around 300 to 600 samples are sent for testing monthly. Since January 26, three days after Singapore had confirmed its very first imported case of COVID-19, these samples have also been tested for the Coronavirus as part of the sentinel surveillance approach. As of April 28, a total of 1,200 samples have been a part of this testing, of which 13 cases of COVID-19 have been detected at polytechnics and general practitioners.
Sentinel surveillance in Singapore has illustrated that cases of COVID-19 are still being transmitted within the community, which is mostly the result of those who remain infectious despite displaying symptoms with a mild nature. However, it must be said that the Ministry of Health (MOH) noted that there is a lack of evidence that suggests the presence of widespread community transmission at this point in time, and we have rigorous contract tracing efforts for all confirmed cases to thank for that.
What types of tests are we doing?
For the most part, Singapore carries out two main tests in its fight against COVID-19.
The more commonly conducted test is the Reverse Transcription Polymerase chain reaction (RT-PCR) test, which is essentially a swab tests usually taken from the nose or the back of the throat. The RT-PCR test identifies genetic sequences that belong to the COVID-19 virus and is typically utilized for immediate reaction as it determines within a couple hours whether a person is infected with the virus.
The second test is the serology test, which looks at an individual’s antibodies that are produced by the immune system as a reaction to the virus. It determines whether the individual has indeed been previously infected with COVID-19 virus. Since such antibodies are absent at the point of infection and will only appear approximately two weeks post-recovery, they are not useful in making diagnoses.
It is believed that Singapore is one of the first countries to utilize serology tests on such a large scale in order to understand the effectiveness of its current circuit breaker measures, and hence, identify the subsequent steps that should be taken within the community.
Serology tests have a profound impact on Singapore’s policymaking. It first and foremost enables policymakers to determine the extent of spread among various population groups. Secondly, because of its ability to identify those who have been infected but do not display any or simply very mild physical symptoms at best, it provides crucial insight to the extent of undetected and undiagnosed COVID-19 cases in the community, which have serious implications for the overall health and safety of Singaporeans. As it has been established, most of these cases revolve around young and healthy individuals who tend to be the most active in society. Hence, this gives policymakers an inkling to how different population groups which differ by age or even geographical location contribute to the spread of the virus.
How are we planning to increase testing?
The Singaporean government’s current goal is to increase its testing capacity to around 40,000 per day as soon as possible.
To do a simple comparison, if Singapore were to achieve this goal, it would be doing approximately 70% of the testing that the United Kingdom does on a daily basis (stats taken on May 6, 2020), even though it has only 8% of its population size.
On a monthly basis, Singapore would be conducting 1,120,000 tests. This will likely put Singapore in the running for the top country in Asia with the highest testing rate per million population. It may also catapult itself into a serious contender to belong to the group of countries that have the highest testing rates in the world.
In an interview with The Straits Times, Dr. Ong Siew Hwa, the director and chief scientist of Acumen Research Laboratories (ARL), a local biotech firm that specializes in the diagnosis of infectious diseases, declared that Singapore is “in a good position to do mass testing”.
The firm, alongside several companies here in Singapore, has the ability to manufacture testing kits, and local health authorities have already initiated discussion with them regarding testing purposes.
It is reported that ARL, which have developed and produced its own COVID-19 test kits in January, currently can conduct up to 20,000 tests in a given day. As of now, the Health Sciences Authority have granted them provisional authorization for their latest two out of their collection of three tests in March and early April. The firm is now setting its sights on carrying out sample analysis in its laboratories to aid the COVID-19 testing efforts in Singapore.
Dr Ong Siew Hwa also rightfully pointed out the importance of collaboration between the various public and private health institutions, where such teamwork can overcome the various challenges that Singapore faces with respect to its testing capacity. She elaborated by mentioning how private firms can offer support with their expert knowledge, testing equipment, and much needed manpower to complement the existing efforts and funds provided the public sector.
In acknowledging Singapore’s manpower constraints, the Ministry of Health Office of Healthcare Transformation (MOHT) has introduced iConnect.Covid, an information technology system that is designed to inform patients from polyclinics about their negative COVID-19 test results via SMS directly from the laboratories that have conducted their clinical testing. MOHT expressed that this is aimed at alleviating the workload of frontline healthcare workers who are required to inform patients of their negative test results—which is the case for the majority of tests done here—with the foresight of increased community testing. It also improves the efficiency of the entire healthcare system as a whole as more new cases continue to be detected.
iConnect.Covid is also programmed to alert healthcare institutions about newly identified cases of COVID-19, which reduces the number of steps that healthcare workers have to complete, freeing up their schedule to deal with more important and urgent healthcare tasks.
As of right now, iConnect.Covid is in active use in 6 polyclinics, with the remaining 12 to follow suit by mid-May.
Who should we test in the future?
With a rising number of frontline healthcare workers and supporting staff, residents and staff members of nursing homes, as well as migrant workers being infected with COVID-19, these groups of individuals, deemed as high-risk, will likely receive the bulk of viral testing that are to be conducted with the increase of daily testing to around 40,000.
Singapore will also likely increase testing to those who work in essential services as well as the broader community at large in time to come.
While the impact of Singapore’s nationwide testing strategy still remains to be seen, it is certain that Singapore has put up a strong fight in its battle with COVID-19 and will continue to do so in the coming future. This global pandemic, like the SARS outbreak, will definitely leave its impact on Singapore in more ways than one. But one thing is for sure. Singapore now stands more prepared as a nation to weather such future challenges that may await us.