#covidsg 23 Sept 2021

#covidsg

WYSIWYG – an old computer acronym meaning What You See Is What You get

If you read the Covid response in the mainstream news, it’s just one side of the story, it’s (mostly) the public mouthpiece that the Gov / MTF wants to put out. That’s not wrong, and largely it keeps the messaging concise, clear, focused, and controlled.

But of course, as with everything, it is important to have independently verifiable data, a healthy dose of skepticism, and proper critical thinking. Not to mention to understand different viewpoints, intentions, and to take care of yourself because nobody else will.

So the other sides of the stories include anything from the pure anti-vax movements, the standard conspiracists, the grassroot WhatsApp chats, the online forums, the coffeeshop chats, scientific community, healthcare community. And of course the actual C+ patients themselves.

It’s not easy to tell who is telling the truth, and how much of the truth. It’s rare for anything to be completely true, or completely false. Anything clearly false would be dismissed immediately, but half truths are more dangerous.

The Current Endemic Mess

So anyways, now we have MOH MTF going headlong into their concept of “endemic” – the dangers of which is that they branded it with this silly name, and over equate it with influenza without the same conditions.

MOH still pursues extensive quarantine and isolation. Not wrong per se. It has great intentions in slowing down spread, flattening the spike, helping hospitals. Really. Slowing down, not reducing to zero. That’s the crux of ‘endemic’, that’s all.

But MOH’s team, despite whatever sugarcoating that LHL/MTF says, cannot micromanage thousands and thousands of home quarantine/patients/phonecalls/home service of swabs+checks+carepacks.

A radical radical radical conceptual change is required. From a top-down to a bottom-up approach. We need to clearly look at the needs vs possibilities and pare it down.

We can guess what is happening at MOH team: anything super critical is attended to: require hospitalization/ICU. breathlessness, low SPO2. everything else is on a best-effort basis. Leads to dropped calls, dropped cases.

The methodology needs to change to prioritize: 1. Entry/registration of C+/QO/IO, 2. Automate entry, followup, exit. Except for escalations and special cases. 3. Digitalize: use of integrated online case status, tracking, QO status etc.

MOH needs to not just resolve 500 caseloads per day. They need to implement new solutions that continuously automate 10% of the above issues per day, at the end of the week, it will lead to scalable solutions that can handle the increasing daily case rates in a sustainable way.

Change in Mindset

It’s incredibly difficult. Firstly the healthcare side themselves do not have the confidence to 100% say that hey if you’re Covid PCR positive or ART positive (somewhat different states here), that you can do some/all the following:

  • Take MC for 2-3 days (typical flu MC duration), take normal GP medication, continue work/school after that
  • Monitor own condition (as a layperson) until severe enough to require to go to the GP, or to the Next Escalation Point (NEP), currently A&E.
  • Stay at home, with isolation, with other vaccinated household members (v v ideal and rare situation)
  • Stay at home, without isolation, with other vaccinated household members
  • Stay at home, without isolation, with other ‘vulnerable’ members like unvaccinated kids or vaccinated elderly (common)
  • Stay at home, without isolation, with other really vulnerable members like unvaccinated adults/elderly with comorbidities
  • Continue to work or go to school after the initial 2-3 day MC

There are some basic premises we need to establish

  1. Very serious Covid+ patients need to be able to be seen by a doctor at NEP. This can be A&E, or I propose setting up dedicated Covid sites if possible. It will help in triaging.
  2. People should be easily able to self-isolate, basic needs are actually an official MOH policy, an official MOH notification or verifiable certificate just like the MC system, and employer participation in this scheme (voluntary or enforced)
  3. Social support in terms of food supply, logistics, staying alive.

That’s all! It’s so simple. Everything else is ‘good to have’.

  • Requirement for people to self ART daily while on QO – good to have, but a big $ cost and logistics. Suggestion: Reduce interval
  • Requirement for entry/exit PCR tests – good to have, but a big $ cost and logistics. Suggestion: downgrade to ART, self submit.
  • Requirement for isolation room at home – good to have, rare. drop this if we don’t mind community transmission. It’s a huge effort and low use if everyone is eventually going to be infected. if it is “vulnerable” like kids and vaccinated elderly, does MOH have the guts to go ahead?

We know that

  • Sars-Cov-2 / Delta will still rip through a double-pfizer-vaccinated population. This is now a Known fact that we wished not to happen, but it does. Layman need to realize this and stop thinking vaccination can stop infection.
  • Sars-Cov-2 infection is layman-mild for most person. Meaning manageable flu symptoms that can self resolve, or with GP visit.
  • Sars-Cov-2 infection can lead to medical-mild for vaccinated persons. In a layman flu concept, it feels serious enough that we would definitely go to a doctor, or maybe a second visit, an extended MC. In a layman Covid-era concept, we would rush to the Next Escalation Point, and the only thing offered is A&E / hospitalization. I believe in the medical concept, this might still be considered mild.
  • In the medical ‘serious’ case concept, hospital admission is offered. We all agree this is serious.
  • Sars-Cov-2 in an unvaccinated person, will have a XX-times higher rate of serious illnesses. Everything tends higher. We really can’t do much for them right now.

MOH’s strategy now is still focused on one end point: juggle hospital capacity for serious cases. We all can say that it’s ‘endemic’ yada yada, but as long as the percentages above lead to a temporary unmanageable spike in hospital load, and I mean hospital load for truly serious cases, then it’s game over and back to a lockdown.

MOH wants to go to a hands-off self isolation no QO concept. But if we do that, how fast is the rise in serious cases, how high does this serious case spike go? We won’t know if the wave is going to stop doubling at 5 cycles, or further! It’s a prediction. Do we wait to 6X, 7X and see? If we don’t measure new/mild cases, we don’t have a predictive value of serious/ICU cases – we’ll be blind until people turn up at A&E.

We currently log 1500 Sars-Cov-2 positive people per day. Unmeasured let’s say 2x this number. And people who got challenged but not infected, … let’s say it all totals 10k exposures a day? 6 million popn, 10k..600 days to finish one round of exposures. If we abandon full QO, exposures a day should go up 10x, say 100k a day. Can we manage serious cases for this rate? This is the true end point question.

So what kind of theoretical public health measures will lead to a manageable serious case load?

And can MOH and society support and implement these public health measures properly?

In an analogy, MOH’s current rules and on the ground implementation is like saying you Must wear a mask outside of your home, but then 20% of people don’t have masks, 20% forget to bring it out, 20% only remember to put it on after 1 hour outside, 20% still fall sick, etc etc. Is it really then still effective?

#covidsg 23 Sept 2021

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