#covidsg 24 Sept 2021

It arrived. The latest tranche of changes / restrictions for Covid-19. It wasn’t a surprise that changes were incoming, there were so many clues and indications that things weren’t going well. It was a simple prediction that the next possible scheduled press conference (fridays) was the day to go for, that the news was delayed due to the ongoing press conference, that so many things needed to be changed due to how massively the Covid situation has evolved in the past 1-2 weeks.

So let’s see the latest changes

Social:

  • Social gatherings reduced from 5 pax to 2 pax sizes for 1 month
  • Dining-in at F&B similarly reduced from 5 pax to 2 pax. No change to 2pax at Hawker centres and coffee shops.
  • Indoor Mask-off gym and exercise, 2 pax groups
  • Marriage solemnisations 1000 vaccinated, 50 unvax. Wedding receptions 250pax, 5 per group. Unvax and elderly discouraged
  • Workplace: WFH as default for 1 month, ART if required to be in office
  • Workship: 1000pax, 50 unvax. Elderly discouraged
  • Funerals: 30pax, 2 per group

Healthcare:

  • Home Recovery Program (HRP) is now default for Covid-19, unless you have certain high risk factors.
  • If unsuitable home environment, push to Community Care Facilities CCF (basically isolation facility)
  • If need monitoring, push to Community Treatment Facilities CTF (CCF with medical)
  • If need active treatment of serious breathing or other conditions, push to main Hospitals
  • CCF capacity expanded from 3500 to 4600
  • CTF capacity to expand to 1200
  • Hospital beds to expand to about 1600?
  • Expand capacity of HRP support/management, with more telemedicine resources, hotline resources, buddy resources, support in Telegram group, print article ads, People’s Association
  • Covid-19 testing on weekends expanded to Regional Screening Centres
  • ART rate increased

Education:

  • Primary school HBL extended slightly
  • Tuition mandatory virtual/remote

Vaccination:

  • Boosters expanded to 50yo and up.

Financial:

  • Businesses affected will get additional rental support, wage subsidies

Please refer to StraitsTimes or MOH for the latest correct versions, there are just too many announcements, including add-on announcements by MOM, ECDA etc etc on their respective industry specific adjustments, many of which are more minor, but nevertheless impactful.

Is this the right path?

Since we are at a very ‘open’ state of conditions, there are so many opinions from different parties on how we should proceed, how good/bad a situation we are in. It’s not easy to come to any consensus, or balance.

  • Infectious Disease experts who believe that high vaccination is sufficient to provide “mild” status to high majority of infected vaccinated individuals
  • Infectious Disease experts who believe that the current numbers of severe/ICU is still risky
  • Layperson who believes high vaccination is the endpoint and we have reached it
  • Layperson who believes Covid is still dangerous and refuses to get infected
  • Layperson who has kids and is extremely worried about their kid getting it
  • Layperson who has kids and is more concerned about kids not getting social interaction
  • Layperson who has elderly parents and is concerned
  • Vaccinated adults who believe Covid is dangerous for themselves
  • Infectious Disease experts who believe Quarantine system is overly strict
  • People under Quarantine who feel that MOH is doing a bad job by poor management of HRP
  • People with Covid who rush to hospital A&E
  • People with kids or elderly with Covid, who rush to A&E
  • People with Covid who are panicking at home

Wow it’s a major mess with a thousand cooks making this soup.

Some premises though:

the most sobering factlet i can offer you in terms of how singapore is handling covid, is that literally nobody in healthcare expected the numbers to go up so quickly. yes. even the most pessimistic and most cynical expected the numbers to go up fairly fast. but this fast? nope

https://twitter.com/saanenziege/status/1441406103586160645

OYK also said that the rise was faster than expected, with insufficient time to ramp up resources.

It would appear to be true, that Singapore’s daily case count curve, is very rapid, higher than a normal modelled 80%(or higher) vaccination rate. But models and stats and predictions are only as good as the source data, and we know that many countries do not have a comprehensive finger on their pulse, they might not know the exact real world statistics, they don’t have insane testing and ring fencing like we do, they might only have had resources to focus on the more serious or symptomatic cases. So it is possible that our extensive testing is throwing up so many more case counts, that we’re off their charts.

Going into 23 Sept, we knew that there was strong public interest in the daily case counts crossing 1000, there was a huge pressure on the hospitalization and A&E tranche, there was a pretty much overwhelmed HRV / QO system. Something needed to be done, something more extensive than some slight adjustments, 250 enhanced CCF beds, primary school HBL. On 22 Sept LHL himself posted about the MOH QO team being beefed up. So obviously 23 Sept is going to be a change and anyone with a brain will be waiting to hear it, don’t make big plans before the weekly friday time.

Question is, did MTF deliver correctly? And what do their plans indicate.

  • No change to the requirements that Covid positive individuals (PCR positive), need to be Isolated for 10 days. This might sound duh but it’s a huge tenet in the basis of endemic Covid management.
  • ART positive test is not sufficient for official diagnosis, PCR test is still required for confirmation.
  • No change to the requirements that close contacts of C+ individuals need to be under Quarantine.
  • No change to HRW
  • No change to upgrade of higher risk C+ individuals to CTF and CCF
  • Hospitalization criteria is much stricter due to handing over of monitoring to CTF. Essentially CTF is covid-hospitalization-lite?
  • Stricter entry barriers to hotel-or GQF based Quarantine

CCF should have been increased way way earlier, or be able to ramp up even faster. Note LW keeps harping on exponential numbers. Can you double CCFs overnight? or in 1 week for example. Covid can.

CTF should have been active earlier, instead of sending to hospitals. Full ward isn’t optimal? Expo needs to be re-activated. Dumb usage of the facility for entertainment purposes should never have been allowed.

GQF is a toss-up right now, at 80% vax it seems like we should drop this, but there are other competing factors.

The continuation of IO, QO, all means that MTF is still ringfencing and controlling Delta spread. They want to keep Rt number at 1+, not at 5 or 6 in a full blown no quarantine no testing situation. If we go up to full Delta Rt … , wow it’s gonna be over in 2021. If we drop QO, we don’t need GQF. If we drop IO for C+, we don’t need HRP, don’t need admin manpower, don’t need to distribute care packs, don’t need QO society support, we will go straight to managing full CTF-hospitalization-ICU.

Is the general population ready for this? Has anyone tried to convince them that 1. Covid is usually very mild if you’re vaccinated or young, 2. you can just walk around the house and to work if C+, 3. you can self medicate, or go to GP if needed?

Is it right to say we just want you to isolate at home so we reduce the overall speed of spreading, but then once you isolate at home we think that it’s mild and we’re not going to support you? That would feel at odds. So we can’t put that together. We can’t isolate without providing support, test kits, payment, tests.

Can and should we say that if you isolate at home, it’s ok to have your kids and elderly stay together? If we don’t let you roam around in society, why should you risk your kids and elderly? Again it seems at odds. Can we have partial rules or must it be all-or-nothing?

Because of this all-or-nothing, we need to prepare the hospitalization system to also cope with all-or-nothing. Currently it’s not nothing, as they’re already pretty dang busy with real work, but they don’t seem to have bandwidth for ‘all’.

‘All’ in this sense means retain masks, retain dining-in limits, retain event limits, retain travel limits, but without any mass routine ART testing, without mass Quarantine Orders, without sudden workplace WFH requirements. These will have a big impact on the healthcare system capacity, it will reduce the load on the administrative side, and workplace side. However it will increase the load on the treatment side, which is the poorer decision. Because treatment side – doctors, nurses, hcw, support staff, beds, resources – these are very hard to ramp up magically.

So, to protect this resource, they can only do it by reducing the Rt rate and hope the conversion to serious illness stays low. Serious only meaning requiring hospitalization. This is where the new social restrictions come in. They will allow us to see what our special brand of Singapore 80% vaccination conversion rate is going to be, find the comfortable steady state of daily new cases that convert to the serious case rate, and maintain that until the wave dies out or everyone is infected.

I feel that the high vaccination % still doesn’t equate to a safe enough level for full opening. We don’t know the % of people who need medical care. By medical care meaning anything above a 3 day MC and simple flu medication of zyrtec / piriton / paracetamol / cough medication / phlegm thinner. Heck if a high % require basic flu care, it is already overwhelming. But if a large enough % require 14day rest, higher level medication, second follow up, or more, that is bad. And this large enough % is not counted as a % of the population, what we are concerned with, is the % increase workload arriving at clinics and hospitals, and whether they can cope.

If a hospital receives 1000 new patients a day, and in the pandemic now receives 2000 a day. That’s an increase of 100%. This 1000 number, might only be 1000/6million, which is a tiny %, but it’s still bad news.

Every other restriction stems from these numbers. Nothing else matters. The current vaccination rate is not important, the type of vaccine you took is not important, the number of jabs is not important, what is important is at the end of the day, what are the actual numbers of people falling significantly ill and whether the healthcare system is coping.

So I can understand why MOH is still doubling down on the quarantine / test-trace-isolate model, which is undoubtedly painful on a good day and catastrophic when they are overwhelmed. They just really ought to have way more slack and ramp up faster on their procedures, with much more automation.

They should also seriously push out more education info on self-management of covid, manage people’s expectations, change the risk profile ever so slightly, do things that scale.

In hindsight, giving out oximeters to each household doesn’t seem like a dumb thing to still be doing in Q3 2021 now.

Surprised that Temasek hasn’t publicly stepped in to do anything in this wave. They seem to just be happy-happy do things whenever it suits their convenience – at least publicly. I hope the GLCs are doing something on the backend.

#covidsg 24 Sept 2021

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