How did Singapore SUCCEED in the coronavirus outbreak?

Singapore was one of the first countries affected by the novel coronavirus (SARS-CoV-2) outbreak. Nevertheless, Singapore became one of the rare countries observed to have brought the novel coronavirus disease (COVID-19) under control in a very short time. Officials in Singapore worked like health detectives; they tracked potentially infected cases while trying to stay one step ahead of the virus. So how did Singapore achieve this, and is it too late for the rest of the world?

Coronavirus detectives

"In mid-January, a group of 20 tourists arrived in Singapore from Guangxi, China, for the Chinese New Year. This group visited some of Singapore's most popular tourist attractions. During their trip, they also stopped at a traditional Chinese medicine shop that was very popular among Chinese tourists. The Chinese tourists bought many products, from crocodile oil to herbal products, and even had their arms massaged with medicinal oils. The Chinese group finished their sightseeing and returned home. But they had left something behind..."

The government's first announcement was not delayed

On 4 February, the Singapore government announced that the virus had spread to the local population. This shop visited by the Chinese group had become the location associated with 18 coronavirus cases in Singapore. The shop, along with the local tour guide and the enthusiastic salesperson who provided massages, became the first place where the virus spread.

The virus spread to 9 people, including the salesperson's spouse, their 6-month-old baby and their Indonesian helper. Later, the virus also appeared in two other staff members.

Those infected have now recovered. However, if Singapore had not followed the chain of the virus passing from one person to another through a multifaceted and comprehensive contact programme, the situation could have been much worse. Officials isolated the virus before it spread further through a system that tracked infected people and everyone they had contacted.

Singapore government adviser and Mount Elizabeth Novena Hospital infectious diseases specialist Dr. Leong Hoe Nam said: "We could have been like Wuhan; our hospitals could have been overwhelmed. "

As of 22 March, Singapore had reported only 455 cases and 2 deaths. Approximately 40% of these were people whom the health minister said needed to be tested and isolated.

Often starting with a simple telephone call, police investigations using a combination of CCTV footage and old-fashioned but labour-intensive detective work tracked people in 6000 homes.

A telephone call from a stranger

One of these telephone calls took place during a barbecue on a sunny Sunday afternoon held by Melissa, a British-born Singaporean yoga teacher (this is not her real name). The person on the telephone was talking about the possibility that Melissa had been exposed to the virus.

Describing the call she received from an unknown number, the yoga teacher said: "I said this cannot be real. Were you in a taxi at 18.47 on Wednesday? they asked. It was very specific. I think I panicked a little and could not think clearly. " Later, however, she finally remembered being in the taxi. Until the call, Melissa did not know whether the taxi driver and the other passengers were infected.

All she knew was the telephone conversation and an official working at Singapore's health ministry who told her she had to stay at home under quarantine. The next day, when three people wearing quarantine clothing and surgical masks came to her door, Melissa began to understand how serious the authorities were.

"It was like a scene from a film. They gave me a contract containing the quarantine orders; it was a legal document, and it said that I would be fined and imprisoned if I went outside. To make it clear, they told me once again that I must not leave the house. I could have disobeyed, but I know I live in a place where what is said is done", she said. After 2 weeks, Melissa had shown no COVID-19 symptoms and was able to leave her home.

In Singapore, most people know someone who has been part of this situation and has undergone contact tracing. Singapore is one of the most densely populated countries in the East, with 8000 people per km². Therefore, a community whose infection had not been identified could easily have spread the disease very rapidly in this country.

The potential strain on the economy and the health service could have grown. Singapore had little choice, but they had tried to find and isolate everyone at risk.

Detectives solving the puzzle

They provide vital information to the Ministry of Health staff who continue the process; "Nothing can be put together without the first piece. It is like a jigsaw puzzle; you have to put all the pieces together", they said.

Because of Singapore's low crime rate, it was relatively easy for the police to trace contacts. The officers also occasionally received help from criminal investigation departments such as police intelligence and the narcotics bureau. For example, when identification became difficult because a customer who had not booked a taxi through an app paid in cash, it was possible to find them using CCTV footage providing visual and investigative information.

Efficiency was crucial, and this could be seen clearly in Julie's case. Julie went to hospital in early February with dizziness and a fever. In less than an hour, doctors told her she had contracted the virus, and the system went into action. Julie said: "I was in hospital when I received the call. They wanted to know who I had been with over the last 7 days, what I had done, and their names and numbers. "

The officials who questioned Julie thoroughly were investigating close contacts, generally people with whom infected individuals had spent more than 30 min within two metres After approximately 3 hours of questioning the Ministry of Health contacted the 50 people Julie had identified and gave all of them 14-day quarantine orders. At the end of this period, the virus was not detected in them either.

The gold standard

Contact tracing was not actually a new method and had been used for years to track people who passed diseases to others. Singapore successfully used this system during the crisis that began in February. This approach was praised by Harvard epidemiologists and described as "the gold standard of detection“. Unlike America and most European countries, Singapore had started monitoring through contact tracing early, before the virus spread among the public. The World Health Organization (WHO) also praised their being so active even before Singapore's first case was detected.

Associate Professor Dr Siousxie Wiles of Aucklan University in New Zealand said: "If we had left this until later, it would have been much harder to do afterwards, because there are so many cases. ". As the World Health Organization also pointed out, not many countries have Singapore's level of vigilance, which allows cases to be detected and managed quickly.

Government determination

Singapore's infectious diseases law treats anyone who refuses to cooperate with the police during information gathering as breaking the law. This offence carries a $10,000 fine, 6 months in prison, or both. For example, two Chinese people were penalised for giving the police false information about their whereabouts during contact tracing.

Chong Ja Ian, a lecturer at the National University of Singapore, says: "Using the police for contact tracing was quite natural for Singapore. Singaporeans grow up and live in a highly monitored society, so this was normal for them. The kinds of access the state has are not questioned very much; they are accepted. People are taught to live with this"

Similarly, Taiwan, Hong Kong and South Korea successfully kept their numbers under control by using different strategies involving big data, widespread testing and social distancing.

Unlike other Asian countries with large populations, the situation is not particularly good in countries such as Indonesia, where healthcare and detection systems are weak. Trying to find people infected with the virus in such countries is like looking for a needle in a haystack. It is almost impossible to know who the next case will be and where they will go.

James Crabtree, a professor at the National University of Singapore, says: "Strong societies that can manage long-term planning and have high levels of trust in experts and governments achieve better results against the virus outbreak. This is why Singapore, South Korea and Taiwan have been more successful than Italy and America during this outbreak"

When should it be abandoned?

On 15 February, the final Chinese New Year Dinner was held at a club, attended by hundreds of people. This party caused 47 people to become infected. Then, on 5 March, Singapore announced what could have been its latest and largest number of new cases so far.

As transmission to other people in the community continued rapidly, contact tracing appeared to have lost its purpose. The rapidly increasing number of contacts was wasting labour and time. They therefore increased much stricter measures, such as mandatory school closures and restrictions on passengers entering the country.

Dr Said says: "The government's contact tracing is still valuable. The data collected through contact tracing help decision-makers decide which strategy to apply at different stages of the outbreak"

For almost two months, there have been only 2 deaths from the outbreak in Singapore. Singaporeans trust the healthcare system as well as the contact tracing system. Although the practice is difficult and demanding, doctors have treated people who actually need treatment in hospitals, unlike the health centres in Wuhan.

On the other hand, contact tracing is expensive and labour-intensive work. If case numbers continue to rise, Singapore will also have to abandon contact tracing, because the spread of the virus will then outpace the contact tracers. Until then, however, contact tracers racing an invisible criminal will remain at work and find a few more cases before the virus spreads towards the public. 

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