In 'post-Covid' Singapore, doctors warn against complacency as XBB cases surge

Singapore's approach to living with Covid-19 has helped it remove almost all pandemic-era curbs and open the door back up to tourism.

But as the city state embarks on an "open for business" path, doctors worry that a sense of complacency among residents, who are accustomed to the virus and eager to move past the health crisis, could put pressure on its nimble medical system.

The financial hub has seen a resurgence in Covid-19 cases fuelled by the highly transmissible XBB Omicron subvariant, prompting warnings against "abandoning all precautions".

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"Patients are generally more laid-back about the whole thing. They're more relaxed. They're not like previously when they were really worried," Dr Sunil Joseph said.

Joseph, a general practitioner, said his patients had also displayed other easy-going behaviour towards the disease, including not wearing a mask when they were home with family members and even declining a medical certificate and continuing to work.

Singapore, one of the few economies in Asia to have embraced a post-pandemic transition, recorded almost 60,000 infections in the week ending October 17, up from about 41,000 the week before.

Authorities expect daily cases to reach a peak of 15,000 by mid-November. While the government is optimistic that Singapore's hospitals can handle the present surge, healthcare experts suggest that complacency among residents could be costly.

This is especially so when most of the population - over 70 per cent - have caught the virus over the past two years, with some infected twice or more.

Even as members of the public have largely dropped their guard on Covid-19, Singapore has retooled its fight against the virus.

From pushing for greater vaccination to setting up a centralised health-record system and conducting studies on long Covid, how the island nation addresses public complacency and other challenges can offer clues as to how countries around the world might deal with future waves of infections.

Already, there is growing global concern that the coming winter and flu season could herald a significant spike in cases - especially in countries that have declared victory over Covid-19 - and paralyse healthcare systems that have long been under stress.

Health officials and ministers in Singapore have repeatedly spoken of the need to guard against complacency, often saying the city "was not out of the woods" despite its plan to live with the virus.

"We are practically living with Covid as an endemic disease. Endemicity does not mean we ignore the virus. We accept it exists, and take the necessary steps to live with it," Health Minister Ong Ye Kung wrote in a recent Facebook post, reiterating the government's message.

Ong added that Singapore might need to bring back some pandemic-related measures like reinstating the mask mandate "if the situation worsens". However, he stressed that such a disruptive move must be avoided if possible.

Doctors and healthcare experts who spoke to This Week in Asia suggested that the pace at which Singapore was opening up compared to its regional neighbours - welcoming throngs of tourists and hosting major and large-scale events - might have seeded some complacency among residents, although many were still cautious.

Teo Yik Ying, the dean of the National University of Singapore's (NUS) Saw Swee Hock School of Public Health, said: "Judging by the high percentage of people who continue to wear masks in public spaces and shopping malls, it is quite clear there is an inherent degree of caution against Covid-19 in most people."

Dale Fisher, a professor at the NUS Yong Loo Lin School of Medicine, agreed.

"I don't see complacency," Fisher said. "I see an appreciation of what has been achieved and a respect for what could happen and what could be asked of us going forward."

But Leong Hoe Nam, an infectious diseases expert at Singapore's Rophi Clinic, said those who were young and healthy were likely the ones who would take the virus more lightly as it did not really affect them. He said this behaviour could mean that they bring the virus home to those who are far more vulnerable.

"We are dealing with human nature. Unless the problem affects them directly and immediately, there will be a dearth of cooperation and a bounty of complacency," Leong said.

Teo noted that most residents were not allowing the circulating virus to interfere with their daily activities, social gatherings and holiday travels. There had also been visibly less resistance to unmask as compared to when the rule was lifted in late August.

While this was the "right attitude" towards Covid-19, he said Singaporeans should have a "sense of personal responsibility" and adopt habits like wearing a mask, observing hand and respiratory hygiene and avoiding crowded places when feeling unwell.

Teo said a greater collective commitment could help countries, including Singapore, weather repeated waves of infection.

Echoing his views, Joseph, the general practitioner, said individual responsibility was key in the response to the virus.

Citing the example of Japan, where mask-wearing is normalised, he said: "Even before Covid-19, the culture there is if you're sick, you wear a mask.

"You exercise extra precautions like staying away from crowds. It becomes very individual; you do your part and society does its part so it kind of works both ways."

Experts say a lack of personal responsibility coupled with complacency could spell trouble for Singapore's healthcare system, which is seeing an influx of Covid-19 patients and long waiting times for hospital admission.

Ong, the health minister, had earlier said that life was "not as normal" in hospitals. "Our healthcare system is bearing the brunt of the current wave. Healthcare workers have been very busy."

He added that polyclinics, where outpatients receive both general and specialist examinations and treatments, and general-practitioner clinics both saw higher patient volumes.

According to local media reports, the waiting time for admission to some hospitals has gone up to as much as 50 hours, around three times as long as in September last year, with public emergency departments seeing a rush of patients.

Clinics like Joseph's are also scrambling to cope with more patients. "I'm already reaching the limit," he said.

In March and February - when Singapore experienced an Omicron-driven surge in daily cases - Joseph said there were about 100 patients each day and he had to work until late. While the present wave had not led to that level of intensity at his clinics, there had been a stark increase in patients in recent weeks, he added.

Teo from NUS suggested that pressures on the healthcare system would always exist, and this was true for every country.

"Just like during the peak of seasonal influenza, waves of Covid-19 will repeatedly challenge the healthcare system due to the possible surge in the number of infected people who may deteriorate to the point that they require hospital care."

In the region, some countries are already facing strains on the public health system. China's National Health Commission has said 43.5 per cent of its specialist public hospitals were running in the red, almost double that of the 25.8 per cent in 2019.

Singapore's rival finance hub Hong Kong is preparing for a spike in patients over the winter by increasing hospital capacity and having more cases sent to private health centres, as well as reintroducing additional designated Covid-19 clinics and remote consultations.

In Malaysia, Health Minister Khairy Jamaluddin has floated plans to reform the country's primary healthcare system to help ease the load on public hospitals.

Several governments in the West have raised concerns over a looming winter wave as well. Covid-19 cases in Europe are on the rise and many tourists headed abroad for their year-end holidays are not well protected against the dominant Omicron variant.

Dr Paul Tambyah, president of the Asia-Pacific Society of Clinical Microbiology and Infection, said: "A bad influenza season with a significantly drifted influenza virus which is not covered by the current WHO influenza vaccine recommendations would aggravate the problem of overcrowding in our healthcare facilities and also those in the northern hemisphere."

NUS' Teo said Singapore, as a global aviation hub that has seen air traffic numbers recovering, would thus be at the mercy of others.

"I expect Singapore will see the local spread of new variants faster than many other countries in the world, just like how we have seen the recent rapid spread of the XBB variant," he said.

"What can thus set Singapore back is when we relax on our international surveillance and partnerships, to the point that we are unaware of the global Covid-19 situation or the emergence of new variants."

But he added that it was an unlikely scenario as Singapore authorities and academics still spend "considerable effort" engaging with international partners to stay ahead of global developments and would take measures to avoid the escalation of a situation that would affect the healthcare system.

Teo noted that pushing vaccination as part of a long-term plan to live with Covid would lessen the burden on healthcare facilities, adding that inoculations significantly reduced the risk of complications when one was infected and cut the need for hospital care.

Singapore will next week roll out vaccination for children aged six months to four years. Health Minister Ong said that those aged between 18 and 49 would be called to take their bivalent booster shot (targeting two variants of the virus) by the end of the year, as more supplies come in.

Currently, second booster doses are prioritised for residents aged above 49.

Teo cautioned against taking Covid-19 and other lifestyle diseases lightly.

"Complacency in health matters is always dangerous, and it's not just against Covid-19 but equally against conditions such as diabetes, hypertension or high cholesterol," Teo added. "When a person believes the risk of contracting a disease is low, this person may not think about the prevention measures that help to reduce risk."

A degree of laxity in attitudes towards Covid-19 could be expected "at some point in the future", he added, pointing to how people downplayed the risks of influenza, even when it could still be deadly to the elderly.

Another health challenge Singapore could potentially grapple with is long Covid, a global phenomenon in which individuals suffer from prolonged breathlessness, fatigue and so-called brain fog for a lengthy period.

A study on long Covid, which tracked patients identified in 2020 before Singapore's vaccination programme, found around 10 per cent of respondents had persistent symptoms for six months after the initial infection. Researchers, however, could not tell if the lasting symptoms were a result of the virus or other viral respiratory infections.

"It's worrying," said Leong, the infectious diseases expert, who has seen a growing number of patients with symptoms linked to long Covid. "So far, it's unpredictable, unpreventable and untreatable," he added.

Jeremy Lim, an associate professor at the NUS Saw Swee Hock School of Public Health, said long Covid was "certainly cause for concern" but little was currently known about it. The focus, he said, should be on research and the active tracking of recovered patients.

Given Singapore's coming digitalisation and centralisation of health records, through an integrated system that would allow medical organisations to view patients' test reports, the city state would be in a good position to detect anything amiss and intervene accordingly.

Teo again stressed the importance of updated vaccination, saying there was evidence suggesting that it could reduce the risk of long Covid.

Apart from the upgraded bivalent vaccine available in Singapore, Leong suggested a mix of measures that the government could adopt, including the use of antiviral drugs and treating Covid-19 patients outside hospitals so as to not overwhelm the healthcare system.

Lim said that beyond efforts by the state, Singaporeans must also continue to exercise due care when going about their daily lives to help keep the virus under control.

"Eternal vigilance is the price to pay for peace and Singapore cannot let our guard down," Lim said.

"Besides Covid, there will be other outbreaks [different pandemics]. At the same time, living in lockdown states and in fear perpetually is not an option, and we have to strike the right balance."

This article originally appeared on the South China Morning Post (SCMP).

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