Our country, Singapore, has managed to contain the spread of the SARS-CoV-2 virus within its borders, as have mainland China, Taiwan, Hong Kong, and South Korea. Commonalities of these successful responses include extensive preparation in the wake of the severe acute respiratory syndrome (SARS) outbreak in 2003, aggressive testing and transparent case reporting to both domestic and international stakeholders, swift and decisive interventions to promote or impose social distancing, and frequent and consistent public health communications.
Singapore was one of the earliest countries to detect Covid-19 and in early February was near the top of the confirmed cases list by territory. Yet there has been no exponential rise in cases to date. Some of the reasons for these are unique to the Singapore system, which invested heavily in outbreak preparation and building health care infrastructure capacity building after the SARS wake-up call. Others, however, offer more broadly generalizable lessons that we have learned at the disease level as well as at the community, health system, and national levels.
As doctors who served as frontline physicians at Singapores Communicable Disease Center during the SARS outbreak and are now involved in responding to the Covid-19 challenge in the country, in the spirit of international cooperation we are sharing our experiences and observations that may be of benefit to other countries, systems, and individuals during this global challenge.
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Beginning in 2003, Singapore built a task force across multiple government agencies to coordinate interventions and messaging during any future pandemics. This task force was tested in 2009 during the H1N1 pandemic and again in 2016 during the Zika outbreak. It was reassembled by January 2020 for SARS-CoV-2.
One clear example of essential inter-agency cooperation was between the contact tracing teams of the Ministry of Health and the Singapore Police Force for the purposes of rapidly determining links between individuals with confirmed Covid-19 and their contacts.
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Singapores biomedical research and laboratory community was similarly mobilized. Over the years, the Singapore government has consistently prioritized the development of innovative clinical diagnostics, with the creation of a national Diagnostics Development Hub in 2014. With this integration between researchers, technology transfer offices, and industry, a test kit was successfully created through this avenue for clinical service by Feb. 9.
Testing every citizen may not be feasible and can overwhelm labs. Finding a way for the health system to manage its volume to quickly identify and triage the highest risk patients is vital.
Singapore did this primarily through designated public health preparedness clinics. These private clinics there are approximately 1,000 of them across the country provided primary care physicians with additional training and preparation for outbreaks. Patients displaying respiratory symptoms receive government-subsidized treatment and medication at these clinics, including up to five days of medical leave for them to stay home and avoid transmission to others.
High-risk Singapore residents with suspected Covid-19 undergo diagnostic testing at no cost to them. All health care costs for Singapore residents with confirmed cases of Covid-19, including hospitalization, are borne by the government, which reduces barriers for individuals seeking help.
Quarantining close contacts of those diagnosed with Covid-19 and the use of stay home notices for workers returning from countries with community transmission of SARS-CoV-2 have limited or broken viral chains of transmission. These targeted actions have helped reduce the pressure on the health care system.
Stay home notices are unique to Singapore. They are similar to quarantine orders, in that they are legally enforceable, but are used as a precautionary measure for residents of Singapore who have returned from territories with active community spread of the virus, rather than those who are close contacts of an infected person. People who flout these notices may be prosecuted under the law, although the penalties are not as severe as for those flouting quarantine orders. To relieve the financial impact of quarantine, the government provides a daily SGD 100 ($75 US) allowance to self-employed individuals. For employees, quarantine is classified as paid hospitalization leave.
Public health communication has been rational, transparent, and frequent, with uncertainties and gaps in knowledge specifically acknowledged. Multiple communication approaches have been adopted in both traditional and social media channels.
There is ongoing engagement between the public and leaders of civic society. With a national level WhatsApp group for one-way messaging, the government delivers trusted information frequently and consistently to the citizens of Singapore. Other instant-messaging groups have been created allowing two-way discussion between frontline clinicians and Ministry of Health senior officials.
When public anxiety and panic buying peaked on Feb. 7 after the announcement of a heightened state of alert regarding SARS-CoV-2, the prime minister gave a televised address to the nation that was calm, analytical, and reassuring without pulling any punches. This quickly allayed public anxiety.
During an epidemic, we fight a war against disease, and health care workers are the soldiers. Everyone must rally around their efforts.
As physicians, the two of us directly witnessed the impact of SARS on the health care community in 2003. Health care workers were initially shunned by the public as possible carriers of SARS. But as health care workers became infected, and some died, public sentiment changed and generous donations post-SARS led to the creation of the Courage Fund, which was aimed at providing relief to SARS victims and health care workers.
In the Covid-19 pandemic, the public has rallied around health care workers from the beginning, with an outpouring of gratitude and encouragement via social media and physical gifts (including food and thank-you cards). The Courage Fund has also been substantially topped up by corporate and individual donations.
The most likely scenario is that SARS-CoV-2 will continue to spread around the world for the foreseeable future, perhaps eventually becoming endemic. Its threat will not be completely eliminated, even in the optimistic scenario where a safe and effective vaccine eventually becomes commercially available. Sustainability over the long term is crucial, as fatigue is inevitable.
Even in Singapore, the current efforts are an adaptive response that will need further calibration as the pandemic evolves.
Li Yang Hsu, M.B.B.S., is the program leader for infectious diseases at the Saw Swee Hock School of Public Health of the National University of Singapore. He is the former clinical director of the National Centre for Infectious Diseases and former director of the Singapore Infectious Diseases Initiative, and published the first SARS case series from Singapore in 2003. Min-Han Tan, M.B.B.S., is the founding CEO and medical director of Lucence, a molecular diagnostics company headquartered in Singapore and Palo Alto, Calif.
The effort to combat the spread of the coronavirus pandemic globally relies on testing as a core component of the current strategy, which primarily focuses on isolating individuals to slow the transmission of COVID-19 and give researchers time to develop potential treatments and vaccines. The availability and amount of testing can help chart how the virus is moving through a population, to inform and direct necessary quarantine and contact tracing measures, but one key data point might be the spread and availability of testing sites.
A new group of volunteer coders and medical professionals, including Air Force software organization Kessel Runs Chief Data Officer Andrew Kemendo, and data-driven doctor and researcher Jorge A. Caballero, have created a new findcovidtesting.com website, which aims to provide up-to date location info for all testing sites in the U.S.
Immediately, please note that a resource like this is not meant as a directory for private individuals who are looking to show up at a test site, expecting to receive diagnostics. Health officials and experts are attempting to roll out testing as far and wide theyre able, but for the safety of frontline workers, and in order to allocate limited supply of testing materials as effectively as possible, you should always only consult with a medical professional via telehealth, or use one of the various official online screening tools in order to get a test. Just showing up somewhere wont get you a test, and could put a lot of other people in danger.
That said, this database, which was built by a team of around 15 developers working remotely one the course of just one week, should be viewed as a potential resource to inform those working on the countrys emergency response and COVID-19 mitigation strategy, or efforts to ensure that testing is available across the country in a way that accurately addresses population needs, and that can provide a full picture of the extent of the actual virus spread.
It also could be very useful for individuals provided its used in tandem with screening and telehealth guidance to make sure that people are getting tested based on case prioritization, and according to all possible safety guidelines for the health of those doing the testing.
Kemendo also says that the plan is to potentially scale this to cover countries outside the U.S., provided the group can find a scalable way to populate the location data. Right now, the site info is being scraped and validated manually, while the team works on some kind of infrastructure that might help automate the process as more test sites come online.
The effort and its resulting data will not be monetized at all, Kemendo says, and while it has no single sponsor, the company is working with credits from both Google Cloud Platform and AWS for running the backend. The team is currently looking for suggestions on how best to scale, and reduce the manual workload involved with maintaining an up-to-date listing, and their GitHub project is available here.
As the number of Covid-19 cases rises worldwide, parents trying to protect their children from the disease can take solace in one thing: the disease has generally been milder in children.
However, there are many unknowns about coronavirus, and research is ongoing. Here is what we know now.
Yes. They can be infected with and appear to be able to transmit coronavirus, even if they do not have symptoms. That is why it is important for children to practice social distancing and hand-washing, even if they do not appear ill.
It is generally believed to cause milder symptoms in children, but the specific impacts by age are becoming clearer as the outbreak goes on.
Much of what we know today is based on reports out of China, where the outbreak began. There 2.4% of all identified cases were in children under 19 years old. An even smaller number within this group of children had severe symptoms, 2.5%, or what the World Health Organization (WHO) described as a very small proportion. But more research is being done and a clearer picture is still emerging.
That remains unknown. Dr Jay C Butler, deputy director of infectious disease at the US Centers for Disease Control and Prevention, said, The phenomenon is very significant, on a live-streamed show hosted by the Journal of the American Medical Association, but that the mechanisms are really unknown.
People aged 60 and older or with existing health conditions remain the most vulnerable to the coronavirus. That includes people with conditions such as high blood pressure, diabetes, cancer, cardiovascular disease and chronic respiratory conditions, according to the WHO.
Respiratory conditions such as asthma often result in more severe cases of viral diseases such as influenza. But the coronavirus is new, and it remains unknown whether it will more severely affect children with asthma.
Similarly, there is not yet evidence about whether coronavirus could more negatively affect children with diabetes, which is a risk factor for adults. That said, experts at Johns Hopkins University are warning parents to be vigilant.
In many countries that decision has been taken out of the hands of parents, with school and educational establishments being closed by governments and local authorities in order to try and halt the spread of the virus.
If your kids are at home, they will still need regular exercise and will need to be practising social distancing when they are outside.
After Mr. Moran reported his Sunday morning encounter with the senator, Mr. Pauls staff posted on Twitter that he had left the Senate IMMEDIATELY upon learning of his diagnosis.
He had zero contact with anyone & went into quarantine, they added, sidestepping why the senator had been in the gym in the first place.
Mr. Paul, an ophthalmologist by training, was a practicing doctor before joining the Senate. Like his father, Ron Paul, a former member of Congress, he considers himself a libertarian. Last week, he was one of only three senators to vote against a multibillion-dollar rescue bill to help fight the coronavirus because its costs had not been paid for and would contribute to the national debt.
Mr. Paul could be at elevated risk for adverse effects from the novel coronavirus, which can cause pneumonia, sometimes severe. In November 2017, Mr. Paul was violently attacked by his neighbor in Kentucky during a dispute and had to be hospitalized. As a result of the ensuing injuries, Mr. Paul had to undergo surgery in August to have part of his lung removed.
Two other members of Congress Representative Mario Diaz-Balart, Republican of Florida, and Representative Ben McAdams, Democrat of Utah have also tested positive for Covid-19. Mr. McAdams said in a statement on Sunday that he had been hospitalized and given oxygen over the weekend, but that his condition had stabilized.
When a half dozen other senators were exposed to individuals who had tested positive for the virus, they voluntarily self-isolated, as top health officials have advised. They also made sure to communicate with constituents that following the guidelines was an important matter of life and death, even for their elected leaders. Senator Cory Gardner, Republican of Colorado, has been absent from the Senate for much of the week for that reason.
Privately, some lawmakers were incensed that Mr. Paul had continued to circulate among colleagues when he knew he might have the virus.
The U.S. Food and Drug Administration (FDA) is moving much more quickly to grant special emergency use authorization to equipment and tests that could help increase testing for the novel coronavirus in the U.S., which lags behind most countries in the world when it comes to tests conducted relative to the size of its population. One type of test just approved for use could help expand the availability of frontline testing in hospitals and at clinics where patients are receiving care without requiring round-tripping to a dedicated diagnostics lab.
Cepheids COVID-19 test, which the agency approved this week, also has the advantage of being able to be run either with or without use of a nasal swab, which is key because supplies of nasal swabs are taxed globally in light of the need for testing. Its also a molecular, PCR-based test, with high rates of accuracy just like the lab-based testing thats already in place across facilities in the U.S., but it uses the companys GeneXpert machine (basically a diagnostics kit the size of an inkjet printer cartdrige lab in a box roughly the size of an inkjet printer) to produce results on-site.
Cepheid says that around 23,000 of its GeneXpert micro-labs are already in use around the world, with around 5,000 of those located in the U.S. The companys hardware has been running tests for the flu for years already, with high reliability rates. The new COVID-19 tests for the system will begin to be shipped out by the Sunnyvale-based molecular diagnostics company starting next week.
Testing in the U.S. has increased over the past week, thanks in large part to widespread efforts to expand availability especially in hard-hit regions like New York State. But the need for more tests is still pressing, as the limits of availability mean that essentially only the most severe cases, often requiring confirmed contact tracing or proof of elevated risk, are being tested.
Solutions like Cepheids, as well as other potential alternative test methods than can be done entirely at home, like Scanwells forthcoming test that looks for antibodies in a persons blood, are much-needed if we hope to truly expand testing to a degree that it can properly inform any coronavirus mitigation strategy.
The UK, US, EU and many other countries are currently in some degree of lockdown, with restaurants and bars, shops, schools and gyms closed, and citizens required, or at least strongly encouraged, to stay home to avoid catching or spreading COVID-19, the respiratory illness caused by the novel coronavirus.
Researchers are well on their way to discovering vaccines and treatments for the virus, but even in a best-case scenario, these are likely to be 12-18 months away.
Until then, extreme social distancing is pretty much the only intervention available to help individuals stay healthy, and to break the chain of transmission - giving more vulnerable populations a fighting chance of surviving this pandemic.
But how exactly does a lockdown work? And why is it important for even younger and healthier people, who face a lower risk of severe illness, to remain in their homes as much as possible?
The purpose of a lockdown, explains a new study from the Imperial College London COVID-19 Response Team, is to reduce reproduction in other words, to reduce the number of people each confirmed case infects.
The goal is to keep reproduction, or R, below one (R<1) with each case infecting fewer than one other person, on average.
The authors of the study say there are two routes to try to get there:
The studys models show that, painful as lockdown may be for many of us, it works.
Without any lockdown or social distancing measures, we can expect peak mortality in approximately three months. In this scenario, 81% of the UK and US populations would be infected, with 510,000 dying in the UK and 2.2 million dying in the US.
Projected COVID-19-related deaths in the UK and US without any interventions
Image: Imperial College London
In contrast, isolating confirmed and suspected cases and social distancing the elderly and vulnerable would reduce peak critical care demand by two-thirds and halve the number of deaths.
To get closer to the goal of R<1, they say, a combination of case isolation, social distancing of the entire population and either household quarantine or school and university closure are required."
The study finds this "intensive policy is predicted to result in a reduction in critical care requirements from a peak approximately three weeks after the interventions are introduced and a decline thereafter while the intervention policies remain in place."
The impact of various social distancing or lockdown measures on ICU bed requirements
Image: Imperial College London
While the word indefinitely isnt one we want to hear, its possible long-term suppression could be the best way to reduce infections and deaths at least until a vaccine is available.
A new strain of Coronavirus, COVID 19, is spreading around the world, causing deaths and major disruption to the global economy.
Responding to this crisis requires global cooperation among governments, international organizations and the business community, which is at the centre of the World Economic Forums mission as the International Organization for Public-Private Cooperation.
The Forum has created the COVID Action Platform, a global platform to convene the business community for collective action, protect peoples livelihoods and facilitate business continuity, and mobilize support for the COVID-19 response. The platform is created with the support of the World Health Organization and is open to all businesses and industry groups, as well as other stakeholders, aiming to integrate and inform joint action.
As an organization, the Forum has a track record of supporting efforts to contain epidemics. In 2017, at our Annual Meeting, the Coalition for Epidemic Preparedness Innovations (CEPI) was launched bringing together experts from government, business, health, academia and civil society to accelerate the development of vaccines. CEPI is currently supporting the race to develop a vaccine against this strand of the coronavirus.
So, have the lockdowns worked?
Starting 23 January 2020, the Chinese government locked down Hubei Province, including Wuhan, the city of 11 million where the outbreak started. They halted transportation in and out and barred tens of millions of people from working or going to school and closed all shops except those selling food or medicine. In some areas, residents were even forced to limit trips to the store, or order supplies for delivery.
This unprecedented lockdown of tens of millions of people was considered a vast experiment but it may have worked. Following the lockdown, cases began to slow. On 19 March, Chinas National Health Commission reported no new confirmed infections in Hubei.
Following the lockdown, new COVID-19 cases in China slowed.
Image: BBC
Italy and Spain have been under similarly intense nationwide lockdowns, from 9 March and 15 March, respectively, with citizens required to stay in their homes except for work, food shopping or medical appointments.
In parts of Italy where lockdowns started earlier, however, we're already seeing a "flattening of the curve". Lodi, for example, locked down on 23 February, but Bergamo did not lock down until 8 March. Now, cases seem to be leveling off in Lodi.
COVID-19 cases in Bergamo and Lodi, Italy
Image: Leverhulme Centre for Demographic Science, University of Oxford & Nuffield College, UK
This week, both Italy and Spain reported their largest daily increases in COVID-19-related deaths. But if the lockdown models, hypothetical and real, are correct, the peaks could be approaching.
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The views expressed in this article are those of the author alone and not the World Economic Forum.
Today, WHO is launching a messaging service with partners WhatsApp and Facebook to keep people safe from coronavirus.
This easy-to-use messaging service has the potential to reach 2 billion people and enables WHO to get information directly into the hands of the people that need it.
From government leaders to health workers and family and friends, this messaging service will provide the latest news and information on coronavirus including details on symptoms and how people can protect themselves and others. It also provides the latest situation reports and numbers in real time to help government decision-makers protect the health of their populations.
The service can be accessed through a link that opens a conversation on WhatsApp. Users can simply type hi to activate the conversation, prompting a menu of options that can help answer their questions about COVID-19.
The WHO Health Alert was developed in collaboration with Praekelt.Org, using Turn machine learning technology.
This live blog has ended. Follow the latest coronavirus updates here.
President Trump has approved major disaster declarations in New York and Washington state, two of the areas hardest hit by the coronavirus pandemic, Mr. Trump announced Sunday. California's request is still being processed.
The president also said the Federal Emergency Management Agency (FEMA) is working to assist states hardest hit by the coronavirus pandemic. That includes activating theNational Guardin those three states.
As the White House Coronavirus Task Force gave its update Sunday night, the Senate failed to pass a procedural vote to move forward with an economic stimulus bill that could cost between $1.5 and $2 trillion. The absence of several senators who are self-quarantining due to the coronavirus sidelined several Republicans who were unable to vote.
Senator Rand Paul said Sunday he has tested positive for COVID-19, making him the first known senator to contract the disease. Senators Mike Lee and Mitt Romney went into self-quarantine after close contact with Paul.
The number of coronavirus patients the U.S. has topped 31,000, putting the number of cases behind only China and Italy. The number of deaths topped 400.
Italy marked grim milestones over the weekend with the deadliest days in the country so far. On Friday, 627 people died from coronavirus, a record that was broken Saturday, when an additional 793 deaths were recorded.
Worldwide, the number of coronavirus cases has increased to more than 329,000 and the number of deaths has topped 14,000, according to Johns Hopkins University.
Visit the Centers for Disease Control and Prevention website for detailed information on coronavirus treatment and prevention.The Associated Press contributed to this report.
ISDH says 58 new cases of COVID-19 confirmed in Indiana; 7 people have died WSBT-TV
During a response to a virus of this nature, it is imperative that the public is confident the government has based its decisions on a representative range of the most up-to-date science advice. In the case of COVID-19, the Scientific Advisory Group for Emergencies (SAGE) has been providing ministers and officials with free and frank advice throughout, based on external scientific evidence and a wide source of essential information.
In fast moving situations, transparency should be at the heart of what the government does.
We have therefore published the statements and the accompanying evidence to demonstrate how our understanding of COVID-19 has continued to evolve as new data emerges, and how SAGEs advice has quickly adapted to new findings that reflect a changing situation.
Government Chief Scientific Adviser Sir Patrick Vallance:
This is an incredibly fast-moving, developing situation and as part of our collective efforts to give the clearest and most reliable scientific advice, SAGE has and continues to draw upon a huge range of experts and a huge range of evidence.
The UK is home to experts who are at the forefront of their chosen fields and we are making full use of their expertise to grow our understanding of COVID-19 as we work tirelessly to tackle this disease.
The collective evidence we have published today has played a considerable role in shaping our recommendations on when, how and why the government have made the interventions it has so far.
The Scientific Advisory Group for Emergencies (SAGE) provides ministers and officials with evidence-based scientific advice in emergencies, ensuring government advisers are informed and best-placed to make critical decisions based on a range of credible scientific evidence.
The advice provided by SAGE is one of many essential sources of information that government weighs up before adopting new policies and interventions, and gives maximum assurance that the complexities and implications of any policy have been properly considered.
SAGE relies on external science advice, including advice from expert groups and their papers. In the case of COVID-19, this includes the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG), Scientific Pandemic Influenza Group on Modelling (SPI-M) in the Department for Health and Social Care, and the Independent Scientific Pandemic Influenza Group on Behaviours (SPI-B).
These groups consider the scientific evidence, and provide their consensus conclusions to SAGE. Both the evidence they have considered and their consensus statements have been included in this current batch of evidence.
Contained within this release are the methods and findings that have informed SAGE advice on the COVID-19 outbreak to date.
Among the papers referenced here, some are pre-prints. These are academic papers that have not yet been through the peer-review process, which can take months, and have been drawn upon by SAGE to ensure that the most current evidence is being reviewed in order to provide rapid advice to policy makers.
Some of the bespoke new modelling that SAGE has drawn upon to formulate its conclusions has not yet been published here. This is to allow scientists time to publish their research through the right academic channels.
As our understanding of the virus grows, we will continue to feed into the essential scientific advice needed by the government to respond to the virus. During this time, we will update these pages with the evidence we are collecting to keep the public informed, while also continuing to provide free and frank advice to policy makers.
