Can Singapore's response to the novel coronavirus guide the U.S.'s own actions?

Former FDA Commissioner Scott Gottlieb, MD, congratulated Singapore last month on its "exquisite reporting" of COVID-19 cases. And a preprint of a Harvard study, published in medRxiv, characterized Singapore's "strong epidemiological surveillance and contact tracing" as the "gold standard."

Michael Osterholm, PhD, MPH, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, called Singapore's response "the model to emulate" in the New York Times last week.

Even CDC Director Robert Redfield applauded the city-nation for its "aggressive containment strategy" and "aggressive case findings."

Asked what Singapore had gotten right, Redfield said, "it's early diagnosis, isolation, contact tracing, and some very targeted mitigation steps" that included closing schools in areas with high case load.

Not every country has to succumb to the "accelerated expansion" of the virus as Korea, Italy, and Iran have, he told MedPage Today last Thursday.

Redfield said the experience in those countries shows it is indeed possible to lose control of the situation. But Hong Kong and Singapore serve as counterexamples, "where they've had a lot of imported cases" but with "an effective public health response" to contain them.

Asked whether the U.S. could replicate their approach, Redfield said, "that's our plan," but it all depends on early case recognition.

Osterholm also stressed the importance of "extensive contact follow-up."

With each new case in Singapore, public health officials look for the contacts of that individual to see if they're infected and "then you keep going to the next level, the contacts of the contacts, if they're infected."

But it's a labor-intensive process, he said. Given that the U.S. whose population dwarfs Singapore's, he said it is "not practical" to think those contact tracing capabilities could be replicated here.

Talking to the Public

One area where the U.S. can follow Singapore's lead is through communication and public education, Osterholm said.

Singapore government officials have been "straightforward" about what could happen if the virus begins to spread in the community.

"They've had lots of transparency, they've been very proactive and they've not tried to minimize it," Osterholm said.

People need to hear "in stark terms" what could happen next, he said.

While there are those who believe troubling information "makes people freak out or panic," Osterholm said, "there's really no evidence to that at all."

People just want to know fair and accurate information, and then "they don't freak out," he said.

"What we need to do is to basically be able to share the news of what we know and don't know, but then tell people what are we going to do about it, how are we going to respond," Osterholm said. "And that's what they're doing in Singapore."

The other thing that separates the U.S. and Singapore is the ability to have a unified response.

In the U.S., policy and science officials' message has been "pretty much all over the board," said Osterholm.

On Feb. 25, Nancy Messonnier, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, told reporters community spread was expected: "It's not a question of 'if' anymore." That same day, Larry Kudlow, the president's chief economic adviser, told reporters that "we have contained this."

And President Trump said incorrectly that the number of cases was declining, and on multiple occasions that COVID-19 would "go away in April."

"We've got different messages coming out of federal government. We need a message," Osterholm said.

"That's where Singapore's been different ... They actually have been trying to provide a consistent message ... there's no division between the prime minister and the minister of health, the local authorities, it's all basically been one message," he said.

Singapore's Response

Singapore, the tropical city-nation at the tip of the Malaysian peninsula has a population of about 5.7 million.

As of March 4, the city-nation had 112 cases of coronavirus.

In early January, only a few days after the WHO announced a cluster of pneumonia cases in Wuhan, China, Singapore began temperature screenings at airports, and by mid-January it launched a multi-ministry task force to address the virus.

"While we hope for the best, we must plan for the worst," Gan Kim Yong, Singapore's health minister, told other government officials in a Feb. 3 speech.

He explained that masks were to be used by those who are sick to prevent others from catching the virus. Those who are healthy should focus on washing their hands and avoid touching their faces.

Yong drew on Singaporeans' sense of moral and civic duty: "All of us must play our part and exercise social responsibility, to prevent or to curb the potential spread of the virus in the community."

"Here I want to reiterate the government's firm commitment that we will spare no efforts in protecting our people. We will act swiftly and share information on the novel coronavirus openly and as soon as possible," he said.

In a video press release on Feb. 8, Prime Minister Lee Hsien Loong also addressed his citizens. He reassured viewers that Singapore had learned a lot from SARS. "We know that we can get through this too," he said. He explained the differences between SARS and coronavirus -- coronavirus is "harder to stop" but much "less deadly." He said the new coronavirus's mortality rate was 0.2% outside of the Wuhan area (it later became much higher), compared to the 0.01% from seasonal flu and the 10% fatality rate with SARS.

Loong described some of the measures already being taken to prevent the viruses spread, in addition to isolating confirmed cases and quarantining their contacts, the government called for "reducing mingling in schools," tightening access to hospitals, and taking extra precautions during large public events.

He acknowledged that if the number of cases continue to grow and the virus becomes more widespread, "we will have to reconsider our strategy."

It may be that the government would direct those with only mild cases to visit their general practitioner so that hospitals remain available for the more severely ill patients.

"I'm sharing these possibilities with you so that we are all mentally prepared for what may come," he said.

In closing, he told Singaporeans to take "sensible precautions" and urged them to "stay calm and carry on with our lives."

Public Alerts

Singaporeans can subscribe to WhatsApp updates from the Ministry of Health or find them on the ministry's website. These updates summarize the current situation in the country.

For example, the update on March 3 stated:

As of 12pm:

New cases: 2

Total COVID-19 cases in Singapore: 110

Discharged today: 0

Total discharged: 78

Total remaining in Hospital: 32

1 new case is linked to a known cluster, contact tracing is underway for the other case.

Most in hospital are stable or improving. 7 are in the ICU.

These updates usually clarify whether any new case is of unknown origin or if it's linked to a previous cluster.

The government also issues updates by WhatsApp and a press release on "entry approvals" for individuals wishing to return to Singapore from affected countries, travel advisories, and guidelines on swab tests at checkpoints. These come with warnings about prosecution for those who don't comply with testing, as well as on contact tracing scams.

Yong, the health minister, told Singapore's parliament on March 5 that the country still faces a major threat from COVID-19 and the situation may get worse, according to The Straits Times.

He noted the spread outside China. "This is worrying, as they pose a high risk of importation of cases into Singapore," he said. "Even among our closest neighbours, the situation is also evolving. Therefore, it is likely that this disease will stay with us for a long time."

Yong also said border controls will probably lose their effectiveness soon: "We cannot ban visitors from every country and shut ourselves out from the world."

Enforcing Quarantine, Finding a Single Voice

The U.S. has already borrowed from Singapore's playbook in certain respects, ramping up testing, implementing "social distancing" in some locales, and at-home quarantines. But Singapore is often described as a police state, albeit a relatively gentle one, and some of its threats would be less credible in the U.S.: jail for those who violate their 14-day quarantine rules, fines for providing false information to government agents.

Lawrence Gostin, JD, who holds appointments at Georgetown University School of Medicine and Johns Hopkins University, said it was "unlikely" that U.S. health officials would be so "prescriptive and punitive" as to impose penalties for non-compliance with quarantine and isolation protocols.

While containment strategies such as school closures will probably increase, "the U.S. will try to do most of its social distancing through voluntary measures" and "only rarely use coercive measures like mandatory quarantines," he predicted in an email to MedPage Today.

On the communications front, it appears the Trump administration, or at least HHS, is listening to the advice of experts like Osterholm and attempting to speak with one voice.

At a hearing on coronavirus in the Senate, Health, Education, Labor and Pensions Committee on Tuesday, witnesses from different arms of HHS -- the FDA, CDC, the National Institutes of Health, and the Office of the Assistant Secretary for Preparedness and Response -- submitted a single document as written testimony for all four witnesses.

And in a speech on Wednesday, Vice President Pence described the "whole-of-government" approach "deployed" by President Trump in response to coronavirus, perhaps channeling Yong's speech which described Singapore's own "whole-of-government" strategy.

Whether this more unified front or appearance of one can hold, only time and Twitter will tell.