How Singapore Managed COVID-19 Outbreaks Among Foreign Workers

A report from Singapore-based investigators highlighted the benefits and compromises of a massive isolation institution used at the height of coronavirus 2019 (COVID-19) outbreak this year.

The series of telemedicine-centric isolation units, called Community Care Facilities (CCF), allowed for an especially lower ratio of healthcare workers to low COVID-19 mortality-risk patients, thousands of in-house consultations, 100-plus successful hospital transfers, just 1 post-discharge death, and not a single SARS-CoV-2 infection among its healthcare workers at the peak of spread.

The CCFs were established in the densely-populated island nation were established to response to massive COVID-19 outbreaks among the mostly foreign construction industry workforces—by early August, more than 94% of Singapore’s 53,000-plus cases were observed in foreign workers living in dormitories at the time.

These institutions were designed to provide stepdown care post COVID-19 diagnosis, allowing both low-risk foreign employees and previously hospitalized patients who are on the mend to seek full recovery. CCF-admitted patients are permitted to stay for 2 weeks before being transferred to another stepdown facility for the remainder of their mandated 21-day isolation following COVID-19 diagnosis.

“It has been demonstrated that SARS-CoV-2 is probably not viable after the second week of illness, despite the persistence of RNA detected on polymerase chain reaction assay,” clinicians wrote. “Therefore, it was deemed unlikely that persons would be contagious after day 14 of illness, and day 21 was chosen to err on the side of caution.”

CCF designers used the 10-hall, 100,000 square-meter Singapore Expo space establish 8000 beds, medical consultation rooms, pharmacies, 150 self-monitoring stations, shower and toilet facilities, WiFi access, self-monitoring stations, and laundry facilities.

The self-monitoring stations were stocked with digital sphygmomanometers, pulse oximeters, thermometers, and computer tablets. Admitted patients were instructed to record and log their own vital signs before disinfecting the station several times daily—without any professional supervision. They received telephone notifications routinely to assure monitoring adherence.

Pharmacies were stocked with antihistamines, antitussives, antibiotics, analgesics, antihypertensives, and diabetic therapy, all prescribed and dispensed directly by physicians, who were also responsible for monitoring the repository with an electronic health record.

The facility was staffed by a group of administrators and pharmacists, as well as 26 physicians and 72 members of health staff varying from nursing and physiotherapy expertise, who were tasked with screening and monitoring patients.

Each of the 10 halls were staffed by 3-4 physicians and 8-14 extra staff at any given time during the day, and 1 and 2, respectively, during the night. All staff were provided N95 face masks and appropriate personal protective equipment.

Admitted CCF patients were gauged on their Ministry of Health’s National Early Warning System (NEWS) score, a composite metric based on respiratory rate, oxygen saturation, supplemental oxygen requirement, temperature, blood pressure, heart rate, and level of consciousness at the time of COVID-19 diagnosis. Patients were generally young, with no severe symptoms, no serious comorbid conditions, appropriate vital signs, and NEWS ≤4.

Patients were encouraged to use physician-managed consultation rooms akin to a primary care provider visit during the day—with teleconsultation capabilities available in the evening.

“Although some of the physicians staffing the facility were specialists, the degree of care was kept at the primary care level,” clinicians wrote. “Patients who needed further investigations or were acutely ill were transferred to a general hospital via an ambulance dedicated to patients with COVID-19.”

Clinicians also wrote on the great emphasis put upon assuring psychological wellbeing for patients: they were educated on the meaning of their COVID-19 diagnosis and overall health status; haircuts and financial counseling was made available at no cost, as were translators, wireless internet connection, movie screenings, and diet-unique meal offerings.

“Apart from looking after patients' health, a patient experience team was created to ensure general well-being and to maintain morale among those housed at CCFExpo,” they wrote. “The team made sure that information was easily understood by the patients.”

In an assessment of the first month of cases from May 10 — June 9 of this year, clinicians observed 3758 patients admitted to the facility. Daily admissions were 121.2, while daily discharges were 124.4—giving them a mean bed occupancy count of 2593.5 at a time. On average, physicians provided 159 medical consults daily.

The most commonly reported symptoms during consults were minor respiratory conditions, gastrointestinal symptoms, and musculoskeletal disorder.

Just 136 (3.6%) patients were transferred to a general hospital in the first month. Of them, 1 required intensive care for a post-coronavirus pneumonia case complicated by a bacterial infection, before being discharged from the hospital. The lone patient to have died at the time of the publication had suffered a massive pulmonary embolism 2 weeks after discharge from the facility.

Clinicians reported a vital sign monitoring adherence of 99.3% among its patients.

Writing on the advantages of the CCF, clinicians stressed the limited capacity of the current Singapore healthcare infrastructure. The island had only 11,321 hospital beds and 1100 intensive care beds available prior to the COVID-19 outbreak.

“If we contained the disease by hospitalizing patients with COVID-19, as was the strategy adopted in Singapore during the 2003 SARS outbreak, the nation's health care infrastructure would have been rapidly overwhelmed,” they wrote.

Despite apparent successes in reducing COVID-19 spread and limiting effect of mild COVID-19 cases, the clinicians found difficulties in communicating with the mostly foreign worker population, mitigating levels of anxiety among the new COVID-19 patients, and making the conversion from tertiary to primary care with its staff.

“Most of our team members were used to providing care in a high-volume center, and mental barriers existed early on among the team in delivering medical care at the primary level,” they explained.

Of course, the matter of compromised individual freedom for the sake of healthcare-led COVID-19 response was also on the mind of the clinicians. They agreed with the notion that such a practice may even be disincentivizing for a possibly ill patient to come forward with their symptoms.

“On a practical note, implementing these isolation measures met with little resistance, which may be a result of the collectivistic culture of Asian societies,” they wrote. “However, applying such a strategy in countries with an individualistic culture (where individual freedom is more highly valued) or in less economically developed nations may be more difficult.”

Overall, however, they advocated for the CCF approach as a model for managed healthcare infrastructure with effective patient monitoring and reduced mild virus spread during the pandemic.

“Isolation facilities can be created rapidly to care for patients without serious adverse outcomes,” they concluded. “Lastly, the use of technology, telemedicine, and patient self-monitoring is effective in managing a large cohort of stable patients with COVID-19.”