Singapore's Multi-Faceted Approach Led to Swift Results in COVID-19 Fight

In the United States and elsewhere, much has been written about the supply of testing kits for SARS-CoV-2. Some fear that limits on testing have made a containment strategy infeasible.

In Singapore, however, the story has been different. In the southeast Asian city-state of 5.7 million people, physicians were allowed to test patients for COVID-19 based on clinician discretion, even if the patient did not meet the clinical criteria for the disease.

The aggressive testing strategy was part of a broader, multipronged approach by Singapore’s Ministry of Health (MOH). The plan was largely informed by Singapore’s experience with the 2003 SARS outbreak, which began in China but spread to Singapore and other countries.

The results of Singapore’s early efforts to contain COVID-19 are the subject of this week’s Morbidity and Mortality Weekly Report, published by the US Centers for Disease Control and Prevention.

In the report, Vernon J. Lee, PhD, of the Saw Swee Hock School of Public Health and Singapore’s MOH, outlined the country’s experience with its first 100 COVID-19 patients.

Singapore’s first case of the coronavirus disease was reported on January 2. By March 5, the country’s case-count had grown to 117.

Singapore’s containment approach was multi-faceted. It included applying the case definition during medical consultations, tracing contacts of patients with confirmed cases of the disease, enhanced surveillance among patients with similar respiratory symptoms, and clinician discretion in ordering tests.

About three-quarters of first 100 patients (73%) were identified through the application of the case definition and through contract tracing. However, the remaining 27% were found through enhanced surveillance measures (16%) and tests ordered based on clinician discretion (11%).

The high number of patients identified through extra surveillance and discretion was notable, Lee said. He pointed out that one study found Singapore has the highest COVID-19 surveillance capacity of any country in the world. If such surveillance were applied globally, public health officials would likely be able to identify far more cases than they have to date.

“The study estimated that if other countries had similar detection capacities as Singapore, the global number of imported cases detected would be 2.8 times higher than the observed current number,” Lee notes.

Lee and colleagues stressed that one of the reasons Singapore’s surveillance plan appears to be working is because the tactics overlap; if a high-risk patient isn’t identified through one method, the system was designed to identify the patient through other means.

The country has also boosted its public outreach efforts and also imposed screenings and restrictions on travelers. For instance, short-term visitors who had spent time in regions with high caseloads were denied entry; Singapore citizens who had traveled to those locations were quarantined for 14 days.

Notably, Singapore has not closed its schools. Lee said that is because the country has had so few cases among young people.

Though the report outlines successes in Singapore, the country has continued to see new cases. As of Monday, the country had 509 total cases. Of the 54 new cases reported on Monday, 48 were imported by patients who had traveled outside of the country.