Part 2: The “Perfect” Communicable Disease Outbreak

The first case of Covid-19 infection in Singapore was announced on 23 Jan 2020. We are now into the 4th week of the outbreak in Singapore.

The situation in China appears mixed. The number of new infections each day seemed to have peaked. But apparently those happier numbers were due to under-diagnosis. Yesterday the numbers hit the roof with another 15000 new infections and 254 deaths in China in one day. There are now almost 64,000 cases and 1400 deaths in China. The number cases in Hubei province, including Wuhan, continues to outnumber those in the rest of China by about 4:1. This implies that there is still rapid transmission of cases both within and without Hubei. You know the battle is far from won in China when they have just removed the bosses of Hubei Province and Wuhan City (their party secretaries).

We Haven’t Seen The Fat Lady Yet

The current state of affairs in China is such that we really do not know if the worst is over. But there are some folks out there who repeatedly lobby for a softer stance in the fight against Covid-19. They say this is no more harmful than the common flu, which kills a lot more people every year than any coronavirus outbreak.

This hobbit would like to be a bit more cautious. For one, while we know it’s less deadly than SARS or MERS, we just do not know how less deadly it is. Statistics so far suggests so. Outside of Hubei province, the Case Fatality (CF) Rate is below 0.5%. While for Hubei it’s about 3%.

Why is the CF Rate for Hubei (and it’s provincial capital of Wuhan) so much higher? Many theories have been proffered. For one, being the place of origin of where Covid-19 started, the outbreak went undetected for 2 to 3 cycles longer than other cities, which had heightened awareness and sensitivity to the novel disease. By the time the disease reached other Chinese cities, it had already taken root in Wuhan and its surrounding cities. So the number of infections there are much larger.

But this does not alone explain the higher CF Rate. It could be that hospitals there are overwhelmed and the hospital themselves have become great incubators and reservoirs of the virus. They are so because therein lies a great number of sick people with many comorbidities and their chances of dying are much higher than the average person in the street. This is not much different from SARS where hospitals and hospital staff and patients had a much higher chance of being afflicted with the disease.

This is this hobbit’s theory of why the CF Rate in Hubei is much higher than other parts of China. And therefore, it is vital that we do not let our hospitals get hit by Covid-19. But it is only a theory. The truth is, we really don’t know for sure why Hubei is doing so badly in terms of the CF Rate.

The other two important factors are that we do not have drugs that can definitively treat the disease (like Tamiflu for influenza) and a vaccine.

And so, until we know for sure why Hubei is different from the rest, or that we have a drug for definitive treatment or a vaccine, it is best we don’t throw in the towel by treating Covid-19 like the influenza virus.

And besides, it is early days yet. SARS infected 238 persons in Singapore and killed 33. We have about 67 cases and no fatalities for Covid-19. It is too early to give up the fight.

Another factor to be considered is that China is now returning to work after the Chinese New Year extended holidays. Will that lead to another round of infections as hundreds of millions of people go on the road again from their hometowns to their place of work? Only time will tell. It is true that we have effectively closed off China as a new source of infections since everyone that comes to Singapore from China must be given leave of absence for 14 days. But one can still get infected in other countries before coming to Singapore – an imported case, but not from China, so to speak.

So as the saying goes, “It ain’t over till the fat lady sings”. No one is quite sure if they have seen the fat lady yet…..let alone see her sing.

And so, that means we, the ground troops, must slog and plod on in our clinics and hospitals.

Logistic Fog of War

After three weeks, things are really getting a little edgy on the ground in the private sector, to put it mildly. If you are the grunt troops fighting in the trenches, after three weeks, you are going to be in pretty low morale if you have had only 5 warm meals and 3 changes of underwear and socks and you are down to your last 2 magazines of rounds. You are sick of eating combat rations, you have bad body odour and you are starting to get foot rot.

We have learnt from SARS that when we fight a communicable disease outbreak, we are really fighting on at least three fronts: medical, logistic and psychological.

For the front line troops in the private clinics and hospitals, we are failing quite badly on the logistic front, I am afraid. That is, until the Health Minister announced he was giving 1M masks to the private sector doctors 2 days ago. This hobbit reckons these 1M masks will last the private sector for about 3 to 4 weeks.

Simply put, private sector doctors have no visibility, let alone clarity or assurance, of the government’s resupply plans for them. How much of the National Stockpile of PPEs is meant for the private sector? Nobody knows and all of us in the private sector are fighting Covid-19 while blinded by this fog of war on the logistic side.

Let’s Do The Maths

Let’s take a recap. Up till now, assuming you have been on the ball as a GP securing your masks, here is what you would have gotten from “official channels”:

  • From SMA (they obtain their stocks from government): 3 boxes of N95 and 1 box of surgical masks.
  • From Zuellig Pharma (The government authorised dealer): 1 box of N95 and 2 boxes of surgical if you are a GP, 1 box of N95 and 1 box of surgical if you are a specialist

Which means the MAXIMUM amount of masks you could have gotten so far are 4 boxes (80 pcs) of N95 and 3 boxes (150pcs) of surgical masks after three weeks in the trenches.

Zuelling is selling another round of masks now, also along the same lines as the previous round. Assuming you are lucky and get what you want, you would have accumulated a total of 5 boxes of N95 (100pcs) and 5 surgical masks of N95s (250pcs) if you are a GP. And if you are a specialist, it’s a maximum of 100pcs of N95 and 150pcs of surgical masks after 20+days at the front lines.

Most folks out there do not achieve this maximum allocation of masks. And we haven’t even started talking about isolation gowns.

Strangely speaking, or maybe my memory is failing me in my old age, I can’t seem to recall we were so short of PPEs during SARS, other than for N95s. Certainly, we weren’t so short of surgical masks then.

A typical GP clinic will have 3 to 4 working persons, including the doctor. Assuming each mask lasts 6 hours, you will use up 2 masks a person or about 6 to 8 surgical masks a day. You are also required to put a mask on a person with fever or respiratory symptoms as per MOH requirements. That would easily take up 10 to 15 surgical masks. In other words, a small solo GP clinic working 3 shifts easily consumes 20 to 25 surgical masks in a day if not more. Now that we are in Dorscon Orange, a solo GP practice would use up to 4 N95s a day in addition to the surgical mask utilisation (One N95 for GP and one for triage nurse per shift, assuming 2 to 3 shifts a day, so 2×2 = 4 N95s a day. If you go for extended (stingy) use, then maybe 2N95s a day).

Assuming the GP works 6 days a week, the clinic will consume 120 to 150 surgical masks a week and another 12 to 24 N95s a week

But as the records show, in the last 3 weeks, we could only have received 80 pcs of N95s and 150 pcs of surgical masks with hopefully another 20 N95s and 100 pcs of surgical masks on the way from Zuellig. This is simply not enough to keep the GP and his clinic going.

It is understandable that we teach the public to limit the use of PPEs and to concentrate on efforts to improve hand and personal hygiene as well as to limit large group interaction. But it is another thing altogether when we try to squeeze the PPE supply to the private healthcare establishments and their staff, when they have to face people who are sick, i.e. a high risk segment of the population.

We Need An Integrated Approach to Making PPE-Related Policies

There is a fine line between conserving PPEs and keeping morale up, i.e. winning the psychological war. Ultimately when everyone does not know when the next batch of masks will come, morale will suffer. Just like troop morale will drop when they don’t know if they will be resupplied with food, water, clothing and ammunition. Everyone is thinking of getting or have been getting their masks from private suppliers. And prices are going up. A box of surgical masks (50pcs) have gone up from $3.50 to $4 before the outbreak to around $25! That is, if you can find them in the first place.

The truth is that PPE consumption rate is influenced by a few factors:

  1. The epidemiological features of the disease
  2. Dorscon status
  3. Case definitions of the disease
  4. PPE usage policy

We can’t do much about the natural epidemiological features of Covid-19. It is what it is. But case definitions are largely man-made. If your case definitions are too broad and too many persons fall under the suspect category, then the use of PPEs will shoot up. Likewise for Dorscon status. PPE usage policy also heavily influences usage, although admittedly this is also in turn determined by the epidemiological features of the disease. But whatever the case, the resupply operations must support what the case definitions and mask usage policies demand.

To the uninformed, it would appear that the 4 policies are governed by different groups of people working independently of each other. The resupply practices of 20 pcs of N95 and 100 pcs of surgical masks a week is not keeping up with the demands of the case definitions or the Dorscon status. It looks like the resupply guy is still in Dorscon Yellow while his colleagues in the other departments or ministries have moved on to Orange.

Talk about frustration.

What this Hobbit would like to see is that the authorities commit to a certain rate of resupply for GP and private sector community specialist clinics. E.g. 1 box of 20 N95s every two weeks, 3 boxes or 150pcs of surgical masks a week and 10 isolation gowns a week and maybe 2 bottles of sanitizers/hand rub. Then all of us doctors can concentrate on picking up new Covid-19 cases and treating other patients instead of constantly worrying about where their PPEs will come from. We will pay for the PPEs too, we don’t need freebies. And of course, community clinics with more than one doctor should appropriately receive more PPEs than the solo GP.

Public Health Preparedness Clinic (PHPC)

That brings us to what is listed as a MOH National Scheme called the Public Health Preparedness Clinic (PHPC). This Scheme “consolidates the primary care clinic response to public health emergencies such as influenza pandemic, haze and anthrax outbreak into a single scheme for better management”. (www.primarycarepages.sg/practice-management/moh-national-schemes/public-health-preparedness-clinic-(phpc)

For volunteering to be on this wonderful Scheme, MOH is supposed to provide you with “up to 12 weeks’ supply of PPE for staff at no cost”. This sounds great right now because I know some GPs who will pawn their grandmothers for 12 weeks of free PPEs.

But, according to a circular issued on 11 Feb 2020 by MOH, this Scheme hadn’t been activated yet. Therefore, no one has received any PPE free of charge under this Scheme either. Today it has been finally activated. Maybe it’s about tough love on Valentine’s Day.

Frankly, this hobbit cannot understand why the Covid-19 wasn’t considered a public health emergency until today. The Scheme was increasingly looking like a joke until a powerful necromancer decided to breathe some life into this cadaver of a national scheme today.

Come Down Hard On False Declarations

Doctors and other healthcare workers need to be protected with PPEs. But they also need to be protected against reckless and selfish people who put others, especially healthcare workers (HCWs) and healthcare establishments, at risk. Several people have already been punished for breaking quarantine. But this hobbit thinks there are far more people who give false declarations about the travel and contact history. I think practically all doctors out there know other doctors who have had seen irresponsible people after they had made false declarations, even if they had not met one themselves.

The authorities should protect the public and HCWs by taking these false declarers to task, and charge them under certain provisions of the Infectious Diseases Act. This would send a clear signal that false declarations will not be tolerated, and not just those that illegally break quarantine orders.

The New Battlefront: Private Hospitals

This Hobbit opined in Part 1 that Generals fail when they fight the last war. Generals often assume the new enemy is like the last enemy and they will win against this new kid on the block by bashing him/it the same way as they bashed the previous kid on the block. And they are often proven wrong when they do so.

The recent spate of cases whereby patients and staff have been exposed to confirmed cases underline this point. During SARS, the private hospitals were spared and the restructured hospitals bore the brunt of outbreak. This time is different. The first two hospitals to have unprotected staff exposed to confirmed patients were private hospitals. The first healthcare worker who contracted Covid- 19 was a private sector anaesthetist who was rumoured to have seen patients in more than one private hospital.

It is clear that the private hospitals are at as much risk as restructured hospitals for Covid-19. Some of these hospitals are running very short on PPEs. But this hobbit was told they are expected to source for them on their own. The Singaporean equivalent of the biblical Joseph guarding our National Stockpile should quickly beef up the dwindling stocks in the private hospitals. MOH should also ensure that private hospitals have the same standards of disease control as restructured ones, especially in terms of PPE usage, triage and limitation of doctor movement.

When stocks are running low, private hospitals and clinics have no choice but to make compromises on PPE usage, leading to suboptimal infection control. And we are only as strong as the weakest link, as the saying goes.

Research

Singapore has the most cases of Covid-19 after China. (Other than the cruise liner docked off Japan). It is interesting that Chinese, HK, USA, Germany have all published research papers in reputed research journals and Singapore hasn’t. That’s a shame, given our reputation as a medical hub with top-notch researchers and clinician scientists. What’s happening?

And so…..

Again, as this hobbit has said in Part 1, there will be many twists and turns to this blockbuster saga sequel to SARS. And we are now beginning to see some of these twists and turns.

As Winston Churchill said long ago while fighting another war, “Now this is not the end. It is not even the beginning of the end. But it is perhaps, the end of the beginning”.

3 thoughts on “Part 2: The “Perfect” Communicable Disease Outbreak

  1. With respect to research, the same thing happened during SARS. Nary a peep out of SG until much later and I’m esoteric journals. Maybe it’s the SG obsession with perfection. These early reports in Lancet NEJM etc are in part news conjecture hypothesis. The SG medical mindset is too inflexible. I asked an ID person. He/she merely shrugged and smiled. It’s true we are focussed on the clinical and saving lives. However, now with >50 cases, and increasing daily, surely SG can report the first 50 cases. Perhaps need to break down the silo mentality. Cases are in different Hospital Systems in SG public healthcare system. I heard NCID and Duke-NUS are competing to come up with the first vaccine. Please just work together and learn to be the first to decline first/senior authorship. One can already outline the first 2 papers –
    1. First 50 patients. Demographics and clinical course. Some discharged. Many inflight. But the Public Health interest supports publishing this incomplete data now.
    2. Local clusters – already have elegant infographics published in newspaper. The epidemiological issues etc.

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  2. I am not a medical practitioner. my view is that the frontline troops should be better protected than the population.

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