COVID-19 outbreak in nursing homes in Singapore.

Dear Editor,

We agree with the perspectives on the importance of heightened vigilance to the threat of COVID-19 in long term care facilities (LTCFs) and the recommendations to protect and mitigate this.

COVID-19 is a global pandemic with extensive community spread in many countries. LTCFs have been identified as particularly vulnerable due to the older age of the residents who are likely to have multiple chronic illnesses. Despite initial success in containing COVID-19 transmission, Singapore's rate of community transmission increased exponentially in mid-March 2020 as the pandemic spread across the world and overseas travellers returned to Singapore (Fig. 1 ).

Figure 1

Graph of COVID-19 spread with time in Singapore. Black arrows indicate detection of COVID-19 cases in Nursing Homes (NHs) in Singapore. (Source of graph: https://co.vid19.sg/singapore).

Singapore has 16 059 LTCF places as of 2019. 40% are run by the government, 37% by non-profit organisations and 23% by the private sector. The first case of COVID-19 in a LTCF was detected on 31st March 2020. As of 27th April 2020, 6 LTCFs in Singapore have detected COVID-19 cases. Despite accounting for <0.001% of total cases in Singapore, deaths of LTCF residents due to COVID-19 account for 14% of the total fatalities. This is similar to many developed countries where mortality rates are disproportionately high amongst NH residents.

Many preventive strategies were put in place early on to prevent the spread of COVID-19 to LTCFs. These included early pre-emptive management of LTCF residents with respiratory symptoms, transfer protocols between hospitals and LTCFs, increased temperature screening and social distancing and segregation of staff and residents. After the first LTCF case was detected, the Ministry of Health moved to suspend all visitors to all LTCFs for 1 month, implemented compulsory safe distancing for all residents and split-zones for LTCFs with more than 200 residents. Staff were reminded not to turn up for work if unwell. Despite these tough measures, COVID-19 still found its way into 6 nursing homes in Singapore (Fig. 1). This spread coincides with the exponential community transmission in Singapore especially amongst work pass holders, a proportion of whom work in LTCF. This is similar to the situation in other countries where LTCF often face staff shortages that are exacerbated by the current pandemic situation. Staff management is a key pillar in any preventive strategy in LTCFs. However, preventing COVID-19 transmission to LTCFs remains a challenge if community transmission is not well-controlled. This is because staff remain vulnerable to catching the virus and inadvertently spreading it to LTCF residents especially as the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is highly contagious even while asymptomatic.

Thus far, COVID-19 has not been widespread amongst LTCFs in Singapore and the numbers remain under control. However until global and local community transmission is well under control, LTCFs cannot let their guard down and must continue to implement policies to protect this particularly vulnerable group.