Letter from Singapore: The clinical and research response to COVID-19.

Singapore is a city‐state within Southeast Asia with a multi‐ethnic population. With high levels of travel and economic connectivity to the world, it was a key location of the 2003 severe acute respiratory syndrome coronavirus (SARS‐CoV) outbreak: a memory that significantly influenced the clinical and research response to SARS‐CoV‐2. Singapore was one of the first countries outside China to identify, document and diagnose SARS‐CoV‐2 infections including local transmission. , The first case was confirmed on 23 January and by 4 February 2020, local transmission was reported. As of 27 July 2020, 50 838 cases are reported with 27 fatalities illustrating a favourable case fatality rate compared to other jurisdictions.

When the World Health Organization (WHO) declared a public health emergency at the end of January, Singapore was ready. At the population level, six key factors were most critical in combating coronavirus disease 2019 (COVID‐19). First, an early whole‐of‐government approach to direct public health measures. This included strong consistent communication, necessarily calibrated and incremental. Second, early selective restriction of inbound air travel to reduce imported cases. Third, extensive testing and meticulous contact tracing ensuring proper quarantine and/or isolation. Fourth, clear and consistent public messaging regarding policy that was timely, evidence‐based and trusted. Fifth, a clear mandate to promote innovation and research as part of the whole‐of‐government collaborative effort. Finally, the memories and important lessons of 2003 and the SARS‐CoV outbreak led to operational readiness, posture and attitude of the government, healthcare professionals and the population.

A legacy from the 2003 experience was preparedness for the next pandemic. A new and purpose‐built National Centre of Infectious Diseases (NCID) and National Public Health Laboratory were set up to specifically tackle emerging infectious diseases and potential pandemics. Specific prevention and response plans were in place including the governance of research: the number of negative pressure isolation beds was expanded throughout the public hospital system; stockpiling of masks and personal protective equipment (PPE) was instituted and primary care Public Health Preparedness Clinics (PHPC), run by general practitioners (GP), were established to provide specific care plans, anchoring patients to the same GP while allowing an interface with tertiary care hospitals.

Outbreak management is key, and every national hospital quickly and seamlessly transited to a state of operational outbreak readiness. Although the Tan Tock Seng Hospital (TTSH) and the NCID were managing up to 70% of the national COVID‐19 workload of patients requiring hospital care, every hospital switched from ‘peacetime’ to ‘outbreak’ mode at short notice. This required a scaling down of ‘business as usual’ work, increasing capacity (i.e. beds, ventilators, PPE, drugs, etc.), PCR testing capabilities and managing manpower. At the national level, strategies focused on minimizing transmission and enhancing surveillance (e.g. contact tracing, quarantine orders and an increase to our Disease Outbreak Response System Condition (DORSCON) framework to status orange); social distancing measures (e.g. formal stay‐at‐home notices, advisories for large‐scale events and workplace, school and care home measures); encouraging social responsibility and communication transparency (e.g. good hygiene, use of social media and text messaging to supplement professional communications); and developing treatment recommendations to assist frontline clinicians in the form of clinical evidence summaries.

Several key questions have been posed by others about Singapore's COVID‐19 response: How did we cope with exponential caseloads and yet achieve such low intubation (0.33%) and mortality rates (0.05%) despite our ageing population? Why were there so few infections in healthcare workers (<0.05%)? Did we manage the disease differently? Simply put, the 3P approach served us well: planning, preparedness and protective equipment. We successfully ‘flattened the curve’ and ensured that our healthcare facilities and hospitals did not become overwhelmed despite the higher than usual caseloads, while strictly adhering to our fundamentals of high‐quality and accessible medical care. This includes early case diagnosis, early triage for hospitalization and early intensive care unit (ICU) transfer for those at highest risk of deterioration. We developed innovative approaches along the way including institution of awake prone positioning in oxygen‐dependent patients. Despite a dynamically evolving and phased outbreak, a focus was maintained on increasing bed capacity at the hospital and population levels. Normal wards were converted to COVID‐19 wards to prepare for patient surges once NCID capacity was reached, and several public locations (including our exhibition centres) were converted to community facilities to isolate those not requiring hospital care. Through this, our healthcare systems were never overwhelmed, and patients received the best possible care at the earliest stage.

Singapore's research response to COVID‐19 was as comprehensive, important and robust as our clinical one. Clinical, translational and basic science research was prioritized from the earliest stages of the outbreak and specific national funding schemes such as the COVID‐19 Research Fund was launched through the National Medical Research Council (NMRC). Our early clinical experiences were rapidly reported in the literature in addition to key international contributions in editorial roles, clinical trial participation and the development of empirical treatment guidelines. , , , , Some key achievements thus far include being the third country to successfully culture the virus; world's first successful use of serology for contact tracing; development of a surrogate virus neutralization test to detect neutralizing antibodies without relying on live virus and Biosafety level 3 (BSL3) containment; comparative investigation of SARS‐CoV‐2‐specific T‐cell immunity in cases of COVID‐19 and SARS; and uninfected controls, use of portable RNA‐free diagnostics and the identification of novel candidate antibodies. , , , , , , Ongoing research includes assessing potential mechanisms of viral spread using airway organoids, understanding environmental contamination and the potential influence of air quality on disease outcomes. , With international collaboration, national research teams are also actively involved in developing and clinically assessing candidate vaccines and therapeutic monoclonal antibodies.

Finally, our education and training strategies for medical students and practising residents were also re‐structured quickly including required assessments and examinations, in line with Singapore's digital SMART nation evolution. Our digital transformation capabilities were successfully applied for use in contact tracing, temperature monitoring and even the robotic delivery of meals to patients isolated in community‐built facilities.

While COVID‐19 presented a complex and wide range of clinical, research and logistical challenges, Singapore responded strongly and is now undergoing a carefully calibrated and phased return to a new ‘post‐COVID’ normal. Singapore has risen to this challenge with unity, efficiency and preparedness, a legacy from our SARS‐CoV experience. Employing deliberate but calibrated public health measures to keep pace with the waves and evolution of the outbreak was a key and consistent strategy. As Ernest Hemingway once said, ‘courage is grace under pressure’, Singapore as a nation showed great courageousness in its COVID‐19 response, a testament to our leaders, frontline workers and most importantly our people.