Heightened Concerns and Measures with Local Transmission of COVID-19

Thank you. I think it will be useful for me to give a quick update of the situation. The COVID-19 situation continues to evolve globally and locally. As of 17 February 2020, based on World Health Organization’s report, globally there are 70,548 confirmed cases in mainland China with 1,770 deaths, and 881 confirmed cases outside of mainland China with five deaths.

Locally, as of 17 February 2020, we have 77 confirmed cases of COVID-19. Twenty-four cases have fully recovered from the infection and have been discharged from hospital. Of the 53 cases still in hospital, most are stable or improving. Four are in critical condition in the intensive care unit. Contact tracing has helped us to identify five clusters and investigations on these clusters are on-going. Contact tracing is underway for the other seven locally transmitted cases to establish any links to previous cases or travel history to mainland China.

Since early January, we have progressively put in place precautionary measures to detect and limit the transmission of the virus. These include travel controls, contact tracing and placing identified close contacts under quarantine. Today, we activated the Public Health Preparedness Clinics to strengthen our defenses at the primary care front to better detect and manage COVID-19 cases.

The Public Health Preparedness Clinics (PHPCs) will provide subsidised care for patients with respiratory illnesses in the community. We observed that several of the locally confirmed cases had remained in the community or gone to work, even when they were ill. MOH has therefore given guidance to doctors to provide medical certificates (MC) of five days for patients with respiratory symptoms so that they can and should stay home to rest and recover quickly. We urge individuals with respiratory symptoms – such as fever, cough, sore throat and runny nose – to seek medical treatment at the PHPCs or polyclinics early and stay home throughout their MC period. Let me take this opportunity to once again thank our healthcare workers who courageously rose to the call of duty and in particular our PHPC doctors who had just started up the PHPC clinics today.

I am also heartened to see many ground-up initiatives to support our front line healthcare workers, the needy and vulnerable groups, as well as the affected patients and their families. This whole-of-society spirit is essential in building a resilient nation. When we stand united, we will prevail and I am glad to see Members wearing this SG United button. Let us stay united as we battle this disease.

Knowledge of COVID-19 is still evolving as scientists around the world work to better understand the virus. MOH studies the latest reports, consults international infectious diseases experts and keeps in touch with other health authorities to gain greater knowledge of the virus and how it is transmitted. The current medical assessment still points to COVID-19 spreading mainly through droplets and physical contact from an infected person. Based on evidence available in China, an expert from the Chinese Center for Disease Control and Prevention has said that there is currently no evidence that the virus can be transmitted through aerosol.

Individually, we can each play a part to curb the spread of disease through socially responsible practices. Observing good personal hygiene, such as washing our hands with soap and water regularly, and not touching our face and eyes, remains the key means by which individuals can protect themselves and reduce the risk of transmission. Each person should also monitor his or her health closely, take temperature twice daily, see a doctor when unwell and stay home to rest, and if they must go out – for example, to see a doctor – wear a mask.

We expect to see more cases in Singapore, partly as a result of enhanced surveillance we put in place recently. We must be prepared for the possibility of wider community spread. We will continue to monitor the situation and prepare for different scenarios I sketched out during the Ministerial Statement at the last sitting. We will also fine tune and adjust our measures accordingly as the situation evolves. Together, with everyone playing our part and staying united, we are confident that we will overcome this outbreak and emerge stronger as a nation.

Thank you, Sir. I just wanted to check with the Minister for Health, when Prime Minister Lee made his speech to the nation on 8 February, he said, there is no need to panic, carry on with our lives. But of late, some of the activities seem to suggest that people are reacting in a slightly different manner. When DBS had a case, they evacuated people from the whole of the floor at Marina Bay Financial Centre (MBFC). And the Catholics have stopped Mass. I am just wondering what is the advice from MOH to the rest of the people? Do we carry on with our lives or should we react whenever a case comes out? Should buildings evacuate the buildings' occupants when they find that there is someone who had been in contact with an infected person?

I thank the Member. This is a very important question. In fact, we have been briefing those who have been affected, including corporations, entities, organisations. As I had mentioned, last week, I met the religious leaders, church leaders to explain to them what are the precautions they can put in place. As the Prime Minister said, life must go on. We have to continue as normally as possible while taking the necessary precautions.

For church organisations, for example, we have advised them to continue with their services, minimise unnecessary social interactions so as to minimise contact to prevent transmission within the church and to also continue to take temperature and remind members that if they are unwell, they can stay at home and rest rather than to come to church. These are the types of advice we have given to the churches. Depending on the situation, different organisations may adopt different measures where practical and if they are in doubt, we have also invited them to contact us. We will provide the necessary advice. We have done the same to the other religious organisations – the Buddhist organisation, the Taoist organisation, the Hindu organisation. We are reaching out to them and any organisations that have questions or are uncertain as to what they should do, they can contact us.

When a case is identified as positive, we will also inform the organisation to do the necessary cleaning and disinfection and so on. Sometimes, organisations may over-react and take upon themselves to do things that may not be necessary and may cause misunderstandings. Therefore, we advise organisations that when there is a confirmed case, if they are not sure, to consult us or to consult NEA which oversees the environmental cleaning processes. This way, we will then be able to react calmly and respond effectively to any confirmed cases. I would advise organisations that are uncertain to please contact us. We will provide the necessary guidance and advice.

Mr Speaker, I thank the Minister for the update. I just have one specific question on the effectiveness of temperature screening because this has caused a lot of surge in the demand for thermometers. More importantly, whether it is actually effective because some of the patients that have been discovered, showed very mild symptoms. It also uses a lot of manpower. I am really not sure if it is the best way. The other thing is, there have also been reports about how there were some faulty infra-red thermometers that were not very accurate. So, I just want the Minister's thoughts on this and the guidelines that can be given to the organisations on this matter.

Temperature screening remains one of the very important part of the measures that we have put in place to prevent people who are ill from joining activities and participate in mass gatherings. That is very important. Individually, it is also important for you to take temperature regularly so that you know whether you are well or unwell. But very often, you also find that individuals know that they are unwell even if you do not have a temperature. It is also evidenced from the studies that shows that for COVID-19, sometimes, the high temperature comes much later, in the later part of your illness. In the beginning part, when you are in the initial phase, your symptoms may be very mild but you do carry viral load and you can still be infectious.

Therefore, we encourage Singaporeans who feel unwell, especially with the symptoms that I had mentioned, respiratory symptoms – coughing, running nose and so on – to please consult a doctor, particularly with the PHPC, now that we have activated them. Or come to our polyclinics for a proper assessment. Once we have made the assessment, if we find that you are at risk, we will then refer you to the hospitals for assessment and testing. If not, doctors are given guidance to give you five-day MCs so that you can rest at home. If your symptoms recover within that five days, well and good. If not, please go back to the same doctor. If you go to a different doctor, they may not know the history and you have to repeat all over again, and you may have missed out certain indications. We encourage you to go back to the same doctor so that there is a continuity of care. This way, we will help to minimise transmission.

To answer the Member's question, temperature-taking is an important part of our precaution measures. But if you do not have a temperature, it does not mean that you are perfectly well. We still have to make an assessment, whether you feel well or unwell.

For organisations, we also advise them. Even after they have taken the temperature, observe the individual. If he does not look well, please advise him to go back and rest, rather than rely solely on temperature taking.

I thank the Minister for the update. I just have two clarifications about the DORSCON level – the acronym of the year, so far! First, some clarification about how this DORSCON is arrived at – is it by independent committee that makes this decision and recommends to Minister? Or is it through any other process? The second question which, I think, many Singaporeans would be interested in is, what are the parameters by which the DORSCON level may be adjusted? In this case, specifically, what are the parameters under which they would consider lowering it from Orange to Yellow?

The conditions for DORSCON levels are published on our website. These are guidelines. At the end of the day, we would need to make a judgement. In making the judgement, we have to take into account inputs from the professionals, input from the community and make an assessment of the situation. So, there are multiple factors that need to be considered. It is not just counting the numbers and ticking the boxes, before we decide to switch either way.

Currently, we have a Ministerial Taskforce. The Taskforce will assess and recommend, and eventually, the Minister for Health is the one who declares the DORSCON level. Just for avoidance of doubt, let me repeat this. We have no plans to go to DORSCON Red. Whenever I hold a press conference, rumours will fly around that we are going to go to DORSCON Red. Every time, we would have to spend resources and efforts to address the rumours. So, please help us not to spread rumours that are untrue. Well, rumours are by nature untrue!

Again, as we continue to monitor the situation, there may be a time when we will have to adjust the DORSCON level downwards to Yellow or to Green. Again, we will take into account multiple factors – the number of infections that we are seeing, the severity of the diseases and whether or not the viral transmission is able to be controlled. So, there are many factors that we will consider; including outside Singapore, what is the situation globally. Therefore, it is not a straightforward answer. It is eventually a judgement, taking into account all the various relevant factors.

Thank you, Mr Speaker. I just have a few follow-up questions on the announcement yesterday with respect to the transition from the Leave of Absence regime to the new Stay-Home Notice for individuals, residents, long-term pass-holders returning from mainland China. That takes effect tonight, at midnight. My first question is how many individuals does the Government expect to be transitioning into this Stay-Home Notice regime. Because a lot of these individuals, as Members know, would be living in the community, in households, in HDB flats and so forth.

The second question is, there would ostensibly be a higher chance of community spread, in view of these returnees. To that end, what are the enforcement resources that the Government has at its disposal, to ensure that returnees actually comply with the requirements of the Stay-Home Notice?

I thank the Member. We do not have an estimated total number of people returning because it depends on the decision of the individuals, whether or not they intend to return. Many of these who are on Stay-Home Notices are required to stay at home and we are leveraging on technology as well, to monitor them. We call them, we have video calls as well and we also track their location, where they are. This will help us to reduce the manpower resources that we need to ensure that they stay at home. This is a step-up from the Leave of Absence (LOA), that we have introduced, where they were allowed to go out occasionally for meals and so on. For the Stay-Home Notice, they are required to stay home all the time and we will do spot-checks on them through telephone calls and so on, to make sure that they are at home. I think this is the enforcement regime, which was explained yesterday.

Thank you, Speaker. I have to first commend MOH for putting up a lot of timely information and good information for people's use. But, as Minister rightly pointed out, rumours and also misinformation can create unnecessary fear and panic. There are, of course, a lot of closed chat groups now. I just wonder if Minister can shed some light to whether any actions will be taken against those who intentionally spread some of the information that creates the panic that goes around. I was actually asked to evacuate my building the other day because the office building apparently had an ambulance that came by. But what we found out was that there was no COVID-19, the person actually was choked. If the Minister could shed some light.

This is a very difficult challenge because they are, by nature, closed chat groups, it is very difficult for us to monitor. We encourage Members or members of public, if you come across any of these closed chat groups. If the information does not look real, please check with us, go to gov.sg, wait for the notices to be sent to you through WhatsApp, those are accurate, official information. And we have been sharing as much as we can. All that we know, we share with the public. We have daily press briefings and occasional press conferences by Ministers and regular updates from time to time, even within the day. So, rest assured that we will provide as much information as possible, once we obtain it. There is no need to second guess what the situation is.

If you do come across messages or statements that look suspicious, that cannot be verified, please do not forward them to your friends. You may find that amusing or entertaining, but please refrain from forwarding because this will then multiply. You can also help us, if you find that they are suspicious and you are not sure, do forward it to us and we will check on whether they are correct or not and let you know the details. So, we have to deal with it one by one, there is no easy solution, but each of us can play our part by not forwarding unverified information and informing the authority if you come across any of them.

Thank you, Speaker. I would like to ask the Minister, there are quite a lot of cases where the person that has it, he goes to the GP or polyclinic a few times and only on the third or fourth visit, then he is referred to the acute hospital for the test. Does it make sense to make the test kits available at least at the polyclinics or some of the GPs so that they can test earlier. Because, in one case, the person, from the onset of symptoms and until he went to NUH, it was almost 10 days. So, throughout that period he could be spreading to a lot of people.

I thank the Member. Let me just put in context. Every day, we have about 30,000 people down with flu-like symptoms – running nose, cough, cold and so on. So, it is not possible to test all 30,000 of them. In the end, every day we find about five to 10 cases as you have seen in the past. So, to find this five to 10 cases every day by testing 30,000, is not going to be very helpful. On top of that, you may have a lot of false positives that you have to chase around. And therefore, the best way for us is for the doctors to make a clinical judgement as they see the patients. If they find that you have signs of pneumonia, then they will refer the patient to the hospital for assessment. If not, our strategy is to encourage the individual to please stay at home, for the first five days so that your body will be able to recover. If it is the normal common cough and cold, you are likely to have recovered within these four or five days. This will reduce the amount of noise in the system to allow us to identify cases that are more likely to be problematic.

Even for those who do not recover within these five days, it does not mean that you have COVID-19 because there are still a lot of other possible infections that you may be suffering from. In fact, a very small number everyday will be COVID-19 positive. So, therefore, if you are asked to stay home with five-day medical certificate (MC), do not panic, it does not mean you definitely have COVID-19. The vast majority would not have. This is a means for you to stay at home to rest, to minimise transmission. This will also help by reducing the normal cough and cold transmission, if you stay at home and recover, rather than move around in the community. I also encourage individuals when you are sick, if you have not recovered within these five days, please go back to the same doctor, rather than to move from doctor to doctor and then we have less ability to track the history.

This is the advice I would give to individuals: if you are ill and not well, see a doctor. If the doctor gives you an MC, stay at home throughout the MC period, do not go around and do not go and queue up to buy toilet paper and so on. Please stay home and if you need help, there is always the MOH hotline that you can call if you need some help. If you are very ill and you need the ambulance, you can always call for the ambulance and we will convey you to the hospital. When you finish your MC, if you are still unwell, go back to see the same doctor and the doctor will then be in a position to make a clinical judgement, whether or not you should be sent to the hospital.

Our doctors are well trained and they are familiar with the assessments they need to do on the ground. But it is also not appropriate to ask our primary care doctors to do the test because it requires swabs and special techniques. Some of the doctors may not be familiar with how to do that and it also exposes the doctors unnecessarily to potential infection because swabbing can be quite a hazardous process. It is better done in a hospital environment so that our trained professionals will be able to do it properly. Some private hospitals are planning to do that because they are also trained and they also have the equipment and the facilities to do so safely. We are working with the private hospitals to also allow the private hospitals to do some of these testing in order for us to share the patient load.

Thank you, Speaker. I would like to ask the Minister for Health, pertaining to the guideline on the five days MC. We understand the reasoning behind the five days recommendation and also how we will assess in giving this MC. However, there has been many misinterpretation perhaps and spin-offs from these five days and I am asking this question on behalf of frontline healthcare workers. Because people are now coming and demanding, "Why is it just three days and not five days? MOH says it is compulsory for you to give us five days".

So, therefore, we make the decision based on clinical judgement and case-by-case basis. Can we just get clarification and reinforcement that it is really not mandatory, but it is a guideline, a recommendation, but it is really up to the doctor and the frontline healthcare personnel as to how many days we want to give. We understand the five days and we understand that if you do have upper respiratory tract symptoms with fever and all that, and even with no travel history, the five days is definitely justifiable. But for others who may not have all the components of the symptoms, but there are other problems, I hope that the Minister can reinforce that it is really up to us on a case-by-case basis to decide on this.

I thank the Member. It is important to read the footnote of our guidelines. And the footnote does say that "doctors are to exercise judgement and to decide how many days to be given". For example, the patient might have already been ill for four days, and so, there is no need to give another five days. So, it is the clinical judgement of the doctor. We said five days and this is a guideline given to the doctors. We encourage doctors to exercise their judgement and we also want Singaporeans to know, to trust the doctors' judgement. Our doctors are well-trained and they know what to do.

At the same time, we also want to take this opportunity to appeal to employers to allow the patient – your employees – to go on the five-day MC if he is given five days MC. Please do not ask him to come back to work, because by coming back to work, if he has the virus, it may actually be exposed to your other employees and your whole company may be affected. So, it is in the interest of the employees to rest at home so that they can recover quickly and it is also in the interest of the employers to ensure that their employees, the workers, stay at home and rest rather than come to work.

I also want to take this opportunity to seek the support of our employers to allow us to implement these guidelines so as to minimise the transmission in the community.

Thank you, Speaker. Minister, I have noticed during my walkabouts in my constituency, in some GP clinics, the receptionists wear masks and the nurses wear masks. But in some GP clinics, it could be just next to the one where the nurses wear masks, they do not don masks at all. So, are there some guidelines for the GP clinics to follow?

I thank the Member. I think that the clinic managers and the GPs know exactly what to do. For those who are patient-facing and potentially have a risk of exposure to potential COVID-19 or other infectious diseases, they would usually wear masks. And sometimes, if their clinics are more for health screening and so on, they are less likely to encounter patients with these illnesses or infectious diseases, they may not need to wear a mask. So, we leave it to the clinics to make a judgement, but we would encourage them that where they have a risk of facing patients who potentially have infectious diseases, including COVID-19, they ought to wear a mask to protect themselves as well as to protect the patients because they may inadvertently pass on the disease to the patient as well.

I thank the Minister for the update. In the recent press conference, Minister Lawrence Wong said that COVID-19 is less deadly, more infectious and it is more like H1N1 than SARS. I have got some feedback asking if this means we have to prepare for the long haul and how long is long; and whether we will get back to normal day-to-day life.

Maybe I should ask Minister Wong to answer this question, but let me try to answer the Member's question. I think what Mr Wong intended to say is that, in terms of statistics, based on today's evidence, that transmissibility seems to be much faster, much higher, quite close to H1N1. And therefore, we do expect a significant number of cases both globally as well as in Singapore in time to come. In terms of fatality, the numbers today show that in the whole of China, it is about 2% to 3%. Outside Hubei, it is about 0.5%. Whereas SARS was closer to 10%. And therefore, it is quite different in terms of fatality compared to SARS. This is the nature of the disease and the knowledge of the disease is still evolving – as I had mentioned in my reply – and the scientists are still discovering new things about the disease.

These numbers may change over time. We are watching them, but this is as it stands today. Therefore, it looks more like H1N1, we do need to expect to live with it for quite a long time. H1N1 has infected more than 400,000 Singaporeans in Singapore alone, within a year. And H1N1 is still with us today; occasionally, we still see cases of H1N1. We may have to learn to live with it. That is why even today, we are encouraging Singaporeans to live life as normal as possible. Life must go on, take the necessary precautions, but we can continue to live normally as much as possible so that there is no need to have drastic shifts from one way to the other. But precautions like temperature taking, see a doctor when unwell, these are normal precautions, which in fact, even without COVID-19 or H1N1, we should be practising. This is also an opportunity for us to reinforce these socially responsible practices – ensure that when we are sick, see a doctor and observe personal hygiene practices, wash your hands frequently. It does not mean that once COVID-19 is over, if it is ever over, we stop washing hands. So, I think it is a habit that we should inculcate today and live life as normally as possible and take necessary precautions.

Mr Speaker, I am glad to hear the Minister saying we should try to live life as normally as possible. I want to ask about the more vulnerable groups, such as the elderly, whom I understand, of course, the state is trying to protect. The Senior Activity Centres (SACs) which actually serve many of the elderly, especially in rental estates, are instructed to wind down many of their activities in order to protect the elderly. Some of us on the ground find that many of these elderly residents are loitering around and they are no more exercising. Maybe they will queue up to get food packages, but they do not get to sit down to have meals together anymore.

So, I am wondering if there is an alternative to this while protecting them, for example, splitting them so that there are not more than a hundred in a group and maybe have some part-time activities so that they can actually continue to have a platform where they can be educated and updated on the latest news and be encouraged to exercise or maybe co-clean some shared facilities and so forth.

I wonder if Minister's message to live life as normally as possible could be extended to the beneficiaries of the SACs.

Indeed, Mr Speaker, we do want SACs to continue as much as possible. But it is also important that some SACs and organisations have temporarily suspended some of the activities in order for them to put in place some precautionary measures. Some of the measures may need time for them to set up. Some organisations may need time to work out exactly how to manage some of these activities. Therefore, I assure Ms Denise Phua that we do want to work with the organisations which are overseeing these activities to put back as many of these activities as possible and practicable while taking necessary precautions, particularly all the health promotion activities and exercises. In times like this, exercise is important to keep ourselves healthy and resilient. So, we do want to encourage the activities and exercises to continue with the necessary precautions.

HPB as well as the various VWOs may take some time to study the situation, put in place the necessary appropriate precautions and we encourage them to restart as soon as possible. And instead of coming to the SACs, some of them may congregate in the coffeeshops, which has the same effect of mixing. So, rather than being in the coffeeshops, we might as well organise them in the SACs so that we are able to manage them to prevent transmission.

We take the Member's point fully and will work with the various organisations to do that.

Mr Speaker, may I just bring the Minister back to his answer to these Stay-Home Notices. Supposing a worker who has just came back from China has been issued with a Stay-Home Notice and he breaches his Stay-Home Notice in that he deliberately ignores the notice and he goes out, what is the risk to the community that he may carry the COVID-19 virus and spread it to the community at large? What is MOH's assessment of the risk to the people who may meet up with him in the community?

First, let me explain that there are different categories of people who are served certain notices and orders. For those who are ill with COVID-19, confirmed cases, all of them are in the hospital. So, once they are confirmed, they are treated in the isolation wards in the hospital. They are not running around in the community.

But at the same time, once we have identified a positive case, we identify the contacts of these positive cases. These are the people who have been with the confirmed cases for an extended period of time and they are potentially exposed. These people are served with what we call quarantine orders. For quarantine orders, there are strict rules for compliance and there are staff and officers who will do surveillance and make sure that they are in our quarantine centres. Some are served home quarantine orders. They are also very strict orders under the Infectious Diseases Act and they have the full force of the law to ensure that they stay under the home quarantine orders.

But I also need to emphasise that these people who are served quarantine orders are not sick. They are exposed to persons who are sick but they themselves are not down with COVID-19. Once they have symptoms, because they are under close surveillance, they will be immediately conveyed to the hospital for treatment and follow-up. So, again, if they become one of the confirmed cases, they will be treated in the hospital. So, they are all in isolation.

There will be a group of people like those returning from China. They were exposed in the community but they do not have direct contact with a potential case. So, their risk level is significantly lower than the close contacts of confirmed cases. Therefore, they are served these Stay-Home Notices to allow them to stay at home, minimise contact with the outside community to minimise the risk of spread. These are generally healthy people and they do not have immediate known contacts with confirmed cases. So, as a precaution, we want them to stay at home. We want to minimise the risk of exposing them to the community and, therefore, we have this Stay-Home Notice which is enforceable and requires them to be at home all the time until the notice period is over. This is a precautionary measure.

So, there are actually three different levels: (a) those who are confirmed cases, they are in hospitals; (b) those who have close contacts with confirmed cases, they are of a higher risk and they are served quarantine orders; and (c) those who are returning from China, have been exposed in China, but no direct contact with known cases and these are served with Stay-Home Notices.

Mr Speaker, it seems that many cases of COVID-19 will not progress to pneumonia. They will be quite mild. So, it suggests that a mild case seen by a general practitioner and told to stay at home and rest, that case will progress, the person will recover but it will never be detected. So, I wonder whether this could actually be a good thing because, internationally, we have been called the "gold standard" in detection. That is a good thing normally. But, now, it is perhaps giving us an undue reputation for risks when actually we may not have that many real cases compared to many other countries.

I think the conclusion is the other way around. The cases that we have determined as confirmed are real cases. But other countries may have more cases than what they have reported. That is what the reports say.

The Member is right that some of the cases may have mild symptoms. But, generally, they may last quite some time and, therefore, after five days, if you have not yet recovered, then we are suspicious of you. Even then the doctors have to make a clinical judgement. It does not necessarily mean that once you have pneumonia, you will be referred and, if you do not have pneumonia, they will rule it out. The doctor will make a clinical judgement based on your condition and history, whether you have been in contact with multiple groups of people that have been exposed, for example. They also want to take your history, whether you have indirect contacts. The doctors are well-trained and very experienced in making clinical assessments. So, we will leave it to the doctors to make their ground assessments.

But the Member is right that it is not possible to detect 100% of the cases. We are doing the best we can. Usually, it is not done like that. We do proactive surveillance, meaning we look at all possible cases of pneumonia and some non-pneumonia cases we also investigate to see whether we are able to pick up cases. We also have a sentinel surveillance programme, which means we actually randomly pick patients in the community to test for potential respiratory infections, including COVID-19. This will allow us to pick up cases that would otherwise have gone totally unnoticed. It is a surveillance. So, it is not 100% testing everybody. As I have said, we cannot test 30,000 cases every day. It is just not possible. So, we do sampling. This will allow us to have a sense of what is happening on the ground in reality and give us a sense of judgement of how the situation is evolving. This is a useful approach.