A protective face mask is seen left on the ground in Singapore on January 28, 2021. Photo: AFP / Roslan Rahman

SINGAPORE – Wet markets, hawker centers and coffee shops have once again gone quiet after tighter Covid-19 restrictions were reinstated on July 22 to counter the highest incidence of community cases in 11 months, a development that health authorities say is a “huge setback” for the city-state’s reopening plans.

Despite making vaccination strides with the highest inoculation levels in the region, the threat of runaway infections fueled by the more transmissible Delta variant led the country to reimpose restrictions in place during May and June, prohibiting dining in at restaurants, closing indoor venues such as gyms, and limiting gatherings to two people.

After reporting very few locally transmitted cases in recent weeks, new infections rapidly mushroomed with major clusters at karaoke bars and a fishery port that soon spread to fresh seafood markets frequented by the elderly, a demographic given early priority for vaccination but with the lowest take-up rate among all eligible age groups.  

Health Minister Ong Ye Kung told reporters on Wednesday (July 21) that stricter curbs were needed to prevent “an uncontrollable rise in cases, which could potentially result in many severe illnesses or even deaths” among unvaccinated seniors. He said that more than 200,000 residents over age 60 have yet to be immunized.   

“We felt it is not the time to risk it all now,” said Ong, who is co-chair of Singapore’s multi-ministry Covid-19 task force, in reference to the city-state’s goal of having two-thirds of the population vaccinated by August 9, when the city-state commemorates national independence.

Over 50% of the population of 5.7 million have so far been fully immunized against Covid-19.

“Vaccination rates are probably not high enough at present to prevent a sharp rise in more severe disease and probably deaths from Covid-19 if this current wave is not brought under control,” said Hsu Li Yang, an infectious diseases expert at the NUS Saw Swee Hock School of Public Health.

A man waits outside a clinic to receive a Covid-19 vaccine on June 24, 2021, in Singapore. Photo: AFP via NurPhoto / Suhaimi Abdullah

Tightened restrictions will last until at least August 18 and will be reviewed in two weeks. The measures have come as a blow to many in Singapore who are eager to move on from the pandemic, particularly business owners whose operations have again been disrupted despite overwhelming compliance with social distancing and other strict rules.  

Covid-19 has also cast a shadow over celebrations to mark Singapore’s independence, with the annual National Day Parade (NDP) postponed to August 21 due to rising cases. The parade, which was downsized last year, was scheduled to be held on August 9 with plans for spectators to undergo required pre-event testing and be fully vaccinated.

The latest outbreaks have stoked anger over a lack of closer enforcement of karaoke or KTV bars that were allowed to operate as food and beverage outlets despite being notorious for facilitating gambling and sexual services known to be offered by foreign hostesses, at least 29 of whom have since been arrested by police in a crackdown on nightspots.

Authorities have, however, deemed the largest major cluster at the Jurong Fisheries Port to be of greater concern than the karaoke cluster that predominantly infected young people. A strain of coronavirus associated with imported cases from Indonesia, now the regional epicenter of Covid-19 transmission, has been linked to the port outbreak.  

Singapore’s highest recent daily toll was 182 cases on July 20, still only a fraction of those reported elsewhere in Southeast Asia but an alarming surge for a nation that reported zero daily cases only ten days earlier. The overall number of new community infections rose to 964 cases between July 17-23 from 126 cases detected between July 10-16.

“Our hospitals and [treatment facilities] are probably already stretched by this new daily triple-digit case count. Although not everyone is happy about this, understandably, the cautious approach here is reasonable,” said Hsu. “The Delta variant is too transmissible and virulent to be allowed free and rapid spread, even in a highly vaccinated population.”

The city-state’s return to lockdown-like conditions comes after authorities last month outlined a road map for loosening restrictions and treating Covid-19 as an endemic and manageable disease rather than a pandemic. Some observers have thus criticized the latest curbs as being contrary to the spirit of the much-publicized “new normal” approach.

Visitors walk past the Merlion at the Marina Bay in Singapore on 18 July, 2021, the day before stricter public health safety measures kicked in. Photo: AFP via NurPhoto / Joseph Nair

As part of this new strategy, the city-state’s health authorities have said daily cases would not be the primary data relied upon to make decisions on public health interventions. Instead, health outcomes would be the focus and take into account broader data on hospitalizations, death rates and intensive care unit (ICU) patient numbers.  

Though the number of active cases tripled over the last seven days to 1,179 and has seen many more people hospitalized, only one person is in critical condition, while only 36 people have died since the start of pandemic, facts that some argue should have led authorities to take a less risk-averse response to rising cases given the current rate of immunization.

Indeed, just prior to the announcement of tightened rules, authorities were planning to allow differentiated safe management measures for vaccinated people to participate in social and dining activities that carry a higher risk, though that approach was put on hold over concerns of cases rising too sharply and endangering the unvaccinated.

Teo Yik Ying, dean of the Saw Swee Hock School of Public Health at the National University of Singapore (NUS), said there is a general misunderstanding that Singapore has already commenced an endemic strategy, though authorities have explained it is contingent upon a sufficiently high level of vaccine uptake among the population.

“This is only expected to happen sometime in August. Until then, Singapore remains on high alert to limit the extent of community infections happening in order to protect those that are unvaccinated or only partially vaccinated,” said Teo, who added that Singaporeans’ frustration over tightened restrictions was understandable.

“Many people in Singapore have cooperated and complied fully with the requests by the government, including getting vaccinated and minimizing social gatherings. The latest curbs do seem to be punishing the cooperative masses because of the slippages of the few, but I must state that this is a necessary burden to bear in the short-term,” he said.

Singapore’s government has encouraged the elderly to get vaccinated against Covid-19 with door-to-door outreach and rules that allow seniors to walk into any vaccination center without an advance booking to receive their shots. But many have not done so, fearing possible side effects or aggravating their pre-existing medical conditions.

Teo said that some elderly residents have deliberately decided not to be vaccinated due to safety concerns linked to messenger RNA (mRNA) vaccines like Pfizer-BioNTech or Moderna that are currently used in Singapore’s national vaccine program, while others are ambivalent to vaccination and may require door-to-door vaccination services.

Two men wait outside a clinic after receiving the China-made Sinovac vaccine on June 24, 2021 in Singapore. Photo: AFP via NurPhoto / Suhaimi Abdullah

Offering other non-MRA vaccines such as those produced by China’s Sinovac Biotech or American biotech firm Novavax as part of the national vaccination rollout – provided there is sufficient enough safety and efficacy data to support their inclusion – could help to allay some concerns of the elderly and increase vaccine uptake, the professor suggested.

Sinovac’s vaccine has yet to be approved by the city-state’s regulators, though it is available for purchase at some private clinics. Authorities signed an agreement with Novavax in June to purchase its protein-based Covid-19 vaccine, which has shown to be more than 90% effective in late-stage clinical trials in the United States.

Health experts expect Singapore’s tolerance for community infections to be much higher once at least 70% of the population are fully vaccinated by early August, though measures limiting group sizes for social activities and dining, as well as mandatory mask-wearing, are likely to remain in place for some time to allow for even higher levels of vaccination.

“I do think that Singapore will tolerate around 100-200 new cases a day as long as the majority are mild, like they are right now. This would lead to a scaling down of public health measures, perhaps to what is done for influenza,” said Paul Tambyah, president of the Asia-Pacific Society of Clinical Microbiology and Infection.

Though an endemic approach to Covid-19 remains somewhat “aspirational” in Singapore and most of the world, “it is something that we all agree needs to be done,” Tambyah added.

“When the vaccination rates rise and the number of individuals who are seriously ill remains in the single digits, we will move on to learn to live with the virus,” he said.