S’pore doctor shares insights on Covid-19 reinfection & containment measures after WHO China mission

Singaporeans need to keep things in perspective and not panic over every little piece of news, he said.

Mothership| March 06, 09:18 AM

Dale Fisher is an infectious disease specialist and professor at the National University of Singapore.

Apart from being a senior consultant at the National University Hospital and Singapore’s Ministry of Health, he has also been involved with the World Health Organisation’s Global Outbreak Alert & Response Network (GOARN) for 15 years.

He came to Singapore to help with the SARS situation in 2003, and is now a Permanent Resident after relocating here in 2004.

Crucially, Fisher was also on the World Health Organisation-led team that visited China to increase understanding of the virus and guide the global response to the outbreak.

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How did you end up working in Singapore?

I actually went to high school here. I went to the United World College of Southeast Asia in Dover Road, and then went back to Australia to get my university degree and worked there for a while. Eventually, when I got to about 40, I saw a job in Singapore, so I came during SARS to help with the situation in 2003.

I remember thinking to myself, Wow, is it always like this with infectious diseases in Singapore? (Of course it isn’t). But at that time, it was pretty insane. It was a severe illness where healthcare workers were at a serious risk of getting infected and dying.

After that, I relocated here with my family in 2004.

You recently went to China as part of the WHO contingent of international experts. Can you tell us a bit about this team and how you were selected?

I have been privileged to be an invited member of the WHO-China Joint Mission on Covid-19 at the request of Mr Xi Jinping, President of the People’s Republic of China and Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization.

On this mission we learnt a lot about transmissibility, severity and containment measures.

There were 25 of us on the mission. There are 12 from China, and 12 internationals and Bruce Aylward was the lead. So that made 25.

I visited Beijing, Sichuan and Guangzhou. A few of my colleagues, about five or six of them, went to Wuhan.

I've known all the people in Geneva since about 2007. And I've been on the international steering committee [of GOARN] for the last seven years, and I've been the chair of it for the last two… So I’ve had the opportunity to meet lots of people.

When putting together an expert team, I think they aren’t just looking for experts, but also people they can trust, people who can work independently as well as in a team.

They were looking for people who were going to see both sides of an argument, and weren’t going to be offensive.

So I was half of all these characteristics because I was offensive and obstructive (laughs) – no, I’m just joking.

I think I was picked because I complemented the overall dynamic of the team plus I have been on many missions before as a case management and infection prevention and control expert.

Did you visit any hospitals when you were in China? We’ve heard anecdotes on social media about medical staff breaking down and being overstretched. What was the situation like on the ground with the medical response teams?

When the disease runs unchecked and health services get overwhelmed then mortality rates climb.

I’ve seen it in other situations. I've seen hospitals overwhelmed by Ebola. I've seen hospitals overwhelmed by H1N1.

I’ve reviewed case notes for patients from hospitals located in less-developed nations. There were emergency cases handled in the corridor of the emergency department, with family members in the hallway pumping a bag to blow air into their lungs all night.

That's what happens when you get overwhelmed by huge numbers of cases. And this is also what we want to prevent in Singapore – people will become infected but we can best manage if infection occurs through the population slowly and in a controlled way.

In the beginning it was a lot more chaotic, but I think more order in the outbreak has been put in place in China over time. You know that they're ready for more cases too but I think they are so primed, they wouldn't let another city become a Wuhan.

We’ve seen how they have scaled up their infrastructure, and how there’s really a lot of expertise there.

I didn’t see patients when I was in China, but I did meet some doctors to better understand what was going on.

In Wuhan, there’s been quite a lot of makeshift and temporary hospitals. Thousands of doctors have also been deployed to Wuhan. They've got more beds and more testing capacity now.

You were in Beijing, Sichuan and Guangzhou. What did you observe in these cities?

I did not expect to see everybody wearing a mask. It was law, actually -- if you're out in public, you have to wear a mask. So we had to wear a mask the whole time as well.

Did you feel it was necessary, though?

So we [in Singapore] would say that if you're sick, wear a mask. In some sense, we're allowing people to make that decision.

But in parts of China, this law means that it doesn’t matter if one is sick or not. They should wear a mask, regardless.

Were the streets significantly emptier too? Can you tell us a bit more about what it’s like in these Chinese cities?

The cities were empty -- no cars or few cars on the streets, few walking along the pavements, almost all the shops were closed.

There's no social activity -- you know, I could walk for 10 or 15 minutes along the streets in Beijing, and I might go past three or four people. All our meals were sent to our room via room service.

I also noticed that the government has curbed and controlled certain social activities to mitigate the spread of the virus.

People are mostly in their houses, and strongly encouraged to work from home. The movement of people is also quite tightly controlled. In Chengdu, we went to an apartment block where non-residents weren’t allowed in. Basically, they weren’t allowed to have visitors.

I have heard of other places where everyone was home quarantined. And they had a pass to leave: one family member, every two days.

If people aren't allowed to spend any time together, all the infection clusters become family clusters because no one has left their homes.

I think this is why people hoarded groceries in Singapore, because Singaporeans feared a lockdown. And that somehow they’ll be stuck in their homes with no toilet paper.

So your experience in these cities was quite similar to the experiences of your colleagues in Wuhan?

I think so. Right now, as China continues to ramp up its own readiness efforts, people are not out and about.

From your experience dealing with infectious diseases, how worried should Singaporeans be at this point?

Of course we should be concerned. It is what it is and we have to deal with it by minimising any problems coming in from it.

Overall, internationally, I don’t believe the world is ready for this outbreak. But Singapore is.

We've got great lab capacity, we can convert private wards into isolation wards, or cancel elective surgeries. We can do a lot here and we have done it.

All these need to be kept in perspective, so that we don't panic over every little [piece of] news or every new little finding.

Of course we have to be particularly wary of the ones at risk: those with compromised immunities and the elderly. These are the ones most likely to be seriously affected by the disease.

For people of your age (editor’s note: the interviewers are in their mid-20s and early 30s), I don’t think it’s going to be a very serious disease. But you can still spread it, so one should always take precautions.

There has been some talk about people getting reinfected in Japan. Is reinfection something to be worried about?

They’re not reinfections; it’s a question of ongoing, asymptomatic infections.

It could be a very borderline case – at the time of testing, the amount of virus is just at the very lowest level [to be considered positive], and sometimes if it dips below, the test will turn out to be negative.

But what this means is that there are asymptomatic people who may have been discharged. When they're still asymptomatic, they can have the virus but i doubt it is very infectious and such cases won’t be driving the outbreak.

While contact tracing is underway, there are some cases in Singapore that appear to be unlinked. Is the fact that we've not tracked down where they got it from a cause for concern?

Now let's say there’s someone with a little bit of a cough that never went to the doctor, and actually got better, so they were never diagnosed. But they've somehow given it to someone else, who then gets sick. It then becomes hard to trace this intermediary person.

This is why it’s so important to educate the public on staying away from others or wearing a mask if they’re ill, washing their hands frequently, and going to the doctor if they are concerned.

So it’s true that once you get a virus you can’t technically get re-infected?

The likelihood is once you've had it, you're immune to it.

If Covid-19 turns into a full-blown global pandemic, how is Singapore’s situation likely to be? Could there be a case where we would turn people away from our hospitals even though they are sick?

I've seen plenty of respiratory illnesses before so it doesn't really matter what it is. From my observations, about 80 per cent of these don't actually really need to be in hospital. They're just warded for quarantine reasons.

So hypothetically speaking, if we’re in [DORSCON] Red with free community transmission, we would likely adjust our containment strategies and focus more on looking after the very sick people.

Is there anything Singapore should be thinking about next?

When the outbreak happened, a lot of people had their non-essential clinic appointments, procedures and surgeries cancelled.

But we can’t put these on hold forever, so hospitals are going to have to work this out eventually.

Top photo collage from Dale Fisher and People’s'>

Daily China/Facebook

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