Singapore's coronavirus response, marked by digital surveillance and quarantines in hospitals, was initially successful. But it's reaching a tipping point.

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A woman wears a face mask at a shop in Little India district, as the spread of coronavirus disease (COVID-19) continues, in Singapore, April 2, 2020.

Edgar Su/Reuters

  • Singapore applied the lessons it learned from the 2003 SARS outbreak to its coronavirus response. 
  • The country built isolation hospitals, developed a clear communication strategy, and used digital surveillance.
  • Singapore has seen just over 1,620 cases and six deaths, leading it to be hailed as a success story and a model for how to effectively confront the coronavirus.
  • But the country is facing a new wave of spread from presymptomatic carriers — showing how difficult it is to contain the coronavirus once the number of patients hits a critical mass.
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Singapore is about 2,100 miles away from Wuhan, China, the original epicenter of the coronavirus outbreak. But the country has seen relatively few cases: roughly 1,620 infections and six deaths.

Singapore's quick-moving, proactive, aggressive public-health response has been hailed as a success story. It closed its borders early, began tracking citizens and their contacts, tested frequently, and put anyone who tested positive — regardless of the severity of their symptoms — in quarantine in a hospital.

That initially allowed public life — schools, work, shopping — to continue as usual while many other countries instituted lockdowns.

But Singapore's domestic cases have doubled in the last week, showing how hard it is to contain the spread of the virus even with these measures in place. Singapore's Prime Minister Lee Hsien Loong shuttered non-essential businesses on Tuesday and schools on Wednesday, with the closures expected to last at least four weeks.

The coronavirus outbreak in Singapore

On January 31, Singapore had reported 13 cases of the coronavirus — all among travelers from Wuhan. It was the third country to report cases. By mid-February, Singapore had 80 patients — the highest number outside of mainland China.

A couple walk past a temperature screening check at Changi International Airport in Singapore on February 27, 2020.

Getty Images

To prevent the virus' spread among Singapore's 5.7 million residents — and the potential impact on the economy — leaders set aside $800 million in February to fight the outbreak.

Then the country took early measures: It banned travelers who'd been in mainland China on February 1. By mid-February, it closed its borders to all foreigners. Singapore also set aside resources for extensive contact tracing, built up testing capacity, and started to quarantine anyone suspected of having the virus. 

On March 27, Singapore's Ministry of Health issued a ruling that people who don't maintain a distance of 1 meter and who meet in groups of 10 or more face jail time or a fine.

Health authorities began to test all influenza-like and pneumonia cases for the virus. Patients with confirmed cases, even mild ones, were kept isolated in hospitals, rather than home quarantines.

Then a team of government employees meticulously traced their contacts.

Identifying the sources of cases

Singapore employed a team of 140 contact tracers to work in shifts from 8:30 a.m. until 10 p.m. every day of the week. They interview the country's COVID-19 patients; Dr. Leong Hoe Nam, a Singaporean infectious-disease specialist, told The World that the questioning is fairly straightforward.

"'Think of what has happened in the last five days,'" he said. "'What did you do?' 'Where did you go?' 'Who did you meet?'" 

Based on the answers, the tracers create a 14-day activity map and try to figure out where the patient contracted the virus. People who came into close contact with a sick person, such as family members, are put into a 14-day home quarantine. They are required to respond to text messages from the government multiple times a day to confirm that they're staying put — they have to click a link that checks the phone's location.

Lying to investigators is illegal and can result in jail time or thousands of dollars in fines.

The disease investigators also use surveillance footage from local businesses and digital pay records. They created a digital surveillance app to monitor people's physical interactions. The app uses Bluetooth data to show users if they were close to someone who has tested positive for the virus. If so, the app gives that exposed user the option to notify the government, which then organizes a COVID-19 test.

singapore whatsapp coronavirus update

Edgar Su/Reuters

Singapore's government also sends people updates about COVID-19 via WhatsApp twice a day. The messages include the numbers of new and recovered cases, plus specific locations of suspected outbreaks.

Some of these practices came from lessons learned during the 2003 SARS outbreak (SARS is also a coronavirus), when 33 people died in Singapore. The government instituted a similar quarantine policy then and used cutting-edge technology of the time — thermal scanners, internet-connected cameras, and electronic bracelets — to track SARS cases, according to the New York Times.

It also built up its medical infrastructure: more isolation hospitals and negative-pressure rooms.

But Singapore's case total is growing

Singapore's population is similar to that of Colorado, though its size is similar to that of New York City. For comparison's sake, Colorado had more than 5,600 cases and 193 deaths as of Wednesday. New York City had more than 81,000 cases and 4,500 deaths. 

But recently, Singapore has reported some of its biggest daily jumps in coronavirus cases — on Wednesday, it reported 142 new cases, its highest new case total yet. Since April 1, its case total has grown by about 700, and the total doubled the week prior, according to Reuters.

This second wave of infections shows how difficult containing the virus is.

A study of 243 COVID-19 cases in Singapore from January 23 to March 16 identified seven clusters of cases that likely led to the new wave, and found that "presymptomatic transmission is the most likely explanation."

People with the coronavirus can be infectious before their symptoms appear — the average incubation period is about five days, but can be up to two weeks or more.

"Very frankly, I am worried, because we do see an increasing number of unlinked cases ... and that is a sign that there are sporadic transmissions in the community that we are unable to get a handle on," Teo Yik Ying, a dean of the public health center at the National University of Singapore, told Reuters.

Aaron Holmes and Hilary Brueck contributed reporting.

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