Janil Puthucheary
Singapore
“Sir, I thank Ms Lee for her two supplementary questions, which address what are our targets and what is it that we measure. Indeed, the issue of how we should think about recycling and waste disposal will be at the heart of our review of our Zero Waste Masterplan.”
“Another strategy that we are embarking on is the strengthening of the reuse of waste residue and treated toxic industrial waste before and after they are landfilled.”
“Sir, about half of our recycling material is exported. It is processed overseas. There are business arrangements between businesses here in Singapore and businesses in the region or overseas, to be able to handle the recycling of waste and recycling of material, whether domestic or non-domestic, already today.”
“Sir, I thank Ms Poh for her questions. Indeed, we do have to shift behaviours. The incentives and disincentives around recycling and waste disposal are an important part of it. We will consider her suggestion on looking at the fees.”
“The heat advisory that goes out is clearly defined. In my original answer, I explained what a heat wave was. There are clear definitions that we have been using in Singapore since 2016, if I recall. It was then last revised in 2023.”
“Sir, in the planning of schools, the Ministry of Education ensures that our students can access a primary school near their homes. Except for a small number, 15 of Special Assistance Plan schools, all primary schools offer the three official mother tongue languages.”
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“Sir, we continue to study all the different modes for patients and citizens to interact with Government. LifeSG is one of those that aggregates a number of services. There are other portals and means through which citizens engage with Government. And the engagement with Government is different from the engagement with your healthcare provider. So, where it works for the patient experience – maybe for safety, for information gathering, or for user experience – we will always be considering how to optimise and streamline. The nature of many of the products' platforms that the Member refers to, is that they are the front-end for common core services. The backbone is common, the data standards are common, the information sharing processes are common. But then, engaging with a particular provider allows a user experience, as well as facilities specific services to then be deployed. So, it is not an "either or". The example that the Member gave with LifeSG is salient to this because in LifeSG, many of those functions are also accessible through other means, where it is appropriate for either the provider or for the citizen. We will continue to review the entire space.”
“Over time, some of these new innovations that are well-received and successful in engaging patients can be incorporated as common services that are then made available to all patients in their preferred platform, be it HealthHub or one of the cluster apps. We will continue to improve our digital services and enhance our offerings to improve the user experience.”
“Sir, there are ongoing efforts to improve information sharing and the delivery of digital services to enhance the patient experience. The National Electronic Health Record (NEHR) system enables sharing of patient summary health records across care providers, including the three public healthcare clusters. We will progressively build up its coverage to include information from more healthcare providers to support care continuity. A common pharmacy system for the three public healthcare clusters is underway, to allow consolidation of patient information, which allows providers to have a more holistic view of patients' medications and facilitate the filling of prescriptions. MOH and the healthcare clusters are also developing a national charging and billing system to streamline processes and enable a more consistent experience for patients. Common digital services across the clusters, such as the scheduling of appointments and bill payments, are available on the national HealthHub mobile app and web portal. HealthHub also displays personal health records drawn from national systems, including for example, the COVID-19 vaccination records and COVID-19 test results. These common services are also made available through the clusters' apps. This reduces duplication of development effort and facilitates consistent user experience, regardless of the platform a person prefers to use to connect with our healthcare system. Meanwhile, the presence of healthcare cluster-specific apps enables those healthcare providers to customise features tailored to their specific facilities and services, and also to innovate on user-interaction features that could better engage their patients.”
“If we extrapolate that approach to our situation here, the estimate is that between September 2021 and January 2022, comparing similar data-sets over about those four, five months, the contact tracing approach that we have taken in Singapore may have saved about 290 deaths and slowed down the progression to avoid about 144,000 cases. I hope the Member would agree that these are useful outcomes. When will we no longer need such an approach, when will we phase out and what may the criteria be, it is a bit too early to tell. We need to wait until we no longer need VDS, we need to wait until we are quite sure that the pandemic and COVID-19 is no longer epidemic but is endemic. We have not reached that point yet. It is very hard to say with some degree of certainty what that date will be. But I think we have explained before that as long as we need the measures in place – the public health measures, the VDS – then, today, the easiest way and the least burdensome way and the cheapest way for businesses, for us to roll out these measures, is to continue with the TraceTogether and SafeEntry systems that we have in place, rather than standing up a whole new system and a whole new infrastructure in order to get those outcomes. So, when we no longer need those measures, then we would stand down the systems.”
“I thank the Member for his questions. Indeed, measures that affect public health and safety do have a compliance burden. This is not unique to TraceTogether and SafeEntry. Neither is it unique to the COVID-19 situation. If we look at, for example, the automobile industry, the use of seat belts is a cost burden, but we do it now after many decades of education because it has proven its worth. So, really, the issue is whether or not the approach that we are taking has proven its worth. I hope the Member will agree that it has the ability to issue Health Risk Warnings and Notices very quickly in the face of a rapidly progressing pandemic; is an important public health measure. These have managed to keep our case fatality rate low as we have slowed the spread and allowed people to self-isolate and seek help very early on in the illness. As long as we are able to do that and to demonstrate an effectiveness of using TraceTogether, SafeEntry and VDS in our public health response, then I hope the Member will agree that the ability to save lives, prevent morbidity and mortality through this disease is a beneficial outcome and is worth paying that compliance cost and compliance burden for. Studies in other parts of the world, there was a UK study that was published looking at this, looking at some modelling and the extent to which this automated contact tracing approach saves lives, prevents cases, and we have every reason to believe the same is true here in Singapore. The study that was done in the UK.”
“Sir, as we have described in previous responses to Parliamentary Questions, TraceTogether and SafeEntry continue to play important roles in our pandemic response system. TraceTogether and SafeEntry enable verification checks into venues or activities where vaccination-differentiated safe management measures (VDS) are in force. This is necessary to protect unvaccinated persons who remain at higher risk of severe disease. We aim to keep rules and requirements simple, and we regularly review the need for these. We will continue to rationalise and simplify our safe management measures.”
“Sir, I thank the Member for the questions. The issue is not whether a vaccine is or is not effective. There is a matter of timing of those and the circumstances. So, the matter continues to be studied by various people around the world, as well as our experts here. For children in the age groups that the Member mentioned, where the vaccines are already being rolled out, indeed, we continue through our various public health processes, to monitor and measure the effectiveness of the vaccination process.”
“Sir, the Member asked three questions. For the first, the specific data is a slightly different issue from the Parliamentary Question (PQ) he had filed. I suggest he file a PQ, potentially a written PQ, for that data. We will get it to him. For his second question about other vaccines, we are studying all clinical data that is being produced for all the therapeutic interventions for COVID-19. We will take that data, we will take the recommendations from our professionals and experts, and we will assess the various products as they become available for licensing here in Singapore. In terms of what parents can do, hygiene continues to be important. Making sure that we stay at home if we are feeling unwell, engage with the testing procedures, the various protocols that we have explained for community protocols – Protocols 1, 2 and 3. These are not just for ourselves. They are for our family, our loved ones and society at large. And if we can all play our part in helping, then, the youngest, most vulnerable and all vulnerable members of our society will be better protected.”
“Sir, the Pfizer-BioNTech COVID-19 vaccine is currently approved for use in individuals aged above five. The use of vaccine for younger children is still being studied in clinical trials. MOH, in consultation with the Expert Committee on COVID-19 Vaccination, the EC19V, continues to examine different vaccine strategies, based on the risk-benefit assessment to the relevant subpopulation, in the context of the evolving COVID-19 situation.”
“Sir, in November 2021, the US Department of Commerce placed several companies on the Bureau of Industry and Security’s Entity List, including a local company, Computer Security Initiative Consultancy, also known as COSEINC. The effect of being placed on this List means that US persons intending to export, re-export or transfer items that the US regulates to COSEINC must first obtain a licence to do so from the US Government. Arising from this, the Cyber Security Agency (CSA) looked into COSEINC. The company’s offerings include cybersecurity training courses. We can share that, in this regard, it is one of many vendors to have provided training services to the Government and the contractual terms were standard. CSA also found no evidence that COSEINC had breached cybersecurity laws in Singapore. Companies found to have contravened our laws and regulations will be dealt with in accordance with the law.”
“Mr Deputy Speaker, the Expert Committee on COVID-19 Vaccination (EC19V) has determined that most residents can be safely vaccinated. Only those who are allergic to COVID-19 vaccines are medically ineligible. Individuals with specific medical queries or requiring detailed medical consultation, can approach their own doctors for a more detailed discussion on their health conditions and their suitability of vaccination. All vaccination centres are also equipped to screen for and advise on the medical suitability for the COVID-19 vaccines under the National Vaccination programme. The vaccination centres are staffed by trained medical personnel who are also guided by clinical guidelines developed in consultation with EC19V.”
“Thank you, Mr Deputy Speaker. Mr Perera had asked his Question No 10 in two parts, I had failed to answer the second part. If I may just finish off the reply. Visitors who are allowed into hospital wards and Homes on an exceptional basis will need to produce a valid negative antigen rapid test (ART) result obtained within the last 24 hours of the visit, prior to their visit. Fully vaccinated visitors are allowed to show photographic proof of the result of a self-administered ART done at home prior to the visit. Such hospital visitors who have not done the test before the visit will be able to purchase ART kits from vending machines or the retail pharmacies at public hospitals. [Please refer to "Visitation Policies for Visits to Severely Ill Patients in Hospitals and Care Homes", Official Report, 18 February 2022, Vol 95, Issue No 49, Oral Answers to Question section.]”
“Mr Deputy Speaker, in-person visits to hospital wards and residential care homes, or homes, are suspended from 24 January to 20 March 2022 to protect our healthcare capacity. Hospitals and homes have the discretion to allow visits for exceptional cases, for example, if the patient or resident is severely ill. MOH had made exceptions for severely ill patients in hospitals to have up to five pre-registered visitors. [Please refer to "Clarification by Senior Minister of State for Health", Official Report, 18 February 2022, Vol 95, Issue No 49, Clarification section.]”
“Mr Speaker, may I propose that we proceed with the original amendments to the process that Leader had articulated, to split the second vote because there are other Members in the House and they may have different views from the clauses as we have described. I would propose that we do split the Second Motion into two votes.”
“Sir, I thank the Member for her question. The short answer is that we are always looking at the systems that we have in place to gather information for clinical results and information that is useful for us to fight the pandemic and to secure our public health systems. So, some of these include audits, some of these are about how we look after the licence issuing governance processes of the professionals at the clinical sites involved. But, so far, the system appears to be working well.”
“Mr Speaker, MOH takes a serious view of the accuracy of vaccination records and Antigen Rapid Test (ART) results that are recorded and stored into our national systems, as this has a direct impact on public health and safety. MOH had lodged a complaint with the Singapore Police Force as soon as our investigations against the alleged errant clinic detected false vaccination and false positive ART results. Both MOH and the Police are working closely to establish the false records in the clinical database. Investigations are ongoing but once the records are verified to be false, MOH will make the correction on our national systems immediately and these patients will have their vaccination or recovered status correctly recorded. Patients who have obtained falsified vaccination status or false positive ART results and have had the false data uploaded to our national systems will also be referred to the Police for investigations.”
“Sir, as the Member will appreciate, the issue of safety when it comes to medication, vaccines, medical therapeutics, is not absolute. Nothing is completely absolutely safe or absolutely unsafe. It is about the relative risk and the relative benefit. The individuals under the age of 17 who are getting the non-mRNA vaccines – currently, the Sinovac-CoronaVac vaccines – in those circumstances, because they are medically ineligible for the mRNA vaccines, the benefits of being vaccinated with any vaccine are, indeed, outweighed by the risks and safety concerns that currently exists for those vaccines, and weighed up against the risk of getting a Coronavirus infection. But for the others who are not medically ineligible, the safety and efficacy data are quite clear. Therefore, we would continue to recommend for them an mRNA vaccine. Because it is not just about their risks and their immunity at this point in time, but over the next few months, as the pandemic continues to be a challenge for us and around the world, we have to think about how quickly their immunity will wane, what would be their ability to deal with the future waves or even this existing wave as it makes its way through our society. So, we continue to recommend the mRNA vaccines. As I have explained, we are trying to bring in other options for these individuals in the near future.”
“In January 2022, the programme was further extended to eligible children aged five to 11, after the data from the older age group indicated that the safety profile of the vaccine was generally consistent with that of other registered vaccines used in immunisation against other diseases. MOH is working to bring in other non-mRNA options for those who are medically ineligible. The Novavax COVID-19 vaccine has been assessed by HSA to be safe and effective for persons aged 18 and above, with two doses demonstrating a vaccine efficacy of 90% against symptomatic infection and 100% against severe disease with the wildtype SARS-CoV2 and the Alpha variant, with no significant safety concerns. Therefore, in February 2022, HSA issued its PSAR interim authorisation letter to Novavax for its COVID-19 vaccine. Novavax recently released data that the vaccine was found to be 80% effective against COVID-19 in a late-stage trial in adolescents aged 12 to 17 in the United States when the Delta variant was the dominant strain. HSA and MOH will evaluate the data from this study and will continue to monitor for more data on its efficacy and safety in children and adolescents. The Expert Committee for COVID-19 Vaccination (EC19V) has also reviewed data on the vaccine’s safety and efficacy and has recommended the use of the Novavax COVID-19 vaccine under the NVP for primary and booster vaccination in individuals aged 18 and older. We hope that the initial doses of the Novavax COVID-19 vaccine will arrive in Singapore within a matter of months, provided that there are no disruptions to the shipment schedule. Meanwhile, those who are medically eligible are encouraged to take the available mRNA vaccines as they offer more optimal protection.”
“Sir, as of 9 February 2022, there were about 1,000 individuals who completed the primary vaccine course with non-mRNA vaccines and would have their “fully-vaccinated” status expire by 14 February 2022. Persons who are medically ineligible to receive the mRNA vaccine and aged 18 and above, can receive Sinovac-CoronaVac vaccine under the National Vaccination Programme (NVP) as a booster vaccine. The use of the Sinovac-CoronaVac vaccine under NVP is only for persons aged 18 and above, as the vaccine manufacturer did not include children and adolescents when filing for interim authorisation of the vaccine under the Health Sciences Authority (HSA)’s Pandemic Special Access Route (PSAR). Both Sinovac-CoronaVac and the Sinopharm vaccines are also not currently recommended for routine use in persons aged below 18 by the World Health Organization. Notwithstanding the manufacturer’s filing on the use of the vaccine, limited data from the Sinovac-CoronaVac vaccine manufacturer’s early Phase I and II trials in healthy children and adolescents aged three to 17 do not show safety concerns and we recognise the need for alternative vaccines for persons medically ineligible for the currently approved vaccine in this age group. MOH has, therefore, also separately introduced a dedicated public health programme – Sinovac after mRNA (SAM) – outside of the NVP, to offer the Sinovac-CoronaVac vaccine to individuals aged 12 to 17 who are medically ineligible for the Pfizer-BioNTech/Comirnaty COVID-19 vaccine, to afford them some level of protection against COVID-19 while closely monitoring their safety. SAM is, therefore, part of a research study which, under our current regulatory framework, enabled the administration of the Sinovac vaccine to an age group outside the scope of PSAR approval.”
“Mr Speaker, may I seek your permission to take Question Nos 6 and 7 together, please?”
“Sir, I thank Dr Wan Rizal for his questions. For the first question which is paternal and grandparent involvement, the answer is yes. We are looking at this from a mother and child view, with respect to the science, because that is really where we have the research in terms of pre-conception, what happens in pregnancy, early neo-natal period. But getting things done, the service delivery kind of programmes and activities are really from a family-centric point of view. And so, the whole family is indeed encouraged to join in, to be part of this and to come along the journey. I hope that the fathers out there do not need a special invitation with their name. We are asking the whole family to turn up. So, as the father, he is part of the family, please come and get involved in looking after the young child and the young child's mother, and helping to support them through the journey. The grandparents are naturally involved in very much part of the caregiving in our society. So, we take a family-centric view to involve the whole family. For the actual strategies around screening and interventions, these are still being studied and we have to look to see where we will implement programmes and activities. We will make the announcement in due course. But indeed, getting the right tools to make sure the interventions are effective are going to be important. We will be studying this.”
“Mr Speaker, the Taskforce on Child and Maternal Health and Well-being was set up by MOH early last year to oversee the development and implementation of a five-year Strategy and Action Plan. The strategy will focus on supporting women and their children to attain good health and well-being, leading to a healthier next generation. The efforts of the Taskforce are organised along three main thrusts. First, we are focusing on translating evidence-based findings into policies and programmes to address health risks. We will also go further upstream, as early as the pre-conception phase, in implementing preventive health efforts for women and children. Second, we are reviewing service delivery for children and their families to minimise the number of touch points that our citizens need to navigate across services. And third, we are reviewing our approaches to engage stakeholders and the public and to hear what matters most to them and to ensure that our messages and support to them stay relevant. Over the past year, the Taskforce, comprising members from the public, private and academic sectors, has conducted focus group discussions with parents, parents-to-be and caregivers. We have also conducted some 20 site visits and engagement sessions with frontline officers from across the health, social and education domains to better understand what matters most to children and their families. The Taskforce is reviewing and finalising its recommendations for the Strategy and we will be announcing more details soon.”
“Sir, I thank the Member for his question. The answer is partly in the last line that he stated, which is, that we took that approach in the early stages of the adult vaccination drive because, at that time, the amount of data that we had was less and the amount of experience that we had was less. Now we know a lot more about both the disease as well as the vaccination, including in children. So, the approach for children is not so different from adults. If they have an underlying condition – and there is a list that the doctor will know about it – then some review needs to happen. But if the child is otherwise healthy, then the recommendation is to proceed with the COVID-19 vaccination. The issue of allergies is slightly different in that, for any drug, you cannot necessarily tell whether an allergy will happen or not happen on the basis of prior underlying conditions. Hence, the team at the site of the vaccination is trained to then detect and deal with the rare allergies that do happen. And again, our experience with COVID-19 is, it does not happen any differently from other vaccinations that we are giving to children on a regular basis. So, the short answer to the Member's question whether all children should go for medical review prior to COVID-19 is "no".”
“As of 6 January 2022, there are 14,097 individuals between the ages of 12 to 19 who are unvaccinated, of which, only 14 are medically ineligible for the Pfizer-BioNTech/Comirnaty COVID-19 vaccine. COVID-19 vaccination is an important national effort in our fight against the pandemic. Vaccination for children aged five to 11 will help to protect more members of our society from the risk of developing severe illness from COVID-19 infections and further minimise the risk of community spread. We strongly encourage all parents, all guardians, to allow their children who are medically eligible to please take up the vaccine when offered to them.”
“If introduced, MOH will continue to ensure that families with children are able to access vaccination services in a convenient manner. As of 7 January 2022, MOH has not received any report of serious adverse events or myocarditis from vaccination in children in Singapore since the rollout of the national vaccination programme to children aged five to 11. We will continue to monitor this closely. We assure parents that all our designated paediatric VCs are equipped with paediatric monitoring and resuscitation equipment, and the medical personnel are trained to manage any on-site emergencies arising from allergic reactions. Most side effects experienced by children after vaccination have been mild, such as injection site pain, fatigue and fever, which typically resolve in a few days. Members have asked if children are covered by VIFAP, and the answer is yes, as long as they are Singapore Citizens, Permanent Residents or long-term pass holders. At present, only the Pfizer-BioNTech/Comirnaty COVID-19 vaccine is authorised for use in children aged below 18. Special exemptions are made for those aged 12 to 17 who are not medically eligible for the Pfizer-BioNTech/Comirnaty COVID-19 vaccine to receive the Sinovac-CoronaVac vaccine under a dedicated public health programme. MOH will work with the EC19V to review if the dedicated public health programme should be extended to children aged five to 11 who are medically ineligible to complete the Pfizer-BioNTech/Comirnaty COVID-19 vaccine based on further studies on the safety and effectiveness of Sinovac-CoronaVac vaccine. Among those aged 12 to 19, less than 4% remain unvaccinated.”
“4% of the children experienced serious adverse events, such as fever, vomiting, myocarditis and seizures. The incidence of myocarditis, which is what many parents are most concerned about, is about one in a million doses. The children reported with myocarditis following vaccination had either recovered or were recovering at the time of the report. Vaccination will allow our children to be protected against the disease and reduce the likelihood of infecting others, including vulnerable or elderly family members. On the other hand, the incidence of myocarditis among individuals aged 12 to 17 infected with COVID-19, is about 45 per 100,000 infections. [Please refer to “Clarification by Minister for Health”, Official Report, 10 January 2022, Vol 95, Issue 44, Clarification section.] So, Members can see that the risk is much lower with the immunisation and, hence, the benefits are much greater. To facilitate the vaccination of younger children, 15 designated paediatric vaccination centres (VCs) located island-wide are being progressively stood up. All 15 VCs will be manned by medical personnel trained in paediatric care and staff experienced in administering vaccinations for children. To provide greater convenience for parents or guardians with more than one child or ward, from 10 January 2022, all accompanying siblings of a child with an appointment from Mondays to Thursdays can walk in for their vaccination without a prior appointment. MOH has also worked closely with MOE and the Early Childhood Development Agency (ECDA) to organise webinars with parents to address common concerns on the safety and efficacy of the COVID-19 vaccine. Currently, there are no recommendations for children to receive booster shots.”
“Sir, my response will also be addressing questions on similar topics filed by Ms Hany Soh, Dr Wan Rizal1 and Mr Sharael Taha for 11 January 2022. The Ministry of Health (MOH) commenced COVID-19 vaccinations using the paediatric formulation of Pfizer-BioNTech/Comirnaty vaccine on 27 December 2021, starting with older children and with a plan to progressively expand the programme to include younger children, which has now happened. The take-up so far has been encouraging. As of 7 January, about 123,000 children aged five to 11 have received at least one dose of the vaccine or booked their vaccination appointments. In 2021, there were 15,540 children below the age of 12 who were infected with COVID-19, of which 3,145 had ever been in a hospital or a COVID-19 facility. Fortunately, as of 8 January 2022, none of these children remained hospitalised. Although fewer children have been seriously ill with COVID-19 compared to adults, there is still a risk of them becoming seriously ill or developing severe COVID-19 complications, such as Multisystem Inflammatory Syndrome in Children (MIS-C). Since mid-October 2021, we have observed several serious cases of COVID-19 in children, with some requiring intensive care. This is why it is important for children aged five to 11 to take up the COVID-19 vaccination. The Pfizer/BioNTech COVID-19 vaccination for children has been assessed by HSA and our own Expert Committee on COVID-19 Vaccination (EC19V) to be safe. The assessment is corroborated by international data. In the United States of America, where about 8.7 million doses had been administered to children as of 19 December 2021, most of the adverse events reported were not serious and no safety concerns have been raised; 2.”
“Mr Speaker, may I have your permission to take Question Nos 13 through to 15, please?”
“Sir, I do not have the data in terms of specific hospitals or clinical sites which have backlogs and which do not. Part of that is because we do operate as one system and where there is a little bit of capacity here or there, there is some load balancing and different sites work together. So, that is going to be dynamic, they are working to try to clear this as best they can. We are also uncertain how long this will go on for, so it is a bit hard to predict where we will be in terms of this – the rest of the healthcare system's duties and responsibilities once COVID-19 starts to wane – because we do not quite know when that will happen. So, there is a stress on the healthcare system, it will persist for some time after COVID-19 starts to come down, precisely for the reasons the Member has identified. Will this affect leave? Possibly. But the hospitals and the staff, the leadership are going to try to find ways to give their teams some rest and I do not think this is something that we can settle on a policy basis, it is very granular, it depends on the size of your team and the various other duties, when is your lull time, when is your up time. And I suspect what will happen is that the different teams, the different departments, the different divisions will allow rotating leave in different patterns to suit their acuity levels. And probably, you may have some people who are on leave but have a relatively short notice to be present, or they may be on local leave and another proportion which are allowed overseas leave and so forth. I think these are operational parameters and you have to let the clinical teams make these decisions on their own. We need to try to support them at a more systemic level.”
“I hope that adds some clarity to the Member's question.”
“Sir, I thank the Member for her question. It is not straightforward to answer. Because the definition of well-controlled will vary and the way in which you see the impact of good control of the disease when you get COVID-19 will also be quite different. Let me give some examples. Let us just use diabetes for example. If you have had diabetes for many years, diagnosed young, struggling with it, living with it, but you have had it kind of controlled. Do you have a lower risk than someone who perhaps had it diagnosed only one or two years ago, but really has not had it well-controlled yet? I am not entirely sure what the answer to that question is. And when you then encounter COVID-19, even if you had it well-controlled, because your body is fighting another illness, now COVID-19, your diabetes control goes out. So, do you then look at well-controlled at the point that you got infected, or the point that you got into ICU? The data that we have does not help to inform us to the point where we can make a recommendation and we can say, "Well, if you have diabetes and your blood sugar is like this, you are okay; if your blood sugar is like that, it is not okay". We are still at the point where we say, "If you have diabetes, control it as best you can. Whether you have COVID-19 or not, that is a risk. Now that COVID-19 is present, you need to really make sure you take care of yourself." And this then applies to a wide variety of conditions. So, it is quite clear that poorly controlled diseases do increase the risk very significantly. But there are some patients even with well-controlled diseases, it appears that having that disease means that they handle COVID-19 poorly even if the disease was well-controlled when they get COVID-19.”
“We are trying to tread a middle path and trying to get the best of both. He asks then what caused the infections in our country and what are the routes of infection for seniors who are living alone, in their own homes. The route of infection is largely from human-to-human contact. That is how people get this infection. If you were truly isolated and you were entirely living alone, with no human contact, you could maybe get away without this. But I think, people find that sort of life is also fairly unbearable. So, whether you are living alone as a senior or in a nursing home or in your own home, usually there is some form of human contact. And that is precisely why we cannot think of our population as the seniors and the rest of us, the unvaccinated and the rest of us. We intermingle and we meet each other and we pass on the infection to each other. Our vaccine-differentiated measures are trying to make the risk lower for one than the other, but it is not about separating us out into completely separate populations and that would not be possible.”
“I thank Mr Leong for his questions. I would point out that his questions have some contradictions. He asked if there was a change or some treatment which could prevent COVID-19 for seniors who either get sick or get unwell. I presume that by asking that question, he then requires us to use a preventive treatment. If I propose to him that there is a preventive treatment which is 10 times effective, it would reduce your risk by 10 times, he may even then ask me to mandate it and require it. We have one; it is called vaccination. If you are above the age of 60, you are 17 times more likely to pass, if you are unvaccinated than if you are vaccinated. So, a vaccination answers Mr Leong's second question. Hence, when he then asks, "How do we justify our vaccine-differentiated measures and how do we justify imposing something on people who chose not to get vaccinated?" Our justification is that we are trying to save their lives, we are trying for their loved ones and their family not to lose a family member. We are trying to prevent them from becoming sick and overwhelming our healthcare system so that them and the rest of us, then do not lose the ability to have good care for heart disease, diabetes and cancer, and all the other things we need healthcare for. So, his second and third questions seem to me to contradict each other and I think he needs to decide does he believe that we should be fairly liberal about this and choose to allow people to take on for themselves a really unacceptable degree of risk and impose the consequences of that risk on all of us? Or does he want us to go and tell people exactly what to do and constrain their lives in a way that protects all of us? He seems to, in his two questions, choose extremes at one end of the other.”
“Sir, I thank the Member for his question. Mr Ang Wei Neng is correct that the high total number, because 99% are asymptomatic, does not in itself mean whether we can lift or not lift restrictions. What we have to look at is the number of cases that require assistance and help from our healthcare system and make sure that we are able to provide for that. But it is not the case that only looking at the ICU utilisation rate will we then make the decision. The reason is we have a much larger group of people who require oxygen. Not all of them require ICU care but you cannot entirely predict which of them will end up requiring ICU care. So, if we have a very large base of people requiring oxygen, you have to be ready that some of them will deteriorate and so there is a forward projection for ICU care that we have to take into account in terms of our decisions to open up or loosen or lighten. Because as the total number of patients increases, the total number of patients requiring oxygen will also increase in proportion. So, he is right but there is a little bit more nuance to the consideration. And so, this is why in the previous MTF press conference, they talked about the doubling rate or the expansion rate of the ICU care. It is not the number. It is whether we think it is going up and how fast we think it is going up or coming back down here. So, these are some of the factors we have to take into account, Sir.”
“And what we are concerned about is what happens if you get the infection despite having had the vaccination. With our national vaccination programme, if you get the infection even though you have had the vaccination, having had the vaccination converts it to a mild illness, a mild illness you may not even be aware of, an asymptomatic infection and, potentially, rest at home as a result. We do not have such data for Sinovac and so, given that is the case, we feel it is our clinical responsibility to recommend that if it is possible, our population take the mRNA vaccine. Sinovac is available as an option when that is not possible. And so, it is better than nothing, but it is not what we would see as the most appropriate, given that it is the Delta variant that is spreading through our population and given that we are trying to avoid serious illnesses and convert this infection into a mild infection.”
“Sir, I thank the Member for his questions. I think he has misunderstood. The availability of healthcare workers is not what will decide whether we reopen or do not reopen. It is how many with severe illnesses and how many deaths we are prepared to tolerate in that controlled process of getting to the point whereas a combination of vaccination, boosters and mild or asymptomatic infections, our overall population is much, much more resistant to COVID-19. Getting there is not a function of how many healthcare workers we have. How many deaths we have on the road to that destination is a function of how many healthcare workers we have and how many cases we can manage at a time. So, as I have said and as many other people have said, this will pass, this will get better. We do not know exactly when but we are building up our entire society's immunity and resilience against COVID-19. And as we do so, every day that passes, every extra time that we can hold the situation, we are more likely to be able to open up safely. When we do lighten restrictions, you can expect there will be more cases and there will be more waves. But if our immunity and our resilience is built up, each wave will be less threatening, there will be less cases than the last. And hence, our restrictions do not have to be anywhere near as tight. So, I do not know that I have answered his question directly, but I disagree with the way he has framed it. And I hope he understands the explanation that I have given. For Sinovac, I think we have to remember that the proportion of people who prefer Sinovac and who need Sinovac is very, very small. It is 1% or 2% of our total base. But also that its effectiveness with the Delta variant has not been demonstrated to the same degree as all the other vaccines.”
“So, let us say about 135 each, about half-half, that is 270 ICU patients across the hospital ecosystem that our teams have to manage. Pre-COVID-19, 2019, we had about on average in the hospital system 180 ICU patients across the across the landscape. So, that is a workload increase to 150%. You can sustain that for a short period of time. Can you sustain that for a prolonged period of time? So, I hope that answers the Member's questions in terms of are we being conservative or are we planning ahead. What we are hoping to do is chart a middle path, ramp up capacity just ahead of demand, with enough time to give the staff some degree of orientation, training and be ready for when the surge comes in, but not so much that we end up sacrificing the rest of our healthcare system. That would be the inappropriate thing to do. We are trying to tread a middle ground.”
“Ultimately, as I say, we may end up having to accept a lower standard of care, but we will want the lower standard of care, as it were, to be evenly spread across so that no part of the system breaks, that everybody is under some degree of strain and going through this together. But in terms of maybe understanding where we are, the 63% of certain number of beds, 280 beds, it is a bit hard to grasp in terms of the proportions because we keep changing the denominator. We keep increasing the number of ICU beds. So, when you had 100 ICU beds, you may have 60% occupancy; now, we have got 280 ICU beds, you are still at 60% occupancy. So, it sounds as if it is not too much of an issue, but if we try to think of it in terms of workload; so, currently, we have about 160 ICU beds set aside for non-COVID-19 patients. Not all of them are occupied. We will come to that in a minute. But they are there. There is an administrative and logistical load keeping those beds on standby. We also have, by the end of this week, 280 beds set aside for COVID-19 patients in the ICU. That is a total of about 440. So, 440 beds, currently set aside in ICU. What does that compare to in 2019? It is exactly 298, but let us say 300; so, essentially, the hospital system is carrying a logistical and administrative load of about 140%, 145% compared to peacetime, just on standby. But if you look at the actual number of patients that we have in the ICU, the actual number of patients that our care teams are working on, it is about between 130 and 140 non-COVID-19 ICU patients, what we would call the business-as-usual patients; and today, it is about 130, a few days ago is 139 for COVID-19.”
“Sir, I thank the Member for her question. Maybe I can start with the last part first, which is, is there no impact and no deterioration? Actually, I would say, firstly there is an impact. And I think the statements and quotes from my professional colleagues, what I have described as the conditions under which they are working and their concerns for themselves, that is the impact. But there has not been a deterioration, that is the outcomes. So, it is through their heroic efforts, their resolve, their resilience and, frankly, the excellence of the people that we have in our healthcare system, that in these conditions, as a result of this impact on our manpower deployment, they have been able to deliver excellent clinical outcomes. I think the uncertainty is how long do we expect them to do this for? Do they know and do we know? And there is some uncertainty with this. I think in this issue of being too conservative or do we have the right number of beds, maybe I can try to phrase it the other way around. First, let me assume that she agrees with me that actually we cannot over-divert resources from non-COVID-19 patients to stand by for COVID-19 patients that have not arrived yet. People will have heart attacks, people will have accidents and they will need care; and if you have nurses, doctors, beds ready only to accept COVID-19 patients and not to accept all these other conditions, we will see an increased death rate, we will see excess mortality not from COVID-19, but from all these other conditions. So, we must increase slowly step by step trying to be just ahead of the curve.”
“And I say this not as matter of hyperbole but that lowest mortality rate in the world is matched by any number of other patient care and clinical quality indicators which I think we and our healthcare workers should be justifiably proud of.”
“The reduction in elective work to free up resources, that was a concerted effort during the lull. But the thing about ICU manpower, you cannot stand it up and have it lying around waiting. If a year ago, we said we needed to increase our manpower by three times or by four times, what would those nurses have been doing in the ensuing 12 months or six months? They certainly would not have been getting experience at ICU care because you need to look after ICU patients in order to become an ICU-trained staff. So, you can see that what we have been doing is opening up capacity ahead of the curve, but not so far ahead of the curve that we are having people sit around idle, while other services are undermanned or unmanned. But ahead of the curve, so that we can do some of that training and redeployment training and redeployment. Intensive care, critical care, whether you talk about the doctors, the nurses, the respiratory therapists, the social workers, the pharmacists that are deployed in there, it is a clinical practice. It is not something that you can learn and be ready for by reading textbooks and doing online courses. You have to be mentored and precepted into looking after patients with your hands, eyes and senses. So, it is not something that you could have gone five X, four X, in vacuo in peacetime and held everything ready in abeyance. It would have been a waste of resources but it also would not have been effective in terms of changing the outcomes currently. I stress again that while the healthcare system is under stress and our healthcare workers are tired, they are delivering excellent outcomes.”
“Sir, I thank Assoc Prof Lim for the question. Sir, as I have explained, pre-COVID-19, peacetime, we had about 300 ICU beds for the country; 298 to be precise. And the average occupancy was about 63%. So, it is not that we did not have spare capacity pre-COVID-19. But as I have already also explained, if you wanted to open up more of this capacity and keep it empty, it would have an impact on resources that could have been applied elsewhere. So, I do not know if that addresses his first question about why we did not do more before we knew about COVID-19. I think comparing with other countries is fraught in this situation because the number does not reflect, for example, clinical practices, the demographics in terms of the health patterns that they have. So, I do not think one can take the view that there is a certain number of ICU beds that you must have per population. I think what we are most interested in is what the ICU system and the healthcare system is able to deliver in terms of clinical outcomes. I think if the Member dove into those details, he would find that our clinical outcomes and our ICU outcomes are much more than comparable to any of those countries that he has listed, with perhaps less total beds per population. Some of these also rest on what counts as an ICU admission. It is quite different from country to country because of the way in which the nurses are licensed, the way in which drugs are licensed, the way in which doctors practise. He then asked about a more concerted effort to increase capacity. Well, it is not that we stood still and waited to see what happened. We were indeed doing the cross-training. As I had explained, the cross-training and the cross deployment of nurses, that was a concerted effort.”
“So, if you have diabetes, control your diabetes well. If you are requiring medication, take your medication regularly, comply with all the usual prescriptions around maintaining good health. For those of us that are fortunate not to have health problems, all the usual rules apply: eat better, sleep better, get more exercise and reach out to your loved ones. And if you are a smoker, stop smoking. If you get a lung infection with COVID-19 and you have knocked out some of your lung function through smoking, you are not off to a good start. These are the ways in which we can prevent mortality and morbidity in COVID-19.”
“Sir, I thank the Member for his questions. Why are deaths rising? The proportion of deaths has not changed. Of people who get COVID-19, the risk of dying, the proportion of them who go on to need the ICU and then, subsequently succumbed actually has not changed. There are two major reasons why we are starting to see the absolute total numbers rise now. The first is that the base number of our population that is being infected with COVID-19 has risen very, very significantly compared to the time period that he was talking about. The second is that although some patients with COVID-19 who pass on, will pass on very soon after getting the infection, most will take a long time to get seriously ill and may take some time before they succumb, which is a testament to the care that we have put in place and their attempts to fight the infection. So, there is a lag. The deaths that we are seeing now are not necessarily the same people who are being infected this week. There are people who are infected, perhaps, two weeks ago, maybe even a month ago. After you get the infection, it takes time before you develop the need to go on oxygen support. And then, once you are on oxygen, not everybody will go on to the ICU or succumb, but it takes time for conditions to worsen to the point where then you need further care. So, there are two main reasons why the deaths are rising in total number: baseline has increased and it is that effect of the lag. But I stress, the proportion of patients who then succumb has not changed. How to prevent the deaths? Well, vaccinations, as I have explained; booster jabs, as I have explained. But even if you have had those, you may have other underlying illnesses and the underlying illnesses need to be well-controlled.”
“Your surge capacity at the start of a low-intensity conflict is very, very different after two years or after one month. Even this current surge when it started, there was really no way to know or model how long it was going to last and what the peak of peaks would be. So, what the Minister talked about is the logistical planning parameter. If you do not have 1,000 bed spaces, you know that you cannot get there. But if you do, that is physically where you can locate people. If you need the equipment and, thankfully, as a system over the last two years – but it started long before the last two years, through emergency planning and resilience preparedness – we actually have the stocks of equipment that we need: the consumables, the little parts to drive the machines as well as the drugs, in order to cater for many, many more patients than we have today. So, as the colleague of mine said, we are not resource-constrained at the moment. The manpower issue is not something that we can do a simple calculation for. As I said, it depends on how long this goes on for, how long the peak goes on for. Crucially, today, coming to the end of 2021, the amount that we can reduce business-as-usual is really quite different from where we were, let us say, six months ago; in fact, where we were, even three months ago. That is an additional factor that we have to take into account. So, the number is something that we have to think about in a fairly dynamic way.”
“Sir, I do not have the specific numbers of recruitment figures for the different clusters and organisations. We can get them. But I think one of the challenges we have to appreciate is that even if we recruit from overseas, anybody coming into that environment is new, they are inexperienced. By definition, they are inexperienced with the environment, our healthcare protocols, but they may actually be literally new in terms of their training as well. So, their role is going to be quite different. It is going to be augmenting manpower where, perhaps, that level of acuity and that level of complexity does not exist. So, while we are recruiting – and we have been actively and I will get the numbers – operationally, I cannot see that that is going to make a huge difference in the ICUs. It will make a difference in other parts of our ecosystem. We hope that can displace a little bit of the manpower into some of the higher acuity areas and then release a few people to go and help in the ICU. But I think this is a bit more of a medium-term strategy rather than something that we can rely on as an urgent fix to our current problem. If I may make a comment on the first part that Minister for Health talked about, some of the uncertainties are about how long we have to carry a certain load or a certain number of patients within the ICU. If you have a terrible disaster, mass casualty, a very bad accident, you may have many times the number of patients that we currently have in the ICU. But as a one-off incident, the patients will not stay as long. What we have today is the equivalent of a low-intensity conflict and having to be on readiness and high alert for weeks and weeks, and months and months.”
“Sir, making COVID-19 vaccination compulsory is a significant move. It should be carefully considered. We would have to consider a number of factors: vaccination coverage, international practice and the availability or performance of fully registered COVID-19 vaccines. The introduction of the vaccination-differentiated measures, in a way, is to try and get around some of that problem, to expose the different segments of the population to different risks. But in terms of making vaccination compulsory, it is also quite difficult in terms of the execution. You can imagine that for something like childhood vaccines, you may say that without it, you cannot have access to play groups or school. There is a specific thing that you want to do and for that, you are getting the vaccine. But here, we are talking about all the normal activities of life and so policing it, executing it, implementing it is not without challenges. And the question is, how much benefit will there be? So, I think it is something to consider but there are a whole lot of complications associated with that. Sir, the Minister for Health has indicated that he will answer the second question. 1.07 pm”
“Sir, I thank the Member for the question. In a way, that is what we are trying to do with our vaccination-differentiated measures: expose some people to a lower level of risk while allowing other parts of our population to do the things that make life a bit more bearable. But there is only so far that we can go. If you are a senior and you are unwell and, for some reason, unvaccinated, you cannot be isolated completely. You need fresh air, food, contact with other people. So, I understand what the Member is asking. The question is, how far can we go and we do not think we can go much further than where we are today, with vaccination-differentiated measures. But there is another dimension to this question. Because it supposes that the seniors and the vulnerable are a different segment of the population from the rest of us, who are younger, healthier and vaccinated. The truth is, we interact and we meet and we pass infections on to them. I think the experience of the last two years, in a way, has demonstrated just how much intermingling and interconnectedness there is between all kinds of networks and communities here in Singapore. It is part of our human response. Our grandparents want to see their grandkids. We want to go and look after our parents. Each of those interactions poses a very small but measurable risk to them as well. So, I think we have to assume that whatever it is that we are doing, we must treat the whole population as one. We will try with the vaccination-differentiated measures but there is only so far that we can go.”
“Words will never be enough, but I express our gratitude on behalf of this House. [Applause.]”
“Vaccination remains critical, every single extra person who gets vaccinated makes a difference, to themselves and for all of us. Getting your booster shot as soon as you are eligible makes a difference. Following the safe management measures makes a difference. Regular testing makes a difference. Using the right healthcare resources appropriately makes a difference. The current situation will not last forever. We will eventually come out of this. Eventually, enough of us will be vaccinated or will have been infected, that we will see the case numbers come down and the situation stabilise. But in getting there we should try to keep the number of deaths as low as possible. That we got to this point, where after nearly two years of fighting a pandemic, I can explain our hope to maintain one of the lowest case fatality rates in the world, is a small miracle. It did not happen by chance. It happened because Singaporeans stood together, looked out for each other, did their duty and put the interests of others ahead of their own. And the healthcare workers of Singapore have done all this and much, much, more, caring for us all. I received another message from a colleague: "we are one of the few countries in the world where ICU teams don't have to worry about resources and equipment – very grateful for that. Healthcare workers have given everything in the last two years, we have held ourselves up to the highest standards; we have the lowest mortality in the world; our people are still pushing on". Our people are still pushing on! The healthcare workers we are worried about are also the same healthcare workers who are committed to doing what is needed to look after all their patients. They will do their duty, do their best and try their hardest.”