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Why few Singapore health workers have caught the coronavirus

Uncooperative patients, long hours and a lack of protective equipment are hampering health care workers across the world as they take the fight to the coronavirus.
Many health workers have fallen sick themselves, and a fair number have died .
In Malaysia, a pregnant woman who did not disclose that her father was infected tested positive after giving birth, leading to the shutdown of the entire hospital for cleaning.
In the Philippines, nine doctors have died, two of whom had dealt with a patient who lied about her travel history.
In Spain, where more than 5,400 health care workers have been infected, accounting for about 14% of the country’s patients, there are no longer enough workers to care for patients.
However, amid all the gloom, Singapore’s experience is being held up as a reason for optimism.
The city-state has reported more than 840 cases of infection, all of which are being treated in a hospital. Yet, only a handful of its health care professionals have been infected.
What’s more, even these cases, according to Vernon Lee, director of communicable diseases at the Ministry of Health, are thought to come from outside of the health care setting.
Experts suggest this has been more than just luck, pointing to a case in which 41 health workers were exposed to the coronavirus in a Singapore hospital yet evaded infection.
The workers had all come within 6.5 feet of a middle-aged man with Covid-19 who was being intubated, a procedure which involves a tube being inserted into the patient’s trachea. The procedure is seen as being particularly hazardous for health workers it generates aerosol particles that might contain the coronavirus.
The workers had not known at the time that the man had the virus and all were quarantined after he tested positive. However, on their release two weeks later, none of them had tested positive.
The case garnered widespread attention because the workers were wearing a mix of standard surgical masks and the N95 mask, which doctors see as the gold standard as it filters out 95% of airborne particles.
The conclusion, published in  The Annals of Internal Medicine  this month, was this:
“That none of the health care workers in this situation acquired infection suggests that surgical masks , hand hygiene, and other standard procedures protected them from being infected.”
With critical supplies running short in many countries, experts say it is increasingly vital that countries share both knowledge and resources.
Infectious diseases expert Leong Hoe Nam said that being “bitten by Sars” (severe acute respiratory syndrome) in 2003 had prepared Asia for Covid-19, while Western countries were not similarly prepared and hence lacked sufficient protective equipment.
He pointed to how about 2,000 health care workers had fallen sick in China early in the outbreak because workers did not initially have protective gear. The trend reversed as equipment became available.
“Once the defenses were up, there were very few health care workers who fell sick at work. Rather, they fell sick from contact with sick individuals outside the workplace,” he said.
Malaysia is a case in point. While it has reported 80 health care workers falling ill, most are thought to be community infections.
Amid increased sharing of advice in between countries, Singapore is often held up as an example to replicate.
Despite the country grappling with a rising load of Covid-19 patients, most of whom have recently returned to the city-state from abroad, its health care system has continued to run smoothly.
Doctors say this is because it has been preparing for a pandemic ever since Sars caught it by surprise. During the Sars outbreak, health care workers accounted for 41% of Singapore’s 238 infections.
Consequently, its hospitals swung into contingency planning mode early on in the coronavirus outbreak, telling staff to defer leave and travel plans after its first cases emerged.
Meanwhile, its hospitals swiftly split their workforces into teams to ensure there were enough workers if the outbreak worsened, and to ensure workers got enough rest.
Singapore has 13,766 doctors, or 2.4 doctors for every 1,000 people. That compares to 2.59 in the US, 1.78 in China and 4.2 in Germany. Places like Myanmar and Thailand have fewer than one doctor for every 1,000 people.
The key is to ensure an adequate doctor-to-patient ratio and that there are enough specialists for the critical work. It’s important to have doctors and nurses who can provide intensive care and operate mechanical ventilators or machines to pump and oxygenate a patient’s blood outside the body.
At the emergency department where pediatrics emergency specialist Jade Kua treats Covid-19 cases in addition to regular emergencies, doctors are split into four teams of 21. Each team takes alternate 12-hour shifts and does not interact with other teams.
“We are in modular teams so the teams move together. So you and I would do morning, off, night, off, morning off. Together. And then the other teams would do the same, and we don’t intermingle,” said Kua.
Not every country has a plan like this. Last year’s Global Health Security Index by the Economist Intelligence Unit found that 70% of 195 countries scored poorly when it came to having a national plan for dealing with epidemics or pandemics.
In India, with a population of 1.3 billion, only about 20,000 doctors are trained in key areas such as critical care, emergency medicine and pulmonology.
In contrast, Singapore published its first Influenza Pandemic Preparedness and Response Plan in June 2005 and has since honed it to a tee.
Hospitals regularly war-game scenarios such as pandemics or terrorist attacks and the simulations are sometimes observed by the Ministry of Health, which grades the performance and recommends areas for improvement.
The plan also covers the need to stockpile equipment to avoid the sort of shortages many countries are now facing, another lesson inspired by Sars, when masks, gloves and gowns were in short supply.
In a pandemic preparation paper published in 2008, Singapore public health specialist Jeffery Cutter wrote that Singapore’s stockpile was sufficient to cover at least 5 to 6 months’ use by all front-line health care workers.
During the Covid-19 outbreak, the country has also told citizens not to wear masks so it can conserve supply for medical staff.
Despite the many positives to emerge from the Lion City, its health care workers are struggling with another problem: discrimination.
While in France, Italy and Britain, residents cheer health care workers from their windows. In Singapore health care workers are seen by some people as disease carriers.
“I try not to wear my uniform home because you never know what kind of incidents you may encounter,” said one Singapore nurse.
“The public is scared and wearing our uniforms actually causes quite a bit of inconvenience. One of my staff tried to book a private-hire car to the hospital for an emergency and she was rejected by five drivers.”
Lim, from the Saw Swee Hock School of Public Health, said the worst human impulses and “every man for himself” attitudes could emerge in crises and “that is exactly why governments have to step in.”
Discrimination could affect both the performance and motivation of health care workers, Lim warned.
Meanwhile, when health care workers are infected, it creates a “triple whammy” threat.
“It means one fewer professional in an already-strained system, another patient to care for and, potentially, a team of colleagues who need to be quarantined,” said Lim.
“We must do everything possible to keep our health care workforce safe and free from Covid-19.”
This story originally appeared on Inkstone , a daily multimedia digest of China-focused news and features. Like what you see? Sign up for our newsletter , download our app , or follow us on Twitter and Facebook .
Copyright (c) 2020. South China Morning Post Publishers Ltd. All rights reserved.
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