A matter of numbers

Ronald Ng says data highlights differences in Covid approaches by Hong Kong and Singapore

W hen the pandemic first reared its ugly head, governments responded with different policies. In Singapore, right at the start, pandemic policy was made very clear. Our economy depends on us being an open society, and at the same time, the lives of citizens are important. We therefore promoted masking, social distancing, contact tracing and quarantining of infected individuals.

On top of that, before the advent of the vaccine, there was a brief period when public spaces were closed and people largely worked from home. Once the vaccine was available, there was an aggressive push to get everyone fully vaccinated and boosted. The push is based on Ministry of Health data showing that the death rate among those fully vaccinated is extremely low: in fact, for example, among those aged 80 and above who are vaccinated and boosted, the figure is less than 1 per cent. Given all the measures, and the clearly articulated principles guiding the government’s action, there has been little panic among citizens in Singapore.

Hong Kong chose a different path. Quite rightly, as part of China, the city has stuck with the zero-Covid approach, while the push for vaccination was not as aggressive as in Singapore.

The zero-Covid policy was successful for about two years, and even in the midst of a fifth wave, Hong Kong’s data still looks better than Singapore’s. According to Our World in Data, in terms of cumulative infections per million population, as of March 4, Hong Kong had 53,368 cases while Singapore had 147,313.

In terms of cumulative deaths per million, as recently as at February 23, Hong Kong’s was 50.97 to Singapore’s 176.58. It was only recently that Hong Kong’s number leapfrogged Singapore’s – becoming 205.75, to 195.65 as of March 4.

In any pandemic, it is notoriously difficult to judge the real number of infections or deaths due to the disease. People might go undiagnosed, or people dying from some other disease but testing positive for the pandemic disease could be labelled as having died from that disease.

During a pandemic, intensive care beds might be in short supply, and a patient with another disease who dies because of the undersupply of beds may not be classified as having died from the virus. But, in that case, is the cause of death the pandemic or the original disease? For these reasons, most epidemiologists use a measure called “excess deaths” to gauge the impact of a pandemic on mortality.

Excess mortality is the number of deaths minus the average recorded over the past five years. For example, if the average number of people dying in January in a country is 5,987 and this year, 8,020 died in

January, the excess mortality would be 2,033.

In Singapore, there has been no excess mortality in the past two pandemic years. Although the number of Covid-19 deaths was high, the overall death rate remained the same. How could that be? The answer lies in something called “mortality displacement”. Many of those who tested positive for Covid-19 and were classified as dying from the coronavirus would probably have died from another underlying condition anyway. This now begs the question: is a zero-Covid policy necessary if a disease does not yield excess mortality?

The zero-Covid policy has had a tremendous effect on the economy. Besides, when precious hospital beds are occupied by infected people who merely need to be quarantined, people with other diseases might have difficulties receiving treatment, with fatal results. Although such deaths would not be recorded as Covid-19 deaths, they are still deaths.

In recent days, the daily caseload has soared to more than 50,000 in Hong Kong, with deaths exceeding 1,000.

Last month, Singapore recorded its highest number of new daily cases, more than 26,000. A week after that, the number of patients in intensive care units due to Covid-19 was 53, while the number of other patients in ICU was 174. Singapore has 350 ICU beds in total.

Extrapolating roughly from those numbers for Singapore, a city of 5.8 million people, to Hong Kong, with 7.5 million, Hong Kong could expect some 130 Covid19 cases requiring ICU beds in the coming week. Concurrently, if other medical care is to carry on in Hong Kong as usual, the city could have another 220 patients requiring ICU beds. That adds up to 350.

How many ICU beds does Hong Kong have? The latest figure in the public domain is 3.5 per 100,000, but that was from a few years ago. Assuming the rate is now 4.5 per 100,000, there could be 338 ICU beds. That means ICU beds will be maxed out. Hong Kong could be facing a medical disaster.

Hong Kong is also gearing up for mass testing. If 0.5 per cent of Hongkongers test positive, there would be 37,500 cases. Is it possible to isolate them all? The newly built facility in Tsing Yi can house around 3,900 and there should be seven more like it, yielding a total capacity of about 31,200. But this would still fall short.

Apart from rapidly increasing the rate of vaccination, especially among the vulnerable elderly, Hong Kong should increase its ICU capacity. It could consider allowing the temporary registration of ICU specialists and nurses from the mainland so they may work in Hong Kong, as additional ICU beds would need to be run by trained personnel. Hong Kong could also halt all elective surgical procedures, and rope in private hospitals to manage non-Covid-19 ICU cases.

One of the reasons there is no panic in Singapore is that the government is open about data on Covid-19 and the impact on the health system. The messaging has also been very consistent. The government has kept a close watch on ICU capacity through the pandemic. The public has also come to understand that if one is fully vaccinated, Covid-19 is not a death sentence.

Apart from rapidly increasing the rate of vaccination … Hong Kong should increase its ICU capacity

Dr Ronald Ng is a specialist haematologist practising in Singapore, and formerly a senior lecturer in clinical haematology at University College Hospital Medical School, London University, and University of Hong Kong