News analysis

The new normal: How will Covid-19 continue to change the way we live?

Experts say that even with vaccine, life will not return to pre-Covid-19 normal for years

The Olympic Games as we know it will not happen next year, how helpful vaccines may be is still in question, and another lockdown like Singapore's circuit breaker period would reflect a failure in public health response.

So, people have to learn to live with the fact that Covid-19 will constantly be in their midst and act accordingly - and responsibly - say experts. Even after vaccines are on the market, life will not return to pre-Covid-19 normal for many years to come, if at all - and certainly not next year as some are hoping will happen.

There will be travel, but not to the extent of pre-pandemic days. Even as more people return to the workplace, many will continue working from home, at least part of the time.

Covid-19 is here to stay and has, and will continue to change the way we live.

It has spread to too many countries for the novel coronavirus to be contained the way Sars (severe acute respiratory syndrome which comes from the same viral family) was in 2003.

Not only that but, as Dr Asok Kurup who chairs the Academy of Medicine's Chapter of Infectious Disease Physicians said, since no one even knows which wildlife Sars-CoV-2 - the virus that causes Covid-19 - came from, it would not be possible to control the infection at its source.

It might well be eradicated one day, like smallpox has been. But smallpox had been around for about 3,000 years before that happened.

Said Associate Professor Hsu Li Yang, an infectious diseases expert at the National University of Singapore (NUS) Saw Swee Hock School of Public Health: "The likelihood of it (Sars-CoV-2) disappearing is as likely as other current human respiratory viruses, which is not at all."

Professor Leo Yee Sin, head of the National Centre for Infectious Diseases, said this new coronavirus "forces humans to rethink and re-design our social interaction fabric". Society, she said, has to redesign how to connect in as safe a way as possible, and to put in place countermeasures if that fails.

VACCINES NOT A CURE-ALL

Having effective and widely available vaccines will certainly help, say the experts, but not to the extent many people are expecting them to, and certainly, they will not be in play for some time.

Said Professor Dale Fisher, a senior infectious diseases specialist at the National University Hospital (NUH): "The perfect vaccine has no major side effects, is 100 per cent effective, is taken up by the whole population, is a long-lasting, single dose and does not need a cold chain. Even better if it is not an injection."

While there are many vaccines being developed, expecting the perfect vaccine is like still believing in fairy tales.

Not only is it unlikely that any would give 100 per cent protection, Dr Kurup said, from available data of vaccine forerunners, it appears that they may "need to be tweaked regularly or may need boosting".

Prof Hsu expects that at the very least, the vaccines "will be like the influenza vaccine, meaning repeated vaccinations required every one to three years and with just over 50 per cent protection. But nonetheless still helpful".

 
 

Professor Ooi Eng Eong, deputy director of the emerging infectious diseases programme at Duke-NUS Medical School, said a vaccine that is 50 per cent effective "would be a great place to start".

He said the proportion of the population that needs to be vaccinated will depend on how effective it is, and whether vaccination prevents disease or infection.

The best is, of course, one that prevents infection, since that would break the chain of transmission and allow for herd immunity.

A vaccine that only prevents disease would help reduce illness and deaths, but does not stop those who are infected from transmitting the disease to others, including people who have not received the vaccine. This is especially since it is now known that infected people with no symptoms can also infect others.

How useful a vaccine is will depend on both its effectiveness, and the proportion of people in the population who are vaccinated.

There will be a rush globally for any proven vaccine, and production is unlikely to match demand for quite a while. This will be more so if the vaccine needs to be given annually, like the one for influenza.

So a vaccine that is 50 per cent effective and given only to half of the population equals 25 per cent protection for society. While it will reduce the transmission rate, it will not be enough to provide herd immunity.

Associate Professor Alex Cook, who works on disease modelling at the NUS Saw Swee Hock School of Public Health, said depending on the transmission rate, it generally requires at least half the population to be immune to reach herd immunity.

But in places like the foreign worker dormitories where the transmission rate is higher, an even larger percentage of immune people is needed.

 
 

As there will not be enough vaccines for everyone, even in the long run, Prof Ooi suggested: "Developing a practical strategy on how limited doses of vaccines can be implemented for maximal benefit to society should thus be finalised well before vaccines become available."

Nevertheless, he added: "If vaccination can be rolled out smoothly and rapidly when vaccines with proven safety and efficacy become available, we should be able to reduce the incidence of Covid-19 cases and end this pandemic."

But ending the pandemic does not mean people no longer get infected, just that the scale of the outbreak would be reduced.

Prof Fisher, who hopes vaccines will at least prevent the disease or make it less severe in those vaccinated, said: "The outcomes of the vaccine story could range from it being very useful to not at all useful."

MEASURES THAT MAY CONTINUE

Professor Teo Yik Ying, dean of the NUS Saw Swee Hock School of Public Health, said that some degree of safety measures, at least for the next couple of years, would be prudent.

But living with Covid-19 does not mean moving into lockdown mode every time the number of infections goes up, such as what happened in the Australian state of Victoria.

Prof Fisher said: "Lockdown is a very blunt measure and really represents a failure of the public health response." He added that measures such as selectively limiting high-risk activities, community buy-in on safety measures like mask wearing, distancing and hand hygiene, should be adequate.

He said: "Follow the rules and don't make up your own."

The problem in Victoria was the large number of people who refused to follow the rules. About a third of those who had been close to someone with Covid-19, and who were later found to be infected, ignored the stay-home rule, thus spreading the disease to many others.

To deal with such irresponsible people, Australia had to raise the penalty for those who breached quarantine and other safety rules, and bring in the army to ensure that rules were followed.

Prof Teo said: "If countries are able to find that sweet spot between some restrictions and a manageable degree of community transmission that is never allowed to get out of hand, lockdowns can be avoided completely.

"I am cautiously optimistic that the circuit breaker will be the last we see of a multi-sector lockdown in Singapore."

 JASON QUAH
Some degree of safety measures, such as mask wearing, at least for the next couple of years, would be prudent, say experts. Such practices help curb not only the spread of Covid-19, but some other diseases as well. ST PHOTO: JASON QUAH

Dr Kurup added that public education and cooperation from everyone are important factors in keeping Covid-19 at bay.

He added that wearing masks in public and hygiene practices are good as they not only help curb the spread of Covid-19, but they also "mitigate overall risk of acquisition of other contagions".

Far fewer people this year sought medical care for infectious diseases like diarrhoea, conjunctivitis and respiratory infections than last year. For example, the number of polyclinic patients with acute upper respiratory infection was 692 a day in the first week of this month, against a five-year median of 2,378 such patients daily. The lowest daily figure of 268 cases a day was in the first week of June, following the two-month circuit breaker here.

Prof Hsu said: "Hand hygiene as well as mask wearing and physical distancing when ill have always been important principles, so I would certainly hope that they remain in the future."

 
 

Historically, societal adaptations have occurred with most major infectious disease outbreaks. One such example, he said, is the anti-spitting (a common practice in the past) campaign to stem the spread of tuberculosis here.

So people's behaviour can change.

Possible adaptations include better hygiene practices, and perhaps even isolation by people who have been in close contact with a Covid-19 patient.

Said Prof Fisher: "In Singapore, I believe we know how to live with it (Covid-19). We need, however, to stay true to our behaviours and each understand that we have our roles in this."

Unfortunately, not everyone here is willing to abide by the rules.

Education Minister Lawrence Wong, who co-chairs the Covid-19 ministerial task force, said last Wednesday: "There are still a few breaches that we pick up on a daily basis, and they typically happen at popular nightspots."

They include drinking after 10.30pm, customers from different groups intermingling, not wearing masks and gathering in groups of more than five.

While not exactly a breach, there are also often people talking in MRT trains, even though there are signs asking them not to talk while commuting as that increases the risk of virus spread, especially during peak hours in an enclosed area.

Changes to leisure activities may be more drastic, experts predict.

Prof Hsu said: "It may take a long while before we would feel safe at large mass events like concerts, football matches and megachurch services again."

The Olympic Games as we know it, with large contingents of athletes from across the world, and huge spectator crowds, is not going to happen next year. It had been postponed from this year to allow the world to get over the pandemic.

Said Dr Kurup: "It's hard to imagine that the Olympics can take place next year with mass events and large number of spectators; the 'norm' of virtual spectators is likely to prevail until 2022."

TRAVEL

While the experts all expect some travel to resume, given its importance in the global economy, they were divided on how safe it may be.

The International Air Transport Association claims on its website that there is lower risk of getting Covid-19 in an airplane cabin than at a shopping centre, as aircraft cabins have air changed many times more frequently than offices or shops.

"For most modern aircraft types, the air supplied to the passenger cabin is either 100 per cent fresh or is a mixture of fresh and re-circulated air that is filtered through Hepa (high efficiency particulate air) filters of the same efficacy (99.97 per cent or better) in removing viruses as those used in surgical operating rooms," it states.

Prof Ooi said all that may be true, but: "The problem on airplanes is not the air quality but the proximity to the next passenger. If that person is unwell, knowingly or unknowingly, it would be very difficult to avoid being infected."

Airlines configure their planes for profit, which is understandable, but that ends up packing a lot of people close together. "Perhaps it is time we also consider how aircraft should be configured to reduce the risk of infection," he said.

Over the long term, he expects "we can travel as we did again".

 
 

Prof Teo is another who believes mass market tourism will return, once a vaccine is available and widely distributed. Until then, he said, "incoming mass market tourism from some of the worst-hit countries may not be allowed to resume as the risk to the rest of the community and the broader economy is simply too great".

Dr Kurup said "testing pre-and post-travel should be part of any international strategy" but admits that it will be difficult to harmonise methods of testing. He added that many foreigners arrive here testing positive when they were tested negative prior to travel. Singapore has close to 1,000 imported cases.

Prof Fisher, on the other hand, does not support airport testing. He prefers opening borders to places with similar standards and outcomes as Singapore. He said it would be quite safe to not swab visitors from places like China, Taiwan, New Zealand, most of Australia and Thailand as the risk is tiny.

"Once in Singapore that individual needs to apply the local behaviours such as no large groups, mask wearing, et cetera and that should ensure minimal, if any, spread in the unlikely situation where they do become a case," he said.

Prof Fisher said "the main impediment to travel is the border restrictions and potentially the health insurance cover".

 
 

THE FUTURE

Prof Ooi expects Covid-19 to "spike periodically, even in Singapore and especially after international travel restrictions ease".

"However, I think it is possible for the extent of virus transmission to remain limited, despite more imported cases, if we all practise good hygiene, practise mask wearing and manage physical distancing, wherever possible."

Prof Fisher agrees that the virus will become endemic "with a propensity for clusters and sporadic cases even after there is considerable immunity in populations".

But he added: "We need to live with the virus on the basis that if and when we have a vaccine it will help and allow some easing of restrictions."

 
A version of this article appeared in the print edition of The Straits Times on September 14, 2020, with the headline 'Living with Covid-19: The new normal'. Print Edition | Subscribe