Addressing Endemic COVID-19 With High Vaccination Success: Lessons From Singapore

To the Editor:

Singapore has shifted to an endemic COVID-19 strategy with more than 80% of the population vaccinated.^{1 , 2} The country is adopting a “middle path” approach³ through progressive reopening of social, economic, and travel activities while trying to forestall unfettered COVID-19 mortalities. There has been an exponential increase in community COVID-19 cases at levels not seen since the pandemic started.¹ Up to 98% of cases have no or mild symptoms owing to the high vaccination rate. Home recovery is the default care arrangement for individuals who are fully vaccinated, have minimal symptoms, no severe comorbidities, and do not have household members who are 80 years or older. This protocol was established as the surge in cases threatened to overwhelm hospitals’ and community care facilities’ bed capacities. Home recovery was limited to persons aged 12-50 years but this has since been extended to persons up to 69 years old based on data and available health care capacity.¹

Despite achieving one of the highest vaccination rates in the world, an endemic COVID-19 strategy still presents many challenges to the health care system. The increase in mortalities since this strategy was pursued is of concern. More than half the total number of deaths since the start of the COVID-19 pandemic have taken place in the weeks since opening up. The deaths have invariably occurred in unvaccinated older adults.¹ An unprecedented total ban on visitors to all nursing homes and hospitals has been put in place in September 2021 to reduce transmission among those most vulnerable to COVID-19.¹ Although the rest of society anticipates a return to normalcy, older adults will continue to be disproportionately affected by restrictions and disruptions from the pandemic. Older adults may face greater social isolation and attendant harms if mitigating measures are not put in place.⁴

Based on our early experience, we expect that aged care facilities and services, which include hospitals, nursing homes, day care centers, and home care, will continue to have social distancing and movement restrictions in an endemic COVID-19 situation. Geriatric care services will need to double down and scale up innovative practices that have been deployed during the pandemic. These include the following:

• 1.Adoption of telehealth to deliver care.⁵ This includes teleconsultations, home monitoring using medical apps and devices, and the establishing and leveraging of Internet of Medical Things (IoMT) systems.⁶ An endemic COVID-19 should not attenuate but instead further catalyze the digital transformation of health care. During the first lockdown of nursing homes in May 2020, government and community groups came together to pass tablets and various devices to care facilities and geriatric service providers to help mitigate the social isolation faced by seniors. Government subsidies were given to speed up tech adoption and digital transformation.⁷
• 2.Making provisions for the care of mental health and social needs of seniors. Even if physical checks are not always possible, geriatric service providers should continue to leverage on technology to maintain communications with and for seniors. Geriatric service providers have used technology to allow families to communicate with loved ones in hospital, nursing homes, and even at home.
• 3.Ramping up geriatric care workforce and skills training. The need for geriatric care skills and expertise is even greater than before. The majority of hospitalized patients will be older adults. These individuals are at even greater risk of functional decline, delirium, falls, and mood disorders and face care issues because of the disruption of many older adult services even in an endemic COVID-19 scenario. Hospitals need to continually retrofit to cater to a predominantly geriatric population amid infection control considerations. Thoughtful design changes and technology adoption can help to address these challenges.
• 4.Enhance support for caregivers. Continued social distancing has led to reduced and limited capacity in day care centers, care facilities, and home care services, increasing the burden on caregivers. In recognition of the toll of the pandemic on caregivers, various enhancements have been made to the national caregiver support action plan that was first established in 2019,⁸ the key areas being enhanced caregiver respite services, work-life support, care navigation, financial support, and caregiver empowerment and training. Measures should also be put in place to reduce the risk of COVID transmission while remaining open to essential family and caregivers.⁹ Most elder care facilities already have protocols in place to allow designated caregivers to visit and these should be deployed and/or enhanced^{9 , 10} to facilitate safe visiting of older adults.

COVID-19 has brought the geriatric population to the forefront of policy making and catalyzed many changes in care provision and service models. These efforts must continue and are ever more important even as we transition to an endemic COVID-19 phase.