Implications of Study on Excess Mortality During COVID-19 Pandemic

13 Dr Tan Wu Meng asked the Minister for Health (a) whether there will be a continued, further and deeper study of excess mortality from the COVID-19 pandemic including the impact of COVID-19's long-term effects and how this may contribute to excess mortality; and (b) what is being done to identify potentially preventable causes of excess mortality.

The Minister for Health (Mr Ong Ye Kung): Mr Speaker, Sir, my response today will also address the question filed by Mr Yip Hon Weng¹ which is scheduled for a subsequent Sitting.

The COVID-19 pandemic has posed a severe dilemma – summarised as lives versus livelihoods – for all regions in the world. When you close the borders and lock down society, you can save lives, but people will suffer tremendously from economic paralysis and children held back, perhaps permanently, in their learning. When you open up society and the economy to resume normalcy quickly, many people will suffer from falling severely ill and die from infections.

Every region in the world knows it has to strike a very careful balance between lives and livelihoods. Three years into the pandemic, Singapore has been able to open up our society and economy, with life almost going back to normal and yet we maintain an excess mortality rate that is one of the lowest in the world.

In September 2022, the Ministry of Health (MOH) released a public report on the excess deaths in the Singapore resident population over the pandemic. Between January 2020 and June 2022, there was an increase of 24.9 deaths per 100,000 persons per year, using the pre-COVID-19 year of 2019 as the baseline. So, our death rate during this pandemic, essentially, took us back to 2018 levels, wiping out improvements over a few years.

The World Health Organization (WHO) uses a slightly different methodology to compute excess deaths, but the results are similar. Based on WHO's estimates for the years 2020 and 2021, Singapore experienced 26 excess deaths per 100,000 persons per year, compared to our estimate, which was 24.9. It is about the same. But it is still, again, much lower than many countries, especially those that have opened up like us.

Members have asked for a breakdown of the numbers by year. So, if we break up our estimated excess deaths, there were 1,140 from January 2020 to December 2021 and 1,350 from January to June 2022 respectively.

There are two key ways to reduce excess deaths associated with the COVID-19 pandemic. The first is vaccination.

COVID-19 vaccination plays a big part because it significantly reduces the risk that infections translate into severe illness and deaths. The fact that Singapore got 93% of its population vaccinated – and that base includes children who are not eligible – and 80% boosted, is a key reason why we have low excess deaths.

To answer Mr Yip Hon Weng's question, which has been scheduled for another Sitting, in the same vein, in Singapore and elsewhere in the world, unvaccinated persons disproportionately contributed to COVID-19 deaths. In the first half of 2022, about 5% of the eligible population are not fully vaccinated, but they contributed to 28% of COVID-19 deaths.

MOH does not comprehensively track the number of persons who are medically ineligible for COVID-19 vaccinations. However, as at 30 June this year, the number of persons who applied to be exempted from vaccination-differentiated safe management measures (VDS), claimed they have adverse reactions to COVID-19 vaccines and we have looked at them and have granted 2,100 such exemptions.

For this group, the observed rate of COVID-19 deaths in these individuals was about two in 1,000, compared to 0.3 in 1,000 observed in the whole population. Again, this is the group which applied to be exempted from VDS. In reality, the number of people who are medically ineligible for COVID-19 vaccines is small, given the choice of vaccines that they have access to.

It is worth reiterating here that, to be properly protected against the Omicron virus of COVID-19, we need to get a booster, in other words, three doses of mRNA vaccines. It will reduce the risk of severe illnesses and deaths significantly. Two shots do not do the job properly. We are currently bringing in the updated bivalent vaccines that can offer better protection against variants.

The second factor is whether the healthcare system had been overwhelmed at any point during the pandemic – the second factor for excess deaths. "Overwhelme" is not the same as hospitals being very busy, which ours have been and are still very busy. "Overwhelme" means there were so many severely ill COVID-19 patients that the hospitals ran out of beds, oxygen and medical staff to take care of them. Patients are, essentially, left to demise. Whenever a bed or an equipment becomes available, doctors have the unenviable task of choosing whom they should save amongst everyone that is waiting.

When that happens, many non-COVID-19 patients, such as those with heart attacks, injuries, strokes will be affected and, without proper care, many of them will also die. And that happened in many countries.

In Singapore, we did not let that happen, mostly because when there was a risk of that happening, we went into the circuit breaker mode or the heightened alert mode to slow down the rate of infection to protect our healthcare system. Hence, throughout the pandemic, despite our public hospitals being strained while coping with the pandemic, our hospital and ICU beds were able to support patients with urgent medical needs.

Looking ahead, we can continue to prevent deaths by preserving healthcare capacity and ensuring that our healthcare workers are well-resourced in such situations. If and when there is a surge in infection and severe illness numbers, we cannot rule out the re-imposition of safe management measures. But we will only do so when it is absolutely necessary to save lives and to protect the healthcare system.

What we managed to achieve is due to the fact that the great majority of our people did their part and did the right thing. The pandemic is not entirely over, but we hope we are at the end game and will continue to navigate through the crisis with resilience and unity.

Mr Speaker: Dr Tan Wu Meng.

Dr Tan Wu Meng (Jurong): I thank the Minister for his comprehensive answer. I have one supplementary question. Does the Government have plans to study more deeply the impact of socioeconomic status as well as housing type on the excess mortality risks from COVID-19?

Mr Ong Ye Kung: I thank the Member for that suggestion. It is a good one. We have the Saw Swee Hock School of Public Health. Maybe that is something they can look into but, so far, we have not compiled those numbers. But if we look at the literature and our own experience, the two main drivers of excess deaths have been, first, are you vaccinated? Second, your age, and that will continue to be the case. Notwithstanding, it is an interesting line of enquiry which our researchers will definitely look at.

Mr Speaker: Mr Yip Hon Weng.

Mr Yip Hon Weng (Yio Chu Kang): Thank you, Mr Speaker. I thank the Minister for his reply. I have two supplementary questions.

First, with more data, does MOH intend to periodically review the vaccination eligibility criteria to allow more people who were previously ineligible for vaccination to get vaccinated and protection from COVID-19?

Second, how does MOH intend to increase the vaccination rate, especially amongst those who are seniors and have comorbidities?

Mr Ong Ye Kung: On vaccination eligibility, the question is actually the other way around. We would very much want people to be vaccinated but, usually, it is the resident who comes forward to say "I am not eligible. I have got eczema, I have this, I have that". And then some are not so valid medically; others we have to take a closer look, especially if they have some adverse reaction after their first shot and they then may become ineligible. And that is a medical indication which we will have to respect, notwithstanding the fact that we bring in different types of vaccines now with different technological platforms and, hopefully, they will be able to take one of them.

Second, how do we further increase the rate of vaccinations? We have to keep on explaining why it is beneficial to vaccinate. We have to get the momentum. Vaccination begets vaccination. When we see more of our friends and relatives vaccinated, we also, notwithstanding some hesitancy, will get vaccinated. So, we have to bring vaccinations to the community, which we are still doing through our mobile teams. And also for those who are not mobile and are stuck at home, we will go to their homes to provide the vaccination.

But, as mentioned in the House earlier, we are trying to move to a new definition of "up to date" vaccination. Today, vaccination is pretty much all covered. Whoever is holding out probably is very hesitant, unable to change their mind or, indeed, have medical contraindications and you cannot vaccinate them.

Moving forward, it is more the booster rate and we should move to a stage where we stop counting the number of boosters, such as booster one, two, three and so on, but move to a concept where we really live with the virus closer to how we live with influenza. Every year, when there is a season, take an influenza vaccination that will protect you throughout the year and we need to. As we gather more data, as we have the shipments in and operations are ready, we will announce the details and move to a new mode of vaccinating the population.