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Highly-vaccinated Singapore is battling a record wave of COVID-19 infections just as the city plans to re-open to the world. But Singapore's 80% vaccination rate has kept severe cases and deaths down, potentially proving that living with the virus—versus trying to eradicate it—is the surest path out of the pandemic.

On Monday, Singapore recorded 1,647 cases of COVID-19, bringing its seven-day daily average to 1,545 cases, higher than any other previous wave of the pandemic. But even as cases soar, COVID-19 deaths in Singapore have remained low. The city-state of 5.7 million people has averaged three deaths per day in the last week.

Singapore’s saving grace is its high vaccination coverage.

Singapore has now fully vaccinated over 80% of its population, one of the highest rates in the world. China's fully vaccinated rate is 73%, while the European Union and U.S. have fully vaccinated 65% and 55% of their populations, respectively, according to Bloomberg.

Singapore’s high caseload was, in part, baked into its plan to ‘live with COVID’ after 18 months of trying to every case, and ministers say that the city still plans on dropping quarantine requirements and re-opening to the world in coming weeks, even as the government reimposes some short-term social distancing measures.

Experts say that Singapore's climbing cases, more than half of which are in vaccinated individuals, may signal that COVID-19 is becoming an endemic disease in the city-state, meaning COVID-19 circulates in a population like its four coronaviruses cousins but doesn't upend lives due to widespread immunity. As long as deaths remain low, Singapore can set an example for how other countries, especially those that have maintained zero tolerance for COVID-19, can emerge from the pandemic.

Living with COVID

In May, Singapore Prime Minister Lee Hsien Loong introduced the government’s plan to 'live with the virus' and transition away from a 'COVID-zero' approach.

“Our aim must be to keep the community as a whole safe while accepting that some people may get infected every now and then,” Lee said in May, announcing that Singapore would gradually open up internally and then to foreign visitors.

Singapore has largely followed the re-opening plan Lee laid out. In June and July, Singapore began loosening restrictions for dining establishments, workplaces, and entertainment venues. By August many businesses were allowed to operate at or near full capacity.

But Singapore’s growing caseload has raised alarms nonetheless because of the speed at which cases have climbed.

Throughout July and August, cases in Singapore ticked up to over 100 per day after nearly a year of almost no infections due to the city’s previous zero-tolerance policy. That policy included stay-at-home orders, intensive testing and contact tracing, and a ban on foreign visitors. This month, cases have risen exponentially, from 180 on Sept. 1 to roughly 500 by mid-September and to nearly 1,500 this week.

On Monday, Singapore said that it would reintroduce some social distancing measures, including reducing dining groups from five to two people at restaurants and directing companies to allow employees to work from home. Singapore's government said the measures will be in place for at least one month to prevent the health care system from being overwhelmed and allow the city to scale up services to help infected patients recover at home. Currently, 30 people in Singapore require ICU beds due to COVID-19, up from five cases at the start of this month.

"The current outbreak will slow Singapore’s re-opening and potentially prolong the process," says Dr. John P. Ansah, assistant professor in health services at the Duke-NUS Medical School in Singapore.

Singapore in early September opened up 'vaccinated travel lanes,' through which vaccinated travelers from low-risk places like Hong Kong and Germany can enter Singapore without quarantines. Singapore had hoped to expand the program later this year in an effort to fully reopen its border and says those plans are still on track despite the ongoing outbreak.

“Our overall strategy has not changed,” Finance Minister Lawrence Wong said in an interview with Bloomberg on Monday. “We are committed to reopening our economy and our society progressively, but our aim has always been to do this without putting too much stress on our hospital system.”

Endemic endgame

The rise of the Delta variant and breakthrough infections is partly to blame for the surge of infections. Singapore’s data shows that 52% of infections in the last month have been among the vaccinated while 48% have been unvaccinated.

Singapore has used COVID-19 vaccines from U.S. makers Pfizer and Moderna for its national campaign, while some private clinics have also distributed doses from China's Sinovac for individuals that prefer the Chinese jab.

But the city's high vaccination rate is keeping people from suffering the worst effects of the virus. Authorities said on Sunday that 98% of people infected in the last 28 days have recorded mild or no symptoms of COVID-19. Singapore is discovering asymptomatic cases by testing close contacts of infected individuals. Kenneth Mak, Singapore’s director of medical services, told Singapore’s Straits Times last week that the vaccinated in Singapore have been 12 times less likely to die or require hospitalization than the unvaccinated.

In Singapore, and elsewhere, Delta-driven outbreaks are leading to higher rates of breakthrough infections among the vaccinated. But such infections are not necessarily a cause for concern due to the protection from severe disease and death that vaccines offer.

"The whole world is going to be transitioning to considering [COVID-19] as being endemic," says Ashley St. John, an immunologist at Duke-NUS medical school in Singapore. "It will not be possible to eliminate it any time soon, but we have the tools now to manage it, including vaccines that work."

Ben Cowling, an epidemiologist at the University of Hong Kong, says that even amid its new outbreak, Singapore still provides a model for how COVID-zero countries like New Zealand, Australia, and China can successfully emerge from the pandemic.

"It is likely that case numbers will further increase in the coming weeks as Singapore continues to relax measures," he said. "[But] I would expect very few severe infections to occur."

The shift to 'living with COVID' also requires a change in mindset, from an obsession with absolute case counts to focus instead on cases that may require hospitalization. Singaporean authorities have begun to lead daily health briefings with the number of severe cases and deaths as opposed to the number of new infections. Health authorities also have stopped providing data on whether cases were traceable or not in their effort to deemphasize mild infections.

"[Daily infection data] is no longer as relevant as before, given our current strategy of living with Covid-19," the government said in a statement on Sept. 9.

And once on the re-opening path, places like Singapore can evaluate the costs of tolerating some level of infection in the community with the economic benefits of re-opening. In August, Singapore's government raised its 2021 economic growth forecast from a 4-6% GDP growth in 2021 to 6-7%, citing the prospect of resumed international travel.

"What are the alternatives for Singapore? Reverting to a COVID-zero strategy would have enormous economic consequences," says Cowling.