Revised discharge criteria for Covid-19 patients

       The Multi-Ministry Taskforce has studied and evaluated the latest local and international clinical and scientific evidence which show that viable virus was not found in COVID-19 patients after the second week of illness despite the persistence of polymerase chain reaction (PCR) detection of ribonucleic acid (RNA). This means that COVID-19 patients are not likely to be infectious after Day 14 of illness and are not infectious by Day 21 of illness.

2.     The Taskforce will therefore revise the discharge criteria for COVID-19 patients in Singapore. With immediate effect, all COVID-19 patients who are assessed to be clinically well by Day 21 of onset of illness can be discharged without the need for further PCR tests. This revised approach will allow recovered patients who are well and no longer infectious to return to the community in a timely manner.

Scientific evidence strongly supports time-based discharge

3.     There is consensus amongst infectious diseases experts based on the clinical data presented locally and internationally that the risk of secondary transmission of COVID-19 is unlikely by Day 14 of onset of illness [1] . COVID-19 patients are usually most infectious one to two days before the onset of symptoms and the infectivity declines thereafter. After Day 14, while PCR tests may pick up minute fragments of the COVID-19 virus RNA, these RNA fragments are no longer transmissible and infective to others and the virus is no longer viable. This means the patient is no longer infectious beyond this period.

4.     This is corroborated by local research. The recent position statement on the period of infectivity by the National Centre for Infectious Diseases and the Chapter of Infectious Disease Physicians, Academy of Medicine, Singapore, noted that viable COVID-19 virus was not found after the second week of illness despite the persistence of PCR detection of RNA. Local and international clinical observations therefore support the discharge of well patients after Day 14 from the onset of illness.

5.     Internationally, various countries that adopt or recommend a time-based discharge policy include the South Korea, United Kingdom, United States, Estonia and Ireland. These countries have typically discharged patients after a range of seven to 14 days from onset of symptoms. South Korea discharges asymptomatic patients from isolation after three weeks from date of confirmation. More recently, on 27 May 2020, the World Health Organization (WHO) has also recommended a time-based discharge criteria. WHO recommends that patients who are clinically well can now be discharged after 10 days from the onset of illness, plus at least three days without respiratory symptoms or fever.

Extra precaution of discharge after Day 21

6.     The majority of COVID-19 patients in Singapore have mild or no symptoms, and the majority are admitted to a community care facility where most recover with minimal intervention. Those with higher risk or more serious conditions requiring close medical care are admitted to hospitals. Patients will remain isolated in a community facility until after 21 days.

7.     While clinical evidence has shown that patients are generally non-infectious from Day 14 of illness, we will continue to isolate all patients until Day 21 of onset of illness as an extra precaution. All COVID-19 patients who are assessed to be clinically well after 21 days from the onset of illness can be discharged from isolation without the need for further tests, but they will be given leave to remain at home (or place of residence like dormitories) for a further 7 days to rest and recover. After Day 28, these recovered individuals can return to work.

8.     This revised discharge criteria will not be applied to patients who have a history of being immunocompromised. Such patients will still require two negative PCR tests before discharge, as they may still continue to shed viable virus for prolonged period because of their impaired immunity.

9.     The Multi-Ministry Taskforce will continue to review the latest evidence with medical experts as the situation evolves, and make evidence-based adjustments to Singapore’s medical plan for COVID-19 patients, to ensure the wellbeing of all patients.

MINISTRY OF HEALTH
28 MAY 2020

^[1] In clinical practice, the onset of illness is defined as the date when the symptoms are reported by symptomatic patients or the date of first positive polymerase chain reaction (PCR) test or seven days before first positive serology test for asymptomatic patients.