The Philippine COVID-19 Pandemic: Where Are We Now?
There are a lot of mixed messages going around again as to whether the pandemic is better, worse, or something in between. We’re also comparing countries with widely different populations, resources, demographics, and dynamics. All these are happening while the virus continues to evolve and behave in ways that no one anticipated. This leads to a lot of anxiety, uncertainty, and a lot of finger-pointing.
Here is my informed opinion as an infectious diseases doctor and molecular biologist on what’s going on. This is with the understanding that even those of us who battle the virus face-to-face on a daily basis and study its behavior at a cellular level are constantly adjusting our recommendations as we learn more.
1| Each country is unique and responds to its pandemic depending on its resources, population, population density, culture, and behavior.
There is no one size fits all. Countries that have done well have used different strategies—Taiwan did not lock down but used intense tracing and isolation, Vietnam used massive testing, local lockdowns, and tracing, China employed massive lockdowns and testing, Iceland did massive testing but did not lock down, and Japan did not do massive testing or lock down but controlled it anyway. The U.S. has tested more people than any country, and yet its cases are surging. Peru locked down early but its cases are also surging. Brazil is in really big trouble due to poor testing, tracing, and limited lockdowns.
Perhaps the most instructive country is Singapore. It did massive testing and tracing early on and seemed to control the epidemic, then ended up with a large outbreak from migrant workers who were living in close quarters, resulting in another lockdown. Australia and Vietnam are now reporting new cases as they open up.
While containment is possible early on, as the pandemic progresses there are just too many factors to control. The main objective of a good pandemic response is to limit deaths. Different aspects of the response require resources: testing, tracing, isolation, treatment, and prevention. While all are important, countries with limited resources need to make hard decisions on what to prioritize. Many developing countries have used up massive resources in rushing molecular testing in response to the initial outbreak but struggled to muster more resources in tracing and treatment. The imperfect performance of molecular tests, along with the misguided deployment of highly inaccurate rapid antibody tests to compensate for a perceived lack of testing capacity knee-capped the initial response of many countries.
Now that the flaws of over-reliance on a testing strategy have been laid bare, many countries are struggling to shift resources to isolation and treatment facilities. Many still cling to the hope that they can test themselves out of the pandemic, but the truth is that just as much of resources are needed to keep severe and critical cases alive as the numbers continue to surge. Even the gold standard RT-PCR, when used at the height of viral shedding on the third day of symptoms, is only 80-percent sensitive, and much less than that on other days. The testing model as a means of controlling an epidemic is most useful for diseases that only transmit when one is symptomatic. With the CDC stating that up to 40 percent of patients are asymptomatic, it becomes much more difficult to rely on a testing strategy for control. This does not mean we abandon testing, since this is still important for confirming cases and surveillance. It just means that trying to meaningfully apply testing to capture a significant number of emerging cases is nearly impossible. Therefore, there needs to be just as much, if not more, investment in other pandemic response aspects such as tracing, isolation, and treatment facilities.
So how did the Philippines do? Not too badly in the initial phase.
The widespread lockdowns were successful in preventing our healthcare system from being overwhelmed. Various groups including the World Bank have estimated that the enhanced community quarantine prevented nearly three million cases and over 100,000 deaths. In a country with cities as densely populated as Metro Manila, and knowing what we know about how contagious this virus is, those numbers seem modest.
With a healthcare system capacity of about 10 percent that of the United States, an outbreak of American magnitude would easily have resulted in hundreds of thousands of deaths over a few months. The surge in the number of cases we are seeing is likely a result of opening up the economy. In addition, the large influx of OFWs contributed to the rise in cases and served as new clusters for outbreaks in different parts of the country.
The confirmed entry of SARS-CoV-2 with the G614 mutation, which seems to confer increased infectivity, is likely further driving the rise in cases. The one bright spot is that deaths have remained relatively low. Having under 2,000 deaths after six months from the first case is a near-miracle, and is a direct result of shutting down early. However, this can easily change if our hospitals are overwhelmed. For now, the overall grade is incomplete. Areas for improvement are better support for the healthcare system and improving triage of mild cases away from hospitals to community isolation facilities so they do not get overwhelmed.
Finally, testing needs to be better rationalized. Quarantine and isolation of suspect cases should be a clinical decision and not dependent on the final test result since this is inevitably delayed. Knowing the limits of testing and imposition of isolation and quarantine should be decided by trained healthcare personnel. Trained healthcare personnel appreciate the nuances of timing for testing and occurrences of false negatives and false positives.
2| Deaths have been low, but the potential for these to rise exponentially is still there.
While the response has been successful at keeping deaths low, this is not a reason to become complacent or expect that the virus will go away any time soon. If it did, I would be the happiest man on earth, but my infectious disease training tells me that that probably isn’t going to happen.
At 150,000 deaths in the United States and 650,000 deaths globally, this virus is a proven killer. Given the exponential growth of infection, we cannot afford to let our guard down for a second. The combined deaths in the last 24 hours for the U.S. and Brazil are more than our entire number of deaths for the whole pandemic. This terrifies me because the way outbreaks grow is explosive and it can kill a lot of people very, very quickly and without warning.
The lockdown prevented this, but our current efforts are barely keeping the virus contained. Deaths are rising again, and there is no indication this virus is burning itself out or becoming less deadly. We need to double down on prevention strategies to keep our numbers manageable and keep the economy open at the same time. It is the only way that the greatest number of people will survive.
3| This isn’t forever, but it won’t be the last pandemic either.
All pandemics end. Whether it is with a vaccine, an effective treatment, or it burns itself out, the pandemic will be controlled and the human race will survive. In a few short months, we already have two treatments that significantly decrease the risk of death for critically ill COVID-19 patients: remdesivir and dexamethasone.
There are many vaccines in clinical trials and more than a few are showing promising results. Other interventions are being developed by the best and brightest humanity has to offer. We are not helpless. However, the simplest interventions—wearing a mask, physical distancing, and hand hygiene—remain the most accessible and cost-effective. We have to buy time for our scientists to figure things out.
The number of people who die until we reach the goal of ending this pandemic one way or another is completely dependent on our collective response. As a people, we have responded in our own unique Filipino way to this crisis. It was not perfect, but it wasn’t bad either. We saved a lot of lives, but at great economic cost.
Could we have done better? Perhaps. Do we get another chance? You bet. If there is one thing I am absolutely sure of, we will never run out of infectious diseases.
Edsel Maurice T. Salvana, MD, DTM&H, FPCP, FIDSA is an award-winning infectious diseases specialist and molecular biologist at the University of the Philippines and the Philippine General Hospital. He has written and spoken extensively about HIV in the Philippines, the Dengvaxia controversy, and the COVID-19 outbreak. As a senior TED fellow, he is constantly seeking ways to communicate complicated scientific concepts to a lay audience and strongly believes that this is the best way to combat pseudoscience and fake news.