18/04/2020
Thoughts on the Philippine COVID-19 Response and A New Normal
1. Enhanced Community Quarantine (ECQ) has flattened the curve, but this can surge again at any time if we let our guard down.
At a little over 200 cases a day holding steady for the last few days, there is little doubt the ECQ has succeeded in slowing down the spread of COVID-19 in the Philippines. Even without “mass testing,” the fact that we are measuring the severe/critical population on a daily basis gives us a good picture of the SHAPE of the curve. We have gone from a 3-day doubling time from March 28 to 31 (from 1k to 2k, the tail end of the number of cases prior to ECQ since incubation time is up to 14 days) to a current doubling time of 14 days (from 3k to 6k between April 4 to April 18). This is an objective international measure and is even more encouraging since it has done this in the face of increased testing.
As for total cases, the severe and critical only represents 20% of actual cases since 80% of cases are expected to be mild. The continued quarantine and isolation of symptomatic mild patients either at home or in community isolation facilities is of utmost importance and it is encouraging to see that more and more LGUs have set up these facilities. While testing these mild cases is important, it is more important to keep these symptomatic patients isolated because we know testing is imperfect and will still miss up to 1/3 of symptomatic patients.
Due to the extreme cost to the economy, ECQ is NOT a sustainable intervention. We do know that the ECQ has resulted in some REAL gains. We have bought time for our healthcare facilities to prepare; we have increased testing capacity and we are on track to be at 5000 to 8000 tests/day by month’s end; and there are more isolation facilities coming online. We have PREVENTED an overwhelming surge of patients to our hospitals – something that has occurred even in rich countries like the US and Italy. There is no doubt that early intervention has saved tens of thousands, if not hundreds of thousands of lives. But we can lose all these if secondary and tertiary surges occur. We must realize that this time was BOUGHT AT GREAT COST and it is imperative we don’t let our guard down. THIS IS THE ONLY CHANCE WE GET TO CONSOLIDATE OUR GAINS because our economy will not be able to tolerate another prolonged lockdown.
2. Mass testing is NOT a panacea, and we need to be aware of the limits of the tests and act to minimize risk of undetected cases.
RT-PCR WILL miss 1/3 of cases. Much more than 1/3 if we test asymptomatic/presymptomatic infected patients because their viral loads will be low. Antibody/rapid testing is not yet well validated. We will miss almost ALL active cases if we do antibody testing earlier than 5 days from onset of symptoms. The purpose of testing is to give us an IDEA of the burden and spread of infection. It needs to be INTERPRETED PROPERLY. Tests cost money, use up PPE, and put our healthcare workers at risk whenever they test potential cases. BEST USE of testing is as follows:
ALL SYMPTOMATIC patients need an RT-PCR test to DOCUMENT infection. Right now, we are prioritizing severe and critical, but mild cases can be tested as our capacity improves. RT-PCR detection is best done when someone HAS SYMPTOMS, and even in the best of conditions will miss 1/3 of positive cases. IF there is any reason that RT-PCR is not available, or there is a substantial delay in results, these SYMPTOMATIC patients need to be isolated to be safe. Even if they test negative, patients who get worse may need to be tested again. Stable patients who test negative can go home but should continue to isolate for 14 days after symptoms are gone. This is the SAFEST way to ensure that we don’t get blindsided by FALSE NEGATIVES.
ALL ASYMPTOMATIC patients who have had CLOSE CONTACT EXPOSURE (usually household members) of a known POSITIVE case should be quarantined for 14 days regardless of whether they are tested or not. IF they get tested, EVEN if RT-PCR is negative they should remain isolated for 14 days. This is why it isn’t advisable to test asymptomatics with RT-PCR because it might give you a false sense of security and it might not be cost-effective. If we HAVE ENOUGH RT-PCR capacity and enough resources (once we hit >8,000 tests per day), we can do this, but for now we need to prioritize symptomatic patients. If they develop symptoms at any time, they need to be RT-PCR tested.
Antibody testing will help map out cases, but we need to use these properly. As validation results become available, we can choose the best performing ones and these can really make a difference in tracking the spread of COVID-19. Antibody testing will only be useful if we can consistently get a reliable result.
As for those who are testing positive again after having cleared, we think that this is more an issue with the RT-PCR test – it can detect even “dead” or nonviable virus that can persist in infected patients and these can move from deeper compartments like the lungs to other areas where they can be detected by testing. It is unlikely these are reinfections or reactivations – a lot of these patients remained asymptomatic and viable virus could NOT be cultured. Of course more studies need to be done to be sure but for now we know that most people who recover do develop immunity, and these reports of “relapse” may have more to do with a test that is just not a good test for cure.
3. All proposed treatments are undergoing proper clinical trials, and there is no proven safe and effective treatment at this time.
There have been some promising treatments and a lot of early studies have been published. Unfortunately, the results are mixed, and some have been stopped due to unacceptable toxicity. There is no way to know if something is safe and effective without a randomized placebo-controlled trial (RCTs). These are ongoing. Treatment with “off-label” drugs can be done on a “compassionate use” basis where doctors can assess if a drug can potentially benefit a patient despite the risks. Any others offering “cures” without proper evaluation are potentially dangerous and should be avoided. We expect interim results in 1 to 2 months from the ongoing RCTs. For vaccines, it will be over a year before we have good enough data, and that is an optimistic estimate.
4. What can we expect if the ECQ is modified/lifted?
The potential to SURGE is always there. We won’t see a potential surge until TWO WEEKS after the ECQ is lifted because the first two weeks will be made up of cases that were acquired during the ECQ (incubation period is up to 14 days). This may LULL us into a false sense of security if it stays low until there has been REAL HARM done. Therefore, if ECQ is going to be modified, it needs to be done SLOWLY and ALLOW for the data to catch up, so we know what is truly going on. Social distancing and universal mask wearing need to continue. Schools should remain closed. Those who can work from home should continue to work from home. Always wear a mask (cloth or surgical mask is fine, leave the n95s for the healthcare workers) when you are out in public so you don't transmit in case you are incubating the virus. Gatherings of more than 10 people should remain banned. As always, our priority should be to take care of the most vulnerable sectors and make sure that there is enough food to feed them. This is a long-term commitment and it will be our new normal.
If we are successful, we can keep cases low and prevent these from overwhelming our healthcare system while restarting our economy. There is a long and hard road ahead of us, and everyone needs to help each other to get through it. It is man versus virus. We should all do our best to save lives and to take care of those who are at the highest risk for a bad outcome. This includes those at highest risk for dying from the virus, and from the economic disaster the virus has brought.
Stay safe everyone. Thank you.
