Pandemic musings or where are we now since it started?

Published June 9, 2021, 12:17 AM

by Raymundo W. Lo, MD, FPSP

 

Raymundo W. Lo, MD

More than a year into the COVID-19 pandemic, where is the Philippines heading — or more precisely, where is it not heading? Let’s look at several aspects.

On the medical front, we now know more about how to treat COVID-19. What works and what doesn’t. Our doctors can treat patients better with the experience gained over a year. Choloroquine has been ditched. But now, we’re making a big fuss over Ivermectin. Remdesivir doesn’t seem to help, according to the latest studies.

Convalescent plasma has mixed reviews, but I think it’s because early on, we had no reliable indicator of which donors were most suitable for extracting plasma from. Anecdotal experience seems to show some benefit if given early in moderate to severe cases. Some patients are claiming almost immediate relief after, or even during, the transfusion of convalescent plasma. But this should have high levels of neutralizing antibodies to effectively counter the viral invasion. Future studies should use reliable tests for neutralizing antibody levels for donor selection and use in early cases.

Monoclonal antibodies are a modern version of convalescent plasma. They are state-of-the-art, laboratory-produced antibodies of the same kind, unlike convalescent plasma, which is a mixture, as generated by the immune system. But its use is still just a gleam in the infectious-disease experts’ eyes, being unavailable and quite expensive. Nevertheless, the use of monoclonal antibodies should be the way to go in the future.

 Another treatment  modality in use is hemoperfusion, which is an adaptation of the dialysis method used for renal-failure patients. The rationale seems to be that it cleanses the body of the circulating inflammatory mediators and thus possibly the circulating virus.

Diagnostics-wise, we have progressed from the early days of the rather unreliable rapid antibody test to molecular testing (RT-PCR), and now the rapid antigen test. The last has been widely used but frowned upon by the Department of Health for low sensitivity. But what do you do when RT-PCR is not only too costly but also largely unavailable? In my opinion, antigen tests are useful in select situations and with proper use, as in serial testing when employed in the non-clinical setting.

The use of pooled RT-PCR testing has been established as being effective in surveillance testing. With economy of scale and same length of time to release results as individual testing, it is capable of testing many more than can be achieved by individual testing.

It will be an effective tool in suppressing localized outbreaks because it quickly identifies the infected and allows the cleared individuals more economic activity. But health authorities seem to be too conservative to embrace this idea. Pooled testing will also be a major tool in combating future pandemics, and we should keep training our laboratory staff in its use.

Contact tracing is the bugaboo in this scenario. It really leaves much to be desired. Without improvement in this area, no amount of testing will  abate the spread of COVID-19. There should be an honest-to-goodness training of contact tracers to immediately find cases, isolate them, and test close contacts. Otherwise, we risk having a semi-endemic situation, with outbreaks every now and then in different areas.

Isolation and quarantine facilities also seem to be in short supply. The government can’t seem to afford renting or constructing proper facilities to isolate those infected but not requiring hospitalization, and quarantine close contacts who need to be monitored and tested. You wonder where the billions of pesos allotted for this purpose went.

The big question is, who wants to get tested when the  consequence for those who test positive is to be isolated and prevented from going to work, but whose priority is to feed their families? This is why many of our fellow Filipinos do not want to be tested even when they have symptoms, and so will ignore that slight cough or fever, or loss of taste and smell (who can detect that anyway, right?) just so they can continue working. With the Bayanihan 1,2, 3 or up to infinity and beyond, funds should be allotted for supporting these workers’ families while they have to be isolated. And so, the pandemic continues….

An apparent form of democratization is the unnecessary loss of lives among both the well-heeled and the hoi polloi. During every pandemic surge, many of the more serious cases are turned away from both private and government hospitals owing to the limited number of beds and the severe shortage of health workers. At such times, there have been such long waiting lines to the emergency rooms that patients started dying while in line. There was the case of the mother of a doctor at a prestigious medical center who succumbed in her car while waiting for space in the ER. A more recent case is that of Claire de la Fuente, a famous singer and businesswoman who suffered the same fate.

Yet those at the very top of the pyramid will still outdo the high and the mighty below them, what with all the resources at their disposal. Your life may be spared if you can afford half a million pesos’ worth of monoclonal antibody cocktail — as was reportedly given to a former president. As the pundits would say,  “Masamang damo, mahirap patayin.”(Bad grass, hard to kill.)

Even the simplest public health protocols can expose such inequities. Currently, face masks and face shields are required outside of our homes. By and large, the general population has mostly adhered to observing these protocols, although of course, we see occasional instances of violations by both high government officials and the public. But, while the high and mighty go scot-free, the down-and-outs are cited, hauled off to jail, and penalized. So much for an egalitarian society.

The raging issue now is the utility of face shields in preventing infection. Manila Mayor Isko Moreno has questioned its imposition on the public and asked for the scientific basis for that decision. He cites the hardships imposed on people, both economic (buying face masks) and safety (accidents due to wearing face shields) and asks if its benefits outweigh such burdens imposed on an already suffering population.

The studies he cited say there is no  benefit to adding face shields to face-mask wearing alone. Indeed, most studies show the benefit only in the hospital/health care settings, where close contact and aerosol generation are more likely to be encountered.

Simulation studies show minimal, if any, benefit to adding face shields to mask wearing. No real-world situation studies are available.  It is only in the Philippines that face shields are required. Yet, it did not prevent surges from happening even while it was being strictly enforced. That says a lot in favor of letting go of face shields and concentrating on face masks and social distancing. Are face shields then just another manifestation of hygiene theatre?

As for social distancing, we Filipinos are a very gregarious lot. We thrive on communality, a sense of belonging, and really mixing together at close quarters. This pandemic wreaks havoc on our psyche simply by forcing us to put ourselves at two arms-length from each other, especially from our loved ones. So wonder no more if we have difficulty distancing from each other.

It’s even more difficult for our less fortunate folks who live cheek by jowl in cramped homes. How can they isolate or quarantine at home, where all they have is one small room?

As for vaccination — remember our president saying this is our ticket out of the pandemic? Now that it’s within arm’s reach, we seem to be stumbling from step to step. From balls being dropped to just plain waiting for donations, our vaccination campaign is lurching along. We need 140 million doses of two-dose vaccines to achieve herd immunity and yet, we’re only getting trickles, a few hundred thousand doses here, a million there.

There seems to be no effort to actively purchase a sizable number of vaccines. Businesses which volunteered to buy for their employees and their families were stymied by government bureaucracy even while offering to donate half their purchases to the government.

The rollouts were enthusiastically received by those willing and desiring to be jabbed. The current demand outstrips the supply, which should be a good situation if sustained. It creates a bandwagon situation and when more vaccines are available, we hope for more clamor for the jabs.

However, there are ominous signs that all will not be well with the vaccination program.

In 2016, after the Dengvaxia controversy broke out, vaccine confidence dropped precipitously from 92 percent to 32 percent. The claim that the Dengvaxia vaccine caused children’s deaths led to mass hysteria, resulting in all vaccines being refused by previously receptive parents.

Current surveys show essentially the same figure. Only a third are willing to get shots, another third are hesitant, and the last third are against the vaccine. Unless we resolve the vaccine hesitancy engendered by the Dengvaxia furor, we will have great difficulty achieving herd immunity, even with hundreds of millions of vaccine doses on our hands. (Disclosure: I am one of the accused in the Dengvaxia cases after I testified in Congress about the inaccurate conduct and conclusions of the PAO autopsies).

Ticket out of the pandemic? Not so fast. In this particular instance, a political solution is needed for a politically induced mess. No medical solution here. This administration must confront the elephant in the vaccination room if we are to see our way out to a new normal.

Otherwise, we may be condemned to a painful series of surges with our economy contracting and wasting away to being the sick man of Asia again. More families will slip into poverty. Social unrest may not be far behind.

 Better buckle up and hunker down. It will be a wild ride.

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