And what to expect in the next few months
CLINICAL MATTERS
Dr. Edsel Maurice T. Salvana
There is an internet saying that goes, “This too shall pass. It may pass like a kidney stone, but it will pass.” I’ve never had a kidney stone, but I have had many patients who passed one. They all tell me it was the worst pain of their lives, and they would never want to repeat the experience again.
The COVID-19 pandemic has hit countries with varying degrees of pain and suffering. At the start of the pandemic, the worst hit country was China. The lockdown in Wuhan was unprecedented, and the severe disruption of people’s lives was terrible. Then outbreaks in Brazil, Italy, and the US made China’s response look quite efficient. Countries with initially good responses like Thailand and Malaysia are now wilting under an onslaught of Delta. COVID-19 came full circle to China with Delta, and China seems to again be managing their pandemic somehow.
The initial optimism of ending the pandemic early with the vaccines seems to have been severely tempered by Delta. As the United States Centers for Disease Control reinstated the indoor mask mandate in recognition of the extreme transmissibility of Delta even among vaccinated persons, other countries sought to manage expectations for their pandemic-weary population. After touting how achieving herd immunity with the vaccines was within reach in order to encourage people to get vaccinated, many countries are backpedaling in light of the decreased efficacy of vaccines to interrupt transmission of Delta. Due to the extreme cost of lockdowns and its decreased potency against Delta, many countries are reevaluating their drastic containment strategies. Many are considering less radical mitigating measures to minimize the impact on their healthcare systems while allowing enough sustainable economic activity.
So, what now and what will we expect in the next few months? As explained in a previous column, the preemptive ECQ was done in anticipation of the Delta tsunami. Due to how fast it spreads, all scenarios ended up with all-time high levels of cases. Even six weeks of ECQ alone would have ended up with our healthcare system overwhelmed. We decided to lock down preemptively at a healthcare utilization level of just above 50 percent in anticipation of the overshoot.
The only way to mitigate the impact was to get vaccination rates as high as possible, so that even with very high case numbers, the proportion of people needing hospitalization would be enough for the healthcare system to handle. For instance, if we have 150,000 active cases, the proportion of severe cases if all of them were unvaccinated is three percent, translating to 4,500 cases needing hospital beds. If instead we had 150,000 active cases and all were vaccinated, only 0.3 percent would be severe and only 450 cases would need hospital beds.
The record highs of COVID-19 cases in the last few days were predicted by the models. This was expected since Delta is up to two to three times more contagious than the original virus. In NCR, many people were puzzled by the downgrade from ECQ to MECQ after two weeks despite increasing cases. This was done due to several reasons.
Mobility data shows that the last two weeks of ECQ did not reach the level of mobility restriction from previous ECQs. The reasons for these are multifactorial. One likely reason is that people can no longer afford to stay at home, and they go out to try to find work despite the ECQ or else go hungry. Another possibility is pandemic fatigue. Enforcement was as strict as ever, with over 30,000 apprehensions for failure to adhere to Minimum Public Health Standards (MPHS) in the first week of ECQ in NCR. Despite these police actions, the decrease in mobility was suboptimal.
The cost of each week of ECQ in NCR is over ₱100 billion. Having to pay that price without the commensurate decrease in mobility was no longer worth it. In other words, ECQ as a “medicine” was causing more side effects than the benefit that was being derived from it. The compromise was to tighten up on potential high-risk activities that were allowed in previous MECQs. These potentially high-risk activities include churchgoing, dining in, and non-essential services. MECQ with these modifications still hurts, but the overall economic cost is half that of ECQ.
NCR cases are starting to plateau. With hope, this means we are seeing the effects of the two-week ECQ plus the enhanced vaccination program on case numbers. It usually takes two to three weeks for interventions to take effect, so this is about the time we see the full impact. When we ran the models, all the scenarios showed an overwhelming number of cases if Delta took over. Delta has taken over as shown by recent genomic surveillance. ECQ was at best going to blunt the effects of Delta. The healthcare system was really going to take a major hit due to the extreme transmissibility and the expected higher severe disease rate of Delta, whatever we did. The good news is that the enhanced vaccination program has successfully fully vaccinated over half of the eligible population in Metro Manila. The current number of active cases in NCR are on the low end of projections, and this is likely because of enhanced vaccination. The percentage of severe and critical cases from two weeks ago has gone down from 2.8 percent to 1.8 percent—a clear sign that vaccination is making an impact. As it is, the healthcare system is being severely stressed with the current case load. Without vaccination, the healthcare system would have been completely overrun. In addition, Metro Manila hospitals are also taking in cases from the surrounding regions, which are seeing large Delta spikes as well.
Even countries, which controlled COVID, are now seeing major Delta spikes. The objective of the preemptive lockdown was to minimize the loss of life from this overshoot of the healthcare system capacity. Beyond that, continuing to vaccinate rapidly and wearing masks with shields and minimize non-essential mobility will help lessen the pressure on the healthcare system. Delta is different, and it will kill. We all need to work together to minimize the damage.
The news from outside NCR isn’t good either. Many areas are dealing with surges and their healthcare systems are already overwhelmed. There are many reasons for this, but the root causes are the high transmissibility of Delta and the imperfect application of best practices. Vaccination is the way out. Even with high numbers of cases, high vaccination rates will decrease the load of hospitals and healthcare workers. While waiting for more people to get vaccinated, we need to slow down the spread to a level where the healthcare system can cope. We can do this by wearing masks, face shields, and sticking to the public health standards, whether we are vaccinated or not.
All pandemics end. Let’s protect each other to ensure as many of us as possible survive to see the ending. When we hit a good vaccination percentage in the next few months, we can continue to open up while keeping severe cases manageable. In addition, reformulated vaccines that are tweaked against the variants are already in clinical trials. These may restore clinical efficacy and transmission blocking efficacy against Delta when the studies are completed. These may be the ideal boosters rather than using current vaccines designed against the old virus type.
Over 100 other COVID-19 vaccines with different platforms are also in clinical trials, including live attenuated viruses and virus-like particles, which are expected to generate more transmission blocking efficacy. As COVID-19 evolves, we can also continue to evolve our response. The most important element is time. Time to vaccinate as many people as we can and time to develop better vaccines. We buy that time by using public health standards and innovating our containment strategies. The pandemic has hurt us badly, but it will end. How fast the pain will go away and how much it will cost us will be determined by the choices we make.