How Delta precipitated a pre-emptive ECQ of Metro Manila

CLINICAL MATTERS

Dr. Edsel Maurice T. Salvana

Last June 21, 2021 (https://mb.com.ph/2021/06/22/delta-covid-19-variant-very-dangerous-tag-member/), the Technical Advisory Group (TAG) of the Department of Health was asked to brief the President on the need for stringent facility-based border control of our international ports of entry. Given that previous variants of concern had entered the Philippines from international sources, the TAG wanted to make sure that returning Filipinos were properly quarantined and tested prior to being allowed into the community.

This presentation was in response to the initiative of Cebu province to modify the 10-day facility-based quarantine plus four-day home quarantine, with a test on the seventh day. We explained to the President that if a person contracts COVID-19 during his or her flight, a 10-day mandatory facility-based quarantine would neutralize almost all risk of bringing in a new variant of concern to the Philippines. We recommended testing on the seventh day with an RT-PCR and an additional four days of LGU-monitored home quarantine for good measure. Cebu wanted to test people on arrival and monitor them at home, which was inconsistent with our recommendations. The TAG felt that this would miss almost all cases of infection acquired en route to our country, since it typically takes three or more days for RT-PCR tests to turn positive from the time of exposure. In addition, they could potentially expose their families to a variant of concern.

This was the first time we presented the threat of the Delta variant to the President and his cabinet. At that time, face shields had also become controversial as many Filipinos felt that these were no longer needed, especially outdoors. Earlier risk calculations by scientists serving as government advisers showed that wearing face shields constituted an added layer of protection, giving over 90 percent protection when combined with face masks. Logically, given the lower risk of COVID-19 outdoors because of good ventilation, many felt that a face shield obscuring one’s vision was more of a hazard and less beneficial. Part of the reason we were asked to present was to clarify if face shields needed to be used both indoors and outdoors.

During my presentation, I outlined the threat of Delta as the newest variant of concern. Delta, or B.1.617.2, was first described in India. It is the most transmissible COVID-19 variant yet. The horrific surge of cases in India was still fresh in the minds of many people. Hospitals were completely overwhelmed, people were gasping for breath amid widespread oxygen shortages, and parking lots became makeshift crematoriums. As Delta started to spread across the world, scientists found that vaccines were less effective in preventing transmission, and that people sickened with Delta were more likely to have severe disease and die.

Israel, which had one of the highest rates of vaccination worldwide, was starting to see a spike in Delta cases despite their impressive inoculation rate. In the UK, a significant number of partially vaccinated people were getting sick, although the vaccines continue to protect against severe disease. In Australia, a limousine driver acquired Delta after chauffeuring some airline crew. When he went to a mall, he transmitted Delta to two other people. What was extremely worrisome is that these infected people only had fleeting contact with him, no more than a few minutes. This was in contrast to the usual 15 minutes of exposure needed to be considered a high-risk close contact. The TAG’s message to the President was clear. We needed stringent border control to slow down the introduction of Delta. Otherwise, our healthcare system could get overwhelmed by an exponential rise in cases.

A month earlier in May 2021, a handful of returning overseas Filipinos had been diagnosed with Delta. The first few patients had ended up under my care and I was scared by what I saw. One patient had some of the highest inflammation markers I had ever seen and spent 60 days in the hospital. Another one very quickly died, and two others who had relatively mild disease still had very high levels of inflammation.

After the briefing, the President was concerned enough to reiterate the face shield mandate even for outdoor use. This was in response to the report that Delta was also up to 40 percent more transmissible outdoors. He ordered the DILG to ensure that Cebu followed the stringent border control measures as recommended by the Interagency Task Force for Emerging Infectious Diseases (IATF-EID), and that genomic surveillance continued to look for incoming and local cases of Delta.

Despite the President’s directives, Cebu remained in favor of their less stringent protocols. Some IATF-EID and TAG members, including myself, went to Cebu at the end of June and presented the threat of Delta to the Cebu Provincial Board. We warned that if Delta got into Cebu due to lax border control, a bad surge was forthcoming. Delta is now in Cebu causing a large spike in cases, overwhelming their healthcare system. Some of the Delta outbreaks in Mindanao have been linked through whole genome analysis to returning Filipinos who entered through the Cebu airport. While it might have been impossible to completely stop Delta from coming in, it could have been further slowed down.

Toward the end of July, healthcare capacity in Metro Manila was at 50 percent and cases were increasing steadily. The metrics were still consistent with a quarantine status of GCQ with Heightened Restrictions. We had enough hospital rooms and ICU beds, and the case numbers were still manageable. The IATF-EID approved this classification for NCR for Aug. 1 to 15, 2021. Appeals by local government units, however, are always entertained. The Metro Manila mayors who saw some concerning clusters in their cities wanted to escalate further, especially with additional Delta detections in NCR.

In order to assess this added risk, the IATF Sub-technical Working Group for Data Analytics did extensive modeling work. These intricate models looked at the latest Delta spread, including the latest genomic data. Based on these models, the downstream effect of Delta was such that some sort of lockdown was inevitable if we wished to avoid the fates of Malaysia and Indonesia. One mitigating factor would be a significantly increased vaccination rate. Even if a large increase in cases may be inevitable, the 90 percent decrease in severe cases from widespread vaccination should prevent the healthcare system from being overwhelmed.

The IATF-EID therefore made the decision to lock down in order to give time to increase vaccination and delay the spread of Delta. They did this with eyes wide open on the drastic economic implications of another ECQ. This is an unprecedented escalation because it is not within the usual metrics. This is a preemptive response to Delta, and will be in conjunction with an accelerated vaccination program to get as many people vaccinated in the shortest amount of time.

Let’s not waste this opportunity. If you aren’t vaccinated, try to get a schedule with your LGU. If you know anyone who is not yet vaccinated, please ask them to get vaccinated as soon as possible. The government has committed to provide as many vaccine doses as it can spare.

The situation is quite fluid and can change from day to day. If we meet our goals early and cases do not rise as fast as predicted, the ECQ might be reevaluated. If things look worse and not enough people are vaccinated, it might be extended. The biggest objective of this ECQ is to vaccinate as many people as possible in NCR. We are tempering the anticipated increase in Delta to protect as many people as possible. There may still be some sort of large increase of cases due to the nature of Delta. But if most people are vaccinated, then our hospitals will be able to manage. There will be a lot less severe cases, and very few people will die.