The role of proper information
CLINICAL MATTERS
Parallel to the Covid-19 pandemic was an unprecedented pandemic of misinformation. A combination of evolving knowledge of SARS-CoV-2, poorly moderated social media, and outright disinformation campaigns contributed to an excess of pandemic-related deaths and disabilities. Nowhere is this more evident than in the US, which has by far the greatest number of confirmed Covid-19 deaths at over one million.
The US was supposed to have been one of the most pandemic-prepared nations. It had strong public health science-based policies and huge stockpiles of medical equipment and medicine. Unfortunately, disjointed implementation and the outright refusal of people to follow restrictions and preventive measures contributed to the unprecedented death toll. Out of the over a million confirmed Covid-19 deaths in America, experts estimate that about two-thirds could have been prevented with better implementation of public health measures and compliance with mask and vaccine mandates.
Exponential growth of an unknown pathogen like SARS-CoV-2 with no pre-existing population immunity means that early and decisive interventions are paramount to preventing deaths. The delayed implementation of mobility restrictions and preventive measures, coupled with poor compliance, resulted in overwhelmed healthcare systems and unnecessary infections in many Western countries. Death rates of up to 10 percent were typical in the first few months of 2020 (Figure 1). Larger numbers of cases during this time resulted in many more deaths in many developed countries as a direct result of failing to do hard lockdowns. Early attempts to manage resources, such as personal protective equipment and testing kits, were compromised by the overwhelming wave of cases flooding hospitals. Aside from the actual impact of Covid-19 on health, fear inflamed political tensions and led to personal attacks on scientists and government workers by partisans with their own agendas.
Figure 1. Mortality rates over time for selected developed countries and the world. Note very high fatality rates at the beginning of the pandemic.
Contributing to the confusion was the World Health Organization’s (WHO) recommendation not to wear masks for asymptomatic individuals at the start of the pandemic since SARS-CoV-2’s sibling virus SARS-CoV (the causative agent of SARS) was not contagious prior to the development of symptoms. It soon became apparent, however, that SARS-CoV-2 was transmitted even among those without signs of illness. This early flip-flop, among many others, undermined people’s confidence in public health policies. Insistence on “mass testing” was fueled by a lack of understanding of how tests worked and led to a clamor to test everyone in a misguided effort to identify cases for quarantine and control spread. Unfortunately, the imperfect sensitivity of the test itself and the propensity to test negative during the window period quickly showed that this strategy was impractical and ineffective. Mass testing has been shown to not be cost-effective and only contributes to a two percent decrease in transmission. The lack of RT-PCR testing kits led some sectors to propose and resort to unscientific antibody testing in an attempt to simulate mass testing. Antibody testing for the diagnosis of acute Covid-19 led to an unacceptably high false-negative rate, which may have further contributed to the spread of Covid-19. Uninformed policies such as these, which were pushed by politicians and non-experts, wasted resources and diverted attention from more effective countermeasures.
Political posturing and widespread panic led to disinformation on a global scale. This also gave rise to pseudoscientific disinformation that resulted in the use of inappropriate medications, such as hydroxychloroquine, azithromycin, and ivermectin. While doctors scrambled to treat patients with whatever they could muster, the disinformation and anti-science platforms went into overdrive and undermined established health authorities for their sinister purposes. A brisk trade in off-label medications was quite lucrative, and proponents resisted attempts to regulate these interventions long after high-quality studies debunked them as useless or harmful.
How then, with all this misinformation and disinformation, was it possible for the Philippines to control the pandemic? A look back at the different waves of infection shows that the willingness of the Department of Health, the IATF-EID, and the president to listen to health experts despite the noise was instrumental in keeping deaths low. The population cooperated and accepted these measures, which ensured their success. The early draconian lockdown proposed by the Technical Advisory Group kept cases low in the initial phase of the pandemic. The drastic limitation in mobility arrested the exponential spread of the virus and gave the healthcare system some breathing space to learn more about Covid-19 and consolidate stockpiles of equipment and medication. The use of multiple layers of protection, including face masks and face shields, served to keep cases low relative to subsequent waves and gave enough time to procure vaccines and effective therapies. Stringent border control and quarantine protocols enabled repatriation and international travel while delaying the entry of more transmissible and deadly variants of concern. While the Philippine response was not perfect, the overall science-based approach and policies have now shown their worth in sustaining low case rates despite fully reopening the economy.
Despite a clear and sustained decline in severe Covid-19 cases and deaths, people remain understandably skittish whenever case numbers go up. An increase in daily cases from 200 to over 300 last week was enough to launch media and netizens into speculating that lockdowns or at least Alert Level 2 for NCR were in the offing.
Metrics for escalating from Alert Level 1 to Alert Level 2 are more stringent than those for deceleration. These metrics include a healthcare utilization rate of 50 percent or more, and an average daily attack rate (ADAR) of over six per 100,000 population sustained over two weeks. An ADAR of six would translate to about 6,600 cases a day nationwide, far from the current average of 200 to 300 a day. Meanwhile, health care utilization capacity has been below 20 percent for several weeks now. The reason some LGUs remain in Alert Level 2 is not from high case rates or hospital utilization. It is because a requisite for de-escalating to Alert Level 1 is a vaccine coverage of 70 percent of the eligible population and at least 70 percent of the A2 (elderly) population. This requirement was added to the metrics in order to ensure that the greater risk of infection brought about by higher mobility in Alert Level 1 areas is tempered by the majority of the population having significant protection against severe disease.
There needs to be a shift from a pandemic mindset, which is risk-averse and causes significant economic losses, to an endemic mindset that manages risk and preserves both lives and livelihood. The availability of effective vaccines and efficacious treatments has drastically reduced the deadliness of Covid-19 to the point of becoming a manageable and predictable disease. Despite continuing mutations leading to the emergence of more transmissible variants, the continued use of public health standards has successfully kept case numbers in check. The high public acceptance of a mask mandate means we can keep this useful tool onboard as added security as we continue to relax other measures. People will eventually get used to the idea that even if cases spike, these won’t translate to severe cases and deaths as long as vaccines are up to date. Until then, masks remain an essential public health measure that will see us through to endemicity and continue to protect our people against Covid-19.