Managing the risks and are we there yet?
CLINICAL MATTERS
Change is hard. Once people have gotten used to a routine, it is very difficult to go to a different one and many get worried about the risks. When the pandemic upended our lives, we learned to wear masks, distanced ourselves from others, and only went out for essential reasons. When vaccination began to significantly decrease the risk of death from Covid-19, the government began to relax restrictions to spur economic growth. Quarantine times were shortened or eliminated, home isolation was allowed, and venue capacities were increased. Despite some understandable opposition and hesitancy from some sectors of society, we opened cautiously using a risk-based approach. This had to be done because continued closure of society was becoming detrimental to our health and economy.
When the Technical Advisory Group and the IATF saw these figures, it became apparent that the widespread restrictions needed to be shifted down to a more targeted nature. Hence, the creation of the Alert Level System (ALS) and granular lockdowns to replace the blanket community quarantines in 2021. Even the ALS and granular lockdowns, however, still called for a significant number of restrictions. Full economic capacity was still not possible under the revised rules. As vaccination rates improved and protection against severe disease increased, the restrictions were further relaxed since healthcare utilization rates remaining low.
The Philippines has been more careful than most countries in managing Covid-19. After having the second highest number of cases in Southeast Asia early in the pandemic, this cautious approach allowed our country to weather the challenges of Delta in August 2021 and Omicron BA.2 in January 2022. Currently, the Philippines is fifth in Southeast Asia in terms of cumulative confirmed Covid-19 cases despite having the second highest population. Looking at population-based numbers, the Philippines is 154th in the world in total cases per million population, and 130th in deaths per million population. Our total deaths of about 63,000 are 17 times less than that of the over one million deaths of the US. Even taking into account undocumented Covid-19 deaths, we have done much better than many developed countries in the world. This is in large part due to the early lockdown and the gradual relaxation of restrictions, even as vaccination coverage ramped up.
After achieving high vaccination rates, many countries prematurely got rid of their mask mandates. As vaccination continued to drastically decrease severe disease and deaths, many countries started to treat Covid-19 as the flu. When Omicron hit, it spread like wildfire due to its extreme contagiousness and its ability to dodge the transmission-blocking effects of the old vaccine formulations. This was amplified in many places where people no longer wore masks. While the overall case fatality remained low, the sheer number of people infected still meant a significant number of deaths. Continued mask wearing in the Philippines managed to keep cases relatively low after the BA.2 spike, even as restrictions were relaxed and the Philippines had nationwide elections. When BA.5 finally arrived in the Philippines, cases did go up but peaked at about 4,183 cases in August 2022 despite a slow booster uptake. In the light of increasing mobility and less restrictions, this modest increase could have been much higher if not for the continuation of mask mandates.
Looking at our Covid-19 pandemic curve, endemicity was being hinted at as early as January this year. Despite having double the peak number of cases of Delta, the number of deaths attributable to Omicron BA.2 did not reach even one half of the confirmed fatalities from Delta. Even with the phenomenon of immune escape by SARS-CoV-2 variants of concern (VOCs) causing more breakthrough cases, the number of deaths continued to decrease and healthcare system capacity remained adequate. Unless a particularly virulent VOC emerges in the near future, it is unlikely that any subsequent rise in cases will be sufficient to overwhelm the healthcare system. It is in this context that the government approved the resumption of face-to-face classes in late August. It is also the reason behind the cautious lifting of the outdoor mask mandate was allowed on Sept. 12, with Executive Order 3.
In the last couple of weeks, daily cases have been rising. This is not unexpected, as any increased mobility or decrease in public health measures will naturally increase the risk of transmission. This moderate bump of just under 3,000 cases a day is more likely from the school openings and not yet from the new policy of voluntary outdoor masking, which was more recently enacted. This means that cases might go up even more. It is also likely that many positive cases have not been captured since many people are just doing antigen tests and isolating at home. Despite the rise, however, only two severe cases were reported between Sept. 19 and 25 out of 17,891 confirmed cases. During this time period, healthcare utilization decreased despite a 22 percent increase in cases from the previous week.
Notwithstanding these encouraging numbers, the most telling manifestation of endemicity is the distinct change in outlook of our patients in the hospital. When people got Covid-19 in 2020, the most commonly asked question to doctors was a panicked, “Doc, am I going to die?” Nowadays, thanks to vaccines, the usual question is, “When can I get out of isolation?” This clearly shows that people are ready to move on with their lives beyond the pandemic.