And how things have changed
CLINICAL MATTERS
DR. EDSEL SALVANA
Walking around nowadays, except for the masks that people continue to wear in the Philippines (thank goodness), there is little indication we are still living in pandemic times. Google now shows significantly higher mobility compared to the pre-pandemic baseline. Christmas traffic is back with a vengeance, and face-to-face parties are commonplace. Despite the continued threats of new variants like the XBB and BQ.1, there have been no big increases in reported Covid-19 cases.
Hospitals are only using one-fourth of their Covid-19 bed capacity. Vaccines and masks have turned the tide, enabling us to safely coexist with the virus.
Even as we celebrate, it is useful to look back to how we got here. There was so much noise and disinformation in the early part of the pandemic that it was difficult to appreciate how lucky we were at still coming up with a successful pandemic response. Anti-vaxxers, pushers of dubious Covid-19 cures, and partisan trolls attacked the Philippine response to further their own agendas. Despite many needless deaths because of disinformation and vaccine hesitancy, most Filipinos followed sound scientific advice and survived. They put on their masks and accessed the free vaccines offered by the government and weathered the worst of the pandemic. Both the private sector and the government worked together to ensure a good outcome.
There does need to be accountability for agents of misinformation, especially those who personally profited from other people’s gullibility. Unfortunately, some victims of these unscrupulous individuals ended up paying the ultimate price, despite widespread availability effective interventions. It is important to review our response and point out uncertainties that were exploited by these opportunists to prevent these from happening again.
The composite graph below shows the number of cases versus associated deaths per week throughout the pandemic and labels the peaks by the dominant variant. Early case numbers and deaths were quite low thanks to the early lock downs. There was limited testing during this time so there were cases that were missed. Subsequent examination of excess deaths for the year 2020, however, showed that the total number of expected deaths was 40,000 deaths less than in past years. This decrease in deaths despite the pandemic is likely due to the protective effect of masks and decreased mobility on both Covid-19 and non-Covid-19 infectious diseases. Without the initial lockdowns and early response, excess deaths in the first year of the pandemic alone would have exceeded 200,000 based on comparisons with other countries and mathematical modelling.
This is partly because the original three cases reported in the Philippines from Chinese tourists, detected in January 2020, were contained and did not spread into the community. There was a lot of partisan noise that these cases were not really controlled and that the Department of Health was withholding information despite WHO confirmation of containment. Subsequent whole genome sequencing data failed to find any link between these three cases and the March 2020 community transmission, which was due to a completely different lineage. This confirms that the heroic efforts of our healthcare workers in early 2020 along with the flight bans from China worked, delaying Covid-19 community transmission by at least a month. Given the exponential growth of infectious diseases, this translates to hundreds of thousands of infections averted because of the initial response.
The lineage responsible for the first wave of community transmissions was B.6. This was likely introduced in late February or early March 2020.
This sublineage originated from India and Southeast Asia, and could have been brought in by travelers from any of those countries. Opening from the initial lockdown and the entry of B.1 likely from someone repatriated from Europe caused a modest wave in June 2020. Despite shrill criticisms, the institution of the community quarantine system and universal masking, with the addition of face shields, successfully controlled what could have been a bloodbath. It was clear that even as testing capacity improved, daily cases peaked at under 7,000 a day and flattened out until late January 2021.
Toward the end of December 2020, the Technical Advisory Group was called to Malacañang, and the Taskforce for Covid-19 Variants was formed to monitor the new variants of concern Alpha and Beta. Strict travel quarantine was instituted, leading to the designation of some countries as “red,” which meant no travel to and from them was allowed, except for special flights for repatriation of Filipino citizens. Alpha was first detected in the Philippines in December 2020 but these measures delayed community transmission until February 2021. Beta followed closely and cases peaked at 15,000 a day as the first Covid-19 vaccines finally arrived.
The first vaccines to become available were the Chinese vaccines, even as the availability of mRNA vaccines was uncertain due to stockpiling by richer countries.
There was a lot of misinformation on how Chinese vaccines were supposedly less effective in interrupting Covid-19 infection. These were very effective, however, in preventing severe disease and death. The difference in efficacy was later explained by the fact that the predominant variant of concern in Brazil during the clinical trials was Gamma, which proved to have higher rates of immune escape. Subsequent population-level data and real-world evidence showed that the Chinese vaccines were just as good as other vaccine types in preventing severe disease while Western vaccines were less effective than advertised against variants of concern. The WHO affirmed this by including Chinese vaccines in their vaccines under Emergency Use Listing. Unfortunately, many people did not accept Chinese vaccines because of bad information, and some succumbed to Covid-19 while waiting for the mRNA vaccines to arrive. These people could otherwise have been saved if not for the hesitancy generated by disinformation. It was also around this time that ivermectin came into the picture as a now-debunked cure for Covid-19. It was used haphazardly despite no strong evidence of any positive effect. Over time, well-designed trials showed no benefit and many early trials touting effectiveness were debunked as either methodologically flawed or outright fraudulent.
Delta was first detected in May 2021 but did not achieve community transmission until August 2021 due to travel quarantine measures. Preemptive lockdowns and aggressive vaccination tempered the case numbers in Manila, but Delta caused a lot of deaths around the country. Cases tapered off in December 2021 despite shifting to granular lock downs as vaccination rates increased and we had below 500 cases throughout the holidays.
Unfortunately, Omicron BA.2 caused a huge spike in cases in January 2022. Interestingly, BA.1 did not achieve dominance unlike in other countries as quarantine measures slowed down its introduction. Despite double the case peak of Delta, deaths from Omicron BA.2 were one-third the number compared to Delta, thanks to aggressive vaccination and early boosting. We were one of the first countries to start boosting at three months from second dose. This saw the beginning of decoupling of deaths from cases and was the first indication of endemicity.
Following the BA.2 wave, cases remained low even after elections and only picked up toward June or July 2022 with the introduction of BA.5. This did not reach the magnitude of .2 and peaked at under 5,000 cases daily. Severe cases and deaths remained low. Currently we are watching the effects of XBB and BQ.1, but all indications say there will be no big surge at Christmas. One major factor in our continued success is that people never stopped wearing their masks. In the meantime, the US CDC, in the light of unprecedented influenza case numbers and continued tens of thousands of new Covid-19 cases every day has now recommended mask wearing anew after having discarded the masks for over a year. The Philippines, with its culture of caring for one another, has clearly done the right thing.