A good Christmas
Published Dec 6, 2022 12:05 am
CLINICAL MATTERS
DR. EDSEL SALVANA
It has been more than a month since we shifted to voluntary masking. Full face-to-face classes have been going on for some time now. Despite many misgivings, Covid-19 cases in the Philippines have remained stable. Healthcare utilization remains low. Many are asking the obvious question, are we endemic yet?
DOH weekly reports have shown stable numbers and single digit severe case counts for many weeks now. While it is true that RT-PCR testing is down and many antigen positives are not being captured, there is little doubt that Covid-19 has now gone from a full-blown pandemic to a much less potent actor in our day-to-day lives. There are several reasons for this, but the two biggest reasons are vaccines and masks.
The problem with pegging the end of the pandemic to a particular announcement or action is that Covid-19 does not affect everyone equally. Vulnerable populations are at higher risk than the rest of the public, and these groups saw higher death rates. When vaccination became available, the death rates dropped tenfold. The risk of a vaccinated elderly person, however, remains significantly higher than that of a vaccinated young person without comorbid conditions. In fact, for most non-vulnerable populations, the pandemic was effectively over once they completed their primary vaccination. The residual risk of death outside the A2 (elderly) and A3 (individuals with comorbids) groups following vaccination is already at the level of influenza or even lower. In other words, endemicity is already here for most people.
So why didn’t new Covid-19 cases spike dramatically when the mask mandate was lifted? Aren’t cases still going up in the US as winter sets in and people move indoors? Will the bivalent boosters blunt this expected spike in cases?
Cases did show a small spike shortly after the mask mandate was lifted. This was not sustained, however, despite the recent entry of XBB and BQ.1. XBB, which caused the large spike of cases in Singapore with more than 10,000 cases a day in October 2022, does not seem to be behaving the same way in the Philippines. BQ.1 is the current Omicron subvariant du jour. It is thought to be more immune-evasive. The current dominant variant BA.5. BQ.1 and its sublineage BQ.1.1 are starting to take over in the US. There is no evidence these subvariants cause worse disease than other Covid-19 variants of concern. Moreover, even the old monovalent vaccines continue to protect against severe disease despite the added mutations. Bivalent vaccines that cover BA.4/BA.5 also seem to work well against BQ.1 and BQ.1.1. This was expected because BQ.1 is a sublineage of BA.5.
The first 14 cases of BQ.1 in the Philippines were detected between Oct. 28 and Nov. 18. An additional two cases were found between Nov. 21 and 24. So far, it has not taken over as the dominant variant. The current dominant variants are still BA.5, BA.2.3.20, and XBB. In the meantime, XBC cluster of cases, which was reported in Mindanao a few months ago, seems to be fizzling out. XBC, a recombinant of an Omicron and a Delta sublineage, was yet another variant that made some people nervous since there was speculation that it could combine the extreme transmissibility of Omicron with the deadliness of Delta. Fortunately, this virus did not live up to the hype, and the number of XBC viruses in the most recent genome sequencing runs has gone down substantially.
BQ.1 and BQ.1.1 are now the dominant variants in the US, having overtaken BA.5. The US continues to report 20,000 to 30,000 new Covid-19 cases a day, and some epidemiologists are predicting these will rise as more people spend time inside in the winter months. The US is also seeing a “tridemic” of Covid-19, influenza, and RSV (respiratory syncytial virus), which is most severely affecting children. The US has long removed its mask mandate, and so transmission of Covid-19 remains at a high setpoint. Why then did we not see the same spike in the Philippines after the mask mandate was lifted?
If you walk around Metro Manila nowadays, it is quite clear that a substantial number of people have kept their masks on. After more than two years of meticulous mask wearing, it is now second nature to most people to wear their mask. In the first year of the pandemic, the increase in mask usage not only protected against SARS-CoV-2, it also decreased the number of pneumonia cases by over 40,000. Throughout the pandemic, mask use combined with other public health measures served to attenuate transmission even as mobility increased and immune-evading variants were introduced. With a combination of a highly vaccinated populace and sustained high levels of mask use, Philippine cases have remained low. More important, healthcare utilization remains low since even breakthrough infections are generally mild.
As the Christmas season ramps up, traffic jams and crowds are becoming worse. Face-to-face parties are making a comeback with a vengeance. Despite all these potentially risky activities, the expected worst-case scenarios are nowhere near that of previous Covid-19 case spikes.
Modeling projections from the official Department of Health modeling partner FASSSTER show daily Covid-19 cases peaking at less than 2,300 this month even with decreased masking and increased mobility. Further projections by DOH partner network AuTuMN showed that even if a new immune-evading variant did enter the country over the holidays, the highest ICU occupancy projected for January 2023 is at 800 ICU admissions. This is much lower than the over 1,200 ICU admissions during Delta, which overwhelmed our hospitals. This number can be absorbed by the 2,789 ICU beds that are presently available, of which only 20 percent are currently occupied.
Looking at these projections and our current situation, it really looks like we are going to have a good Christmas. We have a lot to be grateful for, and it is quite rewarding to see that all our efforts to protect one another are paying off. As added insurance, it is still best to keep your masks on as much as possible, and to get your bivalent booster when it arrives. After all, the best gift we can give our loved ones is a safe, joyful, and meaningful celebration together this holiday season.
DR. EDSEL SALVANA
It has been more than a month since we shifted to voluntary masking. Full face-to-face classes have been going on for some time now. Despite many misgivings, Covid-19 cases in the Philippines have remained stable. Healthcare utilization remains low. Many are asking the obvious question, are we endemic yet?
DOH weekly reports have shown stable numbers and single digit severe case counts for many weeks now. While it is true that RT-PCR testing is down and many antigen positives are not being captured, there is little doubt that Covid-19 has now gone from a full-blown pandemic to a much less potent actor in our day-to-day lives. There are several reasons for this, but the two biggest reasons are vaccines and masks.
The problem with pegging the end of the pandemic to a particular announcement or action is that Covid-19 does not affect everyone equally. Vulnerable populations are at higher risk than the rest of the public, and these groups saw higher death rates. When vaccination became available, the death rates dropped tenfold. The risk of a vaccinated elderly person, however, remains significantly higher than that of a vaccinated young person without comorbid conditions. In fact, for most non-vulnerable populations, the pandemic was effectively over once they completed their primary vaccination. The residual risk of death outside the A2 (elderly) and A3 (individuals with comorbids) groups following vaccination is already at the level of influenza or even lower. In other words, endemicity is already here for most people.
So why didn’t new Covid-19 cases spike dramatically when the mask mandate was lifted? Aren’t cases still going up in the US as winter sets in and people move indoors? Will the bivalent boosters blunt this expected spike in cases?
Cases did show a small spike shortly after the mask mandate was lifted. This was not sustained, however, despite the recent entry of XBB and BQ.1. XBB, which caused the large spike of cases in Singapore with more than 10,000 cases a day in October 2022, does not seem to be behaving the same way in the Philippines. BQ.1 is the current Omicron subvariant du jour. It is thought to be more immune-evasive. The current dominant variant BA.5. BQ.1 and its sublineage BQ.1.1 are starting to take over in the US. There is no evidence these subvariants cause worse disease than other Covid-19 variants of concern. Moreover, even the old monovalent vaccines continue to protect against severe disease despite the added mutations. Bivalent vaccines that cover BA.4/BA.5 also seem to work well against BQ.1 and BQ.1.1. This was expected because BQ.1 is a sublineage of BA.5.
The first 14 cases of BQ.1 in the Philippines were detected between Oct. 28 and Nov. 18. An additional two cases were found between Nov. 21 and 24. So far, it has not taken over as the dominant variant. The current dominant variants are still BA.5, BA.2.3.20, and XBB. In the meantime, XBC cluster of cases, which was reported in Mindanao a few months ago, seems to be fizzling out. XBC, a recombinant of an Omicron and a Delta sublineage, was yet another variant that made some people nervous since there was speculation that it could combine the extreme transmissibility of Omicron with the deadliness of Delta. Fortunately, this virus did not live up to the hype, and the number of XBC viruses in the most recent genome sequencing runs has gone down substantially.
BQ.1 and BQ.1.1 are now the dominant variants in the US, having overtaken BA.5. The US continues to report 20,000 to 30,000 new Covid-19 cases a day, and some epidemiologists are predicting these will rise as more people spend time inside in the winter months. The US is also seeing a “tridemic” of Covid-19, influenza, and RSV (respiratory syncytial virus), which is most severely affecting children. The US has long removed its mask mandate, and so transmission of Covid-19 remains at a high setpoint. Why then did we not see the same spike in the Philippines after the mask mandate was lifted?
If you walk around Metro Manila nowadays, it is quite clear that a substantial number of people have kept their masks on. After more than two years of meticulous mask wearing, it is now second nature to most people to wear their mask. In the first year of the pandemic, the increase in mask usage not only protected against SARS-CoV-2, it also decreased the number of pneumonia cases by over 40,000. Throughout the pandemic, mask use combined with other public health measures served to attenuate transmission even as mobility increased and immune-evading variants were introduced. With a combination of a highly vaccinated populace and sustained high levels of mask use, Philippine cases have remained low. More important, healthcare utilization remains low since even breakthrough infections are generally mild.
As the Christmas season ramps up, traffic jams and crowds are becoming worse. Face-to-face parties are making a comeback with a vengeance. Despite all these potentially risky activities, the expected worst-case scenarios are nowhere near that of previous Covid-19 case spikes.
Modeling projections from the official Department of Health modeling partner FASSSTER show daily Covid-19 cases peaking at less than 2,300 this month even with decreased masking and increased mobility. Further projections by DOH partner network AuTuMN showed that even if a new immune-evading variant did enter the country over the holidays, the highest ICU occupancy projected for January 2023 is at 800 ICU admissions. This is much lower than the over 1,200 ICU admissions during Delta, which overwhelmed our hospitals. This number can be absorbed by the 2,789 ICU beds that are presently available, of which only 20 percent are currently occupied.
Looking at these projections and our current situation, it really looks like we are going to have a good Christmas. We have a lot to be grateful for, and it is quite rewarding to see that all our efforts to protect one another are paying off. As added insurance, it is still best to keep your masks on as much as possible, and to get your bivalent booster when it arrives. After all, the best gift we can give our loved ones is a safe, joyful, and meaningful celebration together this holiday season.