A review of our response and how to safely exit
CLINICAL MATTERS
As cases continue to drop in NCR and across the country, many people are talking about the pandemic “end-game.” The exponential increase in cases in early January 2022 quickly peaked and has precipitously dropped. This occurred in NCR at a rate even faster than that of South Africa where the Omicron variant was originally described.
Despite having more than double the peak of the Delta wave, healthcare capacity in Metro Manila was not overwhelmed, and hospital bed utilization rates are going down. Even though the number of infections reached record highs, the number of severe and critical infections remained flat throughout the month.
The biggest implication of these numbers is that in a highly vaccinated country, COVID-19 is no longer the deadly disease it once was. This means that drastic measures to limit mobility, including lockdowns and reduced transport capacity, may no longer be necessary since many people are vaccinated. The risk of ending up in the hospital with severe disease has gone down nearly 10-fold for fully vaccinated individuals, along with the risk of death.
For those not part of the vulnerable population, this means a drop in the risk of dying from COVID-19 from one percent to 0.1 percent. This is a number that is very close to the mortality of the seasonal flu. For those in the vulnerable population, vaccination decreases the risk of death from about 10 percent to one percent.
For those who develop breakthrough infection, they can be treated with new antiviral medications, which can lower the risk of hospitalization and dying by up to 90 percent. This translates to a mortality risk of 0.1 percent, which is also that of the seasonal flu. With both vaccination and effective medications, COVID-19 is no longer the disease that it was in 2020.
Throughout this pandemic, policy makers have struggled with trade-offs. All interventions have a cost, and the benefit should outweigh the risk. For instance, the early lockdown in March 2020 was done because there was very little that was known about COVID-19. The virus spread very quickly in Wuhan, and the only thing that was able to arrest its spread was locking down the city. With a mortality rate of up to 10 percent, especially in vulnerable populations, it was like a rapidly spreading version of SARS. There were no available vaccines, and there were no proven treatments at that time.
Countries like Spain and Italy were being overwhelmed, with widespread deaths. People were dying in their homes since there was no longer room in the hospital. There was a huge shortage of personal protective equipment, and many healthcare workers died in the initial wave of cases. The situation at that time called for drastic measures to prevent this from happening in the Philippines. Our healthcare system capacity was much less than that of those countries that had already been overwhelmed, and so any delay could cost immeasurable lives.
Retrospective analysis has shown that this was the correct decision. The early lockdown saved at least 200,000 Filipino lives and prevented millions of infections in the first year of the pandemic. While some recent analysis allege that lockdowns did not decrease deaths by much, this did not take into account the timing and severity of the lockdowns. China’s extreme lockdown has resulted in less than 5,000 deaths for a country of 1.4 billion. Similar strict lockdowns in New Zealand (53 deaths), and Australia (3,987 deaths) also clearly protected people. In contrast, the US has over 917,600 deaths at the time of this writing in a country of 334 million while the UK has 157,409 deaths in a country of 68 million people.
Doing this comparison clearly shows lockdowns work when implemented properly and instituted early.
Unfortunately, the economic cost of lockdowns was staggering, and it plunged the country into the worst recession since World War 2. As the government attempted to roll back some of the restrictions, subsequent waves of new variants along with the relaxed measures resulted in case spikes, which ended up stressing the healthcare system and precipitating another lockdown. But with each subsequent wave, we learned a little bit more. Proper management of COVID-19 became more and more defined, with life-saving interventions such as dexamethasone, high flow nasal oxygen, tocilizumab, baricitinib, and remdesivir significantly increasing survival from severe COVID-19. The biggest breakthrough was the formulation of safe and effective vaccines, which have now significantly decreased severe disease, hospitalization, and death.
The number of excess deaths in 2020 in the Philippines was minimal compared to other years. This reflects the success of the early lockdown in preventing many deaths compared to other countries. This includes richer and more advanced ones. Unfortunately, lockdowns significantly disrupted healthcare services, particularly outpatient clinics and preventive medicine.
Healthcare policy makers expected increased excess deaths the following year due to missed treatments for chronic disease. This indeed has been the case, with many excess deaths reported from 2021 above that of deaths from COVID-19. This will likely be seen in 2022 and beyond since the disruptions brought about by the pandemic have a snow-ball effect as a result of missed opportunities to detect cancer early and treat heart disease and other chronic illnesses properly. This increasing mortality from other diseases that are being neglected is a clear sign that lockdowns are unsustainable and should be replaced by other measures.
Now that we have vaccines and proper treatment, it is time to transition to a more balanced approach. Lockdowns were really just to buy time and save our healthcare system. It did that and it saved lives. Now that we know what to do, lockdowns are no longer needed, and we should move on and move forward. The Omicron wave has shown that we can keep deaths to a minimum and keep our healthcare system from being overwhelmed as long as we have a high vaccination rate. Masks will stay for now while we are transitioning to a newer and safer normal. Quarantines for exposed, vaccinated people may eventually be removed, as they will no longer pose much of a threat to a highly vaccinated population. As COVID-19 becomes closer to an endemic disease, we should not forget that endemicity does not mean it is no longer deadly. Endemic diseases like TB and dengue continue to be deadly and affect millions of people a year. Endemic merely means we are aware of what the virus can do and we have the means and tools to manage it properly. With that, we can carefully resume our lives.