What to expect under Alert Level 1
Can we now throw away the masks?
CLINICAL MATTERS
Lockdowns have been a major feature of the pandemic since the first city-wide lockdown in Wuhan. Faced with a novel coronavirus for which there was no pre-existing immunity and no known treatment, the world had little choice but to drastically limit mobility as the new respiratory illness spread like wildfire and the body count began to increase. The unprecedented increase in the numbers of cases, coupled with the uncertainty of basic information such as mortality rate and mode of transmission, forced countries to shut down as their hospitals were overwhelmed and their citizens started dying.
In the early days of the pandemic, there was a lot of uncertainty. Everyone thought that if they got COVID-19, they would die. It was this fear of their patients dying that led many doctors and non-doctors to experiment with different, unproven treatments including lopinavir/ritonavir, hydroxychloroquine, and azithromycin. It became apparent later that none of these early treatments worked. It also became evident that not everyone with COVID-19 was going to die. In fact, the deaths from COVID-19 were disproportionately high in elderly persons and those with comorbid conditions. Younger populations were less likely to die or develop severe disease. Nevertheless, the absence of adequate treatment meant that extreme measures were needed to slow down the spread of COVID-19 while effective medications and vaccines were being formulated.
Metro Manila was put under a lockdown on March 12, 2020. As medical advisers who proposed the initial community quarantine, we were acutely aware of the severe societal disruption this would cause. Having seen the tragedies that were hitting China, Spain, and Italy during those early days, however, we felt that not locking down would result in horrific numbers of casualties, especially with our much lower healthcare capacity compared with those countries. The only intervention that had been shown to work at that time was the extreme lockdown in Wuhan. Given the circumstances, quickly limiting the mobility of large numbers of people was the only way we could hope to attenuate the spread of the disease. In retrospect, this kept case numbers from exploding and saved the healthcare system. Conservative estimates put the number of Filipino lives saved by this early lockdown at over 200,000 people.
From the most extreme lockdown, which included shutting down public transportation, it became apparent that a gradual loosening of restrictions needed to be done in order to temper the effect on the economy. The provision of financial aid or “ayuda” was designed to address some of the disruption caused by shutting down entire cities. This, however, was not going to be adequate or sustainable.
Hence, the IATF decided to implement the community quarantine system, which was based on levels of mobility and capacity controls, depending on the level of virus transmission and the healthcare utilization. After several iterations, the community quarantine classification system ended up as follows: enhanced community quarantine (ECQ), which was the highest level of lockdown and mobility restriction; modified enhanced community quarantine (MECQ); general community quarantine (GCQ); and modified general community quarantine (MGCQ).
The community quarantine system was designed to limit mobility in large segments of the population. The most affected by mobility restrictions were the vulnerable population, including the elderly and those with comorbid conditions who were at highest risk for dying. Children below the age of 18 were also confined to their homes since they might bring home the virus, especially those who lived with the vulnerable population. At the time this was done, there were no proven effective treatments or vaccines. The hospitals were barely coping, and mortality rates for the most vulnerable were up to 10 percent even if they got proper care. Patients with severe disease who could not get into the hospitals because of bed shortages were almost certainly going to die. The community quarantine system was eventually modified and tweaked as effective treatments for COVID-19 were discovered, and the healthcare system was reinforced with specialized COVID-19 hospitals, dedicated beds, and temporary treatment and monitoring facilities (TTMFs).
When vaccination started in March 2021, discussions on eventually decreasing restrictions to a “new normal” began as the possibility of a safe path to acquiring population immunity presented itself. Given the global vaccine shortages and the daunting logistics of inoculating millions of people, this was not expected to take place until many months later. With the economy in dire straits, however, there was a push from many sectors to allow more mobility to increase financial activity. By this time, the healthcare system had already gone through two lockdowns, but it was still at risk of collapse since healthcare workers were just starting to get vaccinated. Medical care was becoming more sophisticated, with remdesivir, dexamethasone, tocilizumab, and high-flow oxygen making a substantial impact on survival of severe COVID-19.
To accommodate these many competing priorities, a pilot alert level system was formulated in September 2021. This was initially implemented in Metro Manila. The main difference between the community quarantine system and the alert level system was that the latter was not going to rely on blanket lockdowns but instead would implement granular lockdowns where there were outbreak clusters. With the finding that 80 percent of cases were mostly concentrated in 20 to 30 percent of the barangays, this was a calibrated response to suppress outbreaks where they were occurring but allowing the less affected areas to remain open for business. The emphasis was on capacity controls for the 3Cs (closed, crowded, and contaminated) while allowing more capacity for less risky activities. The Alert Level system was eventually implemented nationwide, resulting in marked recovery for the economy in the third and fourth quarters of 2021, despite the Delta wave in the third quarter.
The Alert Level system is in five tiers, with alert levels 4 and 5 approximating MECQ and ECQ respectively, and alert levels 2 and 3 approximating MGCQ and GCQ respectively. Alert level 2 has been the lowest implemented alert level so far, and it has allowed reopening of schools and many business sectors that were previously not allowed to operate on higher alert and quarantine levels. Even though some alert level 1 metrics were reached after the Delta wave receded, the IATF held off implementation since many areas still had low vaccination rates. As an additional safety net, alert level 1 metrics included high vaccination rates. Target vaccination rate prior to shifting an area to alert level 1 was set at 70 percent of the eligible population and up to 80 percent vaccination rates in the elderly population.
As cases of Omicron recede nationwide, the implementation of alert level 1 in some areas of the country is very likely. Metrics for alert level 1 include a less than 50 percent healthcare capacity utilization rate, an average daily attack rate of less than seven, and a negative two-week growth rate. While this target was marginally reached by NCR during the second week of February, the MMDA requested more time to streamline its implementation. This request was granted by the IATF.
Alert level 1 means 100 percent capacity for all businesses, provided that adherence to minimum health standards is followed. It means allowing full resumption of onsite work, school, and other normal activities. In situations where not all the minimum health standards can be maintained, only vaccinated persons might be allowed to participate to minimize the risk. Guidelines are continuously being updated and may change depending on whether there are signals that the virus is making a comeback.
Alert level 1 means we will be living alongside the virus. Unlike other countries that have completely done away with mask mandates, we will continue to use masks and other layers of protection in order to prevent unforeseen case spikes.
Living with the virus doesn’t mean going back to normal. It means we are in a new normal where the risk is manageable, and each individual must do his or her part to keep the virus under control.