CLINICAL MATTERS

It has been nearly four years since the start of the Covid-19 pandemic and some people are getting a bit nervous because many people are testing positive for Covid-19 again. The latest Department of Health (DOH) report showed a 50 percent increase in confirmed Covid-19 cases. If we look closely, however, the healthcare utilization rate remains low and the ICU bed utilization went down. This means that most new cases are mild, and there is no imminent threat to our healthcare system. There is little chance we will need to institute anything drastic at this point.

There is a new Omicron variant making the rounds: JN.1, which seems to have a survival advantage over the other circulating Omicron variants. It is slated to become the dominant variant in many countries. Fortunately, there is no indication it causes worse diseases and the current vaccines continue to protect against severe diseases from this variant. The World Health Organization (WHO) has declared that JN.1 is low risk for public health. Nevertheless, it is good to remain vigilant without panicking. 

Historically, we have had good Christmases even during the height of the pandemic.  Prior to vaccination, the use of face masks, face shields, physical distancing and mobility restrictions limited the exposure of most people to Covid-19. The worst spikes came after Christmas in 2021 when we had the entry of Alpha and Beta; in July to August 2021 with the entry of Delta; and finally the highest number of cases in January 2022 with Omicron BA.2. Even with a pandemic going on, Filipinos still felt the need to celebrate the holidays while taking precautions to protect one another. It seems people were extra careful during past holiday celebrations, with a few notable exceptions like the Poblacion girl.

So, how best to protect ourselves from the increasing incidence of respiratory infections this holiday season? The majority of Filipinos have already done the most important thing that enabled us to get out of this pandemic—vaccination. If you’re fully vaccinated and have had at least one booster, you are still good. While there have been bivalent and updated monovalent vaccines as boosters available in other countries, there is currently no availability of either of these new boosters in the Philippines. There was a short period of time when we had bivalent boosters primarily for healthcare workers and seniors, but these were quickly snapped up. There have been no new approvals for the updated monovalent vaccines at this time. With hope, the drug companies are already working on this with our local FDA.

Fortunately, it seems even the old primary series of vaccines plus one or two boosters (and a third one for the vulnerable population who were able to get the bivalent booster) continue to significantly protect against severe Covid-19. The mortality rate for vaccinated people who get Covid-19 nowadays is >90 percent lower compared to those without Covid-19 vaccination. This does not mean no one among the vaccinated people will get severe disease. It just means that the chances of ending up in the hospital due to Covid-19 is much, much, much less for vaccinated people compared to someone who never got the vaccine.

What happens if you get Covid-19 anyway despite all your precautions? If you are vaccinated, it is unlikely you will progress to severe disease. If you aren’t vaccinated for whatever reason, there are medications available to lower the risk but you will need to talk to your doctor. Please don’t self-medicate and do not use ivermectin, which has already been shown to be ineffective against Covid-19. Let’s review the latest guidelines for quarantine and isolation since many people seem to have forgotten them.

• If you test positive for Covid-19 whether with an antigen or an RT-PCR test, the DOH still recommends isolation for five days from the start of symptoms. If you are asymptomatic, count five days from the first positive test. This is only true if the symptoms are mild and you are fully vaccinated. If you have shortness of breath or have low oxygen levels (<94 percent), see a doctor immediately or go to the emergency room. Wear a mask if you have to leave isolation to seek care.

• The five days from start of symptoms are the most infectious, but it doesn’t mean you are no longer infectious after five days. You can leave isolation after five days from the start of symptoms but continue to wear a mask as much as possible for at least 10 more days or until your symptoms are gone, whichever is longer. If you want to be sure that you are no longer infectious, especially if you are visiting elderly friends and relatives, you can repeat the antigen test before leaving isolation and if it is still positive, stay isolated as much as possible and keep wearing your mask around other people. You can test daily or every other day until the antigen test is negative before you mingle with other people.

• People who take antivirals against Covid-19, particularly nirmatrelvir-ritonavir (Paxlovid), can have a viral rebound and may remain infectious longer. In these cases, retesting with an antigen before stopping isolation can be helpful as a guide. Wear a mask as long as you have symptoms or for at least 10 days, whichever is longer. Some guidelines recommend you test twice with antigen before discontinuing isolation. Only antigen tests correlate with infectiousness, useful for determining if someone is no longer infectious. Do not use RT-PCR for retesting because it will remain positive for weeks. There is no role for antibody tests in testing for acute Covid-19.

• If you start out with mild symptoms only but are not getting better or your symptoms are getting worse, contact your doctor. You may be progressing or developing a secondary bacterial infection. Fever, worsening respiratory symptoms, increasing sputum production may indicate the development of a bacterial pneumonia. If you are short of breath or have low oxygen levels, go to the emergency room. 

• You will not need antibiotics if what you have is mild Covid-19. Some people may benefit from antivirals. Antivirals such as remdesivir and nirmatrelvir-ritonavir are only indicated for those at high risk for hospitalization. Neither drug is currently available due to supply issues. Only molnupiravir has some availability, but its benefit it marginal, especially among those who already vaccinated. Talk to your doctor to find out if an antiviral is appropriate and do not self-medicate. Molnupiravir should not be used in pregnant women.

Health care utilization remains low so even with higher case numbers for Covid-19 and other respiratory illnesses, there is little chance we will have any big problems this season. Wear a mask if you want to maximize your protection and stay home if you are sick. It’s a good Christmas, thanks to vaccination. There should be a good year ahead, even better without the sniffles.