CLINICAL MATTER

Last week, many anxious people messaged me for comment when a major newspaper plastered a headline on their online page stating, “IATF raises Covid-19 alert level in most parts of the Philippines; some restrictions in effect.” Coupled with the modest increase in cases following Holy Week and the residual paranoia from lockdowns, this inaccurate headline spawned all sorts of fake news. Alarmist messages including the usual anonymous Viber posts that hospital X was full again and that the latest Covid-19 variant Y was going to kill us all went viral (no pun intended).
A simple fact check reveals that most parts of the Philippines have been on Alert Level 1 since the start of the year. None of these places have been escalated to Alert Level 2 since then. The 26 provinces that remain on Alert Level 2 have been at that same status since June 2022, and the main reason they have not been de-escalated is because they have not reached the minimum 70 percent threshold of vaccination for their general population and senior population. If the reporter had bothered checking, it would have been clear that Alert Level 1 was not being “raised” but was being maintained as has been the practice every 15 days since the system was implemented.
Metrics for alert level escalation have been modified significantly throughout the pandemic, the most drastic of which occurred in the last days of the Duterte administration. When the system was first conceived, we looked at healthcare utilization rate (HCUR), average daily attack rate (ADAR), and two-week growth rate (TWGR) as the major metrics that determined the alert levels. As vaccines became widely available, the percentage of eligible persons vaccinated was added to the metrics to incentivize the LGUs into pushing their vaccination program. The rationale for making a high vaccination rate a requirement for dropping to Alert Level 1 is that with so many people vaccinated, the chance of a spike in cases resulting in many severe cases needing hospitalization is much less likely.
As the pandemic progressed and more people were vaccinated, the larger proportion of cases that were being reported were found to be mild. Even significant spikes in cases did not result in hospitals being overwhelmed. Because of this, at the last IATF meeting under the Duterte administration in June of 2022 we adjusted the alert level metrics to reflect this new reality. ADAR and TWGR were relegated to secondary metrics and the major metric for escalation and de-escalation was HCUR since only if the hospitals were full would the integrity of the healthcare system be threatened. Even if there were large numbers of incident cases and these were spreading rapidly, if the cases were mostly asymptomatic or mild then not very many people would need to be admitted and the hospitals can still cope. This was why Alert Level 1 cities and provinces have not been escalated since the new metrics were implemented despite some increases in cases. Unfortunately, the provinces who have remained on Alert Level 2 have not reached the vaccination threshold for de-escalation and so they have maintained their classification even as cases and hospital occupancy dropped.
The recent detection of XBB.1.16 in Iloilo also contributed to the scare. Nicknamed “Arcturus” which is a nonsensical unofficial label made on a whim, the WHO upgraded its classification as a variant under monitoring to a variant of interest. This is still below the “variant of concern” designation (although as an Omicron subvariant, it is technically a VOC) and so there is no evidence it causes more severe disease. The reason for the upgrade is a possibly higher transmissibility as evidenced by case increases in some countries. It is unlikely that XBB.1.16 caused the recent increase in our cases since this is just the first detection. More likely the increase was due to the Holy Week increased mobility coupled with the relaxation of mask mandates. Whether a further increase will occur if XBB.1.16 gains a foothold is uncertain, but based on current scientific risk assessments, the probability of a major spike in cases remains low. The DOH report is very instructive. Despite an over 30 percent jump in cases, the healthcare utilization remains below 20 percent, there were only 15 severe cases for the week, and no new deaths occurred. The five reported deaths were all backlogs from more than a year ago.