Back to normal, finally

CLINICAL MATTERS

With the proposed lifting of the state of emergency from the Covid-19 pandemic, the country joins many others in adopting the recommendation of the World Health Organization (WHO) to lift the emergency phase of the pandemic. As has been repeatedly pointed out, this does not mean the pandemic is over. It only means that the emergency phase, which required extraordinary measures, such as lockdowns and quarantines, is now officially at an end. Many countries lifted their states of emergency months prior to the WHO declaration. Some countries, such as Sweden, never instituted any lockdowns and opted to rely on the personal choices of its citizens. Other countries like China had prolonged, draconian lockdowns and enforced mass testing. The pandemic response of each country reflected many aspects of its people, from the value they put on their personal freedoms to beliefs on vaccination and evidence-based policy. The availability of resources was also a major factor in determining the response, from the ability to procure personal protective equipment, vaccines and treatments to financial aid or “ayuda” to populations that could not work during the lockdown, and to the ability of the economy to rebound without significant scarring. All these competing priorities meant that governments had to make hard choices. What was a life worth? Are some lives more important than others? Are we preventing people from dying of Covid-19 only to have them die of hunger? In retrospect, there are many lessons that can be learned from each country’s response. Ultimately, governments are accountable to their people and the final tally of cases and deaths is only one aspect of the outcome. Deaths and cases, however, are an easily measurable and comparable metric across different countries. While testing capacity and willingness to test can significantly affect the official numbers, there are ways to account for these variables and still come out with good estimates. For deaths in particular, using the excess deaths metric, which compares year on year deaths with previous years, is an acceptable measure to capture undiagnosed Covid-19 deaths. Using these metrics, the Philippines most definitely punched above its weight compared to many richer and developed countries. We had 37,032 cases per million, which is 155th in the world and we had 591 deaths per million, which is 130th in the world. Contrast this with the US [320,622 cases per million (59th) and 3,490 deaths per million (15th)] and France [612,013 cases per million (ninth) and 2,556 deaths per million (37th)] and it is clear we did very well. The government instituted science-based policies and the people followed. It was far from perfect but it was much better than many of us dared hope. Even the economic recovery has been better than expected, and for this we have a strong team effort from the public and private sectors to thank. Lifting the pandemic emergency isn’t like an off switch. The drawdown of pandemic measures has been proceeding for more than a year now. The turning point was the availability of effective vaccines, which has drastically decreased the risk of death from severe Covid-19. The earliest clue to endemicity was in January 2022 when Omicron hit. Despite having more than twice the cases of Delta, Omicron cases caused less than half the number of deaths and did not overload hospitals as much as Delta did. Some antivaxxers claimed that this was because Omicron was a milder strain of Covid-19. The most current studies show, however, that Omicron is at least as virulent as the original Wuhan virus and many, many times more transmissible. Had the vaccines not been around when Omicron hit, the death toll would have been unprecedented. Following the Omicron wave, cases remained low and these low numbers persisted even after national elections where there were huge rallies and people spent long periods of time lined up to vote in close quarters. It was also during this time that restrictions were further relaxed and the metrics for escalation were modified on advice of the experts. From basing alert levels on a composite matrix using number of new cases (average daily attack rate or ADAR), two-week growth rate (TWGR), and health care utilization (HCUR), only HCUR was retained since it was clear that most new cases were mild, thanks to vaccines. Since then, new Omicron sublineages have entered the country with minor blips in cases but none ever threatened to overwhelm the healthcare system. The latest increase in cases purportedly from XBB.1.16 or “Arcturus” briefly increased anxieties as the usual suspects engaged in scaremongering, but the variant never really took over and fizzled out as expected. To be sure, there are probably more Covid-19 cases circulating than those that are being officially reported. Very few people are testing with RT-PCRs or even with rapid antigen testing at all. This, however, also reflects the substantially decreased impact of Covid-19 on our daily lives. Even if many cases are being missed, the continued masking and the high level of vaccination is keeping any potential outbreaks at bay. The virus is no longer dealing with an immunologically naïve population. With most breakthrough cases being mild, and effective treatment available for those who progress, there is little chance that Covid-19 can ever overwhelm our healthcare system again. With this in mind, and once the emergency is lifted, can we finally take of our masks? The mask mandate has been lifted since October 2022, except in healthcare settings, but many people have opted to keep their masks on. This is not necessarily a bad thing as masks continue to protect not just from Covid-19 but from other respiratory illnesses. But masks are not completely innocuous. Some people have a hard time breathing with them, they cost money, and they generate waste. As we move forward with our lives, people can gradually do away with masks at their own comfort level. It may still be a good idea to bring these back when there is a high number of respiratory illnesses in the community, but daily use may no longer be necessary. For the vulnerable population and those who live with them, judicious use can still have its benefits. Masks can be treated in the same way we use seatbelts. It is best to have them around and to use them as needed to further decrease risk. Meanwhile, the availability of bivalent vaccines for healthcare workers and seniors is a welcome additional layer of protection. The granting of a certificate of product registration finally makes the vaccines available through the private market. This will go a long way in decreasing the pressure on government to procure vaccines for everyone’s needs. In the meantime, the next generation of vaccines are being worked on. These include vaccines that are tailored against future variants and vaccines that will increase protection against infection. The next generation of treatments are also in clinical trials and will be added insurance against future coronavirus outbreaks. In the early days of the pandemic, there was so much uncertainty but we always prayed and hoped for better days as we fought the virus tooth and nail. Those better days have arrived. Let’s not forget the lessons we learned along the way and always remember those who sacrificed so much to get us to where we are now.