By Dr. Jun R. Ruiz
As we entered August, which marks our fifth month of quarantine in Metro-Manila, we breached the national 4,000 new cases per day mark on July 31. That was truly alarming to me as an individual and as a health care worker. We were ranging between 1,600 to 2,100 new cases the previous seven days, and the sudden doubling of new cases was another sad moment for the country as we would continue to reach a new peak in this pandemic. On August 10, records were broken again when 6,958 new cases were reported by the Department of Health (DOH). This was the fifth time over that period that the Philippines broke its record for the single-day increase in new cases. We are definitely not winning the war against COVID-19.
As a physician and a concerned citizen of the country who has followed our fight against the SARS-CoV-2 virus from the beginning, I have my own personal thoughts and perspectives why the country has not been able to turn around the direction in controlling the pandemic. There are now more than 20 million persons worldwide who developed COVID-19. The countries with the most affected patients are the United States, Brazil, India, Russia, and South Africa. The countries in the top twenty are a mixture of developed and developing countries. As of this writing, the Philippines ranked number 22 in the total number of cases worldwide, just ahead of our neighbor Indonesia.
Europe became the epicenter of the pandemic after China was able to control its contagion through aggressive measures of strict quarantine and lockdown. The biggest European countries, like Italy, Spain, the United Kingdom, Germany and France, were the most affected. The European Union (EU) accomplished European solidarity, as EU leaders regularly met via video conference during the peak of the COVID-19 crisis. They closed its external borders to non-essential travel, mobilized resources to support the emergency response among its member countries, ensured supply of protective equipment, and promoted research for treatments and vaccines. Subsequently, the number of infections declined in Europe in May.
Despite having one of the longest and strictest lockdowns in the world during this pandemic, the Philippines is losing the war against COVID-19. The strictest Enhanced Community Quarantine (ECQ) was implemented on March 15 till May 15 in the National Capital Region. The restrictions were gradually eased in the metropolis. This was transitioned to Modified ECQ starting on May 16, and eventually switched to General Community Quarantine (GCQ) from June 1 to early August, as requested by the Metro-Manila Mayors and the business sector due to concerns in the economy. There may be conditions unique to the Philippines that contributed to the country’s downward spiral.
Eighty medical societies and associations, led by the Philippine College of Physicians and the Philippine Medical Association, made a public appeal on August 1 to the government to place Metro-Manila and the surrounding areas under ECQ for 14 days to give medical workers a “timeout” to recalibrate strategies to stop the record-surge of the pandemic from worsening. The healthcare system has already been overwhelmed. President Rodrigo Duterte implemented MECQ again in Metro-Manila and the surrounding provinces from August 4 till 18.
Despite all of the above measures, the national government fails to contain the pandemic as we continue to have increasing numbers of new cases. In some countries, the rise in the diagnosed cases can be accounted by increased testing, and the Interagency Task Force (IATF) would like us to believe that this is the case here. However, the second wave of COVID-19 in our country was documented by an overwhelmed health care system in Metro-Manila and the record-high spikes in the daily cases. The reality is that the national situation is worsening, as several hospitals again closed its doors to patients with COVID-19.
Stopping the spread of Covid-19 requires finding and testing all suspected persons so that the confirmed cases are promptly and effectively isolated. Testing was the cornerstone of COVID-19 control in Italy, Germany, South Korea, and New Zealand. The close contacts of all confirmed cases should be rapidly identified so they can be quarantined and medically monitored for the 14-day incubation period. In early March, it was just the Research Institute of Tropical Medicine (RITM) that was doing the testing using RT-PCR swab tests, the gold standard in diagnosing acute infection. There were long backlogs in the lab as doctors waited for more than a week for the results of their patients from all over the country to be available. The lack of testing kits early on handicapped this strategy, as asymptomatic and mild cases were not recommended to be tested and were advised to stay home. Months later, the government compensated by pushing for more testing and are now conducting 30,000 tests a day. There are currently 106 licensed laboratories that can perform RT-PCR and GeneXpert for diagnosis of acute COVID-19.
There are 79 brands of the Rapid Antibody Test (RAT) kits approved by the Food and Drug Administration, mostly made in China. These detect antibodies that are proteins made in response to an infection, and represent efforts of the body to fight the virus. These start to develop only after 1 to 3 weeks after the infection. As these antibodies only develop way after the patient gets first infected and are negative early on the disease, these antibody tests should not be used to diagnose acute infection. The sensitivity of the test is affected by the timing: only 30% in the first 7 days of infection, and increases after 14 days of infection. Because of this poor accuracy, there is a high rate of false positives and false negatives. A false positive test occurs when a person who does not have COVID-19 is diagnosed to be positive, while a false negative test occurs when a person who has COVID-19 is tested negative. In the former case, the person is unnecessarily quarantined and stigmatized. A patient with a false negative result gets a false sense of security and can start spreading the infection to several people.
As the government was easing the lockdown to gradually re-open the economy, there was pressure from the business sector to bring the workers back to the workplace. The Center for Diseases Control and Prevention (CDC) explicitly said that antibody tests should not be used to determine if someone can return to work. The DOH and Philippine Society for Microbiology and Infectious Diseases repeatedly warned the public that use of these tests for clearance to work may result in infected individuals being cleared and inadvertently spreading the virus. The RT-PCR test costs between PHP 4,000-8,000 and takes 2-5 days for the results to be available, while the RAT costs less than PHP 2,000 and only takes minutes for the results. Despite these clear policies against using RAT, its use as a cheaper alternative was promoted by some influential businessmen, local government units (LGUs), private companies, and certain organizations, leading to its misuse as a diagnostic test for acute COVID-19 infection. Even the national government programs, like the Balik-Probinsya, used this as a screening test with disastrous results. Several thousands of stranded and returning workers to the provinces who initially tested negative on RAT turned out to be positive by RT-PCR test. They became “super-spreaders”. This subsequent mixing of infected patients with the uninfected ones is how the disease spread in the provinces. Using the wrong test in this pandemic can be catastrophic.
Quarantine and isolation prevent transmission of infection, especially when implemented in the early stages of the pandemic. Although there were efforts by the government in building quarantine facilities for the COVID-19 positive and suspect cases, the extent of the usage of these large facilities were not clear to the public. It can be assumed that the majority of affected patients with mild symptoms ended up in home quarantine, potentially affecting members of their household. The curtailment of interactions between infected and uninfected is difficult if they do not have individual rooms in their homes. Those patients who needed quarantine or isolation and did not have their own rooms should have been brought to these facilities by the local government.
Case investigation and contact tracing is a key disease control strategy for preventing further spread of COVID-19. Time is of the essence, and immediate action is needed. However, to be done effectively, it requires these contract tracers to have training, supervision, and skills. After testing and isolation, early contract tracing was implemented in most of the successful countries that controlled the epidemic. This past week, we found out that the DOH does not have a contract tracing team as the department believed that “they had already strengthened the capacity of the LGUs to establish their own teams”. Tracing czar Mayor Benjamin Magalong sadly admitted that only 4 of the 614 LGUs have a good contract tracing team in place. In addition, Quezon City Mayor Joy Belmonte claimed that the lack of information on addresses and contact numbers of almost 50% of these infected patients severely hampered the city’s tracing efforts. This highlights the need to set up a coordinated response across different levels and multiple agencies of the government.
There is also a likely failure of Filipinos to maintain social distancing and wearing masks appropriately at all times. According to the Social Weather Stations (SWS) survey in July, obedience to the mask-wearing rule is highest in Metro-Manila. Yet, it appears that several Filipinos are not wearing masks properly. Many pull their masks down, exposing their nostrils and mouth, makings these PPEs useless. Even at workplaces, including the hospitals, persons would eat together without any physical distancing and this has been associated with clusters. In the comfortable company of family and friends, it seems that people let their guard down when they are together. Members of the same household can also get infected from a family member who goes outside to do essential activities or for work. In the densely populated areas of Metro-Manila, the congestion and overcrowding of people in their homes lead to likely household transmission.
I am hopeful that the 2 weeks of “time-out” and additional restrictions imposed during the MECQ in Metro-Manila will bring the country to the right direction in fighting against COVID-19. The increased participation of leading medical experts and physicians in the meetings with the DOH and IATF will provide guidance and the much-needed shot in the arm for these government agencies, where scientists should take the lead instead of politicians. It also time to step up in the basics of pandemic control which are early testing, quick isolation or quarantine, and extensive contact tracing to mitigate the COVID-19 pandemic. Learning the best practice guidelines from the countries who successfully controlled their own epidemics and applying to our situation is not admission of mitigation failure. Individual discipline for every Filipino to prevent super-spreading is as important as the government strategies. We all need to work together, other than waiting for the vaccine to be available. By changing our game plan, only then can we start winning the war against COVID-19.