Relative Joy

[The updates for the topic “Pandemonium” on this blog site provides a rundown on the daily statistics of this viral infection. As the number of cases globally have spread, it’s difficult to keep up with each and every case. The “brief” will be kept short and simple and center on the cases in the Philippines based on information from the Department of Health. Readers are asked to refer to other sites, especially https://www.worldometers.info/coronavirus/ or https://www.who.int/emergencies/diseases/novel-coronavirus-2019 or https://ourworldindata.org for specific information in particular countries. For references for Philippines data, they are cited separately.]

Update as of 7PM 07 June (Sunday)

TOTAL CONFIRMED CASES: 7.007,698

TOTAL DEATHS: 402,683 (case fatality rate: 5.75%)

TOTAL RECOVERED: 3,428,961 (case recovery rate: 49%)

https://www.worldometers.info/coronavirus/

Total cases worldwide (note that every reference has its own cut-off time for reporting. For the global data, https://www.worldometers.info/coronavirus/ is used as its reference.)

We have officially crossed the 7M mark at 7PM. Almost half the total cases having recovered. Of the more than 7M cases, more than half have already had an outcome – 89% have recovered while 11% died. Only a little more than 45% of the cases remain active.

These are good numbers because they indicate that while the number of cases continue to increase (driven by more testing and contact tracing), majority of them already had an outcome and the fatality rate is generally lower now. This could also mean that most the positives were identified from contact tracing and that they are probably mild or asymptomatic/pre-sysmptomatic.

The global data shows that the average cases is still more than 100,000 case per day. The total number of cases are now over the 130,000 per day mark.

And while the daily new cases plateau at over 130,000 for the 3rd consecutive day, the number of deaths declined from 4906 yesterday to 4253 today.

The United States of America continues to lead globally in the number of total confirmed cases at 1,988,545 (up by more than 22,000 cases overnight) with a case fatality rate (CFR) lower today at 5.64% with 112,096 total deaths recorded. Among the states, New York leads at 396,699 total confirmed cases and 30,372 total deaths up with a lower 7.66% case fatality rate (CFR) as the number of deaths slows down for the last week.

Brazil remains in second with a lower CFR at 5.32% with a haul of over 30,000 cases. Total cases are now at 676,494. Russia is in third with a CFR of 1.25% and total cases of 467,673. India remains in sixth spot with 247,195 cases and a CFR steady at 2.81%.

The South American countries are now the hotbeds in terms of cases for the last two weeks. Brazil tops the list at number 2 in the world, Peru stays at 8th today, and Chile remains in a close 13th place. These three countries combined make up more than 1M cases in the world.

In Southeast Asia, Singapore slips down further to 29th in the world, with Indonesia going up to 32nd spot and the Philippines moves down to 39th from 38th in the world.

Based on the dashboard of the World Health Organization https://covid19.who.int, the global data shows the Americas leading the number of cases, followed by Europe and the Eastern Mediterranean.

As several countries ramp up testing in various degrees, more new confirmed cases are being reported. With more testing and aggressive targeted contact tracing, patients who may be asymptomatic or pre-symptomatic and who may potentially be infective to the vulnerable population are being identified. With more testing, we see a better picture of the extent of the pandemic. There are, however, some countries who may not not be performing a lot of contact tracing and/or testing, but have better outcomes than others that do.

For a discussion on how much testing is “enough” testing, the link to this discussion is here https://relativejoyforyou.wordpress.com/2020/06/04/enough/

There are multiple factors that determine how outcomes of pandemics play out. Policy responses include school and workplace closures, cancellation of public events and gatherings, restrictions on public gatherings, public information campaigns, stay-at-home restrictions, international and domestic travel (public transport, restrictions on internal movement and international travel controls), and of course, testing and contact tracing.

The median average of case fatality rates worldwide has further declined to 5.75% (from 5.8% yesterday). For the past 2-3 months, over 89% of patients are either asymptomatic or have mild disease and have recovered.

The good news? Recoveries far outnumber the deaths with a ratio of approximately 8.5:1. (The ratio of recoveries continues to increase, and will reassuringly do so, over deaths because of increased testing and better minimum healthcare standards.)

Philippines Statistics

Refer to the link https://www.doh.gov.ph/2019-nCoV for up-to-date data or to http://www.covid19.gov.ph (this latter is not a secure site). The new site for the Department of Health is supposedly migrating to COVIDKAYA so that data is updated. The current site still maintains the COVID19 tracker. Readers can check their official site where Data Drop for raw data can be found.

One useful site is https://covid19stats.ph where one can see the dashboard of information from the DoH website. Unfortunately, because of the migration of the data drop into COVID Kaya, no one is able to break down the numbers to the finer details as in the previous posts.

Good news. Bad news: The wrap for the day

There are 555 new confirmed cases today compared to the 714 yesterday. And expectedly so. Since we’re doing an average of 10,000 tests a day, and the positivity rate is around 7%, (assuming that the positive rate is constant), we should have an output of approximately 700 positive cases a day (not including backlogs).

Today we breach the 1,000 mark for deaths at 1,003 total deaths with 9 deaths publicly reported.

Of the 555 new confirmed total cases, there are more fresh cases (378) than late (177).

Of the 350 “fresh cases”, Region VII has 104 cases, NCR with 67, others at 204, and repatriates with 3.

Of the 177 “late cases”, Region VII has 63 cases, NCR 25 and Others 89.

Fresh or late, the other regions are bothersome because we have 293 of the 555 cases from these “other” areas. Region VII continues its upward trajectory with 167 total cases while the NCR has 92 reported today.

With more backlogs coming in, the numbers are expected to rise. The good news is that the deaths remain low in spite of the increase in number of positive cases. Whether these remaining positive cases are retests from previously positive patients who are recovering or have recovered are unknown.

As of today, the Philippines still adopts the criteria of having two negative consecutive tests to be considered a recovery. This most likely accounts for the low recovery rate because many patients don’t take the initiative to have retesting done, especially when they are mild or asymptomatic and have clinically recovered. Other patients who are retested over and over but remained positive in spite of clinical recovery past the clinical course of illness are probably included in the count on positive tests.

Today’s total brings the case fatality rate of the Philippines to its lowest of 4.58% (good news) and recovery rate is again a tad lower at 20.7% as the number of total cases are still more than 500 today. The low recovery rate is probably due to the reporting system of recoveries in the country with the LGUs having different data from the national agency.

According to the Department of Health, based on the remaining 15,905 active cases remaining as of June 06, 2020, 95.1% (15,131 cases) are mild while the remaining 4.4% (698 cases) are asymptomatic. Only 0.5% of the remaining active patients are severe (57) or critical (19).

With the current data, the growth rate eases at around 3% but the doubling time remains approximately 10 days. While Indonesia has a higher case fatality rate compared to the Philippines (6% vs 4.58%), recovery rates in Indonesia are far better than ours (32% vs 20.7%). Overall, 82% of all cases in the Philippines are recoveries, while 18% lead to death. Making us the lowest among the Southeast Asian countries in terms of recoveries-to closed cases ratio.

Testing capacity

As more RT-PCR laboratories are being licensed, we’re having more tests conducted. At least 3735 test/M population are being carried out per day. As of June 5, a little over 2,000 samples are left in the backlog. Hopefully, this closes in towards the middle of next week.

Of the 420,166 total tests conducted in 386,726 individuals tested, the positivity rate is now lower 7.1% from a previous 7.3% (which means that we are testing enough to see the prevalence of the pandemic in the country. The number of positivity is also going down in spite of the higher testing capacity). This is an important issue to discuss as certain areas in the country have a very high death rate compared to the over-all case fatality rate. It is recommended that those areas with high death rates (>10-12%) should have more aggressive testing and contact tracing done.

For example in one community if there is one death in 1 case, the case fatality rate is 100%. Because the virus is highly infectious, there must be other cases undetected within the community. Targeted aggressive contact tracing should be done within that community so that those that are positive can be quarantined or isolated, in order to contain a potential outbreak.

Majority of the patients tested (~93%) tested negative. This means for every 13 patients, 1 would most likely test positive.

Breakdown the day before

Yesterday, of the 714 new cases announced by the Department of Health, 415 had residence information tagged. 273 cases were reported in Luzon, 173in Visayas, and 5 in Mindanao. There was no report among the repatriates.

Based on cases per region, the NCR still has the most number of cases followed by Region VII and Region VI-A. While Region VII may have more than 3100 cases, it has the lowest fatality rate.

Based on cases per city, 9 of the top 10 cities are within the NCR. Quezon City ranks first, followed by Manila and then Makati. While most of the cities have seen a growth in cases over the past week, the highest increase in growth rate goes to Cebu City with a 4.73% growth rate overnight (from 4.4% the previous day).

These places matter

How many tests should be done to say we’re doing enough testing?

Among countries that do extensive testing, if < 12% are coming back as positive results, then we’re most likely doing enough tests in the country. The benchmark of a system that’s doing enough testing to pick up all or most of the cases is getting 10-30 negative cases per confirmed cases for an overall positivity rate of 3-10%.

How does that kind of data extend to the 7,641 islands of the Philippines? And how can the community use this kind of information in order to determine if they are testing enough?

The death rate or number of deaths is another good indicator if there is sufficient case finding in the community. The same parameter above can be used to determine if the regional or local community is doing enough to combat the virus through targeted testing.

Based on region breakdown for example, Regions 1, 10 and BARRM have >10% case fatality rates, Region 1 has 16% death rate (12/74), Region 10 has 24% (9/34) and BARMM 18% (7/22). [In parenthesis are deaths/confirmed cases]. An indicator that we’re not testing enough or looking for more cases in those regional communities. The likelihood missing out positive cases among deaths due to COVID in these regions is high.

As I previously mentioned, breaking down the cases per barangay or city provides better information to the local community on mitigation actions that they may need to take in order to control the spread of the pandemic. As a general guide, if the death rate in the area is >10-12%, they’re probably not testing enough.

Sometimes the numbers look impressive because the general rule is that the region is doing fine in numbers but the better numbers are being carried by the general data of the region. For example, in the National Capital Region (NCR), where we do extensive testing, the case fatality rate is 6.3%. This is driven by the fact that there are 752 deaths in almost 12,000 cases as of yesterday for the NCR. If you break them down according to cities on the other hand, Pasig (10% CFR), Muntinlupa (10% CFR) and San Juan (13% CFR), have the highest case fatality rates in the National Capital Region.

What is confusing in the gap of information is the disparity in the data on confirmed cases, deaths and recoveries per city compared to that of the Department of Health. This must be reconciled at the soonest.

Remember, there should be ‘enough’ cases for every death because a high death rate implies that the specific locality is not doing enough in contact tracing. It is highly unlikely that the locality had 1 case with 1 death with no other person in the community being infected.

Outside of the National Capital Region, the following cities (according to the Data Drop of the Department of Health as of June 6, 2020) have death rates more than 10-12% and positive cases less than 50: Lipa Batangas (15%), San Mateo Rizal (18%), Marilao Bulacan (12%), Malolos Bulacan (17%), General Trias Cavite (13%), Nasugbu Batangas (14%), Meycauayan Bulacan (17%), Angono Rizal (12%), Bacolod (19%), Cagayan de Oro (33%), Silang Cavite (15%), Trece Martires Cavite (17%), Calauag Quezon (10%), Tarlac City (10%), Calapan Mindoro Oriental (11%), Candelaria Quezon (13%), Naga Camarines Sur (14%), Naic Cavite (14%), Guinobatan Albay (17%), Lambunao Iloilo (21%), Iligan Lanao del Norte (40%), Bayambang Pangasinan (40%), Alitagtag Batangas (25%), Norzagaray Bulacan (25%), Obando Bulacan (25%), San Miguel Bulacan (25%), Labo Camarines Sur (25%), President Roxas Capiz (25%), San Jose Occidental Mindoro (25%).

33% each (1 death in 3 cases) for the following cities: Tabaco Albay, Alfonso Cavite, Guimbal Iloilo, Dumaguete Negros Oriental, Solano Nueva Vizcaya, Bacolor Pampanga, Floridablanca Pampanga, Lingayen Pangasinan, Malasigui Pangasinan, Rosales Pangasinan, Jalajala Rizal, Castillejos Zambales, Pagadian Zamboanga.

The following municipalities/cities reported only 2 cases but had either ONE or TWO deaths: Cuenca Batangas, Taal Batangas, San Ildefonso Bulacan, Carcar Cebu, Daanbantayan Cebu, Samal Davao del Norte, Malta Davao Occidental, Barotac Nuevo Iloilo, Agoo La Union, Banaue La Union, Mantao Lanao del Sur, Tudela Misamis Occidental, Jimalalud Negros Oriental, General Mamerto Natividad, Jaen Nueva Ecija, Puerto Princesa Palawan, Candaba Pampanga, Alaminos Pangasinan.

The following areas had 1 case and the only reported case had died for a 100% death rate: Catarman Cebu, San Juan La Union, Sta. Maria Laguna, Tayasan Negros Oriental, Naujan Oriental Mindoro, Apalit Pampanga, Barista Pangasinan, San Fabian Pangasinan, Urbiztondo Pangasinan, Tiaong Quezon, Lambayong Mariano Marcos Sultan Kudarat, and Indanan Sulu.

[Disclaimer: The aforementioned data are from the Department of Health data drop as of June 6, 2020. LGU data may be different and the author recommends that the LGU coordinate with the DILG and the DoH regarding reconciliation of data.]

The week in review

To recap the week in one word – shocker!

With all the backlog details returning in bulk, the Philippines had seen a significant rise in cases as more tests were being conducted as well.

While we had an upsurge in cases at the start of the week, the good news is that the number of deaths have remained low. As a matter of fact, generally the average deaths for the week was 6 deaths/day, while the average number of confirmed cases (fresh or otherwise) was 588 cases/day. Recoveries were very slow considering that most of these patients should have recovered as the majority (~94%) are mild and around 5.5% are asymptomatic. Cases as far back as May 22 should have seen outcomes already based on the DoH claim that of the remaining over 15,000 active cases being mild/asymptomatic.

In the last graph above, this shows a summary of how we’re doing overall since the beginning of the pandemic. The blue curve showed a decline in cases (bending of the curve) until a week ago when the backlogs and more testing results came in. This resulted in the increase in the number of cases for the past week. But the green curve shows a continuous trajectory of the death rates in the country in spite of the single day surge of publicly announced death reports.

• Over the past week, the National Capital Region had 1,174 additional cases but the 7 day average growth rate was at 1.49% with a CFR of 6.31% and recovery rates at 27%. Region VII on the other hand saw a spike of 1,164 additional cases over the week with a 7 day average growth rate at 6.48%, a low CFR of 0.86% and a low recovery rate of 4.16%.

• Children below 19 years old make up 7.57% of the total cases while 18.14% are the senior citizens (> 60 years old). This means that almost 75% belong to the 20-59 year old age group (out of 21,340 data points). The group that’s actually allowed to roam around and go out.
• In terms of fatality rate, those below 19 years old have a death rate of 2.3% whole those above 60 years old have a death rate of almost 65%.

How is the coming week going to fare?

With the backlog data coming in and more testing being done, we may probably still be averaging over 500-1000 cases a day in the coming week. As long as the death rates remain low, then that’s the good news. The better news? The positivity rates decline significantly so that the numbers start going down. If we get both, it’s called a blessing.

To get in touch with the Department of Health, the COVID hotline is (02)894-COVID loc 1555.

Disclaimers:

(1) These three parameters (new confirmed cases, new recoveries, new deaths) ARE NOT real-time data. The data provided by the Department of Health is the date of public announcement. Even global data will vary in time of reporting, depending on the reporting capacity of that country. To date, the latency period of the Department of Health on reporting recoveries averages almost 10 days (with more than 50% reported after 8 days and more) and deaths averaging almost 12 days (with more than 50% being reported after 8 days or more).

(2) Depending on where testing is done, RT-PCR test results take an average of 12hrs – 2 days to process. Barring any delays, all tests done should ideally be released by at least 48 hours (the earlier the better). However, the test results released from government facilities now range from 3-7 days (based on Data Drop) when compared to private hospitals where fewer number of tests are performed.

They announce the summary in the evening…but the specific data in the Data Drop are not available until 10AM the following day. So here”s what happened yesterday and announced at 8PM last night.

Their “fresh cases” today are up at 252 from 46 the previous night. The “late cases” (> 4 days into validation) is 338 for a grand total of 590 cases reported last night – lower than the yesterday’s 1046 but higher than the previous day’s 539. There were 8 deaths and 88 recoveries reported, bringing the case fatality rate to an all time low of 5.5%. Unfortunately, because of the higher number of confirmed cases (fresh or otherwise), the recovery rates have also been dragged down a low of 22.1%.

This change in the reporting system in order to address the backlog in data has sparked confusion, not only to the ordinary layman but to the medical community as well who’ve been constantly following the numbers in order to craft policies at the workplace (hospital or business) as the GCQ (general community quarantine) takes into effect tomorrow.

Unfortunately, it is what it is and we need to contend with what is in the Data Drop system.

Let’s the dissect the available data.

As of May 29, more than 340,000 tests have been conducted (+8138 tests done) in 312,463 (+7347) total unique individuals. Of the total number of individuals tested only 6.9% are positive. Or a total of 23,498 positive individuals (both validated and unvalidated cases). Since there are only 17,224 confirmed cases as of last night, there are around 6000+ missing positive patients. These may not necessarily be NEW confirmed patients but previously positive patients who have had repeat testing done, remained positive and are still up for repeat testing. It is also difficult to separate patients who have tests done in one facility and have repeat tests done in another facility. But since I am not privy on how information is collected for these patients, I am speculating that this may be a problem that the health agency is plagued with. Validating this kind of information is labor intensive and leaves no room for human error. Elaborating on this discrepancy by the agency should allay the public’s fear of why the numbers have recently gone up.

Consistency and accuracy in data is vital to any report or pronouncement by the agency.

When they announce a total of 17,224 cases in their summary press release last night and yet in their own website announce this, you know that we have a problem even in validating the official information that is dished out by the agency.

Of the 252 “fresh cases” and 338 “late cases”, 162 and 218, respectively came from the National Capital Region. This makes a total of 380 cases from the NCR alone (fresh or otherwise). There is no breakdown on which are fresh or late but of the 380, 236 (62%) are still for validation. Those validated are: Caloocan City (27), Manila (20), Malabon (20), Marikina (15), Quezon City (12), Navotas (7), San Juan (6); Valenzuela, Pasay City, Pasig, and Makati with 5 each; Taguig (3); Parañaque (2), and 1 apiece for Las Piñas and Muntinlupa.

What I don’t get is how these places got included in the NCR as separate cities.

Region VII reported 18 fresh cases. There were no late cases reported. The only conclusion one can make from this is that (a) there’s no backlog in the Region VII data and (b) all the data yesterday – 11 from Cebu City and 7 from Mandaue are within the three days window.

The 9 reported repatriates are all late data (> 4 days ago).

The remaining 183 (72 fresh and 111 late) are a basket of information where you cannot discern which are “fresh” and which are considered “late”.

Region IV-A for example has 29 data for validation while those with reports are from Rizal (4), Laguna (1), Cavite (4).

Region III (Central Luzon) has 4 for validation with confirmed reports from Bulacan (5), Bataan (1).

Region VI reported 1 apiece from Iloilo Province, Antique and Bacolod City.

Region I had 1 case from Pangasinan and 2 from La Union.

The Bicol Region (Region V) has 4 cases for validation but reported 1 from Albay and 1 from Camarines Sur.

Region IX reported 1 case from Zamboanga City.

Region II (Cagayan Valley) reported 1 from Isabela.

Region IV-B (MIMAROPA) have 2 cases for validation still.

Region XII has 1 reported case from General Santos City.

And there are 117 cases for validation from – well, your guess is as good as mine.

I am surmising (again) that these for validation (for validation) are probably patients without tagged residences. Again, as to why there is no information on them needs to addressed by the health agency. Perhaps informing the local government RESU on the completeness of the documents submitted to them should be the rule rather than the exception. Actually, for awhile there, the Department of Health was able to consistently provide almost 100% tagged residences especially during late April to mid-May.

Finally there is the BEAT COVID informatics they provide. While there is a wealth of information there, the barrage in information that may not be totally relevant to the public is difficult to keep up with.

For example, under case breakdown of ACTIVE CASES as of May 29, it is good to know that most the active cases are actually mild (93.4%) and that the asymptomatic comprise only 6% of the total cases. As of this date, 56 have severe illness and 18 are critical.

In the same Philippine Situationer https://drive.google.com/file/d/1cDD9G8QKK_y5Bc3o6Pq5k4fXGYhkCVkx/view, I get confused at the available beds and mechanical ventilators dedicated to COVID-19 cases.

If there are only 18 critical (let’s even throw in the 56 severe) cases among the active cases, why are 358 mechanical ventilators in use and 463 ICU beds occupied? This is under the heading of Hospital Beds and Mechanical Ventilators Dedicated to COVID-19 CASES!

While I can feel how overwhelmed the health agency is, pointing out these inconsistencies is intended to make them aware that people are following them. After all, who else can we trust our health if not from our health agency?

Integrity of data is vital to every healthcare system. After all, it is the basis of policies made by the government.

There are two terms that are used complementary to one another to determine if a country has the pandemic under control.

Bending the curve refers to the graphical representation that the number of daily cases is plateauing and later on sees a continuous decline in the trajectory of the curve.

Figure 1 above illustrates the current condition of various countries based on days since the first cases reached 30/day (X axis) and the number of cases (in logarithmic scale, Y-axis). One can see that there are countries that are still on an upward trajectory while others have begun to bend (slightly or significantly) their curves.

Has the Philippines bent its curve?

Figures 2 & 3 above show how we are faring. And while the United States may have the most cases in the world, they have also begun to bend the death curve with less daily deaths vs total confirmed cases as well. Brazil on the other hand is the new epicenter in the world to watch out for as its death rates begin to climb staggeringly. Indonesia still has an upward trajectory for deaths (in proportion to their upward trajectory in cases, see Figure 6 below).

The other term used by epidemiologists is more commonly known as “flattening” the curve. Let me delve on this a bit as this has caused some confusion among the public.

Flattening a curve does not imply that the curve should flatten to ZERO. It is a misconception among lay that a curve in order to be called “flattened” is pressed to the ground.

In a pandemic, the curve varies in shapes from country to country, with some countries taking a steeper climb than others. As a general rule, when a country has a steeper rise in cases (more people get infected), it will also have a steep fall (the patients either get better or die because the virus has infected a large segment of the population already).

A steep rise in cases carries a large burden on the health system. Too many sick people overwhelm the healthcare system and overloading beyond the capacity to treat people results in greater death rates. More people die not only because there are no more hospital beds, but the overall health system – from healthcare workers to basic supplies – are exhausted rapidly.

Interventions like the ECQ and social distancing, hygiene, wearing masks and other ways at minimizing the transmissibility of an infection from one person to another (i.e.. school closure, limiting travel and work, closing borders and minimizing movements) are ways to flatten the curve. A flatter curve does not mean that we pummel the curve to the ground (although wouldn’t that be great?). When we flatten the curve, we slow down the infection rate. It assumes that the same number of people eventually get infected, but over a longer period of time. Slowing down the infection de-stresses the health care system.

That’s the story of the COVID-19.

There is currently no vaccine or drug to treat this disease and we’re all scrambling at the availability (or unavailability) of testing. The collective action of everyone in the community is needed in order to address the challenge of seeing a decline in the cases of COVID19.

Have we flattened our curve?

Figure 4 above illustrates the health care capacity of a country in the broken lines. Without precautions during a pandemic, the number of people infected would be disproportional to the health care capacity resulting in a direct collapse of the health system and indirectly leading to more deaths. The “flatter curve” (in orange hue) has the same area under the curve (number of patients) but spread out over a period of time when compared to the more steep curve (in dark pink when no precautions are observed).

There are two major criteria (shown in figure 5) to say that the curve has flattened. (1) Slow acceleration of number of cases, and (2) reduction in the peak number of cases and related demands on hospitals and infrastructure. I would boldly venture on saying that the overall reduction in death rate is an ideal parameter to indicate that we’ve reduced the demand on hospitals and infrastructure.

As of May 20, 2020, the DoH reports that facility capacity of various hospitals in the Philippines is not overwhelmed. Only 34.5% of total ICU beds and 17.8% of mechanical ventilators are being used.

The death rates have also dramatically dropped weekly. From April 26 – May 2, the average deaths was 16/day. May 3 – May 9 showed an average of 15/day. May 10 – May 16 an average of 16/day. May 17 – May 23 show a dramatic drop to 6/day.

Number of new confirmed cases are also on the decline. The last 4 weeks (since April 26) saw a 7 day average of 240 cases/day. To say that we’re slowing the acceleration of cases is to see a conservative decline by at least 10% from the average of the previous week. We ended last week with an average of 242 cases/day. I wanted to test the threshold of 225 cases/day for the week. THE 7 DAY AVERAGE FOR THE WEEK OF MAY 17-23 is 210!

With this new 7 day average for last week, we now test the threshold of 190 cases/day for the coming week. If this is sustained in spite of latent data, then we can confidently say that we have not only begun to, but we have flattened the curve. (This has to be something consistently seen over a 4 week period).

Figure 6 above shows the Philippines and the United States plateauing on cases, with Brazil now in an upward trajectory. A plateauing of cases means a slowing down in the trajectory (shifting the curve to the right). If we sustain at declining by 10% the weekly threshold, we will have similar bending curves as South Korea and Italy. While Indonesia may have lower death rates compared to the Philippines, its cases remain on an upward trajectory and have not plateaued yet.

Statistics for the day

The world is now at 5,328,548 confirmed cases with 340,425 deaths (6.39% case fatality rate) and 2,175,290 recoveries (40.8% case recovery rates). The ratio of recoveries to deaths is higher at 6.4:1.

Back home in the Philippines, the Department of Health has publicly announced 180 new cases, 85 new recoveries and 6 new deaths.

Our case fatality rate has improved and is now down to 6.26% with recovery rates up at 23.06%. Globally we rank now lower in recovery rates at 140 (out of 165 countries), and are doing much better at number 30 (from number 29) in death rates.

The Department of Health website has not updated the Data Drop files as of this writing but reported that of the 180 new cases today, 114 (63%) are from the NCR while the remaining 66 (36%) are from others. The NCR remains to be a hotspot contributing to more than 60% of the daily cases reported in the Philippines.

Update (May 24, 2020)

Based on the DoH website this morning of the 114 cases in the NCR, Quezon City is back on top of the heap (25), followed by Manila (23) and Makati (16). The rest include: Caloocan City (15); Malabon (6); Marikina and Mandaluyong (5 each); San Juan (2); and Parañaque, Pasig, Taguig, Pasay City, Muntinlupa, Las Piñas and Pateros with 1 apiece. Only Navotas had no reported case yesterday. There were 9 cases for validation.

Of the remaining 66 cases, almost 60% was from Davao City alone with 38 new cases. The rest were from Rizal (4), Laguna (1), Cavite (5), Batangas (1), Quezon (1), Bulacan (3), Bataan (3), Nueva Ecija (1), Iloilo Province (1), Iloilo City (1), Baguio (1), Cagayan de Oro (1), Cotabato (1), Surigao del Norte (1) and the remaining were for validation.

Testing Capacity

As of May 22, 2020, a total of 287,294 tests have been done among 265,061 individuals with 20,264 testing positive (7.6% positivity rate). There were a total of 9,504 tests done yesterday alone (6% of who were positive). As of yesterday, there are 7,128 samples in the backlog.

Disclaimer: All information provided in the daily reports and updates are based on the Data Drop of the Department of Health website. The accuracy of information is dependent on the information released from the DoH. All other graphs, citations and projections are referenced appropriately. Any change in future data particularly on latency reporting may affect the overall trend cited in this post.

The wave

The pronouncement of the health secretary that we’re in our “second wave” in the pandemic deserves an explanation for why I disagree.

According to reports, the claim is based on the fact that the first infections and death seen in the archipelago was the first wave. To him it may make sense because we came from zero cases. The first three cases and the first death were interpreted by their epidemiologists as the first wave. If that argument were to hold water then every country that has not reported any case at the start has had its first wave already. As a matter of fact, we have overtaken China because Wuhan has not even declared a second wave. Nor has South Korea and Singapore, in spite of the minimal uptick in cases.

Which means that all 212 countries are in their second wave of the infection. A most likely unacceptable argument regarding the understanding of what epidemiological waves of diseases are. But let’s simplify it for clarity.

If you look at the above figure, let’s focus on the temporal dimension (time on the X axis). The cases are on the Y axis. The epidemic wave plots cases against time. During an epidemic the number of new cases increases rapidly to a peak then falls gradually till the epidemic is over.

The concept of epidemic wave helps describe the number of people affected by the disease (new confirmed cases) and the possibility that the course of the epidemic may be predictable. The reasons for many disciplines – from biology to mathematics to even economists – to become interested in the subject.

Figure 2 on the left above shows new cases. In red, it shows that the cases rise then gradually tapers off until the epidemic comes to an end with 0 cases. In blue is the cumulative number of cases. Notice that there are two X axes – on the outermost left is the number of new cases while on the outermost right the cumulative number of cases (overall total). As the new cases reach a peak and then begin to decline (in red), the cumulative cases plateau because there are no added cases (in blue).

Every case has an outcome. Either the infection is resolved or results in death. On the right side of Figure 2, you see deaths as the endpoint. The pattern for people dying from the disease is a bit different from the number of cases. Notice this time (in blue) that there are peaks and troughs in between. The swings mean that death is not constant.

Nevertheless, during the whole epidemic, as you see the number of cases decline, there is also a proportional decrease in mortality. When there are no more cases, there are also no more deaths.

To get a clear understanding of an epidemic wave, Figure 3 above shows how waves from one disease alone – measles as an example – would differ from country to country. Some epidemics may occur annually (like the US) while it is more spaced apart for other countries like Denmark or even Iceland. Epidemic waves occur when public health measures are not properly instituted. Nevertheless, if you look at Figure 3, notice that these so-called “waves” have different peaks. Which means that after one outbreak is controlled, because of ongoing local transmission of the disease, another outbreak is likely to happen but not necessarily of the same magnitude.

Figures 4 and 5 show the number of daily confirmed cases and deaths in the Philippines. I am unsure where the basis of the first wave to the declaration of a second wave of infection lies. First of all, we have not even flattened the curve. So I don’t know what wave their epidemiologists are talking about. The number of daily new cases remain above 200 (in fact today we saw another rise above the 7 day average threshold last week of 242). But that cannot be faulted on actual cases reported because in reality, the latency of data is stupendous. Recoveries now take almost 10 days to report, while deaths more than 9 days. There are so many layers of validation that it’s so difficult to make heads or tails of the data. Are we or aren’t we doing better? In spite of the almost 2 1/2 months of community quarantine, we seem to not be gaining much headway in terms of new confirmed cases.

Perhaps the secretary of health should provide a clear explanation on his basis for saying we are actually in the second wave to allay public fears on how and when this second wave appeared. Because if indeed a first wave occurred when three cases occurred with one death way back in the end of January of early February, it goes back to the question – what did the agency do to mitigate this “first wave”? Should there not have been more aggressive measures recommended instead of having to wait for the tsunami that came along in March? And the fault for not having defused the first wave goes back to the agency.

Nevertheless, the good news is that we are actually seeing a slowing down in death rates. As I mentioned, every pandemic will have an endpoint – death or recovery. It is common sense that when there are no more cases, there will be no more deaths due to that infection. In the meantime, I defer to the other epidemiologists to provide an explanation of the so-called “second wave”. Personally, and I may be wrong here, we have not even flattened the curve.

In the interest of transparency, the health agency must reveal how much more backlog information they have and when the surprise reveal will be.

The curve has flattened (?)

Interestingly, an economist attempted at making sense of the data as well. In an article published by Rappler https://www.rappler.com/thought-leaders/261410-analysis-has-philippines-flattened-curve-coronavirus-pandemic?utm_campaign=Echobox&utm_medium=Social&utm_source=Facebook#Echobox=1589948202, there are two figures that make this analysis both truthful and disturbing.

The bar graph above shows the daily deaths reported (in blue) and the date they died (red). Which actually is what the reports of the DoH show (not considering that a lot of data is still latent). Hopefully we will not get surprise numbers in the end. And that the number of deaths continue to actually decline.

The second graph shows us data on hospital admissions. The dramatic decline in hospital admission is also a good sign that perhaps we’re not getting sicker patients. Less severe and less critically ill. Which means that the intervention of quarantine, social distancing, hygiene and PPE actually created a large impact on the number of patients requiring hospitalization. The more vulnerable patients stayed home. The general population was less at risk.

But to declare that we have flattened the curve based on these two parameters is not accurate from the medical point of view. The majority of cases we’re seeing now are asymptomatic or mild cases. As long as the number of new confirmed cases are up, there will always be risks to the community at large. Hence, it is disturbing that one cherry picks on data without looking at the over-all picture.

Let’s agree that there are gains being made in the challenging fight against this virus. But let’s have a more uniformed scientific approach by being cautious at what we predict and not be alarmist to a public that is already on the edge of their seats at this pandemic.

Then there’s the confusion on return to work requirements

If the twin confusion above was not enough for the day, there’s a statement from one of the advisers of the president that all the doctors do is to complain. Particularly on the use of the rapid testing kits.

For the record, while it may seem like a complaint to him, for those of us who know what we actually are doing and recommending, the use of rapid testing kits as a requirement for workers to return to work is not scientifically sound and adds up additional expenses to the employer for a tool that may not be at all that useful.

Rapid diagnostic tests are antibody detection tests. Which means that while they may find some use in the latter phase of the infection after a quarantine period, it give you a false sense of complacency when patients get tested during the first 10 days of illness – during the incubation period. Most likely they will test negative EVEN if they have the virus.

To address the issue that all the doctors do is to complain, let me write down what I believe should be a sound recommendation.

1. Nothing works as good as a good triage. In short you need to assign people who will check each and everyone (including the employer) for symptoms before they are allowed to work. This is because more than 80% of transmission of COVID19 are from patients who have symptoms. Always ask returning workers about a history of FEVER and RESPIRATORY SYMPTOMS in last 2-3 weeks. If they had a combination of these, test with RT-PCR if you suspect them to have COVID19. Keep them isolated for 2-3 weeks regardless of the RT-PCR result. If they turn out positive, then they need to be cleared based on the protocol of the Department of Health before they are able to return to work. If they test negative and have had no symptoms after being quarantined for the last 2-3 weeks, then they can return to work.
2. I have not encountered any literature or recommendation on the ideal laboratory test to clear workers who have no symptoms for work. If you refer to Figure 6 above, a rapid antibody will be falsely negative in a patient who is incubating with the virus in the early part of the infection. If a patient has been asymptomatic for 2-3 weeks and test (+) IgG and (+) IgM it’s either the patient has had an infection and recovered or may have false positive results.
3. If you do RT-PCR in a patient who doesn’t have symptoms, it may NOT be cost-effective to screen everyone considering the cost of doing RT-PCR. Besides, one negative test does not mean that the patient does not have the virus. After all, even RT-PCR will be negative in 1/3 of patients.
4. Not all the antibody tests are the same. If a company decides on using them to screen their workers who come back to work, make sure that it’s a validated test kit. It does not mean that just because it is registered with the Philippine FDA, it has been validated already. Use kits that have high sensitivity and specificity. While these may be more expensive than some other kits, precision is a price worth paying for.

The takeaway message is that this virus will be with us for quite awhile and yes the economy is hurting. That includes us, the doctors who practice and yet risk our lives to see patients who are sick.

Yet reality and practicality tells me that even if you test once and test negative, you can still get infected tomorrow or anytime in this pandemic. Because it isn’t over yet. And the numbers tell us that we’re nowhere near a flattening of the curve.

While testing has its use and may be part of the solution, it also has its limits. Let us use these tests judiciously at the same time without having to burden employers with additional costs for something that may not have much cost-benefit in the end. Moving forward, really need a paradigm shift in the way we live, work and play.

The Brief

As predicted in the world:

Back home:

Our case fatality rate is lower at 6.37% (we now rank 28 of 163 countries in deaths) compared to the global average of 6.5% and the ASEAN average of 2.43%. Our case recovery rate is also up at 22.2% ( we still rank lower at 134 out of 163 countries) compared to the global average of 39.4% and the ASEAN average of 40.7%.

The site of the Department of Health is down as of this writing so we cannot verify the additional information that they released. Nevertheless, I’m posting what they announced. We had a jump in new confirmed cases up now at 279 with 150 (54%) from the NCR, 14 from Region 7 (5%) and 115 from others (41%).

[After this explanation, we go back to THE BRIEF tomorrow.]

Tomorrow, would be our last day into the next extension of our enhanced community quarantine (ECQ), otherwise called a lockdown.

While I try to make sense of the numerical values that are being provided by the government, one cannot help but be skeptical about the kind of information that is being gathered.

During one of the online meetings, the easiest question asked was – “what do I make of the numbers” that are being announced daily regarding the aCOVID-19 statistics?

After all, it’s been 45 days since the lockdown.

The anatomy of disappointment are expectations.

We expect that the government has and is doing enough at addressing the pandemic in the Philippines. Although we know that politics plays a role in how this pandemic is addressed, I will not delve into this. (But I would still caution any government or anyone for that matter that utilizes politics as a means for future political mileage to check their moral compass.) After all, no one will ever be prepared for a crisis of this magnitude. No government will have concrete immediate answers to the crisis at hand. All they can do now, is try the very best to approach this issue in a scientific, sensible, feasible, realizable, rational manner.

I am sure most of us were expecting that with the initial 30 days ECQ, the number of cases – admission and deaths – would have gone down, and see more recoveries. But the first 30 days simply showed dismal numbers. Plotted on a linear graph, Figure 1 below shows the see-saw of daily data being reported.

So we go back to the question asked. How do you interpret this data?

The answer is simple. With caution.

The numbers that come in are just numerical values. Considering the various constraints the Department of Health is encountering in the transmittal, accuracy of information being given to them from the various local government units, and verification of data – it is difficult to make heads or tails with the numbers. These factors account for latency in data. Many people look at the numbers and jump to the conclusion that we have too many deaths and too few recoveries. A quick look at daily data being churned out makes one presume that all these may have happened “the day before”.

On the other hand, if I converted the graph to a logarithmic scale, the data of the Philippines would look like what we have in figure 2. Instead of the see-saw pattern, you’d get a curve.

A logarithmic scale is very different from a linear one. In short, a logarithmic scale best expresses the exponential growth of what we want to measure. In this case on Figure 2, the total confirmed COVID-19 cases and how rapidly they are increasing.

The logarithmic scale can only be plotted once the first 100 patients are reached (so that we can measure exponential growth). The Philippines reached that on March 15, 2020 with 111 confirmed cases. The X-axis shows the cases over time (number of days since the 100th confirmed case). The light grey colored lines at the background show where we are in terms of doubling time based on the data we have. Twenty (20) days after our first 100th confirmed case, our doubling time was approximately 3-5 days (~4.2) with 3,870 confirmed cases around April 4. Forty days after our first 100th confirmed case, our doubling time is now between 5-10 (~7.5) with 8212 total confirmed cases to date.

Which means, we’re now bending the curve because the growth rate has markedly decline to an average of 2.8%.

But all these data have no meaning when you take into consideration the inaccuracy due to reporting errors and problems seen on the ground.

Why do we need to be obsessed with data accuracy?

It’s a simple answer.

The decisions being made for and on behalf of this crisis hinges on quality data. Any decision for that matter cannot be drawn from gut feeling. Decisions and recommendations made need to make recommendations backed up by solid data that will withstand scrutiny. While there will be acceptable gaps, these gaps when recognized early on should be addressed immediately because the extension of the ECQ was primarily based on the issue of not being able to “flatten the curve” or in this case, bending the curve.

The second important parameter will always be death.

Deaths (more than recoveries) provide closure to any event. Looking at the curve for death from an overall number of cases (see Figure 1) may give us a false sense of security. One glance and one can see that on a linear scale, our deaths are but a handful each day. But the latency in death reports in the Philippines average ~6.5 days, with more than 35% being reported after 8 days or more. As of yesterday, 316 of the deaths were reported posthumously – they died before they were even declared positive from the virus.

The quality of these numbers is disappointing because the other ramifications of good contact tracing, isolation and quarantine and work-up of patients exposed to those that have had the disease becomes a work nightmare and is hazardous to healthcare workers who are falling off the grid like flies.

Figure 3 transforms the linear data into a logarithmic scale. It reported its 5th death on March 28. On the 20th day up to the publication of this article, it has remained above 10. Those numbers need to be “bent” in order to see the impact of the ECQ on death rates due to SARS-CoV-2.

So why do I feel that we’re into the perfect storm?

As a general rule, COVID is not the only health problem we currently have. The nonCOVID cases, far outnumber the Coronavirus cases. In short, SARS-COV-2 or COVID-19 has served as a major distractor in seeing the real health picture of the country. At the beginning of this storm, we were battling poliovirus. Last year we hardly recovered from the onslaught of measles and dengue. One infectious disease after another. Where are we now with cases of polio and dengue and measles? I would appreciate it if someone could give us clear data that the war against COVID is a far greater one than other vaccine preventable diseases. After all, at the current crisis, I am sure that the Department of Health has all hands on deck with COVID. We also need clear data on the other noncommunicable diseases (NCDs) and the mortality from NCDs.

Based on published data from the Department of Health’s website, http://www.doh.gov.ph/mortality in 2013, there were 531,280 registered deaths from all causes in all age groups. That’s an average of more than 44,000 deaths a month. Deaths mostly came from the most dense populations – 13.4% from NCR (71,050) and 14.3% from Calabarzon (75,743). How are the 558 deaths (from January to April 29, 2020) from COVID-19 impacting the overall health care of the Filipino people? Focusing our attention solely at COVID-19 is poor planning in the allocation of health resources and healthcare because the greater majority (those with cancer, heart disease, on dialysis, had a stroke, accidents, infants with sepsis, dengue, etc.) will need equally, if not greater attention, than COVID cases alone.

June is fast approaching.

And the onslaught of the rainy season brings with it a cycle of other infectious diseases the present in a similar way as Coronavirus would present at the onset of illness.

Fever. Colds. Chills. Cough.

Dengue. Measles. Seasonal Flu…to name a few.

Hence the urgency in getting out of this pandemic really quick.

It is a difficult and arduous task ahead for the head of state to bring its people out of this pandemic. But it needs to be done in unison. It needs to make policies based on worthwhile real-time factual data that is not confusing. People in government cannot just make senseless statements that there’s nothing we can do about this pandemic because there is. Other countries are able to bring down their mortality rates and eventually the cases by doing more testing and channeling more resources at contact tracing and practical measures in isolating those who come in contact with positive cases.

While it may be a tall order, it is one that requires a sense of urgency not only through ECQs or praying that a cure or vaccine be made available soonest. The most practical and doable is getting the numbers right from the get go. Only then can we make valuable and sensible plans on how to win the war against this virus.

I cannot overemphasize the urgency in getting out of this Coronavirus pandemic. Otherwise, like a ship that sails into a deep vast unknown ocean with no tracking device, we’re heading into the perfect storm.

I always tell my students that data can always be interpreted correctly or end up confusing to the reader. https://www.doh.gov.ph/covid19tracker

I have provided the link of the Department of Health’s Covid-19 tracker. There are various sources where one can obtain good data analytics from. If you go to this link, you will find out that the improvement in the COVID-19 tracker.

Then there’s the down side. The data analytics is wanting in useful information. The kind of information that should make us decide on how bad this Novel Coronavirus pandemic is in the Philippines and whether we’re actually “flattening the curve”.

Once you get into the site, this is what you see.

It gives you a pretty good picture of the daily information on the epidemiology of COVID-19 in the country. 4,932 confirmed. 3082 currently admitted (they don’t identify how many are critically ill and the rest are probably mild and quarantined.) 315 died so far. 242 recovered. Then in the gray bar are the ones “for validation”. There’s a caveat that says that “around 25% of province-level data are still undergoing validation”. But wait…there’s more!

If you scroll down a bit, you will see the table on testing capacity. Here’s where the data actually differ. The testing capacity as of April 11, 2020 showed 4,913 positives. The total confirmed as of April 13, 2020 is 4,932. On April 11, the DOH officially reported 4,428 confirmed cases. What accounts for the discrepancies in the numbers coming from the agency?

The 1,293 case for validation (said to be province-level data) is confusing.

I would assume that province-level data would point to tests coming from Southern Philippines Medial Center, Baguio General Hospital, Vicente Sotto Memorial Medical Center, Western Visayas, and Bicol Regional Diagnostic Laboratory. If you total their positive cases, that would just be 204 positives from the provincial testing centers.

We can assume that some specimens were sent to Manila for analysis. How many were sent to Manila? These inconsistencies in the numbers makes one wonder if they just deduct the total cases from the remaining cases in order to arrive at the discrepancy?

Let’s look at the numbers again.

4932 total confirmed. 3082 currently admitted. 315 died. 242 recovered.

Assuming the numbers are correct, that’s 3639 cases (admitted currently, died and recovered). What are remaining 1,293 cases “undergoing validation”? What does undergoing validation mean?

First, if they’re still not yet validated they shouldn’t even be part of the total statistic.

Second, is why are the numbers in the provincial testing centers not tallying (202 from all the provincial testing sites vs 1293 cases at the national level)?

The third and most vital query is – does the DOH actually have data on the patients that tested positive but were sent home for quarantine? How many of them returned for retesting? When you look at the numbers – of 4932 confirmed only 3082 are currently admitted. Or 1850 cases distributed as follows: 315 deaths, 242 recovered and 1293 for validation(?).

Data integrity is important in the analysis of outcomes and planning of mitigation strategies. It is, after all, the basis of our life after April 30.

The new site, while providing information on cases, deaths, recoveries, is wanting in the type of severity of the illness. We all know that not all admitted cases are in the ICU or are critically ill.

If we scroll down a bit, there’s interesting information regarding the availability of beds and mechanical ventilators in various hospitals.

This above information above while helpful is disturbing. If you look at the ICU beds, only 391 beds (out of 1,085) are filled. The remaining 2/3 are unoccupied. There are more than 87.29% mechanical ventilators still available. Yet reports coming from various private hospitals are that they are filled to the brim and that the healthcare system is overwhelmed by the coronavirus infection that some hospitals had to turn away patients.

Based on the data provided in the DoH website, of the 3082 currently admitted, 391 are in the ICU (as of this writing). That means only 12.7% are critically ill (needing intensive care).

There are more deaths than daily recoveries among those currently admitted. The graph below is a screenshot of the new daily deaths and new daily recoveries on the website. Implying that of the 391 cases in the ICU, 315 have died. An 80% mortality rate when intubated or in intensive care.

Of the 3082 cases admitted in the hospital, assuming that only 391 are in the ICU, what happened to the remaining 2691? That’s the majority of the patients. Who happen to be mild or moderate and probably recover.

Finally, there’s the interpretation of the data.

Cumulative is the operative word in the presentation of data.

Which means that regardless of patients getting better or dying, the total cases is what you see. But in reality it is not. Minus the deaths and recoveries, we actually are tracking 4375 cases that are still active. The deaths and recoveries are considered closed.

The red herring here? The ones for validation. They form the inconsistent information that needs an explanation so that it is not misinterpreted.

I’ve always told my former students in biostatistics that all the numbers should have an explanation. It is imperative that data gathered is accurate, valid and not confusing to the reader. It is also important that all tables and graphs are reconcilable. Otherwise, any conclusion or decision that is made with this kind of data is confusing and simply leads to bad decisions in preparation and planning.

The bottom line of good solid data? The April 30 deadline.

…well, that’s wishful thinking. But let’s pretend it happens…

NUMBERS MATTER

We all know that the only reason for people in government to consider re-extending the extension are the “numbers”.

Larger number of cases. Longer recovery time from more critically ill patients. Poorer recovery rates. Increased doubling rates. These are the numbers and endpoints that matter from an epidemiological point of view. And because these numbers matter, we need a unified accurate data in order to predict whether we’re getting out of April 30 alive or not. The Department of Health has made an announcement that this is currently in the works and that perhaps the deadline they set on April 11 for syncing all data should be helpful to the decision makers on any exit plan.

It cannot be a mathematical modeling that is predicted based on several assumptions that are not constant. Mathematical modeling has its limitations, because while it incorporates available actual data, its accuracy depends on the number of actual data into the various incorporated variables. If the variables used in the prediction model are “constants” and “assumptions” as well, then the modeling accuracy is compromised. Hence, my caution in using modeling parameters because this virus does not recognize the variable nor the constants of a mathematical equation. It will behave the way it does. Unpredictably.

All data must be coming from the National Government. Seriously, it is difficult to make heads or tails with the discrepancies in data between the Local Government Units and that of the National Government (Department of Health). You get reports from LGUs that report more cases than what the National Government releases, while other LGUs report less cases. You actually have this feeling that you don’t know who’s actually running the show.

Let’s use one website: https://covid19stats.ph as reference for all discussions in my blog (unless otherwise I use a different reference). I think it’s a very good one considering that it provides both national and local government data as well as the global data. While it is not in real-time, it is updated at least before 4PM (Manila Time).

Figure 1 above shows the data as of yesterday. Note also that this website started with information on March 27 at a 803 cases, 54 deaths and 31 recoveries. In short, by March 30 (3 days later) we stood at 1546 cases, 78 deaths and 42 recoveries. A doubling rate of 3 days. Which means that on April 2 we should see more twice the number of cases we saw on March 30. Did we? Well almost. On April 2, we had a total of 2633 cases, 107 total deaths, and 51 total recoveries. Which moved the actual doubling rate now to around 3.3 days. If you used a constant mathematical model, you would have expected that by April 5, we would have more than 5200 cases, on April 8 more than 10,400 cases on April 11 more than 20,800 cases and so on and so forth. The slope (rise in numbers) would be steep. The casualties would rise disproportionately as well. Yet on April 5, the total cases was 3246; 3660 on April 6; 3764 on April 7; 3870 on April 8; and 4076 yesterday April 9. Note that the doubling time also became longer from 7 days to 10.76 days.

Doubling time is the number of days it will take confirmed cases to double and is based on the 7-day daily average growth rate. The other variable that’s important to look at is the daily growth rate. The lower the growth rate, the more contained the outbreak is. (Table 2 below)

This is why accuracy in data is important. This is the first trigger that will decide on life after April 30, 2020.

As the growth rate slows down, and the doubling time is prolonged, there is no reason why there should be an extension of the ECQ.

TESTING MATTERS

The second trigger in determining whether we’re getting out of this lockdown alive on April 30 is the capacity of the testing centers in the country. The backlogs in reporting. The backlogs in printing out the results. The number of accredited centers. How many tests are done per day and all these numbers I mentioned – should have a denominator. Out of how many tests are the reported cases? This will give us a better grip on the the first trigger because they are co-existent. A backlog in reporting is bad data mining.

THE ECONOMIC AND OTHER HEALTH IMPACT

This is the third trigger. Regardless of data, talking about the disease versus jobs and the economy that has faltered is moot and academic. We all want to come out of this pandemic in one piece. No one wants to be a statistic. I’ve lost too many colleagues close to me to this virus. And yes, we’re all afraid of the unpredictability of this virus. As of this writing, there are several promising experimental treatment models that are being conducted – from the Japanese experimental antiviral Favipiravir (Avigan) developed by a subsidiary of Fujifilm to Hydroxychloroquine + Azithromycin +/- Tocilizumab to the recently US FDA approved protocol for convalescent plasma. We see some light at the end of the tunnel, but that’s a topic that I will discuss some other day when we have better and more reliable clinical trials are available. And then there is the promise of a vaccine on the horizon.

Which means that there’s a waiting period. We need to sit back and wait. The magic potion is not within our midst. But the economic backlash is hurting not only the country but the world as well. As to how long a hungry stomach can withstand the wait is a different story altogether.

INTERPRETING AND REPORTING CONSISTENCY

I cannot tell media how to report. Every media outlet will have its way of trying to grab the attention of the viewer. As the late Mr. Felix Bautista once taught us, the first line of your story is the most important. It is what will enthrall your readers to read on or ignore your writing.

But I can teach my readers how to interpret the data.

The data on Figure 3 shows you that we have 4,076 confirmed cases. I think what the media outlets should be reporting are the new cases. The 4,076 cases include all the cases since the beginning of when we were registering them. Again, if you look at the recoveries and deaths, these are closed cases. In short, of the 4,076 cases, 327 have had outcomes. They either died or recovered. In short, we’re just monitoring 3749 cases. And waiting for their outcomes.

We will not really know how many will recover (or die) until a few months when we’re seeing the trough of the curve.

Figure 4 above shows the data from China who had exited from their lockdown last April 8, 2020. They are still reporting new cases (in beige) and new deaths (in red) but their overall recovery is 77,455 cases (94.56% recovery rate), with 1,116 active cases remaining (no outcome yet, and 144 of them being in critical condition), and 3336 deaths (4.07% case fatality rate).

Their new cases are mostly foreigners or people who have returned from foreign travel.

EASING THE RESTRICTIONS

We need to learn from Wuhan, Singapore, Taiwan and HongKong the lessons of the aftermath of a lockdown when it was lifted. https://www.nytimes.com/interactive/2020/04/09/world/asia/coronavirus-hong-kong-singapore-taiwan.html

Figure 5 above shows the glaring data where there were so few cases after the lockdowns and a resurgence in cases after lifting it. Taiwan was hit most with the surge in new cases (orange bars) imported from other countries. Local transmission remains low. In HongKong, Singapore and Wuhan, the stories are similar, except that Singapore is reporting a surge in local transmissions.

Some normalcy should be brought back slowly. To ease the restrictions will require a concerted effort from every sector. Like a master conductor for a Philharmonic orchestra, he must be able to create a harmonious exit out of this lockdown.

Easing it will be the way to go.

Address the triggers. Set a deadline for the respective agencies. The deadline was yesterday. Obligate and hold responsible agencies that are part of the problem instead of being the solution.

Schools in the Philippines are literally jampacked. Online learning when applicable should be the mode for the rest of the remaining school year for college and graduate schools. Those in grade school should be made to stay home and allowed to move up in August. All schools should now be synchronized to open at at specific time. My suggestion – August 1, 2020.

Social distancing, hand washing, hygiene and wearing masks should be the new normal. Malls can slowly be opened (for essential goods) with strict social distancing and allowing people up to probably 1/4 the parking capacity of every mall. Restaurants can only operate if there are reservations made so that only half the capacity of the place is occupied at any one time. Take outs are encouraged. Drive throughs as well.

Hospitals should open its doors to NONCOVID patients. A triage should be in place at every hospital. Patients should be honest enough to disclose why they are there. Patients who fulfill the criteria as PUIs or PUMs should automatically seek medical consultation at a COVID designated facility. Hence, every private hospital should be encouraged to have a designated facility only for COVID patients separated from the rest of the hospital. This is so that other patients (which is the majority) that have other acute or chronic illnesses can be seen by the respective doctors. HMOs should put up their own facilities outside of the hospitals for COVID patients. For example, if you are a COVID-suspect, you can only be seen at the hospitals accredited by the HMO for COVID patients. This will partly address the issue of local transmission and contact with COVID patients. Remember, the majority of patients that require both elective and urgent care are NONCOVID patients.

There should be limitation of travel in and out of the various regions for the next 2-3 months in order to limit other sources of local transmission. Those who live outside of the NCR but work in the NCR should consider renting a place near their workplace for awhile. Regional travel can be reassessed after 2-3 months or earlier depending on the state of the pandemic.

Public transportation should be limited to the locality. Perhaps in order to avoid crowding, people who are unemployed or do not have work should not be allowed outside the homes in the meantime unless for essential errands (marketing or buying food). The type of transportation is important. Public transportation should only be filled to 1/2 its capacity.

Children and the elderly are encouraged to stay at home during this transition period.

Gigs, concerts, crowds, bars, night outs, movie houses, conventions, and other nonessential activities should remain cancelled until after the transition period is reassessed.

I cannot overemphasize the reintroduction of another wave after we have “flattened the curve”. The only way to sustain it is to close the borders into and outside of the Philippines in the meantime. This means that anyone who decides to travel outside of the Philippines or is a foreigner who wants to visit the Philippines will need to undergo BOTH of the following upon arrival: (1) PCR or rapid testing (2) mandatory quarantine for the next 14 days. If symptoms appear or patients test positive, they should be admitted to designated centers for PUIs and managed accordingly.

We should not overlook one other fact.

The flu season in the Philippines is the rainy season. That’s usually June. Encourage everyone to get flu shots. That’s one virus less that will complicate the management of any respiratory infection.

As the rainy season is around the corner, it would be disastrous that we’re going to be seeing a mix bag of infections – from dengue to flu – breaking out in the midst of an uncontrolled coronavirus pandemic.

I hope we get it right in the next two weeks. This is your best time the government can practice on what it intends to do after April 30. Seriously – we are left with no other option. Because life after April 30 must go on…

In a dazzling (dizzying) display of desperation (?), a visibly confused rambling of frustration on how to control the novel coronavirus pandemic and how it was affecting the dire economic resources of the Philippines was seen in the face of the president over a live announcement last night.

He didn’t mince words.

Behind all the garbles on afterthoughts from his trip to the toilet to urinate, asking the secretary of finance to generate money whether he steals or borrows, telling the people that there is a limit to what the government can offer and offering to sell Dewey Boulevard (so retro), asking for patience (which I am sure has run out of especially for the daily wage earners) because the virus has torn the very frail economy of this nation, and finally ending with the vast unknowns…I could understand his annoyance at the circumstances he’s in.

Huwag ka mahawa. Huwag ka lumabas ng bahay. Paano pagkain namin? Maghanap ka ng paraan.

Hindi ko alam kung [hanggang] kailan ko kayo sabihan. “bahay lang kayo”.

Hindi ko alam kung kailan ako makapaghatid ng pagkain sa lahat.

Hindi ko alam saan ako magkuha ng pera.

Hindi ko alam kung ano ang ipagbili ko. Kung may magbibili.

Hindi ito trabaho ng abogado. Trabaho ito ng medical experts, scientists. I just happened to be here. To my chagrin, bakit sa panahon ko tumama.

I end this with a prayer. Whatever be the correction – ang anomaly sa mundo. He created the world. And if God wants it ended, so be it. Salamat po.

The live telecast surely didn’t sit well with the audience.

It was not surprising then that after that exasperated moment, the announcement came this morning – the lockdown would be extended. Period.

The objective for extending it till the end of the month?

According to Secretary Nograles, it was necessary “in order for the government to determine the impact of the ECQ and further increase health capacity in Luzon and other areas, including ramping up COVID-19 testing to 8,000 to 10,000 tests per day with a turnaround time of 24 hours.” https://www.gmanetwork.com/news/news/nation/732935/iatf-recommends-extension-of-luzon-wide-quarantine-to-april-30/story/

Let’s give people credit where credit is due. I actually see how hard the IATF (Inter Agency Task Force) is working trying to complete the arduous task of containing this global pandemic among our islands. As I’ve said in the past, in pandemic, some things will require decisive action immediately. Waiting for tomorrow is another day wasted.

And that’s what happened with the first ECQ and the night before the extension. The first lockdown sent people into a frenzy. Panic buying for the those who could afford. For those who had less in life, it was just pure panic. An exodus for the unemployed. A wait and see for those that are still holding on to jobs, which probably some will have none to return to when this crisis ends. The last three weeks was spent in prayer and hope. That life would be what it used to be on April 14.

I am sure that most (if not all of us) are glued to the daily numbers – new cases, new deaths, new recoveries. Media are quick to draw conclusions or confusions to the numerical values that are being churned out by the Department of Health. If you ask any grade school student to draw a graph based on the numbers culled the past 3 weeks, they’d tell you that there’s no consistency. And that’s probably because of the backlog in reports. The death of a 7 year old in the Ilocos region is a glaring example of how long it took for the results to come back. Five days after her death. And that’s just one case. How many more cases have had dismal reporting timelines? This is important because the management of patients (from treatment to contact tracing and quarantine measures of exposed individuals) highly matters on how quickly (and accurately) we get back the results and the number of people tested based on the released report. Moreover, accurate and timely data provides us the best picture on whether the lockdown is “flattening the curve”.

I understand the frustration of the president. I, too, share his frustration. And I’m a doctor already! When you can’t make heads or tails of the data, the frustration is real.

The first lockdown has shown us how much more work there is to do, and how unprepared we are at crisis management in a pandemic. Let’s face it, the only way this virus will ever go away is sadly – probably never. Even with the availability of vaccines for flu or any other disease, we’ve hardly eradicated many vaccine-preventable diseases except for smallpox in the last century. The search for a cure or treatment is at best for now, a trial and error method. A lot of theories and anecdotes, with little science (robust clinical trials) to back up various treatment regimens.

As a people, it’s only when we accept our shortcomings can we realize that there’s much more we don’t know. There are few short-term plans plotted out but a dire lack in medium- and long-term plans.

Those short-term plans are panned out at providing measly change for the poorest of the poor. The people who work in government are better taken care than those in the private sector. After all, no one will lose a job when you’re with the government unless there is no more government. How does the government plan to assist the private sector with respect to repayment and restructuring debts particularly for the micro, small and medium enterprises? Supplies purchased from large companies should be given a longer term grace period for payment rather than the original payment dates. But many multinational companies will not agree to this because they have employees to pay and their own needs to fill. While people in government are willing to take a cutback in salaries, are the people in the private sector willing to negotiate a 90 days payment option instead of 30 days for various goods? Mall tenants and other stall/store owners are in a similar situation. How many landlords are willing to forego rent to tenants who did not use the rented spaces due to the lockdown? These are just examples of incongruence in the “bayanihan” spirit of the Filipino people. The irony here is that it’s mostly these same people who provide donations in times of disaster as public relations promotions that are in disguise of being concerned with the poorest of the poor but take from the small and medium entrepreneurs. That is why I am not a believer of these corporations who give out “donations” yet don’t look after the smaller companies that keep them afloat. This domino effect, trickles down to the vendors and consumers in the end. And as the pandemic deepens, the economy will continue to falter to the point of collapse.

Then there’s the medium- and long-term goal. The idea of having designated centers for COVID cases in every local government is both doable and a good one. Remember, isolating infectious diseases and waiting out the course of illness until the patients recover on their own is the oldest method of containing an infection. Before the end of this week, every local government unit must be able to put up one. There are many unused edifices in the local government and placing their city health office in charge of such centers will free up the communities from having the cases monitored where they reside as well as the hospitals in having PUIs and PUMs occupy the necessary space for the hospital to operate regularly once more. People don’t know that there are more patients sick with other acute and chronic diseases who will require hospital care than COVID19 patients. Segregating the COVID19, PUIs and PUMs is vital in reducing the spread of the virus and thereby restoring some sense of normalcy in the community. It will also allow other sick patients without COVID19 to get better healthcare, and hopefully be at less risk or when they do get infected with SARSCOV2, be immunologically stronger at combatting this virus. Comorbidities that are well controlled have better outcomes than those that are not.

The real problem I see are actually the local government units. They’re like little kingdoms. There are those who have best practices. Then there are those who are a bit off not only in science but common sense as well. And that’s where the difficulty lies. There is no consistency in the implementation of recommendations. When the mantra is “every kingdom for itself”, it will be difficult to curb a pandemic of this proportion.

A long-term plan should also be discussed today. Not a week from now. Not after April 30. As the president mentioned, this is after all a battle. And a prolonged drawn out battle it will be. At the end of the war, only one will emerge victorious. Our fate depends on the strategist who put this plan together.

What do we do on April 30, 2020?

Is another extension in the horizon? And that’s the question that’s begging for an answer. I hope and pray not.

But I guess that depends on whether we’ve gotten our act together or not. At the rate we’re going, the plans the IATF have put forth should be strengthened and every LGU should abide by the general guidelines (if any) of the IATF. Additional local strategies must be in congruence with the general guidance provided by the IATF. Any local plan that deviates from the IATF should not be allowed. There should only be ONE agency responsible for the success OR failure of the mitigation efforts during the next 2 weeks extension period.

Allow some flexibility in mobility. We need to mobilize not only frontline workers but some other essential business establishments vital to the economy of Luzon (where the lockdown is limited to). Some form of public transportation should be restarted with conditions on how many to accommodate and the practice of social distancing. Trains and MRTs should not be operational yet. There should be no crowded places or events for quite awhile. Schools will be out probably till the upcoming school year but that’s the least of our problem because the kids will get their wish – long vacation – at last. To keep the crowd down, malls and bars and other recreational facilities should remain closed until such time that we have actually reached the lowest part of the flattened curve. Nonessential travel (both in and out of the country) should be avoided in the meantime.

We must set the expectations early on as we approach the deadline and prioritize the economy while taking into consideration the general health of our people (not only COVID19). Both the economy and health are inseparable in the equation of a healthy nation, with each of them being dependent on each other. We cannot care only for the COVID cases. There is a greater majority of patients who are sick with cancer, hypertension, diabetes, measles, dengue, hyperthyroidism, cardiovascular problems, COPD, etc. yet one case of COVID overwhelms a whole community and healthcare system.

In the spirit of transparency that there was a well-thought plan to begin with, the public should know the basis or criteria on when the lockdown can be lifted, the restrictions that remain after the lifting, and when and what to expect as we monitor the lifting in the next year or so.

Sadly, this is one virus that will never go away. It will have its peaks and troughs all year round. As doctors, we will probably look at every fever, sore throat, cough or colds and diarrhea in a different light from now on. The general public will not forget this pandemic for awhile. But for everyone’s sake (physically and mentally), we will need to get back to some sense of normalcy. That’s why we need to sing the song in the same tune now. And get our acts together in how to deal with this invisible invincible enemy in our midst.

It’s almost 3 weeks since the lockdown in Luzon.

I’m sure we are already at the edge of each others nerves. And for good reasons. When the norms of daily life are perturbed, it gets crazy. An unseen enemy. Unknown cure. A race against time. The number of cases rising. The death toll insurmountable. The last century alone, all the gains and accolades of medical science wiped away with one virus. A microscopic pathogen indisputably eroding governments, economies, and lives.

The battlefield in the hospitals are at a different level. We’ve never been more fearful of a disease as this. Every front liner is fearful for their lives but still serve the sick. In our communities, paranoia and fear has hit the core of every family – from the gated villages to the informal settlers surrounding them. But let me say this for the record and with certainty – the informal settlers have the least to lose here in terms of health and wealth. It’s the middle and upper class that are panicking. The poor, well, they’re just worried about their day to day existence. Work for daily wages, food on their table, a house over their heads. They don’t have bank deposits or stocks and investments and businesses to worry about. They’re used to what they have. All they worry about is a tad of health care, their grumbling stomachs, somewhere to lie down on after a weary day. Day in. Day out.

So my readers asked me one good question.

Will (or should) the lockdown be extended?

My disclosure is that what I write are based on all the data I can cull available for public access. Other “unpublished” or unreported information are factors that may change the opinion later on.

So here we go.

The answer is YES.

It should, however, be modified because we have now seen its promises, and gaps.

As the number of new cases rise (and it will rise because we have more testing kits now), the number of daily deaths will be the predictor of whether the lockdown is working or not. Let’s remember, the number of new cases IS NOT a reliable predictor of whether the lockdown of a community works or not because when the lockdown was declared, the number of cases were already on the uptrend.

Figures 1 and 2 above show that the slope began toward the middle of March. I cannot overemphasize the fact the importance of testing here. It was an outbreak waiting to happen. We slept while the enemy was awake. Complacency and poor foresight. As long as we see those numbers go up for awhile, don’t expect the recoveries overnight. They won’t go down until 2-3 weeks from the time they went up. We started the steepest climb only last week. How steep will we go depends on multiple factors.

The good news is that if this lockdown did not happen, there would be more new cases and new deaths.

The bad news is that, as in all lockdowns, the lockdown came too late. By the time an outbreak has occurred or is recognized, the virus has already taken over a proportion of the population for it to spread. The R naught (R0) of SARS-COV2 is low. Scientists say it’s round 2-3. The R0 tells us the infectivity. For every case, 2-3 patients probably get infected with the virus. Compared to the seasonal flu where the R0 is around 1.3 or chickenpox virus where the R0 is 10 or measles virus where the R0 is 15. https://www.livescience.com/new-coronavirus-compare-with-flu.html

Why do these numbers matter? Because they are part of the basis in decision making for our exit strategies.

What works?

• 1. We know that physical distancing works. The less crowded the place is, the less infectivity rates are. That’s common sense.

• 2. Unlike the World Health Organization, I disagree that masks should not be worn. The WHO has flip flopped several times on various recommendations or whatever it recommends. They are, a political organization. They are not a regulatory agency. What may be effective in Uganda or the Philippines may not necessarily apply to Japan or the United States. Every country has its own vulnerable spot. And ours is relying on the WHO for an opinion. Their observations are noted. Do we need to follow it? No.
• Masks should be provided and worn outside of the home, in public, when tending and seeing patients. The proper mask is also essential. Those washable porous masks that have Dora or whoever character etched all over don’t work. Wearing a mask should be the norm now. I cannot overemphasize how much a highly useful preventive equipment it is for many respiratory pathogens. The mere fact that SARS-COV2 is a respiratory virus, protecting your face with a barrier is just common sense.

• 3. The surge of OFWs returning home is scary. Not that we don’t want them home. We do. What do we do when they get here? More than anything, they must all be swabbed. Their absence of signs and symptoms, fever or other factors ARE NOT reliable. Majority of our patients do not reveal a history of travel. Travel has become a stigma suddenly. We learned that with the death of a doctor from a patient who lied. The patient had a travel history. Got sick. Got people infected. Didn’t tell the truth. And a doctor died. Where’s the fairness in that? Swab them all. Quarantine them for 21 days. For patients that are positive, they need to have 1-2 negative swabs depending on the clinical status of the patients on discharge. Patients that develop symptoms and are critically ill must have 2 negative swabs before being discharge. And its not only the OFWs. Even those that have arrived in the Philippines in the last 30 days should get swabbed. The Department of Foreign Affairs and the Bureau of Immigration surely has a list of all these people who have arrived. They should look for the travelers and swab and quarantine them until all results are available.
• 4. PUIs with mild symptoms should be segregated and admitted to a facility only for PUIs. They must not be allowed to be part of the home or community. This is to make sure that they are not violating any quarantine measures. You know how ingenious the Filipinos are. Segregating them will minimize having a total lockdown in the communities.
• 5. All PUMs should be monitored properly. There are many ways that the local governments and barangays can assist. The identities of these patients can be provided and the data privacy act can and should be waived under these extreme circumstances , otherwise we end up in a catastrophe. The barangay can monitor the household 2-3 x a day. Everyone in the household should isolate the PUM in one room dedicated for the patient. Protocols are in place for self-quarantine. For the informal settlers or those that have no dedicated room for PUMs, the government should be able to provide makeshift places for these. Tap the public and private schools which are currently closed. PUMs have no signs and symptoms and will need very little monitoring except for food, water, shelter and keeping them locked in a room for the next 14 days.
• 6. Malls, stores, movie houses, bars, offices and restaurants should remain closed until May 3, 2020. We can reassess later the situation. Restaurants can serve take out food only but no dine in. Businesses that can work from home should be encouraged to work from home until May 3. Businesses that will need physical presence of workers should have a minimum work force or skeletal schedule so that it is not packed.
• 7. Curfew should remain in place from 9pm-5am every single day. This will minimize movements in any community.
• 8. Schools should remain closed until the end of May. The highest transmission of a virus will always be a crowded environment and believe me when I say that the physical distancing is least observed in pediatrics.
• 9. All children and the elderly (> 60 or 65 years old) should stay at home as much as possible. Unnecessary travel should be avoided among this group.
• 10. Public transportation should be limited. Jeepneys and Buses and Taxis can be allowed but the number of passengers should be limited. No tricycles or bike riding apps should be allowed. Trains and MRT/LRT should not be allowed until such time that we have seen flattening of the curve.
• 11. Every region must have its own accredited testing center before you can even consider lifting or modifying the lockdown. We need to capacitate every region because the delayed results due to backlogs are deadly. Some patients will present in an unusual manner. By the time you get the results, some of them can end up infecting 2-3 patients who in turn have infected 2-3 more people and so on down the line depending on the day the results come out! Without this being in place, you cannot lift the lockdown OUTSIDE of the National Capital Region.
• 12. The Bureau of Immigration and Department of Health need to work together and we cannot rely on patient information. Every patient that is a PUI, PUM, positive (dead or alive) should be verified with the BI for a travel history – when, where, and what aircraft? This is for documentation and contact tracing purposes. Contact tracing is much easier when the patients are truthful with their information.

These are all common sense. They will work. If our government officials can work together. It’s disappointing that there are government agencies that create issues that are divisive in times of crisis so that they can lick the ass of people in power. Hey – this pandemic is about all of us, not about your political future. Get a grip on reality! If and when we all get out of this alive in the next few months, believe me, it will be payback time. Accountability among the government officials shall be made. And those that stole, corrupted, abused, and conspired evil during this pandemic should be held responsible for the outcome.

So yes. The lockdown should stay unless these issues are addressed. Then we can work on a week to week basis on how we can go back to our “normal” lives. In the meantime, this will be our new normal.

Oh before I end, the kit is still the most important tool we have here. I started blogging about this virus way back in January. It started with one simple article entitled “Pandemonium”. The rest is history.

How we tell the story, who we listen to and how factual the information is, and how it impacts on peoples lives and futures – that’s what matters. Let’s hope and pray that this government has an exit plan. Not one out of ranting but one that is well thought of. Because you accepted the role to lead, you have no choice but to lead us out of this pandemic with the least casualties.

We have only two scenarios as we approach the April 12 deadline of the Luzon Lockdown period.

It either gets extended a few weeks more or it gets lifted.

Either way, the bottom line is not only the human toll this pandemic is causing but the economic toll as well.

COVID-19 has changed the paradigm of what is the “new normal”. The millennials and the more recent “alphabet” Generations have never seen anything like this. Neither have we.

Two scenarios will play out as we go towards the end of the second week of being “locked down”.

Let’s be realistic. The number of new cases (and sadly new deaths) WILL NOT go down overnight. Or soon, for that matter. So let’s keep our expectations real. Locking down everyone for the next month will not make the statistics decline NOW. Remember, it took China in general and Hubei in particular almost 3 months to bring their numbers to where it is today. But they had a different model. And isolating Wuhan from the rest of China and the rest of the world took an economic toll on the country. But China will always be China. They are, after all, an economic powerhouse. They can build a hospital dedicated to managing SARS or COVID-19 in a matter of 10 days.

Keeping it real, the Philippines will always be the Philippines. The eternal beggar for donations. Let me call a spade a spade. We recognized this problem early in January. There was one death in three cases. From a foreigner who traveled from Wuhan, China to the Philippines via Cebu into Dumaguete and finally into Manila. He later passed away in a government hospital. That alone should have served as a red flag.

How we even got from that point to where we are today is a different story altogether. But the answer partially lies in what President Duterte said – The Kit is the Kit.

BEST CASE SCENARIO

The 4-week lockdown will hopefully slowly bring the number of positive cases down in the remaining 2 weeks. By “containing” everyone and presuming everyone is positive for the infection or are potential carriers (note: asymptomatic), we make the viral “infection” run its normal course. People within the same household who probably have mild to no infection will recover on their own. If enforced properly, this will curtail ongoing community transmission. Those that progress to being critically ill are then hospitalized, isolated and hopefully, recover with minimal sequelae.

The numbers should gradually slow down. The “curve” will flatten. The limited healthcare resources will not be usurped. And perhaps in another two months, life will breath new air.

WORST CASE SCENARIO

Then again, the success of a lockdown is a hypothetical presumption. It may work best for highly disciplined countries. Those with very few informal settlers. Those with better healthcare resources. And those with best economies because they have the means to feed and fend for its people. Like a zombie movie out of Netflix, the gated communities will probably be the last or least affected because they have the most resources.

How long do we lockdown and what are our grounds for endpoints? The anatomy of disappointment are expectations. As we near the date, are we seeing what we want to see? Why or why not? Should we extend the lockdown? If we do, how long do we extend?

Metro Manila is a highly dense city. We have more people here than Wuhan alone. More than 15% of people in the Philippines residing in Metro Manila. While there are many gated communities in the metro, they comprise only 1/3 of the population. Majority are informal settlers. How to quarantine a family of 10 that live in a 15 square meter area or a community whose homes are a thin plywood board apart with access alleys measuring 1 meter in width is a virtual nightmare.

So, yes. We need to get out of this lockdown in the next few weeks. Extending it is an option but a calculated risk on the economy of a third world nation like ours. As the poor would say, they will not die of Coronavirus but of hunger. We cannot keep giving them dole outs. Micro, small and medium enterprises will eventually crumble, with the smallest losing the most and most likely will be unable to recover at all. People will lose their jobs as these owners will need time to recuperate losses. Half of them will not be able to bounce back. The remaining half will struggle against the tide. There will be massive lay offs. Riots, violence, looting, unrest are worse case scenarios.

Is the lockdown the only solution?

No. And we need to get out of this rut quickly while taking into account the lessons learned from how other countries are managing their own crisis.

That’s why we need a plan B. This government should learn to shift gears now by appointing experts who understand crisis management and not rely on amateurs who only have political clout as the qualification for being appointed into public office. Sadly, some Filipino politicians use any form of crisis or disaster to be able to tap into government funds for their personal gain. Greed, power, and ambition are well entrenched in the DNA of corrupt politicians who run for public office because to them, it is a business enterprise. For a country like ours, it is a family affair.

As the various cities and provinces move into lockdown mode, the longer the time to relief, the more the economy will take the brunt of the pandemic. It has hurt more affluent nations already. Imagine the impact it will create in a small country like ours whose financial reserves are being depleted to sustain the fledgling business sector and the jobless.

The cash assistance program of the government IS THE WRONG solution to the current crisis. It is not a sustainable solution. The small patches being addressed include giving cash assistance to the informal settlers and those unemployed due to the crisis. Which I personally think is a bad idea. This is a problem that will last into Plan B. Which means that the government will need to sustain the micro, small and medium enterprises in a time of difficulty. They will need to give up more than just dole outs to the poor. The question is, are they willing to?

This would mean not collecting taxes, SSS, Pag-Ibig, Philhealth, GSIS and other contributions for an agreed period of time. This would also mean that losses can be claimed against taxes. Loan reprieve should not be voluntary but mandatory. All banks and other lending agencies should be mandated to require those who have existing loans if they wish to restructure their loans to lower rates. It is unfair that current lending rates have been lowered but not adjusted for those whose loans are locked in at a fixed rate at a time when they borrowed money from them. Those who are willing to hold off payment for say, 3 months, should be allowed to do so in order to recoup the financial losses of this lockdown. Local governments should be mandated to provide a reprieve to local businesses as well. Rebates in business permits can be given. For example, for those that pay quarterly instead of annually, the second quarter payments should be waived. While the business permit may be based on the gross income of the company in the year before, it should be able to assist the local business sector these unexpected extraordinary losses. In addition, it should be fair in next year’s assessment when paying for a mayors permit. (I am sure everyone knows that the LGUs turn a blind eye when it comes to the business permits. They will not believe the income tax statements you declare and insist their own computations.) Reprieve from rental of business establishments where the offices or stalls or stores in malls should be granted as per duration of the lockdown. In short, greed must be tempered from all sectors.

Sustaining the smaller and medium enterprises is essential. The aftermath of the pandemic will impact not only on health and lives of everyone but on the economic repercussions of the lockdowns. Let us face it, at the end of the day, it is those who have the least in life that suffer the most. If these small and medium enterprises close, there will no jobs to go back to. And everyone loses.

PLAN B

There are two models that can be used. The China experience (total lockdown) or the South Korea experience (no lockdown at all). The people in the government can integrate the experience of both countries and perhaps create a hybrid one for the Philippines. Using either of models (China or South Korea) ALONE will not work because our economic structure is fragile and poor.

The New York Times published an interesting article on “How South Korea Flattened the Curve” https://www.nytimes.com/2020/03/23/world/asia/coronavirus-south-korea-flatten-curve.html. In a nutshell, Fisher and Sang-Hun point out the strategies on how to contain the coronavirus without shutting down the economy. The downside? It may not work abroad.

The article points that the lessons, “while hardly easy, appear relatively straightforward and affordable: swift action, widespread testing and contact tracing, and critical support from citizens.” The four lessons are:

Lesson 1: Intervene Fast, Before It’s a Crisis

We were there in the beginning of this war. Three cases all foreigners. One death among them. Then we were stumped. Too few testing kits were at our disposal. Even up to today, we’re stuck with the bureaucratic red tape and the parasites and opportunists who take advantage of their positions in government to overtake the queue or by-pass the algorithm on who we prioritize for testing.

We intervened ahead of the world. Our major mistake was the mixed messages being sent by various agencies. Basic epidemiology would have taught us that if there was 1 death in 3 cases, the overall case fatality rate is 33% for the country. A number far too high from the average case fatality rate of 4-5%. Which means we were not picking up the real numbers. To have one casualty from the virus, you needed to find at least 25 cases.

But the virus has arrived. And the traditional response may not be the solution here.

Lesson 2: Test Early, Often and Safely

Culled data as of March 20 shows how far behind we are when it comes to testing. As the kits came in last week, the numbers began to swell. Everyone wanted to get tested. Understanding testing is vital in the decision on whether we test those at risk, those exposed, those at highest risk and/or test everyone?

But should we test everyone?

No. That would be a waste of resources. And may provide a false sense of security.

Like any laboratory test – reliability and accuracy is crucial. The tests should be be done in a safe place by well trained people who pass accredited and quality standards. In a nutshell, the validity of a testing kit will need to get verified. Results can vary between 30-60% accuracy. Other reports include 10-30% pick up rate depending on what you use. And are dependent on the timing, how the specimen was obtained and transferred, the severity of illness, the viral load and of course the way the specimen is run in the laboratory. These factors alone will make testing in a country with 7,641 islands a strategic impossibility.

The model used in Korea is opening more testing centers. The question is – do we have enough testing centers that fulfill the requirements for biosafety in handling specimens for these tests – in the country? The answer is a NO. Even if we beef up capacity, it will take months before we can have enough accredited laboratories for testing along.

To show you the model of South Korea, here is what they did:

This is most unlikely easy to put up in the Philippines. Hygiene, the very basic tenet of infectious disease is difficult to enforce in a community that lacks water, basic toilet facilities, and garbage disposal. Ignorance is also important to manage, doctors included.

What can we do realizing these limitations?

After the curve sees some flattening (which won’t be anytime tomorrow), mitigating the spread is vital. The key is to do testing on EVERY SUSPECTED CASE (not on everyone). This way we can conserve resources. All patients who are positive, regardless of severity of symptoms should be admitted to a designated COVID facility. Since schools have been closed, public or private schools can be used as COVID facilities for those that DO NOT have severe symptoms that will require hospital care. Food, water, and isolation is all that is needed. Making them stay AT HOME in the community will place more people at risk. Knowing the Filipino mentality and culture, home quarantine will not work.

Lesson 3: Contact Tracing, Isolation, and Surveillance

The Department of Health through their Epidemiology Bureau does a lot of contact tracing. The challenge is the patient. Some (if not many) of whom are afraid to reveal they have come in contact with patients for fear of being positive for the virus and the idea of being isolated. In short, people must be willing to lose a part of their privacy as a necessary trade-off for the good of the community.

Here is the model used in South Korea:

For all the technological wizardry of this nation, and how socially connected Filipinos are with their gadgets and other platforms, creating an app similar to this is a walk in the park. Two large telcos – Globe and Smart – should be mandated to work with the government in providing free data to those who will eventually need to use this app during self-quarantine.

Lesson 4: Enlist the Public’s Help

And this is where it gets a bit tricky.

Our bayanihan spirit defines us as Filipino race. But sadly that same spirit isn’t a consistent one. When people do things in order to be recognized as heroes in the end, we all end up as losers. Finding recognition at the heart of an outbreak of this proportion is not a solution. It is a problem. While government needs to listen to suggestions from private sectors, the private sectors should be able to sit down and work with the government on various matters. For example, certain corporations can help at procurement of PPEs and face masks (eg. banks and other lending institutions), while others focus on their special fields (telecommunications, food manufacturing, etc). We don’t ALL have to donate food. Equipments, health facilities, testing kits, disinfectants, etc are at the core of lacking in support. Let’s segregate it. And it would be fantastic if we had only ONE keeper of funds for the private sector donations that would turn it over and do accounting with ONE recipient of funds from the government sector (perhaps the Department of Finance). This way, accountability is transparent.

LIGHT AT THE END OF THE TUNNEL

Either way, the virus will disappear slowly.

Will it ever go away?

Scientifically speaking – No.

At best, after the dust has settled, we will understand how to recognize early this disease, manage the infection and hopefully find a treatment, and discover a vaccine.

The next two weeks will be crucial. It will be a defining moment on whether we proceed to doing mop up operations after the war or prolong the war. This invisible enemy in our midst is so far winning the war. A measly virus that has claimed lives, disrupted economies, changed the normal way we live and breath and engage with families and friends has the upper hand now because we hid under the rug the red flag two months ago when a foreigner died of COVID19 in our country.

The perpetual beggar stance of our nation is disappointing. We have billions to spend on intelligence resources, private planes and foreign travel and yet we wait for donations for – THE KIT.

The next two weeks is crucial. We either have plan B or the virus continues to decimate us medically and economically.

This government can have its most defining moment now or be the ultimate lackey because no one will ever forget this pandemic that will forever be etched in the history of science and economics. Ever.