Perspectives on COVID-19

Arts and culture

But Prince Prospero was happy and dauntless and sagacious. When his dominions were half depopulated, he summoned to his presence a thousand hale and light-hearted friends from among the knights and dames of his court, and with these retired to the deep seclusion of one of his crenellated abbeys… They resolved to leave means neither of ingress nor egress to the sudden impulses of despair or of frenzy from within. The abbey was amply provisioned. With such precautions the courtiers might bid defiance to contagion. The external world could take care of itself. 

Edgar Allan Poe. The Masque of the Red Death, 1842. Full text here.

Even in the midst of a pandemic, life goes on. In some corners of the world, this means staging extravagant parties and going on ill-timed vacations and taking advantage of the empty malls. I would say I’m surprised, but Edgar Allan Poe clearly saw the same thing happen 200 years ago. Capitalism and elitism aren’t new. Plagues and pandemics kill the poor before anyone else.

I was thinking of this a couple of days ago when there were only 24 confirmed cases of COVID-19 patients in the country. Most of the patients were admitted in private hospitals. Even now, the DOH reports show that patients are admitted in St. Luke’s Medical, The Medical City, Makati Medical Center, Cardinal Santos, and Manila Doctors. These are the hospitals frequented by Manila’s rich.

With our inadequate testing scheme still in place, there could be thousands of Filipinos walking around with the disease, being one with the jam-packed train crowds and touching all sorts of dirty doorknobs –possibly without the time or the money to get themselves tested.

CNN Philippines Staff. Metro Manila to be placed on ‘lockdown’ due to COVID-19, 2020. Photo as credited. Article here.

It’s not just the health-seeking behavior that’s different among people. It’s also consumer behavior. I thought that reports of hoarding alcohol and toilet paper (WHY TOILET PAPER) are only limited to the weird cultural pot that is America, but it’s also here. Someone tried to sell alcohol for PHP750 per bottle. Why can’t people just use soap and water? Why can’t the middle and upper class use their privileged brains and purchasing power for the greater good?

At the very least, the Department of Trade and Industry stressed that hoarding and overpricing medical devices and products would merit criminal charges. All basic goods are also under price freeze for 60 days.

Public policy

Two days ago, the WHO declared COVID-19 a pandemic, pointing to the 118,000+ cases of the coronavirus illness in over 110 territories around the world. In contrast, an epidemic is an outbreak in a community or several communities at a particular time. A pandemic justifies changes in public policy, such as travel and trade restrictions, and more aggressive efforts for the sake of public health.

That day of declaration was also the day all Ateneo medical clerks were pulled out from duty. Due to the rapid transmission of COVID-19 among healthcare professionals, our dean decided to pull us out and to transition to web-based and alternative learning. Interns are still part of the frontline. The Commission on Higher Education appealed to officials of these training hospitals to exercise leniency during this difficult time for medical and nursing students. For Metro Manila, classes are suspended until April 12.

Last night, our national administration announced a Metro Manila lockdown, effective March 15 until April 14. It’s honestly the weirdest lockdown I’ve ever heard of; there are unconfirmed reports that day-time workers can still pass go through the borders, and goods for commerce can still definitely come through. It’s supposedly business as usual for retail stores and banks…

But not business as usual for government entities, which will be operating on a skeletal basis. (???)

Finally, part of that same resolution read out by the president last night is social distancing. Mass gatherings will be prohibited in the next month. Mass public transports such as the LRT, MRT and PNR will remain operational, but there will social distancing guidelines to be issued. I have no idea how we are expected to pull that off. Have you seen an LRT station?

Social distancing is the concept behind the trending #FlattenTheCurve.

An infographic that shows the goals of mitigation during an outbreak with two curves. The X-axis represents the number of daily cases and they Y-axis represents the amount of time since the first case. The first curve represents the number of cases when no protective measures during an outbreak are implemented and displays a large peak. The second curve is much lower, representing a much smaller rise in the number of cases if protective measures are implemented.
Vox. Flattening the curve. View article here.

This strategy is less about preventing illness, but more about slowing down the rate of transmission. With the congestion of hospitals and the lack of manpower, keeping the pandemic in slow motion can do wonders for our health system’s capacity.

#FlattenTheCurve is about decongesting hospitals and making the health system burden manageable. It’s honestly better for young, healthy persons to get sick with COVID-19 later on, rather than competing with the COVID-19 patients who have co-morbid diseases or who are elderly now. Less strain means more effective treatment and healthier workers.

Science and medicine

At a time like this, it’s really the heroes in the research field that standout. As I mentioned, one of the biggest hindrances to an adequate national response is inadequate testing. Foreign testing kits apparently cost around Php8500 per test; you know the Philippines won’t be shelling out for that.

But the GenAmplify COVID-19 detection test by Manila HealthTek, Inc., as developed by experts from the Philippine Genome Center and the National Institutes of Health of the University of the Philippines-Manila, cost only Php1320 per test. There are now around 6000 detection kits in stock. PhilHealth now offers benefit packages to COVID-19 patients.

We need to increase the capacity for testing even more.

On the other side of the diagnostic spectrum, I’ve seen the algorithm for triage of COVID-19 evolve through the weeks. Initially, at least in Medical City, only those with travel to Chinese territories and Daegu, Korea were seen as suspect for COVID-19. With the onset of local transmission, screening has become more sophisticated.

The current decision tool for novel coronavirus assessment considers the following symptoms: fever (>=38C), respiratory infection (cough AND/OR colds), fatigue, and difficulty of breathing. Persons have either travel history or history of exposure.

Designed by Dr. Miguel Berba @docberbi
Designed by @docberbi

Why 14 days?

An analysis of early case reports published in the Annals of Internal Medicine revealed that the median incubation period of COVID-19 –meaning the period from infection to onset of symptoms– is approximately 5.1 days. Among those who develop symptoms, 97.5% will do so within 11.5 days of infection. This means that a monitoring period of 14 days is sufficient, though their estimates still suggest that 101 out of every 10000 cases will still develop symptoms after 14 days of quarantine. Finally, the researchers still maintained that longer monitoring periods might be justified in extreme cases (Lauer et al., 2020).

So for now, if you’ve had exposure to a confirmed case, you are considered a Person Under Monitoring. Even if you are asymptomatic, you need to self-quarantine for 14 days to see if symptoms develop.

How effective is quarantine?

I already mentioned the movement to #FlattenTheCurve early on. But there’s actually a pretty big question regarding the effectivity of isolation and quarantine in the case of COVID-19. Namely… is it effective?

According to an article published in The Lancet, viral characteristics between Severe Acute Respiratory Syndrome (SARS) and coronavirus disease 2019 (COVID-19) influence the effectivity of traditional public health measures in containment versus mitigation. Why did containment work in SARS, and why won’t it work today?

Syndromic surveillance and isolation were effective for SARS back in 2003 because “peak viral shedding” generally occurred after patients presented with respiratory illness. Like the term suggests, viral shedding simply refers to the expulsion or release of virus after they’ve reproduced inside the host. In contrast, COVID-19 transmission during the early asymptomatic phase seems to be significant (Wilder-Smith, 2020). Other small studies suggest it may even be more contagious before symptom onset.

This means that quarantine is only truly effective if it is initiated at the right time. A better recommendation is to observe social distancing and proper hygiene, even if you are pre-symptomatic.

Helpful links

That’s it for this week. Stay healthy!

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