The road to COVID-19 endemicity
A little over two years after COVID-19 shut down our world, the Philippines is back in business. From having one of the biggest outbreaks in Southeast Asia, the Philippines’ daily case numbers have significantly lowered. Notwithstanding mammoth crowds at rallies and national and local elections with the biggest turnout in our history, no major spikes occurred. These low numbers have been sustained despite our mobility restrictions having been drastically relaxed. As the two-week incubation period from Election Day passed without a sharp rise in cases, we all heaved a huge sigh of relief. Endemicity for COVID-19 seems to be tantalizingly close.
What is endemicity? Endemicity for a disease does not necessarily mean elimination, or no deaths from the virus. Endemicity refers to a state where the impact of a disease is predictable and manageable. For COVID-19, this means that future outbreaks are no longer expected to severely impact healthcare systems to the point where we have to shut down our communities. It also means that sufficient prevention and treatment measures are in place to mitigate the impact of the virus.
With widespread vaccinations, effective medication, and public health standards in place, the continued low numbers of cases despite fewer restrictions show we will be achieving endemicity very soon. The World Health Organization (WHO) will determine whether to end the declaration of a public health emergency of international concern after taking into account the overall global situation. Barring the emergence of a truly terrible new variant, this will likely occur before the end of the year.
After all that we have been through and considering where we are now, the last two years seem surreal. As one of three infectious diseases doctors on the Technical Advisory Group (TAG) to the Department of Health (DOH) and the Inter-Agency Task Force on Emerging Infectious Diseases (IATF), I was intimately involved in the crafting of health-related policies throughout the pandemic. These policies included the initial lockdown, quarantine and isolation strategies, and vaccination strategies, all the way to the eventual exit plan. The TAG also sat on multiple committees, technical working groups, and ad hoc bodies. We were frequently invited to Malacañang to directly brief the President, especially when new variants threatened our country. We attended over 500 meetings throughout the pandemic. Our fingerprints are all over the major pandemic policies and IATF resolutions. We sat in every single IATF meeting since March 12, 2020, and we scrutinized every single agenda item in these meetings. While final decisions were ultimately up to the IATF principals and the President, the TAG, along with a large team of experts, vetted the science behind each policy document. Over 90% of our recommendations were followed, and the President frequently adopted our suggestions.
A careful review of genomic data and an objective comparison of cumulative case numbers suggest that the Philippines did flatten the curve in the first year of the pandemic. The detection of the three imported Chinese cases at the end of Jan. 2020 (lineage A and B, see graph) was managed well and decisively contained. Community transmission did not occur from these initial lineages. When a new lineage entered in March 2020 (B.6) from Southeast Asia and caused the first cases of community transmission, an early lockdown prevented over 200,000 deaths. It slowed down exponential spread and gave the healthcare system time to consolidate its resources.
Reopening in June 2020 resulted in a modest spike in cases (under 1,000 cases at its peak), which coincided with the entry of the B.1 and B.1.1 lineages from Europe. Unlike many other countries, the Philippines continued to repatriate overseas Filipino workers throughout the pandemic on humanitarian grounds. Many Filipinos had no place to go and it would have been inhumane to deny them entry into the Philippines for two years. Unfortunately, this did allow some new variants into the country, but this was a calculated risk. Quarantine and testing protocols were formulated to mitigate this risk, and the government decided to shoulder all costs for returning OFWs.
With no vaccines available yet in 2020, the Philippines adopted a combination of public health measures. These included mask mandates supplemented with the politically contentious use of face shields. Calculations by local scientists and epidemiologists showed that the combination of physical distance, masking, and face shield/eye protection decreased the risk of transmission by over 90%; this mandate was recommended by infectious diseases experts and various other medical societies.
While many sectors pushed for unscientific indiscriminate mass testing, the government continued to increase RT-PCR testing capacity and expand healthcare facilities to deal with potential outbreaks. Some sectors insisted on using antibody tests despite warnings from experts that these were not useful. Antibody testing was eventually shown to be useless for detection of acute COVID-19 disease. This vindicated the government’s insistence on scientifically sound testing methodologies. Pushing science-guided PDITR (prevention, detection, isolation, treatment, and integration) strategies resulted in low numbers of cases throughout the Christmas season in 2020, despite increased mobility.
Whatever happens next, the worst of the pandemic is behind us.
The first variants of concern (VOC) emerged in the United Kingdom (Alpha) and South Africa (Beta) in Dec. 2020. The TAG was called to Malacañang to reinforce quarantine policies and a task force on COVID-19 variants was formed. As a result of the task force’s recommendations to the President, community transmission of Alpha and Beta was delayed by two months despite the earlier detection of these VOCs among travelers.
In Feb. 2021, the Alpha and Beta waves finally took off. With vaccines in scant supply and only beginning to be rolled out among healthcare workers, there was very little immunity to the virus. With the onslaught of the more transmissible VOCs, the daily case numbers approached 10,000 for the first time. Hospital capacity was strained, and daily deaths breached more than 100.
As cases began leveling off in April 2021, the first instances of Delta infection were detected in returning seafarers. I took care of the first four cases, and I was alarmed at how much more virulent Delta was. But widespread community transmission of Delta did not occur until Aug. 2021 as a result of stringent travel restrictions and quarantine protocols. A preemptive lockdown and enhanced vaccination program in the National Capital Region prevented an estimated 150,000 cases of Delta infection. This paved the way for low cases throughout the 2021 Christmas season and facilitated the further reopening of the economy.
The best way out of this pandemic is still a gradual and careful approach, with a healthy appreciation for what this virus has already cost us.
The Omicron wave in Jan. 2022 was the largest yet, with nearly 40,000 new cases a day reported at its peak. Still, despite the much larger number of confirmed COVID-19 cases, hospitalizations and deaths from Omicron were less than those seen during the Delta wave. This was a direct result of the country’s vaccination program. Three things may have further helped the Philippines weather the Omicron storm: early boosting at three months, heterologous vaccinations, and continued strict mask mandates. We were one of the first countries to implement early boosting. Heterologous vaccinations (the mixing of different brands) due to shortages of supplies of Western vaccines turned out to be a blessing in disguise, as these regimens seem to work better against VOCs. Compliance with mask mandates remains high since Filipinos do not seem to mind wearing masks for everyone’s protection.
Following the Omicron wave, cases have stayed low. Even with the entry of new Omicron sublineages, cases have not spiked and most new cases are mild or asymptomatic. We have arrived at a much better place by listening and sticking to the science. Compared to more advanced countries with vast resources, we have kept deaths and cases per capita low. Our economy is growing at a robust clip, we are open, and endemicity is just around the corner. With the government, the private sector, and our people all working together, the Philippine pandemic response has been quite successful.
Whatever happens next, the worst of the pandemic is behind us. Despite decreased efficacy against infection with the new Omicron variants BA.4 and BA.5 which have entered the Philippines, the current vaccines continue to significantly decrease the risk of severe and critical disease. This is a very different and much less deadly virus compared to two years ago, thanks to vaccines and effective treatments. The need for lockdowns and community quarantines has long since passed. The biggest question is when we should remove masks and the rest of the remaining restrictions. While COVID-19 is now more predictable, preventable, and treatable, this does not mean it can no longer hurt us.
Our knowledge of the extent and burden of long COVID-19 in the Philippines remains incomplete. We know that even mild COVID-19 in vaccinated and boosted elderly people can still increase the risk of heart attacks and strokes. Thus, it is prudent to proceed with caution in relaxing our remaining restrictions. New treatments and updated vaccines are on the way to further improve our armamentarium against COVID-19. The best way out of this pandemic is still a gradual and careful approach, with a healthy appreciation for what this virus has already cost us.
