IN CHARTS: How is PH doing after 6 months of lockdown?

AT A GLANCE

• Metro Manila is still the country’s pandemic “epicenter,” with more than half of all confirmed cases in the region alone.
• COVID-19 has hit working-age people more, but mortality rates are still concentrated in older age groups.
• The country’s death rate remains low, while recoveries are high. The positivity rate, however, still hovers above the World Health Organization benchmark.
• Hospitals got a breather after temporary reversions to stricter quarantines in some hot spots, but critical care levels are still far from reassuring.
• Issues on COVID-19 case data persist.

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It’s been over 6 months since Metro Manila went on lockdown on March 15 due to the coronavirus. Two days later, the rest of Luzon was placed under quarantine. Since then, Filipinos have been introduced to multiple acronyms – from ECQ to MGCQ – as the country experienced different levels of community quarantines mirroring varying degrees of restrictions.

On the day the Metro Manila lockdown began, there were only 140 confirmed COVID-19 cases nationwide. Six months later, as of September 20, total cases have breached 286,000, the biggest caseload among Southeast Asian nations. 

Of the total count, 51,894 (or nearly 1 in 5 cases) are active, of which around 95% are either mild or asymptomatic cases, while the remaining 5% have critical or severe symptoms.

As the Philippines continues to battle the pandemic, and as the government strives to keep it under control, here are 6 takeaways from the COVID-19 cases dataset of the Department of Health (DOH) 6 months after the first lockdown order was imposed.

1. Metro Manila is still PH pandemic ‘epicenter’

The National Capital Region (NCR) still leads in COVID-19 cases, with 153,144 confirmed cases as of September 20, or more than half (53%) of all cases nationwide. Of the number, 23,524 (or 15%) are active cases.

NCR has consistently been the country’s pandemic epicenter. On August 21, over 5 months after it was locked down, Metro Manila breached the 100,000-mark for total cases, and accounted for more than half of newly-reported cases that day.

“Metro Manila has a lot of ‘perfect storm’ situations for pandemics to spread,” said Peter Julian Cayton, associate professor at the University of the Philippines (UP) School of Statistics and a member of the UP COVID-19 Pandemic Response Team, in a video call with Rappler. Factors like the metropolis’ high population density and a complex transportation system contribute to the fast spread of the virus, he said.

On September 6, UP professor Guido David of the Octa Research Group reported that NCR’s COVID-19 curve has flattened because its reproduction number – or the number of people one confirmed case can infect – stood at less than 1. However, David warned the public and the government against complacency in observing health protocols, because the reproduction number is “not irreversible” or could still go up again.

Meanwhile, in June, a surge of infections in Cebu made Central Visayas the “second major battleground” of the virus, according to experts. From June throughout July, Cebu City’s total caseload also exceeded Quezon City’s, which had the highest number of cases in Metro Manila. 

“It came to a point where there were a lot of cases in Cebu, but they responded with a proactive approach. MECQ (modified enhanced community quarantine) for 4 weeks really gave a breather to the province’s health sector and government, which they used appropriately,” Cayton explained in a mix of English and Filipino. Contact tracing efforts and stricter community restrictions helped slow down the spread of infections in the region.

The chart below shows the progress of confirmed cases per day in each region.

Ranking after NCR is nearby Calabarzon, with 48,207 total cases – of which 11,485 are active – as of September 20. It overtook Central Visayas on August 10.

Central Visayas placed third so far in terms of total cases, but looking at active cases, Central Luzon ranked third.

According to Cayton, the spikes in cases outside Metro Manila may be linked to the government’s mass exodus programs, which he said weren’t implemented consistently. “Even provinces are saying that most of their index cases are from locally stranded individuals (LSIs), repatriates, or these other kinds of situations,” explained Cayton, citing some of the country’s efforts to bring Filipinos back to their home provinces. “Biglang kumalat (It suddenly spread) in a way that is counterintuitive to the natural features of our country being an archipelago,” Cayton continued.

The only province that remains COVID-free is Batanes. Cayton attributed this to its geographic edge as an island group far from the Luzon mainland.

2. COVID-19 hits working-age group more

As of September 20, the most affected age group in the Philippines is the 20-39 bracket, followed by the 40-59 age group.

The animated chart below shows that the 20-39 age bracket took the lead from both the 40-59 and 60-79 age brackets on April 19. By August 2, 20-39-year-olds had more confirmed cases than all other age brackets combined. 

This echoes the August 25 situation report of the World Health Organization (WHO) for the Philippines, which said that around half of all COVID-19 cases came from patients aged 20 to 39 years. Just 4 months ago, in WHO’s situation report on April 6, 60-to-69 year-olds were the most affected.

Cayton said the shift may be due to the country’s approach to testing. “At the start, we only tested those who were symptomatic, who were, more often, older individuals because they tend to be more immunocompromised or have other comorbidities.”

“As we opened our economy, with increased testing capacity and expanded testing, it became more apparent that it’s going to be the younger working-age people with higher numbers of cases, because they’re the ones who are now having a lot more interaction [with other people] relative to the other age groups,” he continued in a mix of English and Filipino.

Cayton also attributed the low number of cases among non-working young people and elderly people to restrictions on their movement based on government-issued guidelines.

He noted, though, that mortality rates are higher among older age groups. This mirrors WHO’s August 25 report which said that COVID-19 deaths are still concentrated in the 60-79 bracket, who are most at risk because of underlying health conditions.

3. Death rate remains low, recoveries are high

The country’s case fatality rate, or the share of deaths versus total cases, has logged below 10% starting in March, when the country reached 10 confirmed cases. Since July 5, it has remained under 3%, and has gone down to 1.74% as of September 20. This is lower than the global death rate of around 3%, according to WHO’s COVID-19 dashboard.

Compared to ASEAN, the Philippines’ case fatality rate ranks 4th behind Indonesia, Vietnam, and Brunei so far. In terms of deaths per capita, the country ranks first in ASEAN, with 45 deaths per 1 million people, but is in the middle of the pack worldwide out of 168 countries, based on Johns Hopkins University’s Mortality Analyses tracker as of September 20.

Meanwhile, around 4 in 5 COVID-19 cases in the Philippines, or 80.16%, have recovered as of September 20. This is the 3rd lowest case recovery rate so far among ASEAN countries, after Myanmar and Indonesia.

The country’s case recovery rate has fluctuated since late July, due to the DOH’s time-based recovery scheme. Implemented weekly since August, this scheme allows mild and asymptomatic patients to be tagged as “recovered,” in line with WHO’s discharging criteria, as endorsed by Philippine medical societies. 

Its implementation has been met with some skepticism, as many cases previously tagged as “recovered” would later be tagged as a death or an active case after validation. Plus, due to DOH’s scheme, the “jagged” or zig-zag look of charts for recoveries and case recovery rate – and as a consequence, the chart for active cases – may be “unique” to the Philippines, said Cayton.

Cayton stressed that the DOH’s scheme is valid, but its methodology could be improved towards a more regular, ground-based approach, “instead of waiting for a call from DOH just to update” the recovery counts.

At the regional level, Central Visayas, Zamboanga Peninsula, and the Bangsamoro Region have the highest death rates. Meanwhile, Metro Manila and Calabarzon have relatively low death rates, despite having the highest number of cases and deaths. 

As for recovery rates, regions with the country’s largest metropolitan areas – Metro Manila, Cebu City, and Davao City – are among the ones on top, with 83% for NCR, 88% for Central Visayas, and 81% for Davao Region, respectively, as of September 20. Eastern Visayas has the same recovery rate as Metro Manila so far.

Cayton explained that the level of access to healthcare facilities may help explain these regional observations.

“We have to admit that there is going to be a huge variation of access between different areas in the country in terms of the healthcare sector,” he continued. For instance, he explained, “More often than not, areas close to Metro Manila like Calabarzon would access [healthcare sector] resources in Metro Manila…which is still – relative to the whole country – better than those existing in other areas.”

As for Cebu, Cayton observed that it earlier “had a low case fatality rate, but they had so many active cases. It reached the point that death rates really went up. Then, there’s the series of strict quarantines in Cebu, until they’re able to lower [their cases]. That’s when their recovery rates improved.”

4. Positivity rate still hovers above WHO benchmark

The WHO recommended in May that communities could adjust public health and social measures like quarantines if they observe a 5% positivity rate – or the percentage of tests that come back positive – for at least 14 days.

In April, the country logged a positivity rate of as high as 17.5%. With community quarantines implemented and testing capacities gradually increased, the government managed to bring this down to its lowest so far, at 6.86%, in mid-June. 

But after several high-risk cities were placed under the more relaxed general community quarantine (GCQ), the positivity rate surged again, returning above 10% on August 9. It has since steadied, standing at 10.47% on September 19.

According to the Johns Hopkins School of Public Health, a high positivity rate suggests that either transmission is high, or that the number of total tests is too low. In either case, Johns Hopkins suggests that a high positivity rate may indicate the need to implement interventions like expanded testing or social restrictions such as quarantines to reduce transmission of the virus.

The Philippines, however, has gradually begun to reopen in recent months, with the country mostly under modified GCQ (MGCQ) – the most relaxed restrictions – while a few select virus hot spots (including Metro Manila) remain under GCQ. Some economic activities have also been allowed, but government guidelines that contain measures on physical distancing, maximum capacity or occupancy, and minimum health standards like the wearing of face masks and face shields are still enforced.

The WHO also noted that positivity rates “can be interpreted only with comprehensive surveillance and testing of suspect cases,” which it recommended to be at 1 out of every 1,000 people each week. With an estimated population of 109.9 million Filipinos, this would translate to about 109,900 individuals tested a week.

The Philippines has met this criteria so far, with 240,938 total tests from September 13 to 19, a bit down from 268,432 in the previous week, from September 6 to 12. The country has so far tested over 3.1 million individuals in total, reported the DOH.

The country had lagged in daily testing capacity in the first few months of the lockdown, catching up only on July 23, when testing laboratories breached their target of 30,000 tests. Since then, or from July 23 to September 19, an average of 33,856 tests have been conducted daily.

As of September 19, 129 licensed RT-PCR and GeneXpert laboratories nationwide are conducting COVID-19 tests, while 98 other labs are being prepared to handle tests. The government targets to test a total of 10 million Filipinos by 2021.

However, testing capacity is not distributed equally across the country so far. “We had one region in the country that had their first testing center only in August: Caraga Region. [Before this,] they had to process their tests in other areas, in other regions,” Cayton said, resulting in situations where “testing results from a specific area might not necessarily be from that area.”

5. Hospitals get a breather, but critical care levels far from reassuring

The usage of COVID-19 critical care beds in hospitals nationwide reached its first peak of 42% in early May, before dropping to its lowest levels from mid-May to mid-June, at around 35%. This coincided with the country’s low positivity rates, and the implementation of strict community quarantines.

After COVID-19 hot spots transitioned to GCQ on June 1, critical care beds began to fill up again. The occupancy rate peaked in late July, when several hospitals in Metro Manila and in other regions like Central Visayas, Calabarzon, Davao Region, and Central Luzon reported reaching critical to full levels.

Since August, after a two-week return to MECQ for Mega Manila, the occupancy rates have relaxed a bit, though still above the first peak recorded in May. Several hospitals across the country reported reaching critical levels well into August.

The DOH said in September that a bed occupancy rate of below 30% nationwide would help in “flattening” the COVID-19 curve.

“Quarantines do have an impact, such in the case of Cebu and Metro Manila, but the impact of quarantine in Cebu was greater, because they had a longer quarantine,” explained Cayton in a mix of English and Filipino. “There was a trend down and we do believe it is an effect of the stricter quarantine that was based in the National Capital Region and other areas.”

Relating active cases with bed occupancy rate per region, as seen in the chart below, Metro Manila stands out from the rest of the pack, with Calabarzon and Western Visayas at above 50% occupancy.

Mimaropa has the lowest rate so far, with 15%.

6. Issues on COVID-19 case data persist

Extracting these insights from DOH’s COVID-19 dataset is not without its share of problems. Data issues earlier pointed out by Rappler and by other data professionals still remain.

Looking at DOH’s data drop as of September 20, only 98% of cases are either tagged to locations or classified as repatriates. Then, while almost all reported deaths have actual dates of death, only 22.37% or nearly a quarter of reported recoveries, have actual dates of recovery.

On July 10, the DOH removed from its validated database the information that indicates when they recorded a death or recovery in their COVID-19 daily case bulletins. With already incomplete dates of recovery, this would have been the next best thing to use to analyze the recovery data, Cayton explained. 

Complete dates of recoveries enable researchers like Cayton’s team to reconcile recoveries historically and break them down by area. “Once they removed it, they removed the power of independent data professionals…to be able to track the recovery situation of the country,” he said.

In addition, the DOH, in its daily case bulletins, reported removing since June over 5,300 duplicate cases from its COVID-19 dataset. There have been many revisions, too, where cases initially reported as recoveries later turned out to be deaths or active cases upon further validation. 

In a statement on September 13, the DOH explained that they rely on reports sent from the ground. “There will sometimes be instances wherein our [regional offices], [local governments] and health facilities, upon further validation, correct their own initially-reported recoveries and re-tag them as deaths.”

Add to these issues the amount of testing backlogs – which DOH-licensed laboratories just recently cleared. As of September 19, there are 48,856 positive cases that have yet to be validated by the DOH. These could be seen in the charts below.

To fix these persistent data issues, Cayton reiterated their recommendations to the DOH in a policy note issued last May. “Again, they need to standardize and harmonize: DOH and the testing centers, DOH and the local governments, DOH and the regional offices.”

“There’s still a need for DOH to improve its data infrastructure in general,” he continued.

Given all these observations, Cayton said, “We still have more to work on, and it is best for us to continue with this trend. People, however small in what they do, are doing well in controlling the pandemic.”

He added, “We should be actively putting our government in check, so that they are actively doing the good things that are necessary for us to curb the pandemic.” – Michael Bueza, with research interns Rianna Cruz and Christine Okubo/Rappler.com