MANILA, Philippines – Some commentators, both in the public and private sector, have referred to the Omicron surge as the beginning of the end of the pandemic. They have called for a transition to a state of living with COVID-19.
However, Omicron is not the end of viral evolution and there is no guarantee that the next variant will not be even more transmissible than Omicron while simultaneously being more virulent than Delta. In fact, there is emerging evidence that the BA2 subvariant of Omicron, which is now the dominant strain in the Philippines, may be more transmissible and pathogenic than the BA1 variant.
Rather than merely wishing that the transition to the endemic state will be brought about by succeeding Omicron-like variants, we should undertake the difficult and unfinished public health actions that will make endemicity more likely.
The first thing that needs to be done is to set goals for ending the pandemic. Instead of using both cases and hospitalizations as bases for modifying the stringency of restrictions, the government should just use hospitalizations as a goal for this purpose.
Why? Because of the dominance of the Omicron variant, more cases will be asymptomatic, mild, or tested at home. That will make official case counts highly inaccurate and unreliable. In addition, most Omicron cases can be managed at home uneventfully or treated with oral antivirals outside of the hospital.
Hospitalizations are more accurately counted and measure only serious outcomes. This prevents premature lockdowns that will also impact the treatment of non-COVID-19 diseases. Recently, the Philippine Statistics Authority reported about 450,000 excess deaths in 2021 compared to the same period in the five years before the pandemic. Most of these deaths could be attributed to patients being afraid of getting care, losing access to outpatient care that could have prevented deaths, and hospitals turning non-COVID-19 patients away during surges because of inadequate resources.
Strategy 1: Get vaccinated, mask up
After agreeing on goals, the most vital strategies to prevent severe disease and death are vaccination and masking.
For COVID-19, we have multiple vaccines that are highly effective in preventing severe disease and death. However, the Philippines has been slow to procure, distribute, and administer the vaccines, as described in two Rappler articles.
The graph below shows the vaccination rates of the Philippines and of European countries which have decided to lift COVID-19 restrictions. Countries which have chosen to live with the virus have done the public health work of vaccinating rapidly and at a high level of population coverage. After a year of vaccinations, the Philippines has only vaccinated a little more than half of the population.
By December 2021, the Philippines had procured sufficient vaccines to cover 100% of its population. However, vaccines do not end pandemics, vaccinations do. We need to create an immunity wall that is both high (that is, highly effective against severe disease) and and broad (that is, inclusive population coverage).
The graphs below show two views of the immunity wall that we currently have. The red areas represent sub-populations who remain vulnerable to the virus. Whether by geography or by age groups, almost half of our immunity wall is still breachable by the virus.
If we could only do one thing, the most effective way to end the pandemic would be to vaccinate the elderly. About 2.6 million elderly Filipinos are still unprotected from the virus. A little more than 70% of COVID-19 deaths are 60 year or older. So, by vaccinating this age group, about 60% of COVID-19 deaths could be prevented – vaccines are 91% effective in preventing death.
In a study of vaccine confidence among the elderly, the major barriers for seniors in getting vaccinated are: ease of the process of vaccination and concerns about vaccine safety. Problems with the former include long waiting times, physical limitations, and difficulty in getting appointments. These are issues that will need more creative and imaginative solutions from the agencies of government that are responsible for the vaccination program.
A second preventive measure is to provide reusable, high-quality masks to all citizens. Because of the higher transmissibility of the Omicron variant, cloth masks are no longer sufficient to protect people from exposure and infection. Only high filtration efficiency masks can do that. These are the K95, KN95, and KF94 masks. Of these, the KF94 has washable and reusable versions and are the most cost-effective for most people to purchase. They can be used for a month before they need to be replaced. Over the long-term, the country needs to develop manufacturing capacity for high filtration efficiency face masks.
Finally, once vaccination has reached a high enough level, the government needs to clearly communicate to the public what the remaining risks are and how they can protect themselves. The public will need to know how to keep home, work, and school settings safe, how to improve indoor ventilation, and when to wear masks. These messages need to be delivered in a transparent manner in order to create trust by the public. Government needs to tell people what they know, what they don’t know, what it is doing about it, and what people can do.
For example, when we get to 90% vaccination rate, will masks still be needed? Where do they need to be worn and who needs to wear them? In most outdoor settings where distancing can be observed, masks are probably not needed. In indoor settings with poor ventilation or crowds, masking will probably still be needed even with high vaccination rates, especially if eldery or other high-risk people are present – for example, in malls and restaurants. One rule of thumb is: if the setting is one where cigarette smoke would bother you, you would probably need a mask.
Strategy 2: Prevent disability and death, rehabilitate patients
The second strategy is to prevent the progression of symptomatic disease into disability and death, and also to rehabilitate patients back to health. Seniors and persons with comorbidities are the ones most likely to be hospitalized; 70% of COVID-19 patients who died were elderly. New oral antivirals are now available that can prevent hospitalization when given within the first 3-5 days of symptoms. That means these patients should have access to self-administered antigen tests so that they can be tested as soon as possible.
In addition, patients who test positive for COVID-19 need to be linked to treatment with as little delay as possible. These tests and medicines need to be available at the barangay level. This will require full approval from the Food and Drug Administration so that the medicines can be made available in more accessible locations and not just in Department of Health hospitals.
Finally, about 5% of COVID-19 patients develop a condition called “long covid,” which is characterized by brain fog, fatigue, muscle pain, and other symptoms. With 3.6 million Filipinos infected, about 180,000 people could be suffering from this condition. They will need long-term rehabilitation requiring multiple specialists. PhilHealth needs to create a long COVID rehabilitation benefit package to support their continuous care.
We can’t rely on the virus evolving into a milder form to exit the pandemic. Instead, we have to accelerate the building of an immunity wall against the virus and to do so in an equitable manner. In order to do this, we have to address structural barriers to equitable distribution and administration of vaccinations, make sure high-quality face masks, antigen tests, and antivirals are accessible everywhere, and finally address the long-term consequences of covid in some patients. – Rappler.com
John Q. Wong, MD, MSc, is an associate professor at the Ateneo School of Medicine and Public Health and an epidemiologist with over 30 years of experience in community health, biostatistics, health financing, and Philippine health system management. He is also co-founder and senior technical adviser of EpiMetrics.
EpiMetrics Inc. is a public health research institution focused on the achievement of health equity through rigorous and creative conception, execution, translation, and communication of health systems and policy research.