The two or three months after the lockdown lifts will be crucial according to Dr. Benjamin Co. Photo by Mark Demayo, ABS-CBN News
Culture Spotlight

Life after lockdown: An infectious diseases expert on how we could avoid a surge in COVID-19 cases

Eased restrictions, more testing, accurate and unified information, and other essentials that would help the nation transition from the ECQ. BY BENJAMIN CO, MD
| Apr 13 2020

When it comes to COVID-19 and its possible scenarios, it is worth listening to what Dr. Benjamin Co has to say. Co specializes in infectious diseases and clinical pharmacology (he holds clinics at UST Hospital, Asian Hospital and Medical Center, and Cardinal Santos Medical Center). An educator, speaker, scientist, administrator, mathematician, and part-time blogger, he recently wrote about the factors that should already be in place for the lockdown to end. It was a point-by-point dissection of what we, gorvernment included, must do to help the nation move past the enforced community quarantine.

In his most recent post, however, the good doctor explains the numbers we should be seeing before the government should lift the imposed lockdown. And, more importantly, he describes the structures by which the new normal should be like in the crucial months after the lockdown.

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We all know that the only reason people in government are considering re-extending the duration of the lockdown is “numbers.”

Larger number of cases, longer recovery time for the 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. 

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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. 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

Figure 1 above shows the data as of yesterday (Ed: The post is dated April 10). Note also that this website started with information on March 27 at 803 cases, 54 deaths and 31 recoveries. In short, by March 30 (three days later) we stood at 1,546 cases, 78 deaths, and 42 recoveries. This is a doubling rate of three days. This means that on April 2, we should see twice the number of cases we saw on March 30. Did we? Well, almost.

On April 2, we had a total of 2,633 cases, 107 total deaths, and 51 total recoveries. This 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 5,200 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 3,246; 3,660 on April 6; 3,764 on April 7; 3,870 on April 8; and 4,076 on April 9. Note that the doubling time also became longer, from seven days to 10.76 days.  

Doubling time is the number of days it will take confirmed cases to double and is based on the seven-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)

Table 2

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 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 can not tell media how to report. Every media outlet will have its way of trying to grab the attention of the viewer. As the late 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.

Figure 3

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 3,749 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

Figure 4 above shows the data from China which had exited from their lockdown on 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 percent recovery rate), with 1,116 active cases remaining (no outcome yet, and 144 of them being in critical condition), and 3,336 deaths (4.07 percent 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 Hong Kong the lessons of the aftermath of a lockdown when it was lifted

Figure 5

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 Hong Kong, 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. Obligate and hold responsible agencies that are part of the problem instead of being the solution.

Schools in the Philippines are 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 a 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 non-COVID 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 non-COVID patients.

There should be limitation of travel in and out of the various regions for the next two to three 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 a while. Regional travel can be reassessed after two to three 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 can not 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 the 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.