More than half of today's new COVID-19 cases come from Cebu City. Photo from Mayor Edgardo Labella's Facebook account
Culture Spotlight

Cebu City leads a spike of new COVID-19 cases—could it be the next epicenter?

The bulk of new coronavirus cases today comes from the southern capital. Meanwhile, our recovery rate still goes up. BY BENJAMIN CO MD
ANCX | Apr 23 2020

Infectious diseases and clinical pharmacology expert Dr. Benjamin Co has been thankfully breaking down coronavirus numbers in his personal blog since the outbreak started. The perspective he provides is informative, and comforting to those who are craving for a clear picture of how we are faring against the virus. Dr. Co will share daily updates and analysis of the Department of Health reported numbers with ANCX. 

Additional notes from Dr. Co today: “Not much change except for the spike in cases because of Cebu City reporting 136 additional cases overnight, the highest for one city alone. Accounting for 50 percent of the total new cases in the country. Recovery rates and fatality rates remain the same. Doubling time is still around 23 days. Growth rate is stable around 3 percent. Region I has higher CFRs at 21 percent (compared to NCR at 7 percent). Region XI is second at 15 percent and Region VI in third at 14 percent. Among cities with >50 cases, the highest CFR is Davao City at 18 percent, followed by Pasig at 14 percent and Caloocan in third at 10 percent.”

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Refer to the link DOH.gov.ph  or up-to-date data or to COVID19.gov.ph. (The latter is not a secure site.) The new site for the Department of Health is user friendly, provides more information but is still direly lacking in what the relevant information should be. I advise the readers to look through their official site. 

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COVID19stats.ph is a new site which gives you a very good summary of the Philippines data. (summary of those that are unable to access this site is seen below)

Overall situation. Of the total cases, 1,139 are considered resolved.

The figure below shows the daily new cases (blue), new deaths (red) and new recoveries (green) since the start of the first case reported in the country. Notice the increase in new cases after the initial Metro Manila quarantine followed a day later by the Luzon-wide ECQ (enhanced community quarantine). When mass testing had begun in some sectors, the number of new cases started to decline. The green line shows the slow and gradual increase in daily recoveries.

Note that the recoveries in green have been higher than the deaths in red for the past 10 days.

One important data is the doubling time. The doubling time tells us how many days it takes for confirmed cases to double, based on the 7-day average daily growth rate. Hence, the shorter the doubling time, the steeper the slope, the more the number of cases within that span of time. The doubling time in the US for example is around two to three days. Which means that if the doubling time does not lengthen in the US, they would see an increase of 100,000 cases every 3 days. The doubling time in the Philippines started around 4, but now averages more than 14 days. In spite of the increase in new confirmed cases, the latest doubling time remains ~23 days. In addition, the growth rate in confirmed cases was at 5.25 percent last week . Yesterday it was 3.01 percent. Today it is at 3.04 percent a slight bump up of 0.03 percent due to a spike in cases.

A case is considered closed when patients either recover or die.

The table above shows the number of closed cases in the South East Asian region. The Philippines has 1,184 closed cases. This means that of the 6,981 cases to date, 1,184 have had outcomes—with 61 percent recoveries (722 cases) and 39 percent (462) resulting in death.

On the Department of Health website, there are 2,622 patients that are still for “validation”. These 2,622 patients are confirmed positive cases with many who may have already had outcomes (most likely recovered) but remain undocumented. If they are positive, asymptomatic, and home quarantined, what is the current status of these cases that are for “validation” and how are the various local government city health offices assisting the Department of Health in having these patients retested and reported?

There were 19 new admissions to various hospitals as a possible, suspect or confirmed case of COVID-19 in the past 24 hours.

 

Are we testing enough?

Figure 4 below shows the overall summary of SARS-CoV-2 testing in the country as of April 18, 2020. On the average, more than 86 percent of patients tested (with symptoms or asymptomatic or those who came in contact with positive patients) would test negative.

There were 271 new confirmed cases with almost 4,000 tests conducted in 3,532 individuals.

SARS-CoV-2 Testing in the Philippines

Number of tests conducted and number of individuals tested

The figure above that shows the tests conducted, number of people tested. For now, at least 13 percent of patients tested turned out positive while the remaining 87 percent were negative.

Testing is a vital instrument in identifying patients who are both asymptomatic and those who have the disease. While testing is not perfect, when done correctly and timely, it helps in identifying patients that are positive, asymptomatic and have the potential for infecting other people. By knowing this subgroup of population, early intervention by segregation from the community or family breaks the transmission of the virus. Breaking the transmissibility of an infection is vital in containing an outbreak, especially for one as invisible and invincible as SARSCoV2 where there is currently no recommended treatment or vaccine available.

In short, testing is our window into how this pandemic is spreading in the country. It is a tool that provides information on how we’re doing in our fight versus COVID19 and whether our efforts are reducing the spread and impact of the virus are working. It helps allocate medical resources and staff more efficiently because we are able to isolate those infected, trace and quarantine all contacts. It helps allocate scarce medical resources and staff more efficiently. The generation of accurate epidemiological data is important in making critical decisions for exit plans after a lockdown.

As a strategic measure in the lifting of a lockdown, testing allows us to properly assess interventions that should be implemented including the most costly ones called social distancing and the paralysis of various business, industries and regions. The economic cost of testing is nothing compared to economic losses of not understanding the pandemic and the risk it poses.

Data on testing is needed. Without data on COVID-19, we cannot understand how the pandemic is progressing. We cannot respond to the threat—individually or as a society. We cannot know if our countermeasures are working. Finally, the reliability of data on testing is necessary to assess the reliability of data that informs us about the spread of the pandemic: the data on confirmed cases and deaths.

While it is understandable that even on a global scale, reports of deaths and recoveries may be delayed when reporting to authorities, it is important that the turnaround time not be too delayed. An acceptable delay of three to four days is acceptable in order for government to understand whether the measures implemented at addressing the pandemic is working or not.

Currently it takes an average of 8 days before a recovery is announced publicly while it takes 5.59 days before a death is announced publicly.

With 17 accredited testing centers now available, the capacity of the Department of Health to double the tests per day (from the current 4,000 tests) should be achievable. Hopefully, the turnaround time is also shortened and that all patients who test positive but are on home quarantine should be tested as well. Otherwise, we defeat the purpose in testing for recoveries as well.

The delayed reporting (backlogs from testing centers) and missing follow-up recoveries may account for underreporting of outcomes and may not provide a more accurate picture of how COVID-19 is evolving in the country. There needs to be better coordination between local government units with the Department of Health, as consistency and accuracy of data being reported are vital in any decision making to an exit plan from an enhanced community quarantine.

 

By demographics (as of April 22, 2020)

Majority of the cases are more than 25 years old. The pediatric age group (<18 years old) makes up only 2.5 percent of the total cases while the senior citizens make up almost 37.2 percent of the total. Recovery rates are better in those less than 54 years old with a mortality rate of more than 48 percent for the senior citizens.

 

By location (as of April 22, 2020): Most vs Least COVID cases

Deciding which communities to extend, enhance or ease the ECQs will depend on data in each region. The total number of cases is not enough to say that most of the confirmed cases are found in that region. We need to remember that the density of the region and individual cities and municipalities are important parameters.

The table below shows the cases by region. One glance and you can tell that the majority of cases (4,265) are in the NCR where there are 331 cases/million population. While confirmed cases provide information, it is important to remember that not all confirmed cases are serious in clinical status. It is important to look at the case fatality rate (CFR). Deaths are the most important data. The actual death toll is likely to be higher than the number of confirmed deaths and is due to limited testing and problems in attribution of the cause of death. Deaths also provide a window as to how effective are the measures being implemented in various localities. Among the regions with the most confirmed cases of COVID-10, region I has the highest CFR at 21 percent (11 deaths in 52 cases), followed by region XI at 15 percent (17 deaths in 115 confirmed cases). The NCR has a CFR of 7 percent (298 deaths in 4265 cases).

Top 10 regions with confirmed COVID-19 cases in the Philippines

While Quezon City has the most number of cases by city (1072 confirmed cases), its CDR is only 8 percent. The table below shows that the highest CFR is in Pasig with 36 deaths in 253 confirmed cases.

 

Top 10 cities with COVID-19 cases in the Philippines

One city outside of the National Capital Region is in the top ten of confirmed cases of COVID-19. Cebu, which was in number 10 with 169 confirmed cases is now suddenly in number 6 with 5 deaths in 312 confirmed cases. Cebu City had the most number of cases with 136 new confirmed cases (or almost half of the 271 new cases in the Philippines overnight alone). Davao City is in number 16 with 17 deaths of 97 cases, or a CFR of 18 percent, the highest among all the urban cities in the country.

The Department of Health hotline is (02)8-6517800 loc 1149-1150. People who present with fever and/or respiratory symptoms are encouraged to get in touch with the DoH.

 

Global statistics

Update as of 7pm 23 April 2020 (Thursday)

TOTAL CONFIRMED CASES: 2,646,462

TOTAL DEATHS: 184,353 (case fatality rate: 7 percent)

TOTAL RECOVERED: 723,734 (case recovery rate: 27.3 percent)

 

Total cases worldwide

The total cases has exceeded the 2.6 million mark. The average trend in the past week has averaged ~75000 confirmed cases daily. It seems to be plateauing at this number with the United States contributing to almost 850,000 cases and the rest of Europe with more than 1.17 million cases. The United Kingdom now has 133,495 confirmed cases. The United States, Europe and the UK contribute to around 2 million of the cases in the world.

The next two graphs will show the cumulative number of cases (by number of days since 10,000 cases were reached) and the cumulative number of cases (by number of days since 100 deaths were reached) from the top seven countries that contribute to the pool of cases in the world. The United States of America contributes to almost one-third of the total cases in the world.

The United States has the steepest climb averaging 30,000 cases daily the past week as they approach the 850,000 total cases. China and Iran have plateaued. The other countries in the top seven are still seeing slight increase in cases at a significantly lower rate compared to the past two weeks. [The X-axis is the number days since the first 10,000th patient (Y-axis) was recorded.]

The number of deaths due to COVID-19 in the United States now far exceeds that of Italy, as they close in the 50,000 mark. Deaths continue to increase but in lower numbers for France, Italy, and Spain. Germany, Iran and China on the other hand are seeing a plateau in the death rates. [X-axis is the number of days and y the number of deaths since the first 100th death was recorded.]

The United States of America leads globally in the number of total cases at 842,624 with a case fatality rate (CFR) of 5.62 percent with almost 47,000 total deaths recorded. The recovery rate for the US is at 9.9 percent (much lower than the recovery rate in the Philippines). Among the states, New York leads with 262,268 cases with 20,354 deaths with a CFR of 7.76 percent.

While the United States may have the highest number of cases and number of deaths in the world at 46,785, Belgium has the highest case fatality rate at 14.95 percent (6262 deaths in 41,889 cases). 8 countries have > 50 cases but no fatalities reported from COVID-19. They are: Vietnam, Cambodia, Maldives, Uganda, Sierra Leone, Rwanda, Madagascar, and Guinea-Bissau.

Germany has the highest number of recoveries with 103,300 of 150,648 (68.47 percent) confirmed cases . China has the highest recovery rates at 93.25 percent, while the following countries have the lowest recovery rates: Netherlands (0.29 percent, 101 recovered from 35,034 cases), Norway (0.436 percent, 32 recovered from 7,338 cases), and the United Kingdom (0.51 percent, 691 recovered from 134,639 cases).

 

Top Twenty Countries in the World with COVID-19 Cases

Total cases, recoveries, and deaths of top 20 countries with COVID-19.

The median average of case fatality rates is now at 7 percent and is predicted to climb to ~7.2 percent before the end of the month.