Coronavirus Research with UP OCTA Team

COVID-19 research with the University of the Philippines-OCTA Team

A wicked problem is defined as a social challenge that is difficult to approach for as many as four reasons: the prevalence of incomplete or contradictory knowledge, the number of people and opinions involved, the impact of a large economic burden, and the interconnected nature of this problem with other social problems. Understanding and managing a once-in-a-century global pandemic is a wicked problem.

Tackling wicked problems requires out-of-the-box, non-traditional thinking that involves interdisciplinary approaches among experts from a diverse scholarly background.

Last month, the UST-CoV2 scientists entered into a collaboration with our colleagues from the UP OCTA research group to create an inter-disciplinary team of experts from the natural, medical, and social sciences to better understand the current COVID-19 pandemic in the Philippines.

Our goal is to provide models and projections to help government and our people mitigate the morbidity and mortality associated with SARS-CoV2.

The most recent report of our collaborative effort is described here. Please note that the findings and recommendations are those of the authors and do not reflect the official position of the University of Santo Tomas, the University of the Philippines, Providence College, or any of their units.

-Rev. fr. Nicanor Austriaco, O.P., PhD, SThD

Forecast Report No. 12 (July 16, 2020)
COVID-19 FORECASTS IN THE PHILIPPINES: NCR, CEBU and COVID-19 HOTSPOTS as of July 10, 2020

  • Guido David, Ph.D., Professor, Institute of Mathematics, University of the Philippines and Fellow, OCTA Research (www.octaresearch.com)
  • Ranjit Singh Rye, MPA, Assistant Professor, Department of Political Science University of the Philippines and Fellow, OCTA Research (www.octaresearch.com)
  • Ma. Patricia Agbulos, MBM, Associate, OCTA Research (www.octaresearch.com)
  • Rev. Fr. Nicanor Austriaco, O.P., Ph.D., S.Th.D., MBA, Professor, Department of Biology, Providence College and Fellow, OCTA Research(www.octaresearch.com); Visiting Professor Designate, College of Science, Pontifical University of Santo Tomas

With contributions from

  • Erwin Alampay, Ph.D., Professor, National College of Public Administrations and Governance, University of the Philippines
  • Eero Rosini Brillantes CEO, Blueprint Campaign Consultancy (www.blueprint.ph)
  • Bernhard Egwolf, Dr. rer. nat.Associate Professor, Department of Mathematics and Physics, College of Science and Research Fellow, Research Center for Natural and Applied Sciences, Pontifical University of Santo Tomas
  • Rodrigo Angelo Ong, MD, Professorial Lecturer, Science Society Program, College of Science, University of the Philippines
  • Michael Tee, MD, MHPED, MBA, Professor, UP College of Medicine; Chair, Philippine One Health University Network
  • Benjamin Vallejo, Jr., Ph.D., Professor, Institute of Environmental Science and Meteorology & the Science Society Program, College of Science, University of the Philippines

BACKGROUND
On June 1, 2020, the National Capital Region (NCR) was placed under General Community Quarantine (GCQ) after being under Modified Enhanced Community Quarantine (MECQ) for two weeks. As of July 10, community quarantine has been in effect in National Capital Region for nearly four months. In this report, we examine, using data from the Department of Health (DOH), the state of the pandemic in the Philippines. We also would like to emphasize the following:

  1. The opinions and recommendations in this report are those of the authors and contributors, and do not reflect the position of the University of the Philippines, University of Santo Tomas, or Providence College.
  2. A mathematical model is just an approximation of reality. Models are based on assumptions and are only as good as the data used in its calculations. Despite its limitations, the model has a lot of value in measuring the rate of spread of the pandemic and in projecting the number of cases of Covid-19, so that hospitals and the government may be better prepared.
  3. The period of the study is from March 1 to July 10, 2020.

COVID-19 in the PHILIPPINES
As of July 11, there are a total of 54,222 Covid-19 cases in the Philippines. Recent figures suggest that the number of cases is still increasing, with 2,434 cases added on July 5, the highest number recorded in the country. Figure 1 shows the average number of new Covid-19 cases per day in the Philippines, for each week from May 8 to 14 (denoted May 11) to July 3 to 9 (denoted July 6). Three measures were used: incidence report, which refers to the date the specimen was collected from the patient, test report, which refers to the date when an individual was tested positive (based on the reports from test centers), and case report, which refers to the date the case was added to the database. All three measures indicated a pattern of increasing cases of Covid-19. As of May 22 to May 28, the average number of new cases (based on incidence and test reports) was less than 500 per day. This increased to more than 900 per day by June 19 to 25, more than 1,400 per day by June 26 to July 2, and based on test reports, more than 2,000 cases per day for July 3 to 9. The increases in late June and July are substantial, indicating an upward trend in Covid-19 cases in the Philippines.

Figure 1. Average number of new Covid-19 cases per day in the Philippines, from the week of May 8 to 14 to July 3 to 9, based on the date of specimen collection (incidence report), positive test result from accredited test centers (test report) and date of report (case report). All three indicators show an increasing number of new Covid-19 cases in the Philippines. As of the latest week from July 3 to 9, the average number is about 2,000 new cases per day, up almost 50% from the previous week. On May 8 to 14, during Enhanced Community Quarantine (ECQ), the average was less than 300 based on incidence reports.

In our previous report (UP Octa Report No. 11, June 29), we stated that incidence reports and test reports were better indicators of the trend of the pandemic, compared to case reports. The drawback to using incidence reports is the testing lag, which takes up to one week. This means that only incidence reports at least one week old are reliable for trend analysis. The problem with using case reports is that it underestimates the number of cases. However, our previous report (Report No. 11) suggested a loading factor of 15 to 25% of case reports to estimate the true number of cases by incidence. For example, as of June 30, the total number of Covid-19 cases reported (i.e. case reports) was 37,514. As of July 11, the number of Covid-19 cases that occurred by June 30, including the lag from testing, is 46,228, which represents a 23% increase, well within the 15 to 25% loading factor. The number of cases based on test reports is just slightly higher than incidence reports on the same date, as shown in Figure 2, which shows the aggregate number of Covid-19 cases in the Philippines based on the three measure. The small difference between number of cases based on incidence reports and test reports shows that the Department of Health has cleared most of its backlog of cases, and that the discrepancy between the case reports and test reports is mostly due to the testing lag (i.e. the time it takes to process a PCR test).

Figure 2. Total number of Covid-19 cases based on test reports (green bars), case reports (yellow line) and incidence reports (blue line). The discrepancy between test report and incidence report numbers indicate that the Department of Health has cleared most of its data backlog, and that the remaining discrepancy is mostly due to the testing lag (or the time it takes for a PCR test to be processed by the test center).

Figure 3 shows the calculated reproduction number Rt in the Philippines based on the number of Covid-19 cases according to test reports, incidence reports and case reports, shown as a moving average. The incidence reports and test reports more closely reflect the pattern of the pandemic. A value of Rt < 1 is needed to flatten the curve, while a value Rt > 1 indicates the pandemic is spreading. From the figure, we observe that during ECQ (Enhanced Community Quarantine) in NCR, the average value was about Rt = 1.19, but it was also trending downward. During Modified Enhanced Community Quarantine (MECQ) in NCR, the average value increased to about Rt = 1.27, and during General Community Quarantine (GCQ) in NCR, the reproduction number increased to an average of Rt = 1.45, suggesting that loosening of quarantine restrictions resulted in an increase in the rate of infection. Caution must be taken because the reproduction number under GCQ is still increasing, with a 7-day average value of Rt = 1.75. Based on data from Apple Mobility, driving and transit in Manila were down by 80% during ECQ, but during GCQ, driving was reduced by 35% while transit was down by 70%. Increased mobility of people may have been a factor in the increased rate of infection. Once NCR transitions to Modified General Community Quarantine (MGCQ), there will likely be another increase in the reproduction number Rt. Assuming that the current transmission rates continue, this projects to more than 85,000 cases and 2,000 deaths by end of July. This is higher than our previous projection of 60,000 to 70,000 cases by end of July due to an increase in transmission rates.

Figure 3. Reproduction number Rt in the Philippines, based on the number of Covid-19 cases according to case reports, incidence reports and test reports, shown as a 7-day moving average. The reproduction number is best estimated using the incidence reports, but test reports will produce good estimates. A value Rt < 1 indicates the curve is flattening. The trend in Rt is increasing, coinciding with an increase in community transmissions in NCR.

COVID-19 in NCR
As of July 10, there are 22,765 Covid-19 cases in National Capital Region, an increase of more than 5,000 from the end of June. In response to the numerous reports of increasing numbers of Covid-19 positive cases in the National Capital Region (NCR), we analyzed the current pandemic data provided by the Department of Health up to and including July 10, 2020, to evaluate the extent of the surge. The current epidemic curve for the NCR is shown in Figure 4. It confirms reports that the number of Covid-19 positive cases is on the rise. As shown in Figure 5, however, the number of daily deaths from Covid-19 continues to fall in the NCR. This is expected since the number of deaths from Covid-19 usually lags behind the number of cases of Covid-19 by two weeks.

Figure 4. Number of new Covid-19 cases in NCR, indicating a steep increase in July.

The increase in positive cases can be attributed either to an increase in testing capacity and/or an increase in the spread of the virus. As shown in Figure 6, testing capacity has also dramatically risen in NCR.

Figure 5. Number of deaths in NCR due to Covid-19.

To determine which of these options best explains the data, we examined both the positivity rate and the hospitalization rate for the NCR. The positivity rate is the percentage of Covid-19 tests that are positive. It is an indication of the extent of community transmission in a population. The hospitalization rate reveals the change in Covid-19 bed occupancy in a geographic region. Both increases when the pandemic is spreading through a local community.

Figure 6. Testing capacity in NCR.

As shown in Figure 7, the positivity rate for the NCR has been increasing gradually for the past two weeks. Just over two weeks ago, the positivity rate hovered between 6% to 8% of tests. Today, the positivity rate is around 12% and has exceeded 10% for the past week or so. To maintain control of their pandemics, the WHO recommends that countries try to reduce their positivity rates to below 5%.

Figure 7. Positivity rate in NCR.

As shown in Figure 8, the hospitalization occupancy for Covid-19 patients has also spiked in recent weeks. Both the percentage of occupied total Covid-19 and ICU Covid-19 beds have increased. Mercifully, the percentage of occupied ventilators has not spiked as dramatically, supporting claims in the news media that the current Covid-19 patient population is younger and experiencing milder cases of the disease.

Figure 8. Hospitalization resource utilization in NCR.

Together, the rise in the positivity rate and in the hospitalization rate indicate that the NCR is undergoing a real surge in the pandemic which needs to be addressed immediately by public health authorities.

To determine if we could identify hotspots for the pandemic surge in the NCR, we broke down the daily cases in June at two-week intervals and assigned each of them to one of the component cities of the NCR. As shown in Figure 9, though there have been noticeable increases in cases in several of the component cities of the NCR, a significant percentage of the surge can be attributed to a dramatic rise in the number of positive cases in the DOH category labelled “Unknown City.” These are positive cases that are not assigned to a particular city but are known to be in the NCR. It does not help our cause if the surge is occurring in this “unknown” geographical category. The number of Covid-19 positive persons is disproportionately increasing in this category relative to the other geographical regions in the NCR. Statistically, this cannot be explained by random clerical or encoding errors. Without proper geographical identification of positive cases, it will be difficult for public health authorities to properly understand the extent of the surge and to control the pandemic through contact tracing, tracking, and isolation.

Figure 9. Breakdown of daily cases in NCR by LGU. The high number of cases in NCR that are not attributed to an LGU (i.e. unknown city) is not within statistical error.

Finally, we chose to break down the hospitalization occupancy data by component city to determine hotspots where hospital capacity may be overwhelmed by the local pandemic. As shown in Figures 10a and 10b, on July 8, 2020, several component cities of the NCR were exceeding the 70% “Danger” occupancy limit established by the DOH. Cities that were exceeding this “Danger” limit for both total Covid-19 beds and ICU Covid-19 beds included Makati, Las Pinas, Quezon City, Valenzuela, and Muntinlupa.

Figures 10a and 10b. Bed and ICU occupancy in NCR according to LGU.

The reproduction number Rt for NCR is shown as a 7-day moving average in Figure 11. The patterns show an increasing value of Rt from the end of June, when its average value was Rt = 1.35. Since the beginning of July, this value has increased to Rt = 1.75. This is a significant increase and will lead to a surge in cases in NCR, and possibly affect the neighboring regions of Calabarzon and Central Luzon. The value of Rt in NCR was around 1from mid-April to mid-May. This value started increasing once ECQ was relaxed. This shows that ECQ worked in reducing community transmissions. The effects of implementing a quarantine and easing a quarantine are not immediate: it takes at least 15 to 30 days before the quarantine significantly reduces the transmissions. Relaxing a quarantine will also lead to gradually increasing transmissions due to increased mobility.

Figure 11. Reproduction number Rt for NCR shown as a moving average. The transmission rate has been increasing since mid-June and is currently around 1.8.

The projections in NCR are shown in Figure 12. The blue bars show the projections using the current transmission rates under GCQ in NCR. This projects to 40,000 cases by end of July and more than 80,000 cases with 2,800 deaths by end of August. The green line shows the projection using a decreased transmission rate, similar to the values observed during MECQ in NCR. This projects to 36,000 cases by end of July and 56,000 by end of August with 1,900 total deaths. More importantly, the value of Rt will decrease to around 1.1 by end of July and close to 1 by end of August, which means that with sustained efforts, we will be close to flattening the curve. The third projection assumes an increased rate of transmission following a possible relaxation to MGCQ (Modified General Community Quarantine) in NCR. This projects to 45,000 cases by end of July and more than 120,000 cases by end of August with 4,000 deaths, while Rt will increase. In all scenarios, the effects of lifting the quarantine or relaxing the quarantine had a much larger impact over the long term.

Figure 12. Projections for NCR, assuming the current transmission rates observed during GCQ continue (blue bars). The second scenario assumes a decrease in transmissions and reproduction number to the levels observed during MECQ (green line), while the third scenario assumes an increase in transmissions due to relaxation of community quarantine (red line).

UNCATEGORIZED CASES

There are 9,299 cases in the data of Department of Health that were not assigned to any province. This is about 6,500 cases more than the 2,794 uncategorized cases reported in our previous report (report No. 11 published June 29). This means that 17.5% of the cases in the database are not assigned to any region or province. In addition, 4,492 cases in NCR do not have a city indicated (i.e. “no city”). The high number of uncategorized cases makes it more difficult to pinpoint surges and emerging hotspots, or to conduct localized lockdowns.

COVID-19 in CEBU AND OTHER HOTSPOTS

The province of Cebu has 10,215 Covid-19 cases as of July 10. The rate of transmission has decreased since Cebu was placed under ECQ on June 16. The reproduction number Rt in Cebu has now decreased to 1.14 from more than 2 during MECQ. Cebu remains a hot spot with the high number of community transmissions, but it is on a downward trend due to effects of the community quarantine.

The medium to high risk provinces is given below. Bulacan, Laguna and Basilan have moved into high risk following an increase in new case reports. The number indicated is the number of new case reports over the past 14 days. A province is classified as medium risk if the number of new case reports over the past 14 days is at least 2 per million of population per day. A province is classified as high risk if the number of new case reports over the past 14 days is greater than 5 per million of population per day, or there are more than 100 new case reports per week over the past 2 weeks.

High Risk:
Basilan (69); Bulacan (208); Cavite (219); Cebu (3,646); Laguna (288); Leyte (146); NCR (6,925); Rizal (259)

Medium Risk:
Bataan (56); Batangas; (95); Benguet (17); Bohol (40); Camarines Sur (66); Davao Del Sur (103); Iloilo (100); Lanao Del Norte (43); Negros Occidental (98); Negros Oriental (23); Samar (40); Southern Leyte (40); Surigao Del Norte (19)

KEY FINDINGS
1. As of July 10, 2020, data from the Department of Health (DOH) shows an increase trending of new Covid-19 cases in the Philippines. As of the most current week, there is an average of 2,000 cases per day in the Philippines, an increase of almost 50% from the previous week.

2. The current reproduction number Rt in the Philippines is about 1.75 and increasing. Based on the current number of cases in the Philippines, this projects to more than 85,000 cases and 2,000 deaths by end of July.

3. The number of cases, positivity rate and hospital resource utilization have all increased in National Capital Region (NCR), indicating a genuine surge is happening. The reproduction number Rt in NCR has increased to 1.75. Despite the mortality rates decreasing in NCR, there is a real danger that hospitals will become overwhelmed with this surge.

4. A continuation of General Community Quarantine (GCQ) in NCR will lead to 40,000 cases by end of July and more than 80,000 cases with 2,800 total deaths by end of August. Moving NCR to a stricter quarantine such as Modified Enhanced Community Quarantine (MECQ) will reduce the reproduction number Rt to about 1.1 by end of July and close to 1 by end of August, resulting in about 35,000 cases by end of July and 56,000 cases with 1,900 deaths in NCR by end of August. On the other hand, lifting the quarantine will very likely increase the community transmissions and increase further the reproduction number, leading to 45,000 cases by end of July and more than 120,000 cases by end of August with 4,200 deaths in NCR.

5. The testing capacity in NCR has increased to about 14,000 tests per day. In the Philippines, the number of tests per day has exceeded 20,000 with a peak of 23,352.

6. The positivity rate in NCR has increased to about 12% from a low of 6% in May. WHO recommends a positivity rate less than 5%.

7. Hospital resource utilization in NCR has increased. Beds have passed the critical level of 70% occupancy, while ICU occupancy is reaching critical levels. In particular, the following LGUs have exceeded the 70% critical level for ICUs and beds: Makati, Las Piñas, Quezon City, Valenzuela, and Muntinlupa.

8. The reproduction number of Cebu has been decreasing due to the Enhanced Community Quarantine (ECQ) in the province and is currently at 1.14. NCR and Cebu remain as high-risk areas, along with Basilan, Bulacan, Cavite, Laguna, Leyte and Rizal.

9. The number of uncategorized cases, i.e. cases in the database of Department of Health (DOH) that are not ascribed to any region or province, has increased to 9,299 cases as of July 10. As of our previous report (No. 11 published June 29), the number of uncategorized cases was 2,794. The increase over 2 weeks is 232%, or more than 6,500 uncategorized cases. The high number of uncategorized cases makes it more difficult to pinpoint surges and emerging hotspots, or to conduct localized lockdowns.

10. In NCR, the number of cases with “no city” indicated is 4,492, nearly 20% of the total number of cases in NCR.

11. As of July 10, 2020, data from the Department of Health (DOH) shows an increase trend of new Covid-19 cases in the Philippines. As of the most current week, there is an average of 2,000 cases per day in the Philippines, an increase of almost 50% from the previous week.

SUMMARY AND RECOMMENDATIONS

Based on the above findings, we are still in a situation where there is very significant community transmission in the Philippines. In our view, the national and local trends point to a significant surge in Covid-19 transmissions in the country.

Our estimate of the reproduction number of the virus in the country is around 1.75 and is increasing.  Assuming that the reproduction number, Rt remains and there is no significant change in the interventions and strategies by the government, our revised projections show that the current number of cases in the Philippines will increase to more than 85,000 cases and 2,000 deaths by end of July 2020.

At this time, the community spread continues to be uneven throughout the archipelago with the National Capital Region (NCR) and Central Visayas, especially Cebu City, having significantly higher transmission rates then the rest of the country.

Our estimate of the reproduction number of the virus in the National Capital Region (NCR) is now 1.75 and the trend is still increasing.  This classifies the NCR as a High-risk area, which means SARS-CoV2 is still spreading in the region. The NCR continues to be the epicenter of Covid-19 in the country.

Assuming that the reproduction number, Rt remains and there is no significant change in the interventions and strategies by the government, the current number of cases in the NCR will lead to 45,000 cases by the end of July and more than 80,000 cases with 2,800 deaths by the end of August.

In Cebu province, the average reproduction number Rt during ECQ has gone down to 1.14 (from a high of 2 based on our last forecast of June 29, 2020). While Cebu remains a high-risk area with a high number of community transmissions, the interventions of the national and local governments, in cooperation with the community, has resulted in a significant reduction in the transmission of the virus all over the province. We also observed a downward trend in the reproduction number in Cebu province.

In other parts of the country, the other high-risk areas where significant government monitoring and intervention are needed are in the provinces of Basilan, Bulacan, Cavite, Laguna, Leyte, and Rizal.

In our view, the aforementioned national and local trends represent a significant increase in transmissions and are a very serious cause for concern that needs to be examined and given appropriate and immediate response by the government. To this end, we recommend the following:

1. We caution the national government against prematurely downgrading the quarantine status in the high-risk areas identified and most especially in Cebu City and the NCR.

For Cebu City, the strategy to contain the virus has been working. The stricter quarantine status together with the scaled-up testing, tracing, isolation, and treatment strategies implemented by the national and local governments and supported by the community have significantly decreased the Rt  for Cebu province to 1.14 from a high of 2 a month ago. Cebu City has been able to contain the surge and is on the way to flattening the epidemic curve. For Cebu City, we recommend the continuation of the strict quarantine strategy to sustain the gains already achieved.

On the other hand, the situation in the NCR is particularly concerning as the number of cases, as well as the positivity rate and hospital resource utilization, have all increased. These indicate that a surge is happening in the NCR. The reproduction number Rt in NCR has already increased to 1.75. This surge, if left unabated, poses a real danger of the virus leading not just to exponential growth in the number of cases and deaths but also to the overwhelming of the health care system in the NCR.

Given the complexity of deciding an appropriate and aggressive intervention to curtail the surge in the NCR, we are recommending the following options for consideration:

Option 1: To sustain the current General Community Quarantine (GCQ) in NCR with provisions for more aggressive and effective localized lockdowns and stricter border controls, apart from a scaled-up test, trace, isolate and treat program to suppress further transmissions.

The effective implementation of the GCQ and the LGU-led localized lockdowns in the NCR. Implementation of LGU-led localized lockdowns should highlight the health aspect of compliance, and hence should avoid projecting it as a peace and order matter.  As such, it is important to underscore the medical aspect and we should discourage having guns and police forces leading the enforcement of contact tracing and quarantine.

This implementation of this option must be augmented with better pandemic surveillance, more effective strategies for physical distancing, and compliance with other health protocols, including the vigorous promotion of personal hygiene practices, and the wearing of masks and other personal protective equipment (PPE).

Based on our models and forecasts, a continuation of General Community Quarantine (GCQ) in NCR will lead to 45,000 total cases by the end of July and 80,000 total cases with 2,800 deaths in NCR by the end of August

Option 2: To address the steep increase in Rt in the NCR, the government may consider tightening the quarantine restrictions to slow down the spread of the virus.  Recognizing the need for an aggressive health intervention to quickly suppress further transmission and mindful of the economic consequences especially for the informal economy, the government may consider placing the NCR under a Modified Enhanced Community Quarantine (MECQ) for 14 days, with emphasis on stricter compliance with minimal public health standards.

This option is informed by the recent experience in Cebu province, where the national and local governments’ intervention to impose a stricter set of quarantine measures such as the Enhanced Community Quarantine (ECQ) in Cebu City and the Modified Enhanced Community Quarantine (MECQ) in Talisay City has dramatically slowed down the transmission of the virus.  The enhanced community quarantine measures, implemented together with the scaled-up testing, tracing, isolation and treatment strategies significantly decreased the Rt  for Cebu province to 1.14 from a high of 2 a month ago. If an ECQ or MECQ status is sustained in Cebu City for another 14 days, then the whole province will be on a trajectory towards flattening its epidemic curve. 

We believe that this option will work in the NCR as well. The primary benefit of the MECQ option for the NCR at this time is that it will curtail mobility and slow down the rate of transmission of the virus. The desired impact is to quickly and drastically lower the transmission rate and mortality rate of the disease. The MECQ option for the NCR will also buy time for its already burdened hospital infrastructure to cope with current challenges. However, the implementation of this option comes with significant socioeconomic costs.

At any rate, based on our models and forecasts, moving the NCR to a more strict quarantine such as a Modified Enhanced Community Quarantine (MECQ) will reduce the reproduction number Rt to about 1.1 (from current Rt of 1.75) by the end of July. This will also result in about 35,000 total cases during the same period.

If we continue the option for another 14 days then the rate of transmission will go down and be close to 1 by end of August, the NCR by this time will be close to flattening the curve and effectively reducing the spread of the virus. We forecast that there will be 56,000 total cases with 1,900 deaths in NCR by end of August.

2. Whatever type of quarantine the government chooses to implement, the front and center of the strategy against Covid-19 has always been hinged on increased testing, aggressive tracing, improved treatment and the establishment of more quarantine and other isolation facilities, especially in hotspots around the country. Getting the T3 and isolation strategy scaled up and effectively implemented is key to controlling the spread of the virus.  To this end, the government should continue to invest in expanding its laboratory capacity to ensure both accessible testing for Covid-19 and a faster turn-around-time for Covid-19 test results.

3. We exhort the government to review its national and local strategy to combat Covid-19, as these have failed to arrest the significant spread of the virus in the country. The government must re-examine and re-calibrate its strategies to ensure that the transmission of the SARS-CoV2 virus does not increase beyond the capacity of the health care system to respond. This requires having clear targets to measure whether the strategies are effectively working.

4. Given the increase in Covid-19 cases among younger working adults, we also recommend that LGUs limit the mobility of all non-essential workers at the barangay level through localized lockdowns. While we anticipate that this will negatively affect the economy and livelihood of families, we believe that drastic measures such as strictly localized lockdowns must be undertaken now at the barangay level to prevent further spread of the virus.

It is against this backdrop that government must focus on various strategies to further improve the efficiency, effectiveness, and implementation of the “localized lockdowns.” Localized lockdowns, as implemented by our local government units, can be an effective tool to reduce the transmissions of the virus at the community level.

But localized lockdowns can often fail if they are not quickly and securely enforced.  As we have recently witnessed in the city of Melbourne in Australia, poorly implemented localized lockdowns failed to arrest the spread of the virus. As a result, the entire city has just entered a six-week total lockdown to prevent a surge of cases beyond what their health capacity can handle.

For those LGUs already implementing these policies, we strongly recommend that they continue to enforce local and targeted lockdowns in their respective geographical areas. In the case of Cebu City, local authorities were initially hesitant to go into lockdown. We urge the national government to closely supervise local governments in the implementation of this strategy to ensure that local lockdowns are enacted in a timely, efficient manner and that these are always protective of the rights and the welfare of citizens.

Corollary to this, is a reiteration that community contact tracing should be ramped up and made more efficient to identify vulnerable areas and institute immediate courses of action to contain and control the situation. Community contact tracing must be undertaken in a timely, efficient manner and should always be protective of the rights and the welfare of citizens.

5. We urge the Department of Health (DOH) to urgently resolve issues regarding the accuracy and timeliness of its data on Covid-19 cases in the country. The number of uncategorized cases, i.e. cases in the database of the Department of Health (DOH) that are not ascribed to any region or province, has increased to 9,299 cases as of July 10. As of our previous report (No. 11 published June 29, 2020), the number of uncategorized cases was 2,794. The increase over a two-week period is 232% or more than 6,500 uncategorized cases. The high number of uncategorized cases make it more difficult to pinpoint surges and emerging hotspots, or to conduct localized lockdowns. In the NCR, the number of cases with “no city” indicated is 4,492, nearly 20% of the total number of cases in NCR.

If not urgently resolved, these significant and continuing challenges regarding DOH Covid-19 data will undermine not just the government’s ability to monitor the spread of the virus, but also hamper its ability to implement appropriate and timely responses to manage the pandemic on the ground. Without accurate and accessible DOH data on Covid-19, our national and local government officials, as well as other stakeholders, will not be able to make decisions crucial to managing the pandemic.

6. We support the recent position of the IATF-EID to discourage home quarantine for managing mild and asymptomatic Covid-19 patients to prevent intra-household transmission. The World Health Organization (WHO) recommends home quarantine for mild cases subject to 9 guidelines which essentially separates the patient in terms of infrastructure (e.g. separate toilets, dining areas, separate eating utensils, separate bedrooms, separate garbage disposal, and laundry) and function (e.g. strictly limiting social interactions) from the rest of the household and community, as well as mandating the stricter wearing of protective gear and more intensive handwashing and disinfection procedures for the household members.

Given the nature of Filipino households, it is unlikely that all these guidelines can all be fulfilled. The US Centers for Disease Control (CDC) for the SARS CoV-1 pandemic in 2002 also recommended a dedicated family member at low risk for infection to service the needs of the patient such as buying food and other necessities, financial transactions, and ensuring compliance to WHO recommended twice a day body temperature monitoring. Many Filipino families will be unable to provide this level of care during fourteen days of mandatory quarantine.

7. We, therefore, recommend the establishment of more community quarantine and isolation facilities in each municipality or barangay and especially in the hotspots in the NCR and Cebu.  We are also recommending that the IATF consider expanding the use of available but non-essential public spaces and facilities of government as temporary quarantine and isolation units for the LGUs during this surge. Moreover, the Department of Education (DepEd) and the State Colleges and Universities (SUC) may also consider allowing more of its facilities to be utilized as quarantine facilities in LGUs, while face to face classes have not resumed especially in the NCR and Cebu.

The expansion of isolation and quarantine facilities in the LGUs for patients with mild symptoms of Covid-19 will help prevent intra-household transmission, and decongest our hospitals and other health facilities.

Essentially, what WHO recommends for home quarantine will be implemented in these community facilities serviced by trained health workers. In the barangay setting, properly trained Barangay Health Workers (BHW) together with volunteers from the community, can provide the compliance services for patients under quarantine. These facilities shall be regularly assessed by a community physician or a public health professional or official. It is also recommended that food and water be provided by the local government for patients using the isolation facilities.

For workers who are essential and have a great risk for exposure, a work quarantine center can be established where workers can be billeted after work hours and undergo regular medical examinations and SARS CoV-2 testing. The same WHO standards for community quarantine facilities apply to work quarantine facilities. If workers do not develop symptoms after 14 days of working quarantine, they may return to normal working arrangements.

Community and working quarantines and other related isolations facilities must be serviced by a dedicated ambulance system if a patient needs to be transported to a designated Covid-19 hospital facility.

8. At this time, there is a direct correlation between the easing of the quarantine restrictions and the increase of the daily new cases reported. Factors contributing to this are the increased mobility of people and the return to operation of some non-essential businesses, as evidenced by the predominance of the working, productive age groups having tested positive. Tighter safeguards must be enforced against the spread of the virus during the daily commute and in the workplace.

As people are returning to the workplace, the business establishments have the responsibility of safeguarding the health of their employees and clients. Occupational health workers should be aware of the return to work protocols as recommended by the Department of Health. DOH Memorandum No. 2020-0220 dated May 11, 2020, recommended that return to work protocols using IgG and IgM rapid antibody tests should be correlated with proper documentation of clinical findings with retesting should be done every 14 days.

Proper engineering controls such as facility disinfection must be performed regularly, adhering to Occupational Safety and Health Standards. A system for employee contact tracing should be instituted such as the use of QR codes.

As businesses and public facilities reopen during the COVID-19 pandemic, the government should inform the public about the risk of going to certain types of commercial/business establishments. At the very least, it should come out with system of classifying or rating such establishments based on the risk of exposure to the Covid-19. This Covid-19 risk classification should be vigorously disseminated the public.

Moreover, following the model of Japan, the DOH information campaign should now focus  on informing the public to avoid the 3Cs namely closed spaces with poor ventilation, crowded and close-contact settings, all of which creates a higher risk of exposure to the virus.

9. We also recommend that hospital capacity be carefully monitored and expanded in component cities which are approaching the limit of their bed capacity during this period of surge in Covid-19 cases. Hospital capacity would benefit from the establishment of more isolation facilities within LGUs, as mild cases of Covid-19 can use these facilities instead of going to the hospital.

Moreover, hospital utilization, although in full capacities in some areas in the NCR and Cebu, may still be further managed by improving clinical management through the sharing of clinical best practices from medical centers with experience in successful Covid-19 patient management. This may further reduce the average hospital Length of Stay (LoS) and relieve the stresses on hospital capacities. Moreover, capacities should be raised by adding manpower and critical care equipment in hospitals.

10. We reiterate that the LGU system will be the key implementor of the national government strategy and program to fight Covid-19. Health service delivery is mostly devolved to local governments, making them important partners especially during this public health crisis. Moving forward, there is a need to strengthen the capability of local government units through the allocation of more resources and through capacity building. It is against this backdrop that the national government, through the support of Congress, must ensure that the greater share in the stimulus package and in the national budget be allocated for LGUs to enable them to implement the national strategy to fight Covid-19 and to realize their goal of creating “safe communities” around the country.

As we deal with the surge of Covid-19 transmissions not just in the NCR, citizens must be mindful that what they do as individuals will be as important as any effort the government undertakes in the fight against Covid-19. It will also be incumbent among citizens to exercise their civic responsibility to ensure that that they do physical distancing, use PPE such face mask and shield, practice proper safety and hygiene, as well avoid the 3Cs: namely, closed spaces with poor ventilation, crowded and close-contact settings – all of which creates a higher risk of exposure to the virus.

These everyday acts of citizenship are now the cornerstone of our forward approach in the fight against Covid-19. Everyone becomes a front liner in curbing the spread of the virus in this time of the surge

We reiterate, that without continued vigilance as well as timely and appropriate interventions on the part of the government, private sector and every citizen, this very significant surge in Covid-19 transmissions in the country may lead to more deaths, a longer period of disruption resulting in higher economic costs. We already had the momentum of declining cases back in May, and we need to regain this momentum again. Coupled with the significantly improved testing capacity and our improving implementation of the T3 strategy, and with the greater levels of cooperation and contribution coming from our private sector and citizenry, there is a window of opportunity that we need to seize to reverse this crisis.

In closing, each life counts and in this moment of trial, our unity and sense of collective community will define us as a nation.

References:
1. Department of Health Covid-19 Tracker. Retrieved from: https://www.doh.gov.ph/covid19tracker
2. David G, Rye, RS, Agbulos, MP, Austriaco N, Alampay E, Brillantes ER, Egwolf B, Lallana E, Ong RA, Tee M, Vallejo B, June 29, 2020. Forecast Report No. 11 – COVID-19 FORECASTS IN THE PHILIPPINES: NCR, CEBU and Covid-19 Hotspots as of June 25, 2020. Retrieved from: https://www.up.edu.ph/covid-19-forecasts-in-the-philippines-ncr-cebu-and-covid-19-hotspots-as-of-june-25-2020/
3. World Health Organization (WHO). Retrieved From: https://www.who.int/publications/i/item/considerations-for-quarantine-of-individuals-in-the-context-of-containment-for-coronavirus-disease-(covid-19) 4. US Centers for Disease Control. Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html