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CLINICAL MATTERS
COVID-19 was a watershed moment for the world. Whole countries were shut down by the SARS-CoV-2 virus, and millions of people died despite all the advances in modern medicine. It was the first pandemic to play out in real time on mainstream and social media, and it was the first pandemic where genomics played a major role in detection, tracking, and evolution of the disease. It was also a period of unprecedented innovation, with an effective vaccine rolled out within one year of the identification of the pathogen. It also had the dubious distinction of having a parallel pandemic of disinformation, eventually dubbed an infodemic.
While the characterization of COVID-19 as a pandemic occurred on March 11, 2020, the initial declaration of a Public Health Emergency of International Concern (PHEIC) occurred on January 30, 2020. Despite persistent rumors that SARS-CoV-2 originated from a laboratory, the preponderance of scientific evidence points to a zoonotic (animal-to-human transmission) origin that occurred sometime in December 2019.
The closest genetically related virus to SARS-CoV-2 was found in bats. Humans likely contracted the ancestral strains of the virus either directly from bats or intermediate animal hosts in the Wuhan market. There were at least two transmission events, as evidenced by two distinct SARS-CoV-2 lineages that were initially seen in humans, lineages A and B. Lineage A seems to have been outcompeted by lineage B, and the predominant lineages that continue to circulate are originally from lineage B. This is important because a laboratory leak would likely have only shown one lineage, while a natural viral spillover event can occur multiple times. This is not unique to SARS-CoV-2. For instance, HIV had at least five spillover events from apes or monkeys to humans: HIV-1 group M (chimpanzee), HIV-1 group N (chimpanzee), HIV-1 group O (gorilla), HIV-1 group P (gorilla), and HIV-2 (Sooty mangabey). Therefore, the existence of two ancestral SARS-CoV-2 strains is strong evidence of its natural origins.
One major difference SARS-CoV-2 had versus the original SARS-CoV virus was that asymptomatic SARS patients were not thought to transmit the virus. This was a critical difference that allowed SARS-CoV-2 to gain a stronger foothold than SARS-CoV and escape standard containment strategies, leading to the pandemic. As the first cases spread in China, the world watched with increasing trepidation as one of the most advanced societies struggled to manage the surge of critical people while attempting to understand what was going on. In the Philippines, those of us in the scientific community were particularly concerned that if China was having a hard time with this new virus, then what would happen to us with our limited healthcare capacity and crowded spaces, especially in Metro Manila?
When the first three cases of COVID-19 arrived on our shores in January 2020, there was a flurry of activity in attempting to trace all the sick contacts, preparing emergency rooms for suspected cases, and ramping up testing capacity. These first cases were all Chinese nationals who were touring the Philippines and became ill. Subsequent genomic sequencing revealed that the first case was ancestral lineage A and the second and third cases were both ancestral lineage B (https://ritm.gov.ph/ritm-releases-first-17-sets-of-sars-cov-2-genome-sequences-from-ph-cases-through-third-generation-sequencing-technology/). This also led to a ban on travel from China.
There was a more than 28-day gap between these initial three and the subsequent SARS-CoV-2 cases, which is considered two long incubation periods for COVID-19 and translates to containment of the initial outbreak. This suggests that the initial steps taken by the Department of Health were adequate for those first three cases. This was confirmed by genomic sequencing of the March 2020 samples, which were all lineage B.6, only two of whom had a travel history. Lineage B.6, which was likely introduced from India or a Southeast Asian country based on genomic similarities, was the lineage responsible for the first instances of community transmission in the Philippines. The lesson learned in this case is not to limit travel bans only to countries with known cases, but to consider them as well for at-risk countries, since silent community transmission is likely already occurring.
In retrospect, it would have been difficult to justify travel bans preemptively, and at least some simulations show a limited impact of travel bans. The one thing that did work in decreasing cases in Wuhan was hard lockdowns. This was why the Technical Advisory Group recommended lockdowns for the initial response, to allow our healthcare system to adapt and buy time for ongoing research into effective treatments to catch up. The initial lockdown was estimated to have saved between 200,000 to 350,000 lives, but at a grave cost to our economy. Simulations, however, have shown that not locking down would have resulted in those excess deaths and would have destroyed the healthcare system. We would have ended up locking down anyway as patients flooded the hospitals, resulting in the same grave economic cost on top of the deaths. With this scenario in mind, the early lockdown was the correct call, and we are glad the government listened to this recommendation.
As we got used to living in a pandemic, effective treatments and vaccines were developed, which renewed hope of a quick end to the PHEIC. Unfortunately, the variants of concern emerged, and Delta took more lives than any other SARS-CoV-2 variant. As we got better at treating cases and vaccination rates surpassed 70% of the eligible population, the mortality rate for COVID-19 approached that of seasonal influenza which enabled us to open safely and resume our lives. Overall, following a science-based approached allowed the Philippines to perform much better than the United States and many other developed countries. Our final tally of under 67,000 deaths was nearly twenty times less than the 1.2 million deaths in the US. Our deaths per million are several times lower than those of France, the United Kingdom, Spain, Belgium, and many other rich countries. This was accomplished despite allowing Filipinos to return home for humanitarian reasons. In contrast, many countries refused to allow their citizens to come home for fear of the introduction of new variants. I had an Australian patient who was stuck in our country for two years.
Five years since the pandemic, what have we learned and what can we do better?
Good communication and proactively battling misinformation are keys to efficient pandemic management. Due to mistrust of the government and partisan politics, there was a lot of wasted energy in explaining to the public how mass testing was a futile exercise, and that ivermectin was not a viable treatment for COVID-19. Despite being non-partisan academics, even the experts advising the Department of Health were attacked since they were seen as government workers. A trusted, non-partisan source of information should be cultivated and supported, similar to how public health messaging is done in countries like Singapore.
Self-sufficiency in diagnostics, vaccines, and drug treatment is another area that deserves strong support. We were at the mercy of richer and more powerful countries when it came to the procurement of testing kits, life-saving medications and treatment, and vaccines, which would have enabled us to open earlier, saving more lives and decreasing the damage to our economy.
Finally, a long-term commitment to health literacy and education, which will allow Filipinos to make good health choices and be less prone to anti-vaccine and pseudo-science rhetoric, is perhaps the only viable solution in preventing self-destructive behavior that happened during the last pandemic. There are many more items in our to-do list, but if we continue to make progress on these three lessons, we will be much more prepared when the next pandemic occurs.
