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Health Adaptation Under COVID and Restarting the Economy

By , | April 08, 2020

The new normal for the world is that, until a vaccine is found, the covid19 virus is here to stay. We had better learn how to live with it.


HEALTH ADAPTATION UNDER COVID AND RESTARTING THE ECONOMY

Eckie Gonzales, Chairman, The Medical City

The new normal for the world is that, until a vaccine is found, the covid19 virus is here to stay. We had better learn how to live with it.

The New Normal

We now know that it's very easy to pick up the Covid19. Up to 50% of those infected with covid are asymptomatic, that is they have zero symptoms! This was the case for all 3711 passengers in the Diamond Princess Cruise Ship off Yokohama, and for Iceland, where 6% of the population has been tested, by far the largest proportion in the world. For those who will feel sick, the incubation period can be up to 5 days before one feels fever, dry cough, phlegm, mild aches, diarrhea. 30% of patients will also lose their sense of taste. If you are elderly, or in not-so-good health, then around days 7-12, you can experience difficulty of breathing, and have to check into a hospital. If not, and this is true for 80% of the cases, you could self-quarantine and recover by day 14. This is not like the regular flu. Incubation period for the flu is only 1-4 days. Though most commonly 5 days, the incubation period for covid can go up to 14 days. Flu affects 9% of the world s population every year, or around 700 million people, and 5% of the cases are severe. The death rate is 0.1%, or around 700,000. By comparison, global covid19 cases already exceed 1 million, with a mortality rate of 5%, or close to 40,000 people. We should stop this number from going up quickly until we find the vaccine. On a best-case basis, according to US Heath Czar Dr. Anthony Fauci, this will take 12-18 months. We originally thought that the virus was not easily transmitted, that it was expelled in the form of droplets that fell to the floor. We now know that, in addition to living on plastic for 3 days, it can remain airborne in smaller particles. That s why you hear of massive infections in Korea and Singapore churches, or for that matter in the cruise liners. 80 Filipino crew tested positive on the Diamond Princess. That is why all doctors, because they examine patients so frequently, should also wear face shields.

It s bad therefore to be in gatherings in closed air-conditioned rooms. If you have to, open windows or do it in parks, while maintaining social, now called physical distancing. Most of all, the best protection against infection from all that singing and shouting is to wear masks in public. Of course, wash your hands regularly with soap and water.

The Mask Culture

The number one impact on reducing cases, is for everyone to wear a mask in public. The government already decreed this nationally. Let it be enforced. Masks are THE major factor that flattened the curve for Korea, Japan, Taiwan, Hong Kong, Singapore, and China. The Europeans and Americans are now beginning to recommend it. WHO resisted, saying that you should only wear a mask when unwell. Now the evidence is incontrovertible.

Managing Space

The safely recommended personal physical distance now is two meters. It used to be one, until studies showed a potentially higher trajectory of the virus with a big sneeze. There is also community physical distance, where the community has to adjust spaces to minimize spread. Early on, the government closed schools and churches, limiting how many can gather in one place. There are no more fiestas or concerts. But what about residential communities that are almost as crowded as a church during Mass?

The only way to address crowded homes within crowded barangays is threefold:

- first, make sure the community identifies who has symptoms immediately;

- second, make sure that the person, plus all those he or she has come into contact with, has enough space to quarantine;

- third, if the person is over 60 or has a compromised lung, heart, kidney, liver, condition, send the person to the hospital right away for testing and treatment. We need to put our heads together to help Tondo with a population density of 77,000 per sq. kilometer, and other dense neighborhoods.

There is such a thing as viral load. When you are in a two-hour concert, you are breathing in lots of droplets and absorbing a high load of virus. Even if you are young and healthy, your immune system may not be able to handle all this. That s why if one family member gets covid, everyone should get a separate place to quarantine alone.

Protecting Health Care

Much has already been written about health care support. The critical factors are Personal Protective Equipment (PPEs), ICU beds, and ventilators. Most critical for HCWs is the N95 mask, which can now be disinfected in a clean room with hydrogen peroxide. Full head-to-toe biocontainment Biosafety Level 2 suits that are re-washable at the hospital laundry. Negative pressure tents that are being created locally for the strongly symptomatic patients. All these options bring the cost of treatment down by 90%. Much of the value created by reuse can be passed on as compensation to our frontliners. Thankfully, no HCW in full PPE gear at TMC has been infected. Next are the ICU beds and ventilators. For a population of 110 million, we have 106,000 beds. 75,000 belong to Level 2 & 3 hospitals, which have critical care capacity. If two-thirds of their 3,700 ICU beds will support covid patients, then the health care system can handle 50,000 cases. If there are more than that in a surge, Emergency Rooms will pick up the slack. The key constraint is ventilators. In Italy 88% of all critically ill patients need a ventilator. The DOH just ordered 1,500 more ventilators to supplement the 1,500 currently in place. That should be enough to support 50,000 cases - if we get them soon.

The Test Kit Supply Chain

The local test kit developed by UP scientists was given commercial certification by the FDA on April 3. It is the first clinically validated study on covus detection prior to public launch - in the world. Between local kit production and the imported kits, there will be 250,000 available in the next month. What we lack is Polymerase Chain Reaction (PCR) processing capacity. Certification for laboratories has been slow. It might take one more week to get to 1,200 per day processing - and we ll be almost at the end of the national lockdown. We need to get processing capacity up to 5,000 per day, so we don’t get a second wave when restrictions are relaxed. We need these test kits so hot spots can be identified quickly and with good contact tracing, areas of infection locked down. South Korea has done 400,000 tests. 1 of 41 was covid. The Japan ratio is 1:28. The Philippine ratio is 1:2. A paltry 4,000 tests, 2,100 cases as of March 31. The WHOrecommended ratio is 1:10. Let s not put all our bets on these kits however. Even if they are the gold standard, they are only 63% accurate. The rapid test kits which detect the antibodies ten days after infection, are half as accurate. The doctor needs to examine you and, combined with other tests and diagnostics, make the final determination of your illness.

Mitigating Factor 1 - The Demographic Dividend

Most of us panic when we hear of Italy's 12% case fatality rate. Actually, the case fatality rate will be much lower than the infection fatality rate for the whole population. In Korea's case, with massive testing, it is only 0.6%. Why is this so? The first reason is that when you test more, the rate lowers, as one tests the less sick. When there are not enough kits, as is the case currently, testing is limited to the elderly or those with comorbidities. The second can best be illustrated by comparing the population pyramids of Italy and the Philippines. Italy s population is 60 million, with 30 million below 50 years old, 10 million between 50-60, and 20 million above 60. It has the second oldest population in the world, after Japan. The Philippine population is 110 million, with 90 million under 50, 10 million between 50-60, and 10 million above 60. This demographic dividend works also in the case of health care. The case fatality rate for 50 and under is 0.1%, around the same as the seasonal flu. 50-60 is around 2%, and 8% above 60. The third is that the number should be lower because of those that bother not to test because they are asymptomatic or mildly symptomatic. By comparison, Italy’s case mortality rate is 12%. Ours is 4%.

Mitigating Factor 2 - The Summer Bonanza

Some studies suggest that the virus does not like high temperature and high humidity. There is a belief that when summer and rain arrives in the Northern hemisphere, transmission risk will be reduced, while in the Southern Hemisphere winter, the illness will simultaneously ramp up. Being in the equator, where heat and humidity are constants during the wet and dry season, we could have less to worry about.

Prescriptions for Rebooting the Economy

Shelter the Elderly in Place

The initial outbreak of covid in the United States happened in a number of nursing homes in Seattle, where sick staff members worked in multiple long-term care facilities caring for the elderly. 35 deaths were linked to one center alone. In Italy, there were 62 deaths in two nursing homes. Spain was also hard-hit.

Until the vaccine is found, the elderly should cut down mall visits, and especially traveling. They should monitor their temperature regularly. Those who live with them should maintain a healthy physical distance, and be extra careful in social or workplace settings so that they don’t carry unnecessary exposure risk home. This health care system adjustment is primarily for our senior citizens.

All senior citizens, including the immunocompromised, should be required to wear a visible ID in public.

Maintain Community Standards of Hygiene

Covid has redefined how we should relate to each other physically. This also has implications for how communities are managed. In a business setting, a community can be a factory, office building or mall. In a residential one, it can be a subdivision or barangay. A rating system for hygiene, with regular monitoring, should be built and maintained by different private sector associations, or public sector agencies and LGUs. There are hierarchies of communities, or groups of people with common interests, that can work together on this.

As an example, does a factory or office now have a workstation distance rule for sewers or call center agents? Are elevators marked off, with buttons pressed by elbows and not hands? Are building surfaces and bathrooms wiped down daily with a chlorox and water solution? Are there more stringent standards for when employees should and should not come to work? Are more employees working from home, particularly seniors, so building occupancy is reduced? Does everyone wear a mask at the office?

Each industry association should adapt standards that adhere to best practices in community hygiene, sensitive to their unique business needs but cognizant of the social engineering rules necessary to keep the virus within bounds. Particular attention should be made to high-contact professions, like those that transport goods and people, maintain and clean buildings and facilities, and serve customers in stores and restaurants. Or large gathering places like malls and markets. Hospitals of course will have the highest standards of community hygiene.

Similarly, does a city have enough spaces to handle outbreaks of covid, so that the mildly symptomatic, PUIs and PUMs are appropriately isolated? Is mask use being consistently enforced in public? Are there enough hospital beds within its radius for the severely symptomatic? Are the public markets managed for crowding? Do vendors there wash their hands regularly?

The country, as a political unit under the auspices of a national government, needs to set the stage for a new social contract. Too much self-interest can violate the community interest of the many to the benefit of a few. A covid superspreader can consciously not disclose symptoms during a hospital visit with a spouse and bring many HCWs down. How much of social media shaming is appropriate, versus significant penalties for noncompliance?

Let s start with a checklist. Here s a link to an impact assessment form that is being continually refined as we crowdsource community behavioral standards for covid: https://forms.gle/DUiCJ1qTdtL6x4xr6

Redefine Border and Transport Management

A whole industry was built around fighting terrorism after the 2001 World Trade Center attack. We now take a lot of the security norms at our airports for granted. Since 2001, global travel expanded exponentially, with pauses in 2003 for SARS, 2009 for swine influenza, and 2015 for MERS. With covid, this has come to a screeching halt. It need not.

Airplanes are the epitome of crowded spaces. The longer the flight the riskier the exposure. Airplane flights defined the modus operandi of our OFWs. The Philippines became a bedroom community to the rest of the world, with workers sending $30 billion plus home. The safest way to fly now is to dress up like a HCW, with full PPE, including goggles, and not eat during the trip.

As we continue to find a safer way to fly however, we need to keep our borders open to facilitate economic exchange. Korea, Taiwan, Singapore and Japan have kept their borders open, mostly to their expatriates. 20-30% of their covids come from these flights. Their protocols are to screen them for fever and test them at the airport, and mandatorily quarantine anyone for 14 days who comes from abroad. Korea and Taiwan use geo tracking on cellphone apps to ensure compliance.

The contact tracing network in Wuhan was composed of 1,600 five-person teams. Do we have a strong tracing network to enforce border control at our airports?

Japan has 25 million more people than us, the oldest country in the world, with currently the same number of covid cases. It has kept its subways open. Everyone there wears a mask. That s the social norm. In addition, Japanese do not do touch skin, nor wear shoes at home, nor eat with their hands, nor speak in public transport. This could be the last sector bastion to open if we adhere to new norms.

The Keys to Beating the Virus: Be Patient until Health Capacity is Built Up, Modify Behavior, Act as One

The big question is - should we open up April 15? The big answer - if we don t have the tracing infrastructure with test kits, test results, quarantining facilities, and community surveillance and monitoring ready, we ll have a big spike in covid. And it ll be worse.

Examples primarily in East Asia have shown that countries can operate relatively normally, even with covid. But citizenry needs to cooperate - as individuals with good hygiene practices, and in cohorts where behavior is managed as a pool of social norms. The less legal intervention, the better. We did not need formal government to fight in World War 2. We only need ourselves, acting in an empowered way as one nation, to beat covid.



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Share


Health Adaptation Under COVID and Restarting the Economy

By ,

April 08, 2020


The new normal for the world is that, until a vaccine is found, the covid19 virus is here to stay. We had better learn how to live with it.

HEALTH ADAPTATION UNDER COVID AND RESTARTING THE ECONOMY

Eckie Gonzales, Chairman, The Medical City

The new normal for the world is that, until a vaccine is found, the covid19 virus is here to stay. We had better learn how to live with it.

The New Normal

We now know that it's very easy to pick up the Covid19. Up to 50% of those infected with covid are asymptomatic, that is they have zero symptoms! This was the case for all 3711 passengers in the Diamond Princess Cruise Ship off Yokohama, and for Iceland, where 6% of the population has been tested, by far the largest proportion in the world. For those who will feel sick, the incubation period can be up to 5 days before one feels fever, dry cough, phlegm, mild aches, diarrhea. 30% of patients will also lose their sense of taste. If you are elderly, or in not-so-good health, then around days 7-12, you can experience difficulty of breathing, and have to check into a hospital. If not, and this is true for 80% of the cases, you could self-quarantine and recover by day 14. This is not like the regular flu. Incubation period for the flu is only 1-4 days. Though most commonly 5 days, the incubation period for covid can go up to 14 days. Flu affects 9% of the world s population every year, or around 700 million people, and 5% of the cases are severe. The death rate is 0.1%, or around 700,000. By comparison, global covid19 cases already exceed 1 million, with a mortality rate of 5%, or close to 40,000 people. We should stop this number from going up quickly until we find the vaccine. On a best-case basis, according to US Heath Czar Dr. Anthony Fauci, this will take 12-18 months. We originally thought that the virus was not easily transmitted, that it was expelled in the form of droplets that fell to the floor. We now know that, in addition to living on plastic for 3 days, it can remain airborne in smaller particles. That s why you hear of massive infections in Korea and Singapore churches, or for that matter in the cruise liners. 80 Filipino crew tested positive on the Diamond Princess. That is why all doctors, because they examine patients so frequently, should also wear face shields.

It s bad therefore to be in gatherings in closed air-conditioned rooms. If you have to, open windows or do it in parks, while maintaining social, now called physical distancing. Most of all, the best protection against infection from all that singing and shouting is to wear masks in public. Of course, wash your hands regularly with soap and water.

The Mask Culture

The number one impact on reducing cases, is for everyone to wear a mask in public. The government already decreed this nationally. Let it be enforced. Masks are THE major factor that flattened the curve for Korea, Japan, Taiwan, Hong Kong, Singapore, and China. The Europeans and Americans are now beginning to recommend it. WHO resisted, saying that you should only wear a mask when unwell. Now the evidence is incontrovertible.

Managing Space

The safely recommended personal physical distance now is two meters. It used to be one, until studies showed a potentially higher trajectory of the virus with a big sneeze. There is also community physical distance, where the community has to adjust spaces to minimize spread. Early on, the government closed schools and churches, limiting how many can gather in one place. There are no more fiestas or concerts. But what about residential communities that are almost as crowded as a church during Mass?

The only way to address crowded homes within crowded barangays is threefold:

- first, make sure the community identifies who has symptoms immediately;

- second, make sure that the person, plus all those he or she has come into contact with, has enough space to quarantine;

- third, if the person is over 60 or has a compromised lung, heart, kidney, liver, condition, send the person to the hospital right away for testing and treatment. We need to put our heads together to help Tondo with a population density of 77,000 per sq. kilometer, and other dense neighborhoods.

There is such a thing as viral load. When you are in a two-hour concert, you are breathing in lots of droplets and absorbing a high load of virus. Even if you are young and healthy, your immune system may not be able to handle all this. That s why if one family member gets covid, everyone should get a separate place to quarantine alone.

Protecting Health Care

Much has already been written about health care support. The critical factors are Personal Protective Equipment (PPEs), ICU beds, and ventilators. Most critical for HCWs is the N95 mask, which can now be disinfected in a clean room with hydrogen peroxide. Full head-to-toe biocontainment Biosafety Level 2 suits that are re-washable at the hospital laundry. Negative pressure tents that are being created locally for the strongly symptomatic patients. All these options bring the cost of treatment down by 90%. Much of the value created by reuse can be passed on as compensation to our frontliners. Thankfully, no HCW in full PPE gear at TMC has been infected. Next are the ICU beds and ventilators. For a population of 110 million, we have 106,000 beds. 75,000 belong to Level 2 & 3 hospitals, which have critical care capacity. If two-thirds of their 3,700 ICU beds will support covid patients, then the health care system can handle 50,000 cases. If there are more than that in a surge, Emergency Rooms will pick up the slack. The key constraint is ventilators. In Italy 88% of all critically ill patients need a ventilator. The DOH just ordered 1,500 more ventilators to supplement the 1,500 currently in place. That should be enough to support 50,000 cases - if we get them soon.

The Test Kit Supply Chain

The local test kit developed by UP scientists was given commercial certification by the FDA on April 3. It is the first clinically validated study on covus detection prior to public launch - in the world. Between local kit production and the imported kits, there will be 250,000 available in the next month. What we lack is Polymerase Chain Reaction (PCR) processing capacity. Certification for laboratories has been slow. It might take one more week to get to 1,200 per day processing - and we ll be almost at the end of the national lockdown. We need to get processing capacity up to 5,000 per day, so we don’t get a second wave when restrictions are relaxed. We need these test kits so hot spots can be identified quickly and with good contact tracing, areas of infection locked down. South Korea has done 400,000 tests. 1 of 41 was covid. The Japan ratio is 1:28. The Philippine ratio is 1:2. A paltry 4,000 tests, 2,100 cases as of March 31. The WHOrecommended ratio is 1:10. Let s not put all our bets on these kits however. Even if they are the gold standard, they are only 63% accurate. The rapid test kits which detect the antibodies ten days after infection, are half as accurate. The doctor needs to examine you and, combined with other tests and diagnostics, make the final determination of your illness.

Mitigating Factor 1 - The Demographic Dividend

Most of us panic when we hear of Italy's 12% case fatality rate. Actually, the case fatality rate will be much lower than the infection fatality rate for the whole population. In Korea's case, with massive testing, it is only 0.6%. Why is this so? The first reason is that when you test more, the rate lowers, as one tests the less sick. When there are not enough kits, as is the case currently, testing is limited to the elderly or those with comorbidities. The second can best be illustrated by comparing the population pyramids of Italy and the Philippines. Italy s population is 60 million, with 30 million below 50 years old, 10 million between 50-60, and 20 million above 60. It has the second oldest population in the world, after Japan. The Philippine population is 110 million, with 90 million under 50, 10 million between 50-60, and 10 million above 60. This demographic dividend works also in the case of health care. The case fatality rate for 50 and under is 0.1%, around the same as the seasonal flu. 50-60 is around 2%, and 8% above 60. The third is that the number should be lower because of those that bother not to test because they are asymptomatic or mildly symptomatic. By comparison, Italy’s case mortality rate is 12%. Ours is 4%.

Mitigating Factor 2 - The Summer Bonanza

Some studies suggest that the virus does not like high temperature and high humidity. There is a belief that when summer and rain arrives in the Northern hemisphere, transmission risk will be reduced, while in the Southern Hemisphere winter, the illness will simultaneously ramp up. Being in the equator, where heat and humidity are constants during the wet and dry season, we could have less to worry about.

Prescriptions for Rebooting the Economy

Shelter the Elderly in Place

The initial outbreak of covid in the United States happened in a number of nursing homes in Seattle, where sick staff members worked in multiple long-term care facilities caring for the elderly. 35 deaths were linked to one center alone. In Italy, there were 62 deaths in two nursing homes. Spain was also hard-hit.

Until the vaccine is found, the elderly should cut down mall visits, and especially traveling. They should monitor their temperature regularly. Those who live with them should maintain a healthy physical distance, and be extra careful in social or workplace settings so that they don’t carry unnecessary exposure risk home. This health care system adjustment is primarily for our senior citizens.

All senior citizens, including the immunocompromised, should be required to wear a visible ID in public.

Maintain Community Standards of Hygiene

Covid has redefined how we should relate to each other physically. This also has implications for how communities are managed. In a business setting, a community can be a factory, office building or mall. In a residential one, it can be a subdivision or barangay. A rating system for hygiene, with regular monitoring, should be built and maintained by different private sector associations, or public sector agencies and LGUs. There are hierarchies of communities, or groups of people with common interests, that can work together on this.

As an example, does a factory or office now have a workstation distance rule for sewers or call center agents? Are elevators marked off, with buttons pressed by elbows and not hands? Are building surfaces and bathrooms wiped down daily with a chlorox and water solution? Are there more stringent standards for when employees should and should not come to work? Are more employees working from home, particularly seniors, so building occupancy is reduced? Does everyone wear a mask at the office?

Each industry association should adapt standards that adhere to best practices in community hygiene, sensitive to their unique business needs but cognizant of the social engineering rules necessary to keep the virus within bounds. Particular attention should be made to high-contact professions, like those that transport goods and people, maintain and clean buildings and facilities, and serve customers in stores and restaurants. Or large gathering places like malls and markets. Hospitals of course will have the highest standards of community hygiene.

Similarly, does a city have enough spaces to handle outbreaks of covid, so that the mildly symptomatic, PUIs and PUMs are appropriately isolated? Is mask use being consistently enforced in public? Are there enough hospital beds within its radius for the severely symptomatic? Are the public markets managed for crowding? Do vendors there wash their hands regularly?

The country, as a political unit under the auspices of a national government, needs to set the stage for a new social contract. Too much self-interest can violate the community interest of the many to the benefit of a few. A covid superspreader can consciously not disclose symptoms during a hospital visit with a spouse and bring many HCWs down. How much of social media shaming is appropriate, versus significant penalties for noncompliance?

Let s start with a checklist. Here s a link to an impact assessment form that is being continually refined as we crowdsource community behavioral standards for covid: https://forms.gle/DUiCJ1qTdtL6x4xr6

Redefine Border and Transport Management

A whole industry was built around fighting terrorism after the 2001 World Trade Center attack. We now take a lot of the security norms at our airports for granted. Since 2001, global travel expanded exponentially, with pauses in 2003 for SARS, 2009 for swine influenza, and 2015 for MERS. With covid, this has come to a screeching halt. It need not.

Airplanes are the epitome of crowded spaces. The longer the flight the riskier the exposure. Airplane flights defined the modus operandi of our OFWs. The Philippines became a bedroom community to the rest of the world, with workers sending $30 billion plus home. The safest way to fly now is to dress up like a HCW, with full PPE, including goggles, and not eat during the trip.

As we continue to find a safer way to fly however, we need to keep our borders open to facilitate economic exchange. Korea, Taiwan, Singapore and Japan have kept their borders open, mostly to their expatriates. 20-30% of their covids come from these flights. Their protocols are to screen them for fever and test them at the airport, and mandatorily quarantine anyone for 14 days who comes from abroad. Korea and Taiwan use geo tracking on cellphone apps to ensure compliance.

The contact tracing network in Wuhan was composed of 1,600 five-person teams. Do we have a strong tracing network to enforce border control at our airports?

Japan has 25 million more people than us, the oldest country in the world, with currently the same number of covid cases. It has kept its subways open. Everyone there wears a mask. That s the social norm. In addition, Japanese do not do touch skin, nor wear shoes at home, nor eat with their hands, nor speak in public transport. This could be the last sector bastion to open if we adhere to new norms.

The Keys to Beating the Virus: Be Patient until Health Capacity is Built Up, Modify Behavior, Act as One

The big question is - should we open up April 15? The big answer - if we don t have the tracing infrastructure with test kits, test results, quarantining facilities, and community surveillance and monitoring ready, we ll have a big spike in covid. And it ll be worse.

Examples primarily in East Asia have shown that countries can operate relatively normally, even with covid. But citizenry needs to cooperate - as individuals with good hygiene practices, and in cohorts where behavior is managed as a pool of social norms. The less legal intervention, the better. We did not need formal government to fight in World War 2. We only need ourselves, acting in an empowered way as one nation, to beat covid.


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