The Office of Civil Defense (OCD) led by the National Disaster Risk Reduction and Management Council (NDDRMC) Undersecretary Ricardo Jalad, activated the pre-agreement with United Nations Office of Disaster Risk Reduction (UNDRR) ARISE Philippines network and partner Nature Spring, with the 1st batch delivery of 43,000 SM Bottled Water to various frontliners in Metro Manila, dealing with the COVID-19 health emergency.
ARISE is the Private Sector Alliance for Disaster Resilient Societies, the DRR network of private sector entities in the Philippines. SM Prime is the UNDRR ARISE secretariat, headed by Hans T. Sy, Chairman of the Executive Committee, and its lead partner is the National Resilience Council (NRC). ARISE network pre-agreements are signed MOUs between members of the public and private sectors for immediate assistance with goods and services during times of calamity or crisis.
The Chief Data Scientist and top policy strategists of PUBLiCUS Asia, Inc. (PAI) have collaborated to publish Competitive Intelligence (CompIntel) Report No. 1, Series of 2020 titled “#FlattenTheCurve: Effects of Exposure Risk Reduction and Quarantine Policies on COVID-19 Local Transmission Rates in the Philippines”.
This CompIntel Report is PAI’s contribution to COVID-19 literature for consideration of Philippine decision-makers in the public and private sectors. It provides an epidemiological model of the spread of the infection in Metro Manila under various levels of Exposure Risk corresponding to the number of acts or interactions that could cause the virus to spread from one person to another.
The report finds that strict compliance with and strict implementation of severe, even draconian quarantine or lockdown policies for an extended period of time within Metro Manila, Luzon, and possibly the entire Philippines is the only feasible way to flatten the local transmission curve of COVID-19 before it strains the Philippine health care system to the point of complete collapse. The report also outlines specific policy recommendations to improve the implementation of the Enhanced Community Quarantine (ECQ) of Luzon.
PUBLiCUS Asia, Inc.Competitive Intelligence Report No. 1, s. 2020
#FlattenTheCurve:Effects of Exposure Risk Reduction and Quarantine Policieson COVID-19 Local Transmission Rates in the Philippines
David B. Yap II, PhD Ma. Lourdes N. Tiquia, MPA, MA Aureli C. Sinsuat
The Coronavirus Disease (COVID-19) caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) has quickly become a global pandemic just months after the first reported infection in Wuhan, China. According to the March 17, 2020 situation report of the World Health Organization (WHO), there are 179,111 confirmed cases worldwide, including 7,426 deaths, spread across every continent except Antarctica. China (81,116 cases), Italy (27,980), Iran (14,991), Spain (9,191) and South Korea (8,320) are the five countries with the highest number of confirmed cases.
The first COVID-19 case in the Philippines was recorded on January 30, 2020, with a second confirmed case and first fatality recorded on February 2. These were considered imported cases as they involved a pair of Chinese tourists traveling together from abroad. The first case of local transmission involving a 62-year old Filipino male from San Juan City, Metro Manila with no recent international travel history was confirmed by the Department of Health on March 7. Since then, the number of confirmed Philippine cases has risen exponentially. As of 12:00 noon on March 18, 2020, 202 cases of COVID-19 have been confirmed in the Philippines along with 17 deaths, resulting in a mortality rate of 8.4% – more than double the global mortality rate of 4.1% as of March 17. Computed from March 17, 2020 WHO situation report (See Note 1).
Following the examples of China and Italy, the Philippine government has imposed aggressive community quarantine policies to arrest the accelerating rate of COVID-19 local transmission. Though styled as ‘quarantines’, these policies are essentially lockdowns. The theory behind this is that by significantly decrease opportunities for exposure to the virus through the imposition of strict limitations on movement and contact with other people, the number of recovered confirmed cases will begin to outpace new infections. This is commonly referred to as “flattening the transmission curve” or simply “flattening the curve”.
This report studies the quarantine policies adopted by the Philippine government through the lens of epidemiological modeling by comparing projected infection and active case numbers based on different levels of exposure risk. We argue that strict compliance with and strict implementation of severe, even draconian quarantine or lockdown policies for an extended period of time within Metro Manila, Luzon, and possibly the entire Philippines is the only feasible way to flatten the local transmission curve of COVID-19 before it strains the Philippine health care system to the point of complete collapse. Specific recommendations to the government and general public to optimize lockdown implementation and ensure higher efficacy in policy outcomes are also provided.
Philippine Quarantine Policies
Alarmed by the increasing number of COVID-19 cases in Metro Manila, the Philippine epijustify; of the pandemic, President Rodrigo Duterte announced on March 12, 2020 the implementation of a Community Quarantine of Metro Manila beginning March 15, 2020 and ending on April 14, 2020. Entry and exit from Metro Manila was restricted, classes at all levels and work in executive branch offices were suspended, mass gatherings were banned, and social distancing measures in public places were enforced. However, public transportation within Metro Manila continued to operate and private businesses were only encouraged to adopt work-from-home arrangements. Workers employed in Metro Manila but residing in surrounding provinces were also allowed to enter Metro Manila upon presenting a valid work ID.
After observing mixed results from the original partial lockdown, President Duterte imposed on March 16, 2020 an Enhanced Community Quarantine in the entire island of Luzon effective until April 12, 2020. Public transportation in Luzon ceased operations, and international and domestic travel to and from Luzon were severely restricted. Non-essential business establishments not providing basic goods or services such as food and medicine were shuttered. Residents of Luzon were confined to their homes for quarantine, except for limited trips outside to transact with essential businesses, seek medical attention, or travel to work at essential establishments. Curfews were also imposed via local ordinances to empty the streets from 8pm to 5am every night.
The Enhanced Community Quarantine (ECQ) of Luzon can be characterized, for all intents and purposes, as a lockdown which significantly reduces the risk of exposure to SARS-COV-2. However, it cannot be characterized as a total lockdown. Certain persons are still allowed to enter Luzon via international ports. Individuals are still allowed to leave their homes and come into contact with others, who may or may not already be carriers of the virus. Thus, the ECQ still does not provide the lowest possible exposure risk level, a concept which will be discussed later.
Susceptible-Infection Epidemiological Model
To illustrate the effects of quarantine and lockdown policies on disease prevalence (the cumulative number of infections within the population) and disease incidence (the number of people that may require medical treatment as a specific point in time), we ran the numbers using a susceptible-infection epidemiological model for Metro Manila with Day 1 corresponding to March 7, 2020, the date when local transmission was confirmed. This model is predicated on the following assumptions:
Population of 10 million with a single patient as starting point (March 7, 2020)
No recurrence of infection upon recovery
No inherent individual immunity to infection
Constant rate of infection at 5% (conservative), 10% (moderate), and 20% (aggressive)
FIGURE 1: DISEASE PREVALENCE OVER TIME AT VARIOUS EXPOSURE RISK LEVELS
Exposure Risk (ER) Levels 10 (LEFTMOST) TO 1 (RIGHTMOST)
Figure 1 provides a graphical overview of the progression of disease prevalence over time given various exposure risk (ER) and a moderate infection rate of 10%. Exposure risk levels correspond to the number of acts or interactions that could cause the virus to spread from one person to another. The leftmost graph representing ER 10, the highest level, would correspond to business-as-usual operations in Metro Manila without any restrictions on travel, work, school, and outings, along with a lack of deliberate social distancing. The exposure risk level decreases by 1 after every graph such that the rightmost graph corresponds to an exposure risk of 1. ER 1 would roughly correspond to a total lockdown situation with the most limited number of interactions, assuming complete compliance by the subjects of the lockdown.
ER 10 to ER 6 would allow the virus to spread throughout the population within 27 days or less than a month. ER levels 5 and 3 would require between five to eight weeks, and ER 2 would require 76 days. At ER 1, the spread of the disease would be almost nine times slower than ER 10 at 150 days or five months.
FIGURE 2: DISEASE INCIDENCE OVERTIME AT VARIOUS EXPOSURE RISK LEVELS
Figure 2 provides a graphical overview of the progression of disease incidence (the number of people that may require medical treatment) over time given various exposure risk levels and a moderate infection rate of 10%. Again, the bell curves are indexed by exposure risk (i.e. from 10 at the leftmost to 1 at the rightmost, each curve decreasing by exposure risk increments of 1).
The estimates suggest that the peak number of cases at exposure risk levels 2 to 10 could require as many as between 500,000 to 2.4 million hospital beds assuming 100% of cases were categorized as moderate to severe and required admission. Calculating based on the prevailing global estimated moderate-severe case rate of 20% (generally encompassing all symptomatic cases requiring in-patient treatment) this would equate to roughly 100,000 to 480,000 admitted cases. Meanwhile, ER 1 would require substantially fewer hospital beds and would distribute the strain on precious medical resources over a markedly longer period of time – almost seven and a half months from start to finish.
It must be noted that even the most conservative model at the lowest exposure risk level predicts a terrible strain on the Philippine healthcare system. The peak of the conservative disease incidence at the lowest exposure risk (ER 1) on Day 323 would require as many as 124,992 hospital beds with a 100% admitted case rate. Calculating again based on the 20% moderate-severe case rate, this would require 24,998 hospital beds in Metro Manila. The hospital bed capacity of Metro Manila is only 29,000 according to the Department of Health.
As discussed earlier, the current Enhanced Community Quarantine does not achieve the required level of isolation for Exposure Risk 1. Even going up just one notch to ER 2 would debilitate Metro Manila’s health care system by requiring an estimated 49,977 hospital beds on Day 162 based on the 20% moderate-severe case rate – almost double the actual bed capacity of all Metro Manila hospitals combined.
Interpretation of Models
The results above suggest that Metro Manila and perhaps even the entire Philippines – which has a national hospital bed capacity of only 106,000 – is headed towards a potentially debilitating overload of local and national health care systems as the rate of transmission of COVID-19 cases remains at a sharp upward trajectory. Therefore, it is evident that immediate action must be taken to reduce COVID-19 exposure risk by massive amounts. Insisting on a business-as-usual strategy would increase the rate of infection and increase the risk of overloading the medical system.
Unfortunately, the Philippines simply does not have the financial or technical capabilities to adopt the mass testing and individual isolation strategy employed by the Republic of Korea to flatten their country’s transmission curve. In that case, the most feasible and proven strategy available would be to implement widespread lockdown policies such as those implemented in Hubei, China and Italy. Thus, it is clear that strict compliance with and strict enforcement of the Luzon Enhanced Community Quarantine and any future quarantine or lockdown policies are essential to averting a public health disaster or even the complete collapse of the Philippine health care system.
It is not a question of whether or not the virus will spread. Rather, it is a question of how rapidly it will spread. The macro effects of the virus will be spread out over a longer period of time and become more manageable if exposure risk among the entire population is minimized as much as possible. This would allow the government more time to secure emergency funding, undertake emergency construction of medical facilities, procure medical supplies and personal protective equipment, coordinate with international and humanitarian actors for technical and financial assistance, and perform other essential tasks to keep the situation under control.
Based on the foregoing, the following recommendations are humbly submitted:
1. All persons subject to Enhanced Community Quarantine or any other quarantine protocol in Luzon or any part of the Philippines should strictly observe the prescribed quarantine protocols toward the end of bringing down their individual and household exposure risk levels down to 1 for extended periods of time.
2. Private enterprises employing no-work, no-pay employees for non-essential business purposes should commit to and immediately deliver wages equivalent to 30 days of work (excluding rest days) to incentivize these employees to stay home instead of attempting to work.
3. The Stimulus Package currently being formulated by the national government should focus on immediately disbursing funds in a way that would incentivize strict compliance with quarantine procedures by individuals and businesses.
Suggested programs include:
Identification of informal sector workers by DOLE, who would then receive payouts from DSWD, thus incentivizing informal workers to stay at home rather than plying their goods or trade outside;
Joint DTI-LGU Buy-Back Program where basic necessity goods will be procured from available stocks of micro-enterprises (sari-sari stores, etc.) and distributed to residents subject to quarantine by the respective LGUs;
DOH-LGU Frontline Health Workers Program to provide medical personnel and public health workers on duty with food, transportation, and other essential goods and services for the duration of the COVID-19 pandemic, thus reducing the need for health workers to come in contact with people outside of their clinics/hospitals;
The COVID-19 Inter-Agency Task Force (IATF) should create three sub-teams: a Policy Team, a Forecasting Team, and an Implementation Team, to streamline the tasks of the various officials and foster greater efficiency in operations.
4. IATF Implementation Team (ImT) must establish better coordination with LGUs, especially those outside of Luzon, to facilitate logistical concerns during these times and to answer in a timely manner questions of LGUs, AFP, and PNP on the implementation of the ECQ and other quarantines.
5. ImT should also adopt a National Supply Chain Protocol (NSCP) utilizing public and private land vehicles, airplanes, and ships to facilitate the speedy delivery of goods for distribution in quarantine areas. The NSCP should also include mechanisms for the speedy delivery of test kits to the National Institute of Tropical Medicine for confirmation of COVID-19 cases before the used test kits expire.
6. IATF Forecasting Team (FT) should regularly review all available data to forecast national and local trends in infections for the consideration of the President and the IATF Policy Team (PT).
7. PT should regularly review the implementation and forecast notes to make changes to the quarantine guidelines as necessary, most especially the severity, geographical coverage, and duration of ongoing and future quarantines.
8. IATF must adopt a Crisis Communications Protocol (CCP) to communicate necessary updates and information to the general public in a concise, timely, and easy-to-understand manner. IATF should also reduce the amount of officials authorized to speak to the media on its behalf or on behalf of its member departments and agencies, as well as the length of their press conferences. Information overload should be avoided at all costs.
ANNEX A: ADDITIONAL CHARTS
FIGURE 5: DISEASE PREVALENCE OVER TIME AT VARIOUS EXPOSURE RISK LEVELS
FIGURE 6: DISEASE INCIDENCE OVER TIME AT VARIOUS EXPOSURE RISK LEVELS
FIGURE 7: DISEASE PREVALENCE OVER TIME AT VARIOUS EXPOSURE RISK LEVELS
The World Health Organization yesterday declared the COVID-19 a pandemic, meaning that its spread is global and there is widespread local transmission. It signals that health authorities must now change focus from containment to mitigation. Much is unknown about the COVID-19, but it seems to have the capability to spread faster and be more virulent than the flu. The fatality rate of COVID-19 is currently at 3.4 percent, but as more tests are conducted, that rate will go down to what some say is around one percent. One death, of course, is one too many.
A kit, a kit, my kingdom for a (testing) kit!
Although China seems to have turned the corner on the disease, the rest of the world are just beginning to feel its severity. The Philippines has proven to be ill-prepared for this new disease. We are particularly vulnerable because we have a large number of fellow citizens working in places where risk to exposure is high.
The crucial element in containment is diagnostic testing especially considering that people infected with the virus may be infectious even without exhibiting any symptoms. DOH Secretary Duque has said that funding is not a problem, but rather the availability of testing kits. True, but like in the US this was compounded by delaying the onset of mass testing and by limiting it to those who have exhibited symptoms.
The other issue is that diagnostic testing is a two-step process requiring field testing results to be sent to accredited laboratories for confirmation. Thus, it takes anywhere from 24 to 48 hours turnaround for the results — crucial time lost. Previously, samples had to be sent to a laboratory in Melbourne. I understand that RITM now has that capability, but that means far away regions will have longer turnaround counting the transport time. Secretary Duque said four more regional centers would be opened soon. Those labs require sophisticated devices to provide definitive positive or negative results. I hope they have them or are allocated funds to acquire them. As more tests are conducted, the number of those identified as infected will rise dramatically. As in the US, the question being asked here is if the delay and paucity in testing has enabled the disease to gain a toehold in the country.
Although now is not the time for finger pointing, but rather for a concerted effort by all of society to mitigate its impact on the country, it would be instructive to learn from the experience of others in dealing with infectious disease — which seem to be the “new normal” — now and for the long term.
Given its proximity to China and the magnitude of the flow of people and goods across the Taiwan Strait, Taiwan was expected to be hit hard by the initial outbreak. But contrary to expectations, it has been able to contain the spread of the disease to manageable levels in contrast to others in the region, notably Japan, South Korea, Hongkong and Singapore.
Firstly, Taiwan has a specialized agency tasked with infectious disease prevention and control. The Center for Disease Control was established in 1999 and is responsible for formulating disease prevention and control policies, conducting research on pathogens, and implementing rapid response measures to emerging infectious diseases. Taiwan was, therefore, able to take pre-emptive measures — utilizing digital technology like Big Data and AI — as the disease was developing in Wuhan.
The closest equivalent we have is the Epidemiology Bureau in the DOH which has inadequate resources and limited mandate. Rep. Joey Salceda recently introduced a bill that would create a Philippine equivalent agency.
Our handling of the current crisis has shown the importance of having a specialized agency with the resources and authority to tackle infectious diseases on a sustained basis.
Secondly, Taiwan had in place the mechanism to coordinate all relevant government agencies to rapidly respond to such outbreak. The National Health Command Center (NHCC) is part of a disaster management center and acts as the operational command point for central, regional and local authorities. Under the NHCC, Taiwan’s CDC activated the Central Epidemic Command Center (CECC) to coordinate efforts by various ministries including transportation, economic affairs, labor, education and the Environmental Protection Agency to counteract emerging public health crisis. In the Philippines, I am surprised that the Office of Civil Defense is not at the center of our government’s effort to deal with what may turn out to be a public health disaster.
Although not as dramatic as an earthquake, a volcanic eruption or a super typhoon but just as deadly, this pandemic should be treated the same way we respond to disasters. In past situations, presidential leadership was crucial in delivering an effective response. All of us should, therefore, take this seriously – starting from the top!
To support government efforts on mitigating the impact of the disease, the National Resilience Council is scheduling a roundtable on COVID-19 to increase awareness of the status of its spread and mitigation efforts at national and local levels in the Philippines. The roundtable will respond to a growing number of questions regarding the policies and their implementation with respect of early detection, containment, mitigation, and their implications on socio-economic stability and security; highlight potential interventions and solutions based on leading global practice; identify lessons being learned to inform future actions to address similar hazards; and emphasize the need for crisis management and leadership, and organizational capacity for national resilience. Key government officials and local and foreign experts will be invited to participate.
Postponement of the Roundtable on digital agriculture
The APEC Business Advisory Council (ABAC) has made the sensible decision to postpone its meeting in Manila out of concern for the participants given that the disease is not yet under control and in fact, now declared as a pandemic. Unfortunately, that means the CPR Foundation co-sponsored Roundtable on digital agriculture, which was part of a series of events during the meeting, will have to be postponed as well. We will announce the new date once it is confirmed. The event and the subject have drawn considerable support, most specially from DA Secretary William Dar.
GENEVA, 12 March, 2020 – The UN Secretary-General’s Special Representative for Disaster Risk Reduction, Mami Mizutori, today acknowledged WHO’s declaration of a pandemic in relation to the global outbreak of the COVID19 virus which has claimed over 4,000 lives to date.
Ms. Mizutori who also heads the UN Office for Disaster Risk Reduction (UNDRR), urged national disaster management agencies to continue with the development of their preparedness and response capacities to include health emergencies as a top priority, alongside earthquakes, floods, storms and other natural hazards.
“Events such as the COVID19 pandemic, Ebola epidemics and Zika virus outbreaks underline how important it is to break down the silos in disaster prevention and management. We need to recognize the multiple ways in which such outbreaks can have a ripple effect across sectors of society and lead to the breakdown of systems that we take for granted, including health care, the provision of education, global supply chains, travel, trade and financial services.
“It is understandable that there is a strong disaster management focus on natural hazards. They are visible, and affect over 100 million people every year, but this machinery must also be ready for deployment in public health emergencies when the trigger is a virus like COVID19.
“This is a red-letter year for disaster risk reduction. UN Member States adopted the global plan to reduce disaster losses, the Sendai Framework for Disaster Risk Reduction on 18 March 2015 and committed to have national and local strategies for disaster risk reduction in place by this year. It is essential now that these strategies are revisited to ensure that they prioritize the management of biological hazards and resilient health systems.
“The Sendai Framework is a valuable instrument for ensuring better health outcomes in disasters. It emphasizes the need for resilient health systems and the integration of disaster risk management into health care provision at all levels.
“Its full implementation will help break down any silos that exist between disaster managers and health workers. It will also help to shift the focus from disaster response and management to preparedness, surveillance and disaster risk management in the health context.”