‘We don’t have time’: What gov’t must do, what you can do

We’re now seeing an exponential increase in the number of COVID-19 cases in our country.

We urgently need to mobilize primary care physicians (PCPs), other health-care workers (HCWs) and trained barangay health workers (BHWs) before health-care exhaustion — and, ultimately, collapse—sets in.

We don’t have time. We have failed in the first phase of the battle — disease containment—which, to be fair to our health officials, is much more complex than it seems.

The next phase, which we can’t afford to lose, is impact mitigation on the population. A whole-of-government and whole-of-society approach is mandatory.

Our best bet is to mobilize all available resources now. If health care collapses, the rest — the economy, peace and order, national security, etc.—are also at risk of breaking down, like dominos falling one upon another.

A matter of weeks

We’re not being alarmist. Our health-care system will likely be overwhelmed and exhausted very soon, as in a matter of weeks.

That will likely happen if everyone with COVID-19 symptoms keeps going to hospitals to seek consultation and admission. If they are not served, or are shut out because the emergency rooms are overcrowded, unrest and then chaos may follow.

Even if the lockdown works, the best-case scenario, with an optimistic 6-day doubling rate, is this: more than 50,000 new cases by April’s end, with deaths of around 3,000.

Without enough test kits, we cannot document all new cases, including deaths. Many persons under investigation (PUIs) die without benefit of testing, so they’re not recorded as COVID-19 deaths. In short, our reported cases and deaths are significantly less than the actual situation.

Our major hospitals are packed. Health-care providers and volunteer paramedicals will have to actively help manage mild to moderate cases as outpatients so as to decongest hospitals and reserve the beds for severe cases.

Mild to moderate cases comprise 85 percent of the COVID-positive (+) population. Only around 15 percent—those classified as high-risk patients and those with severe/very severe signs and symptoms—should be hospitalized.

Around 5 percent will require intensive care with respirators or breathing machines. But there are not enough respirators in the event of a full outbreak.

If our PCPs, HCWs and BHWs are harnessed well, we may ease the congestion in hospitals and possibly buy time to improve our preparedness to fight this pandemic.

Whole-of-society approach

Here’s how a whole-of society approach can help avert health-care exhaustion:

PCPs and other volunteer doctors—including surgeons, pediatricians, obstetricians and other specialists—can do the preliminary evaluation. The other HCPs and BHWs can do the follow-up on treated low-risk patients with mild to moderate COVID-19. In many instances, phone follow-up will suffice.

Telcos can waive fees for the use of mobile phones or reduce these to the bare minimum in the next two to three months for optimal communication between patients and health-care providers. President Duterte’s emergency powers may perhaps be used to convince telcos about this altruistic gesture.

In the next weeks, when we breach the 10,000 mark for confirmed cases, the Department of Health may consider temporarily suspending the prescription requirement for drugs used in the treatment.

Phone consultations with volunteer physicians should be encouraged for mild to moderate symptoms. Should there be no means or time to send an e-prescription, drugstores should allow dictated prescriptions, as long as patients fully understand how and up to when the drug should be taken.

Manufacturing and mechanical industries should harness their resources and creativity to mass-produce ASAP reliable test kits, protective garments for front-liners, and basic respirators, with features sufficient to sustain patients with COVID-19 lung injury.

The Philippine Medical Association, with its more than 50,000 actively practicing physicians, and all the medical-specialty groups under it, should provide support and urge its physically able members to volunteer for this mission.

Protect health-care providers

The novel coronavirus is highly contagious. The strict personal protection of health- care providers is required in face-to-face consultations with suspected patients.
Personal protective equipment (PPE) consists of face mask (preferably N95, but if not available, surgical mask will do), eye shield/goggles, cap, disposable nonpermeable gown, booties, gloves.

The services of health-care providers are badly needed. They must thus ensure their own protection at all times so they don’t get infected themselves.
In their fervor to serve, many health-care providers neglect themselves—hence, the high fatality rate among doctors, including four of my friends, in the early days of the pandemic. Several more are fighting for their lives.

The government should provide enough PPEs to those enlisted for this mission, including training in proper donning and doffing of the equipment to prevent infection.

Simplified treatment plan

I’ve prepared a simplified treatment plan based on my personal experience with a reasonable number of COVID-19 patients I was requested to comanage, with some recommendations based on published literature on the subject.

Depending on their clinical presentation and exposure to a COVID+ person (travel history is no longer a major factor), patients should be classified as PUIs or persons under monitoring (PUMs), and if they’re PUIs or COVID+, whether they’re low-risk or high-risk.

PUIs may have direct exposure or COVID-related symptoms, or both. PUMs may have indirect exposure and are asymptomatic or symptom-free.

For PUMs, we advise:

• Strict home quarantine for 14 days.
• Melatonin, 1 3-milligram capsule (any brand at major drugstores) taken 4 times daily (on waking up, before lunch, at 4 p.m., and at bedtime). Take for two weeks and discontinue if symptom-free.
  Other immune-system-­boosting supplements may help, such as vitamin C (3-6 grams a day, as tolerated), vitamin D3 (2,000-5,000 units a day), or zinc (30-60 mg a day).
  For PUIs and COVID+ patients who are symptom-free, we advise:
• Strict isolation at home until tested negative twice (around two weeks from diagnosis). If COVID testing cannot be done, continue isolation at home for two weeks for asymptomatic PUIs and three weeks for asymptomatic COVID+ patients. Hopefully, we would have enough testing kits soon to test all PUIs and retest all COVID+ patients.
• 2 capsules melatonin taken 4 times daily for two weeks, then if still symptom-free, gradually reduce to a maintenance dose of 1-2 capsules at bedtime.
  Take note that COVID-19 test kits have varying accuracy and reliability in terms of sensitivity and specificity (generally less than 65 percent). Thus, a considerable number of cases may be missed (i.e., false positives and false negatives). Treatment must still be based on clinical grounds as assessed by health-care providers.

Low to intermediate risk

Low- to intermediate-risk symptomatic PUIs and COVID+ patients with atypical pneumonia but NO difficulty in breathing or shortness of breath may still be managed as outpatients. For them, we recommend:

• Azithromycin (500 mg to be taken by mouth on the first day, then 250 mg once daily for another 4 days).
• Hydroxychloroquine (200-mg tablet twice daily for 10 days. (Caution: In those with known heart problems especially ischemic heart disease and heart failure, it may cause serious life-threatening arrhythmia or irregular heartbeat.)
• If still with cough but no shortness of breath or difficulty in breathing after five days, start Cefuroxime (500 mg tablet twice daily for 7 days). If difficulty in breathing develops at any time, the patient should be taken to hospital for confinement.
• On Day 1 also, start melatonin (3 capsules 4 times daily). Gradually increase dose every two days as tolerated, and as mandated by clinical response up to a maximum tolerated dose of 60 mg a day (5 capsules 4 times daily).
  Maintain at maximum tolerated dose for two weeks or until two negative COVID tests (whichever is longer), then gradually reduce dosage for two weeks for a maintenance dose of 3-6 mg (1-2 capsules) once daily at bedtime.
  Symptomatic PUIs and COVID+ patients should ideally remain in home isolation for four weeks after onset of symptoms or two weeks after discharge with two negative COVID tests. Strict toilet hygiene must be practiced since viral shedding in stools can last up to four weeks from onset.

Antiarrhythmia

Melatonin, which can be bought from any major drugstore as an over-the-counter food supplement, is recommended as adjuvant therapy in COVID-19. For me, even generic brands, so long as they’re approved by our Food and Drug Administration (FDA), will do.

If you’re not buying from a major drugstore, ask for the FDA registration number.

Melatonin does not kill the virus and will not impact viral shedding. But it can help neutralize practically all the deleterious effects of severe viral infection.
It also has an antiarrhythmia effect, which may help those given drugs that may trigger it, like hydroxyquinolone, azithromycin, or quinolones—commonly used drugs in COVID patients.

High-risk cases

High-risk cases (elderly and younger but with ailments like diabetes, hypertension, COPD or chronic obstructive pulmonary disease, morbid obesity, metabolic syndrome, etc.) and those with difficulty in breathing and other severe symptoms must be confined or admitted to a hospital equipped to manage COVID cases.

They should be managed by an infectious disease specialist, a lung specialist or pulmonologist, and other referral physicians depending on the other illnesses present.
Because COVID-19 is highly dynamic and rapidly evolving, it’s like shooting a moving target: very difficult to treat in complicated cases with severe atypical pneumonia and respiratory distress.

In high-risk cases like in the elderly, it can rapidly progress from mild symptoms to end-stage respiratory distress in a few days.
PCPs and HCPs should not be misled by seemingly benign initial symptoms in high-risk cases. At the first complaint of shortness of breath, a patient should immediately be referred to a tertiary hospital.

Lessons

This health crisis is truly unprecedented and poses more questions than we have answers for.

But we’re not exactly treading on thin ice. We can benefit from the lessons provided by experiences in Wuhan and other big cities ravaged by this minuscule virus.

In these experiences, an agile response of the health-care system was key in catching up with the virus that seemed to be always a few steps ahead. If we get overwhelmed this early and falter in our response, it may be “game over” in a few months.