Questions about increasing COVID deaths

By Rafael Castillo M.D.

We share the optimism of Fr. Nicanor Austriaco Jr., OCTA research fellow, who reported during the President’s weekly “Talk to the People” that the Philippines appears to be attaining the much sought-after herd or population immunity as a result of natural infection and vaccination for COVID-19.

Indeed, new cases have decreased by more than 99 percent compared to the peak of more than 26,000 new cases a day in September. Less than two out of a hundred tests done in recent weeks turn out to be positive.

For the first time in quite a long while, big medical centers in key cities are now reporting near-zero admissions for COVID-19. All these despite the highest level of mobility allowed since the pandemic started in March of last year. Consequently, our COVID recovery performance as gauged by foreign observers is now improving tremendously.

Congratulations are in order, and the Department of Health (DOH) and our Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF) must be doing the right thing. Many are quick in attributing the marked decrease in new cases to the ramped-up vaccination, but Father Austriatico was careful enough to mention natural infection first before vaccination. We’re now getting more reports weekly showing that a previous natural infection provides a more robust and durable or longer-lasting immunity compared to vaccine-generated immunity.

Natural immunity

At the very least, natural immunity is equivalent to vaccine immunity based on more than 120 studies; yet the DOH and the IATF apparently still do not recognize infected and recovered individuals as possessing sufficient immunity to match vaccine immunity, since the mandate to vaccinate includes all, including those who already recovered from a previous infection with the SARS-CoV 2 virus.

We fully agree with everything included in the latest OCTA report. As we wrote before, we believe the group has been a big help in guiding the DOH and various anti-COVID working groups or task forces.

But there was one thing sorely missed in Father Austriatico’s report. There is one glaring red flag in the daily report issued by the DOH that seems to have been missed.

We have already raised the question in recent columns: Why is the number of COVID patients dying progressively increasing despite the more than 99-percent drop in new cases? This is uniquely peculiar in the Philippine situation.

It’s logical to expect, as what happened in other countries, that with the significant reduction in cases, the decrease of deaths follows. There may be a lag of one to two weeks due to leftover severe cases, but by the third or fourth week after the peak of cases, there is already a progressive decrease in deaths proportionate to the reduction in new cases. But the opposite seems to be happening in the Philippines.

It’s been 12 weeks now since the peak in mid-September, but the case fatality (CF) risk, which is a reflection of the percentage of people dying in proportion to the new confirmed cases, continues to increase. In fact, the weekly CF risk average has increased 22-fold compared to the weekly average when we had more than 20,000 new cases daily.

Logically, we would expect more COVID patients to die during the peak of surges, since the hospitals get overwhelmed with cases and some severe cases die at the emergency rooms while waiting for a bed to be vacated in the wards or intensive care units. But as the number of cases goes down, COVID-related deaths also go down. This pattern has been noted in practically all the countries that experience overwhelming surges. The opposite pattern is happening here, so it’s something the DOH, the IATF and all who have access to the data like OCTA should look into.

We reported previously that the weekly CF risk average was progressively increasing. In July to September, we were averaging 1.5 percent to 1.6 percent weekly. Since then, it started to go up, and in October-November, our weekly CF risk averaged 5.1 percent, 6.9 percent, 12.3 percent and 16.8 percent, starting in the last week of October.

Correct explanation

In the last two weeks, the increase continued, such that from Nov. 26 to Dec. 2, the CF risk increased some more to 23.3 percent, and from Dec. 3 to 9, it continued its upward trend to 33.9 percent. That means if you take the CF risk as a crude indicator of people dying from COVID-19, does this mean one-third of infected patients are dying? That can’t be true, so we must find out the correct explanation to reassure those who were keen enough to notice this red flag which the authorities seem to be missing or ignoring.

What validates this concern is that the number of mild and asymptomatic cases has dramatically gone down from almost 96 percent up to the peak of the last surge in September to 46.7 percent as of Dec. 9. That means that the majority now consists of moderate, severe and critical cases who need hospitalization, and yet the big hospitals are now reporting a relatively smaller percentage of cases, and the intensive care units are now free of COVID cases in many big hospitals in key cities of the country.

Does this mean that the admitted COVID patients have now shifted to the provinces, and many of these patients are confined in provincial hospitals which may not be completely equipped with the necessary machines and medicines to treat severe cases? The DOH and the IATF have to find out the answer, so they can determine what could be done to stem the tide of COVID-19 deaths.

Uncanny similarity

Father Austriatico explained the marked reduction in cases as an indicator “that the virus is struggling to find new Filipinos to infect, (and it) suggests that we have attained substantial population immunity.”

We agree that this is likely the logical explanation, but in view of the increasing percentage of deaths, it must be ruled out that the virus variant we have now is getting more virulent, and because the virus kills its host victim, the virus colony dies with the victim and is no longer transmitted to other persons. That happened with the more virulent predecessors of the SARS-CoV-2 such as the Middle East Respiratory Syndrome coronavirus, which had a death rate of 32.7 percent in its final months.

Although this death rate has an uncanny similarity to the 33.9 percent the country registered last week, we believe this is a highly remote possibility. Nonetheless, for Pinoys’ sake, it has to be ruled out. The other possibility, as mentioned earlier, is that the patients are now confined in smaller provincial hospitals with fewer life-saving medicines and machines.

With the data the DOH has, it should be easy to determine the answer to this conundrum, so we don’t have to second-guess each other as to the correct explanation, and we can institute the corrective measures that need to be carried out. If the smaller provincial hospitals are now carrying the brunt of cases, all means must be exerted to assist them by way of expertise, machines and medicines.Unless the health authorities address this question of increasing death risk, we can never really be assured that we’re headed for the exit door out of this protracted pandemic.