It looks like the upward trajectory has been set. We’re now seeing an exponential increase in the number of new coronavirus disease (COVID-19) cases in the country. The Rubicon has been crossed, and we have no choice but to fight with all our might to survive.
There is urgent 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, set in.
Time is not on our side anymore.
We have failed in the first phase—disease containment, which, to be fair to health officials, is a lot more complex than it seems.
The next phase of the battle, 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 to avert health care collapse, because if it does, the rest—economy, peace and order, national security, etc.—is also at risk of breaking down, in a domino effect.
We’re not being alarmists, like the boy who cried wolf, but the Philippine health care system will likely be overwhelmed and exhausted very soon—repeat, very soon, in a matter of weeks.
This will happen if everyone with COVID-19 symptoms goes to the hospital, seeks consultation and admission. It’s not exactly the same, but could be akin to a bank run. If they aren’t served in hospitals or are shut out because the emergency rooms are overcrowded, unrest and chaos may follow.
Even if the lockdown and other stringent efforts at flattening the curve work, the best-case scenario, with an optimistic six-day doubling rate, is that there would be more than 50,000 new cases by end of April, with deaths of around 3,000.
If there won’t be enough test kits, health officials won’t be able to document all new cases, including deaths. Many persons under investigation (PUIs) die without the benefit of testing, so they’re not recorded as COVID-19 deaths. In short, reported cases and deaths are apparently significantly less than the actual situation in the country.
No place for complacency
So, we should not feel complacent that the numbers are still much lower than in other countries. It’s just that we’re not testing enough. We’ve done only around 1,800 COVID-19 tests, compared to more than 300,000 done in South Korea.
Major hospitals are packed with just 1,418 confirmed cases. Imagine how it would be with 50,000 confirmed cases, plus at least an equal number of PUIs.
Our PCPs, other HCWs, even trained BHWs and other volunteer paramedical professionals must help manage mild to moderate cases of COVID-19 as outpatients, so as to decongest hospitals and reserve the hospital beds for more severe cases.
These mild to moderate cases comprise 85 percent of the COVID-19+ population. Only around 15 percent—those classified as high-risk patients and those with severe/very severe COVID-19 signs and symptoms—should be hospitalized.
Around 5 percent will require intensive care with respirators or breathing machines. We don’t have enough respirators in the event of a full outbreak. We dread the scenario, like what is happening in Italy and Spain, where patients 65 years and older, who need respirators, are just left to die, so younger patients could use the available machines.
If our PCPs, HCPs and BHWs are harnessed well ASAP, we may possibly just be able to ease up the congestion in hospitals, and with the flattening of the curve, we may be able to buy enough time to improve further our preparedness for this pandemic, preventing health care exhaustion and collapse.
Whole-of-society approach
Here’s how a whole-of-society approach can help avert health care exhaustion:
The PCPs and other physicians—including surgeons, pediatricians, obstetricians and other specialists who would volunteer—can do the preliminary evaluation, and the other HCPs and BHWs can do the follow-up on treated low-risk patients with mild to moderate COVID. In many instances, phone follow-up would suffice.
The telcos can do the altruistic act of waiving fees for the use of cell phones or reducing it to the bare minimum for the next two to three months to optimize communication between afflicted patients and all health care providers.
The President’s emergency powers could perhaps convince the telcos on this voluntary gesture.
In the next few weeks, when we breach the 10,000 mark for confirmed COVID-19 cases, the Department of Health may consider temporarily suspending the prescription requirement for drugs used in the treatment of COVID-19.
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, the drugstores should allow dictated prescriptions. However, the drugstore pharmacist should make sure the patients understand well how and up to when the drug should be taken.
Our manufacturing and mechanical industries should utilize their resources and harness their creativity to mass manufacture ASAP reliable COVID-19 test kits, protective garments for front-liners, and basic respirators, with features just enough to sustain patients with COVID-19 lung injury.
The Philippine Medical Association, with a membership of more than 50,000, and all the medical-specialty organizations under it should support this undertaking, and enjoin its physically able members to volunteer for this mission.
Empirical treatment of COVID-19
I’ve prepared a simplified empirical treatment plan of COVID-19 and suspected COVID-19 cases for PCPs, HCPs and BHWs to help guide them in protecting themselves and treating most cases of mild to moderate COVID-19.
This is empirical, based on my personal experience (particularly with high-dose melatonin in COVID-19) with a reasonable number of COVID-19 patients I was requested to comanage, with some recommendations based on published literature on the subject.
• Personal protection: The 2019 novel coronavirus is highly contagious. Strict precautions for the personal protection of PCPs, HCPs and BHWs is a must when they do face-to-face consultations with suspected COVID-19 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 health care providers’ services are badly needed, so they must first ensure that they’re properly protected at all times. In their fervor to serve, many health care providers neglect themselves; hence, the high fatality rate among doctors during the early part of the pandemic. Four of my doctor-friends lost their lives in the initial skirmishes with COVID. Several more are struggling for their lives.
The government should provide enough PPEs to PCPs, HCWs and BHWs who will enlist for this mission. Training on proper donning and doffing of PPEs must be given because infection may also happen in the doffing or taking off of the PPE.
• Patient classification: Depending on the patient’s clinical presentation and exposure to a COVID-19+ person (travel history is no longer a major factor now), patients should be classified as PUIs or persons under monitoring (PUMs); if they’re PUIs or COVID-19+ already, whether they’re low-risk or high-risk.
PUIs may have either direct exposure or COVID-19-related symptoms, or both. PUMs may have indirect exposure and are asymptomatic or symptom-free.
Advice for PUMs, PUIs, COVID-19 patients
For PUMs, we advise the following:
1. Strict self-quarantine at home for 14 days
2. Melatonin (any brand in major drugstores) 1 capsule (3 mg) 4x daily (with first dose upon waking up, before lunch, 4 p.m and at bedtime). Take for two weeks and discontinue if symptom-free.
Other immune system-boosting supplements may also help. These include: vitamin C, 3-6 grams/day as tolerated; vitamin D3, 2,000-5,000 units/day; zinc, 30-60 mg/day.
Asymptomatic PUIs and asymptomatic COVID-19+ patients:
For PUIs and COVID-19+ patients who remain symptom-free, we advise the following:
1. Strict isolation at home until tested negative twice, which is around two weeks from diagnosis. If COVID-19 testing could not be done, continue isolation at home for two weeks for asymptomatic PUIs and three weeks for asymptomatic COVID-19+ patients. Hopefully, we would have enough testing kits soon to test all PUIs and retest all COVID-19+ patients, and make sure they’re no longer capable of infecting others.
2. Melatonin, 2 caps 4 times daily for two weeks; then, if still symptom-free, gradually reduce to a maintenance dose of 1-2 capsules at bedtime.
It is to be noted that COVID-19 test kits may have varying accuracy and reliability, in terms of sensitivity and specificity (generally less than 65 percent). So, a considerable number may be missed (ie., false positive and false negative tests). Treatment must still be based on clinical grounds as assessed by the PCP, HCP or BHW.
Low- to intermediate-risk symptomatic patients
For low- to intermediate-risk symptomatic PUIs and COVID-19+ patients with atypical pneumonia but no difficulty of breathing or shortness of breath, they may still be managed as outpatients. The following are recommended:
1. Azithromycin 500 mg to be taken by mouth on the first day, then 250 mg once daily for another 4 days.
2. Hydoxychloroquine 200 mg, 1 tab twice daily for 10 days (caution in those with known heart problems, especially ischemic heart disease and heart failure, as it may cause possible serious life-threatening arrhythmia or irregular heartbeat)
3. If still with cough but no shortness of breath or difficulty of breathing after five days, start Cefuroxime 500 mg, 1 tab twice daily for seven days. Should the patient develop difficulty of breathing at any time, he/she should be brought to the hospital for confinement.
4. Start on Day 1 also—Melatonin, 3 caps 4 times daily. Gradually increase melatonin dose every two days as tolerated and as mandated by clinical response up to a maximum tolerated dose of 60 mgs/day (5 caps 4 times daily).
Maintain at maximum tolerated dose for two weeks or until two negative COVID-19 tests (whichever is longer), then gradually titrate downwards for two weeks for a maintenance dose of 3-6 mg (1-2 caps) once daily at bedtime.
Symptomatic PUIs and COVID-19+ patients should ideally remain under home isolation for four weeks after onset of symptoms or two weeks after
discharge with two negative COVID-19 tests. Strict toilet hygiene must be practiced, since viral shedding in stools can last up to four weeks from onset.
Melatonin as adjuvant therapy
Melatonin, which could readily be boughtfromanymajor 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. COVID-19 is one condition you cannot afford to gamble with in the quality of your medicines.
Melatonin is not a viricidal agent; it 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.
These include the reduction of inflammazomes causing acute lung injury and acute respiratory distress syndrome (ARDS), and attenuation of the cytokine storm, or the excessive release of inflammation- causing substances that damage the lungs, heart and other organs, ultimately causing death
in some COVID-19 patients.
It also has an anti-arrhythmic effect which may help those given drugs that may trigger it, like hydroxyquinolone, azithromycin, quinolones commonly used drugs in COVID-19 patients.
High-risk cases
High-risk cases (elderly, and younger but with comorbidities like diabetes, hypertension, chronic obstructive pulmonary diseases, morbid obesity,
metabolic syndrome, etc.) and those with difficulty of breathing and other severe symptoms attributable to COVID-19 must be confined or admitted to a hospital equipped in managing COVID-19 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 just mild symptoms to end-stage respiratory distress in a few days.
So, PCPs and HCPs should not be misled by the seemingly benign initial symptoms in highrisk cases. At the first complaint of shortness of breath, they should immediately be referred to a tertiary hospital for further investigation and treatment.
This crisis is truly unprecedented. We sometimes can’t predict what would happen, as this is uncharted territory.
COVID-19 poses more questions than we have answers for. The near future looks gloomy.
But we’re not exactly treading on thin ice. We can benefit from the many lessons distilled from the experiences in Wuhan and other big cities ravaged by this minuscule virus.
In all these experiences, an agile response of the health care system was key in catching up with the virus, which seemed to be always a few steps ahead. If we get overwhelmed this early and dilly-dally in our response, it may be “game over” in a few months.
Rafael R. Castillo, MD, MBA, FPCP, FPCC, FESC, is a cardiologist affiliated with Manila Doctors Hospital.