research article about covid 19 in the philippines

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• For authors
• Browse by collection
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 10, Issue 11
• The Philippine COVID-19 Outcomes: a Retrospective study Of Neurological manifestations and Associated symptoms (The Philippine CORONA study): a protocol study
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• http://orcid.org/0000-0001-5621-1833 Adrian I Espiritu 1 , 2 ,
• http://orcid.org/0000-0003-1135-6400 Marie Charmaine C Sy 1 ,
• http://orcid.org/0000-0002-1241-8805 Veeda Michelle M Anlacan 1 ,
• http://orcid.org/0000-0001-5317-7369 Roland Dominic G Jamora 1
• 1 Department of Neurosciences , College of Medicine and Philippine General Hospital, University of the Philippines Manila , Manila , Philippines
• 2 Department of Clinical Epidemiology, College of Medicine , University of the Philippines Manila , Manila , Philippines
• Correspondence to Dr Adrian I Espiritu; aiespiritu{at}up.edu.ph

Introduction The SARS-CoV-2, virus that caused the COVID-19 global pandemic, possesses a neuroinvasive potential. Patients with COVID-19 infection present with neurological signs and symptoms aside from the usual respiratory affectation. Moreover, COVID-19 is associated with several neurological diseases and complications, which may eventually affect clinical outcomes.

Objectives The Philippine COVID-19 Outcomes: a Retrospective study Of Neurological manifestations and Associated symptoms (The Philippine CORONA) study investigators will conduct a nationwide, multicentre study involving 37 institutions that aims to determine the neurological manifestations and factors associated with clinical outcomes in COVID-19 infection.

Methodology and analysis This is a retrospective cohort study (comparative between patients with and without neurological manifestations) via medical chart review involving adult patients with COVID-19 infection. Sample size was determined at 1342 patients. Demographic, clinical and neurological profiles will be obtained and summarised using descriptive statistics. Student’s t-test for two independent samples and χ 2 test will be used to determine differences between distributions. HRs and 95% CI will be used as an outcome measure. Kaplan-Meier curves will be constructed to plot the time to onset of mortality (survival), respiratory failure, intensive care unit (ICU) admission, duration of ventilator dependence, length of ICU stay and length of hospital stay. The log-rank test will be employed to compare the Kaplan-Meier curves. Stratified analysis will be performed to identify confounders and effects modifiers. To compute for adjusted HR with 95% CI, crude HR of outcomes will be adjusted according to the prespecified possible confounders. Cox proportional regression models will be used to determine significant factors of outcomes. Testing for goodness of fit will also be done using Hosmer-Lemeshow test. Subgroup analysis will be performed for proven prespecified effect modifiers. The effects of missing data and outliers will also be evaluated in this study.

Ethics and dissemination This protocol was approved by the Single Joint Research Ethics Board of the Philippine Department of Health (SJREB-2020–24) and the institutional review board of the different study sites. The dissemination of results will be conducted through scientific/medical conferences and through journal publication. The lay versions of the results may be provided on request.

Trial registration number NCT04386083 .

• adult neurology
• epidemiology

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2020-040944

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Strengths and limitations of this study

The Philippine COVID-19 Outcomes: a Retrospective study Of Neurological manifestations and Associated symptoms Study is a nationwide, multicentre, retrospective, cohort study with 37 Philippine sites.

Full spectrum of neurological manifestations of COVID-19 will be collected.

Retrospective gathering of data offers virtually no risk of COVID-19 infection to data collectors.

Data from COVID-19 patients who did not go to the hospital are unobtainable.

Recoding bias is inherent due to the retrospective nature of the study.

Introduction

The COVID-19 has been identified as the cause of an outbreak of respiratory illness in Wuhan, Hubei Province, China, in December 2019. 1 The COVID-19 pandemic has reached the Philippines with most of its cases found in the National Capital Region (NCR). 2 The major clinical features of COVID-19 include fever, cough, shortness of breath, myalgia, headache and diarrhoea. 3 The outcomes of this disease lead to prolonged hospital stay, intensive care unit (ICU) admission, dependence on invasive mechanical ventilation, respiratory failure and mortality. 4 The specific pathogen that causes this clinical syndrome has been named SARS-CoV-2, which is phylogenetically similar to SARS-CoV. 4 Like the SARS-CoV strain, SARS-CoV-2 may possess a similar neuroinvasive potential. 5

A study on cases with COVID-19 found that about 36.4% of patients displayed neurological manifestations of the central nervous system (CNS) and peripheral nervous system (PNS). 6 The associated spectrum of symptoms and signs were substantially broad such as altered mental status, headache, cognitive impairment, agitation, dysexecutive syndrome, seizures, corticospinal tract signs, dysgeusia, extraocular movement abnormalities and myalgia. 7–12 Several reports were published on neurological disorders associated with patients with COVID-19, including cerebrovascular disorders, encephalopathy, hypoxic brain injury, frequent convulsive seizures and inflammatory CNS syndromes like encephalitis, meningitis, acute disseminated encephalomyelitis and Guillain-Barre syndrome. 7–16 However, the estimates of the occurrences of these manifestations were based on studies with a relatively small sample size. Furthermore, the current description of COVID-19 neurological features are hampered to some extent by exceedingly variable reporting; thus, defining causality between this infection and certain neurological manifestations is crucial since this may lead to considerable complications. 17 An Italian observational study protocol on neurological manifestations has also been published to further document and corroborate these findings. 18

Epidemiological data on the proportions and spectrum of non-respiratory symptoms and complications may be essential to increase the recognition of clinicians of the possibility of COVID-19 infection in the presence of other symptoms, particularly neurological manifestations. With this information, the probabilities of diagnosing COVID-19 disease may be strengthened depending on the presence of certain neurological manifestations. Furthermore, knowledge of other unrecognised symptoms and complications may allow early diagnosis that may permit early institution of personal protective equipment and proper contact precautions. Lastly, the presence of neurological manifestations may be used for estimating the risk of certain important clinical outcomes for better and well-informed clinical decisions in patients with COVID-19 disease.

To address this lack of important information in the overall management of patients with COVID-19, we organised a research study entitled ‘The Philippine COVID-19 Outcomes: a Retrospective study Of Neurological manifestations and Associated symptoms (The Philippine CORONA Study)’.

This quantitative, retrospective cohort, multicentre study aims: (1) to determine the demographic, clinical and neurological profile of patients with COVID-19 disease in the Philippines; (2) to determine the frequency of neurological symptoms and new-onset neurological disorders/complications in patients with COVID-19 disease; (3) to determine the neurological manifestations that are significant factors of mortality, respiratory failure, duration of ventilator dependence, ICU admission, length of ICU stay and length of hospital stay among patients with COVID-19 disease; (4) to determine if there is significant difference between COVID-19 patients with neurological manifestations compared with those COVID-19 patients without neurological manifestations in terms of mortality, respiratory failure, duration of ventilator dependence, ICU admission, length of ICU stay and length of hospital stay; and (5) to determine the likelihood of mortality, respiratory failure and ICU admission, including the likelihood of longer duration of ventilator dependence and length of ICU and hospital stay in COVID-19 patients with neurological manifestations compared with those without neurological manifestations.

Scope, limitations and delimitations

The study will include confirmed cases of COVID-19 from the 37 participating institutions in the Philippines. Every country has its own healthcare system, whose level of development and strategies ultimately affect patient outcomes. Thus, the results of this study cannot be accurately generalised to other settings. In addition, patients with ages ≤18 years will be excluded in from this study. These younger patients may have different characteristics and outcomes; therefore, yielded estimates for adults in this study may not be applicable to this population subgroup. Moreover, this study will collect data from the patient records of patients with COVID-19; thus, data from patients with mild symptoms who did not go to the hospital and those who had spontaneous resolution of symptoms despite true infection with COVID-19 are unobtainable.

Methodology

To improve the quality of reporting of this study, the guidelines issued by the Strengthening the Reporting of Observational Studies in Epidemiology Initiative will be followed. 19

Study design

The study will be conducted using a retrospective cohort (comparative) design (see figure 1 ).

• Download figure
• Open in new tab
• Download powerpoint

Schematic diagram of the study flow.

Study sites and duration

We will conduct a nationwide, multicentre study involving 37 institutions in the Philippines (see figure 2 ). Most of these study sites can be found in the NCR, which remains to be the epicentre of the COVID-19 pandemic. 2 We will collect data for 6 months after institutional review board approval for every site.

Location of 37 study sites of the Philippine CORONA study.

Patient selection and cohort description

The cases will be identified using the designated COVID-19 censuses of all the participating centres. A total enumeration of patients with confirmed COVID-19 disease will be done in this study.

The cases identified should satisfy the following inclusion criteria: (A) adult patients at least 19 years of age; (B) cases confirmed by testing approved patient samples (ie, nasal swab, sputum and bronchoalveolar lavage fluid) employing real-time reverse transcription PCR (rRT-PCR) 20 from COVID-19 testing centres accredited by the Department of Health (DOH) of the Philippines, with clinical symptoms and signs attributable to COVID-19 disease (ie, respiratory as well as non-respiratory clinical signs and symptoms) 21 ; and (C) cases with disposition (ie, discharged stable/recovered, home/discharged against medical advice, transferred to other hospital or died) at the end of the study period. Cases with conditions or diseases caused by other organisms (ie, bacteria, other viruses, fungi and so on) or caused by other pathologies unrelated to COVID-19 disease (ie, trauma) will be excluded.

The first cohort will involve patients with confirmed COVID-19 infection who presented with any neurological manifestation/s (ie, symptoms or complications/disorder). The comparator cohort will compose of patients with confirmed COVID-19 infection without neurological manifestation/s.

Sample size calculation

We looked into the mortality outcome measure for the purposes of sample size computation. Following the cohort study of Khaledifar et al , 22 the sample size was calculated using the following parameters: two-sided 95% significance level (1 – α); 80% power (1 – β); unexposed/exposed ratio of 1; 5% of unexposed with outcome (case fatality rate from COVID19-Philippines Dashboard Tracker (PH) 23 as of 8 April 2020); and assumed risk ratio 2 (to see a two-fold increase in risk of mortality when neurological symptoms are present).

When these values were plugged in to the formula for cohort studies, 24 a minimum sample size of 1118 is required. To account for possible incomplete data, the sample was adjusted for 20% more. This means that the total sample size required is 1342 patients, which will be gathered from the participating centres.

Data collection

We formulated an electronic data collection form using Epi Info Software (V.7.2.2.16). The forms will be pilot-tested, and a formal data collection workshop will be conducted to ensure collection accuracy. The data will be obtained from the review of the medical records.

The following pertinent data will be obtained: (A) demographic data; (B) other clinical profile data/comorbidities; (C) neurological history; (D) date of illness onset; (E) respiratory and constitutional symptoms associated with COVID-19; (F) COVID-19 disease severity 25 at nadir; (G) data if neurological manifestation/s were present at onset prior to respiratory symptoms and the specific neurological manifestation/s present at onset; (H) neurological symptoms; (i) date of neurological symptom onset; (J) new-onset neurological disorders or complications; (K) date of new neurological disorder or complication onset; (L) imaging done; (M) cerebrospinal fluid analysis; (N) electrophysiological studies; (O) treatment given; (P) antibiotics given; (Q) neurological interventions given; (R) date of mortality and cause/s of mortality; (S) date of respiratory failure onset, date of mechanical ventilator cessation and cause/s of respiratory failure; (T) date of first day of ICU admission, date of discharge from ICU and indication/s for ICU admission; (U) other neurological outcomes at discharge; (V) date of hospital discharge; and (W) final disposition. See table 1 for the summary of the data to be collected for this study.

• View inline

Data to be collected in this study

Main outcomes considered

The following patient outcomes will be considered for this study:

Mortality (binary outcome): defined as the patients with confirmed COVID-19 who died.

Respiratory failure (binary outcome): defined as the patients with confirmed COVID-19 who experienced clinical symptoms and signs of respiratory insufficiency. Clinically, this condition may manifest as tachypnoea/sign of increased work of breathing (ie, respiratory rate of ≥22), abnormal blood gases (ie, hypoxaemia as evidenced by partial pressure of oxygen (PaO 2 ) <60 or hypercapnia by partial pressure of carbon dioxide of >45), or requiring oxygen supplementation (ie, PaO 2 <60 or ratio of PaO 2 /fraction of inspired oxygen (P/F ratio)) <300).

Duration of ventilator dependence (continuous outcome): defined as the number of days from initiation of assisted ventilation to cessation of mechanical ventilator use.

ICU admission (binary outcome): defined as the patients with confirmed COVID-19 admitted to an ICU or ICU-comparable setting.

Length of ICU stay (continuous outcome): defined as the number of days admitted in the ICU or ICU-comparable setting.

Length of hospital stay (continuous outcome): defined as the number of days from admission to discharge.

Data analysis plan

Statistical analysis will be performed using Stata V.7.2.2.16.

Demographic, clinical and neurological profiles will be summarised using descriptive statistics, in which categorical variables will be expressed as frequencies with corresponding percentages, and continuous variables will be pooled using means (SD).

Student’s t-test for two independent samples and χ 2 test will be used to determine differences between distributions.

HRs and 95% CI will be used as an outcome measure. Kaplan-Meier curves will be constructed to plot the time to onset of mortality (survival), respiratory failure, ICU admission, duration of ventilator dependence (recategorised binary form), length of ICU stay (recategorised binary form) and length of hospital stay (recategorised binary form). Log-rank test will be employed to compare the Kaplan-Meier curves. Stratified analysis will be performed to identify confounders and effects modifiers. To compute for adjusted HR with 95% CI, crude HR of outcomes at discrete time points will be adjusted for prespecified possible confounders such as age, history of cardiovascular or cerebrovascular disease, hypertension, diabetes mellitus, and respiratory disease, COVID-19 disease severity at nadir, and other significant confounding factors.

Cox proportional regression models will be used to determine significant factors of outcomes. Testing for goodness of fit will be done using Hosmer-Lemeshow test. Likelihood ratio tests and other information criteria (Akaike Information Criterion or Bayesian Information Criterion) will be used to refine the final model. Statistical significance will be considered if the 95% CI of HR or adjusted HR did not include the number one. A p value <0.05 (two tailed) is set for other analyses.

Subgroup analyses will be performed for proven prespecified effect modifiers. The following variables will be considered for subgroup analyses: age (19–64 years vs ≥65 years), sex, body mass index (<18.5 vs 18.5–22.9 vs ≥23 kg/m 2 ), with history of cardiovascular or cerebrovascular disease (presence or absence), hypertension (presence or absence), diabetes mellitus (presence or absence), respiratory disease (presence or absence), smoking status (smoker or non-smoker) and COVID-19 disease severity (mild, severe or critical disease).

The effects of missing data will be explored. All efforts will be exerted to minimise missing and spurious data. Validity of the submitted electronic data collection will be monitored and reviewed weekly to prevent missing or inaccurate input of data. Multiple imputations will be performed for missing data when possible. To check for robustness of results, analysis done for patients with complete data will be compared with the analysis with the imputed data.

The effects of outliers will also be assessed. Outliers will be assessed by z-score or boxplot. A cut-off of 3 SD from the mean can also be used. To check for robustness of results, analysis done with outliers will be compared with the analysis without the outliers.

Study organisational structure

A steering committee (AIE, MCCS, VMMA and RDGJ) was formed to direct and provide appropriate scientific, technical and methodological assistance to study site investigators and collaborators (see figure 3 ). Central administrative coordination, data management, administrative support, documentation of progress reports, data analyses and interpretation and journal publication are the main responsibilities of the steering committee. Study site investigators and collaborators are responsible for the proper collection and recording of data including the duty to maintain the confidentiality of information and the privacy of all identified patients for all the phases of the research processes.

Organisational structure of oversight of the Philippine CORONA Study.

This section is highlighted as part of the required formatting amendments by the Journal.

Ethics and dissemination

This research will adhere to the Philippine National Ethical Guidelines for Health and Health-related Research 2017. 26 This study is an observational, cohort study and will not allocate any type of intervention. The medical records of the identified patients will be reviewed retrospectively. To protect the privacy of the participant, the data collection forms will not contain any information (ie, names and institutional patient number) that could determine the identity of the patients. A sequential code will be recorded for each patient in the following format: AAA-BBB where AAA will pertain to the three-digit code randomly assigned to each study site; BBB will pertain to the sequential case number assigned by each study site. Each participating centre will designate a password-protected laptop for data collection; the password is known only to the study site.

This protocol was approved by the following institutional review boards: Single Joint Research Ethics Board of the DOH, Philippines (SJREB-2020-24); Asian Hospital and Medical Center, Muntinlupa City (2020- 010-A); Baguio General Hospital and Medical Center (BGHMC), Baguio City (BGHMC-ERC-2020-13); Cagayan Valley Medical Center (CVMC), Tuguegarao City; Capitol Medical Center, Quezon City; Cardinal Santos Medical Center (CSMC), San Juan City (CSMC REC 2020-020); Chong Hua Hospital, Cebu City (IRB 2420–04); De La Salle Medical and Health Sciences Institute (DLSMHSI), Cavite (2020-23-02-A); East Avenue Medical Center (EAMC), Quezon City (EAMC IERB 2020-38); Jose R. Reyes Memorial Medical Center, Manila; Jose B. Lingad Memorial Regional Hospital, San Fernando, Pampanga; Dr. Jose N. Rodriguez Memorial Hospital, Caloocan City; Lung Center of the Philippines (LCP), Quezon City (LCP-CT-010–2020); Manila Doctors Hospital, Manila (MDH IRB 2020-006); Makati Medical Center, Makati City (MMC IRB 2020–054); Manila Medical Center, Manila (MMERC 2020-09); Northern Mindanao Medical Center, Cagayan de Oro City (025-2020); Quirino Memorial Medical Center (QMMC), Quezon City (QMMC REB GCS 2020-28); Ospital ng Makati, Makati City; University of the Philippines – Philippine General Hospital (UP-PGH), Manila (2020-314-01 SJREB); Philippine Heart Center, Quezon City; Research Institute for Tropical Medicine, Muntinlupa City (RITM IRB 2020-16); San Lazaro Hospital, Manila; San Juan De Dios Educational Foundation Inc – Hospital, Pasay City (SJRIB 2020-0006); Southern Isabela Medical Center, Santiago City (2020-03); Southern Philippines Medical Center (SPMC), Davao City (P20062001); St. Luke’s Medical Center, Quezon City (SL-20116); St. Luke’s Medical Center, Bonifacio Global City, Taguig City (SL-20116); Southern Philippines Medical Center, Davao City; The Medical City, Pasig City; University of Santo Tomas Hospital, Manila (UST-REC-2020-04-071-MD); University of the East Ramon Magsaysay Memorial Medical Center, Inc, Quezon City (0835/E/2020/063); Veterans Memorial Medical Center (VMMC), Quezon City (VMMC-2020-025) and Vicente Sotto Memorial Medical Center, Cebu City (VSMMC-REC-O-2020–048).

The dissemination of results will be conducted through scientific/medical conferences and through journal publication. Only the aggregate results of the study shall be disseminated. The lay versions of the results may be provided on request.

Protocol registration and technical review approval

This protocol was registered in the ClinicalTrials.gov website. It has received technical review board approvals from the Department of Neurosciences, Philippine General Hospital and College of Medicine, University of the Philippines Manila, from the Cardinal Santos Medical Center (San Juan City) and from the Research Center for Clinical Epidemiology and Biostatistics, De La Salle Medical and Health Sciences Institute (Dasmariñas, Cavite).

Acknowledgments

We would like to thank Almira Abigail Doreen O Apor, MD, of the Department of Neurosciences, Philippine General Hospital, Philippines, for illustrating figure 2 for this publication.

• Adhikari SP ,
• Wu Y-J , et al
• Department of Health
• Philippine Society for Microbiology and Infectious Diseases
• Hu Y , et al
• Li Yan‐Chao ,
• Bai Wan‐Zhu ,
• Hashikawa T ,
• Wang M , et al
• Paterson RW ,
• Benjamin L , et al
• Hall JP , et al
• Varatharaj A ,
• Ellul MA , et al
• Mahammedi A ,
• Vagal A , et al
• Collantes MEV ,
• Espiritu AI ,
• Sy MCC , et al
• Merdji H , et al
• Sharifi Razavi A ,
• Poyiadji N ,
• Noujaim D , et al
• Zhou H , et al
• Moriguchi T ,
• Goto J , et al
• Nicholson TR , et al
• Ferrarese C ,
• Priori A , et al
• von Elm E ,
• Altman DG ,
• Egger M , et al
• Li J , et al
• Centers for Disease Control and Prevention
• Khaledifar A ,
• Hashemzadeh M ,
• Solati K , et al
• McGoogan JM
• Philippine Research Ethics Board

VMMA and RDGJ are joint senior authors.

AIE and MCCS are joint first authors.

Twitter @neuroaidz, @JamoraRoland

Collaborators The Philippine CORONA Study Group Collaborators: Maritoni C Abbariao, Joshua Emmanuel E Abejero, Ryndell G Alava, Robert A Barja, Dante P Bornales, Maria Teresa A Cañete, Ma. Alma E Carandang-Concepcion, Joseree-Ann S Catindig, Maria Epifania V Collantes, Evram V Corral, Ma. Lourdes P Corrales-Joson, Romulus Emmanuel H Cruz, Marita B Dantes, Ma. Caridad V Desquitado, Cid Czarina E Diesta, Carissa Paz C Dioquino, Maritzie R Eribal, Romulo U Esagunde, Rosalina B Espiritu-Picar, Valmarie S Estrada, Manolo Kristoffer C Flores, Dan Neftalie A Juangco, Muktader A Kalbi, Annabelle Y Lao-Reyes, Lina C Laxamana, Corina Maria Socorro A Macalintal, Maria Victoria G Manuel, Jennifer Justice F Manzano, Ma. Socorro C Martinez, Generaldo D Maylem, Marc Conrad C Molina, Marietta C Olaivar, Marissa T Ong, Arnold Angelo M Pineda, Joanne B Robles, Artemio A Roxas Jr, Jo Ann R Soliven, Arturo F Surdilla, Noreen Jhoanna C Tangcuangco-Trinidad, Rosalia A Teleg, Jarungchai Anton S Vatanagul and Maricar P Yumul.

Contributors All authors conceived the idea and wrote the initial drafts and revisions of the protocol. All authors made substantial contributions in this protocol for intellectual content.

Funding Philippine Neurological Association (Grant/Award Number: N/A). Expanded Hospital Research Office, Philippine General Hospital (Grant/Award Number: N/A).

Disclaimer Our funding sources had no role in the design of the protocol, and will not be involved during the methodological execution, data analyses and interpretation and decision to submit or to publish the study results.

Map disclaimer The depiction of boundaries on the map(s) in this article does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Read the full text or download the PDF:

Loading metrics

Open Access

Peer-reviewed

Research Article

COVID-19 vaccine hesitancy and confidence in the Philippines and Malaysia: A cross-sectional study of sociodemographic factors and digital health literacy

Roles Conceptualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Clinical Informatics Research Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom

Roles Data curation, Methodology, Project administration, Resources, Validation, Writing – original draft, Writing – review & editing

Affiliations Department of Community Medicine, International Medical School, Management and Science University, Shah Alam, Malaysia, Department of Community Medicine, Faculty of Medicine, Asia Metropolitan University, Johor Bahru, Malaysia, Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia

Roles Conceptualization, Data curation, Validation, Writing – original draft, Writing – review & editing

Affiliation Department of Psychiatry, Faculty of Medicine, University of Cyberjaya, Cyberjaya, Malaysia

Roles Conceptualization, Writing – original draft, Writing – review & editing

Affiliation Department: School of Criminal Justice Education, Institution: J.H. Cerilles State College, Caridad, Dumingag, Zamboanga del Sur, Philippines

Roles Conceptualization, Data curation, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliations Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia, South East Asia Community Observatory (SEACO), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia

• Ken Brackstone, 
• Roy R. Marzo, 
• Rafidah Bahari, 
• Michael G. Head, 
• Mark E. Patalinghug, 

• Published: October 19, 2022
• https://doi.org/10.1371/journal.pgph.0000742
• Peer Review
• Reader Comments

With the emergence of the highly transmissible Omicron variant, large-scale vaccination coverage is crucial to the national and global pandemic response, especially in populous Southeast Asian countries such as the Philippines and Malaysia where new information is often received digitally. The main aims of this research were to determine levels of hesitancy and confidence in COVID-19 vaccines among general adults in the Philippines and Malaysia, and to identify individual, behavioural, or environmental predictors significantly associated with these outcomes. Data from an internet-based cross-sectional survey of 2558 participants from the Philippines ( N = 1002) and Malaysia ( N = 1556) were analysed. Results showed that Filipino (56.6%) participants exhibited higher COVID-19 hesitancy than Malaysians (22.9%; p < 0.001). However, there were no significant differences in ratings of confidence between Filipino (45.9%) and Malaysian (49.2%) participants ( p = 0.105). Predictors associated with vaccine hesitancy among Filipino participants included women (OR, 1.50, 95% CI, 1.03–1.83; p = 0.030) and rural dwellers (OR, 1.44, 95% CI, 1.07–1.94; p = 0.016). Among Malaysian participants, vaccine hesitancy was associated with women (OR, 1.50, 95% CI, 1.14–1.99; p = 0.004), social media use (OR, 11.76, 95% CI, 5.71–24.19; p < 0.001), and online information-seeking behaviours (OR, 2.48, 95% CI, 1.72–3.58; p < 0.001). Predictors associated with vaccine confidence among Filipino participants included subjective social status (OR, 1.13, 95% CI, 1.54–1.22; p < 0.001), whereas vaccine confidence among Malaysian participants was associated with higher education (OR, 1.30, 95% CI, 1.03–1.66; p < 0.028) and negatively associated with rural dwellers (OR, 0.64, 95% CI, 0.47–0.87; p = 0.005) and online information-seeking behaviours (OR, 0.42, 95% CI, 0.31–0.57; p < 0.001). Efforts should focus on creating effective interventions to decrease vaccination hesitancy, increase confidence, and bolster the uptake of COVID-19 vaccination, particularly in light of the Dengvaxia crisis in the Philippines.

Citation: Brackstone K, Marzo RR, Bahari R, Head MG, Patalinghug ME, Su TT (2022) COVID-19 vaccine hesitancy and confidence in the Philippines and Malaysia: A cross-sectional study of sociodemographic factors and digital health literacy. PLOS Glob Public Health 2(10): e0000742. https://doi.org/10.1371/journal.pgph.0000742

Editor: Nnodimele Onuigbo Atulomah, Babcock University, NIGERIA

Received: June 12, 2022; Accepted: September 20, 2022; Published: October 19, 2022

Copyright: © 2022 Brackstone et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data are available on the OSF repository: https://osf.io/ncwjq/ .

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

While many high-income settings have achieved relatively high coverage with their COVID-19 vaccination campaigns, almost 32.1% of the world’s population have not received a single dose of any COVID-19 vaccine as of July 2022 [ 1 ]. The Philippines and Malaysia are among two of the most populous countries in Southeast Asia with an estimated population of 110 million and 32 million people, respectively. To date, Malaysia has seen over 4.6 million cases with a mortality rate of 0.77%, while approximately 3.7 million cases of COVID-19 were detected in the Philippines with a mortality rate of 1.60% [ 2 ]. Malaysia is doing considerably well with their vaccination efforts, with 84.8% of the population currently considered fully vaccinated as of July 2022. However, vaccination campaigns in the Philippines have been more difficult, with 65.6% of the population fully vaccinated [ 3 ]. With the emergence of the highly transmissible Omicron variant across the world [ 4 ], large-scale vaccination coverage remains fundamental to the national and global pandemic response. Regular scientific assessments of factors that may impede the success of COVID-19 vaccination coverage will be critical as vaccination campaigns continue in these nations.

A key factor for the success of vaccination campaigns is people’s willingness to be vaccinated once doses become accessible to them personally. Vaccine hesitancy is defined by the World Health Organization (WHO) as the delay in the acceptance, or blunt refusal of, vaccines. In fact, vaccine hesitancy was described by the WHO as one of the top 10 threats to global health in 2019 [ 5 ]. Conversely, vaccine confidence relates to individuals’ beliefs that vaccines are effective and safe. In general, a loss of trust in health authorities is a key determinant of vaccine confidence, with misconceptions about vaccine safety being among the most common reasons for low confidence in vaccines [ 6 ].

Previously, vaccination in Southeast Asia has been associated with mistrust and fear, particularly in the Philippines, who are still suffering the consequences of the Dengvaxia (dengue) vaccine controversy in 2017 [ 7 ]. Studies suggest that this highly political mainstream event, in which anti-vaccination campaigns linked dengue vaccines with autism spectrum disorder and with corrupt schemes of pharmaceutical companies, continue to erode the population’s trust in vaccines. For example, a survey conducted on over 30,000 Filipinos in early 2021 showed that 41% of respondents would refuse the COVID-19 vaccine once it became available, whereas Malaysia reported 27% hesitancy [ 8 ]. Researchers predict that the controversy surrounding Dengvaxia may have prompted severe medical mistrust and subsequently weakened the public’s attitudes toward vaccines [ 7 , 9 ]. However, there may be many additional factors that weaken confidence in vaccines. For example, incompatibility with religious beliefs is one key driver of weakened confidence in vaccines [ 10 , 11 ], whereas living in urbanised (vs. rural) areas predicts COVID-19 vaccine hesitancy in some countries [ 12 – 14 ], possibly due to being more connected to the internet and social media and being more exposed to COVID-19-related misinformation.

Other predictors of vaccine hesitancy and confidence may include digital health literacy–one’s ability to seek, find, understand, and appraise health information from digital resources–and social media use. Research has shown that beliefs in available information is integral to perceptions of the vaccine safety and effectiveness [ 15 – 17 ]. Previous studies, for example, have associated higher vaccine hesitancy with misinformation about the virus and vaccines, particularly if they relied on social media as a key source of information [ 18 , 19 ]. Social Cognitive Theory (SCT) is a widely accepted theory which may explain individual behaviors, including digital health literacy [ 20 ]. SCT consists of three factors–environmental, personal, and behavioural–and any two of these components interact with each other and influence the third. As such, SCT can assist in establishing a link between one’s behaviour (e.g., information-seeking–one form of digital health literacy) and environmental factors (e.g., availability of information online), which may interact to promote medical mistrust and influence vaccine hesitancy and confidence (personal) [ 21 ]. Thus, health behaviours are often influenced by social systems as well as personal behaviours.

Although vaccine hesitancy and confidence are related concepts (e.g., people who express low confidence in vaccines are more likely to be vaccine-hesitant [ 6 ]), they are also distinct [ 22 ]. Thus, the main aims of this research were to determine levels of hesitancy and confidence in COVID-19 vaccines among general adults in the Philippines and Malaysia, and to identify behavioural or environmental predictors that are significantly associated with both outcomes. Thus, developing a deeper understanding of the factors associated with vaccine hesitancy and confidence will provide insight into how specific population groups may respond to health threats and public health control measures.

Design, subjects, and procedure

This was an internet-based cross-sectional survey conducted from May 2021 to September 2021 in the Philippines and Malaysia. Snowball sampling methods were used for the data collection using social media, including research networks of universities, hospitals, friends, and relatives. Filipino and Malaysian residents aged 18 years or older were invited to take part. The inclusion criteria for participants’ eligibility included 18 years or older, and an understanding of the English language. All invited participants consented to the online survey before completion. Consented participants could only respond to questions once using a single account. The voluntary survey contained a series of questions which assessed sociodemographic variables, social media use, digital literacy skills in health, and attitudes toward the COVID-19 vaccine.

Ethical approval

The study received ethical approval from Asia Metropolitan University’s Medical Research and Ethics Committee (Ref: AMU/FOM/MREC 0320210018). All participants provided informed consent. All study information was written and provided on the first page of the online questionnaire, and participants indicated consent by selecting the agreement box and proceeding to the survey.

Demographics.

Filipino and Malaysian participants indicated their age category (18–24, 25–34, or 35–44), gender (man, woman), community type (rural, urban), educational level (no formal education, primary, secondary, tertiary), employment (unemployed, part-time, full-time), religion (Christian, Buddhism, Muslim, Hinduism, Other, None), income (1 = very insufficient ; 4 = very sufficient ; M = 1.84, SD = 0.81), whether they were permanently impaired by a health problem (no vs. yes), and whether they were social media users (no vs. yes).

Subjective social status.

Participant then rated their own perceived social status using the MacArthur Scale of Subjective Social Status scale [ 23 ]. Participants viewed a drawing of a ladder with 10 rungs, and read that the ladder represented where people stand in society. They read that the top of the ladder consists of people who are best off, have the most money, highest education, and best jobs, and those at the bottom of the ladder consists of people who are worst off, have the least money, lowest education, and worst or no jobs. Using a validated single-item measure, participants placed an ‘X’ on the rung that best represented where they think they stood on the ladder (1 = lowest ; 10 = highest; M = 6.23, SD = 1.86).

Vaccine confidence and hesitancy.

Participants were also asked about their perceived level of confidence in the COVID-19 vaccine (“I am completely confident that the COVID-19 vaccine is safe,” 1 = strongly disagree ; 7 = strongly agree; M = 4.57, SD = 1.48). Then, participants were asked about their level of hesitancy to the COVID-19 vaccine (“I think everyone should be vaccinated according to the national vaccination schedule”; no, I don’t know, yes). These questions were adapted from the World Health Organization, Regional Office for Europe survey [ 24 ]. The tool underwent evaluation by multidisciplinary panel of experts for necessity, clarity, and relevance.

Digital health literacy.

Finally, participants completed the Digital Health Literacy Instrument (DHLI) [ 25 ], which was adapted in the context of the COVID-HL Network. The scale measures one’s ability to seek, find, understand, and appraise health information from digital resources. A total of 12 items (three per each dimension) were asked, and answers were recorded on a four-point Likert scale (1 = very difficult ; 4 = very easy; α = .92; M = 2.15, SD = 0.59). While the original DHLI is comprised of 7 subscales, we used the following four domains, including: (1) information searching or using appropriate strategies to look for information (e.g., “When you search the internet for information on coronavirus virus or related topics, how easy or difficult is it for you to find the exact information you are looking for?”; α = .87; M = 2.15, SD = 0.65), (2) adding self-generated content to online-based platforms (e.g., “When typing a message on a forum or social media such as Facebook or Twitter about the coronavirus a related topic, how easy or difficult is it for you to express your opinion, thought, or feelings in writing?”; α = .74; M = 2.15, SD = 0.65), (3) evaluating reliability of online information (e.g., “When you search the internet for information on the coronavirus or related topics, how easy or difficult is it for you to decide whether the information is reliable or not?”; α = .86; M = 2.20, SD = 0.69), and (4) determining relevance of online information (e.g., “When you search the internet for information on the coronavirus or related topics, how easy or difficult is it for you to use the information you found to make decisions about your health [e.g., protective measures, hygiene regulations, transmission routes, risks and their prevention?”]; α = .87; M = 2.09, SD = 0.68). The reliability statistics for the overall DHL score was 0.92, while the alpha coefficients for the four subscales ranged from 0.74 to 0.87, suggesting acceptable to good internal consistency.

Data analysis

Data were examined for errors, cleaned, and exported into IBM SPSS Statistics 28 for further analysis. All hypotheses were tested at a significance level of 0.05. χ 2 tests were conducted for group differences of categorical variables, and Mann-Whitney tests for continuous variables. Subgroup analyses were performed for Filipino and Malaysian participants.

COVID-19 vaccine hesitancy and confidence were treated as separate dependent variables in a logistic regression model providing the strictest test of potential associations with COVID-19 vaccine hesitancy and confidence among Filipino and Malaysian participants. Low vaccine confidence was operationalised by dichotomising participants’ responses to the statement: “I am completely confident that the COVID-19 vaccine is safe” into those who disagreed or neither agreed nor disagreed (1–4), whereas high vaccine confidence was operationalised by dichotomising participants’ responses into those who agreed to some extent (5–7). Vaccine hesitancy was operationalised by dichotomising responses to the statement: “I think everyone should be vaccinated according to the National vaccination schedule” into those indicating ‘no’ or ‘I don’t know,’ whereas no vaccine hesitancy was operationalized by dichotomising participants’ response into those who indicated ‘yes.’

Independent variables were: age (18–24 vs. 25–34 vs. 35–44 [ref]), gender (women vs. men [ref]), community type (rural vs. urban [ref]), educational level (tertiary vs. secondary or less [ref]), employment (employed to some degree vs. unemployed [ref]), religion (Philippines: Christianity vs. Islam [ref]; Malaysia: Christianity vs. Buddhism vs. Hinduism vs. Islam [ref]), income (low (1–2) vs. high (3–4 [ref])), whether they were permanently impaired by a health problem (yes vs. no [ref]), whether they were social media users [yes vs. no [ref]), their perceived ranking on the MacArthur Scale of Subjective Social Status (continuous variable), and finally the four domains of the DHLI scale (all continuous variables).

A total of 2558 participants completed the online survey. Table 1 shows descriptive statistics of participants from the Philippines ( N = 1002) vs. Malaysia ( N = 1556). Filipino (vs. Malaysian) participants indicated higher rates of education ( p < 0.001), but were more likely to be unemployed ( p < 0.001). Further, Filipino (vs. Malaysian) participants were also more likely to indicate lower income ( p < 0.001) and rate themselves lower on subjective social status ( p < 0.001). Malaysian (vs. Filipino) participants were more likely to live in urban areas ( p < 0.001). Most notably, Filipino participants (56.6%) indicated higher prevalence of COVID-19 vaccine hesitancy compared to Malaysian participants (22.9%; p < 0.001). However, there were no significant differences between Filipino (45.9%) and Malaysian (49.2%) participants in ratings of vaccine confidence ( p = 0.105). Malaysian (vs. Filipino) participants were also more likely to report using social media (96.6 vs. 89.8%; < 0.001).

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

Values are presented as percent (n) or means ± SD.

https://doi.org/10.1371/journal.pgph.0000742.t001

Table 2 shows significant predictors of vaccine hesitancy in both Filipino and Malaysian samples. Among Filipino participants, multivariate logistic regression analyses revealed that factors associated with higher vaccine hesitancy included women (OR, 1.51, 95% CI, 1.14–2.00; p = 0.004), residing in a rural community (OR, 1.45, 95% CI, 1.07–1.95; p = 0.015), and having lower income (OR, 1.62, 95% CI, 1.20–2.19; p = 0.001). Among Malaysian participants, women (OR, 1.51, 95% CI, 1.14–2.00; p = 0.004), being aged 25–34 (vs. 18–24; OR, 1.52, 95% CI, 1.48–2.21; p = 0.027), Christians (OR, 2.45, 95% CI, 1.66–3.62; p < 0.001), completing tertiary education (OR, 2.17, 95% CI, 1.63–2.88; p < 0.001), social media use (OR, 11.59, 95% CI, 5.63–23.84; p < 0.001), and information-seeking behaviours (OR, 2.50, 95% CI, 1.74–3.61; p < 0.001) were predictors of higher vaccine hesitancy, whereas having a health impairment (OR, 0.49, 95% CI, 0.30–0.78; p = 0.003) and higher self-reported ratings on subjective social status (OR, 0.82, 95% CI, 0.75–0.89; p < 0.001) were associated with lower vaccine hesitancy.

https://doi.org/10.1371/journal.pgph.0000742.t002

Table 3 shows significant predictors of vaccine confidence in both Filipino and Malaysian samples. Factors positively associated with higher vaccine confidence among Filipino participants included higher self-reported ratings on subjective social status (OR, 1.16, 95% CI, 1.07–1.25; p < 0.001), whereas factors associated with lower vaccine confidence included women (OR, 0.72, 95% CI, 0.54–0.96; p = 0.026) and information-seeking behaviours (OR, 0.63, 95% CI, 0.49–0.81; p < 0.001). Among Malaysian participants, factors positively associated with higher vaccine confidence included women (OR, 1.27, 95% CI, 1.18–1.60; p = 0.035), completing tertiary education (OR, 1.31, 95% CI, 1.03–1.66; p = 0.026), and higher self-reported ratings on subjective social status (OR, 1.08, 95% CI, 1.00–1.16; p = 0.036). Factors negatively associated with lower vaccine confidence included residing in a rural community (OR, 0.63, 95% CI, 0.47–0.87; p = 0.004), Christians (OR, 0.50, 95% CI, 1.20–2.24; p < 0.001), Buddhists (OR, 0.15., 95% CI, 0.10–0.22; p < 0.001), Hindus (OR, 0.24., 95% CI, 0.17–0.34; p = 0.004), information-seeking behaviours (OR, 0.42, 95% CI, 0.31–0.58; p < 0.001), and determining relevance of online information (OR, 0.68, 95% CI, 0.51–0.92; p = 0.013).

https://doi.org/10.1371/journal.pgph.0000742.t003

Malaysia and the Philippines are among the most populous countries in Southeast Asia. While the economic impact of the COVID-19 pandemic has been permanent in the Philippines, it has been shown thus far to be temporary in Malaysia [ 26 ]. Between January and October 2020, around 30,000 Malaysians had been infected by the virus with a mortality rate of 0.79%, while approximately 380,000 cases of COVID-19 were detected in the Philippines with a mortality rate of 1.9% [ 2 ]. Further, 61.8% of Malaysians had completed their vaccination up until September 2021, while the percentage of completed vaccinations during the same period in the Philippines was only 19.2% [ 27 ]. Vaccine uptake is likely to be a key determining factor in the outcome of a pandemic. Knowledge around factors which predict vaccine hesitancy and confidence is of the utmost important in order to improve vaccination rates. Thus, the core aims of this research were to determine levels of hesitancy and confidence in COVID-19 vaccines among general adults in the Philippines and Malaysia, and to identify behavioural or environmental predictors that are significantly associated with these outcomes.

First, while there were no significant differences in ratings of confidence in the COVID-19 vaccine between Filipino and Malaysian participants, Filipino (compared to Malaysian) participants expressed greater vaccine hesitancy. This may be a consequence of previous vaccine scares in the years leading up to the pandemic, including the Dengvaxia controversy in 2016 [ 7 , 9 ]. Systematic reviews demonstrated that, by the end of 2020, the highest vaccine acceptance was in China, Malaysia, and Indonesia [ 28 , 29 ]. The authors postulated that this elevated awareness was due to being among the first countries affected by the virus, hence resulting in greater confidence in vaccines [ 28 ].

Next, this study shows that women expressed greater vaccine hesitancy in both countries. The evidence base shows mixed findings, with other studies reporting higher hesitancy in women [ 30 ] or in men [ 31 ]. In some countries, the gender gap is not as substantial as others. In a large global study conducted in countries such as Russia and the United States, it was found that there is greater gender gap in vaccine hesitancy among men and women compared to countries such as Nepal and Sierra Leone [ 32 , 33 ]. Unsurprisingly, what drives this hesitancy is the inclusion of pregnant women, where studies have consistently demonstrated that this population is more hesitant toward vaccination due to concerns for their babies [ 34 ]. Hence, after taking all consideration into account, gender differences in vaccine hesitancy cannot be supported with certainty. This also emphasises the need for tailored health promotion towards the key populations at risk.

There are clear differences in predictors of vaccine hesitancy in the Philippines and Malaysia. However, when results for both countries were combined, women, urban dwellers, those of Christian faith, those with higher educational attainment, higher self-reported social class, social media use, and information-seeking tendencies remained as predictors of hesitancy. Urban-dwellers and individuals with more years of education have previously been demonstrated as predictors for vaccine hesitancy [ 35 ], but contradictory results have also previously been shown [ 36 , 37 ]. Urban residents are typically more connected to the internet and social media and, thus, may be more exposed to vaccine-related misinformation than rural inhabitants who have fewer sources of information available to them [ 12 – 14 ]. Nevertheless, reports have shown higher vaccine refusals among those with strong religious beliefs such as the Amish Community in the United States and the Orthodox Protestants in the Netherlands [ 38 ], as well as some Muslim groups in Pakistan [ 18 ].

Frequent social media use is the only strong predictor for vaccine hesitancy in this study, followed by information-seeking behaviours. Research has identified that the safety and effectiveness of the vaccine is the primary concern that people have, including beliefs in available information [ 15 – 17 ]. Unfortunately, high internet literacy is a double-edged sword, since participants in this study preferred to seek information through social media, and thus may have been exposed to inaccurate information regarding COVID-19 vaccine. Previous studies have associated higher vaccine hesitancy with misinformation about the virus and vaccines [ 18 ], particularly if they relied heavily on social media as a key source of vaccine-related information [ 19 ]. A 2022 systematic review discovered that high social media use is the main driver of vaccine hesitancy across all countries around the globe, and is especially prominent in Asia [ 39 ]. Furthermore, vaccine acceptance and uptake improved among those who obtained their information from healthcare providers compared to relatives or the internet [ 40 ].

In terms of vaccine confidence, our findings show that those with higher subjective social status have higher confidence in vaccination, consistent with previous studies describing how those with a higher income had expressed willingness to pay for their COVID-19 vaccination if necessary [ 32 , 41 , 42 ]. Further, those of Christian, Buddhist, and Hindu faiths, as well as those with a tendency to seek out information, were associated with lower vaccine confidence. This is in keeping with the previous findings demonstrating that strong religious convictions are often tied to mistrust of authorities and beliefs about the cause of the COVID-19 pandemic, which is fuelled by social media [ 43 ]. Furthermore, concern on the permissibility of these vaccines in their religion reduces its acceptability [ 10 ]. However, it is interesting to note that, while the majority in Malaysia are Muslims, it did not reduce the rate of vaccine acceptance and confidence in the country.

These findings have important implications for health authorities and governments in areas focusing on improving vaccination uptake. Misinformation about vaccination greatly hampers vaccination efforts. Thus, not only is it important to understand how specific population groups are influenced by digital platforms such as social media, but it is imperative to provide the right information driven by governmental and non-governmental organisations [ 39 ]. This could be achieved by having community-specific public education and role modelling from local health and public officials, which has been shown to increase public trust [ 44 ]. Since the primary reason for hesitancy is concern about the safety of vaccines, it is crucial that education programmes stress the effectiveness and importance of COVID-19 vaccinations [ 45 ]. Participants in this study coped with the pandemic by seeking out new information, but they sought information from social media when information from the authorities was lacking or were viewed as untrustworthy, which may have contained erroneous information. One way to deter this is to empower information-technology companies to monitor vaccine-related materials on social media, remove false information, and create correct and responsible content [ 44 ].

Furthermore, behavioural change techniques have been found to be useful in stressing the consequences of rejecting the vaccine on physical and mental health [ 46 ]. The most effective “nudging” interventions included offering incentives for parents and healthcare workers, providing salient information, and employing trusted figures to deliver this information [ 47 ]. Finally, since religious concerns have been prominent in reducing vaccine confidence and increasing hesitancy in this study, it is important to tailor messages to include information related to religion, and the use of religious leaders to spread these messages [ 48 ]. These are all important factors for increasing uptake of the COVID-19 vaccine, but also may be relevant in acceptability of routine immunisations as countries look to transition towards a post-pandemic delivery of healthcare.

A limitation of this study includes its cross-sectional design and the heterogeneity among participants, which meant that temporal changes in attitudes toward COVID-19 vaccines across time were not captured. Further, the need for internet access among Filipino and Malaysian participants limited the representativeness of the sample population. Thus, certain demographic were under-represented, including Filipino and Malaysian individuals over the age of 45, and people of lower socio-economic status. The surveys were also implemented in English, which may have limited the participation of target participants who were not fluent in English. In addition, due to space limitations, vaccine hesitancy and confidence were each captured using one item, which raises concerns of the items’ validity and reliability. Finally, not all independent variables were accounted for, including medical mistrust [ 49 ], vaccine knowledge [ 50 ], and specific social media platforms used [ 11 ]. We also did not assess whether participants had received any doses of the COVID-19 vaccine previously. Future research should include more important predictors to build a broader picture of vaccine-related hesitancy and confidence in the Philippines and Malaysia, and more items should be utilised to tap into these concepts more comprehensively. Despite these limitations, the core strength of this study relates to its relatively large number of participants from both countries, and its comprehensive analysis of predictors to provide as a starting point going forward.

Conclusions

The main aims of this research were to determine levels of hesitancy and confidence in COVID-19 vaccines among unvaccinated individuals in the Philippines and Malaysia, and to identify predictors significantly associated with these outcomes. Predictors of vaccine hesitancy in this study included the use of social media, information-seeking, and Christianity. Higher socioeconomic status positively predicted vaccine confidence. However, being Christian, Buddhist or Hindu, and the tendency to seek information online, were predictors of hesitancy. Efforts to improve uptake of COVID-19 vaccination must be centred upon providing accurate information to specific communities using local authorities, health services and other locally-trusted voices (such as religious leaders), and for the masses through social media. Further studies should focus on the development of locally-tailored health promotion strategies to improve vaccination confidence and increase the uptake of vaccination–especially in light of the Dengvaxia crisis in the Philippines.

Supporting information

S1 file. inclusivity in global research questionnaire..

https://doi.org/10.1371/journal.pgph.0000742.s001

• 1. Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, et al. Coronavirus pandemic. Published online at OurWorldinData.org. Available from https://ourworldindata.org/covid-vaccinations .
• View Article
• PubMed/NCBI
• Google Scholar
• 3. Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C,Ortiz-Ospina E, et al. Philippines: Coronavirus pandemic country profile. Published online at OurWorldinData.org. Available from https://ourworldindata.org/coronavirus/country/philippines .
• 9. Mendoza RU, Valenzuela, S, Dayrit, M. A Crisis of Confidence: The Case of Dengvaxia in the Philippines. SSRN: doi: 10.2139/ssrn.3519736.

• Open access
• Published: 21 September 2021

Local government responses for COVID-19 management in the Philippines

• Dylan Antonio S. Talabis 1 , 2 ,
• Ariel L. Babierra 1 , 2 ,
• Christian Alvin H. Buhat 1 , 2 ,
• Destiny S. Lutero 1 , 2 ,
• Kemuel M. Quindala III 1 , 2 &
• Jomar F. Rabajante 1 , 2 , 3  

BMC Public Health volume  21 , Article number:  1711 ( 2021 ) Cite this article

551k Accesses

25 Citations

6 Altmetric

Metrics details

Responses of subnational government units are crucial in the containment of the spread of pathogens in a country. To mitigate the impact of the COVID-19 pandemic, the Philippine national government through its Inter-Agency Task Force on Emerging Infectious Diseases outlined different quarantine measures wherein each level has a corresponding degree of rigidity from keeping only the essential businesses open to allowing all establishments to operate at a certain capacity. Other measures also involve prohibiting individuals at a certain age bracket from going outside of their homes. The local government units (LGUs)–municipalities and provinces–can adopt any of these measures depending on the extent of the pandemic in their locality. The purpose is to keep the number of infections and mortality at bay while minimizing the economic impact of the pandemic. Some LGUs have demonstrated a remarkable response to the COVID-19 pandemic. The purpose of this study is to identify notable non-pharmaceutical interventions of these outlying LGUs in the country using quantitative methods.

Data were taken from public databases such as Philippine Department of Health, Philippine Statistics Authority Census, and Google Community Mobility Reports. These are normalized using Z-transform. For each locality, infection and mortality data (dataset Y ) were compared to the economic, health, and demographic data (dataset X ) using Euclidean metric d =( x − y ) 2 , where x ∈ X and y ∈ Y . If a data pair ( x , y ) exceeds, by two standard deviations, the mean of the Euclidean metric values between the sets X and Y , the pair is assumed to be a ‘good’ outlier.

Our results showed that cluster of cities and provinces in Central Luzon (Region III), CALABARZON (Region IV-A), the National Capital Region (NCR), and Central Visayas (Region VII) are the ‘good’ outliers with respect to factors such as working population, population density, ICU beds, doctors on quarantine, number of frontliners and gross regional domestic product. Among metropolitan cities, Davao was a ‘good’ outlier with respect to demographic factors.

Conclusions

Strict border control, early implementation of lockdowns, establishment of quarantine facilities, effective communication to the public, and monitoring efforts were the defining factors that helped these LGUs curtail the harm that was brought by the pandemic. If these policies are to be standardized, it would help any country’s preparedness for future health emergencies.

Peer Review reports

Introduction

Since the emergence of the COVID-19 pandemic, the number of cases have already reached 82 million worldwide at the end of 2020. In the Philippines, the number of cases exceeded 473,000. As countries around the world face the continuing threat of the COVID-19 pandemic, national governments and health ministries formulate, implement and revise health policies and standards based on recommendations by world health organization (WHO), experiences of other countries, and on-the-ground experiences. Early health measures were primarily aimed at preventing and reducing transmission in populations at risk. These measures differ in scale and speed among countries, as some countries have more resources and are more prepared in terms of healthcare capacity and availability of stringent policies [ 1 , 2 ].

During the first months of the pandemic, several countries struggled to find tolerable, if not the most effective, measures to ‘flatten’ the COVID-19 epidemic curve so that health facilities will not be overwhelmed [ 3 , 4 ]. In responding to the threat of the pandemic, public health policies included epidemiological and socio-economic factors. The success or failure of these policies exposed the strengths or weaknesses of governments as well as the range of inequalities in the society [ 5 , 6 ].

As national governments implemented large-scale ‘blanket’ policies to control the pandemic, local government units (LGUs) have to consider granular policies as well as real-time interventions to address differences in the local COVID-19 transmission dynamics due to heterogeneity and diversity in communities. Some policies in place, such as voluntary physical distancing, wearing of face masks and face shields, mass testing, and school closures, could be effective in one locality but not in another [ 7 – 9 ]. Subnational governments like LGUs are confronted with a health crisis that have economic, social and fiscal impact. While urban areas have been hot spots of the COVID-19 pandemic, there are health facilities that are already well in placed as compared to less developed and deprived rural communities [ 10 ]. The importance of local narratives in addressing subnational concerns are apparent from published experiences in the United States [ 11 ], China [ 12 , 13 ], and India [ 14 ].

In the Philippines, the Inter-Agency Task Force on Emerging Infectious Diseases (IATF) was convened by the national government in January 2020 to monitor a viral outbreak in Wuhan, China. The first case of local transmission of COVID-19 was confirmed on March 7, 2020. Following this, on March 8, the entire country was placed under a State of Public Health Emergency. By March 25, the IATF released a National Action Plan to control the spread of COVID-19. A community quarantine was initially put in place for the national capital region (NCR) starting March 13, 2020 and it was expanded to the whole island of Luzon by March 17. The initial quarantine was extended up to April 30 [ 5 , 15 ]. Several quarantine protocols were then implemented based on evaluation of IATF:

Community Quarantine (CQ) refers to restrictions in mobility between quarantined areas.

In Enhanced Community Quarantine (ECQ), strict home quarantine is implemented and movement of residents is limited to access essential goods and services. Public transportation is suspended. Only economic activities related to essential and utility services are allowed. There is heightened presence of uniformed personnel to enforce community quarantine protocols.

Modified Enhanced Community Quarantine (MECQ) is implemented as a transition phase between ECQ and GCQ. Strict home quarantine and suspension of public transportation are still in place. Mobility restrictions are relaxed for work-related activities. Government offices operates under a skeleton workforce. Manufacturing facilities are allowed to operate with up to 50% of the workforce. Transportation services are only allowed for essential goods and services.

In General Community Quarantine (GCQ), individuals from less susceptible age groups and without health risks are allowed to move within quarantined zones. Public transportation can operate at reduced vehicle capacity observing physical distancing. Government offices may be at full work capacity or under alternative work arrangements. Up to 50% of the workforce in industries (except for leisure and amusement) are allowed to work.

Modified General Community Quarantine (MGCQ) refers to the transition phase between GCQ and the New Normal. All persons are allowed outside their residences. Socio-economic activities are allowed with minimum public health standard.

LGUs are tasked to adopt, coordinate, and implement guidelines concerning COVID-19 in accordance with provincial and local quarantine protocols released by the national government [ 16 ].

In this study, we identified economic and demographic factors that are correlated with epidemiological metrics related to COVID-19, specifically to the number of infected cases and number of deaths [ 17 , 18 ]. At the regional, provincial, and city levels, we investigated the localities that differ with the other localities, and determined the possible reasons why they are outliers compared to the average practices of the others.

We categorized the data into economic, health, and demographic components (See Table  1 ). In the economic setting, we considered the number of people employed and the number of work hours. The number of health facilities provides an insight into the health system of a locality. Population and population density, as well as age distribution and mobility, were used as the demographic indicators. The data (as of November 10, 2020) from these seven factors were analyzed and compared to the number of deaths and cumulative cases in cities, provinces or regions in the Philippines to determine the outlier.

The Philippine government’s administrative structure and the availability of the data affected its range for each factor. Regional data were obtained for the economic component. For the health and demographic components, data from cities and provinces were retrieved from the sources. Due to the NCR exhibiting the highest figures in all key components, an investigation was conducted to identify an outlier among its cities. The z -transform

where x is the actual data, μ is the mean and σ is the standard deviation were applied to normalize the dataset. Two sets of normalized data X and Y were compared by assigning to each pair ( x , y ), where x ∈ X and y ∈ Y , its Euclidean metric d given by d =( x − y ) 2 . Here, the Y ’s are the number of COVID-19 cases and deaths, and X ’s are the other demographic indicators. Since 95% of the data fall within two standard deviations from the mean, this will be the threshold in determining an outlier. This means that if a data pair ( x , y ) exceeds, by two standard deviations, the mean of the Euclidean metric values between the sets X and Y , the pair is assumed to be an outlier.

To identify a good outlier, a bias computation was performed. In this procedure, Y represents the normalized data set for the number of deaths or the number of cases while X represents the normalized data set for every factor that were considered in this study. The bias is computed using the metric

for all x in X and y in Y . To categorize a city, province, or region as a good outlier, the bias corresponding to this locality must exceed two standard deviations from the mean of all the bias computations between the sets X and Y .

Results and discussion

The data used were the reported COVID-19 cases and deaths in the Philippines as of November 10, 2020 which is 240 days since community lockdowns were implemented in the country. Figure  1 shows the different lockdowns implemented per province since March 15. It can be seen that ECQ was implemented in Luzon and major cities in the country in the first few weeks since March 15, and slowly eased into either GCQ or MGCQ as time progressed. By August, the most stringent lockdown was MECQ in the National Capital Region (NCR) and some nearby provinces. Places under MECQ on September were Iloilo City, Bacolod City, and Lanao del Sur, with the last province as the lone community to be placed under MECQ the month after. By November 1, 2020, communities were either placed under GCQ or MGCQ.

COVID-19 community quarantines in Regions III, IVA and VII

Comparison of economic, health, and demographic components and COVID-19 parameters

The economic, health and demographic components were compared to COVID-19 cases and deaths. These comparisons were done for different community levels (regional, provincial, city/metropolitan) (See Tables  2 , 3 , and 4 ). Figure  2 summarizes the correlation of components to COVID-19 cases and deaths at the regional level. In all components, correlations with other parameters to both COVID-19 cases and deaths are close. Every component except Residential Mobility and GRDP have slightly higher correlation coefficient for COVID-19 cases as compared to COVID-19 deaths.

Correlation of components to COVID-19 cases and deaths at the regional level

Among the components, the number of ICU beds component has the highest correlation with COVID-19 parameters. This makes sense as this is one of the first-degree measures of COVID-19 transmission. Population density comes in second, followed by mean hours worked and working population, which are all related to how developed the region is economy-wise. Regions having larger population density also have a huge working population and longer working hours [ 24 ]. Thus, having a huge population density implies high chance of having contact with each other [ 25 , 26 ]. Another component with high correlation to the cases and deaths is the number of doctors on quarantine, which can be looked at two ways; (i) huge infection rate in the region which is the reason the doctors got exposed or are on quarantine, and (ii) lots of doctors on quarantine which resulted to less frontliners taking care of the infected individuals. All definitions of mobility and the GDP are not strongly correlated to any of the COVID-19 measures.

In each data set, outliers were identified depending on their distance from the mean. For simplicity, we denote components that are compared with COVID-19 cases by (C) and with COVID-19 deaths by (D). The summary of outliers among regions in the Philippines is shown in Figs.  3 and 4 . Data is classified according to groups of component. In each outlier region, non-pharmaceutical interventions (NPI) implemented and their timing are identified.

Outliers among regions in the Philippines with respect to COVID-19 cases

Outliers among regions in the Philippines with respect to COVID-19 deaths

Region III is an outlier in terms of working population (C) and the number of ICU beds (C) (see Fig.  5 and Table  5 ). This means that considering the working population of the region, the number of COVID-19 infections are better than that of other regions. Same goes with the number of ICU beds in relation to COVID-19 deaths. Region III is comprised of Aurora, Bataan, Nueva Ecija, Pampanga, Tarlac, Zambales, and Bulacan. This good performance might be attributed to their performance especially on their programs against COVID-19. As early as March 2020, the region had been under a community lockdown together with other regions in Luzon. Being the closest to NCR, Bulacan has been the most likely to have high number of COVID-19 cases in the region. But the province responded by opening infection control centers which offer free healthcare, meals, and rooms for moderate-severe COVID-19 patients [ 27 ]. They have also implemented strict monitoring of entry-exit borders, organization of provincial task force and incident command center, establishment of provincial quarantine facilities for returning overseas Filipino workers, mandated municipal quarantine facilities for asymptomatic cases, and mass testing, among others [ 27 ]. Most of which have been proven effective in reducing the number of COVID-19 cases and deaths [ 28 ].

Outliers among the provinces in Luzon with respect to COVID-19 cases and deaths

Outliers among the provinces in Visayas with respect to COVID-19 cases and deaths

Outliers among the provinces in Mindanao with respect to COVID-19 cases and deaths

Region IV-A is an outlier in terms of population and working population (D) and doctors on quarantine (D) (see Fig.  5 and Table  5 ). Considering their population and working population, the COVID-19 death statistics show better results compared to other regions. Same goes with the number of doctors in the region which are in quarantine in relation to the reported COVID-19 deaths. This shows that the region is doing well in terms of decreasing the COVID-19 fatalities compared to other regions in terms of populations and doctors on quarantine. Region IV-A is comprised of Batangas, Cavite, Laguna, Quezon, and Rizal. Same with Region III, they have been under the community lockdown since March of last year. Provinces of the region such as Rizal have been proactive in responding to the epidemic as they have already suspended classes and distributed face masks even before the nationwide lockdown [ 29 ]. Despite being hit by natural calamities, the region still continue ramping up the response to the pandemic through cash assistance, first aid kits, and spreading awareness [ 30 ].

An interesting result is that NCR, the center of the country and the most densely populated, is a good outlier in terms of GRDP (C) and GRDP (D). Cities in the region launched various programs in order to combat the disease. They have launched mass testings with Quezon City, Taguig City, and Caloocan City starting as early as April 2020. Pasig City started an on-the-go market called Jeepalengke. Navotas, Malabon, and Caloocan recorded the lowest attack rate of the virus. Caloocan city had good strategies for zoning, isolation and even in finding ways to be more effective and efficient. Other programs also include color-coded quarantine pass, and quarantine bands. It is also possible that NCR may just have a very high GRDP compared to other regions. A breakdown of the outliers within NCR can be seen in Fig.  8 .

Outliers in the national capital region with respect to COVID-19 cases and deaths

Region VII is also an outlier in terms of population density (D) and frontliners (D) (see Fig.  6 and Table  5 ). This means that given the population density and the number of frontliners in the region, their COVID-related deaths in the region is better than the rest of the country. This region consists of four provinces (Cebu, Bohol, Negros Oriental, and Siquijor) and three highly urbanized cities (Cebu City, Lapu-Lapu City, and Mandaue City), referred to as metropolitan Cebu. This significant decline may be explained by how the local government responded after they were placed in stricter community quarantine measures despite the rest of the country easing in to more lenient measures. Due to the longer and stricter quarantine in Cebu, the lockdown had a greater impact here than in other areas where restrictions were eased earlier [ 31 ]. Dumaguete was one of the destinations of the first COVID case in the Philippines [ 32 ], their local government was able to keep infections at bay early on. Siquijor was also COVID-19-free for 6 months [ 33 ]. The compounded efforts of the different provinces in the region can account for the region being identified as an outlier.

Among the metropolitan cities, Davao came out as a good outlier in terms of population (C) and working population (C) (see Figs.  7 , 9 , and Table  5 ). This result may be attributed to their early campaign on consistent communication of COVID-19-related concerns to the public [ 34 ]. They were also able to set up transportation for essential workers early on [ 35 ].

Outliers among metropolitan areas in the Philippines with respect to COVID-19 cases and deaths

This study identified outliers in each data group and determined the NPIs implemented in the locality. Economic, health and demographic components were used to identify these outliers. For the regional data, three regions in Luzon and one in Visayas were identified as outliers. Apart from the minimum IATF recommended NPIs, various NPIs were implemented by different regions in containing the spread of COVID-19 in their areas. Some of these NPIs were also implemented in other localities yet these other localities did not come out as outliers. This means that one practice cannot be the sole explanation in determining an outlier. The compounding effects of practices and their timing of implementation are seen to have influenced the results. A deeper analysis of daily data for different trends in the epidemic curve is considered for future research.

Correlation tables, outliers and community quarantine timeline

Availability of data and materials.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, Ren R, Leung KSM, Lau EHY, Wong JY, Xing X, Xiang N, Wu Y, Li C, Chen Q, Li D, Liu T, Zhao J, Liu M, Tu W, Chen C, Jin L, Yang R, Wang Q, Zhou S, Wang R, Liu H, Luo Y, Liu Y, Shao G, Li H, Tao Z, Yang Y, Deng Z, Liu B, Ma Z, Zhang Y, Shi G, Lam TTY, Wu JT, Gao GF, Phil D, Cowling BJ, Yang B, Leung GM, Feng Z. Early transmission dynamics in Wuhan, China, of novel coronavirus–infected pneumonia. N Engl J Med. 2020; 382(13):1199–207.

Article   CAS   Google Scholar  

Hsiang S, Allen D, Annan-Phan S, Bell K, Bolliger I, Chong T, Druckenmiller H, Huang LY, Hultgren A, Krasovich E, Lau P, Lee J, Rolf E, Tseng J, Wu T. The effect of large-scale anti-contagion policies on the covid-19 pandemic. Nature. 2020; 584:262–67.

Anderson R, Heesterbeek JAP, Klinkenberg D, Hollingsworth T. Comment how will country-based mitigation measures influence the course of the covid-19 epidemic?Lancet. 2020; 395. https://doi.org/10.1016/S0140-6736(20)30567-5 .

Buhat CA, Torres M, Olave Y, Gavina MK, Felix E, Gamilla G, Verano KV, Babierra A, Rabajante J. A mathematical model of covid-19 transmission between frontliners and the general public. Netw Model Anal Health Inform Bioinforma. 2021; 10. https://doi.org/10.1007/s13721-021-00295-6 .

Ocampo L, Yamagishic K. Modeling the lockdown relaxation protocols of the philippine government in response to the covid-19 pandemic: an intuitionistic fuzzy dematel analysis. Socioecon Plann Sci. 2020; 72. https://doi.org/10.1016/j.seps.2020.100911 .

Weible C, Nohrstedt D, Cairney P, Carter D, Crow D, Durnová A, Heikkila T, Ingold K, McConnell A, Stone D. Covid-19 and the policy sciences: initial reactions and perspectives. Policy Sci. 2020; 53:225–41. https://doi.org/10.1007/s11077-020-09381-4 .

Article   Google Scholar  

Wibbens PD, Koo WW-Y, McGahan AM. Which covid policies are most effective? a bayesian analysis of covid-19 by jurisdiction. PLoS ONE. 2020. https://doi.org/10.1371/journal.pone.0244177 .

Mintrom M, O’Connor R. The importance of policy narrative: effective government responses to covid-19. Policy Des Pract. 2020; 3(3):205–27. https://doi.org/10.1080/25741292.2020.1813358 .

Google Scholar  

Chin T, Kahn R, Li R, Chen JT, Krieger N, Buckee CO, Balsari S, Kiang MV. Us-county level variation in intersecting individual, household and community characteristics relevant to covid-19 and planning an equitable response: a cross-sectional analysis. BMJ Open. 2020; 10(9). https://doi.org/10.1136/bmjopen-2020-039886 .

OECD. The territorial impact of COVID-19: managing the crisis across levels of government. 2020. https://www.oecd.org/coronavirus/policy-responses/the-territorial-impact-of-covid-19-managing-the-crisis-across-levels-of-government-d3e314e1/#biblio-d1e5202 . Accessed 20 Feb 2007.

White ER, Hébert-Dufresne L. State-level variation of initial covid-19 dynamics in the united states. PLoS ONE. 2020; 15. https://doi.org/10.1371/journal.pone.0240648 .

Lin S, Huang J, He Z, Zhan D. Which measures are effective in containing covid-19? — empirical research based on prevention and control cases in China. medRxiv. 2020. https://doi.org/10.1101/2020.03.28.20046110 . https://www.medrxiv.org/content/early/2020/03/30/2020.03.28.20046110.full.pdf .

Mei C. Policy style, consistency and the effectiveness of the policy mix in China’s fight against covid-19. Policy Soc. 2020; 39(3):309–25. https://doi.org/10.1080/14494035.2020.1787627. http://arxiv.org/abs/https: //doi.org/10.1080/14494035.2020.1787627.

Dutta A, Fischer HW. The local governance of covid-19: disease prevention and social security in rural india. World Dev. 2021; 138:105234. https://doi.org/10.1016/j.worlddev.2020.105234 .

Vallejo BM, Ong RAC. Policy responses and government science advice for the covid 19 pandemic in the philippines: january to april 2020. Prog Disaster Sci. 2020; 7:100115. https://doi.org/10.1016/j.pdisas.2020.100115 .

Inter-Agency Task Force for the Management of Emerging Infectious Diseases. Omnibus guidelines on the implementation of community quarantine in the Philippines. 2020. https://doh.gov.ph/node/27640 . Accessed 20 Feb 2020.

Roy S, Ghosh P. Factors affecting covid-19 infected and death rates inform lockdown-related policymaking. PloS ONE. 2020; 15(10):0241165. https://doi.org/10.1371/journal.pone.0241165 .

Pullano G, Valdano E, Scarpa N, Rubrichi S, Colizza V. Evaluating the effect of demographic factors, socioeconomic factors, and risk aversion on mobility during the covid-19 epidemic in france under lockdown: a population-based study. Lancet Digit Health. 2020; 2(12):638–49.

Department of Health. COVID-19 tracker. 2020. https://doh.gov.ph/covid19tracker . Accessed 25 Nov 2020.

Authority PS. Philippine population density (based on the 2015 census of population). 2020. https://psa.gov.ph/content/philippine-population-density-based-2015-census-population . Accessed 11 Apr 2020.

Google. COVID-19 community mobility report. 2020; https://www.google.com/covid19/mobility?hl=en. Accessed 25 Nov 2020.

Authority PS. Labor force survey. 2020. https://psa.gov.ph/statistics/survey/labor-and-employment/labor-force-survey?fbclid=IwAR0a5GS7XtRgRmBwAcGl9wGwNhptqnSBm-SNVr69cm8sCVd9wVmcoKHRCdU . Accessed 11 Apr 2020.

Authority PS. https://psa.gov.ph/grdp/tables?fbclid=IwAR3dKvo3B5eauY7KcWQG4VXbuiCrzFHO4b-f1k5Od76ccAlYxUimUIaqs94 . Accessed 11 Apr 2020. 2020.

Peterson E. The role of population in economic growth. SAGE Open. 2017; 7:215824401773609. https://doi.org/10.1177/2158244017736094 .

Buhat CA, Duero JC, Felix E, Rabajante J, Mamplata J. Optimal allocation of covid-19 test kits among accredited testing centers in the philippines. J Healthc Inform Res. 2021; 5. https://doi.org/10.1007/s41666-020-00081-5 .

Hamidi S, Sabouri S, Ewing R. Does density aggravate the covid-19 pandemic?: early findings and lessons for planners. J Am Plan Assoc. 2020; 86:1–15. https://doi.org/10.1080/01944363.2020.1777891 .

Philippine News Agency. Bulacan shares anti-COVID-19 best practices. 2020. https://mb.com.ph/2020/08/16/bulacan-shares-anti-covid-19-best-practices/ . Accessed Mar 2020.

Buhat CA, Villanueva SK. Determining the effectiveness of practicing non-pharmaceutical interventions in improving virus control in a pandemic using agent-based modelling. Math Appl Sci Eng. 2020; 1:423–38. https://doi.org/10.5206/mase/10876 .

Hallare K. Cainta, Rizal suspends classes, distributes face masks over coronavirus threat. 2020. https://newsinfo.inquirer.net/1238217/cainta-rizal-suspends-classes-distributes-face-masks-over-coronavirus-threat . Accessed Mar 2020.

Relief International. Responding to COVID-19 in the Aftermath of Volcanic Eruption. 2020. https://www.ri.org/projects/responding-to-covid-19-in-the-aftermath-of-volcanic-eruption/. Accessed Mar 2020.

Macasero R. Averting disaster: how Cebu City flattened its curve. 2020. https://www.rappler.com/newsbreak/explainers/how-cebu-city-flattened-covid-19-curve/ . Accessed Mar 2020.

Edrada EM, Lopez EB, Villarama JB, Salva-Villarama EP, Dagoc BF, Smith C, Sayo AR, Verona JA, Trifalgar-Arches J, Lazaro J, Balinas EGM, Telan EFO, Roy L, Galon M, Florida CHN, Ukawa T, Villaneuva AMG, Saito N, Nepomuceno JR, Ariyoshi K, Carlos C, Nicolasor AD, Solante RM. First covid-19 infections in the philippines: a case report. Trop Med Health. 2020; 48(30). https://doi.org/10.1186/s41182-020-00218-7 .

Macasero R. Coronavirus-free for 6 months, Siquijor reports first 2 cases. 2020. https://www.rappler.com/nation/siquijor-coronavirus-cases-august-2-2020 . Accessed Mar 2020.

Davao City. Mayor Sara, disaster radio journeying with dabawenyos. 2020. https://www.davaocity.gov.ph/disaster-risk-reduction-mitigation/mayor-sara-disaster-radio-journeying-with-dabawenyos . Accessed Mar 2020.

Davao City. Davao city free rides to serve GCQ-allowed workers. 2020. https://www.davaocity.gov.ph/transportation-planning-traffic-management/davao-city-free-rides-to-serve-gcq-allowed-workers/ . Accessed Mar 2020.

Download references

Acknowledgements

JFR is supported by the Abdus Salam International Centre for Theoretical Physics Associateship Scheme.

This research is funded by the UP System through the UP Resilience Institute.

Author information

Authors and affiliations.

Institute of Mathematical Sciences and Physics, University of the Philippines Los Baños, Laguna, Philippines

Dylan Antonio S. Talabis, Ariel L. Babierra, Christian Alvin H. Buhat, Destiny S. Lutero, Kemuel M. Quindala III & Jomar F. Rabajante

University of the Philippines Resilience Institute, University of the Philippines, Quezon City, Philippines

Faculty of Education, University of the Philippines Open University, Laguna, Philippines

Jomar F. Rabajante

You can also search for this author in PubMed   Google Scholar

Contributions

All authors are involved in drafting the manuscript and in revising it. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Dylan Antonio S. Talabis .

Ethics declarations

Ethics approval and consent to participate.

Not applicable. We used secondary data. These are from the public database of the Philippine Department of Health ( https://www.doh.gov.ph/covid19tracker ) and Philippine Statistics Authority Census ( https://psa.gov.ph )

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

S. Talabis, D.A., Babierra, A.L., H. Buhat, C.A. et al. Local government responses for COVID-19 management in the Philippines. BMC Public Health 21 , 1711 (2021). https://doi.org/10.1186/s12889-021-11746-0

Download citation

Received : 19 April 2021

Accepted : 30 August 2021

Published : 21 September 2021

DOI : https://doi.org/10.1186/s12889-021-11746-0

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Local government
• Quantitative methods

BMC Public Health

ISSN: 1471-2458

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• My Account Login
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Open access
• Published: 30 March 2022

OCTA as an independent science advice provider for COVID-19 in the Philippines

• Benjamin M. Vallejo Jr 1 &
• Rodrigo Angelo C. Ong 1  

Humanities and Social Sciences Communications volume  9 , Article number:  104 ( 2022 ) Cite this article

5928 Accesses

4 Citations

7 Altmetric

Metrics details

• Health humanities
• Science, technology and society
• Social science

We comment on science advice in the political context of the Philippines during the COVID 19 pandemic. We focus on the independent science advisor OCTA Research, whose publicly available epidemiological forecasts have attracted media and government attention. The Philippines government adopted a COVID-19 suppression or “flattening of the curve” policy. As such, it required epidemiological forecasts from science advisors as more scientific information on SARS CoV 2 and COVID 19 became available from April to December 2020. The independent think-tank, OCTA Research has emerged the leading independent science information advisor for the public and government. The factors that made OCTA Research as the dominant science advice source are examined, the diversity of scientific evidence, processes of evidence synthesis and, of evidence brokerage for political decision makers We then describe the dynamics between the government, academic science research and science advisory actors and the problem of science advice role conflation. We then propose approaches for a largely independent government science advisory system for the Philippines given these political dynamics.

Similar content being viewed by others

Persistent interaction patterns across social media platforms and over time

Michele Avalle, Niccolò Di Marco, … Walter Quattrociocchi

Ecological countermeasures to prevent pathogen spillover and subsequent pandemics

Raina K. Plowright, Aliyu N. Ahmed, … Annika T. H. Keeley

A cross-verified database of notable people, 3500BC-2018AD

Morgane Laouenan, Palaash Bhargava, … Etienne Wasmer

Introduction

Pandemic science before COVID 19 presumed “predictable challenges” (Lipsitch et al., 2009 ) that informs government response especially in planning for containment interventions such as lockdowns. The success of government response is in the public perception of a positive outcome and this is reducing the number of infections. The COVID 19 pandemic is a crisis in which the orderly functioning of social and political institutions are placed into disorder and uncertainty (Boin et al., 2016 ). In political institutions this may be a threat to accepted political power arrangements and requires a response which because of their urgency, are occasions for political leaders to demonstrate leadership. However, to do so they will have to rely on actors who provide science, economic and social information and advice. In many cases these actors are within the government bureaucracy itself, as specialized agencies. Academic research institutions also provide advice. Civil society organizations with science and technology advocacies may provide advice. Science advice provided by civil society organizations, citizen science advocacy organizations and non-government think tanks are independent science advice providers. These organizations are a feature of the technical and science advice ecosystems of liberal democracies.

How governments use science advice and decide in a crisis strengthens political legitimacy. In the United Kingdom with its formal structures of government science advice such as the Science Advisory Group for Emergencies (SAGE) a key outcome is lowering SARS CoV 2 transmission (R) rate and the way this can be achieved is to institute a lockdown. SAGE was placed in a high degree of public, media and political scrutiny in its recommendations. While formal science advice structures may work well in countries with a large and well-established science community, in countries with small science communities, independent science advice actors may be more effective than formal science advice actors.

Previous studies on the use of science advice by governments have revealed a dichotomy. Knowledge producers (e.g., academic science community) perceive high uncertainty in scientific results and consequentially become guarded in their science advice or even dispense with it in recognition of their political costs. In contrast knowledge users (e.g. politicians and science advisors in government) perceive less uncertainty in science advice and require assurances in outcomes (MacKenzie, 1993 ). This present challenges for science advice practitioners since differentiating the roles of science knowledge generation and science knowledge users, both of which can be played by academic scientists, can be conflated, and may result in political risks and opportunities.

To remedy this conflation, science advice mechanisms emphasizing independent knowledge brokerage (Gluckman, 2016a ) define a particular role for scientists in listing down science informed options for politicians and policy makers. These roles have their theoretical basis from post-normal science approaches (Funtowicz and Ravetz, 1993 , 1994 ; Ravetz, 1999 ) which place a premium on managing uncertainty in crises through consensus building and identifying of science informed policy options. The science advice “knowledge broker” will not be functioning as part of the knowledge generation constituency but in a purely advisory capacity identifying policy options. This is the model promoted by the International Network for Government Science Advice (INGSA). This also insulates the science advisor from undue political interference.

However, in countries where the science community is small and politically underrepresented, performing these well-defined functions will be difficult due to a lack of experts and the range of scientific expertise they can provide. In small science communities, the problems of role conflation become more apparent and may place the science advisor prone to political pressure. Vallejo and Ong ( 2020 ) reviewed the Philippines government response and science advice for COVID 19 from when the World Health Organization (WHO) advised UN member states of a pandemic health emergency on January 6 to April 30, 2020 when the Philippines government began relaxing quarantine regulations. They noted the roles of various science advice knowledge generation actors such as individual scientists, academe, national science academies and organizations and how these were eventually considered by the Inter Agency Task Force on Emerging Infectious Diseases (IATF-EID) which is the government’s policy recommending body for COVID 19 suppression. Of these advisory actors, the private and independent OCTA Research Group hereafter referred to as OCTA, which consists of a multi-disciplinary team of academics from the medical, social, economic, environmental, and mathematical sciences mostly from the University of the Philippines, became the most prominent source of government science advice with its proactive but unsolicited provision of government science advice.

Because of this engagement, like SAGE in the UK, OCTA became a focus of intense media, public, and political interest and could represent an effective modality for independent science advice especially in newly industrialized countries where the science community is small but gaining a larger base of expertise. While science advice in this context may involve a conflation of science advice roles, we look into this conflation and their political dynamics in pandemic uncertainty and how consensus was formed in COVID 19 policy advice. This paper explores on how independent science advice has proved to be the chief source science advice in a polarized political environment in a Southeast Asian nation from the start of the pandemic in January 2020–October 2021.

The Philippine science advice ecosystem

Science advice in the Philippines takes on formal (with government mandate), informal (without government mandate) solicited and unsolicited modalities. Formal science advice to the President of the Philippines is provided by the National Academy of Science and Technology (NAST) by virtue of Presidential Executive Order Number 812. The government solicits science advice from the NAST which provides advice as position or white papers to cabinet for consideration. The NAST is not a wholly independent body from government. It is attached to the Department of Science and Technology (DOST) for administrative and fiscal purposes.

Other sources of science advice are from the universities such as the University of the Philippines (UP). The UP is designated by charter (Republic Act Number 8500) as the national, research and graduate university. This mandates it to provide science advice to the government. Academics in their individual capacities, as members of think-tanks or civil society organizations provide unsolicited and informal science advice to government through the publication of scientific and position papers as well as technical reports. Academics who are part of non-government science academies such as the Philippine American Academy of Science and Engineering (PAASE) provide similar advice. The science advice system in the Philippines is diverse with each actor having its own political and development advocacy. The system is largely ad hoc and informal, and science advice are largely unsolicited. This dynamic determines its role with the government. Also, when these science advice actors are consulted by the government, they are all primuses inter pares in dealing with political actors in government. Members of the science advisory bodies are mostly active academics. They are all knowledge producers and users at the same time.

There are few studies that directly examine the politics of science advice and uncertainty in the Philippines, and these are in disaster risk reduction management (DRRM). This can serve as a template for analysis for the COVID 19 pandemic in the Philippines which has been construed by government and the public as a global disaster. The strengths and weaknesses of the present science advisory system may be seen in DRRM advice.

DRRM as a framework for government science advice in the Philippines

Disasters which have affected the Philippines in the first decade of the 21st century such as Typhoon Ketsana (Philippine name “Ondoy”) in 2009 which flooded much of the National Capital Region, have resulted in several studies investigating the resilience of urban communities and how science advice is used in crafting urban resilience policies and governance. This disaster was also the major impetus for disaster legislation with enactment of the DRRM law (Republic Act Number 10121). This law institutionalizes and mainstream the development of capacities in disaster management at every level of governance, disaster risk reduction in physical and land-use planning, budget, infrastructure, education, health, environment, housing, and other sectors. The law also institutes the establishment of DRRM councils at each level of government. The councils are composed of members from government departments, the armed forces and police, civil society, humanitarian agencies but most notably, does not include academic research scientists. Science advice is given by CSOs but that is in accordance with their particular advocacies and their political objectives.

A study commissioned by the independent think tank Odi.org and by researchers of De La Salle University in Manila (Pellini et al., 2013 ) concluded that there is a “low uptake of research and analysis” to inform local decision in DRRM. It also identified a reactionary response to disasters rather than a response to disaster risks. Formal and informal science advice is most effective in local government if local executives prioritize risk reduction with consensus building at the local level. In general, formal, and informal science advice is less effective at the national level. The Philippine science advisory ecosystem is focused on formal science advice at the national level and thus the effectiveness of science advice is placed into question. The disaster-prone province of Albay is held as an example where science advice is more effective at a devolved level from the national (Bankoff and Hilhorst, 2009 ; Pellini et al., 2013 ).

At the lower levels of governance, informal science advice is predominant and is provided by science advice actors such as non-government organizations (NGO) or by civil society organizations (CSO). While NGOs, CSOs and, the government communicate using a consensus vocabulary (Funtowicz and Ravetz, 1994 ) in DRRM, differing risk perceptions have resulted in different domains of political engagement (Bankoff and Hilhorst, 2009 ) tied to different interpretations of the risk vocabulary in terms of political costs. And so the dominant paradigm remains disaster reactive with a general trend in “dampening uncertainties” (Pearce, 2020 ) in order to come up with positive political outcomes for the science advisors and the government.

While the present DRRM law institutionalizes consultation and collaboration, the law does not mandate a science or technical advisor to sit on DRRM councils at each level of governance. This is one possible reason for the “low uptake of research and analysis” at higher levels of governance while at lower levels of governance, science advice is provided by CSO and other advocacy organizations in an independent and ad hoc manner as they are more effective in establishing collaborative relationships with local government executives and councils.

IATF-EID and OCTA Research as an independent science advisor

Vallejo and Ong ( 2020 ) review the timeline for the Philippines government COVID 19 response, the formation of the Inter-agency Task Force on Emerging Infectious Diseases (IATF-EID), the science advisory ecosystem, and how the science community began to dispense informal science advice for consideration by IATF-EID. IATF-EID is the government’s policy recommending body for COVID 19 suppression and is composed of members from the cabinet and health agencies of the government. Informal science advice initially came from individual or groups of academics modeling the initial epidemiological trajectory of COVID 19. The IATF-EID is not a science evidence synthesizing or peer review body. It must rely on many science advisory actors as consultants. The University of the Philippines COVID 19 Pandemic Response Team is a major actor as its scientists are well known in the medical and disaster sciences. But it was OCTA which is composed mainly of academics from the University of the Philippines and the University of Santo Tomas. OCTA that has emerged as the leading government science advice actor for COVID 19.

OCTA bills itself as a “polling, research and consultancy firm”(Fig. 1 ). That OCTA has been identified in media reports as the “University of the Philippines OCTA Research group” is to be expected as academic credibility is a premium in the Philippines as like in other countries (Doubleday and Wilsdon, 2012 ). This however can constrain its political relationship with government science advice actors and so OCTA had to publish disclaimers that while it is composed of mostly University of the Philippines academics, it claims to be an independent entity. OCTA’s polling function is separate from its science advice advocacy which is performed by volunteer scientists as testified by OCTA President Ranjit S Rye to the Philippine Congress Committee on Public Accountability on 3 October 2021. The polling function is supported by paid subscribers while the science advice advocacy is supported by unpaid volunteers. Volunteer OCTA epidemiological modelers and policy analysts have provided robust estimates on the COVID 19 reproductive number R0, positivity rates, hospital capacity and attack rates at the national, provincial, and local government levels every fortnight beginning April 27, 2020. It has since issued 76 advisories and updates (Fig. 2 ). Local and provincial governments have used their forecasts in deciding quarantine and lockdown policies in their jurisdictions. OCTA publicly released these forecasts in academic websites, institutional media and social media. This allowed for public vetting and extended peer review with other independent scientists validating its forecast estimates. Some independent scientists contest methodologies and OCTA has appropriately responded to these.

OCTA is a primarily polling organization but has taken on COVID-19 monitoring, forecasting and advice services.

An OCTA COVID-19 forecast update (7 March 2021).

OCTA like other science advice actors, based its epidemiological analyses on the Philippines Department of Health (DOH) Data Drop whose data quality was publicly perceived as poor even though steps have been taken to improve data quality. The DOH in the interest of transparency began Data Drop on April 15, 2020. Data Drop has information on the number of active cases, recovered cases, and hospital admissions. With Data Drop, OCTA was able to issue its first epidemiological forecast.

OCTA does not belong to the formal structures of science advice in the Philippines but is part of the informal science advice community. Its volunteer experts are publicly known. OCTA has emerged as the leading information and science advice provider for the public. How did it become the leading source of science advice and often cited by social and mainstream media and acknowledged by government?

Uncertainty perception in COVID-19 suppression and the political context of role conflation

OCTA became the leading source of science advice when by publishing weekly forecasts on COVID-19 epidemiological trends, it reduced public perception of uncertainty of the pandemic. The bulletins estimated national and regional R0, attack rates, hospital capacity and ICU bed capacity. While most countries worldwide have adopted suppression as the main strategy (Allen et al., 2020 ) a few countries most notably New Zealand, adopting a COVID 19 elimination strategy. The Philippines decided on a suppression policy or a strategy of “flattening the curve” which necessitated lockdowns with the outcome of reducing R0 and COVID-19 hospital admissions.

The most socially and economically disruptive intervention is lockdown with is tied with the uncertainty of lifting quarantine (Caulkins et al., 2020 ). The Philippines instituted a national lockdown beginning 14 March 2020 and instituted a graded system of “community quarantine” which allowed for almost cessation of economic activity and mobility in enhanced community quarantine (ECQ), a modified enhanced community quarantine (MECQ) which allows for the opening of critical services and a limited operation of public transport, to a near open economy and unimpeded local mobility in modified general community quarantine (MGCQ) and a low risk general community quarantine (GCQ) which allows for most economic activities subject to health protocols (Vallejo and Ong, 2020 ) which regulated mobility between quarantine zones.

It is in lockdown policies that uncertainty perception takes on a large political dimension (Gluckman, 2016b ; Pearce, 2020 ). Science advisors have to provide forecasts on the trajectory of R0 for politicians to make a decision on tightening or relaxing of quarantine. In this manner OCTA has provided not only the quarantine grade option but the best option while recognizing that the constraint to lessening the perception of uncertainty lies on data quality itself (Johns, 2020 ). OCTA has raised this concern questions on the accuracy and timeliness of DOH’s Data Drop. In doing so, it has done multiple scenario models to assess the accuracy of data. If the government takes on lockdown as the main strategy for COVID 19 suppression, then it must ensure that science advisory actors are able to deal with the multiple uncertainties that data quality will generate. Science advisory actors can be both knowledge generators and users and this conflation has several consequences such as a tension between knowledge production and use which is called as the “uncertainty monster” (Van der Sluijs, 2005 ).

OCTA it its business model has role conflation. While its polling services are paid for by subscribers, the science advice advocacy function in COVID-19 is volunteer based. This conflation was questioned by members of Congress. Thus, the political context for OCTA is within the problem of role conflation in science in a particular political and academic context which may be the norm in developing countries. The politics of conflation in science advice in the UK was demonstrated when two esteemed epidemiologists belonging to two research groups, Professor Neil Ferguson of the Imperial College London (ICL) and Professor John Edmunds of the London School of Hygiene and Tropical Medicine (LSHTM) released R0 estimates to the public. ICL and LSHTM provided advisories to media and the UK government SAGE, with two different estimates for R0. The ICL estimate (2.0–2.6) were earlier made known to media while the LSHTM estimate (2.7–3.99) underwent peer review and was published in Lancet Public Health (Davies et al., 2020 ). The two estimates became the focus of controversy as the UK Chief Science Advisor Professor Patrick Vallance echoed Edmund’s claim of a case doubling time of 5–6 days. The SAGE consensus was 3–4 days, thus necessitating a sooner rather than later lockdown. The question on when to impose a lockdown is also a political matter. This placed SAGE and its established protocols of keeping experts anonymous under public criticism and scrutiny.

Pearce ( 2020 ) reviews the problem of role conflation of knowledge providers (the modelers) and the knowledge users (government) if they occupy both positions at the same time. Edmunds is a SAGE member (knowledge user) as well as a producer of science information as an academic. This conflation of roles resulted in the “dampening of uncertainties” for political reasons. The government is not acutely aware that this ultimately stems from poor data quality and the resulting scientific uncertainty has great political costs (UP COVID-19 Pandemic Response Team, 2020 ).

Similarly, OCTA has faced questions in its R0 estimates which differs from estimates by other scientists. OCTA’s estimates are higher (2.3) than what government initially used (2.1) in characterizing the surge in cases beginning Feb 2021. With R0 and positivity rates increasing, OCTA recommended an ECQ for the 2021 Easter break which was extended to a MECQ until 30 April 2021 (CNN Philippines, 2021 ). Like in the UK, this will affect policy decision making based on doubling time and the allocation of health resources. But unlike in the UK where there is a formal process of science peer review, in the ad hoc nature of science advice review in the Philippines, much of this “open peer review” by academics was on social media thus giving a polarizing political environment in policy decision.

OCTA has long been aware of the problem of role conflation which is a problem in a country with a small national science community. The national science community is small with only 189 scientists per million people. It thus has sought the expertise of overseas Filipino scientists to expand its advisory bench and to reduce possible role conflation. The overseas scientists are not associated with government health research agencies and so could act more independently. This was a strategy to deal with the possibility of “dampening of evidence”. The Presidential Spokesperson Mr. Harry Roque said that OCTA should cease reporting results to the public and rather send these “privately” to government (Manila Bulletin, 2020 ; Philippine Star, 2020 ). Roque is misconstruing the role of OCTA as a formal government science advisory body when it is not. The statements of the government spokesman may reflect debates in cabinet about the necessity and role of government science advice in and outside of government and their political costs. IATF-EID has its own experts as internal government science advisors. However, their advice must still be subject to peer review and so a mechanism must be found for these experts to compare forecasts with independent advisors such as OCTA. This will minimize public perception that the government silencing OCTA to dampen uncertainties for political outcomes. Public trust in government science advice has always been low if there is no transparency (Dommett and Pearce, 2019 ).

OCTA forecasts have been criticized by government economic planners especially in tourism (Philippine Daily Inquirer, 2020 ) as the forecasts directly affect plans to reopen important economic sectors. Some criticism is apparently political (Manila Times, 2020 ) and implies alienation of OCTA from its academic institutional linkage base. OCTA forecasts have been more and more adopted by the IATF-EID (ABS-CBN, 2021 ) This is a political dynamic for science advice actors sitting in government. Internal science advice actors will have to deal with populist interests in government and their advice may be “written off” (Boin et al., 2016 ). Independent science advice actors do not want their government science advice to be written off and so are likely to take the public route in presenting their synthesis of evidence and options.

Pandemic policy response is all about the management of multiple epidemiological uncertainties. This is when inability of government to manage it became apparent when doctors through the Healthcare Professionals Alliance Against COVID-19 (HPAAC), an organization which is comprised of the component and affiliate societies of the Philippine Medical Association admonished the government to increase quarantine restrictions from General Community Quarantine to Modified Enhanced Community Quarantine for a period of 2 weeks in August to allow the health workers to recover from exhaustion (One News, 2020 ). This is due to the surge in new cases and the overburdening of the healthcare capacity which OCTA earlier forecasted (David et al., 2020 ). The threat of a “doctors strike” would have been politically damaging to the government and the President decided to heed the doctors’ request.

The Philippines response is not very different from response of the majority of 22 countries examined by INGSA’s COVID 19 policy tracker (Allen et al., 2020 ), where these countries embarked on a monitoring and surveillance policy from January to March 2020. The INGSA study also shows that few countries have utilized internal and external formal science advisory bodies in the first 3 months of the pandemic. The Philippines is not one of the countries which INGSA tracked but similarly it started to seek the advice of individual experts by March 2020. Many of these experts posted their unsolicited science advice on social media.

Like most of the 22 INGSA tracked countries, after the 3rd month of the pandemic, the Philippines enacted legislation to deal with the social and economic impact of lockdowns. But this has not yet resulted in legislation passed in the Philippines Congress to deal with developing and improving systems for pandemic response through research and development initiatives although the late Senator Miriam Defensor Santiago filed Senate Bill 1573 “Pandemic and All Hazards Act” in September 2013 (Senate of the Philippines 16th Congress, 2013 ) in response to MERS and Senator Manny Villar in April 2008 filed Senate Bill 2198 “The Pandemic Preparedness Act” (Senate of the Philippines 14th Congress, 2008 ). Both bills institute a Pandemic Emergency Fund and mandates a Pandemic Emergency Council or Task Force, roughly along the lines of the DRRM Law. Defensor-Santiago’s bill was refiled by Senator Grace Poe as Senate Bill 1450 “An Act Strengthening National Preparedness and Response to Public Health Emergencies by Creating a Center for Disease Control” during the first session of the 18th Congress on 27 April 2020 (Senate of the Philippines 18th Congress, 2020 ). Poe’s bill updates Defensor-Santiago’s bill by proposing the creation of Center for Disease Control

These bills have not been enacted into law. The Philippines also did not enact legislation or executive on creating or strengthening science advisory capacity which 12 of the 22 countries INGSA tracked did. However, a senator has recently approached OCTA for policy input in developing formal crisis science advice legislation.

Prospects for independent government science advice in the Philippines

The Philippines government’s COVID 19 suppression policy is based on science informed advice. However, this has been provided informally by individual experts consulted by IATF-EID and this advice is not subjected to formal peer review. This has exposed experts to political criticism and attack as their identities and roles have been spun by media and government media spokespersons as integral to IATF-EID. At least one expert has resigned from providing science advice due to possible conflicts of interests. In this science advice gap, entered OCTA Research in the second quarter of 2020 and continued to 2021 and 2022.

The informal science advice actors more often give their forecasts directly to the media while the formal actors give it to the government agency that commissioned it. The government uses the evidence in determining what quarantine status to implement nationally and regionally through the recommendation of the IATF-EID.

The government’s policy decisions on COVID 19 suppression are chiefly based on a single statistical estimate, R0 but more recently has included positivity rate and hospital capacity. Science advisory bodies must defend R0 and the other estimates to the government and in the public sphere. The estimates will have incorporated all statistical uncertainties in this number. OCTA has done this by publicly reporting low, moderate and high R0 scenarios and the consequent projections for new cases, hospital utilization and attack rates at the national, regional and local government level. The government has used these estimates in its monthly policy responses.

Considering that both use the same DOH Data Drop dataset, dissonance between OCTA and government scientists’ recommendations have been reported in print, broadcast, and social media. This involves largely the differences in interpreting the framework of quarantine status and risks, with government experts tending to question OCTA’s projections with a very conservative precautionary interpretation of evidence. One doctor with the IATF-EID has accuses OCTA of using “erroneous” and “incomplete” data (Kho, 2021 ). This dissonance has led politicians to label OCTA as “alarmist” (David, 2021 ).

OCTA is a knowledge producer in science advice since it constructs DOH epidemiological data into models informed by epidemiological theory. Even if OCTA has decided to remain completely independent as a science advisory body, it is not completely insulated from political attack. Political attack is a result of perceived role conflation in the science advice ecosystem and process which is exacerbated by the nature of uncertainty in science advice leading to accusations of OCTA being “alarmist. OCTA was misconstrued by the government as its own knowledge producer and its critics demanded that it be completely alienated from its academic institutional linkages. OCTA’s weakness and the weakness of the Philippines crisis science advisory system overall, is the lack of external and extended peer review. This is a consequence of a small science community where there are few actors who can perform this role with citizen scientists. In a postnormal science advisory environment, the role of extended peer review is important in validating policy options and creating public consensus.

OCTA has recently partnered with Go Negosyo, a small and medium business entrepreneurship (SME) advocacy, headed by Presidential advisor for entrepreneurship, Joey Concepcion. Mr. Concepcion has a minister’s portfolio. OCTA in this arrangement will provide data analytics services and science advice for SMEs for a business friendly COVID exit policy with a safe reopening of the economy based on vaccination prioritization strategies (Cordero, 2021 ). This move also evidences OCTA’s influence in setting new policy directions in government’s adoption of a new quarantine classification system of Alert Levels, an idea first proposed by OCTA Fellow and medical molecular biologist Rev Dr. Nicanor Austriaco OP and mathematical modeler Dr. Fredegusto Guido David. This is a political move on OCTA’s part to deflect critics in Congress as the business sector has a large political clout in government.

While a pandemic crisis like COVID 19 gives political leaders an advantageous occasion to demonstrate personal leadership, their constituencies will tend to expect a more personalistic crisis management. In this independent science advice plays a crucial political dynamic by building public trust, ensuring reliable statistical estimates reviewed by the academic science community, and managing political advantages and risks. These are all in the context of epidemiological uncertainties. In the Philippines, public criticism of the pandemic response is fierce due to the primarily law and order policing approach which raised concerns on human rights violations (Hapal, 2021 ) as well as those cases began to rise in the first quarter of 2021 (Robles and Robles, 2021 ). The failure to deal with uncertainties in science without effective science advice may entail large political costs. Managing public perception and the use of government scientific and technical advice is a delicate balancing act in liberal democracies. The press and media will report and scrutinize science informed decisions while shaping public opinion of crisis decisions. Academic science and civil society organizations not part of the advisory system provide another level of scrutiny and critique. Social media has extremely broadened the venue for public scrutiny and, open or extended peer review of crisis decisions.

These realities were not faced by political leaders as recently as 30 years ago. However unfair or unrealistic the critique by constituencies and the press, public expectation is real in political terms. And while politicians can “write off” certain social and political sectors in deciding which crisis response is best, this is no longer tenable in democracies in the 21st century.

In these realities emerge new actors of engaged independent academic science advisors such as OCTA. It has certainly played the role of a knowledge generator and to some extent a knowledge broker. And like any science advice actor, OCTA was not immune to political attack, and this would suggest that SAGE with its embeddedness in the administrative and ministerial structures in the UK, largely missing in the Philippines (Berse, 2020 ), will be subject to great political interference which may limit its effectiveness. Political interference may masquerade as technical in nature (Smallman, 2020 ).

The Philippines government response to COVID 19 has been described as “deficient in strategic agility” (Aguilar Jr, 2020 ) partly due to its inability to mobilize scientific expertise and synthesize science informed advice options in governance. Thus, a plausible proposal to strengthen science advice is in reframing the DRRM policy and advisory structures and applying these to crisis in order to strengthen science advice capacity at all levels of governance. As Berse ( 2020 ) suggests “tweaking the National Disaster Risk Reduction and Management Council structure, which has a seat for an academic representative, might do the trick. This national set-up is replicated by law at the provincial, city and municipal levels”.

Berse also suggests that an academic should be appointed to sit at each of these councils. The major constraint is that there are very few academics willing to sit as this will expose them to political criticism and interference. If academics are appointed, then their expertise should not be unduly constrained by political interference. They should be backed by several researchers and citizen scientists coming from multiple disciplines in reviewing science informed policies. More and more citizen scientists have come up with science advice which for consistency of policy should be reviewed in extended consensus by scientists and stakeholders (Funtowicz and Ravetz, 1993 ; Marshall and Picou, 2008 ).

The closed and elitist system of science advice in the Philippines with its handful of actors, mainly appointed by government, are inordinately prone to political pressure. This necessitates the role of independent science advisors. Independent science advisors can act as a “challenge function” to government experts whose recommendation if ignored contributes to further erosion of public trust in government (Dommett and Pearce, 2019 ). Independent science advice when framed in the context of parliamentary democracy can be likened to “shadow cabinets” in this way they provide a check, balance and review of science evidence and is called “shadow science advice” (Pielke, 2020 )

As pandemics and other environmentally related public health emergencies are expected to be more frequent in the 21st century, the public will be less tolerant of social and political instability and demand a clear science informed response from their politicians. However, most politicians do not have enough scientific and technical competency to do so and so will have to rely on science informed advice which has degrees of outcome uncertainty (Gluckman, 2016b ). If science informed options are ignored for political gains, this is not a result of broken science advice and knowledge generation systems but a dysfunctional political and governance system. The huge cost in life and economic opportunity left by the pandemic demands functional government informed by science advice.

Furthermore, any government to cement its legacy must find a COVID 19 crisis exit strategy after the operational aspects such as a mass vaccination strategy have been met and the social, health (Dickens et al., 2020 ), economic and political situation has been stabilized (Gilbert et al., 2020 ). In COVID 19, this is a gradual relaxation of lockdown and quarantine (Leung and Wu, 2020 ) with the roll out of vaccines.

Vaccination is the main COVID-19 exit strategy of the government (Congress of the Philippines, 2021 ) and given the large existing vaccine hesitancy of 46% as OCTA estimated in February 2021 (Tomacruz, 2021 ), there is a need to increase public confidence on vaccines (Vergara et al., 2021 ). Public distrust of vaccines became a major public health concern due to the Dengvaxia vaccine rollout controversy in November 2017 when Sanofi publicly released a warning that vaccination posed a risk if given to people who never had a dengue infection (Larson et al., 2019 ). The political impact was damaging to the Benigno Aquino III presidential administration, which rolled out the vaccine in 2016 before Aquino III’s term ended. The drop in vaccine confidence was significant, from 93% in 2015 to 32% in 2018. The new presidential administration of Rodrigo Duterte placed the blame on Aquino III, and this resulted in social and political polarization, loss of trust in the public health system which have continued in the COVID-19 pandemic. The “blame game” is political risk in any liberal democracy. This can be a long drawn out affair where government will have to establish accountability and the “blame game” is expected with various independent boards and blue ribbon committees setting the narrative (Boin et al., 2016 ). In the Philippines, several hearings in the House and Senate in which Sanofi and previous Department of Health leadership were called to give testimonies, further worsened political and social polarization to vaccination. These independent boards, blue ribbon committees and fact-finding investigations, however, are prone to agency capture by ruling party politics. This is evident in the Philippines. The government exit strategy for COVID-19 is clouded by these polarizations. OCTA will be expected by the public to provide government science advice on vaccination policies, and this will have great political costs for independent science advice. As vaccination in the Philippines has become a political issue more than as a public health issue, other think tanks and academic research institutions which have investigated Dengvaxia, and vaccine compliance have been more guarded as not to attract undue negative political comment. OCTA to its credit, has successfully navigated political risks in its COVID-19 forecasts and in a political move, has allied with a SME advocacy headed by a close Presidential advisor on economic affairs. OCTA can continue to maintain its credibility by periodically issuing forecasts and policy option recommendations and reducing social and political polarizations through consensus building with the public, government, and science community. Here is where the independent science advice actors will have a place, and that is to set the objective bases for science informed policy decisions while recognizing the political dynamic. How independent science advice will result in lasting policy impacts in the Philippines remains to be seen. The government and the public have relied on OCTA forecasts because of OCTA’s increasing presence in broadcast, print, and social media. This is evidence of the effective science communication strategy of the organization. But with the Government increasingly using OCTA’s forecasts and policy recommendations, this is evidence that government science advice has political dividends and risks which may affect politicians’ political standing with the electorate in the 2022 election.

Data availability

COVID-19 open data cited in this paper can be accessed through the Philippines Department of Health Data Drop https://doh.gov.ph/covid19tracker and through OCTA Research https://www.octaresearch.com/ .

ABS-CBN (2021) Metro Manila COVID-19 surge begins ahead of Christmas: OCTA Research. https://news.abs-cbn.com/news/12/22/20/metro-manila-covid-19-surge-begins-ahead-of-christmas-octa-research . Accessed 3 Jan 2021

Aguilar Jr FV (2020) Preparedness, agility, and the Philippine response to the Covid-19 pandemic the early phase in comparative Southeast Asian perspective. Philipp Stud Hist Ethnogr Viewp 68(3):373–421

Article   Google Scholar  

Allen K, Buklijas T, Chen A, Simon-Kumar N, Cowen L, Wilsdon J, Gluckman P (2020) Tracking global knowledge-to-policy pathways in the coronavirus crisis: a preliminary report from ongoing research. INGSA. https://www.ingsa.org/wp-content/uploads/2020/09/INGSA-Evidence-to-Policy-Tracker_Report-1_FINAL_17Sept.pdf

Bankoff G, Hilhorst D (2009) The politics of risk in the Philippines: comparing state and NGO perceptions of disaster management. Disasters. 33(4):686–704

Berse K (2020) In science we trust? Science advice and the COVID-19 response in the Philippines https://www.ingsa.org/covidtag/covid-19-commentary/berse-philippines/ . Accessed 3 Jan 2021.

Boin A, Stern E, Sundelius B (2016) The politics of crisis management: Public leadership under pressure. Cambridge University Press, Cambridge

Book   Google Scholar  

Caulkins J, Grass D, Feichtinger G, Hartl R, Kort PM, Prskawetz A, Seidl A, Wrzaczek S (2020) How long should the COVID-19 lockdown continue? PLoS ONE 15(12):e0243413

Article   CAS   Google Scholar  

CNN Philippines (2021) OCTA Research: four-week MECQ to “knock out” COVID-19 case surge. https://cnnphilippines.com/news/2021/3/24/OCTA-Research-4-week-MECQ-knock-out-surge.html . Accessed 16 Apr 2021

Congress of the Philippines (2021) An act establishing the coronavirus disease 2019 (COVID-19) vaccination program expediting the vaccine procurement and administration. Providing Funds Therefor, and for Other Purposes, Manila. https://www.officialgazette.gov.ph/downloads/2021/02feb/20210226-RA-11525-RRD.pdf . Accessed 16 Apr 2021

Cordero T (2021) Go Negosyo, OCTA Research ink partnership on data-sharing, proposals to reopen economy. GMA News Online. https://www.gmanetwork.com/news/money/companies/807569/go-negosyo-octa-research-ink-partnership-on-data-sharing-proposals-to-reopen-economy/story/ . Accessed 25 Oct 2021.

David G, Rye R, Agbulos M, Alampay E, Brillantes E, Lallanam R, Ong R, Vallejo B, Tee M (2020) COVID-19 forecasts in the Philippines: NCR, Cebu and COVID-19 hotspots as of June 25, 2020. OCTA Research, Quezon City, Philippines

Google Scholar  

David R (2021) Probing OCTA. Philippine Daily Inquirer https://opinion.inquirer.net/142869/probing-octa . Accessed 25 Oct 2021.

Davies NG, Kucharski AJ, Eggo RM, Gimma A, Edmunds WJ, Jombart T, O’Reilly K, Endo A, Hellewell J, Nightingale ES et al. (2020) Effects of non-pharmaceutical interventions on COVID-19 cases, deaths, and demand for hospital services in the UK: a modelling study. Lancet Public Health 5(7):e375–e385. https://doi.org/10.1016/S2468-2667(20)30133-X

Article   PubMed   PubMed Central   Google Scholar  

Dickens BL, Koo JR, Lim JT, Park M, Quaye S, Sun H, Sun Y, Pung R, Wilder-Smith A, Chai LYA et al. (2020) Modelling lockdown and exit strategies for COVID-19 in Singapore. Lancet Reg Health-West Pac 1:100004. https://doi.org/10.1016/j.lanwpc.2020.100004

Dommett K, Pearce W (2019) What do we know about public attitudes towards experts? Reviewing survey data in the United Kingdom and European Union. Public Underst Sci 28(6):669–678

Doubleday R, Wilsdon J (2012) Beyond the great and good. Nature 485(7398):301–302. https://doi.org/10.1038/485301a

Article   ADS   CAS   PubMed   Google Scholar  

Funtowicz SO, Ravetz JR (1993) Science for the post-normal age. Futures 25:739–755. https://doi.org/10.1016/0016-3287(93)90022-L

Funtowicz SO, Ravetz JR (1994) Uncertainty, complexity, and post‐normal science. Environ Toxicol Chem Int J 13(12):1881–1885

Gilbert M, Dewatripont M, Muraille E, Platteau J-P, Goldman M (2020) Preparing for a responsible lockdown exit strategy. Nat Med 26(5):643–644. https://doi.org/10.1038/s41591-020-0871-y

Article   CAS   PubMed   PubMed Central   Google Scholar  

Gluckman P (2016a) The science–policy interface. Science 353(6303):969. https://doi.org/10.1126/science.aai8837

Gluckman P (2016b) Making decisions in the face of uncertainty: understanding risk Auckland. Office of the Prime Minister’s Chief Science Advisor, Auckland, New Zealand

Hapal K (2021). The Philippines’ COVID-19 response: securitising the pandemic and disciplining the pasaway. J Curr Southeast Asian Aff. https://doi.org/10.1177/1868103421994261

Kho R (2021) House inquiry sought on OCTA Research group. Businessworld https://www.bworldonline.com/house-inquiry-sought-on-octa-research-group/ . Accessed 25 Oct 2021.

Larson HJ, Hartigan-Go K, de Figueiredo A (2019) Vaccine confidence plummets in the Philippines following dengue vaccine scare: why it matters to pandemic preparedness. Hum Vaccines Immunother 15(3):625–627. https://doi.org/10.1080/21645515.2018.1522468

Leung K, Wu JT (2020) The gradual release exit strategy after lockdown against COVID-19. Lancet Reg Health–West Pac 1. https://doi.org/10.1016/j.lanwpc.2020.100008 . Accessed 4 Jan 2021

Lipsitch M, Riley S, Cauchemez S, Ghani AC, Ferguson NM (2009) Managing and reducing uncertainty in an emerging influenza pandemic. N Engl J Med 361(2):112–115. https://doi.org/10.1056/NEJMp0904380

MacKenzie DA (1993) Inventing accuracy: a historical sociology of nuclear missile guidance. MIT press, Cambridge, MA

Manila Bulletin (2020) OCTA Research reporting continues. https://mb.com.ph/2020/10/15/octa-research-reporting-continues/ . Accessed 3 Jan 2021.

Manila Times (2020) Time for UP OCTA research team to account for its Covid forecasting. https://www.manilatimes.net/2020/07/20/opinion/editorial/time-for-up-octa-research-team-to-account-for-its-covid-forecasting/743476/ . Accessed 3 Jan 2021.

Marshall BK, Picou JS (2008) Postnormal science, precautionary principle, and worst cases: the challenge of twenty‐first century catastrophes. Sociol Inq 78(2):230–247

UP COVID-19 Pandemic Response Team (2020) Prevailing data issues in the time of COVID-19 and the need for open data. University of Philippines. https://www.up.edu.ph/prevailing-data-issues-in-the-time-of-covid-19-and-the-need-for-open-data/ . Accessed 4 Jan 2021

Johns S (2020) Neil Ferguson talks modelling, lockdown and scientific advice with MPs. Imperial News. Imperial College London https://www.imperial.ac.uk/news/198155/neil-ferguson-talks-modelling-lockdown-scientific/ . Accessed 2 Jan 2021.

One News.ph (2020) NO REVOLUTION: medical frontliners tell Duterte they had to go public as distress calls went unanswered. https://www.onenews.ph/no-revolution-medical-frontliners-tell-duterte-they-had-to-go-public-as-distress-calls-went-unanswered . Accessed 4 Jan 2021.

Pearce W (2020) Trouble in the trough: how uncertainties were downplayed in the UK’s science advice on Covid-19. Humanit Soc Sci Commun 7(1):1–6. https://doi.org/10.1057/s41599-020-00612-w

Article   MathSciNet   Google Scholar  

Pellini A, Jabar M, Era M, Erasga D (2013) Towards policy-relevant science and scientifically informed policy: political economy of the use of knowledge and research evidence. ODI, Manila

Philippine Daily Inquirer (2020). Baguio tourism industry objects to OCTA ‘high risk’ tag. INQUIRER.net https://newsinfo.inquirer.net/1364601/baguio-tourism-industry-objects-to-octa-high-risk-tag . Accessed 3 Jan 2021.

Philippine Star (2020) Palace tells UP, UST experts to stop publicizing quarantine status recommendations. Oct 10th, 2013. https://www.philstar.com/headlines/2020/10/13/2049279/palace-tells-experts-stop-publicizing-quarantine-status-recommendations . Accessed 3 Jan 2021.

Pielke RJ (2020) On shadow science advice https://youtu.be/PktWL5xNanc . Accessed 24 March 2021

Ravetz IR (1999) What is post-normal science. Futur-J Forecast Plan Policy 31(7):647–654

Robles A, Robles R. 2021. Where did the Philippines’ pandemic response go wrong? South China Morning Post. https://www.scmp.com/week-asia/health-environment/article/3122257/late-and-slow-motion-where-philippines-pandemic . Accessed Apr 16 2021.

Senate of the Philippines 14th Congress (2008) An act establishing a pandemic preparedness plan and for other purposes therefor. 14th Congress first regular session https://legacy.senate.gov.ph/lis/bill_res.aspx?congress=14&q=SBN-2198 . Accessed 15 Jan 2021

Senate of the Philippines 16th Congress (2013) An act strengthening national preparedness and response to public health emergencies. 16th Congress first regular session https://legacy.senate.gov.ph/lis/bill_res.aspx?congress=16&q=SBN-1573 . Accessed 15 Jan 2021

Senate of the Philippines 18th Congress (2020) An Act Strengthening National Preparedness and Response to Public Health Emergencies by Creating a Center for Disease Control 18th Congress. First regular session http://legacy.senate.gov.ph/lisdata/3260429469!.pdf . Accessed 15 Jan 2021

Smallman M (2020) ‘Independent Sage’ group is an oxymoron. Res Prof News. https://www.researchprofessionalnews.com/rr-news-political-science-blog-2020-5-independent-sage-group-is-an-oxymoron/ . Accessed 4 Jan 2021.

Tomacruz S (2021) 46% of adult Filipinos still unwilling to get vaccinated vs. COVID-19. Rappler https://www.rappler.com/nation/octa-research-filipinos-covid-19-vaccine-willingness-february-2021 . Accessed 15 Apr 2021

Vallejo BM, Ong RAC (2020) Policy responses and government science advice for the COVID 19 pandemic in the Philippines: January to April 2020. Prog Disaster Sci 7:100115. https://doi.org/10.1016/j.pdisas.2020.100115

Van der Sluijs J (2005) Uncertainty as a monster in the science–policy interface: Four coping strategies. Water Sci Technol 52(6):87–92

Vergara RJD, Sarmiento PJD, Lagman JDN (2021) Building public trust: a response to COVID-19 vaccine hesitancy predicament. J Public Health Oxf Engl 43(2):e291–e292. https://doi.org/10.1093/pubmed/fdaa282

Download references

Acknowledgements

The authors thank the University of the Philippines Bayanihan Research Grants for COVID-19 for funding support. We also thank Assistant Professor Ranjit Singh and Dr. Fredegusto Guido David of OCTA Research for providing OCTA COVID-19 forecasts and epidemiological model and Mr. Fil Elefante for proofreading. Many thanks also to Prof. Roger Pielke at the University of Colorado at Boulder and EsCAPE ( www.escapecovid19.org ) for encouraging the publication of this paper.

Author information

Authors and affiliations.

University of the Philippines Diliman, Quezon City, Philippines

Benjamin M. Vallejo Jr & Rodrigo Angelo C. Ong

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Benjamin M. Vallejo Jr .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors. Ethics review is not required.

Informed consent

All statements attributed to specific individuals used in this study are in the public record and no informed consent from individuals is required.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Vallejo, B.M., Ong, R.A.C. OCTA as an independent science advice provider for COVID-19 in the Philippines. Humanit Soc Sci Commun 9 , 104 (2022). https://doi.org/10.1057/s41599-022-01112-9

Download citation

Received : 17 June 2021

Accepted : 23 February 2022

Published : 30 March 2022

DOI : https://doi.org/10.1057/s41599-022-01112-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Psychological impact of COVID-19 pandemic in the Philippines

Affiliations.

• 1 Department of Physiology, College of Medicine, University of the Philippines Manila, Taft Avenue, Manila 1000, Philippines; Philippine One Health University Network. Electronic address: [email protected].
• 2 Department of Pediatrics, College of Medicine, University of the Philippines Manila, Taft Avenue, Manila 1000, Philippines. Electronic address: [email protected].
• 3 Department of Psychiatry and Behavioral Medicine, College of Medicine, University of the Philippines Manila, Taft Avenue, Manila 1000, Philippines.
• 4 School of Statistics, University of the Philippines Diliman, Philippines.
• 5 South East Asia One Health University Network. Electronic address: [email protected].
• 6 Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Kent Ridge 119228, Singapore. Electronic address: [email protected].
• PMID: 32861839
• PMCID: PMC7444468
• DOI: 10.1016/j.jad.2020.08.043

Background: The 2019 coronavirus disease (COVID-19) pandemic poses a threat to societies' mental health. This study examined the prevalence of psychiatric symptoms and identified the factors contributing to psychological impact in the Philippines.

Methods: A total of 1879 completed online surveys were gathered from March 28-April 12, 2020. Collected data included socio-demographics, health status, contact history, COVID-19 knowledge and concerns, precautionary measures, information needs, the Depression, Anxiety and Stress Scales (DASS-21) and the Impact of Events Scale-Revised (IES-R) ratings.

Results: The IES-R mean score was 19.57 (SD=13.12) while the DASS-21 mean score was 25.94 (SD=20.59). In total, 16.3% of respondents rated the psychological impact of the outbreak as moderate-to-severe; 16.9% reported moderate-to-severe depressive symptoms; 28.8% had moderate-to-severe anxiety levels; and 13.4% had moderate-to-severe stress levels. Female gender; youth age; single status; students; specific symptoms; recent imposed quarantine; prolonged home-stay; and reports of poor health status, unnecessary worry, concerns for family members, and discrimination were significantly associated with greater psychological impact of the pandemic and higher levels of stress, anxiety and depression (p<0.05). Adequate health information, having grown-up children, perception of good health status and confidence in doctors' abilities were significantly associated with lesser psychological impact of the pandemic and lower levels of stress, anxiety and depression (p<0.05).

Limitations: An English online survey was used.

Conclusion: During the early phase of the pandemic in the Philippines, one-fourth of respondents reported moderate-to-severe anxiety and one-sixth reported moderate-to-severe depression and psychological impact. The factors identified can be used to devise effective psychological support strategies.

Keywords: Anxiety; COVID-19; Depression; Philippines; Psychological impact; Stress.

Copyright © 2020 Elsevier Ltd. All rights reserved.

• Age Factors
• Anxiety / epidemiology*
• Anxiety / psychology
• Betacoronavirus
• Coronavirus Infections*
• Depression / epidemiology*
• Depression / psychology
• Health Personnel / psychology
• Health Personnel / statistics & numerical data
• Health Status
• Mental Health
• Middle Aged
• Philippines / epidemiology
• Pneumonia, Viral*
• Sex Factors
• Single Person
• Stress, Psychological / epidemiology*
• Stress, Psychological / psychology
• Students / psychology
• Students / statistics & numerical data
• Surveys and Questionnaires
• Young Adult

ORIGINAL RESEARCH article

Impact of the covid-19 pandemic on physical and mental health in lower and upper middle-income asian countries: a comparison between the philippines and china.

• 1 College of Medicine, University of the Philippines Manila, Manila, Philippines
• 2 Faculty of Education, Institute of Cognitive Neuroscience, Huaibei Normal University, Huaibei, China
• 3 Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
• 4 Southeast Asia One Health University Network, Chiang Mai, Thailand
• 5 Department of Psychological Medicine, National University Health System, Singapore, Singapore
• 6 Institute of Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore

Objective: The differences between the physical and mental health of people living in a lower-middle-income country (LMIC) and upper-middle-income country (UMIC) during the COVID-19 pandemic was unknown. This study aimed to compare the levels of psychological impact and mental health between people from the Philippines (LMIC) and China (UMIC) and correlate mental health parameters with variables relating to physical symptoms and knowledge about COVID-19.

Methods: The survey collected information on demographic data, physical symptoms, contact history, and knowledge about COVID-19. The psychological impact was assessed using the Impact of Event Scale-Revised (IES-R), and mental health status was assessed by the Depression, Anxiety, and Stress Scale (DASS-21).

Findings: The study population included 849 participants from 71 cities in the Philippines and 861 participants from 159 cities in China. Filipino (LMIC) respondents reported significantly higher levels of depression, anxiety, and stress than Chinese (UMIC) during the COVID-19 ( p < 0.01) while only Chinese respondents' IES-R scores were above the cut-off for PTSD symptoms. Filipino respondents were more likely to report physical symptoms resembling COVID-19 infection ( p < 0.05), recent use of but with lower confidence on medical services ( p < 0.01), recent direct and indirect contact with COVID ( p < 0.01), concerns about family members contracting COVID-19 ( p < 0.001), dissatisfaction with health information ( p < 0.001). In contrast, Chinese respondents requested more health information about COVID-19. For the Philippines, student status, low confidence in doctors, dissatisfaction with health information, long daily duration spent on health information, worries about family members contracting COVID-19, ostracization, and unnecessary worries about COVID-19 were associated with adverse mental health. Physical symptoms and poor self-rated health were associated with adverse mental health in both countries ( p < 0.05).

Conclusion: The findings of this study suggest the need for widely available COVID-19 testing in MIC to alleviate the adverse mental health in people who present with symptoms. A health education and literacy campaign is required in the Philippines to enhance the satisfaction of health information.

Introduction

The World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) to be a Public Health Emergency of International Concern on January 30 ( 1 ) and a pandemic on March 11, 2020 ( 2 ). COVID-19 predominantly presents with respiratory symptoms (cough, sneezing, and sore throat), along with fever, fatigue and myalgia. It is thought to spread through droplets, contaminated surfaces, and asymptomatic individuals ( 3 ). By the end of April, over 3 million people have been infected globally ( 4 ).

The first country to identify the novel virus as the cause of the pandemic was China. The authorities responded with unprecedented restrictions on movement. The response included stopping public transport before Chinese New Year, an annual event that sees workers' mass emigration to their hometowns, and a lockdown of whole cities and regions ( 1 ). Two new hospitals specifically designed for COVID-19 patients were rapidly built in Wuhan. Such measures help slow the transmission of COVID-19 in China. As of May 2, there are 83,959 confirmed cases and 4,637 deaths from the virus in China ( 4 ). The Philippines was also affected early by the current crisis. The first case was suspected on January 22, and the country reported the first death from COVID-19 outside of mainland China ( 5 ). Similar to China, the Philippines implemented lockdowns in Manila. Other measures included the closure of schools and allowing arrests for non-compliance with measures ( 6 ). At the beginning of May, the Philippines recorded 8,772 cases and 579 deaths ( 4 ).

China was one of the more severely affected countries in Asia in the early stage of pandemic ( 7 ) while the Philippines is still experiencing an upward trend in the COVID-19 cases ( 6 ). The gross national income (GNI) per capita of the Philippines and China are USD 3,830 and 9,460, respectively, were classified with lower (LMIC) and upper-middle-income countries (UMIC) by the Worldbank ( 8 ). During the COVID-19 pandemic, five high-income countries (HIC), including the United States, Italy, the United Kingdom, Spain, and France, account for 70% of global deaths ( 9 ). The HIC faced the following challenges: (1) the lack of personal protection equipment (PPE) for healthcare workers; (2) the delay in response strategy; (3) an overstretched healthcare system with the shortage of hospital beds, and (4) a large number of death cases from nursing homes ( 10 ). The COVID-19 crisis threatens to hit lower and middle-income countries due to lockdown excessively and economic recession ( 11 ). A systematic review on mental health in LMIC in Asia and Africa found that LMIC: (1) do not have enough mental health professionals; (2) the negative economic impact led to an exacerbation of mental issues; (3) there was a scarcity of COVID-19 related mental health research in Asian LMIC ( 12 ). This systematic review could not compare participants from different middle-income countries because each study used different questionnaires. During the previous Severe Acute Respiratory Syndrome (SARS) epidemic, the promotion of protective personal health practices to reduce transmission of the SARS virus was found to reduce the anxiety levels in the community ( 13 ).

Before COVID-19, previous studies found that stress might be a modifiable risk factor for depression in LMICs ( 14 ) and UMICs ( 15 – 17 ). Another study involving thirty countries found that unmodifiable risk factors for depression included female gender, and depression became more common in 2004 to 2014 compared to previous periods ( 18 ). Further, there were cultural differences in terms of patient-doctor relationship and attitudes toward healthcare systems before the COVID-19 pandemic. In China, <20% of the general public and medical professionals view the doctor and patient relationship as harmonious ( 19 ). In contrast, Filipino seemed to have more trust and be compliant to doctors' recommendations ( 20 ). Patient satisfaction was more important than hospital quality improvement to maintain patient loyalty to the Chinese healthcare system ( 21 ). For Filipinos, improvement in the quality of healthcare service was found to improve patients' satisfaction ( 22 ).

Based on the above studies, we have the following research questions: (1) whether COVID-19 pandemic could be an important stressor and risk factor for depression for the people living in LMIC and UMIC ( 23 ), (2) Are physical symptoms that resemble COVID-19 infection and other concerns be risk factors for adverse mental health? (3) Are knowledge of COVID-19 and health information protective factors for mental health? (4) Would there be any cultural differences in attitudes toward doctors and healthcare systems during the pandemic between China and the Philippines? We hypothesized that UMIC (China) would have better physical and mental health than LMIC (the Philippines). The aims of this study were (a) to compare the physical and mental health between citizens from an LMIC (the Philippines) and UMIC (China); (b) to correlate psychological impact, depression, anxiety, and stress scores with variables relating to physical symptoms, knowledge, and concerns about COVID-19 in people living in the Philippines (LMIC) and China (UMIC).

Study Design and Study Population

We conducted a cross-cultural and quantitative study to compare Filipinos' physical and mental health with Chinese during the COVID-19 pandemic. The study was conducted from February 28 to March 1 in China and March 28 to April 7, 2020 in the Philippines, when the number of COVID-19 daily reported cases increased in both countries. The Chinese participants were recruited from 159 cities and 27 provinces. The Filipino participants, on the other hand, were recruited from 71 cities and 40 provinces representing the Luzon, Visayas, and Mindanao archipelago. A respondent-driven recruitment strategy was utilized in both countries. The recruitment started with a set of initial respondents who were associated with the Huaibei Normal University of China and the University of the Philippines Manila; who referred other participants by email and social network; these in turn refer other participants across different cities in China and the Philippines.

As both Chinese and Filipino governments recommended that the public minimize face-to-face interaction and isolate themselves during the study period, new respondents were electronically invited by existing study respondents. The respondents completed the questionnaires through an online survey platform (“SurveyStar,” Changsha Ranxing Science and Technology in China and Survey Monkey Online Survey in the Philippines). The Institutional Review Board of the University of Philippines Manila Research Ethics Board (UPMREB 2020-198-01) and Huaibei Normal University (China) approved the research proposal (HBU-IRB-2020-002). All respondents provided informed or implied consent. The collected data were anonymous and treated as confidential.

This study used the National University of Singapore COVID-19 questionnaire, and its psychometric properties had been established in the initial phase of the COVID-19 epidemic ( 24 ). The National University of Singapore COVID-19 questionnaire consisted of questions that covered several areas: (1) demographic data; (2) physical symptoms related to COVID-19 in the past 14 days; (3) contact history with COVID-19 in the past 14 days; and (4) knowledge and concerns about COVID-19.

Demographic data about age, gender, education, household size, marital status, parental status, and residential city in the past 14 days were collected. Physical symptoms related to COVID-19 included breathing difficulty, chills, coryza, cough, dizziness, fever, headache, myalgia, sore throat, nausea, vomiting, and diarrhea. Respondents also rated their physical health status and stated their history of chronic medical illness. In the past 14 days, health service utilization variables included consultation with a doctor in the clinic, being quarantined by the health authority, recent testing for COVID-19 and medical insurance coverage. Knowledge and concerns related to COVID-19 included knowledge about the routes of transmission, level of confidence in diagnosis, source, and level of satisfaction of health information about COVID-19, the likelihood of contracting and surviving COVID-19 and the number of hours spent on viewing information about COVID-19 per day.

The psychological impact of COVID-19 was measured using the Impact of Event Scale-Revised (IES-R). The IES-R is a self-administered questionnaire that has been well-validated in the European and Asian population for determining the extent of psychological impact after exposure to a traumatic event (i.e., the COVID-19 pandemic) within one week of exposure ( 25 , 26 ). This 22-item questionnaire, composed of three subscales, aims to measure the mean avoidance, intrusion, and hyperarousal ( 27 ). The total IES-R score is divided into 0–23 (normal), 24–32 (mild psychological impact), 33–36 (moderate psychological impact) and >37 (severe psychological impact) ( 28 ). The total IES-R score > 24 suggests the presence of post-traumatic stress disorder (PTSD) symptoms ( 29 ).

The respondents' mental health status was measured using the Depression, Anxiety, and Stress Scale (DASS-21) and the calculation of scores was based on a previous Asian study ( 30 ). DASS has been demonstrated to be a reliable and valid measure in assessing mental health in Filipinos ( 31 – 33 ) and Chinese ( 34 , 35 ). IES-R and DASS-21 were previously used in research related to the COVID-19 epidemic ( 26 , 36 – 38 ).

Statistical Analysis

Descriptive statistics were calculated for demographic characteristics, physical symptom, and health service utilization variables, contact history variables, knowledge and concern variables, precautionary measure variables, and additional health information variables. To analyze the differences in the levels of psychological impact, levels of depression, anxiety and stress, the independent sample t -test was used to compare the mean score between the Filipino (LMIC) and Chinese (UMIC) respondents. The chi-squared test was used to analyze the differences in categorical variables between the two samples. We used linear regressions to calculate the univariate associations between independent and dependent variables, including the IES-S score and DASS stress, anxiety, and depression subscale scores for the Filipino and Chinese respondents separately with adjustment for age, marital status, and education levels. All tests were two-tailed, with a significance level of p < 0.05. Statistical analysis was performed on SPSS Statistic 21.0.

Demographic Characteristics and Their Association With Psychological Impact and Adverse Mental Health Status

We received 849 responses from the Philippines and 861 responses from China for 1,710 individual respondents from both countries. The majority of Filipino respondents were women (71.0%), age between 22 and 30 years (26.6%), having a household size of 3–5 people (53.4%), high educational attainment (91.4% with a bachelor or higher degree), and married (68.9%). Similarly, the majority of Chinese respondents were women (75%), having a household size of 3–5 people (80.4%) and high educational attainment (91.4% with a bachelor or higher degree). There was a significantly higher proportion of Chinese respondents who had children younger than 16 years ( p < 0.001) and student status ( p < 0.001; See Table 1 ).

Table 1 . Comparison of demographic characteristics between Filipino (LMIC) and Chinese (UMIC) respondents ( N = 1,710).

For Filipino respondents, the male gender and having a child were protective factors significantly associated with the lower score of IES-R ( p < 0.05) and depression ( p < 0.001), respectively. Single status was significantly associated with depression ( p < 0.05), and student status was associated with higher IES-R, stress and depression scores ( p < 0.01) (see Table 2 ). For Chinese respondents, the male gender was significantly associated with a lower score of IES-R but higher DASS depression scores ( p < 0.01). Notwithstanding, there were other differences between Filipino and China respondents. Chinese respondents who stayed in a household with 3–5 people ( p < 0.05) and more than 6 people ( p < 0.05) were significantly associated with a higher score of IES-R as compared to respondents who stayed alone.

Table 2 . Comparison of the association between demographic variables and the psychological impact as well as adverse mental health status between Filipino (LMIC) and Chinese (UMIC) respondents ( n = 1,710).

Comparison Between the Filipino (LMIC) and Chinese (UMIC) Respondents and Their Mental Health Status

Figure 1 compares the mean scores of DASS-stress, anxiety, and depression subscales and IES-R scores between the Filipino and Chinese respondents. For the DASS-stress subscale, Filipino respondents reported significantly higher stress ( p < 0.001), anxiety ( p < 0.01), and depression ( p < 0.01) than Chinese (UMIC). For IES-R, Filipino (LMIC) had significantly lower scores than Chinese ( p < 0.001). The mean IES-R scores of Chinese were higher than 24 points, indicating the presence of PTSD symptoms in Chinese respondents only.

Figure 1 . Comparison of the mean scores of DASS-stress, anxiety and depression subscales, and IES-R scores between Filipino and Chinese respondents.

Physical Symptoms, Health Status, and Its Association With Psychological Impact and Adverse Mental Health Status

There were significant differences between Filipino (LMIC) and Chinese (UMIC) respondents regarding physical symptoms resembling COVID-19 and health status. There was a significantly higher proportion of Filipino respondents who reported headache ( p < 0.001), myalgia ( p < 0.001), cough ( p < 0.001), breathing difficulty ( p < 0.001), dizziness ( p < 0.05), coryza ( p < 0.001), sore throat ( p < 0.001), nausea and vomiting ( p < 0.001), recent consultation with a doctor ( p < 0.01), recent hospitalization ( p < 0.001), chronic illness ( p < 0.001), direct ( p < 0.001), and indirect ( p < 0.001) contact with a confirmed diagnosis of COVID-19 as compared to Chinese (see Supplementary Table 1 ). Significantly more Chinese respondents were under quarantine ( p < 0.001).

Linear regression showed that headache, myalgia, cough, dizziness, coryza as well as poor self-rated physical health were significantly associated with higher IES-R scores, DASS-21 stress, anxiety, and depression subscale scores in both countries after adjustment for confounding factors ( p < 0.05; see Table 3 ). Furthermore, breathing difficulty, sore throat, and gastrointestinal symptoms were significantly associated with higher DASS-21 stress, anxiety and depression subscale scores in both countries ( p < 0.05). Chills were significantly associated with higher DASS-21 stress and depression scores ( p < 0.01) in both countries. Recent quarantine was associated with higher DASS-21 subscale scores in Chinese respondents only ( p < 0.05).

Table 3 . Association between physical health status and contact history and the perceived impact of COVID-19 outbreak as well as adverse mental health status during the epidemic after adjustment for age, gender, and marital status ( n = 1,710).

Perception, Knowledge, and Concerns About COVID-19 and Its Association With Psychological Impact and Adverse Mental Health Status

Filipino (LMIC) and Chinese (UMIC) respondents held significantly different perceptions in terms of knowledge and concerns related to COVID-19 (see Supplementary Table 2 ). For the routes of transmission, there were significantly more Filipino respondents who agreed that droplets transmitted the COVID-19 ( p < 0.001) and contact via contaminated objects ( p < 0.001), but significantly more Chinese agreed with the airborne transmission ( p < 0.001). For the detection and risk of contracting COVID-19, there were significantly more Filipino who were not confident about their doctor's ability to diagnose COVID-19 ( p < 0.001). There were significantly more Filipino respondents who were worried about their family members contracting COVID-19 ( p < 0.001). For health information, there were significantly more Filipino who were unsatisfied with the amount of health information ( p < 0.001) and spent more than three hours per day on the news related to COVID-19 ( p < 0.001). There were significantly more Chinese respondents who felt ostracized by other countries ( p < 0.001).

Linear regression analysis after adjustment of confounding factors showed that the Filipino and Chinese respondents showed different findings (see Table 4 ). Chinese respondents who reported a very low perceived likelihood of contracting COVID-19 were significantly associated with lower DASS depression scores ( p < 0.05). There were similarities between the two countries. Filipino and Chinese respondents who perceived a very high likelihood of survival were significantly associated with lower DASS-21 depression scores ( p < 0.05). Regarding the level of confidence in the doctor's ability to diagnose COVID-19, both Filipino and Chinese respondents who were very confident in their doctors were significantly associated with lower DASS-21 depression scores ( p < 0.01). Filipino and Chinese respondents who were satisfied with health information were significantly associated with lower DASS-21 anxiety and depression scores ( p < 0.01). Chinese and Filipino respondents who were worried about their family members contracting COVID-19 were associated with higher IES-R and DASS-21 subscale scores ( p < 0.05). In contrast, only Filipino respondents who spent <1 h per day monitoring COVID-19 information was significantly associated with lower IES-R and DASS-21 stress and anxiety scores ( p < 0.05). Filipino respondents who felt ostracized were associated with higher IES-R and stress scores ( p < 0.05).

Table 4 . Comparison of association of knowledge and concerns related to COVID-19 with mental health status after adjustment for age, gender, and marital status ( N = 1,710).

Health Information About COVID-19 and Its Association With Psychological Impact and Adverse Mental Health Status

Filipino (LMIC) and Chinese (UMIC) respondents held significantly different views on the information required about COVID-19. There were significantly more Chinese respondents who needed information on the symptoms related to COVID-19, prevention methods, management and treatment methods, regular information updates, more personalized information, the effectiveness of drugs and vaccines, number of infected by geographical locations, travel advice and transmission methods as compared to Filipino ( p < 0.01; See Supplementary Table 3 ). In contrast, there were significantly more Filipino respondents who needed information on other countries' strategies and responses than Chinese ( p < 0.001).

Information on management methods and transmission methods were significantly associated with higher IES-R scores in Chinese respondents ( p < 0.05; see Table 5 ). Travel advice, local transmission data, and other countries' responses were significantly associated with lower DASS-21 stress and depression scores in Chinese respondents only ( p < 0.05). There was only one significant association observed in Filipino respondents; information on transmission methods was significantly associated with lower DASS-21 depression scores ( p < 0.05).

Table 5 . Comparison of the association between information needs about COVID-19 and the psychological impact as well as adverse mental health status between Filipino (LMIC) and Chinese (UMIC) participants after adjustment for age, gender, and marital status ( N = 1,710).

To our best knowledge, this is the first study that compared the physical and mental health as well as knowledge, attitude and belief about COVID-19 between citizens from an LMIC (The Philippines) and UMIC (China). Filipino respondents reported significantly higher levels of depression, anxiety and stress than Chinese during the COVID-19, but only the mean IES-R scores of Chinese respondents were above the cut-off scores for PTSD symptoms. Filipino respondents were more likely to report physical symptoms resembling COVID-19 infection, recent use of medical services with lower confidence, recent direct, and indirect contact with COVID, concerns about family members contracting COVID-19 and dissatisfaction with health information. In contrast, Chinese respondents requested more health information about COVID-19 and were more likely to stay at home for more than 20–24 h per day. For the Filipino, student status, low confidence in doctors, unsatisfaction of health information, long hours spent on health information, worries about family members contracting COVID-19, ostracization, unnecessary worries about COVID-19 were associated with adverse mental health.

The most important implication of the present study is to understand the challenges faced by a sample of people from an LMIC (The Philippines) compared to a sample of people from a UMIC (China) in Asia. As physical symptoms resembling COVID-19 infection (e.g., headache, myalgia, dizziness, and coryza) were associated with adverse mental health in both countries, this association could be due to lack of confidence in healthcare system and lack of testing for coronavirus. Previous research demonstrated that adverse mental health such as depression could affect the immune system and lead to physical symptoms such as malaise and other somatic symptoms ( 39 , 40 ). Based on our findings, the strategic approach to safeguard physical and mental health for middle-income countries would be cost-effective and widely available testing for people present with COVID-19 symptoms, providing a high quality of health information about COVID-19 by health authorities.

Students were afraid that confinement and learning online would hinder their progress in their studies ( 41 ). This may explain why students from the Philippines reported higher levels of IES-R and depression scores. Schools and colleges should evaluate the blended implementation of online and face-to-face learning to optimize educational outcomes when local spread is under control. As a significantly higher proportion of Filipino respondents lack confidence in their doctors, health authorities should ensure adequate training and develop hospital facilities to isolate COVID-19 cases and prevent COVID-19 spread among healthcare workers and patients ( 42 ). Besides, our study found that Filipino respondents were dissatisfied with health information. In contrast, Chinese respondents demanded more health information related to COVID-19. The difference could be due to stronger public health campaign launched by the Chinese government including national health education campaigns, a health QR (Quick Response) code system and community engagement that effectively curtailed the spread of COVID-19 ( 43 ). The high expectation for health information could be explained by high education attainment of participants as about 91.4 and 87.6% of participants from China and the Philippines have a university education.

Furthermore, the governments must employ communication experts to craft information, education, and messaging materials that are target-appropriate to each level of understanding in the community. That the Chinese Government rapidly deployed medical personnel and treated COVID-19 patients at rapidly-built hospitals ( 44 ) is in itself a confidence-building measure. Nevertheless, recent quarantine was associated with higher DASS-21 subscale scores in Chinese respondents only. It could be due to stricter control and monitoring of movements imposed by the Chinese government during the lockdown ( 45 ). Chinese respondents who stayed with more than three family members were associated with higher IES-R scores. The high IES-R scores could be due to worries of the spread of COVID-19 to family members and overcrowded home environment during the lockdown. The Philippines also converted sports arena into quarantine/isolation areas for COVID-19 patients with mild symptoms. These prompt actions helped restore public confidence in the healthcare system ( 46 ). A recent study reported that cultural factors, demand pressure for information, the ease of information dissemination via social networks, marketing incentives, and the poor legal regulation of online contents are the main reasons for misinformation dissemination during the COVID-19 pandemic ( 47 ). Bastani and Bahrami ( 47 ) recommended the engagement of health professionals and authorities on social media during the pandemic and the improvement of public health literacy to counteract misinformation.

Chinese respondents were more likely to feel ostracized and Filipino respondents associated ostracization with adverse mental health. Recently, the editor-in-chief of The Lancet , Richard Horton, expressed concern of discrimination of a country or particular ethnic group, saying that while it is important to understand the origin and inter-species transmission of the coronavirus, it was both unhelpful and unscientific to point to a country as the origin of the Covid-19 pandemic, as such accusation could be highly stigmatizing and discriminatory ( 48 ). The global co-operation involves an exchange of expertise, adopting effective prevention strategies, sharing resources, and technologies among UMIC and LIMC to form a united front on tackling the COVID-19 pandemic remains a work in progress.

Strengths and Limitations

The main strength of this study lay in the fact that we performed in-depth analysis and studied the relationship between physical and mental outcomes and other variables related to COVID-19 in the Philippines and China. However, there are several limitations to be considered when interpreting the results. Although the Philippines is a LMIC and China is a UMIC, the findings cannot be generalized to other LIMCs and UMICs. Another limitation was the potential risk of sampling bias. This bias could be due to the online administration of questionnaires, and the majority of respondents from both countries were respondents with good educational attainment and internet access. We could not reach out to potential respondents without internet access (e.g., those who stayed in the countryside or remote areas). Further, our findings may not be generalizable to other middle-income countries.

During the COVID-19 pandemic, Filipinos (LMIC) respondents reported significantly higher levels of depression, anxiety and stress than Chinese (UMIC). Filipino respondents were more likely to report physical symptoms resembling COVID-19 infection, recent use of medical services with lower confidence, recent direct and indirect contact with COVID, concerns about family members contracting COVID-19 and dissatisfaction with health information than Chinese. For the current COVID-19 and future pandemic, Middle income countries need to adopt the strategic approach to safeguard physical and mental health by establishing cost-effective and widely available testing for people who present with COVID-19 symptoms; provision of high quality and accurate health information about COVID-19 by health authorities. Our findings urge middle income countries to prevent ostracization of a particular ethnic group, learn from each other, and unite to address the challenge of the COVID-19 pandemic and safeguard physical and mental health.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

Ethical review and approval was required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. The Institutional Review Board of the University of Philippines Manila Research Ethics Board (UPMREB 2020- 198-01) and Huaibei Normal University (China) approved the research proposal (HBU-IRB-2020-002).

Author Contributions

Concept and design: CW, MT, CT, RP, VK, and RH. Acquisition, analysis, and interpretation of data: CW, MT, CT, RP, LX, CHa, XW, YT, and VK. Drafting of the manuscript: CW, MT, CT, RH, and JA. Critical revision of the manuscript: MT, CT, CHo, and JA. Statistical analysis: CW, PR, RP, LX, XW, and YT. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2020.568929/full#supplementary-material

1. Sohrabi C, Alsafi Z, O'Neill N, Khan M, Kerwan A, Al-Jabir A, et al. World Health Organization declares global emergency: a review of the 2019 novel coronavirus (COVID-19). Int J Surg. (2020) 76:71–6. doi: 10.1016/j.ijsu.2020.02.034

PubMed Abstract | CrossRef Full Text | Google Scholar

2. Mahase E. Covid-19: WHO declares pandemic because of “alarming levels” of spread, severity, and inaction. BMJ. (2020) 368:m1036. doi: 10.1136/bmj.m1036

3. Singhal T. A review of coronavirus disease-2019 (COVID-19). Indian J. Pediatr. (2020) 87:281–6. doi: 10.1007/s12098-020-03263-6

CrossRef Full Text | Google Scholar

4. Oxford. Oxford U of. Coronavirus Disease (COVID-19) - Statistics and Research . (2020). Available online at: https://ourworldindata.org/coronavirus%0D (accessed May 17, 2020).

Google Scholar

5. Edrada EM, Lopez EB, Villarama JB, Salva Villarama EP, Dagoc BF, Smith C, et al. First COVID-19 infections in the Philippines: a case report. Trop Med Health. (2020) 48:21. doi: 10.1186/s41182-020-00218-7

6. CNN. TIMELINE: How the Philippines is Handling COVID-19. (2020). Available online at: https://cnnphilippines.com/news/2020/4/21/interactive-timeline-PH-handling-COVID-19.html (accessed May 17, 2020).

7. Worldmeters. COVID-19 Coronavirus Pandemic. (2020). Available online at: https://www.worldometers.info/coronavirus/ (accessed December 4 2020).

8. WorldBank. World Bank National Accounts Data, and OECD National Accounts Data Files . (2020). Available online at: https://data.worldbank.org/indicator/NY.GNP.PCAP.CD (accessed April 16 2020).

9. Schellekens P, Sourrouille D. The Unreal Dichotomy in COVID-19 Mortality between High-Income and Developing Countries. (2020). Available online at: https://www.brookings.edu/blog/future-development/2020/05/05/the-unreal-dichotomy-in-covid-19-mortality-between-high-income-and-developing-countries/ (accessed May 10 2020).

10. Medicalexpress. ‘Slow Response’: How Britain Became Worst-Hit in Europe by Virus. (2020). Available online at: https://medicalxpress.com/news/2020-05-response-britain-worst-hit-europe-virus.html (accessed May 8 2020).

11. Mamun MA, Ullah I. COVID-19 suicides in Pakistan, dying off not COVID-19 fear but poverty? - The forthcoming economic challenges for a developing country. Brain Behav Immun. (2020) 87:163–6. doi: 10.1016/j.bbi.2020.05.028

12. Kar SK, Oyetunji TP, Prakash AJ, Ogunmola OA, Tripathy S, Lawal MM, et al. Mental health research in the lower-middle-income countries of Africa and Asia during the COVID-19 pandemic: a scoping review. Neurol Psychiatry Brain Res. (2020) 38:54–64. doi: 10.1016/j.npbr.2020.10.003

13. Leung GM, Lam TH, Ho LM, Ho SY, Chan BH, Wong IO, et al. The impact of community psychological responses on outbreak control for severe acute respiratory syndrome in Hong Kong. J Epidemiol Community Health. (2003) 57:857–63. doi: 10.1136/jech.57.11.857

14. Cristóbal-Narváez P, Haro JM, Koyanagi A. Perceived stress and depression in 45 low- and middle-income countries. J Affect Disord. (2020) 274:799–805. doi: 10.1016/j.jad.2020.04.020

15. Vallejo MA, Vallejo-Slocker L, Fernández-Abascal EG, Mañanes G. Determining factors for stress perception assessed with the perceived stress scale (PSS-4) in Spanish and other European samples. Front Psychol. (2018) 9:37. doi: 10.3389/fpsyg.2018.00037

16. Shin C, Kim Y, Park S, Yoon S, Ko YH, Kim YK, et al. Prevalence and associated factors of depression in general population of Korea: results from the Korea National Health and Nutrition Examination Survey, 2014. J Korean Med Sci. (2017) 32:1861–9. doi: 10.3346/jkms.2017.32.11.1861

17. Olsen LR, Mortensen EL, Bech P. Prevalence of major depression and stress indicators in the Danish general population. Acta Psychiatr Scand. (2004) 109:96–103. doi: 10.1046/j.0001-690X.2003.00231.x

18. Lim GY, Tam WW, Lu Y, Ho CS, Zhang MW, Ho RC. Prevalence of depression in the community from 30 countries between 1994 and (2014). Sci Rep. (2018) 8:2861. doi: 10.1038/s41598-018-21243-x

19. Sang T, Zhou H, Li M, Li W, Shi H, Chen H, et al. Investigation of the differences between the medical personnel's and general population's view on the doctor-patient relationship in China by a cross-sectional survey. Global Health. (2020) 16:99. doi: 10.21203/rs.3.rs-41725/v2

20. Ferrer RR, Ramirez M, Beckman LJ, Danao LL, Ashing-Giwa KT. The impact of cultural characteristics on colorectal cancer screening adherence among Filipinos in the United States: a pilot study. Psychooncology. (2011) 20:862–70. doi: 10.1002/pon.1793

21. Lei P, Jolibert A. A three-model comparison of the relationship between quality, satisfaction and loyalty: an empirical study of the Chinese healthcare system. BMC Health Serv Res. (2012) 12:436. doi: 10.1186/1472-6963-12-436

22. Peabody JW, Florentino J, Shimkhada R, Solon O, Quimbo S. Quality variation and its impact on costs and satisfaction: evidence from the QIDS study. Med Care. (2010) 48:25–30. doi: 10.1097/MLR.0b013e3181bd47b2

23. Xiong J, Lipsitz O, Nasri F, Lui LMW, Gill H, Phan L, et al. Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord. (2020) 277:55–64. doi: 10.1016/j.jad.2020.08.001

24. Wang C, Pan R, Wan X, Tan Y, Xu L, McIntyre RS, et al. A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. Brain Behav Immun. (2020) 87:40–8. doi: 10.1016/j.bbi.2020.04.028

25. Zhang MW, Ho CS, Fang P, Lu Y, Ho RC. Usage of social media and smartphone application in assessment of physical and psychological well-being of individuals in times of a major air pollution crisis. JMIR Mhealth Uhealth. (2014) 2:e16. doi: 10.2196/mhealth.2827

26. Chew NWS, Lee GKH, Tan BYQ, Jing M, Goh Y, Ngiam NJH, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain Behav Immun. (2020) 88:559–65. doi: 10.1016/j.bbi.2020.04.049

27. Zhang MWB, Ho CSH, Fang P, Lu Y, Ho RCM. Methodology of developing a smartphone application for crisis research and its clinical application. Technol Health Care. (2014) 22:547–59. doi: 10.3233/THC-140819

28. Creamer M, Bell R, Failla S. Psychometric properties of the Impact of Event Scale - Revised. Behav Res Ther. (2003) 41:1489–96. doi: 10.1016/j.brat.2003.07.010

29. Lee SM, Kang WS, Cho A-R, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry. (2018) 87:123–7. doi: 10.1016/j.comppsych.2018.10.003

30. Le TA, Le MQT, Dang AD, Dang AK, Nguyen CT, Pham HQ, et al. Multi-level predictors of psychological problems among methadone maintenance treatment patients in difference types of settings in Vietnam. Subst Abuse Treat Prev Policy. (2019) 14:39. doi: 10.1186/s13011-019-0223-4

31. Cheung JTK, Tsoi VWY, Wong KHK, Chung RY. Abuse and depression among Filipino foreign domestic helpers. A cross-sectional survey in Hong Kong. Public Health. (2019) 166:121–7. doi: 10.1016/j.puhe.2018.09.020

32. Tee ML, Tee CA, Anlacan JP, Aligam KJG, Reyes PWC, Kuruchittham V, et al. Psychological impact of COVID-19 pandemic in the Philippines. J Affect Disord. (2020) 277:379–91. doi: 10.1016/j.jad.2020.08.043

33. Tee CA, Salido EO, Reyes PWC, Ho RC, Tee ML. Psychological State and Associated Factors During the 2019 Coronavirus Disease (COVID-19) pandemic among filipinos with rheumatoid arthritis or systemic lupus erythematosus. Open Access Rheumatol. (2020) 12:215–22. doi: 10.2147/OARRR.S269889

34. Ho CSH, Tan ELY, Ho RCM, Chiu MYL. Relationship of anxiety and depression with respiratory symptoms: comparison between depressed and non-depressed smokers in Singapore. Int J Environ Res Public Health. (2019) 16:163. doi: 10.3390/ijerph16010163

35. Quek TC, Ho CS, Choo CC, Nguyen LH, Tran BX, Ho RC. Misophonia in Singaporean psychiatric patients: a cross-sectional study. Int J Environ Res Public Health. (2018) 15:1410. doi: 10.3390/ijerph15071410

36. Hao F, Tan W, Jiang L, Zhang L, Zhao X, Zou Y, et al. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. Brain Behav Immun. (2020) 87:100–6. doi: 10.1016/j.bbi.2020.04.069

37. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 Coronavirus Disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. (2020) 17:E1729. doi: 10.3390/ijerph17051729

38. Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, et al. Psychological impact of the COVID-19 pandemic on health care workers in Singapore. Ann Intern Med . (2020) 173:317–20. doi: 10.7326/M20-1083

39. Liu Y, Ho RC, Mak A. Interleukin (IL)-6, tumour necrosis factor alpha (TNF-α) and soluble interleukin-2 receptors (sIL-2R) are elevated in patients with major depressive disorder: a meta-analysis and meta-regression. J Affect Disord. (2012) 139:230–9. doi: 10.1016/j.jad.2011.08.003

40. Viljoen M, Panzer A. Proinflammatory cytokines: a common denominator in depression and somatic symptoms? Can J Psychiatry. (2005) 50:128. doi: 10.1177/070674370505000216

41. Li HY, Cao H, Leung DYP, Mak YW. The psychological impacts of a COVID-19 outbreak on college students in China: a longitudinal study. Int J Environ Res Public Health. (2020) 17:3933. doi: 10.3390/ijerph17113933

42. Krishnakumar B, Rana S. COVID 19 in INDIA: strategies to combat from combination threat of life and livelihood. J Microbiol Immunol Infect. (2020) 53:389–91. doi: 10.1016/j.jmii.2020.03.024

43. Huang Y, Wu Q, Wang P, Xu Y, Wang L, Zhao Y, et al. Measures undertaken in China to avoid COVID-19 infection: internet-based, cross-sectional survey study. J Med Internet Res. (2020) 22:e18718. doi: 10.2196/18718

44. Salo J. China Orders 1,400 Military Doctors, Nurses to Treat Coronavirus. (2020). Available online at: https://nypost.com/2020/02/02/china-orders-14000-military-doctors-nurses-to-treat-coronavirus/ (accessed March 22, 2020).

45. Burki T. China's successful control of COVID-19. Lancet Infect Dis. (2020) 20:1240–1. doi: 10.1016/S1473-3099(20)30800-8

46. Esguerra DJ. Philippine Arena to Start Accepting COVID-19 Patients Next Week . (2020). Available online at: https://newsinfo.inquirer.net/1255623/philippine-arena-to-start-accepting-covid-19-patients-next-week (accessed November 18, 2020).

47. Bastani P, Bahrami MA. COVID-19 related misinformation on social media: a qualitative study from Iran. J Med Internet Res. (2020). doi: 10.2196/preprints.18932. [Epub ahead of print].

48. Catherine W. It's Unfair to Blame China for Coronavirus Pandemic, Lancet Editor Tells State Media. (2020). Available online at: https://www.scmp.com/news/china/science/article/3082606/its-unfair-blame-china-coronavirus-pandemic-lancet-editor-tells (accessed May 8, 2020).

Keywords: anxiety, China, COVID-19, depression, middle-income, knowledge, precaution, Philippines

Citation: Tee M, Wang C, Tee C, Pan R, Reyes PW, Wan X, Anlacan J, Tan Y, Xu L, Harijanto C, Kuruchittham V, Ho C and Ho R (2021) Impact of the COVID-19 Pandemic on Physical and Mental Health in Lower and Upper Middle-Income Asian Countries: A Comparison Between the Philippines and China. Front. Psychiatry 11:568929. doi: 10.3389/fpsyt.2020.568929

Received: 02 June 2020; Accepted: 22 December 2020; Published: 09 February 2021.

Reviewed by:

Copyright © 2021 Tee, Wang, Tee, Pan, Reyes, Wan, Anlacan, Tan, Xu, Harijanto, Kuruchittham, Ho and Ho. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Cuiyan Wang, wcy@chnu.edu.cn

† These authors share first authorship

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Advertisement

Supported by

What’s Next for the Coronavirus?

Scientists studying the virus’s continuing evolution, and the body’s immune responses, hope to head off a resurgence and to better understand long Covid.

• Share full article

By Apoorva Mandavilli

Apoorva Mandavilli has been reporting on Covid since the start of the pandemic.

Rat droppings from New York City. Poop from dog parks in Wisconsin. Human waste from a Missouri hospital. These are some of the materials that are readying us for the next chapter of the coronavirus saga.

More than four years into the pandemic, the virus has loosened its hold on most people’s bodies and minds. But a new variant better able to dodge our immune defenses may yet appear, derailing a hard-won return to normalcy.

Scientists around the country are watching for the first signs.

“We’re not in the acute phases of a pandemic anymore, and I think it’s understandable and probably a good thing” that most people, including scientists, have returned to their prepandemic lives, said Jesse Bloom, an evolutionary biologist at the Fred Hutchinson Cancer Center in Seattle.

“That said, the virus is still evolving, it’s still infecting large numbers of people,” he added. “We need to keep tracking this.”

Dr. Bloom and other researchers are trying to understand how the coronavirus behaves and evolves as populations amass immunity. Other teams are probing the body’s response to the infection, including the complex syndrome called long Covid.

And some scientists have taken on an increasingly difficult task: estimating vaccine effectiveness in a crowded respiratory milieu.

“Intellectually, this virus, to me at least, is only becoming more interesting,” said Sarah Cobey, an evolutionary biologist at the University of Chicago.

“In some ways, SARS-CoV-2 has been a fabulous reminder of some of the deepest questions in the field, and also how far we have to go in answering a lot of them.”

Closely analyzing new variants appearing in wastewater may help predict what additional forms may surface, said Marc Johnson, a virologist at the University of Missouri, who has hunted for iterations of the coronavirus in stool samples from rodents and humans.

“They help inform the evolution of this virus and what’s likely to happen next, and possibly could even inform how to make a better vaccine,” Dr. Johnson said.

The ‘Black Swan Event’

Evolutionary biology was once an esoteric pursuit involving humdrum hours staring at a computer screen. The work’s implications for public health were often tenuous.

The pandemic changed that. Vaccines can now be made more easily and much faster than before, so “really understanding how viruses evolve has more and more practical utility,” Dr. Bloom said.

Many evolutionary biologists who now study the coronavirus, including Dr. Bloom, were experts in influenza, which evolves into a new variant every two to eight years from its most immediate predecessor.

The scientists expected the coronavirus to behave similarly. But Omicron arrived with dozens of new mutations — a shocking “black swan event,” Dr. Bloom said. Then came BA.2.86, another huge jump in evolution, signaling that the virus remained unpredictable.

The iterations of a virus that thrive throughout a population have some sort of advantage — an ability to sidestep the immune system, perhaps, or extreme contagiousness. In an individual, “there is no such evolutionary pressure,” said Katia Koelle, an evolutionary biologist at Emory University.

The result is that a chronic infection — usually in an immunocompromised person — offers the virus an opportunity to experiment with new formats, allowing it to hit the evolutionary equivalent of a fast-forward button. (Viral persistence in the body is also thought to play a role in long Covid.)

Chronic infections with the coronavirus are rare, even among immunocompromised people. But the Alpha variant of late 2020, the Omicron variant in late 2021 and BA.2.86, first detected last summer — all are now thought to have emerged from immunocompromised people.

Some mutations acquired as the virus evolves may offer no benefit at all, or may even hinder it, Dr. Koelle said. Not all of the virus versions pose a widespread threat to the population — BA.2.86 ultimately did not, for example.

But these genetic alterations may nevertheless foreshadow the future.

After BA.2.86 emerged, close analysis of its genome revealed one spot where the virus remained sensitive to the body’s immune defenses. Dr. Johnson guessed that the virus’s next move would be to acquire a mutation in that very spot.

“And sure enough, it just appeared,” he said, referring to JN.1 , the variant that now accounts for a vast majority of infections.

“The more we see these lineages like BA.2.86, which appear to be from chronic infections, the more we have an argument like, Hey, this really is something we should be paying attention to,” he added.

Analyzing more than 20,000 samples of wastewater from across the country, Dr. Johnson has found fewer than 60 viral genetic sequences that are likely to be from immunocompromised people.

Such sequences turn up only when a “super shedder” — an individual who sheds huge amounts of virus in their feces — happens to live in an area with wastewater surveillance. “I’m sure there are a ton more out there,” Dr. Johnson said. “I just don’t know how many more.”

Spotty Surveillance

Scientists looking for signs of renewed danger are constrained by the limited surveillance for coronavirus variants in the United States and elsewhere.

Many countries, including the United States, ramped up tracking efforts at the height of the pandemic. But they have since been cut back, leaving scientists to guess the scale of respiratory virus infections. Wastewater and hospitalizations can provide clues, but neither is a sensitive measure.

“We never have had especially systematic surveillance for respiratory pathogens in the United States, but it’s even less systematic now,” Dr. Cobey said. “Our understanding of the burden of these pathogens, much less their evolution, has been really compromised.”

Not tracking viruses closely has another consequence: With multiple respiratory viruses to combat each year, it is now extremely challenging to gauge how effective the vaccines are.

Before Covid, scientists estimated the effectiveness of the influenza vaccine by comparing the vaccination status of those who tested positive for flu with those who did not.

But now, with vaccines for Covid and respiratory syncytial virus in the mix, the calculations are no longer simple. Patients turn up at clinics and hospitals with similar symptoms, and each vaccine prevents those symptoms to a different degree.

“It becomes this much more complex network of prevention that’s happening,” said Emily Martin, an epidemiologist at the University of Michigan. “It does funny things to the numbers.”

An accurate estimate of effectiveness will be crucial for designing each season’s vaccine, and for preparing doctors and patients to face a rough respiratory season.

In 2021, for example, the University of Michigan experienced an outbreak of influenza. When the researchers worked out that the season’s vaccine didn’t protect against that strain, they were able to warn other college campuses to prepare for clusters in their dorms, and hospitals to stock up on antiviral drugs.

Solving the problem may itself pose complications, because different divisions at the Centers for Disease Control and Prevention work on influenza, Covid and other respiratory diseases.

“It requires problem-solving across these sort of artificial lines of different departments,” Dr. Martin said.

Immunity and Long Covid

As coronavirus variant after variant materialized, it became clear that while the vaccines provided a powerful bulwark against severe illness and death, they were much less effective at stopping viral spread.

For a vaccine to prevent infections, it must induce antibodies not just in the blood, but at sites where the virus invades the body.

“Ideally, you’d want them across mucosal sites — so, in your nose, in your lungs,” said Marion Pepper, an immunologist at the University of Washington in Seattle.

Scientists discovered about 15 years ago that a large part of the body’s defenses comes not just from the cells and organs of the immune system, but from these other tissues.

“One of the things that we’ve been really focused on is trying to understand immune responses in the tissues better than we did before,” Dr. Pepper said.

In a small set of people, the virus itself may also persist in various parts of the body, and may be one of the causes of long Covid. Vaccination and antiviral drugs alleviate some of the symptoms, lending credence to this idea.

At Yale University, Akiko Iwasaki and her colleagues are testing whether a 15-day course of the antiviral drug Paxlovid can eliminate a slowly replicating reservoir of virus in the body.

“We’re hoping to get to the root cause if that’s what’s causing people’s illness,” Dr. Iwasaki said.

She and her colleagues began studying immune responses to the coronavirus almost as soon as the virus appeared. As the pandemic progressed, the collaborations grew larger and more international.

And it became obvious that in many people, the coronavirus leaves a lasting legacy of immune-related problems.

Two years ago, Dr. Iwasaki proposed a new center to study the myriad questions that have arisen. Infections with many other viruses, bacteria and parasites also set off long-term complications , including autoimmunity.

The new virtual institute, started last summer, is dedicated to studying post-infection syndromes and strategies to prevent and treat them.

Before the pandemic, Dr. Iwasaki was already busy studying viral infections with a big lab and multiple projects. But it doesn’t begin to compare with her life now, she said.

“Scientists tend to be obsessed about things that they work on, but not with this level of urgency,” she said. “I’m pretty much working every waking hour.”

A photo caption in an earlier version of this article referred incorrectly to a center at the University of Missouri. It is the Bond Life Sciences Center, not the Lab Science Center.

How we handle corrections

Apoorva Mandavilli is a reporter focused on science and global health. She was a part of the team that won the 2021 Pulitzer Prize for Public Service for coverage of the pandemic. More about Apoorva Mandavilli

• SUGGESTED TOPICS
• The Magazine
• Newsletters
• Managing Yourself
• Managing Teams
• Work-life Balance
• The Big Idea
• Data & Visuals
• Reading Lists
• Case Selections
• HBR Learning
• Topic Feeds
• Account Settings
• Email Preferences

Research Roundup: How the Pandemic Changed Management

• Mark C. Bolino,
• Jacob M. Whitney,
• Sarah E. Henry

Lessons from 69 articles published in top management and applied psychology journals.

Researchers recently reviewed 69 articles focused on the management implications of the Covid-19 pandemic that were published between March 2020 and July 2023 in top journals in management and applied psychology. The review highlights the numerous ways in which employees, teams, leaders, organizations, and societies were impacted and offers lessons for managing through future pandemics or other events of mass disruption.

The recent pandemic disrupted life as we know it, including for employees and organizations around the world. To understand such changes, we recently reviewed 69 articles focused on the management implications of the Covid-19 pandemic. These papers were published between March 2020 and July 2023 in top journals in management and applied psychology.

• Mark C. Bolino is the David L. Boren Professor and the Michael F. Price Chair in International Business at the University of Oklahoma’s Price College of Business. His research focuses on understanding how an organization can inspire its employees to go the extra mile without compromising their personal well-being.
• JW Jacob M. Whitney is a doctoral candidate in management at the University of Oklahoma’s Price College of Business and an incoming assistant professor at Kennesaw State University. His research interests include leadership, teams, and organizational citizenship behavior.
• SH Sarah E. Henry is a doctoral candidate in management at the University of Oklahoma’s Price College of Business and an incoming assistant professor at the University of South Florida. Her research interests include organizational citizenship behaviors, workplace interpersonal dynamics, and international management.

Partner Center

Do you need a spring COVID-19 vaccine? Research backs extra round for high-risk groups

Recent studies suggest staying up-to-date on covid shots helps protect high-risk groups from severe illness.

Social Sharing

New guidelines suggest certain high-risk groups could benefit from having another dose of a COVID-19 vaccine this spring — and more frequent shots in general — while the broader population could be entering once-a-year territory, much like an annual flu shot.

Medical experts told CBC News that falling behind on the latest shots can come with health risks, particularly for individuals who are older or immunocompromised.

"Even when the risk of infection starts to increase, the vaccines still do a really good job at decreasing risk of severe disease," said McMaster University researcher and immunologist Matthew Miller.

Who needs another COVID shot?

Back in January, Canada's national vaccine advisory body set the stage for another round of spring vaccinations. In a statement , the National Advisory Committee on Immunization (NACI) stated that starting in spring 2024, individuals at an increased risk of severe COVID may get an extra dose of the latest XBB.1.5-based vaccines, which better protect against circulating virus variants.

That means:

• Adults aged 65 and up.
• Adult residents of long-term care homes and other congregate living settings for seniors.
• Anyone six months of age or older who is moderately to severely immunocompromised.

The various spring recommendations don't focus on pregnancy, despite research showing clear links between a COVID infection while pregnant, and increased health risks. However, federal guidance does note that getting vaccinated during pregnancy can protect against serious outcomes.

"Vaccinated people can also pass antibodies to their baby through the placenta and through breastmilk," that guidance states .

What do the provinces now recommend?

Multiple provinces have started rolling out their own regional guidance based on those early recommendations — with a focus on allowing similar high-risk groups to get another round of vaccinations.

B.C. is set to announce guidance on spring COVID vaccines in early April, officials told CBC News, and those recommendations are expected to align with NACI's guidance. 

In Manitoba , high-risk individuals are already eligible for another dose, provided it's been at least three months since their latest COVID vaccine.

• Older P.E.I. residents, others at risk, urged to get spring COVID vaccine booster
• High-risk groups can now book spring COVID-19 vaccination in Nova Scotia

Meanwhile Ontario's latest guidance , released on March 21, stresses that high-risk individuals may get an extra dose during a vaccine campaign set to run between April and June. Eligibility will involve waiting six months after someone's last dose or COVID infection.

Having a spring dose "is particularly important for individuals at increased risk of severe illness from COVID-19 who did not receive a dose during the Fall 2023 program," the guidance notes. 

And in Nova Scotia , the spring campaign will run from March 25 to May 31, also allowing high-risk individuals to get another dose.

Specific eligibility criteria vary slightly from province-to-province, so Canadians should check with their primary care provider, pharmacist or local public health team for exact guidelines in each area.

Age still best determines when to get COVID vaccines, new research suggests

Why do the guidelines focus so much on age.

The rationale behind the latest spring guidelines, Miller said, is that someone's age remains one of the greatest risk factors associated with severe COVID outcomes, including hospitalization, intensive care admission and death. 

"So that risk starts to shoot up at about 50, but really takes off in individuals over the age of 75," he noted.

Canadian data suggests the overwhelming majority of COVID deaths have been among older adults, with nearly 60 per cent of deaths among those aged 80 or older, and roughly 20 per cent among those aged 70 to 79.

People with compromised immune systems or serious medical conditions are also more vulnerable, Miller added.

Will people always need regular COVID shots?

While the general population may not require shots as frequently as higher-risk groups, Miller said it's unlikely there will be recommendations any time soon to have a COVID shot less than once a year, given ongoing uncertainty about COVID's trajectory.

"Going forward, I suspect for pragmatic reasons, [COVID vaccinations] will dovetail with seasonal flu vaccine campaigns, just because it makes the implementation much more straightforward," Miller said.

• Just 15% of Canadians got updated COVID vaccines this fall, new figures show
• Spring COVID-19 vaccines available April 2 in N.B. for those at high-risk

"And although we haven't seen really strong seasonal trends with SARS-CoV-2 now, I suspect we'll get to a place where it's more seasonal than it has been."

In the meantime, the guidance around COVID shots remains simple at its core: Whenever you're eligible to get another dose — whether that's once or twice a year — you might as well do it.

What does research say?

One analysis, published in early March in the medical journal Lancet Infectious Diseases , studied more than 27,000 U.S. patients who tested positive for SARS-CoV-2, the virus behind COVID, between September and December 2023. 

The team found individuals who had an updated vaccine reduced their risk of severe illness by close to a third — and the difference was more noticeable in older and immunocompromised individuals.

Another American research team from Stanford University recently shared the results from a modelling simulation looking at the ideal frequency for COVID vaccines. 

• Elderly Canadians remain at higher risk of serious COVID from first infections, study suggests
• Spring vaccine dose suggested to protect seniors in Canada from severe COVID

The study in Nature Communications suggests that for individuals aged 75 and up, having an annual COVID shot could reduce severe infections from an estimated 1,400 cases per 100,000 people to around 1,200 cases — while bumping to twice a year could cut those cases even further, down to 1,000.

For younger, healthier populations, however, the benefit of regular shots against severe illness was more modest.

The outcome wasn't a surprise to Stanford researcher Dr. Nathan Lo, an infectious diseases specialist, since old age has consistently been a risk factor for severe COVID.

"It's almost the same pattern that's been present the entire pandemic," he said. "And I think that's quite striking."

More frequent vaccination won't prevent all serious infections, he added, or perhaps even a majority of those infections, which highlights the need for ongoing mitigation efforts.

ABOUT THE AUTHOR

Senior Health & Medical Reporter

Lauren Pelley covers health and medical science for CBC News, including the global spread of infectious diseases, Canadian health policy, pandemic preparedness, and the crucial intersection between human health and climate change. Two-time RNAO Media Award winner for in-depth health reporting in 2020 and 2022. Contact her at: [email protected]

• @LaurenPelley

Add some “good” to your morning and evening.

A vital dose of the week's news in health and medicine, from CBC Health. Delivered to your inbox every Saturday morning.

Our websites may use cookies to personalize and enhance your experience. By continuing without changing your cookie settings, you agree to this collection. For more information, please see our University Websites Privacy Notice .

UConn Today

• School and College News
• Arts & Culture
• Community Impact
• Entrepreneurship
• Health & Well-Being
• Research & Discovery
• UConn Health
• University Life
• UConn Voices
• University News

March 27, 2024 | Jennifer Walker - UConn Health

Leading the Charge in Endometriosis Care and Research

When Connecticut passed a historic bill in 2022 to create a state-wide endometriosis research program, the state became poised to be the hub for endometriosis research and innovation. The bill created a first-of-its kind endometriosis data and biorepository program which will be located at The Jackson Laboratory and managed in coordination with UConn Health

When Connecticut passed a historic bill in 2022 to create a state-wide endometriosis research program, the state became poised to be the hub for endometriosis research and innovation. The bill created a first-of-its kind endometriosis data and biorepository program  which will be located at The Jackson Laboratory  (JAX) and managed in coordination with UConn Health and required that the University of Connecticut in partnership with JAX  begin plans for additional research into endometriosis diagnosis and treatment. State Rep. Jillian Gilchrest formed the Endometriosis Working Group that helped pass the legislation.

Endometriosis is a chronic, inflammatory uterine disease that causes severe pain both in the uterus and throughout the body. It affects 10 percent of women who are of reproductive age, it can take years to diagnose, and treatment can be difficult to access.

Endometriosis is not simply a “menstruation disease”; it is a disease that can affect the whole body.

It occurs when tissue similar to the interior lining of the uterus, or endometrium, mistakenly migrates and implants in areas outside the uterus, primarily in the pelvic region. These implants respond to monthly fluctuations of hormones (estrogen and progesterone) during the menstrual cycle. During this cycle, estrogen can cause this out-of-place tissue to grow, often causing severe pain. These implants are endometriosis.

Endometriosis is associated with immune and hormonal disruptions. As endometriosis grows, it causes inflammation, which can lead to adhesions, scarring, internal bleeding, bowel or urinary dysfunction, constipation, painful intercourse, or infertility. The physical pain can be severe, which can lead to psychological distress. It’s a combination that, in many ways, can have a debilitating effect on an individual’s life.

UConn Health’s Director for Minimally Invasive Gynecological Surgery (MIGS) Dr. Danielle Luciano , in partnership with Elise Courtois, Ph.D ., an endometriosis researcher and director of single cell biology at JAX are collecting and researching tissues samples of patients to study and learn more about the condition and possible treatments and are part of the Connecticut Endometriosis Working Group.

During Endometriosis Awareness month, the state’s EndoRISE Program , co-directed by Luciano and Courtois, launched a new website. The site is initiative aimed at revolutionizing our understanding and treatment of endometriosis. As the first state-funded multi-institutional biorepository of its kind in the United States, we are dedicated to advancing research, patient advocacy, and clinical collaboration.

The website provides patients, providers and researchers information about the program, ways to get involved in of research and advocacy and learning. Patients are constantly looking for resources and advocacy group and the goal of the website in CT is to put all providers in one place so it makes it easier for patients to find the care they need.

The Minimally Invasive Gynecology Surgery team at UConn Health, designated as a Center of Excellence in Minimally Invasive Gynecology includes Luciano, Dr. Amanda Ulrich and Dr. Alexis Newmark. They are collecting donation tissue samples from patients with and without endometriosis for the research to understand the difference between endometriosis cells and patients without these cells.

“We are trying to understand why these cells grow in 10% of the population but not the other 90%. Once we figure out what is different, we can focus those differences on targeted therapy,” says

Luciano. “Currently we are treating endometriosis with birth control pills that are not designed to treat endometriosis, they are designed to stop you from getting pregnant.”

According to Luciano, “While the research is still in the early stages, we are already seeing some differences in signaling, immune cells, and inflammatory factors, which makes it look more like a systemic inflammatory disease than just a gynecological problem.  This might explain why these women even with few lesions have such significant pain symptoms.”

The MIGS team has seen an increase in patients with the awareness raised, as referrals from doctors who previously did not have an answer to their patients pain now consider that it may be endometriosis.  Luciano has participated in multidisciplinary grand rounds and lectures to community physicians who now consider this may be the answer to their patients issues they could not previously diagnose.

“We look forward to finding the answers and solutions to endometriosis so our patients no longer need to suffer,” says Luciano.

Recent Articles

April 2, 2024

Solar Nanodevices

Read the article

Want to Contribute to Scientific Research? There’s An App – and a Network – for That

Gift of Fuel Cell Units Enhances UConn’s Clean Energy Commitment

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Trop Med Health

First COVID-19 infections in the Philippines: a case report

Edna m. edrada.

1 San Lazaro Hospital, Manila, Philippines

Edmundo B. Lopez

Jose benito villarama, eumelia p. salva villarama, bren f. dagoc, chris smith.

2 School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan

3 Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK

Ana Ria Sayo

Jeffrey a. verona, jamie trifalgar-arches, jezreel lazaro, ellen grace m. balinas, elizabeth freda o. telan, myvie galon, carl hill n. florida, tatsuya ukawa, annavi marie g. villaneuva, nobuo saito.

4 Department of Microbiology, Faculty of Medicine, Oita University, Oita, Japan

Jean Raphael Nepomuceno

Koya ariyoshi.

5 Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan

Celia Carlos

6 Research Institute for Tropical Medicine, Alabang, Philippines

Amalea Dulcene Nicolasora

Rontgene m. solante, associated data.

The novel coronavirus (COVID-19) is responsible for more fatalities than the SARS coronavirus, despite being in the initial stage of a global pandemic. The first suspected case in the Philippines was investigated on January 22, 2020, and 633 suspected cases were reported as of March 1. We describe the clinical and epidemiological aspects of the first two confirmed COVID-19 cases in the Philippines, both admitted to the national infectious disease referral hospital in Manila.

Case presentation

Both patients were previously healthy Chinese nationals on vacation in the Philippines travelling as a couple during January 2020. Patient 1, a 39-year-old female, had symptoms of cough and sore throat and was admitted to San Lazaro Hospital in Manila on January 25. Physical examination was unremarkable. Influenza B , human coronavirus 229E, Staphylococcus aureus and Klebsiella pneumoniae were detected by PCR on initial nasopharyngeal/oropharyngeal (NPS/OPS) swabs. On January 30, SARS-CoV-2 viral RNA was reported to be detected by PCR on the initial swabs and she was identified as the first confirmed COVID-19 case in the Philippines. Her symptoms resolved, and she was discharged. Patient 2, a 44-year-old male, had symptoms of fever, cough, and chills. Influenza B and Streptococcus pneumoniae were detected by PCR on initial NPS/OPS swabs. He was treated for community-acquired pneumonia with intravenous antibiotics, but his condition deteriorated and he required intubation. On January 31, SARS-CoV-2 viral RNA was reported to be detected by PCR on the initial swabs, and he was identified as the 2nd confirmed COVID-19 infection in the Philippines. On February 1, the patient’s condition deteriorated, and following a cardiac arrest, it was not possible to revive him. He was thus confirmed as the first COVID-19 death outside of China.

Conclusions

This case report highlights several important clinical and public health issues. Despite both patients being young adults with no significant past medical history, they had very different clinical courses, illustrating how COVID-19 can present with a wide spectrum of disease. As of March 1, there have been three confirmed COVID-19 cases in the Philippines. Continued vigilance is required to identify new cases.

The novel coronavirus 2019 (COVID-19) is responsible for more fatalities than the severe acute respiratory syndrome (SARS) coronavirus, despite being in the initial stage of a global pandemic. It is thought that the index case occurred on December 8, 2019, in Wuhan, China [ 1 ]. Since then, cases have been exported to other Chinese cities, as well as internationally, highlighting concern of a global outbreak [ 2 ]. The first suspected case in the Philippines was investigated on January 22, 2020, and 633 suspected cases have been reported as of March 1. Of them, 183 were in the National Capital Region of Manila, of whom many were admitted to San Lazaro Hospital (SLH) in Manila, the national infectious disease referral hospital [ 3 , 4 ]. We describe the epidemiologic and clinical characteristics of the first two confirmed COVID-19 cases in the Philippines, including the first death outside China.

In this case report, we describe two cases: patient 1, the first confirmed COVID-19 case, and patient 2, the second confirmed case, even though the symptoms of patient 2 started first. The cases are presented based on reports from the clinicians involved in patient care and results of investigations available to them at the time. Figure ​ Figure1 1 shows a timeline of symptoms for both patients according to the day of illness and day of hospitalisation.

Timeline of symptoms according to day of illness and day of hospitalisation

History prior to hospitalisation

Both patients were Chinese nationals on vacation in the Philippines travelling as a couple. They had no known comorbidities and reported no history of smoking. Patient 2, a 44-year-old male, reported fever on January 18, 2020, whilst the couple were residing in Wuhan, China. It was reported that he was in contact with someone that was unwell in Wuhan, but not that he had visited the seafood market. During January 20 to 25, they travelled from Wuhan via Hong Kong to several locations in the Philippines (Fig. ​ (Fig.2). 2 ). Patient 1, a 39-year-old female, developed cough and sore throat on January 21. Due to persistence of symptoms of patient 2, they travelled to Manila on January 25. In Manila, patient 2 was denied entry to a hotel because he was febrile and both patients were transferred to San Lazaro Hospital (SLH), the national referral hospital for infectious diseases [ 4 ]. On admission, patient 2 was classified as a COVID-19 person under investigation (PUI) based on his travel history and fever [ 2 ] and was transferred to a designated isolation area with negative pressure rooms. Patient 1 did not fit the PUI criteria due to absence of fever, but was also isolated because of possible exposure.

Travels of patient 1 and 2

Clinical course of patient 1

On admission to the ward on January 25 (illness day 5), patient 1 complained of a dry cough, but the sore throat had improved. She was awake and conversant with a blood pressure of 110/80, HR 84, RR 18 and temperature 36.8 °C. Her chest was clear. The remainder of the physical examination was unremarkable. Nasopharyngeal and oropharyngeal swab (NPS/ORS) specimens were collected and sent to the Research Institute for Tropical Medicine (RITM) in Muntinlupa City [ 5 ]. A chest radiograph was reported as unremarkable (Fig. ​ (Fig.3 3 ).

Posteroanterior chest radiograph of patient 1, 27 January 2020 (illness day 7). Unremarkable

On January 27, the results were released of a commercially available respiratory pathogen multiplex real-time PCR for detection of pathogen genes on the NPS/OPS samples (FTD Respiratory pathogens 33, Fast Track Diagnostics) at the RITM Molecular Biology Laboratory. These assays reported detection of Influenza B viral RNA, human coronavirus 229E viral RNA, Staphylococcus aureus DNA and Klebsiella pneumoniae DNA. A 10-day course of oseltamivir 75 mg BID was given on the basis of the influenza result. The NPS/OPS specimen was then sent by RITM to the Victorian Infectious Disease Reference Laboratory (VIDRL) in Melbourne, Australia, for COVID-19 testing [ 6 ].

On January 29, further NPS/ORS specimens were collected and sent to the RITM. On January 30, the result of the initial NPS/OPS sent to VIDRL reported detection of 2019-nCoV (subsequently termed SARS-CoV-2) viral RNA by real-time PCR. The patient was thus identified by the Department of Health as the first confirmed COVID-19 case in the Philippines [ 6 ].

On illness days 6 to 10, she remained afebrile with minimal cough and clear breath sounds. During this time, real-time PCR for detecting SARS-CoV-2 was established at the RITM using the Corman et al. protocol [ 7 ]. Further NPS/OPS specimens collected on January 29 (reported on January 31) and January 31 (reported on February 2) also reported detection of SARS-CoV-2 viral RNA. On illness day 11, the patient reported resolution of symptoms. She remained afebrile and clinically stable apart from two episodes of loose watery stool on illness day 12. Further samples were collected on February 2 and 4. On February 8 (illness day 19), she was discharged when SARS-CoV-2 was no longer detected on an NPS/OPS sample.

Clinical course of patient 2

In contrast, patient 2 experienced a more severe clinical course. On admission (illness day 8), he reported fever, cough and chills. On examination, he was awake and conversant with a temperature of 38.3 °C, blood pressure of 110/80, HR 84, RR 18, and SpO 2 of 96% on room air. His chest was clear. The remainder of the physical examination was unremarkable.

A working diagnosis of community-acquired pneumonia and COVID-19 suspect was made. He was started on ceftriaxone 2 g intravenously (IV) once daily (OD) and azithromycin 500 mg OD. NPS/ORS specimens were collected and sent to the RITM. On January 27, the results of a respiratory pathogen real-time PCR detection panel performed at RITM on the NPS/OPS samples were released, reporting detection of Influenza B viral RNA and Streptococcus pneumoniae DNA. The NPS/OPS samples were sent to the VIDRL for additional testing. Oseltamivir 75 mg BID was commenced on the basis of the influenza result.

During illness days 9 and 10, his fever continued with occasional non-productive cough. He remained clinically stable apart from intermittent SpO 2 desaturations of 93–97% on 2–3 L/min of oxygen. On illness day 11, he developed increasing dyspnoea with reduced SpO 2 at 88% despite 8 L/min of oxygen via a face mask and haemoptysis and was noted to have bilateral chest crepitations. A chest radiograph was reported as showing hazy infiltrates in both lung fields consistent with pneumonia (Fig. ​ (Fig.4). 4 ). Meropenem 2 g IV three times a day (TDS) was commenced.

Posteroanterior chest radiograph of patient 2, 27 January 2020 (illness day 10). Hazy infiltrates in both lung fields consistent with pneumonia

On illness day 12, he became increasingly dyspnoeic, hypoxic and agitated and was intubated and sedated with a midazolam drip. An endotracheal aspirate (ETA) and a further NPS/OPS were collected and sent to the RITM. Vancomycin, 30 mg/kg loading dose followed by 25 mg/kg BD, was commenced with a working diagnosis of severe community-acquired pneumonia due to Streptococcus pneumoniae secondary to Influenza B infection, plus consideration of COVID-19 pending the ETA result. A complete blood count showed values within the normal range (Table ​ (Table1). 1 ). On illness day 13, he continued to be febrile (38.5–40.0 °C) with bibasal crackles. Vital signs were stable with adequate urine output. A chest radiograph was reported as showing worsening of pneumonia (Fig. ​ (Fig.5 5 ).

Clinical laboratory results and vital signs

NPS/OPS nasopharyngeal/ oropharyngeal swab, ETA endotracheal aspirate

*NPS/OPS—result from RITM was received on February 2 and reported detection of SARS-CoV-2 viral RNA

**NPS/OPS—result from VIDRL was received on February 4 and reported detection of SARS-CoV-2 viral RNA

Posteroanterior chest radiograph of patient 2, 30 January 2020 (illness day 13). Endotracheal tube in situ approximately 2 cm above the carina. There is worsening of the previously noted pneumonia

On illness day 14, increased crepitations in both lung fields were noted. Blood cultures showed no growth after 24 h of incubation. An HIV test was non-reactive. On this day, the RITM reported detection of SARS-CoV-2 viral RNA by real-time PCR from the NPS/OPS taken on illness day 12 and hence the 2nd confirmed COVID-19 infection in the Philippines. This result was later confirmed on February 4 on the initial admission sample sent to VIDRL.

On the morning of illness day 15, the patient remained febrile at 40 °C, with BP 110/70, HR 95, RR 30, SpO 2 99% with 80% FiO2, and adequate urine output. However, the patient’s condition deteriorated with the formation of thick sputum and blood clots in the ET tube. Despite frequent suctioning, the patient’s condition deteriorated. He was noted to have laboured breathing followed by a cardiac arrest. Despite several rounds of cardiopulmonary resuscitation, it was not possible to revive the patient. He was thus confirmed as the first COVID-19 death outside of China.

Discussion and conclusion

This case report describes the first two confirmed cases of COVID-10 in the Philippines and highlights several important clinical and public health issues. Despite both patients being young adults with no significant past medical history, they had very different clinical courses, illustrating how COVID-19 can present with a wide spectrum of disease [ 8 ]. Whilst patient 1 had a mild uncomplicated illness consistent with an upper respiratory tract infection and recovery, patient 2 developed a severe pneumonia and died.

One possible explanation for the differing clinical courses is the presence of co-infection. In both patients, the real-time PCR detection panel was reported to be positive for multiple pathogens. The Staphylococcus aureus and Klebsiella pneumoniae detected in patient 1 most likely represent bacterial colonisation, and it is unclear to what extent her presentation was due to influenza or COVID-19 or both. Patient 2 tested positive for COVID-19, Influenza B , and Streptococcus pneumoniae , all of which can cause respiratory infection and severe pneumonia. Unfortunately, sputum culture was not possible due to biosafety concerns. It is unclear which pathogen was the leading cause of death, but previous research has shown that outcomes of acute viral respiratory infection are worse if multiple pathogens are present [ 9 ]. This highlights the importance of testing for other respiratory pathogens in addition to COVID-19 in order to optimise antimicrobial therapy.

Patient 2 developed increasing dyspnoea on day 11 of illness, similar to the first COVID-19 case in the USA, where mild symptoms were initially reported with progression to pneumonia on day 9 of illness [ 10 ]. The median time from illness onset to dyspnoea in a case series in Wuhan was 8 days (range 5–13) [ 11 ]. The explanation for patient 2’s worsening condition and development of haemoptysis was progression of pneumonia rather than acute respiratory distress syndrome or pulmonary embolism, but it was not possible to perform a CT scan, additional laboratory tests or an autopsy to further assess this. Although he was treated with broad-spectrum antimicrobials, it is not clear if the outcome would have been better in a high-resource setting. Both patients were treated with oseltamivir in view of positive results for Influenza B . Further studies are required to establish the optimal treatment and role of antiviral medication for patients with suspected or confirmed COVID-19 infection.

Our cases contrast with the US case in terms of the relative paucity of lab data and time to receive results. Limited in-house testing was undertaken due to biosafety concerns. In the case of patient 2, the diagnosis of COVID-19 was not made until a day before the patient died. This was because SARS-2-CoV testing was being established in the Philippines at the time that the patients were admitted, and initial samples had to be sent to Australia. Although the delay of diagnosis is unlikely to have altered management, expansion of COVID-19 diagnostics including multiplex panels for other respiratory pathogens is urgently needed for prompt diagnosis of patients for screening of hospital personnel or other contacts.

Three SLH hospital staff who were caring for the patients developed symptoms and themselves became PUIs, but were later discharged following negative SARS-CoV-2 testing and symptom resolution. This highlights the risk of an outbreak in the hospital, or a ‘super-spreader’ scenario, as was observed in other settings during the early stages of the SARS coronavirus infections in 2003 [ 12 ]. In the case of SARS, as with COVID-19, SLH managed two cases and was able to contain the infection without further spread [ 13 ].

The third confirmed COVID-19 case was announced on February 3 from a sample taken on January 23, also a Chinese national who had travelled from Wuhan. She recovered and returned to China on January 31. Contact tracing has been undertaken of all three patients [ 14 ]. Despite travel to several locations in the Philippines whilst experiencing symptoms, as of March 1, there has not been any confirmed local transmission arising from these cases and the number of PUIs has decreased [ 3 ]. However, as infection can be mild or subclinical, local transmission cannot be excluded. Increasing the number of laboratories able to perform SARS-CoV-2 testing would allow better surveillance and improve detection of COVID-19 cases.

In conclusion, as of March 1, there have been three confirmed COVID-19 cases in the Philippines including the first death outside of China. No local transmission has been confirmed. Continued vigilance is required to identify new cases.

Acknowledgements

We are very grateful to the patients for allowing us to prepare and publish this case report.

Abbreviations

Authors’ contributions.

All of the authors contributed to the writing of this case report. The authors read and approved the final manuscript.

Not applicable

Availability of data and materials

Ethics approval and consent to participate.

This case report was not part of a research study, and hence, ethical approval was not sought. Written consent was obtained from patient 1 and on behalf of patient 2.

Consent for publication

Written consent for the preparation and publication of a case report was provided by patient 1 and on behalf of patient 2, following discussion with his brother.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Philippines to Boost Diplomacy and Defence Capability as South China Sea 'Countermeasures'

Philippines to Boost Diplomacy and Defence Capability as South China Sea 'Countermeasures'

FILE PHOTO: Philippine President Ferdinand Marcos Jr. looks on as he meets with U.S. Secretary of State Antony Blinken, at Malacanang Palace in Manila, Philippines, March 19, 2024. REUTERS/Evelyn Hockstein/Pool/File Photo

MANILA (Reuters) - Countermeasures by the Philippines to China's conduct in the South China Sea will entail strengthening its defence capabilities with allies and exhausting all diplomatic measures to resolve disputes, a security official said on Monday.

President Ferdinand Marcos Jr last week said the Philippines would implement unspecified measures against "illegal, coercive, aggressive, and dangerous attacks" by China's coastguard, upping the stakes in an escalating row in the South China Sea.

"The proportionate, deliberate and reasonable response the president was talking about covered not only the aspect of strengthening military and defence capabilities with other allies ...but it also talks about exhausting diplomatic efforts to resolve the issue," National Security Council spokesperson Jonathan Malaya said on state TV, describing the package as multi-dimensional.

Marcos also ordered his government to strengthen its coordination on maritime security to confront "a range of serious challenges" to territorial integrity and peace, according to a copy of the directive released on Sunday.

China's foreign ministry on Monday said regardless of what policies the Philippines rolls out, none would affect China's maritime rights of sovereignty claims.

China claims almost the entire South China Sea as its territory, policed by an armada of coastguard vessels, some more than 1,000 km away from its mainland.

The Philippines and China have had a series run-ins at sea in the past year over disputed maritime features, coinciding with Manila ramping up defence engagements with ally and former colonial power the United States.

The latest flare-up occurred on March 24, when China used water cannon to disrupt a Philippine resupply mission to the Second Thomas Shoal for soldiers guarding a warship intentionally grounded on a reef 25 years ago.

Defence officials traded barbs late last week, with China saying the Philippines was to blame for the breakdown of relations, accusing its neighbor of provocations, misinformation and treachery.

The Philippines responded, accusing China of being patronising and intimidating smaller countries.

(Reporting by Karen Lema; Editing by Martin Petty)

Copyright 2024 Thomson Reuters .

Join the Conversation

America 2024

Health News Bulletin

Stay informed on the latest news on health and COVID-19 from the editors at U.S. News & World Report.

Sign in to manage your newsletters »

Sign up to receive the latest updates from U.S News & World Report and our trusted partners and sponsors. By clicking submit, you are agreeing to our Terms and Conditions & Privacy Policy .

You May Also Like

The 10 worst presidents.

U.S. News Staff Feb. 23, 2024

Cartoons on President Donald Trump

Feb. 1, 2017, at 1:24 p.m.

Photos: Obama Behind the Scenes

April 8, 2022

Photos: Who Supports Joe Biden?

March 11, 2020

Labor Market Keeps on Chugging

Tim Smart April 2, 2024

Florida High Court OKs Abortion Vote

Lauren Camera April 1, 2024

The Week in Cartoons April 1-5

April 1, 2024, at 3:48 p.m.

White House Easter Egg Roll

April 1, 2024

What to Know About the Easter Egg Roll

Steven Ross Johnson April 1, 2024

Jobs Back on the Radar to Start Q2

Tim Smart April 1, 2024