Perpetual Lockdown: The State of COVID-19 and Kidney Disease in the Philippines

More than a year since the World Health Organization (WHO) declared COVID-19 a pandemic, the Philippines remains under the grip of one of the world’s longest lockdowns. Despite the draconian measures put in place since March 16, 2020, it has the greatest number of total cases to date (1,478,061) among the 24 states under the WHO−Western Pacific Region,¹ and second behind Indonesia in Southeast Asia. Moreover, the Philippines is experiencing another surge, with new cases averaging more than 8000 daily in April, peaking at 15,298 new cases last April 2. This article highlights the current state of the COVID-19 pandemic in the country and its consequences on Filipinos with chronic kidney disease (CKD).

Crude Contact Tracing and Inadequate Testing

Contact tracing remains a weak link in the country’s response, with falling contact tracing ratios attributed to lack of uniform data collection, lack of trained contact tracers, and poor coordination with the local government units.² The Philippines has lagged in the testing arena as well, reaching a maximum of 62,466 tests per day (Supplementary Figure S1). The persistently high positivity rates (ranging from 10.3% to 23.8% starting in mid-March 2021)³ point to the fact that the Philippines was not performing enough tests daily to detect new cases. Local transmission among dialysis patients within centers were not uncommon, as contact tracing procedures were not exhaustive and reverse transcription−polymerase chain reaction (RT-PCR) tests were conducted sparingly because few patients could afford them. Even when RT-PCR was performed, the scarcity of capable testing centers and the slow turnaround time for test results limited the ability of the dialysis centers to immediately separate SARS-Cov-2−positive dialysis patients from their noninfected peers.

Resurgence of Cases and Lack of Hospital Beds

The sudden upswing in COVID-19 cases during the start of March 2021 saw hospitals experience a spike in admissions and occupancy. In its largest island, Luzon, most hospitals designated to manage severe COVID-19 cases are centered in the National Capital Region (NCR). When the country tallied its largest daily new cases in April 2021, the Department of Health reported that 85.28% of the total intensive care unit (ICU) beds for COVID-19 in NCR were occupied. Furthermore, 32 of its hospitals reached 100% bed occupancy.⁴ In the Philippine General Hospital, the country’s largest COVID-19 referral center, bed capacity has hovered around 90% since the beginning of May. Spillover of patients requiring hospital care to nearby provinces was imminent. People began seeking hospitals with vacant beds in desperation, traveling as far north as the Ilocos Region and as far south as the Bicol Region (both more than 300 kilometers from Manila).

CKD and Hemodialysis Patients: The Collateral Victims

Government outpatient nephrology clinics ceased operations during the start of the pandemic, as most of its resources were diverted to the containment and treatment of COVID-19 patients. Philippine General Hospital, the country’s largest tertiary and training hospital, was converted to a COVID-19 referral center on March 30, 2020.⁵ This led to the closure of the outpatient department catering to large numbers of CKD charity patients. Outpatient hemodialysis patients were transferred to other centers in preparation for the care of COVID-19 dialysis patients. Those who were seen by private outpatient clinics were likewise unable to have face-to-face consultations with their attending nephrologists because of the movement restrictions imposed by the nationwide lockdown.

During the early days of the pandemic, hemodialysis centers were not prepared to handle the COVID-19 surge. Although hospital-based dialysis centers had provisions for isolation areas and personal protective equipment (PPE), free-standing centers were ill-equipped to handle COVID positive or suspect patients. In a survey done among 27 hemodialysis centers (most of which were free-standing facilities) serving almost 1700 patients, only 8 of them were equipped to handle positive patients (Figure 1). These centers had the capacity to cater to only 27 COVID-19 patients in a day. Symptomatic patients were advised to transfer to other centers. Dedicated COVID-19 dialysis centers were designated through the concerted efforts of the Philippine Society of Nephrology and local government units, but were soon overwhelmed with the increasing numbers of patients. The National Kidney and Transplant Institute, which contains the country’s largest government hemodialysis facility, had already sought assistance in accommodating the growing COVID-19 dialysis patients.⁶ Some centers were forced to do dialysis with cohort isolation—the practice of placing suspect or positive patients in a different shift. Even then, some centers developed local COVID-19 transmission among their patients and staff, resulting in their temporary closure. This further exacerbated the shortage of available dialysis centers that could cater to COVID-19−positive patients.

Figure 1.

Survey of hemodialysis centers in the Philippines (Philippine Society of Nephrology, 2021).

Symptomatic patients had to pay for their RT-PCR testing as well as shoulder additional expenses during cohort dialysis (to cover the fees for PPE and hazard pay of staff) amounting to tens and thousands of pesos. Patients who did not have the financial capability to pay the extra fees had to queue to government centers already filled to the brim with patients. In the survey mentioned above, 267 of 1675 patients (16%) developed COVID-19. Of these, 91 (34%) would succumb to the disease (Figure 1). In a study in Philippine General Hospital by Tomacruz et al., mortality among admitted ESKD patients with COVID-19 was high, at 25%.⁷ Because of difficulties brought about by the pandemic such as loss of income, lack of dedicated COVID-19 dialysis centers, and shortage of dialysis center manpower, some patients were unable to resume their regular treatment sessions and ended up suffering pulmonary congestion and other complications leading to hospitalization or death. Although actual data are lacking, there is consensus among the nephrologists in the country that there is a significant proportion of patients whose fatalities can be attributed to complications of missed dialysis treatments.

The pandemic brought about a “silver lining” for chronic dialysis patients, in the form of the Bayanihan to Recover as One Act. Under this act, the number of dialysis treatments subsidized by Philhealth annually was increased from 90 to 144 sessions until December 31, 2020.⁸ This somewhat alleviated the out-of-pocket expenses of hemodialysis patients and enabled them to fully comply with their thrice-weekly dialysis sessions.

Kidney Transplantation Comes to a Standstill

The majority of kidney transplantation surgeries in the Philippines are based on the island of Luzon. Even before the pandemic, the number of kidney transplantation procedures was already low. The National Kidney and Transplant institute only had 561 kidney transplantations last 2018 and 535 transplantations last 2019. From January to March 2020, the transplantations decreased to only 107. As it underwent lockdown in March 2020, all transplantation centers ceased performing procedures to minimize the exposure of transplant patients to COVID-19. Deceased donor procurement activities were also suspended.⁹ Although some of the institutions have resumed performing a limited number of procedures this year, kidney transplantation in the country is effectively stifled for the foreseeable future.

Slow Vaccine Rollout, Hesitancy and Misinformation

The Philippines was the last Southeast Asian country to receive its vaccines, on 28 February 2021. With its initial 600,000 donated CoronaVac shots, the Philippines started its rollout on March 1. It has administered more than 5 million doses (equivalent to 2% of the total population), running at an average of about 140,000 vaccinations per day. Fully vaccinated individuals have reached 3.4 million, or only 4.81% of the total population (Supplementary Figure S2). This is a far cry from the government’s projected 70 million target to achieve herd immunity by the end of 2021. As of 14 June 2021, the country had vaccinated with the first dose more than 1.7 million people belonging to the A3 priority group, which includes patients with CKD, those on hemodialysis, and those who underwent kidney transplantation. Of 1675 hemodialysis patients in the survey, 430 (25.7%) have received at least 1 dose, whereas 265 (15.8%) are fully vaccinated (Figure 1).

Vaccine hesitancy, slow vaccine rollout, and rampant misinformation all contribute to the low vaccination rate in the country. Six in 10 Filipinos did not want to get the vaccine, citing safety concerns as the leading reason for vaccine hesitancy.S1 Informal interviews of the author among dialysis patients have revealed their fear of being vaccinated because of their immunocompromised state. Delays in releasing vaccines from storage facilities, supply issues, transportation issues, and other challenges all serve as bottlenecks that hamper vaccine deployment. The inefficiency trickles down to the municipal level, where lack of coordination, proper communication, and scheduling have caused confusion among those waiting to be vaccinated. Misinformation regarding the dangers of COVID-19 vaccines and fraudulent claims of deaths attributed to vaccines continue to make the rounds on Facebook. The social media platform has become a breeding ground for conspiracy theories and “snake oils” that fuel doubts about the vaccines.

Conclusion

The end of the COVID-19 pandemic is still far from being in sight in the country. With its health care system already stretched thin just from battling COVID-19, it cannot deal effectively with other diseases such as CKD at the same time. Dealing with COVID-19 as quickly as possible is key not only to the resumption to normalcy but to increasing the survival and quality of life of Filipinos with kidney disease. There should be a concerted effort by the government to improve its pandemic response and to flatten the curve as fast as possible. The race to end COVID-19 in the country may well become a race to protect CKD patients as well.

Disclosure

The author declares no competing interests.

Supplementary Material

Figure S1. Daily new COVID-19 tests.

Figure S2. Percentage of Filipinos vaccinated.

Supplementary References