 Good morning, good afternoon, good evening, everyone. Welcome to the 81st episode of the Stop COVID Death Webinar Series brought to you by the University of the Philippines. Thank you for being part of our credible online community. To all those po na for the very first time ay ngayon palam po kami da-discovery, welcome po at sana po masayaan po ka at marami po ka yung matutunan sa ating online community. On November 26 of this year, the World Health Organization called for an urgent meeting. So last week lang po yung ito na to discuss the possibility of a new variant of concern, dahil di pa po siya variant of concern non, based on genetic sequencing of the SARS-CoV-2 virus that had multiple mutations on the spike protein. This was first reported in Botswana and later allegedly responsible for a steep rise in cases in South Africa. Within a few days, the World Health Organization declared the new variant as a variant of concern and named it Omicron. Further sparking tension around the world and warning against travel bans and closing of borders. So mapapansin nyo po, lalo na po sa mga balita, marami na po ang mga bansa talagang hindi po muna nagpapalipad o nagpapapunta ng mga travelers, galing po sa mga selected po ng mga bansa dahil na rin po sa banta ng Omicron variant. So thus the emergence of this new variant affect the current clinical management of COVID-19 to get the latest information from the most credible sources. Please stay tuned. I'm Dr. Raymond Francis Sarmiento, director of the National Telehealth Center, National Institutes of Health University of Philippines Manila. Always a pleasure to be with all of you during our regular Friday lunch date and I always look forward to Fridays because I get to share hosting duties with a beloved mentor, also my partner, our Adjunct Research Faculty at the National Telehealth Center and the special envoy of the President for Global Health Initiatives, Dr. Susie Pineda Mercado. Dr. Susie. Hi Raymond, good afternoon. Magandang happen po siyan lahat, sanman kay na rano, we hope you're okay, you're doing well. We really, what should I say, we're purposely going to change our format a little bit because of this new variant. But before we start, I would like to call for a moment of silence for one of our colleagues na gespo siya rito si Dr. Raul Andutan and you might remember him sometime back we had him when we discussed the COVID variant. He passed away and I just like to have a moment of silence for him. So let's just have a moment of silence. So thank you very much everyone for that pause. Talagang ano yun na, talagang. Talagang mahirap na kasi, pag merong pang nawawala satin mo and in this case it was not a very, what should I say, it was a very unexpected death. So nakiramay po tayo sa kanya, sa kanyang pamilya, sa mga malina, sa buhay at naalala natin siya dahil, sa maon nakatulong din siya sa ating webinar. Okay, so thank you for that. And Raymond, we're going to, parang nawala tuloy ako sa ano. Nawala ako sa bearing ko. We are going to have a brief discussion with all our panelists immediately. Kasi gusto natin pagusapan kagad itong Omicron. Ano Raymond, parang magpapanal discussion na tayo kagad. Do we have everybody here already? I think we do. Can we ask all our panelists please open their... Okay, and let me introduce our panelists one by one. Sabi natin, we'll talk about this right away because there's a strong interest in it and of course one of our guests will talk about it in a little bit more of detail but we wanted to open with a panel discussion because it's really a burning issue. Laman po na lahat ng balita and I'm sure you're all very curious about this. I noted this morning, I noted in our chat box marami tayong mga nanunod from Mindanao, from Sambuanga, from Ipil, from Coronadal. Andami natin ang atos mga kaibigan natin in Isabela and Bulacan. So from all over the country, we have doctors who are watching. So we thought we'd take this time to talk first about this variant and then we'll go into the certain formal presentations later. So in our panel, we have Dr. Franco Filisarte. You know him, Filisarte. You've met him before. He's an infectious disease specialist practicing in the United States. Dr. Drew Britt-Lenedicto from the Philippine General Hospital. Dr. Maria Virginia Abalos, from Sibu. Dr. Teder Bosa from the National Task Force and has been working really day and night on vaccination and Dr. Benny Pachensa. So let's get this rolling, Raymond. Let me ask you. So we wanted to make this a very informal conversation. And I encourage you to talk to each other as we do this very brief discussion. But the first question is, what was the first thing that came to your mind when you heard about this new variant that has been declared a variant of concern? So we'll start with Franco. Go ahead, Franco. Well, I was looking at the mutations and there were 15 mutations in the, that's a record. And in terms of divergence, it's the most divergent of all the variants. Not only that, out of the 50 mutations, 35 are in the spike protein, 15 in the receptor binding protein. And if you look at all the variants, it has all of the necessary irrelevant variants. So it's very concerning. And then if you look at the spikes, if you look at this epidemic curve of South Africa now, it's already starting to surge. Now, the deaths is still stable, but we don't know. We have to wait for the hospitalization rates and the deaths, which will take about one to two weeks after. But it's very concerning, the increased transmissibility and the possibility that it will decrease the vaccine efficacy. Okay. So you're going to talk a little bit more about that, Franco, but you felt very concerned when you first heard about this, you're in the, what should I say, in the belly of PGH, handling critical care, ano may isip mo? What was the first thing that came to you? The first thing that came to my mind was goodbye Christmas break. Kasi parang, I was given being one of the senior consultants that's in this since the pandemic last year. Parang pinagbibigan nila ako pag Christmas time na ako yung mag-off. Pero when I heard about the Omicron, parang nasabi kong a goodbye Christmas break. And then I was really reading through the news being updated in terms of implications of management. So what we're doing right now is kasi parang nag-shift na sa non-COVID mode, just like possibly other hospitals. So what we're doing right now is we're really having a good grasp ng aming inventory in terms of equipment. And then just right, I think last Monday, I was having a meeting with all my RTs and with all of course the fellows and consultants telling them o ano ba yung kailangan natin para wag tayo maging reactive, just in case no there will be a surge and it will hit us ilan ba yung ating mga ventilator, functional balahat, ilan yung ating high flow machine, functional balahat, o yung mga kailangan natin gamot, make sure naka-stock up sa pharmacy. So it was really more on that stage ma'am Susie. So pineprepare ko yung sarili ko and then the others as well since we are of course sliding to the Christmas break medyo nandong sa holiday season yung utak din ang lahat, nagkikrismas party na kahit virtual pero ang poin ko, we should be on our toes and just ready to react appropriately. Okay. So let's hear from Sibu. Doctor Jean Abalos who's medical director of the Tromhwa Hospital in Sibu. What was your reaction, Jean? Well, number one, I mentioned, kailan ba matatapos yung Greek alphabet na to? Number two things came to my mind of course number one because as medical director, we have been doing a lot of meetings already expecting really to have a surge. Parang maslabuti na kasi na inya expect mo na magkaka-surge para hindi tayo na bibigla. Especially with what happened to us with the Delta talagang grave yung pila dito sa Sibu and of course in PGH and everywhere. So just like what Jubert mentioned, we also have a list of all the machines that we have. We even prepared protocols for what we will do just in case talagang hindi makayanan na sa ER. So those things, the medical director stuff and of course as a practicing OBGYN, I was thinking ano na naman kaya ang mga yayari sa mga buntis namin? Because last year, we didn't really have much problems with our pregnant patients. Very minimal complications but this year with the Delta, there is really a market difference which I like to share with you. So nagkiging question ngayon sa atin yung bang vacunado ay protected na. So you know and I believe it's something that is in the minds of everyone especially as Dr. Franco mentioned na ang dami niyang mutations. So that stuff. Okay, so let's move to to Benny, Dr. Benny Achan sa president of the Philippine Medical Association. Benny, what was the first thing that came to your mind? What came into my mind kasi as a pediatrician, palagi kino-i-sip yung mga bata at instinct na how about yung na naman yayari sa 11 to 11 below na wala ka yung vaccine? And during the first surge of the COVID hindi nang ma-affectada yung mga bata 10 yung na kadelta, 10% of 18 below was affected with COVID at saka di perang yung manifestation ng COVID, I don't know bakit ganoon diarrhea lang tapos pagpina-examil mo main yung mga yung bata how about more sa Omicron tumayari and we don't have the vaccines for this less than 11 years old e ngayon napakalaks na natin even independent media, social media and television I told them not to be complacent kasi pala pa silang bakuna kung ta sila ng puta ng mall even the toddlers at being brought to the kasi laks na tayo yung ganoon and na takot ako kasi baka yung mga vulnerable natin less than 4 kasi sa 18 below yung less than 4 years old ang maraming na-affectang ng COVID yung deaths at saka ay how about yung vaccines natin that equity as said nga ng WHO yung equity ng vaccines in lesser yung mga lower economic countries tapos ay nabibigan ng vaccines marami yung sa Europe in different areas and according to the reports na-affecto handong mostly ng Omicron is yung mga universities ay panipagpaso na ating mga colleges more less than 40 daw parang simpili ang symptoms nila at 2 days patig head A then make up napakasimpili na napakakamala lang natin clue Thank you very much Ben another perspective from the point of view of kids Hey Ted, your boss is here Yes Ben is talking about vaccines and congratulations first of all on the tremendous feat that you guys have achieved in vaccinating I don't know how many million they do vaccinate but We vaccinated 7.6 million doses at 6 am today and I'd like to publicly thank the president of the Philippine Medical Association Dr. Benny Atienza The idea of the National Vaccination Day came from him and his colleagues We had a meeting in November 1 Alalam mo yung holiday sabi mi Sek Galbes I'm willing to meet with the PMA even if it's a holiday so we met at 4 pm and one of the agreement was let's hold a vaccination day in fact 2 weeks later ang plano namin pero we realized andami pala ipaplano sa vaccination day so we ended up with the current schedule sa resounding success and it couldn't have been a success if it wasn't government alone it was the PMA doctors the faith-based organizations and everything so malaking bagayon and I also have to thank Omicron by the way, Omicron Barian you are not welcome to the Philippines but thank you, salamat tinakot mo ang aming mga kababayan at dinagsak yung aming mga bakunahan sa bayan ihan bakunahan so hanggang alas jis ng gabay alas onsi ng gabay kaya mga report sa umaga late namin malaman kailan yung mga bakunahan so the other thing I'd like to state is that on November 29 the first day we logged a total of 2.7 million doses which is the fourth largest vaccination in one day all over the world we were only beaten by China India USA and we are fourth and then Brazil had a 2.2 2.2 million in a day but look at those countries that we are with China and India are both over a billion US is what 400 million population so technically tayo 100 million lang pero nakagawa tayo ng 2.7 iba talaga yung Filipino spirit ng bayan ihan we are repeating it as our fight against omicron ulitin pa natin ang this is the best time to do a vaccination drive in public health you do not vaccinate when it is surging you vaccinate during the ebb when there is low and we are having for the past few days less than 500 cases a day never never experience it the more we should continue many LGU said doctor bosa tutuli kami we should continue to do bayan ihan Thursday and Friday so tumulo yung pa sila and also the other for the next 15, 16, 17 sabi ko baka bayan ihan bako nahan week na lang hindi na days kasi talagang andaming pumupunta and I do hope that happens because that is our best defense against COVID-19 so where are we now 92 million doses that is already 45% bosa almost 50% of the targeted 70 and then 50 million have had at least one dose so that was the beauty I said 2.7 million were vaccinated on the day one the total is 7.6 but 85% were first doses so that is interesting so these are the hesitant people and that is why I am thinking omicron because I don't think the bayan I think they got scared but I think the bayan ihan Filipino bandwagon mentality pagtakita nilang may nakapila pipila sila siya takala nila may nagbibigay ng ayuda so madaming pumila but what was your first reaction when you heard about it my feeling was I knew that the healthcare workers were pagod na so this is Dr. Abalos mga pagod na yan kasi dalawan taon na natin binobuno ito and ita mo tumatang mo sila even the nurses are already leaving the Philippines because there were 8 million nurses in the US that resigned napagod na rin yung mga locals nila so saan ba sila ko kuhan ng nurse na tatakutak ko I also got scared because not at this time when people are careless pinatanggal na nila yung face shield they wanted more economy opening the economy and the scariest part when I was reading about Omicron was we were already going to relax in December 1 December 1 was our target day for secretary Berna Romulus opening up of the tourist destinations to people with visas that are 30 and 60 day passports allowed to enter the Philippines dapat inalaw natin yun in December 1 because of Omicron hinoldin yun wala na naman kita yung ating tourist destinations unless magbibiyi si Dr. Abalos at si Dr. Juberth which I doubt they will do because binabat na yan nila yung kanila mga hospital I think this has really got many of us by surprise Paknar Raymond na isip mga agad na sa Viber group namin ka agad yun na uy meron bago gano Raymond what were you thinking? Very trivial Dr. Suzy was because I tried to follow the serial sequence so when I noticed that they picked a new name I was trying to figure out why that was the name that they picked out and lo and behold that was part of the communications packet from WHO on how to explain why they skipped two letters and went to letter O but more importantly I was thinking more of what does this mean for us ka alinsabi po kasi paglabas ng Omicron variant our news saying that there are 50 mutations based on wastewater surveillance yung entire period were in the delta variant was at least in I think in South Africa na in just a few weeks natapatan na yun ng Omicron variant just based on wastewater surveillance so that was a little bit anxiety driving for a lot of us but I still hold on to the fact that the vaccines still hold a high level of effectivity and hopefully that's still also translatable to the new variants thank you very much thank you very much to our panel for your willingness to start our webinar with a discussion we usually don't do this but it's great to just have that personal insight from all of you and that's our segue to call our first speaker who you know very well is an infectious disease and internal medicine specialist with the UP Medical Alumni Society in America he's practicing California right now and you know him Dr. Franco Felizarta who's going to go now into the details of Omicron our title actually is updates on clinical management so we're going to hear about that from Jubert and from Jean but we're going to start a little bit from Dr. Franco Franco take it away, it's yours Thank you Dr. Mercado Magandangapopo sa inyong lahat let me share my screen you're able to see it right? Yes okay Dr. Franco I'm supposed to discuss the updates on COVID-19 on clinical management but of course we have this new variant of concern that was just designated by Omicron of course if you're British it's Omicron so I prepared some slides for Omicron so the first half of my presentation would be in Omicron and then the second half will be on updates on COVID-19 clinical management I have about 30 slides but I'll skip about 10 in between so hopefully we can finish this in less than 20 minutes so these are my disclosures in lots of pharma I've worked with Gilead with the Remdesivir clinical trials I also worked with GSK with the Satromib Satrobimab monoclonal antibody and I'm a site for the NIH for active 2 and I'm a minor contributor for the research team so let's start with the Omicron variant timeline really more of the calendar so it looks like Omicron was first detected in Botswana from a sample collected on November night but most of the samples were from South Africa so from November 12 to November 20 they they noticed that there's an optic of cases in Gauteng, GAUT and Gauteng province of South Africa optic of cases some of them are reinfections some of them are breakthrough cases and they also noticed that more than 50% of the PCR tests that are positive has a spike gene dropout we call it or spike gene target failure I'm going to talk about that later so they sequenced all the 77 samples and of course it came out to be a new variant it's called B11529 so and then they reported it South Africa reported WHO on November 24 and in two days they designated it as a variant of concern that's quite fast two days so from B11529 to Omicron now why Omicron? so it's based on the Greek alphabet of course we already have this four and alpha first detected in United Kingdom beta from South Africa gamma from Brazil delta from India and of course the variants of interest lambda from Peru new from Colombia and the rest are previous variants of interest including data, data is first it was actually first detected in Central Visayas, Philippines so we have we have the data here and the next one should be new but they skip this because it's it's very similar to the word new the English word new and sigh they skip sigh because it's very similar to a common name in China which is she for example the president of China is Xi Jinping so they skip this and then went for Omicron now before I discuss the mutation let's just review the SARS-CoV-2 virus as you can see here this is the nucleocapsid here which encapsulates the viral RNA you have the matrix and the protein but the most important part here is the spike protein and the most important part of the spike protein is the subterbinding domain the RBD why because that is the one ACE2 receptor there's actually a second receptor it's called dnprss2 so this is actually important because of this association with the furan cleavage site between S1 and S2 of the spike protein this actually this site makes it very unique among corona viruses most of the mutations of the variants are in the RBD region the receptor binding domain that attaches to the ACE2 receptor so this is delta versus Omicron a variant spike protein as you can see Omicron has more mutations and most of them are in the RBD region these are all 50 mutations of the Omicron okay all 50 half of them are unique 26 delta has 10 so in terms of divergence Omicron is the most divergent of all the variants 15 of the mutation are in the RBD site 3 3 in the furan cleavage site and if we compare it to the other variants as you can see here 417 to 501 are all RBD 681 is the furan cleavage site so for example beta in terms of mutualization is the worst okay beta is the worst it has two mutations in the RBD and none in the furan cleavage site how about delta delta is the most transmissible it has one in the RBD one in the furan cleavage sites how about Omicron Omicron has all this all of this mutation except 452 okay so what does it mean so you know does it affect transmissibility disease severity risk of infection or impact on diagnostics so let's start with impact on diagnostics the PCR continues to detect Omicron so that's not a problem it probably would not be a problem for antigen because there's not much mutation in the nucleocapsid site so you know the antigen detects the nucleocapsid site but you can take advantage of this S gene which I already mentioned a while ago this is similar to alpha but remember there's not much alpha now so if you have a PCR test that has a S gene dropout it's most likely Omicron so of course you still have to sequence it so for example give me an example you know thermal fissure that path it detects three areas of the gene or F1AB nucleocapsid and the spike so if it's an Omicron this too will be positive but the spike will be negative why? because of the 6970 deletion if there's a deletion there will be a dropout so that's why alpha is the only other variant that has the 6970 deletion so you can take advantage of it so the only thing is you have to use a PCR test that detects the spike gene and if the spike gene is negative then you have a dropout most of the PCR test does not do this so for example sansure I think in the Philippines only detects two and it doesn't include the spike gene so yes it can still detect Omicron but there's only a few like thermal fissure that can differentiate Omicron with other variants so you can take advantage of that in terms of sequencing in terms of transmissibility as you can see here beta was the most dominant in South Africa it was outcompeted by delta look at what's happening now B11529 and Omicron is outcompeting even delta actually the dominance is much faster than delta or beta so this is very concerning of course this could be just because of the low numbers it could be just a founder effect due to for example a single super spreader event but as you can see here the surge in South Africa is real it's starting the depths are stable but remember it lags behind by about two weeks so the hospitalization will actually we'll see if the hospitalization increases too that could be a problem now it doesn't help that the mobility of South Africa is now baseline so this probably affected the surge too there's an increased mobility of course it can affect it can start a surge so this could be a problem in countries where there's no ongoing delta surge with no vaccination rates it's now in 30 countries including of course United States India and Japan and of course a lot of them are in Europe so that is my presentation for the Omicron in interest of time I'll skip this and now I'm going to change to the updates on clinical management I'll be concentrating on all patient treatment options Dr. Vinadikto later will concentrate on inpatient management so this is the therapeutic management of non-hospitalized adults with COVID-19 according to the United States NIH treatment guidelines and really there's only two recommendations here and so for patients not requiring hospitalization or supplemental oxygen meaning the oxygen saturation is 94% in the setting of emergency room in-person outpatient or telehealth visit the recommendation is to give monoclonal antibodies in patients with mild to moderate COVID-19 again the oxygen saturation is 94% and higher who are high risk of disease progression, not for everybody high risk of disease progression there are three monoclonal antibodies that are available Kasiribimab plus Indevimab which is Regeneron and Satrobimab so three in the Philippines I think you already have Kasiribimab plus Indevimab Regeneron the second recommendation is if they're against the use of dexamethasone or other systemic ucohortipones unless there's another indication for example if there's a severe asthma of course you can use a systemic steroids this are the efficacy of the three monoclonal antibodies in phase three trials or published in New England or medicine and for BAM plus this Indevimab the protection is 70% it's quite good this is protection against severe disease which includes hospitalization or death so it's 2.1% for BAM 7% for placebo so this is highly significant for the Regeneron it's the same 70% it's even higher at 85% now remember this is not the head-to-head trial so I cannot say that this Satrobimab is superior to Regeneron or BAM the only thing to remember here though is this is for Delta variants so for example BAM plus Indevimab would not work against Gamma and get Gamma and Beta variants so preliminary analysis that Regeneron could be affected by Omicron and if it affects Regeneron definitely will affect BAM there's some preliminary analysis for Strobimab that it will not be affected by it will not be affected by Omicron so these are the indications for treatment these are the criteria for identifying high risk individuals used for United States and this is for adults and pediatrics so anyone 65 and above is considered high risk BMI of 25 so that's obesity pregnancy, chronic kidney disease diabetes, immunosuppression cardiovascular disease and chronic lung diseases and these are the rest so this is not for everybody at high risk how about oral medications do we have any drugs that are approved for COVID-19 so right now there is no oral medication that is approved by the FDA in the United States or there's also no oral medication that is recommended by the NIH but there are three promising medications one is Provoxamine which is an existing antidepressant but it's not the popular antidepressant we have the Maldipiravir by MIRV and Paxlavid by Pfizer and in terms of efficacy these are based on phase 3 trials the reduction in severe disease at 28 days, this is only for high risk 32% for Provoxamine 32% so not very impressive but this is a significant difference in terms of deaths there's few deaths but still impressive 12 for placebo, 1 for Provoxamine, 12 versus 1 it's given for 10 days 100 minutes twice a day it should be given within 7 days at once it's actually quite cheap just $4 however NIH is not recommend neither for nor against the Provoxamine but this is based on data before this publication Maldipiravir is a protease polymerase inhibitor by MIRV and initially this is quite disappointing initially it was 50% but when all the data came came out it decreased to 30% almost the same as Provoxamine and barely significant and for deaths is still impressive 9 versus 1 it's given for 5 days 800 milligrams twice a day but it comes in 200 milligrams tablet so that's 4 tablets twice a day it's in 5 days should be given within 5 days at once of course it could be expensive although in the Philippines I think it will be much cheaper then you have PaxLivin which is very impressive 89% protection against severe disease where deaths is 7 versus 0 but remember this is just from a press release and the enrollment is only 70% this can go down or this can go up okay it's given within for 5 days with butanobir which is a booster and it's given within 3 days at once if it's given within 5 days at once it's still effective at 85% now in terms of mechanism of action I mentioned that PaxLivin is a protease inhibitor so it acts it blocks the translation of viral replication machinery and PaxLivin is RNA-dependent RNA polymerase inhibitor so it blocks replication however at high concentrations it's mutagenic against animals so this probably will not be available for pregnant women or for children now PaxLivin is an antidepressant has anti-inflammatory and anti-flight antipregnant effects how about inhaled medications there's no approved inhaled medication for COVID-19 and there's no recommended inhaled medication by NIH but these are two promising inhaled medications one is vedicinide and one is syclasinide so in the phase 3 trial there was a 32% protection for vedicinide almost equivalent to fluvoxamine in terms of deaths 10 vs. 6 low numbers it's very impressive 92% but this is only for hospitalization and this is a secondary endpoint it was not the primary endpoint and there were no deaths there were no deaths in the study duration of treatment 14 days for vedicinide 800 micrograms of VID 14 days of onset and for syclasinide for 30 days 320 micrograms of VID and remember this is not recommended by NIH because this is a recommendation based on data before this publication so that should be it these are the inpatient guidelines but I'll let Dr. Vindicto discuss this but just one comment in terms of efficacy it's quite low 11 to 38% so we really need better antiviral medications thank you okay thank you very much Dr. Franco Felisarta excellent presentations always great to have you with us and I think these clinical updates are so important there are so many doctors who are listening to us right now so I'd just like to thank you for that and we'll have probably hear a little bit more from you during the panel discussion over to Raymond. Thank you Dr. Franco and Dr. Susi very important key takeaways from Dr. Franco that we could delve more into during the panel discussion our next presenter is a practicing pulmonologist and he also serves as the head of the critical care unit management action team at the Philippine General Hospital please welcome again to the webinar Dr. Jubert Benedicto Dr. Jubert thank you very much Raymond for that introduction and Dr. Franco as well so my main task in the next few minutes is to give you an update short of a briefer only as what is happening as far as the change in COVID-19 management specifically in the Philippine landscape and I'm glad Dr. Franco was able to give me a very good context napakaganda ng backdrop na susundan ko so this is just my disclosure and disclaimer I will share with you what my perspective more as a COVID frontliner both connected with Philippine General Hospital and Lang Center of the Philippines so this are COVID referral centers so I would like to start by saying of course that since we are looking at the evolution this was the way we were viewing COVID-19 way back in 2020 so we do know that as what you can see we tend to be driven by the patients symptomatology by their presentation. Back then we do acknowledge that there's that big chunk of being asymptomatic some of them will go to the symptomatic phase, the pneumonia and then what we dread the pneumonia with hypoxia. You can see as well that there was that main dictum to possibly start early especially with the introduction of some medications di ba natandaan po natin the hydroxychloroquine even though it was not really some good traction initially we were we tended to push for it especially way back in 2020 and then subsequently gusto po natin siyang ma-maintain and then there was that lopinavir that was a sort of nagshift yung ating perspective and basically we were anchoring everything based on the patient's presentation which is rightfully so even the our local society for infectious diseases came out with this sort of an algorithmic management so para siyang flow in terms of how to manage patients so basically it is really anchored on the patient's severity of presentation and their severity will subsequently dictate how will they be managed so as you can see even back 2020 there was that consideration for possibly IV remdesivir remember earlier on we started remdesivir more as an investigational drug same goes with tocilizumab and as you can see from this main algorithm there was really we should be securing the consent from the patient before they can be given the drug even let's say if they are indicated and if there are no contraindications so as you can see it's still we still went by in terms of how to monitor these patients we were looking at the respiratory status their hepatic status and then of course their cardiac status as well and then possibly trying to encourage the clinician to see if there are contraindications in terms of giving these drugs if you're going to ask me way back in 2020 maganda ba yung evidence for us to really push and in terms of giving these drugs way back then medyo loose pahuyong evidence but there were signals there even if the studies were not the typical RCTs and in terms of levels of evidence they were not that robust it seems like at that particular point in time if you're the front liner and you're at the crossroads mas magandang ibigay mo nalang siya and then you hope na sana yung paciente dun siya sa percentage na nag-respond so even my society the Philippine College of Chest Physicians came out with this main algorithm considering that we were seeing a big chunk of patients in respiratory failure so you can see again it's anchored on the severity mild moderate severe and then looking at certain prognostic indicator as i mentioned kasama na po sa kinukawa kinukawa na kinukawa sa patients kreya so renal function liver function to see if you can give other medications and then we looked at certain inflammatory markers Respiratory wise in terms of support you can see this main dictum that in terms of safety we put premium safety po ng healthcare workers in order for us to be able to assist these patients with their breathing we are calling on the anesthesia team silapu yung nag-arapid sequence intubation of course they are touted as the experts in terms of airway management mas mabilis nila may intubate yung patient assuring safety for everyone concerned of course having the proper PPE etc and then possibly giving the patients effective lang ventilation strategy as you can see here way back then as you can see there was really that push even for the vitamins may vitamin C, plus zinc and then not to use the nebulizers use inhalers in order to lessen of course the spread of the infection and then manage them accordingly if they have other presentation and so let's shift gears a little bit of 2020 this is the way we are seeing this COVID afflicted individuals yes, we still look at them that maybe they are in the early infections phase where in viral replication is really the dominant process there and therefore mas maganda po ang pickup ng RT-PCR during that time once they are in the pulmonari phase we do anticipate that the viral replication is already at a reduction decreased phase compared to the of course earlier infection phase but subsequently we are seeing that once they are in the pulmonari phase you see all imaging studies going abnormal and then subsequently we do know that if we could not stop the main process way back they will go to this hyper inflammatory phase we really see a lot of organ dysfunction it's not just your pulmonari organ going awry it might be your kidneys, your liver et cetera and therefore we realize the main contribution of what we term as the cytokine storm and therefore later of 2020 we were seeing as what Dr. Franco pointed out earlier the possibility or the potential of other antiviral treatment we were not having success with hydroxychloroquine so we were looking at trying to shift our attention to other antiviral agents based on the concept that really is resting on science so we do know that the virus behave this way and therefore if your lopinavir is not acting optimally we tended to try other antiviral agents which may be acting on the RNA replication phase so do na po, talaga po ang pasok yung remdesivir yes, there were some studies looking at barisitinibir, this is a Jack II inhibitor trying to halt the process earlier on but it seems not to get the proper traction it needs unlike let's say remdesivir and that will possibly give the rationale why is it incorporated in our guidelines subsequently as I've mentioned we did realize that a lot of our patients are dying from cytokine storm ayopunamin mangyari yung being in the ICU we are seeing patients na kahit na mababa na let's say yung kanilang viral load di na nga nag-RTPCR positive yet floridly their imaging gauting yung mga typical ground glass pattern or ground glass opacity we are seeing organ dysfunction viral systems it's not just confined to the lungs and therefore we do realize that maybe other agents may have a rational role in terms of halting the cytokine storm dun po pumasok yung tocilizumab so previously yes it was an agent that was introduced kaso ang alam naman po natin sa Philippines, mahal yan there was a time 2020, mahirap pang makakuan ng tocilizumab and then subsequently there were negative studies about it it's not really improving survival as what we hope to considering of course the cost so nag-diedown po yung use ng tocilizumab tapos lumalabas yung results binalika natin yung tocilizumab because we were saying na oh teka lang mukhang meron siyang protection against death and so we tend to evolve in terms of our management just based on that cycle tinitignan po natin yung rationalin nya in terms of scientific logic and then look at the studies trying to see the proof of the studies behind it if what they should do is actually working and then subsequently going back to the patients nangyari ba talaga to sa patient and therefore as time went by I would like this 2020 study came out late 2020, mga around November to December specifically looking at how COVID is affecting our lungs and so we do know that once patient gets hospitalized majority of the time because they are dysnict because they are hypoxic and therefore we did realize as well if you're going to go by pathophysiology it's not just the direct insult salungs which can account for that presentation it is this edima even the vascular involvement giving rise to micro thrombi et cetera all of these contributes to the patient's symptomatology and therefore as you can see sa diagram below dun po pumasok ngayon yung use of possible antiviral agents earlier on we were looking at anti-inflammatory medications especially if your patient will be needing oxygen already kasama po do yung anticoagulation as well and if it all else fails we do know that hindi po makakatakas yung patient from being intubated PCCP now evolved in terms of its approach in terms of respiratory support for this COVID afflicted individuals so in contrast hindi naman po siya dramatic na change but in contrast to the first algorithm subsequently the algorithm that PCCP came out late 2020 na dun na po yung self-proning for awake cooperative patients we do know that if we're going to intubate the patients earlier on we might be doing more harm than good and therefore ito po yung gusto namin i-maximize and as you can see yes and dun na yung high flow nasal cannula we do realize that there are certain tools available to see if our patient is responding to our non-invasive ventilation strategies if not then definitely the patient is getting intubation so yung earlier on na na uuna yung intubation medyo naging later part na siya in terms of our intervention so in the philippine general hospital subsequently april this year we tried to integrate everything kasing na na observed namin during the surge we could not rely just on infectious disease specialist and pulmonologist doing the management so we were calling other colleagues from other disciplines so let's say nephrologist, cardio, even non-IMs na dun po yung mga surgeon et cetera and then encouraging everyone so that hindi po maging suboptimal standard of care we follow this algorithm so to speak so as you can see we still categorize the patient depending on the severity and that will in a way dictate what will they be receiving so we tried to do this during the surge because in response to that surge we would like our standard of care or standard of management not to be sacrificed so as you can see as well incorporated during this particular algorithm na dun na po yung role na nanto silizu mam the role of let's say remdesivir and then subsequently other interventions like hemo perfusion let me now shift gears a little bit eto na po yung alam natin and this is based on the Philippine consensus leaving recommendations for COVID-19 which was updated just November 15, 2021 so around 2 weeks ago I would like to share this with you of course it's freely downloadable from the site so in terms of remdesivir quite consistently it was still recommended for patients who have an auto saturation its recommendation is against patient who have good oxygenation so if they do not require oxygen supplementation we don't give remdesivir it is recommended to be given on top of on top of dexamethasone for patients who may need auto supplementation in order to maintain an auto saturation of at least 94 and as you can see from this last statement it is against the use of remdesivir in patients who are already on invasive ventilation dito po po mo apasok yung ethics because remember there was a time when remdesivir really was hard to find so we were trying to secure a resource and trying to allot it dun sa most possibly mag-re-respond and so they identified it those who are auto requiring high flow low flow pero kasi once na intubate yung patient it seems like hindi po maganda yung outcome and therefore we were trying to conserve it to those patients having said that I do know that especially during the search we still were able to give it amongst patients who are intubated just bear in mind that they may not necessarily be working as good if the patient is not yet intubated so how about tocilizumab so as you can see medyo gumanda po yung evidence behind tocilizumab so the addition of tocilizumab on top to systemic steroids is recommended for patients showing rapid respiratory deterioration or requiring high flow doses of oxygen that means high flow nasal cannula either the patient being in non-invasive yung bipap or C-PAP or invasive mechanical ventilation and with evidence of increased biomarkers of inflammation so among those patients who will not require oxygen tocilizumab should not be given how about convalescent plasma earlier on kasi po maganda ang studies for convalescent plasma way back 2020 we were seeing good things for convalescent plasma we were giving it let's say who may not necessarily who we can catch let's say between 5 to 10 days of their illness based on their symptoms maganda po yung nakikita namin outcome and so subsequently it was resting on that the logic behind it was rational it was science based and so we were trying it out but right now there are studies of them emanating from Philippine General Hospital to show us or to demonstrate that convalescent plasma did not have any advantage and so if you're going to look at the COVID-19 living document it is against the use of convalescent plasma other things for ivermectin kasi po naghag siya ng headlines di ba yung late 2020 still the living documentation the COVID-19 living document is against the use of ivermectin in all types of severity from mild to moderate, severe to critical even let's say among those patients who were given antibiotics this is just a statement possibly supporting yung sinabi ni Dr. Franco kanina the use of kasi revimab and indevimab sa Philippines po yung ginawani lang brand name so it's the same as redgeron pero na preve and yes it is available for emergency use authorization and if I'm not mistaken even the DOH conducted I think it was a month ago some seminars on how to use this because this will be available in DOH retained hospitals so as you can see based on the evidence as what was shown as well in terms of mild patients especially those who have high risk of developing or developing or progressing to more severe forms the risk factors that were included is an age of more than 50 years, obesity cardiovascular disease, chronic lung disease chronic kidney disease or chronic liver disease or other immunocompromised conditions which means na sabi po ng living documents if you have access to this maganda siya ibigay pag mild pa lang especially if you can get the patients within five days of their symptoms so ito po yung maganda saan ang ibigay sa mga isolation facilities natin dahil mild blank for hospitalized patients the data is not that robust compared to let's say those who are not yet hospitalized as what Dr. Franco mentioned maganda yung effect niya in terms of preventing hospitalization and possibly progress of that COVID-19 from mild there are studies that was put forward as well and forwarded to the FDA in terms of post-exposure prophylaxis ibig sabihin yung pung mga paciente natin na sa household let's say may tatludong nag COVID positive yung isa hindi siya COVID positive your RonaPriv or your KasiriviMab IndeviMab has good studies to show us even among healthcare workers there might be a role in terms of post-exposure prophylaxis les po yung chances niya magkarol ng COVID other thing yung molnopiravir as what was mentioned as of now there's insufficient evidence to recommend the use with COVID-19 infection so this was as of November 8, 2021 that said it's also available in a lot of hospitals right now sa Philippines and I will say that for molnopiravir the main studies in terms of its positive effects is yung sa mga milder forms not for severe and critical so other things systemic corticosteroids basically the same maganda po ang studies ng systemic corticosteroids main steroid type of steroid studied was dexamethasone among those who will require supplemental oxygenation consistently across the board low flow, high flow even let's say invasive mechanical ventilator the patients who are given dexamethasone has an improvement in terms of lessening ICU and mechanical ventilation and they do not do not recommend the use of steroids among those who will not require oxygen supplementation how about anticoagulation well this is relatively an evolving field for COVID there was a time where in ang gusto po natin ibigay full dose anticoagulation hindi lang siya prophylactic but right now the main studies are telling us that na po ang prophylactic dose of anticoagulation so prophylactic over the therapeutic dose among those patients who are hospitalized from moderate, severe to critical and then they recommend only the standard dose prophylactic anticoagulation among hospitalized patients with COVID-19 disease so hindi po siya intermediate hindi po siya therapeutic dose for hemoprefusion since it is ready available especially among COVID referral centers medyo magasos lang po talaga yung cartridge niya as of now there is insufficient evidence on the use of hemoprefusion as of this point in time I know lang center of the Philippines has good experience in terms of hemoprefusion we will be sharing the results of that study that was done locally the signal is there in that if you see patients and you offer them earlier on especially those patients who have increased CRP other biomarkers of inflammation e offer mo to it seems like it has a favorable outcome so right now I flash earlier the one that we are doing in TGH it seems like wala na po do yung fabipera beer and then for the hemoprefusion now to be more selective kasi nga yung cost that is involved so right now for Philippine General Hospital we still restore to hemoprefusion among those who have contra-indication possibly to receiving tocilizumam and other let's say agents possibly we can use this intervention more to really caution the effect of your cytokine storm or hyper-inflammatory syndrome so right now this is the way we are viewing the shifting landscape of COVID management I would say that concepts are still evolving I might not be surprised as what Dr. Franco pointed out with the Omicron introduction baka magbago ng kontin management but we are awaiting more data as of now I think we can really just rest on the evidence behind this intervention I still think vaccines work in terms of preventing the severe disease which is the form that we do not want seems like consistent pa rin po yung performance ng vaccines in terms of preventing that severe disease but we just need to have an attitude that is willing to adapt hindi po kwede tayo maging close minded kasi as what we anticipate maybe what we know right now may change the following day or even next week or even in the next few days and I do think even if we change our mind frame if the systems do not change in order to make adjustment easier it will be hard for the frontliner so I'm talking about hindi lang po sa hospital setting nating na systems maskin sa community I do feel that really the community more in terms of trying to prevent this individual landing in the hospitals and possibly not straining the healthcare utilization at this point in time mas baganda na po yung wala tayong masyado nakikita sa hospital I do think that one hospital command or one hospital network right now yung term nila can do a lot in terms of trying to let's say shepherd these patients if they do need hospitalization to hospitals that can possibly accept them because they have a good compliment of manpower and then of course the equipment that's needed just to make sure that the services that we offer these afflicted individuals will not be sacrificed and will always be of good quality thank you for your attention okay thank you very much Dr.Drewbert may dig to my goodness another excellent presentation and Raymond and I were just texting each other na we were showing the history of how treatment has changed and I really like what you said na we have to be open-minded because the science is changing and that's why this webinar is very important because we have to stay updated yung akala nating okay a couple of months back medyo nagbabago no the virus is also changing I don't know Raymond did you want to say something before we go to the next speaker na we just appreciated the fact that Dr.Drewbert took the time to show the differences of the different flow charts and how it evolved from March 2020 to October 2020 and up to the present time so not a lot will automatically notice those changes they would rather refer to something much more easily consumable but thank you to Dr.Drewbert for that. Sometimes the public feels na ano ba kayo pabago-bago datay sabi nyo okay na yun yung di na okay na but that is the nature of the beast it is we are all doing our best I think to bring the best information to you our frontliners and I think this has really been an excellent presentation just to show you that we do our best but we don't always know what's coming next so kailangan yung attitude natin iba na parang omalipaling ginoan natin baguhin natin na that we're always trying to do better and always trying to serve our people with the best knowledge that we have okay so that's our signal to go to our next speaker who is medical director of the Trong Wah Hospital in Cebu City at the Trong Wah Hospital with more than 600 beds and she's a specialist in obstetrics and gynecology we'd like to welcome the medical director Dr. Jean Abalos Jean welcome to the webinar and please go ahead and share your presentation Thank you so much Susie I stand in awe of our two lecturers for me and I would say that with the information that I got today that will help me really as medical director when Stella invited me to talk about this she mentioned about sharing our data to everyone because we have shared this data basically to OBGYN so I would say that in the next 10 minutes I'll wear a different hat I'm an OBGYN so let me share with you the data that we have for the past close to two years this may not really be this may not really be 100% accurate but it's a very good reflection of what we have because we are dependent on our members who are in the hospital so have been giving us the data in the hospitals nationwide so we have connected 2674 confirmed pregnant patients as you will see here most pregnant patients are young so a lot of them 89% are asymptomatic and mild we had 966 cases in 2020 which practically doubled in 2021, 1708 but I want you to take a look at the pie for severe to critical it also doubled from 4% in 2020 to 8% in 2021 and if you want to look at absolute numbers we had 87 severe and 58 critical in 2021 this mirrors what we see in the general population with an increased number of cases during the surge months you see here April and August and September but this one I want you to look at mortality for 2021 is 5 times higher than 2020 so 85 against 17 and geographical distribution reflects the highly populated areas of the Philippines like for example the National Capital Region Central Visayas Calabarzone Area, Central Luzon and Kagayan Valley if you look at the pregnant patients we did not have anything anyone in the first trimester most will be second and your third trimester take note that preterm births are increased among pregnant women with COVID-19 and their newborn are also more likely to be admitted in the neonatal unit cesarean section rate is higher compared to the general population for heterogenic reasons see 59% there is a bias to intervene the threshold for cesarean is lower than usual because of two reasons number one we want to minimize disease transmission with long labors and also for fatal indication for severe cases that we have so the expert opinion today suggest that delivery should be expedited for patients in active labor so live birth still higher at 61% but nevertheless the 39% fatal death in utero is unacceptably high which parallels the disease severity of the mother no so most babies are negative while a lot have not undergone testing so there is a possibility of vertical transmission but it is in a minority so in our series only four positive this is a very powerful slide that I want you to look at carefully while we know that pregnancy is a risk factor for progression that those who died are basically unvaccinated 88% or just first dose in 2% and that's a good 90% so this brings forward our plea for vaccination as an act of patriotism and an act of love for our fellow men I want to introduce you to prevent Johns Hopkins and the ethics division of the Kennedy looking at guidance for preparedness, research and response like what we're having today in an epidemic and they maintain that the absence of evidence the mere theoretical or even documented risk of fatal harm it's not sufficient to justify denying pregnant individuals access to a vaccine in an outbreak or an epidemic therefore if you look at the principle of health equity during an epidemic the default should be to offer vaccines to pregnant women alongside other affected populations and I'm glad that this is also something that our government is rooting for and also our specialty societies as you will see in this slide therefore I'd like to emphasize again COVID-19 vaccination is recommended pregnant trying to get pregnant breastfeeding or might get pregnant in the future you will see from a lot of studies that pregnancy increases a person's risk of severe illness from COVID-19 therefore in the general OB population we need to modify our pre-nated care without the need telehealth and face-to-face consultation I'm sure that Raymond will be happy to hear about telehealth and we tried to consolidate our laboratories also with our consult schedule so we limit the time that patients have to go and see us in our clinics and of course we advise them to be very vigilant not to get infected as we mentioned because pregnancy is a risk factor now let's take a look at pregnant patients multi-disciplinary approach I think Juba also mentioned this for the general COVID patient and this is more so emphasize and of course labor and delivery hindi naman po eding anulang tayo sa birthing center we really need to be in a tertiary facility that will be capable of monitoring both the mother and the baby what I want to emphasize here is oxygen supplementation less than 95% magbigay na tayo because in pregnancy we need to make sure that we ensure adequate oxygen delivery to the baby and also because of the physiological demands of pregnancy and lastly our two speakers have mentioned the medications that are being used in pregnancy so I'd like to say as a general rule do not withhold potentially effective treatment because of theoretical concerns related to safety in pregnancy I think this mirrors the principle that we mentioned to you about the vaccines earlier but of course we emphasize shared decision making safety as also against the severity of the maternal disease chose a few medications because these are the very popular ones today so remdesivir assuring well tolerated therefore should not be withheld from pregnant patients if it is really indicated I forgot to mention that the management of pregnant patients will be similar to non-pregnant patients the only difference there of course will be the obstetric factors that we need to factor in so corticosteroids as obstetricians we have been using dexamethasone but only on a short course to decrease neonatal complications for patients with threatened preterm delivery this is the famous research of ligands and holy and we know from researches today the potential benefits reduction in your maternal mortality with low risk of fetal adverse effects therefore today even in pregnant patient we follow the recommendations as previously mentioned by our speakers dexamethasone mechanically ventilated requiring supplemental oxygen even if not mechanically ventilated tosi is very popular in sufficient data but we know that they are actively transported across the placenta which may affect the immune responses in utero of the exposed fetus therefore today the recommendation is against the use of tosi suma but of course we have to be open so there is still an area where collaborative decision may be done depending on the risk to the fetus and the present condition of the patient this is the new kid in the block your anti-sars-cov-2 monoclonal antibodies recommended for the treatment to moderate COVID-19 infection and post-exposure prophylaxis for people high risk for progression for severe COVID-19 I think this was illustrated very well early on and I would say that if you look at the list pregnancy is one of those at high risk for progression to severe COVID-19 therefore considerations in pregnancy although we know is expected to cross the placenta we have used other IGG products safely in pregnant people before like for example for your chicken packs so today authorized anti-sars-cov-2 monoclonal antibodies should not be withheld in the setting of pregnancy and the last and I'm very happy that this was also discussed by anti-zombotic therapy in patients with COVID-19 again as obstetricians there are occasions that we already used this no like for our APAS patients for example the risk of thromboembolism is greater in pregnancy than in non-pregnant patients but we don't have reported this is not a reported complication even among women with severe disease American College of OBGYN the SMFM Society of Maternal People Medicine and RPIDSOG VTE prophylaxis can reasonably be considered for hospitalized pregnant women particularly for those who have severe disease and are critically ill so that ends my presentation for the pregnant COVID-19 patient and thank you so much for your attention Thank you very much Let's Dr. Jean Abalos of Chonghua Hospital in Cebu Excellent, another excellent presentation I'm sure for the doctors who are out there you want to go to the replay and see all these different slides and all these presentations because the updates are really excellent Thank you so much for that Jean Okay, so we are now eager to go into the panel discussion but many a chance sa from the PMA and we've got Ted Derbosa with us so we're going to move now into our panel discussion I'd like to ask all of our panelists, our speakers to open their videos and while they're doing that we have a public service announcement from TV UP Wala parayman, kumantam mo na tayo We're looking for tropang tigasin I'm waiting for the prompt Yeah, there we go Malagang, lakad na ito Tigasin ka ba? Syempre Mal mas commander? Mal na mahal Pare, mal mo ba ako? O naman ano Mal mo ba ang tropa? O ba Daran na, ang papakuna na tayo Dahil mahal ko kayo magpapapakuna ako Thank you so much TV UP The Covid Communications Public Service Announcement is one of the many outputs of the UP Research Entitled Communicating Covid-19 in post-quarantine Philippines It's headed by the University of the Philippines Vice President for Public Affairs Dr. Elena Perna and funded by the Department of Science and Technology and the Department of Health through its AHEAD HSPR project We also would like to mention baka pumakaliktan po natin we understand that a lot of you are busy so what we tried to do at the heart of our commitment to provide you with bits of information that's easily consumable is that we have selected presentations that we will feature in its entirety Pinatawad po namin SCD Shorts So if you are madalas po kayo na sa YouTube mayro po mga video shorts po na may kita and hopefully you could watch them in the TV UP channel po sa YouTube if you go to youtube.com forward slash TVUPPH Okay, over to you Dr. Susie Okay, thank you very much So let's start our panel with many a chance I was the President of the Philippine Medical Association and I guess the first question would be how are we doing in terms of clinical management how are we doing in terms of updating our hospitals our practitioners in the field and what else do we need to do so obviously there's so many new things happening wala pa dun yung omicron, pero yung sa current pa lang andaming mga pagbabago So what's your assessment of this Dr. Benny and what do you think we should be doing I'm gonna ask Ted the same question go ahead please Actually the one we are doing is that especially in the children the first ano po ng COVID hindi kasama yung especially in the pill health hindi kasama yung studies of care ng ng children and pregnant women and that's one of our concern kasi dumami na yung dumadami COVID sa bata and sa pregnant and we have suggested sa pill health that they should have assessment of our COVID management even sa adult every six months kasi like this na magkakala ng omicron in case and we do have to update our doctors every every now and then and especially to our FDA kasi yung the use of our to see lusumab is not yet accepted by pill health and madami magamit we are still waiting for the the drug to be included in the national pulmonari to be accepted by pill health it's one of our main reasons and as of now our promise that most of our claims for COVID-19 is not yet given to to the doctors and we have lots of problem like now that different in the vaccine man we don't have the vaccine yet for our children below 11 ay we do hope that siguro begin na ng FDA ng emergency use for the 5 to 11 years old life in the other country the US and Europe areas and we need to be beached lang and update our country our country man especially that we have now level 2 ang damig pangpunta sa malls ang damig ano po how can we sustain ay ang isip ng mga tao naglaksang ating health restrictions and especially the mobility of our people around the world and we do hope that ang once na merong news na we must trace the important in this COVID is the tracing parin although we have a low case of COVID now we don't want our people to be complacent Thank you very much doctor I don't want to put you on the spot but you're definitely you're on the board of field health so you don't have to announce that well the board is different from the executive and I will comment on that also but first the question really of what I thought about all these presentations our excellent speakers on the management of COVID-19 updates remember Susie when we started this what was our issue our issue Susie when we started stop COVID death was there was confusion out there on what protocols work and what didn't work there was a lot and we implemented this program which was a housing success and I heard you're now nominated for Gawad Pangulo congratulations but I think the viewership that we have here is a tribute to the fact that people are searching for answers now the problem is we've come to approach this I'm a disaster medicine expert and I live in chaos I mean that I thrive in chaos the problem is a lot of my colleagues in medicine in clinical medicine can't do that because they need to have the standards they need to work with evidence and the policies and that's the hard part the level of ambition is wrong the level of ambition we created for our clinician is the same level of ambition we wanted for our non-COVID era which is you know you have H staff you have evidence based medicine randomized clinical trials when will you get that you have a new variant that comes in you have a new virus that's here you won't get that so I think people should learn how to work in the way we do in emergency medicine we lower the level of ambition and we go out and try no will you be able to standardize no it is going to be a judgment call and if you ask me if I'm going to be treated by Juber I'll ask him use your best judgment of what you're going to use to me based on my clinical status and I think may you pay a doctor his professional expertise I don't want to be treated by a protocol I don't want to be treated by a standard procedure I want my doctor to think about my problem my clinical problem look at the research evidence that's out there and tell me I think this is best for you and I'm going to agree as a patient I will agree Juber that's the right way to do it handle me with that type of therapy or a drug so it seems that we can see it's like a pendulum the knowledge is swinging back and forth this drug works then this drug doesn't work this drug but actually over the past two years I've been observing it it's like a helical spiral we're moving up we're creating more knowledge and we're able to have more confidence and this is proven by the case mortality rates at PGH at the rest of the country so I think we need to put our level of ambition to a lower level because it's a new variant and not expect that all these RCTs will come to us even our government regulators have suffered from the same problem like criticize say the H-TAC for do trying to implement strictly to wait for it but you can't wait for that when you're handling a critically ill patient right in front of you with Omicron right? for example so I think I think I need to have my emergency medicine principles taught to a lot of clinicians who actually work out so we talk about lowering your level of ambition moving your resources to where it's available so I saw the checklist of you were that's the correct thing to do start thinking about my resources that I need if there is a COVID search what are the drugs that is available to me because we talk about all these new drugs not all of them are even available in the Philippines so sometimes people get confused patients get confused because they're reading they're coming to us asking us doctors give me this and then they come to me in the NTF doctors ang mga kakakuha ng ganito ng tocilisumadur and the severe when in fact when I'm looking at how they're using it it was against the principles that Jubert was presenting they're giving it to even dying patients so parang I think a lot more important should be put on educating our clinicians based on our experts I'm very happy that our experts here really share their experience and knowledge and that's my statement on that now on the fill health side on the fill health side there's also a big problem in how we reimburse COVID-19 and there was a promise to actually pay everything but it also created many things because when you start to tweak health financing or health payment schemes you start to change behavior so not all but some hospitals I heard about it when I still wasn't in fill health up casing their cases fraud talking to patients who had patients that died and that you just agree we will put it as COVID and you won't be have to pay anything in the hospital so these things I've heard and that's the reason why fill health behaves as it is and doesn't want to pay immediately so I think I think there's a lot of work to be done on the reimbursement side I think that's why we're confusing the lawyers at fill health about all these clinical protocols because we have so much scientific voodoo that they cannot explain so I think we need to fix that as doctors we need to simplify how to treat a new variant how to treat COVID and give them the simplest and then hope that that is agreeable to almost all majority I know for the clinicians talagang may ko kontra dyan gusto ko gumamit ng ivermectin gusto ko gumamit ng but at least we will have some level of consensus and that way ano lang yan ay parang consensus building maybe more of consensus building so that we can spread all this great new protocols for treatment yan lang susi, thank you very much sorry na grant thank you Ted I think both the three of them Robert Jean and Franco all alluded to what I would call the art of medicine yes, yes yes, you have protocols you have you have some standards but you always and Jean talked about discussing with the patient and making sure if you're using something na sinasabing wag gamitin pwede mo rin gamitin ay kung tingin mo na so I think the problem really is that our patients go to the doctor and say si Kapit Bahay gumamit ng remdesivir begin mo rin di ba parang korak gina jubin na nangyari so Jean you want to speak to that Jean first of all I want to thank Ted because I know now that for pregnant patients it's already free fill health because of fill health as far as the testing is concerned because we're very very particular about our pregnant patients coming in tested na man ng condition when you're in the delivery room na so the high rate of aerosolization et cetera so very important for us and then yes to see I agree with you not everything can be put in a box always the family the patient should be part of our decision making like if you have a very critical patient who you believe will really respond to your steroids then why not even if there is a baby inside and I believe that I also took a look at the ethics part is why I presented the group of Johns Hopkins because they look at the principle of equity I think you and I will agree that as far as research is concerned nakakalimutan ng pregnant or maybe hindi nakakalimutan it's more of we are afraid of the pregnancy of the pregnant patient but now they're saying we should include them especially if scientifically we have data that these medications may have evidence of safety like in animal studies or from previous indications no so we are not robots we need to assess as we go along that's why I also like the last slide by Juber we need to adapt we need to listen always because how can we adapt if you do not know what's happening especially with a novel virus like this is so that's it thank you Juber magami bang pacienting atyaka mga family na dumidikta kailangan ganito dog ganito bibigayin nyo one of the things that that we had to learn pero I'm sure not all doctors are doing is really taking time to talk to the patient and their relatives remember this is a pandemic especially during the surge ang hirap po kung mausap sa mga relatives via viber lang telehealth kasi wala talagang personal connection unlike before na nandun lahat tapos dun tanda nyo surge siya let's say 20-30 patients sa ICU tapos after mo matignan gusto mo mag family conference ideally kada isa para masabi mo so you can share with them what do you think the status of the patient is and what do you think you need to do at this point and set then their expectations so I think that was the main challenge right now tamamam kayo susi sa PGH lang po there was a time na let's say kumonti na lang yung tocilizumab let's say sa pharmacy so we now wire na kami ng pharmacy doc wala na po tocilizumab sa Pilipina sa 10 bayan na lang po yun nandito sa amin so consciously we were really trying to yun ang masamaman pakinggan we were trying to allot the resource dun sa talagang makikinabang so makakadinig po kami ng ganun doc ang alam po namin kayo daw nagdidikta kung sino daw ako kuhanan tocilizumab so pwede po ba yung para po sa akin just in case ma-hospital ako wala naman po ako hindi ako na hospital bigay nyo na lang sa asawa ko na na sa IC yung ngayon so may ganun panghirit so itwa I will say that as doctors parang unchartered territory yun we were doing some things the science behind it pero tama si dr. Ted in saying na napat yung art nang jen pa rin napat madiskas mo sa patient here you are trying to tell the patient alam nyo po yung tocilizumab hindi po mag-work sa asawa nyo at this point in time to sa sabihin niya ano na lang po doc mag-work wala na po nabigay na po natin lahat let's say so in some instances I just allow let's say the patients yung relatives ng patient in full PPE naman sila tapos I'm there at the bedside just to hold there the relatives hand tapos yun po siguro yung parang mag-accept na sila at that particular point in time they will accept na wala ka ng maibigay or as what dr. Ted mentioned hindi naman na talaga available dito sa Pilipinas so kahit nababasa mo sa internet parang hindi practical na ibigay pa natin at this point in time so humbling po yung experience na yun so I will say na dati siguro sanay tayo especially even during the COVID nung wala pang surge alam natin yung gagawin protocolize yung approach but then again you will be humbled by the experiences na hindi mo alam lahat tapos sometimes the patient will be the one the relatives of the patient will be the one to dictate to you in a way ano po yung sa tingin yung maganda but you really just have to you know take a deep breath and then balance out everything kasi at then of the day as what the other panelists have mentioned aniyan eh you are trying to personalize your approach it's based on science but it should be tempered to a huge extent of course by the art behind it Thank you, Drewbert Franco if you compare how doctors pick up on updates in clinical management in the US compared to the Philippines what would your observations be? Well, we're fortunate now we have in the CDC so they're very aggressive in educating the at least the healthcare workers so and you know we're fortunate that we have more choices for example let's say toshilusimab we actually don't have toshilusimab right now in the United States so we're not using toshilusimab but fortunately we have barisitidin so we have another medication that we can use so it's very hard to compare United States and the Philippines just because we have more resources and more choices but if you think about it as a whole as a worldwide we're fortunate that we have three cheap products that work right? Vaccines masks and dexamethasone I mean you know steroids those are all cheap so we are very very fortunate that we have this armamentarian against COVID otherwise it would it would have been a disaster Yeah, I mean you mentioned the CDC and I think we have a question from the audience but I just wanted to to comment a little on that no, parang end of the day in the United States the CDC is like super important right sis you know this is the way the treatment should be and should not be which I think unfortunately we don't have in the Philippines am I Raymond am I saying that out of turn or dead is that correct? That's correct hopefully we could have one soon but not yet now parang ano and now when it came to the to the standards of care the protocols and the treatment we've left it mainly to to what to the what is it then I mean That's correct what we did but we had silos and if it's a trauma case they asked trauma surgeons to make the protocols for cardiology they asked the cardiology but we never had national guidelines just like for example nice in the in UK for the NHS or CDC in the US and we tried to implement that now but we cannot come to par because our is infantile is neonatal our birth of the H-stack and all this stuff and it it was created at at a wrong time when we had a pandemic so I think we should have stuck with our protocols created our system based on what we had which is societies actually creating and giving their their collective consensus dialogues and then letting the government and the regulators listen to that ang hirap na ang kasi ang nangyari ang conflict and we are a birthing in universal healthcare law with the H-stack policies and the and the new FDA laws and everything so so medyo it came at a bad time it hit us at a bad time and of course we didn't invest I think the real bottom line and the bottom dweller here is that we never invested in healthcare for the many decades and we've suffered because of that in the this COVID pandemic din lang susi yeah thank you very much okay I think we have a question from the audience Raymond you want to take it Yes we have one who has joined us actually in the panel I think Mr. Camilo Nogoy has a question and it's one of the more upvoted questions go ahead Good afternoon to everyone my question is about virology I'm a non-medical person but I've read in some books that viruses usually mutate to be weaker so it won't kill the hosts so what are the chances that this Omicron variant goes in that direction that its mutation is towards becoming weaker and turning this COVID pandemic into an endemic one I can answer that Oh Franco Go ahead Dr. Franco as to the idea So this is the problem the overall infection mortality rate of COVID is actually not very high it's not like Ebola or smallpox the overall infection mortality rate it depends on the median age of the country it's from 0.5 to 1.5% so overall about 1% so that's actually compared to other pandemics is lower so you cannot use that what you call this concept with COVID COVID can still go up it can still go up in mortality and it won't affect the transmission so that's the problem COVID started low and actually sometimes that's the problem when you have a significant but low mortality a lot of people will gamble with that risk let's say which was Ebola 10-20% all of them probably listen right away but with the 1% and there's a big difference still with age for example if it's a 90-year-old the chance of dying is 10% versus like a 20-year-old which is 0.01% that's a 1,000 full difference so people with a lower mortality will gamble on this and their behavior will change so it actually increases the risk of transmission so you know the problem with May I add to this may I add to the comment because from a public health perspective even if the virus has a lower mortality if it's highly transmissible you'll have more problems look at measles measles has a reproductive number of about 16 and we have deaths of measles and during my time when I was a yard doctor we had seasons like during the cold season children were dying of post measles pneumonia but it wasn't it doesn't kill that high but if you have so many that are infected the explanation of Franco actually works out because ang daming na mamatay na bata ganun din yung sa influenza when there's now influenza system all these elderly start to die so it's not true that you want this virus to be more transmissible and less fatal because in the end they both will kill huge numbers as well and the stress hospital also so a highly transmissible bug will overload the health system and the Philippines doesn't have a great health system we've got a lot of infrastructure gap and health human resource gap so a highly transmissible virus that enters here will decimate the system look at what happened in India so that's why when people say the Philippines is too strict with its quarantine laws and its public health measures we were protecting the health system because if it collapses more people that shouldn't die will actually die so so hindi rin ganoon sinili nagtanong hindi rin ganoon kasi simple yun na you just want the virus to mutate to more transmissible and less mortality because you might end up with more problems as what Franpa said thank you well again the epidemiologic triad which is the agent host and environment so even if you're agent weekends if your hosts are in this case we've seen that comorbidities hypertension diabetes whatever it is can create severe disease so that's only one factor so the virus is only one factor the other factor is the environment because in the Philippines one out of six people lives in a slum with multi-generational household na mga kasama matatanda bata et cetera so we have to really look at the three the triad the agent the host and the environment in order to understand how you're going to to control it and that is correct yeah we have put in very strict measures precisely because we have environments that are what should I say conducive to infection not only covid but tuberculosis dengue et cetera plus we have a huge high risk population one out of four Filipinos is hypertensive so ano ay parang yeah so I think the virus the virus is just one part of the equation but I think it's a great question because we all want it to be we all want it to be like a common cold we want it to be Raymond did you have another another go ahead this is not just this is not just theoretical so remember from the ancestral virus you have alpha and alpha is 50% more transmissible but there's some data that's actually more severe and then from alpha to delta it's 50% more transmissible there's actually data that is actually more severe so it's more transmissible and more severe so every time it mutates it's actually worse so this is not even theoretical it's still it can go to both directions so Franco are we saying that we don't know this is the problem we don't know what this is going to look like in terms of severity right now we don't know we don't know that the problem is we have anecdotes where there's anecdotes that the symptoms are milder but there's anecdotes too that younger patients less than four years old are actually more effective so I think we probably need another week or two and we'll see the hospitalization rates so the cases will go up and we'll see if the hospitalization rates go up too and of course the problem is it will take about two weeks so we'll see from the hospitalization rate so if it goes up too that could be that could be a problem and you've talked about this before the decoupling of the number of cases versus the number of deaths of severe cases okay unfortunately we are out of time and we are going to ask you now to we're going to ask you to compose your last few words to our audience it's been a great webinar I think everyone learned a lot and Raymond's going to launch our evaluation form which I hope will work this time so last time nakita ko sa chat na kaya naglalagay ng evaluation so go ahead please Raymond thank you so much so as we give a few minutes to our panelists to gather their thoughts for their final messages in front of your screens are the questions as the form part of our evaluation poll as mentioned wala po kami nilalabas na iba pa po ang evaluation poll ito na po yun so hopefully those who are more than 800 attendees in our webinar are able to participate in this evaluation poll po the five questions that we have are as follows the panelists demonstrated thorough knowledge of the topic and as mentioned in previous webinars it's a four point placard scale strongly agree, agree, disagree and strongly disagree second question panelists were well prepared to organize third question panelists spoke clearly number four panelists used appropriate language with technical medical jargos adequately explained and number five the panelists contributed to new perspectives and knowledge on managing virus keek COVID-19 health issues we will not be closing this evaluation poll and I'm very hopeful that it won't be closing pretty much early anytime soon now but before we ask our panelists we'd just like to show to everyone who is asking whether in Facebook messenger or sa email po that only those who have attended at least 50% of the webinar duration they will be the ones who will be receiving ang ating certificates of attendance ito po, ang example ng ating certificate of attendance we made it a little bit more the holiday spirit with the holiday spirit already to match the theme and hopefully that's something that we'll be able to cheer everyone up pa rin po those who are asking we have already distributed all 80 certificates for all 80 webinars after this one we will be looking at our databases also so if you feel that you should have received or have any problems please continue to follow up and let us know we receive a lot of emails with regards to names et cetera we thank you for your patience and hopefully that's something that we can rectify maraming salamat po and we go to Dr. Suzie for the final messages from our panelists so Ted has to leave so he takes the first crack at the closing remark go ahead then thank you Suzie for giving me a crack at the first step let me just meet the other one okay so I think I'd like to thank you for doing this particular topic on Omicron like the beginning when we started this we back last year there was a lot of uncertainty and today with the threat of Omicron it's still a lot of uncertainties again whether the vaccines will work whether it be more transmissible and we've got to learn to live better and work better in levels of uncertainty so I'm really espousing for a change in paradigm of a lot of our clinicians and our healthcare professionals because we need to change our level of ambition we need to look at the resources that we need to handle we need to learn how to triage and really I think that was a lot of difficulty of our critical care people because they're used to throwing the book at our critically ill patients and then they were put to conditions wherein they would choose which one gets the ventilator which patient gets the last vial of Tosilisawa and that's unnerving for them we do that every day in the ER because we have to choose who gets to be admitted in the ICU and we choose which ones are survivable so we have to look at changing the level of ambition looking at survivability as well and we need to invest in the system I think we all need to work together I think the four C's of disaster medicine continue to apply communication, cooperation collaboration and coordination so until all of us in the different specialties really coordinate and work together we should be able to beat this and we're succeeding actually the Philippines is succeeding we've been getting very low rates of new cases and I really appreciate the work everyone has put in and I congratulate the PGH people Chongwa all those people even our colleagues our Kababayans who give us information from abroad first hand new information about how they're doing stuff because we learn from them as well so thank you Franco for sharing a lot of information that's mostly new and not yet known to everyone so thank you also to Susie and also Raymond and the team for doing this I think your success is really the fact that you have a following already and that you continue to provide good knowledge and a good platform for communication against COVID-19 thank you and good afternoon everyone thank you very much is Dr. Teder Boss special advisor to the National Task Force alright let's go to Dr. Benny Achenza who is the president of the Philippine Medical Association Benny over to you yes again thank you for this privilege and it's a great time for us the Philippine Medical Association again to be part of this webinar at khamalimit kami maging guest excuse me again as WMA said we must protect ourselves as doctors before we treat others because during the first second and third search of COVID-19 maraming ko tayo na walang kababayan and we must again go to the first line of our defense we must use our mask PPEs again and during the search in our katanduanas and batanas we gave PPE kasi ang unang protection na mga doctors in batanas in katanduanas and as as like said we must do our part everyone this is a community effort this is a PPP private public partnership must prevail like our bayanihan sabakunahan and we saw that pag kumilos po ang lahat ibinda community kikilos lahat and we always remind our audience our community not to be complacent this time in na jen po ang ano ng COVID ng ano pa natin or micron and we don't know kung makakaputyan here in Manila or other parts of the country samantalahing po natin ang geographical area ng Pilipinas we are islands po and napat na ano po natin ang mobility this is one important kaya po nagsurge ng COVID natin hindi po tayo nagsasabi ng ating travel history kung san tayo ng galing and the symptoms this one way we can protect each other po maging tapat po tayo sa bawat isa sating even lahat po and during this time na jen ang threat of the Omicron and we don't have any vaccine yet allowed for the 11 to 11 below years old and we know that the more batap po ating bagumbarian let's be bechilan and protect our children even our vulnerable member of our community the immunocompromise our senior citizens and all of our members in the family po thank you po thank you very much it's Dr. Benia Chan sa president of the Philippine Medical Association let's go to Dr. Jean Abalos medical director of Truong Wah Hospital in Sebu City Jean go ahead thank you Suzie I think we know a little more this year compared to last year but what's happening today is telling us that there are a lot of things that we still do not know so as medical doctors we really need to be on top of the problem for us to better serve our patients as medical director I would say that I'm lucky that I have good infectious disease specialist and pulmonary physicians however one of the things that I'd like to to say now is how can we really manage a lot of severe critical patients if we are already overloaded so number one I'd like to again say that we need to ramp up our vaccination program upma sebu we are looking into vaccine hesitancy and we go to huge companies to be able to convert their employees those who do not like to be vaccinated and somehow I think we're quite successful and I'm thankful to Ted for their vaccination program number two I think we still need to educate not only our patients but also our clinicians out there ang hirap hirap pagka you have more than 100 waiting patients and some of them are severe to critical as mentioned sometimes there is only so much that we can do so we need to do this together all sectors together thank you Susie ok thank you very much doctor jeena abalos ang trauma medical center ok let's go to jubart jubart benedicto ahead of the critical care unit of the philippine general hospital jubart community yes thank you so ang masasabi ko lang siguro is amidst all this fear there's that always influx of medical knowledge but I think we need to have some order for us to get the proper things from this influx of knowledge so I think we need a systems approach more in order to really combat this COVID and hopefully we should not have parochial perspectives already and let's all be open to dialogues that's all thank you thank you very much jubart benedicto CCU of philippine general hospital ok and dr. franco felisarta who's almost like our in-house usb specialist franco obrity yes sir now with the advent of omicron remember we still have good strategies that we can use against it to prevent transmission we still have masks it still works we actually have a randomized trial showing it works the latest method analysis shows that it might be even better than social distancing the only thing is it has to be well treated or you can do double masks it will prevent transmission number two is even if the variance decreases the efficacy of vaccines against infections it's still the vaccine still has great great protection against severe disease hospitalizations and deaths and third with regards to waning there's some data that there's waning for protections against severe disease in the elderly 65 and above so it's very important for the elderly to get their boosters so masking vaccination and for the elderly if it's available get the boosters I think those three strategies will work against omicron thank you thank you very much dr. franco felisarta infectious disease specialist before we go to our closing remarks raymond do you want to summarize the outcome of the evaluation thank you dr. susie so okay there we go can we share the okay so we have 638 respondents which is relatively high compared to our last month and a half webinars and most of them 95% 95% 94% also on average 95% indicated that they strongly agreed with all the questions as stated here very very consistent with our previous webinars as mentioned we always aim to provide quality content and strive to an endeavor to make sure that all of the information that we provide you is credible and that's something and that's the reason that we try to get experts to form part of our speakers for each webinar so thank you very much for your support it's not only for those who are here on zoom but also for those who are watching on tv up channel on youtube and facebook where we are live streamed on tv up university of filipines and stop covid over to you dr. susie welcome to our closing remarks and we'd like to call on the deputy director marie legaspi who's going to give our summary Stella over to you oh you know wala yata sas Stella thank you for this opportunity to do the closing remarks it has been a very enlightening lecture webinar and i really appreciate dr. franco every time he speaks talaga i want to be here to be present and it's what he said about the omicronis because he came from the us and he's quoting cbc they think that it might be more transmissible but as he said we have to wait for more data and he said monoclonal antibodies for mild to moderate illness for non-hospitalized patients so the indication for this is when the patient is high risk and as an OB pregnancy is considered a high risk condition so the elderly the immunocompromised and those with malignancies are considered high risk and he mentioned about oral meds and the efficacy so here in the Philippines we were all very excited about molupiro beer but in his lecture he presented the efficacy flu box samin 32% so paxlo did ang 89% so we'll wait for that dr. franco dr. benedicto juberth presented the management of covid from the start he was already part of the covid crisis management team he presented that 2020 up to the present he mentioned remdesibir and dexamethasone still being used here although in the states in his presentation dr. Felicarta said they are not so much with remdesibir also tocilisumab but here in the Philippines we still use tocilisumab and systemic steroids especially in patients who are deteriorating rapidly deterioration juberth said no to convalesan plasma no to ivermectin he mentioned that in non-hospitalized mild patients we can give kasi ribimab indebimab and these are given to mild with at least one risk factor molupiro beer he said has insufficient evidence as of now and dexamethasone in patients who require oxygen supplementation he also mentioned about the prophylaxis of anticoagulance and here in PGH we still do hemopurfusion although there is insufficient evidence on its use but parang last ditch effort pa namin yung dito yung hemopurfusion so our renal unit is really very busy with dr. Jean Abalo my co-OB also a member of the PIDSOL she emphasized that vaccination is really important in pregnant women and when she cited the data that we have in our society the mortality for fully vaccinated pregnant women is zero with one vaccine received one dose of the vaccine the mortality is 2, the unvaccinated the mortality is 75 75 pregnant women died so i think that's a very shopping piece of information and i think all pregnant women should be vaccinated really so ang sinasabi ng society namin beyond 40 weeks but it says that if there's a caveat if the patient is a high risk high risk pregnant woman for example a health care worker high risk job she should be vaccinated because the benefit outweighs the risk na mention dini Jean yung principle of health equity yung pregnancy increases the person's risk the pregnant person's risk of severe COVID she mentioned about the multidisciplinary approach and being admitted to a tertiary facility again she said the pregnancy should not be with health in a pregnant patient especially if it's indicated and dexamethasone it's used it decreases maternal mortality and the risk decreases the risk of adverse fetal events again pausilisumab if the benefit outweighs the risk and VTE should be considered in all our pregnant women I think for today we had a very good set of speakers and thank you to all of you to your time Dr. Beni Atienza who's always very willing to help us in our TV UP hindi pa niya na potin ang dihan kahit minsan thank you sir all to you truthfully okay thank you very much it's Dr. Stella Ligaspi Jose who's the deputy director thank you to all our panelists it's been a great webinar great having all of you here next week we have a very interesting topic we are going to talk about Raymond tulungan mo na ako dito parang ang topic natin ano eh will we ever control COVID-19 yan ang hirap na topic that's why we got an expert to lead the discussion for next week so we are very privileged to have her hindi mo nipo siya kilala pero she will be joined by three reactors from the younger generation one a medical anthropologist two a representative hopefully from the Department of Health and number three someone who's working in the public health front lines and used to be affiliated with MSF or Medicine Sun Frontier and it will be really an interesting topic just because when we were trying to schedule this the new Omicron variant was still not yet around and we wanted to be able to cover several different aspects from a public health perspective and this was one of the more challenging topics and we wanted it to be our last webinar for the year which brings me to the point next week na po ang ating huling webinar for the year 2021 we will be going on a brief hiatus and we will be coming back in mid-January hopefully hindi po kayong magulak na wala po kaming webinar towards the end of December and the first part of January we hope to be able to bring you with the latest and up-to-date information through our webinar kailig and something that we hope everyone will be able to encourage their families, relatives and co-workers to join our credible online community so ang speaker po natin ay walang iba kundi ang aking partner si Dr. Susie Pinedo-Mercano she will be tackling different aspects of the public health field so ano po ba ang pandemic, epidemic, endemic ano po ba ang kailangan ating malaman patungkol sa Omicron Barn hopefully there will be more information in a weeks time the different well terminologies we keep on hearing herd immunity is it still within our reach is it really a realistic goal for us this topics will be covered hopefully next week by our excellent panelists for next week Dr. Susie, did you want to add anything? Paka sa ka-announce mo Raymond wala na dumating next week I'll do my best guys it's a difficult topic we'll be able to control COVID-19 it's a very difficult topic but I will rise to the challenge and I'll do my best so I'll see you next Friday before we conclude our program well let's first acknowledge the following these are the men women who are working very hard behind the scenes to make this learning series possible without each and every one of you hindi po talaga tayo magkakaron ng online credible online community for the stop COVID-19 webinar series so marami-marami sa lahat po sa lahat and finally webinars for viewing you can watch it at the playback at the YouTube channel it includes all webinars from webinar one na kimilapot tayo na April to webinar 80 which was last week right after this webinar we will also be archiving this webinar so that you'll be able to watch it I'm sure there are those who are really hankering to be able to watch it again and for those who were who were not able to join us today hopefully you'll be able to watch it over the week and sometime before our next webinar so this formally closes our webinar for this week and sana po ay makita kita po tayo ulit same time same channel from Friday 12 noon to 2pm it's a day together we can stop COVID deaths so keep safe, keep healthy and see you online we are at the end of the mass i look into myself at mass do i have strength to carry on my god our lord when this go on i need you here to keep me strong i'm here to hold the line until my main to read is hold on to the world this time we'll come to pass cause this salvation makes a last you carry you to see the other's pain before my fears the other's lies before my tears but right behind the mass i look into myself at mass do i have strength to carry on my god our lord when this go on i need you here to hold the line until my main to read is hold on to the world this time we'll come to pass before my tears but right behind the mass i look into myself at mass do i have strength to carry on my god our lord when this go on i need you here to hold the line until my pain