 Okay, good morning, good afternoon, good evening nasaaman po kayo ng parten ng mundo. Maraming-maraming salamat po sa pag-attend at pag-join po ninyo sa aming number 64, webinar number 64 or the 64th installment of the Stop COVID-19 Webinar Series. It also marks the start of our Season 6. So maraming na rin po tayong napakusapan na pag-naanat, maraming-maraming salamat po at masaya rin po kami that you continue to join us during this learning journey towards learning more about the management and the treatment and all things related to COVID-19. We now have a credible online community and we hope that our community grows each and every webinar that we hold. So for the past few weeks po, medyo tagulan po tayo, maraming po mga ibat-ibang mga lugar sa atin mga binabaha, we have seen the photos of those who have been lining up para po mabakunahan at kahit po medyo binabaha po ay talaga po masugid pa rin po ang kanilang pag-seek out na sila po ay mabakunahan. So we'll talk about all of those things today, especially the effects po of the torrential rains that result in flooding and also how it affects the potential evacuation of maybe hundreds or even thousands of people po from low-lying areas. So we will compare that against the backdrop of this highly transmissible variant of COVID-19. Maraming-maraming ibang aspeto pa po and complex threats that the health sector needs attention and one of them is as you could have guessed, is leptospirosis. I'm Dr. Raymond Francis Sarmiento, director of the National Telehealth Center, National Institutes of Health University of the Philippines, Manila. Today, we also, is marami rin po tayong ibat-ibang experts. I know you have seen the different posters and the different social media posts and we hope you will continue to join us all the way through the end of this webinar. For those who are in the Zoom Party spot, please, and ninyahan niyo rin po na mag-aten ang inyakibapaponin yung mag-anak, kaibigan, mga katrabaho. But before we move on, let me introduce, I'm very, very happy, alam niyo naman po every Friday, that I get to share hosting duties with my partner and really our adjunct research faculty from the National Telehealth Center. She's also the special envoy of the president for Global Health Initiatives, Dr. Susie Pineda Mercado. Dr. Susie. Hi Raymond, good afternoon. Bagan bang hapon pusingan lahat. We are seeing so many people watching from all over the country, Mindanao, andami Raymond, First National Capital Region, our Metro Manila Hospitals, Kirino, Rizal, Amang Rodriguez. Welcome pusingan lahat and as we continue, we're going to acknowledge those who are participating with us today and Raymond has described our topic we will be talking about. The risk for leptospirosis during a season where it's flooded, pero alam niyo, Pilipinas kasi we're one of the most disaster prone countries in the whole world. So, di naman tumitigil yung disaster dahil may COVID, di ba? So, kailangan nag-iingat talaga tayong lahat. But to get the context at pangunawa ng pangkaraneewan tao o sa tapik natin na COVID na lepto pa, and dito po ang ating person on the street na ginawa po ng TV. So, ay mapapagbako na ka din despite of having problems kailangan nagbaha may leptospirosis. Kasi yung vaccination kayo ay important. Kuna meron tayong bagong variant kayo na na conti-ulting numalaking, nag-pag-epriss yung number sa ating community. So, kapabakuna pa rin ako because yung leptospirosis care could be prevented by using boots or wearing boots. And I think it should not be the burden of the people para mabili kung ano yung ukunahin nila o kung ano yung iiwasa nilang sakit. Kahit napo umuulan, kahit napo may bantapa rin po ng leptospirosis, tutulay pa rin po ako para magpabakuna laban sa COVID-19 para ma-protection po ako. Yes po, for me kasi yung leptospirosis mas kaya siyang ipeverit ay prevent compared sa COVID-19 na airborne talaga. May takot di naman po at the same time pero kung gusto mo po talaga magpabakupo na habang muulan kung willing talaga o para lang po ma-lesin yung matamaan ng COVID po. Nagakarung po ng leptospirosis kapag po ang isang tao po ay lumulublub po sa tubig na meron po, contaminated po ng ihe ng daga. Tapag kakaalam ko kasi yung leptospirosis para po mapasyok siya pan may suga ka somewhere na puen pasukan. Siguro yung pagsusoot ng protective gears, like pagbota. I think in the grander scheme of things, kailangan po ang ayusi ng sewage system kung hindi natin yung ayusi ang patulipa rin babaha. Dapat po maging malinis po yung pamainan natin para at least po kahit na bumaha wala pung daga na mamamahay. Kailangan ng information dissemination sa bangata o how to avoid leptospirosis and kung makakukuhaman where to go, what to do. Kung talagang gusto mo may paraan, kung ayaw mo may dahilan. So tingin ko kailangan kung maging yung mga tao o kailangan dila ang isipin yung safety and security ng lahat sa bahar, pero kailangan pa rin po magbabaksin. For me, sa tini-kilos po ng government is matatagalan talaga siya. Although siguro matagal, pero we can handle naman po siguro kaya mabaga lang. Ang yun na po, slowly but surely po as long as na meron po ang mga taong tumutulong and willing tumulong po sa kung ano po meron tayo. Okay, we've got a great lineup of speakers for you today. Thank you TVUP. Magandang nakikita natin kontexto anong inisip ng mga kababayan natin. Maganda po ang ating pagusapan meron po tayong mga dalubasa. We have experts today and I think we're all going to learn from this. Now for today, we're bringing back the Mentimeter. So I know some of you really like to use the Mentimeter. So ito po ang Mentimeter natin. www.menti.com and use the code 9307-3652. So especially for those who are watching on Facebook or YouTube, you can join our fun quiz natin. So 9307-3652. Okay, over to you Raymond. Thank you Dr. Suzie for those po na who are wondering again and also for those who are participating for the very first time in our webinar. Whatever questions that will be posted in the zoom poll is the exactly the same two questions that you will be seeing in Mentimeter. We have the Mentimeter so we have po a way to engage those who are watching in the livestream po in the Facebook pages of UP, Stop COVID Dets and TVUP as well as those in the YouTube channel po of TVUP. Okay. So we're trying to wait for Dr. Tag but I think he might be taking care of some other business. So for today, we will be tackling a very, very important question po as it relates to the flooding. So the Department of Health, DOH has given warnings po to the public on possible increase in the number of cases, especially ngayong po mga tagbaha, tagolan, tagbaha. There are those diseases that just because COVID-19 has been top of mind for all of us for the past 500 plus days na po if I'm not mistaken. I think it's 520 something. That's sort of neglected po but very, very important especially in light of all of the new CQ restrictions and classifications po. Leptospirosis po is not really a new disease in the country. In the past, we've had a number of cases in that and there is a treatment for it but there are those symptoms na maaring mimicking o parang ginagaya po nya kung ano po yung COVID-19. So sometimes it may be very hard to tell that difference. So we hope that in this webinar, at the end of this webinar, you'll be able to understand po how to really identify and maybe determine po if your condition is more caused by leptospirosis or COVID-19. Pwede bang maari bang magkaron ng pagkakataon na sabay na meron kayo sa ganong katawan. So that part of it, it's something that we hope that you'll be able to call from this webinar and we really are looking forward to all of the presentations of our experts for today. Over to you, Dr. Susie. Okay, so let's start with our fun quiz and thank you for introducing the topic. Raymond, if Eric comes later, then of course he'll join us and I'm sure he has a lot of information to share from the Department of Health. Let's start with our fun quiz. So Raymond, over to you. Anupang mga question natin yung? Okay, TV UP may we have on the screen the mentee meat. There we go. Okay, so we have two questions po, no? Ang dalawang katano. Meron na tayong graphic. Nag-level up. Good. Okay, siging go. Ang galing. Tiratatuwi at tayong sa umpisa. So on the first question po is anong hi-yop ang nagdadala ng leptospirosis? I'm seeing po that there are well, there are only a few of our attendees who are able to input their answers po. Please don't be shy. Just key in your answers po. In the Mentimeter or in the Zoom poll, we hope that you could participate in this fun quiz po. Wala poong grade for this fun quiz or poll. The options are as follows. Rats, option one, option two, dogs, option three cows, option four pigs, option five carabaus, option six goat, and option seven, all of the above. Option eight, none of the above. Okay. We go on to our second question. Ang ating pangalawang katanungan and please, for those who are asking po and maybe nakalimutan na nila, open your browser, go to www.menti.com and use the code that's on the screen, 9307-3652. That's 9307-3652. The second question states, ano po ang mga sin Tomas, lang leptospirosis nakatulad ng COVID-19, we have as our first option joint pain, option two, muscle aches, option three, fever, option four, chills, option five, headache, option six, all of the above, and option seven, none of the above. So, we are seeing po, I think there might be a problem po in terms of the poll. It might have a close prematurely because we are seeing answers being typed in the chat box. Marami-maraming salaman po sa inyong mga kasagutan and we'll ask our, oh, there we go. It's been relaunched. So, pwede nyo po may enter po ang inyong, there we go. Thank you, thank you. Ang inyong mga kasagutan, not in the chat, but in the zoom poll po. Over to you, Dr. Suzie. Mga nakakawa naman, Raymond, may mga pictures pa ngayon. Okay. So, marami sa inyong sokagot sa chat box. Lipat na po kayo di, it's on the zoom, yan na, kung habul na, talaga ang ano, gusto nyo sa magot, sige, Tina na nakakatom. Actually, ano ayano, it's always good to engage you and get your views on things. So, later we will ask our experts to answer this. Okay. So, let's move forward and as mentioned, our country is one of the most disaster-pung countries in the world. And, you know, the disasters don't stop just because there's a pandemic. In fact, because of climate change, lalong nang kakarun ng mga filigro ng mga disasters, mga hazards. And recently, we've seen floods. And of course, ang concern natin dyan, libu-libu yung mga nag-evacuate, pang-evacuate, isiksilikan, di ba? Ay pano kung hindi bakunado yung mga tao sa evacuation center? Di nero na naman filigro. Apart from that, yung mga, ano, yung mga rescue workers lumulusong sa, sa tubig na, minsan, wala silang PPE, wala silang botas, ano, ano, ano, andaming pwede yung mangyari. And I think, you know, I think we're already tired, you're already working so hard. Na, ano ba ito? Merong pang, ibang mga sakit na lumalabas ngayon. Yung iba sabi nga, kinaaban sila dumadami mga kasu nila sa mga shodad and so on. Well, alam niyo lilipas din yan, pero kailangan meron talagang pagbabago sa isip natin, sa pagpplano natin, sa, ano, sa, sa pagawa natin ng, anong talong nito, ng mga paraan, para matuguno natin yung mga, pangangailang pangkolosuhan ng ating mga kanabayan. So, para magkarontayon ng picture ng, ano ba ang nangyayari sa maraming, pag, ano ba, saan ba? Anong, na ano tuloy ako yung parang nablanko ako. Parang, ano ano ba ang mga hazards o mga piligro, na, expect natin, maaring dumapusatin, saan ang mga lugar na, nangyari, saan ang mga lugar na bumabahak. So, kung may mga, alam natin ang mga lugar na bumabahak, dapat siguro nakatutukahedran sa mga pagbabakuna. So, kailangan, ipagsama natin yung katalinuhan natin sa pagunawa ng, ng mga, ano, ng mga sakuna, at siya kayo, kaalaman natin sa, ano, sa kalosugan. So, asama po natin, hindi po siya bago sa inyo, siya pang Executive Director of the UP Resiliency Institute at Director ng UP Nationwide Operational Assessment of Hazards or NOAA Center, Mr. Disaster himself, kinakapatid po ito, alam mo, to yung nakikita ko siya na alalako yung tatayin niya. All right. So, we will welcome Dr. Alfredo Mahar Lagmay. Mahar, welcome to the webinar. Hello, Susie. Oh, yan. Okay. Kamusukan na Mahar? Kamusukan na Susie. Okay naman. Nasaka ba ngayon? Hindi, sa bahay, maguluhin bahay, pero na COVID-19. So, anyway, ready naman ako mag-present na yun? Go ahead, go ahead. All right, nating na natin. Meron pang lumalabas dito na mga pola. Becare ko lang yung screen ko. Bakit ang sinasabi dito? Only host. Advanced sharing options. Lano. You can share na, Dr. Mahar. Oh, ano po host ka na daw ngayon? Sige, thank you. Okay, malik. Lagay ko. Kailangan ko yung lumipat. While you're, while you're, okay. Okay. Okay na ba? Okay, wala pa Mahar. Ulit, yan, okay. Sige, okay. I'm sharing my screen, now, stop. Okay. May hiss ng konte, may hiss? May hiss? Okay. Na-wala na. Na-wala na, okay. All right. Will you see my screen? Yes. Okay, great. You're perfect. Okay, COVID na. COVID na, lefto pa. May malaki ang problema natin. Actually, hindi lang yan ng problema natin. We have a lot of problems in the country. As we saw over the past several, one and a half years, we've been battling against the spread of SARS-CoV-2. And it's really quite difficult and there have been many deaths already and because we also have other hazards makama-compound ng ating mga problema. And this is not unique to the Philippines. It is a problem worldwide, especially those places na maraming natural hazards just like the Philippines. What am I talking about? Bukod sa leftospirosis, which I think is the topic of for today in this webinar, there are a lot of speakers and doctors talking about this. We also have problems about dengue. And another infectious diseases, I've attended other webinars, infectious disease experts. We've been talking about other infectious diseases that pose a problem. It's a continuous threat that we need to look at. We cannot ignore all of these things. Now, after having said that, I'd like to emphasize that there are other natural hazards that we also have to consider in planning. Kelangan, planning should be anticipatory. We should not ignore these things. Like, for example, before the COVID outbreak in the Philippines, we had this very big eruption that generated base surges. We just published this in scientific reports of nature.com, of nature. And these base surges actually is the most feared hazard I think of Taal Volcano. It did happen. You're seeing there a picture of base surges formed in the 1965 and subsequent years na may eruption from Taal generating base surges. In fact, the term base surge was coined by a geologist, a USGS geologist after studying this phenomenon occurring at Taal. And eventually it got mainstreamed into the volcanological literature. And many volcanology agencies still use that term. You're seeing there in that very beautiful picture an elevation model of base surges that formed dunes para siyang desert. And it's really very, it's occupying, it was deposited in a big swath of land southeast of Taal Volcano Island. And you're seeing here the photo of a school, a deaf end school that got overwhelmed by the base surges. They traveled at very high speeds. They're more than 100 degrees centigrade. And definitely if students were there baka na matay sila. It's a good thing that there was our lead time to evacuate the people. So this is one type of hazard associated with volcanism. We also have other hazards like, for example, more recently we experienced bug. It's called volcanic smug. And it's because of aerosols and sulfur dioxide that gets to pollute the air. And that needs to be considered because there are some medical issues when we inhale polluted air like that. Kinatawag na bug. And the bug was actually related to the increase in SO2 emissions from Taal Volcano in the run up to the small eruptions that happened I think early part of July. Apart from volcanism we also have problems about earthquake activity. When faults move there are many faults or earthquake faults in the Philippines. When they move they generate earthquakes. There are many earthquakes in fact as I speak probably one earthquake is happening somewhere in the world. But less frequent yung mga malalaki earthquakes but when they happen we call it as the big one and when it happens in a highly populated area there may be many deaths and if that happens in Metro Manila we have many faults that can move. And when they move it affects Metro Manila that will compound our response to COVID-19. You can just imagine that all of these people will be staying outside. They cannot stay in their house for fear that there will be continuous ground shaking and make the the infrastructure or their houses collapse. So they will stay outside. Just like what happened in Mindanao for several months yung mga tao were staying on the streets. I don't know. So pag kanangyari sa Manila in Mindanao yung less populated. In Metro Manila we are highly populated here. More than 10 million probably 20 million people. So pag nangyari yung people will be staying outside. And we might have a problem with controlling the spread of COVID-19. Apart from that mayan pa tayong mga ibang example. Yung earthquake the most recent example nangyari was the Batangas Magnitude 6.6 earthquake. Also recently in December maybe November or December basa nung Ulysses when that happened it affected several provinces in Busan and it hit even Metro Manila and the impacts were heavy doon sa kagayan Bali. Partly related to the dam release and mostly related to the heavy rains that triggered massive floods along kagayan labor. And these are the things that we need to prepare for. And we also know because of that flooding event nangkaroon ng increase in COVID-19 infections in that area sa kagayan. Apart from the natural hazards we also have problems about yung mga man-made. For example this one in 2017 we had sorry in 2018 we had the rapid decrease of the La Mesa water level. You can see that orange line in the graph. As compared to the 2017 graph we did not have any problems. But later on in 2019 and 2020 we did not have problems anymore because the problem was fixed. Muka man-made yun because the rains when we looked at them as well as the feeding dam wala naman problema nangkaroon nang problema sa La Mesa dam. But a discussion of this is very important we need to look at not only just at the natural hazards things like this because if we have lack of supply of water in Metro Manila for example because there is no water in La Mesa dam wala naman problema sa ula. Pagkakonon tayo nang malaking problema because 90% of the water supply of Metro Manila comes from this place. Pagkakon tayo ng problema. So it's not just the earthquake that can trip or break all of the water lines patirin yung source dahil hindi maganda siguro yung management or whatever it is we need to look at that and secure our water supply. Kasi pagwala tayong water supply especially during the time of pandemic magkakaroon tayo ng napakanlaki yun napakanlaki yung problema. So monitoring this as well sa UP NOAA center and the UP Resilience Institute. As was discussed by Doc Susi earlier sabi niya natural hazards do not stop because of COVID-19 and that is true. Kasi the Philippines is in the pacific ring of fire and we're also in the typhoon belt. You can see here all of the typhoon tracks we have about 20 that are into the Philippine area of responsibility. There are more landfalls probably less than 10 that hit the Luzon and Visayas regions and there are less that happen that make landfall go on sa Mindanao and we're also in the pacific ring of fire. We share the same problems as the countries of Indonesia, Japan places like Alaska Western United States Western Canada Western part of South America it's called the pacific ring of fire because all of these places which have a lot of volcanism and a lot of earthquakes surround the pacific ocean. So it looks like a ring so it's called as the pacific ring of fire. Now when we talk about all of these problems about earthquakes and eruptive activity of volcanoes and typhoons or severe weather they're actually the pinodina we really need to prepare against the hazards brought about by these pinodina. Like for example when there's volcanism what we need to prepare for are the hazards the hazards are the ones that kill. Like for example for volcanism the hazards are pyroclastic pyroclastic fall debris avalanches ballistics lava noctuous gases and tsunamis. Each and every hazard have corresponding maps and everybody must know those hazards if it is present in their neighborhood. So kailangan pinitignan natin lahat yung mga hazard maps see if they are present in your subdivision sa inyong neighborhood or in your schools or maybe your office place sa ang kayo nag tatrabaho before you go there you have to check whether there are hazards in those places. For earthquakes naman there are hazards so the earthquake per se does not kill it's the hazards that kill and we need to look at the hazard maps again know your neighborhood these hazards for earthquakes are called ground rupture, ground shaking subsidence, liquefaction, tsunami, sage, landslides, fire I don't have enough time to discuss each and every one of these hazards because limited yung time but I just want you to take note that it's the hazards that we need to prepare for for severe weather like typhoons we also need to look at the hazards strong winds, floods landslides, snowstorms so I guess everybody is familiar with all of these hazards that we need to prepare for I just don't know if everybody is aware whether these hazards are present at once it's the music part of your presentation no problem ako naman I naturally assume it's part of the presentation it's part of the presentation mas malakas yung music kaysa sa bosses niyo ayyan pinatay ko na ulet ulet na har ulet kasi hindi ka na rinig so for severe weather like typhoons it's the hazards that we need to prepare for strong winds, floods, landslides storm surges I guess everybody is aware of these hazards we've seen them the strong winds, the floods the landslides probably storm surges you've seen sa tv what happened sa takaloban and in the central philippines region I'm just not sure if everybody is aware of the extent of the hazards or whether they are present in their homes in their neighborhood or in their office area or in the schools where your children go to lahat kasi ito they have corresponding maps and when you know that there are hazards like this one this is UP it's quite well planned you see that lagoon walang mga settlements so even if it floods there that's fine but it's not the same for other places so what we need to do is to know all of these areas that are hazardous especially if it concerns the place where you live in your family and know where to go whenever there's a warning is that we do not prepare for the phenomena we prepare for each and every hazard brought by all of these events like earthquakes volcanism and severe weather like typhoons and tropical storms now here is just a short compilation of the lessons that we've learned from past disasters because we've been looking at the disasters that have happened in the Philippines we are a natural laboratory for disaster research here in the country and we can learn a lot from the actual disasters to learn the mistakes in order for us not to repeat them so I list here some of the short term things that we need to do hazard specific area focus and time bound warnings that's very important use of sensors use of maps that show where the safest places are in the community we need to share bawa lang swapang sa disaster work we need to share because the Sendai framework stipulates or the guiding principle is that we have to have a whole of society and science based approach so kailangan we need to share the data sets especially if they are publicly funded data sets long term we need to do anticipatory planning put it into the comprehensive land use plans we need to put the hazard maps or depict scenarios of hazards that are bigger than what we have experience that is called as probabilistic risk assessment and that has to be mainstream into comprehensive land use plans education open data that's very important and more scientific research so far nagkarun tayo during the COVID ilang mga typhoons and I guess when summer was hit by typhoon ambok very minimal ang tawag ang damaging loss ang fatalities five dead and scattered pa yan and they manage well and I think the reason why they were able to manage the typhoon despite its impacts was because they were quite well planned remember that that place was hit by yolanda and because of that there was a lot of help those municipalities and cities in the central Philippines region especially samar were well prepared in terms of planning they planned well they were able to manage the COVID-19 situation quite well as well meron din tayo sa ulysis there was a rise in COVID-19 cases in Thugugarao it was roughly the same type of disaster management as what happened sa samar but I guess that's a lesson for us how do we really do it and ito lang naman gusto natin saan na na maraming tao na we cannot ignore all of these hazards because they are all connected with each other for example this COVID-19 that is just one example we had COVID-19 and nagkaron tayo ng problema sa agriculture sa different sectors of society sa health sa forestry sa energy sa tourism and we all know that so planning the municipalities and cities need to be done across all sectors kasi hindi lang pwede sa health kong by COVID it's a public health issue hindi lang pwede dung tayo nagpaplan we must plan against all of the hazards that I've just discussed we have to have maps of the city or municipality of the community and just to give you an example this is a land use plan this is the storm search map sorry the flood map the storm search map, the landslide map this is the zonal plans of the community now if we can put them all together with the plans of the community for example the settlement area that I'm showing one is full of yellow and orange hazards that is not a good settlement site one is without any hazards without any color actually gray lang that means there are no hazards that is a good plan to make development for settlements for the agriculture sector you can see their plans ay binabaha but not all places are flooded so maybe for climate change they can plan resilient crops and for those areas that are not flooded then they can plant the normal crops and this one which is a tourist area you can see ay maganda yung area kaya lang hazardous that's a good place where they can look at yung kalaw na bird, it's very beautiful and that's the source of revenue from tourism so what they can do is that during times na wala na mong bagyo it doesn't be storms don't happen every day heavy rains don't happen every day so dyan sila, continuous yung tourism manaming pupunta and then pag may bagyo there's a warning from pag asa they can pack up, go to the gray places in gray colored places which are nearby storm is in the south China sea they can quickly go back and resume operations that is called business continuity you're planning for business continuity in the sector of tourism now for our problems like covid compounded by leptospirosis and dengue we must look at the hazards na pag bagyo dyan din yung pinagpupugaran nung mga tawag dito yung mga taga napos pag mabukka baka yung ihin nung daga ay natin sa tubig et cetera that will be discussed later on so we need to know these places we need to use science and technology to find out those places and make visualizations like this that clearly show to us where they are so that it can be communicated to the people kasi mahirap icommunicate ito and we need good visual tools like sa internet ano ba yung mga places na yan where to avoid them yung possible leptospirosis and really the most advanced technologies that we can make use of and the frontier science also make use of we have to apply for our disaster risk reduction and mitigation efforts so upinowa center and the UUPRI will be coming up with a new website a revamped website that will show all of these hazards for hazard specific area focus and time bound warnings and hopefully with this holistic approach in tackling the natural hazards the biological hazards we can make a better plan so that we can reduce the impacts of all of these problems that we face. I think that's it. Thank you very much for giving me the opportunity to talk and thank you very much as well for listening. Thank you very much. That's Dr. Mahar Lagmay of the UPE Resilience Institute that we really need to do for the pandemic and Mahar works with a team who are able to do all this mapping so it's also good to see the health of the people the patient the vaccine but actually at public health so I think this is a good way to start our discussion kasi kung nakikita natin or alam natin saan talaga babaha saan talaga may arong piliigro and I think it's going to be very important as we continue. So over to you Raymond. Thank you Dr. Lagmay and thank you Dr. Suzie. Next up we have another expert pero hindi po siya bagito I've had him for at least two other times here in our webinar series he is the head of the Adult Infectious Diseases and Tropical Medicine section in San Lazaro Hospital and he will be talking about from the clinical perspective in terms of leptospirosis and essentially our topic for today. So please welcome to the webinar Dr. Ron Jean Solante. Thank you Raymond and thank you Dr. Suzie. Thank you also for this opportunity to share also our experience particularly here in San Lazaro Hospital we're also dealing with not only with COVID-19 but also with other infectious diseases but at this point I'll just have to share with you what are some of the important points that we need to remember and hopefully this can also help you in your management of your patients with leptospirosis in this time of COVID pandemic. So my first slide will really be something that I think related with Professor Marlagmai's presentation that our country is really prone to this different infectious diseases and one of that is leptospirosis because of the flooded areas that we have particularly here in the National Capital Region and that in itself is really an important epidemiological data when you have a patient presenting with fever presenting with cough or anything to do with an acute infectious disease and some of the areas here there are similarities with COVID-19 and in a healthcare facility where you will be catering not only for COVID-19 and other infectious diseases it's really a big challenge for us on how to separate one over the other or in some situations where we also have patients with both infection leptospirosis and COVID-19. Just to give you some data here this is from the DOH leptospirosis 2021 they said that 13% increase in leptospirosis compared to 2020 which means that this is driven by the fact that we have more rains compared to last year more flooded early flooding this year and there is also a higher slightly higher fatality rate of around 11.4% compared to 9.8% last year so i'll start first with a sample case and this is one of our cases with leptospirosis this was a case that was diagnosed with leptospirosis during the early first month of the pandemic last year and this is something that we didn't forget because this presented with some overlapping manifestations with that of COVID-19 this patient presented with fever and head ache and then eventually vomiting and LBM and i think these were already signs of metabolic acidosis and what was really important here was that we got the history that this patient was waiting in flood water and the chest X-ray revealed bilateral pneumonia although there are none of the peripheral densities that we observe in patients with COVID-19 but you know reading of bilateral pneumonia we always highly suspect of a viral pneumonia and even at this point in time that's the most common manifestation of COVID-19 the other important part of the laboratory here this patient's creatin was really high so even though that most likely this is leptospirosis what if this is also there's also a concomitant co-infection with COVID-19 especially with continuous community transmission so in a way we need to do the test and we have to rule it out and that's one of the rationality that why we need to rule out because we have to separate this patient purely on leptomanagement and it should not be this patient should not also be in the COVID floors so the current test that we are using we did SARSCO viral RNA and this patient's test was negative we did an RT-PCR leptop part of our protocol here because we need as much as possible a shorter turnaround time to diagnose a patient with leptop as soon as possible time so that we can especially for those who are severe presentation because we know we really make a difference in terms of higher rate of survival compared to higher rate of mortality we ordered for a leptomat which was during the times and out to the Philippine General Hospital but because of RT-PCR positive lepto then we managed this patient as having severe leptospirosis so here we tease out some of the similarities so we'll start first with the similarities of lepto and COVID so I think this is an acute febrile illness same as that with COVID-19 and it can also present with any of these systemic manifestations either in the form of myalgia and headache and in most patients with leptospirosis especially for those who have severe lepto then there is associated with the patient of your transaminases and can also present with severe pulmonary manifestations in the form of ARDS and these are also the same clinical manifestations that we've seen in patients with COVID-19 but we tease out some of the important differences here like for example this patient caftenderness conjunctival suffusion and uliguria are really characteristic of a patient with leptospirosis and somehow this may be an important factor to consider more on lepto rather than a COVID-19 COVID-19 you'll have silent hypoxia sore throat and other manifestations and in the laboratory findings based on what we've gathered in most of our lepto cases most of them always have lepsitosis and like this patient both have leukocytosis and elevated BUN and creatinine and presented with metabolic acidosis wherein in most patients with COVID-19 you'll have leukopenia and in fact the more severe the COVID-19 you'll have lymphopenia and more or less you also have normal platelet count can also be also found in patients with leptospirosis but compatibility of inflammatory markers like your LDH D-dimer, ferritin and your CRP more or less makes this more of you have a significant elevation of these inflammatory markers can make you give you a more higher rate that this patient is more of COVID-19 compared to a leptospirosis there's this article that somehow differentiates disparity between leptospirosis in that of COVID pneumonia based on this number of patients total of 98 and 57 of these are confirmed COVID and 41 are leptospirosis and specific laboratory exams that somehow are significant that leans on the presence of leptospirosis like as we have experience also here in San Lazaro Hospital you have more of leucocytosis in lepto and elevation of your neutrophil and then the platelet count is really lower compared to the mean platelet count of those with COVID but if you look at some of this inflammatory markers the only inflammatory markers that they considered with leptospirosis is the seriactive protein where you have 138 and then for COVID-19 is 40 and then creatinine is really very high that's why one they considered is some of this important disparity that you can differentiate based on these findings that more lean on lepto over that of COVID-19 so there's this article that somehow tells us the importance of considering both and the presence of this overlapping symptoms because of the cytokine storm is also present in patients with leptospirosis especially for those with severe leptospirosis and at the same time since steroids are also can also be given part of the treatment not only for lepto but also as we have seen now in most of our COVID-19 patients that requires oxygen part of the standard treatment now is the use of your steroids so these are two separate infections but producing illnesses with similar spectra driven by the appearance or the due to your cytokine storm can also be common and can also be a co-infection that is somehow challenging to the clinician with regards to the epidemiological investigation this is the one of the important aspect that we have to consider we know that COVID-19 can also be trapped with the direct contact with those patients who have known positive for COVID-19 but with leptospirosis it's a no crossing path meaning it's difficult there's no index patients meaning it's related with the environment that's why you have not only clustering of cases but also cases that are common in some areas in one barangay that has a flooded area and that's where you highly suspect that there are flooded times during flooding times you have to highly suspect and consider leptospirosis as part of your important differentials in any patient presenting with fever and other systemic manifestation so I just like to share with you at this point our of leptospirosis so comparable to 2019 and 2020 we have around 176 cases of leptospirosis in 2019 and compared to 2020 last year there's really significant drop in the number of cases in 2020 so for 2021 we have not yet collated the data yet but significant drop here this is also the start of the pandemic last year and you notice that less of the cases were seen in 2020 compared to 2019 for reasons probably some of these patients are afraid to proceed to San Lazaro Hospital when the time that the government declared also San Lazaro is one of the referral hospitals so this may not be an indication that the cases of leptospirosis in 2020 was was low so leptospirosis as we have always mentioned this is a domesticated primary disease of domesticated wild animals and in our country the most important source in the trigger is always the rat because the rat infestations particular in urban area is really very high and you know that the urine is the one that loaded with the leptospirosis and this is why we encountered a lot of these cases during flood this is the data coming from the different Manila hospitals in 2009 severe flooding and more or less the signs and symptoms are non-specific but fever is the most common you have myalgia at heart, tenderness malice, headache, chills down the line depending on the severity of the clinical manifestations so one of the important part here is really to the high index of suspicion especially in this time of this pandemic and we just like to show you here the criteria for diagnosis of leptospirosis aside from the symptom the presence of manifestations important also to consider the epidemiological risk of exposure and flooded area or wading are two most important part of the clinical history we always have to elicit yes, there are tests that we do and use for leptospirosis but again some of these tests may not be available in some primary or secondary centers and that's why the manifestation is really very important in the history of exposure so these are some of the tests that we use and in our setting we use the math, we use the IGG IGN we also, we don't have that luxury of isolation or culture and sometimes that result will take around three to five days before we get the result and most of the time we get pulse negative based on most of the history of patients with leptop because of late arrival to the hospitals they have been taking antibiotics so that might also affect the activity of both of these tests okay so this is just to show to you the current test and timing which is quite crucial for us to have a better yield for leptospiral infection so specimen and leptospiral tests that can be used during the first five to seven days these are the tests and then after seven to fourteen days that you can utilize now a patient with leptospiros is the most important part is recognition those patients with a higher rate of fatality meaning mortality and we need to know who are these patients and that's really an important aspect in the initial clinical assessment who are those who are having moderate or severe leptospiros is because these are the patients also with a lower survival so we can use some of the important indications of admission and here once a patient will have these manifestations of course these patients when they have these pulmonary manifestations, severe hypoxemia they're also in the state of severe metabolic acidosis and we know that crucial to this is really dialysis and the other parameters that can somehow like ECMO is one of that and it's quite challenging in an area where you don't have the luxury of those therapeutic regimen that can somehow have value in terms of managing the patients especially with these patients with severe leptospirosis so general guideline in the management of leptospirosis of course is still hydration for action of the electrolyte there's a role for antibiotics especially when you catch the patient earlier and for severe cases these are important supportive care renal replacement therapy and I think we'll also discuss this later on ventilatory support and blood products may be required so it just goes through some of the important antibiotics so that you'll have a good review of how we manage our patients here so with mild leptospirosis these are the list of your regimen and then for those with severe we still use the penicillin or subtract zone and these are some of the alternative that can also be helpful especially if you're in an area where you don't have this first line regimen prophylaxis also part of prevention actually the most important prophylaxis really shying away from flooded areas if you cannot from going to this flooded areas you have to protect your skin as much as possible because the entry through cuts and skin lesions are the most important area of entry of most organisms and that's why we'll have this infection so this prophylaxis regimen is given based on the severity of exposure you have low risk exposure moderate risk of exposure and high risk exposure so if you have a low risk exposure with only single history of waiting in flood and or contaminate to the water without wounds, cuts or open lesions of the skin so I think the regimen here is 200 mg of your doxycycline and then for moderate risk you have wounds, cuts or open lesions or accidental ingestion then you have to give 200 mg, 3-5 days at you have to start it immediately so there's a window period that you have to give it as much as possible within 24-72 hours from exposure and if there is continuous exposure then this is also the regimen so something that most of our local government units are also using for their patients' history of waiting in unimportant prophylaxis generally when I talk about leptospirosis even if you don't have the test yet the result of the test it's important that clinically you have to really commit that if this is leptospirosis you need to manage them accordingly because early recognition and early treatment are very important in the clinical outcome of patients so this is my last slide take home message here given the uncertain spectrum of COVID-19 presentations and variable sensitivity of laboratory tests for SARS-CoV-2 there's always a risk that without a high index of suspicion alternative etiologist may be overlooked while pursuing a diagnosis of COVID-19 and similar clinical manifestations shared by COVID-19 and some infectious diseases so I'm not just talking about lepto but other infectious diseases especially those endemic that concern raising more awareness to expand such differential diagnosis and post really big challenge especially in areas where resources is limited based on the availability of specific and highly sensitive diagnosticness with that thank you very much for your kind attention okay thank you very much that's Dr. Jean Solante one of our infectious disease experts from San Lazaro Hospital Jean we learned a lot from your presentation and I'm sure our audience has questions so stay with us for the panel discussion and we're now going to move to our reactors we have two reactors and our first one is someone who you always have seen on the webinar I guess Raymond yung mga kasama natin yun mga suki lahat no parang none of them are first timers none of them are first timers none of them are first timers so anyway thank you Dr. Jean and let's go now to our former dean of the UP College of Medicine of the Philippine Vaccine expert panel Dr. Nina Gloriani and she's going to talk about the pathophysiology and the public health part of leptospirosis welcome Dr. Nina yes thank you Suzie and everyone and thank you to our main presenters so Dr. Maher and Dr. Jean I work with a lot on COVID also so you have actually shown the interconnectedness the relation between these hazards and infections and that we all have to work together to actually try to address them what is this what's happening napad punta tayo sa slide show slide show let's go to ay nga walang ay ko bumaba sorry no problem ok ok perfect now you know that leptospirosis used to be mainly an occupational exposure so we're talking about animal handlers so we're garbage workers farmers anyone who actually handles animals but you can also get lepto from leisure activities so in some of those yung mga white yung mga rafting rafting just yung mga rivers na yan and of course now recently the floodings just to note here you can directly or indirectly get exposed to the urine of infected animals like so ito tin maraming mga animals na to how do they get into you pre-sented earlier although your intact mucus membranes so yung nose, mouth, eyes if you get into a flood na talagang matas na the lepto can get into the mucus membranes but water blood skin is also ay a risk factor kapag antagal nyo na na sa flood lalambut yung skin ninyo and this leptospira can actually enter of course ingestion of contaminated food or water to tell you that we have tested in our lepon program in atyupimanila that water and salt samples from the national capital region and other regions are positive for pathogenic leptospira okay so I think Dr. Jean also mentioned about the pathogenesis somehow so it can actually affect many organs of the body but take note this is for humans but in animals we have all of these animals who can get abortion hepatitis, nephritis merupang uvitis dacentitis or reproductive tract infection but there could be mild infection in domestic animals that could pass unnoticed okay so you have yung talagang sa kanina yung tiser na questions I hope you answered because we have data from actually earlier than 2010 when we had the lepon program established atyupimanila so we have studied all of these animals here and found by antibody positivity and we also were able to isolate the leptospira from their kidneys or from their blood so all of these are actually positive or can carry the leptospira of course you know raps are the main carriers or maintenance hosts of leptospirosis but please take note that dogs are also very important carriers of the leptospira so whether sick or apparently healthy you can get also so if you see any dog swimming during flooding chances are that urinate yung dog don't have lepto so you can transmit that way and we also have data for pigs sa mga abatwa, sa mga slaughterhouses to yung mga pwede cows, goats and carabao and what we have found is that we have different set of syrovars ito yung mga types ng leptospira very very specific to certain areas or geographic areas so talagang sa kanila syrovar, manile galing sa manila syrovar, los baños yung mas older na mga versions syrovar, kanikula pyrogynes, dripotai fosa e pero maganda mga pangalan nila in terasobi and some of them were isolated or are able to infect some of these animals better than others yung mas later yung manile, los baños kanikula, marami sa dogs yung poy ang di na dinasulat yung poy sa pigs yung terasobi sa carabaos or sa cows and many others so how can we control leptospirosis so interventions could be at three levels the source of transmission so yung environment pwede naman urban planning kaya kung mapasok lahat yung sinabi ni Dr. Maher Kanina is the pollution in the rivers, creeks garbage, canals and so on we have to control the transmission route we have well I don't know how much roaded control we're actually following here but if vaccines are available but mainly ngayon yung vaccines are available for dogs I do not know if the Philippines some of our livestock get vaccinated but in other parts of the world they vaccinate horses, cows and other animals and of course we have to control at the level of the human host by proper diagnosis and treatment as Dr. Jin showed us and of course PTE so maybe just to also say that after a 5-7 year actually program on leptospirosis we were able to produce a leptovax vaccine containing the syrovars that are more prevalent in the Philippines versus we have imported lepto vaccines that are being given to our dogs here but you take note that not all, these imported vaccines do not contain the syrovars that we have here in the Philippines so we're looking at fighting leptospirosis with a local vaccine but that is not yet very advanced we're still going to do animal studies so just putting all together you know what to do we have said all of these so with that, thank you very much and I hope we all what's this learn from what we're hearing today okay thank you very much that's Dr. Nina Gloriani of the head of the vaccine expert vaccine panel and also former dean of the College of Public Health and very interesting na hindi lang daga merong pang anon ay baibang animal so we will talk about that a little bit more later thank you very much and I think I think in this webinar we wanted to talk a little bit more about the environmental context of these diseases and so that we're we're well aware of what we can do what we can do as a community what we can do as frontliners so our next speaker again, not someone who you are unfamiliar with kilala nyo na siya we have had her before and she has she has some very interesting information to share with us also reactor to the presentations of Mahar and Jean I am very privileged to to introduce our next speaker who is the deputy executive director of research services at the National Kidney and Transplant Institute who I've also known for a long long time Doctor Rameena Penji Dangilan Penji, welcome to the webinar Hi Susie and thanks for inviting me again and I'm really very happy to share with you our data again, go ahead Penji what well okay, you have to go to slide show there we go okay, so I'm going to talk about something very interesting which is leptospirosis and COVID-19 as a co-infection and I'm going to try and compare that with our population with leptospirosis only and COVID-19 only so because we are a National Kidney majority of our patients are really patients and patients on dialysis so we're talking really about a very severe group of patients with very high mortality rates so here we have COVID-19 um and leptospirosis as shown by Dr. Solante also earlier there are certain in this paper incubation you're not seeing my progression of slides sanitation I've colored those signs and symptoms that may differentiate one from the other so if your patient has conjunctival suffusion, myalgia and then progressing to renal disease jaundice and hemorrhage we look more about this is probably a leptospirosis patient or this is probably a patient even if they have combined disease that will manifest mainly as leptospirosis on the other hand if your patient has more of upper respiratory tract and lower respiratory tract symptoms then probably you're thinking more that this patient is going to be more manifesting COVID symptoms okay now again um COVID-19 and lepospirosis as mentioned also previously we have what is common in both of them is really a cytokine storm as a main precipitating event majority of patients have good outcomes unless they have odds and multiple organ failure this can occur rapidly in patients so that the institutes develop several types of scoring systems so that we can predict which of the patients from the ER already we can already predict who's going to really have a very stormy course who are the patients we will do early intubation and who we will be very aggressive with our management you can see here that if you have a patient with COVID and ARDS mortality goes up to more than 50% and lepto with ARDS again mortality goes up to 26 to 61.5% in these papers and high dose steroids has been used in the early management of severe lepto and severe to critical COVID-19 it's found to be very effective as well for the cytokine storm in the NKTI for our severe patients on lepto our protocol is to do pulse therapy for three doses with methylpredisolone and to give them psychophosphamide 500mg IV for a single dose so you can see that really at the immunologic pathophysiology of this disease and from March 2020 to July 2021 COVID-19 co-infection and I'm going to present some of this early data to you now who are these patients with a co-infection looking at some of their demographic data see here that in the occupation some of them had high risk 43% had high risk exposure so they were factory workers, vendors, construction workers fish port, transporters so they had probably exposure to floods or dirty water then low risk in 33% lineman, driver, supermarket employees call center agents again maybe they had to walk in the floods and then we had also some who were unemployed if you look at where they came from since we're in Quezon City majority of our patients came from Rizal we have Malabon, Pasig and of course Quezon City and again looking at exposure 71% had exposure to or resided a rat infested area in about 71% and none of those with exposure took prophylactic medications now let's look at the time from onset of symptoms to first consult you can see here that it was between 4-7 days with a mean of 5 days and all of them presented with myalgia 95% had fever nuzluria or oliguria jaundice and conjunctival suffusion in 60% and none of them had agnosmia, ajusya, dysjusya or hemoptysis upon admission so our usual symptoms that we see in those with COVID were not really present however in our emergency room all the patients are going to have a COVID swab so that we could cohort them accordingly now let's look at some of the baseline demographic data here we have a very interesting now presentation for you I put here in the middle those presenting with lepto and COVID as I said they were 21 patients then here on the left side we've had a study done on 41 patients with severe leptospirosis severe meaning they had severe lung disease and they were on dialysis and on the right you have severe COVID alone and this is again a study on 102 patients and let's compare them to our middle group which are those who had the co-infection so looking at the age of these patients you can see that those with lepto both lepto plus COVID and lepto alone were younger patients so mean age was about in their 30s while those who were having severe COVID alone were older at 55 mean age majority of them were all male co-morbidities you can see that more of the patients who had COVID alone have our co-morbidities because they're elderly while the younger group will have very little few patients with co-morbids and mean arterial pressures were similar for the severe lepto and lepto plus COVID our WBC counts were elevated for the two and for the creatinids you can see that we get the patients with severe lepto so their creatinids are elevated they will probably need acute dialysis and in our study here on severe COVID we took the dialysis population so let's see how they will do later looking again at more data we wanted to compare the inflammatory markers as shown here on the left and as you can see mean LDH was higher compared to severe COVID alone compared to lepto and COVID compared to severe COVID alone look at ferritids again much higher in those with co-infection compared to COVID alone Crocal citamin which measures bacterial infection we can expect it to be higher in lepto because that is the bacterial infection you can see it's not high in severe COVID because of infection look at HSCRP again another inflammatory marker higher again in the co-infection and just looking at this data without any statistical analysis yet I would say that majority of those with the co-infection will have higher inflammatory markers which might mean since both diseases are characterized by severe inflammation cytokine storm that they will then manifest with even higher inflammatory markers looking at the PF ratio you can see it's lower for our patients with severe leptospirosis and not that bad yet at baseline for our other two groups and SOFA scores which are scores to predict mortality were quite poor already elevated in our severe leptospirosis patients now just looking at the lung involvement at baseline we can see that we have a really severe majority of our severe lepto will have already before quadrants involved while those with severe COVID on admission will have three quadrants involved it's data that we haven't looked at yet in our co-infection so that will be very interesting to see looking at our therapeutics all of our patients receive steroids so I mentioned that our protocol for severe lepto is to give steroids severe COVID all the patients are placed on dexamethasone so the co-infection patients they will receive steroids as well only our severe COVIDs were put on HFNO look at the patients on dialysis so all of these patients with severe disease 100% of them will be on dialysis and our co-infection 76% of them required dialysis hemoporfusion which is a treatment that we give for patients because of the severe inflammatory response and the cytokine storm half of those with severe lepto were put on hemoporfusion 24% of those with a combined infection and 33% of those with severe COVID and then we had ECMO hemoporfusion that we did in about half of the patients who had severe lepto what are our patient outcomes again looking at overall mortality you can see that it's only 14% for patients who come to us with leptospirosis so in 2020 we had 188 patients with leptospirosis and 14% overall mortality if you look at leptoplascovid it was more benign only 21 patients and 5% overall mortality and if you look at our COVID in 2020 we had a 26% overall mortality because again majority of these patients are on dialysis now if we look at the mortality in patients with severe disease so we extracted those with severe infection meaning they were on dialysis a lot of oxygen HFNO or mechanical ventilation then we have here half of the patients on lepto will have died if you have the co-infection if we look at those with severe disease again 33% of them will have a mortality and again again COVID because again these are patients on dialysis the mortality jumps up to 47% so these are very ill patients very prominent inflammatory response and something that we really need to treat very aggressively and we have special treatments for them like hemopropusion we now do ECMO for patients with severe disease so that we can improve our survival now just to end I just wanted to show you okay we are worrying about lepto differentiated from COVID but we can also have lepto and differentiate that with dengue and here is just one slide to show you in this study where they compared patients the incubation period is the same mean age is lower for those with lepto and common findings again where myalgia oliguria ectorrhysia, anemia, leukopenia, low platelets high ESR, low albumin and AKI, acute kidney injury those with lepto mortality was higher in patients with lepto and here you have some predictors of death and this was interesting because they tried to do a sort of a scoring system this is the receiver operator characteristic that would favor leptospirosis as a diagnosis and that was if your WBC was more than 11,000 ESR was more than 40 Kreia was more than 2 Bailey Rubin more than 2 CK more than 500 and albumin less than 3 then those patients would favor a diagnosis of leptospirosis so thank you very much for listening and I just wanted to show you the COVID war that we make out of our gym this was in 2018 and 2019 and just to tell you that we are now in a leptocerm at the NKPI yesterday we admitted 10 patients with COVID today half the day again with severe lepto thank you very much for your attention thank you for that really exciting information that you have brought on new information doctora penji and that picture that last picture really epitomizes the work that's being done at the NKT so thank you for that presentation we'll call on different resource persons to our panel we have doctor mahar lagmai, doctor nina gloriani doctor penji dangilan and also director eric tayag of DOH he was supposed to give his opening remarks but we'll have him start double rolling during the panel but before we start let's take a very very quick break as all of our speakers well, take a breather also while they're opening up their videos for a special public service announcement for today sigurado ka na ba si reservations natin? oh naman bakit bees na bees ka? oh, magiging escort mo ko e mukong may date si lolo-lolo ilagay mo kaya ito ang ganda naman maganda yan special anulakan natin alo, ready ka na? ready nga mom, dad, alisi lolo-lolo oh, anak, after lunch sanalakad nyo po para sa atin lahat ito magpapapakuna kami dahil mahal namin kayo dahil mahal ko kayo magpapapakuna ko thank you again, tv up ang cute cute po nang ating mga infomercials po thank you so much this public service announcement is really part of the COVID communication PSA and one of the many outposts of the UP research and title communicating COVID-19 in post-quarantine Philippines it's headed by none other than our lovely VP for public affairs VP Neni Purnia it's funded by the DOS, the PCH-RID and the DOH through the IHED HSPR project okay Dr. Susi Dr. Eric Tayag get the ball rolling Dr. Tayag any thoughts? you could start with your own talk po just to get the ball rolling for our panel sir okay, thank you Raymond thank you Susi I'm sorry I was a little bit late earlier I had to be at the DOH vaccinating because we're ramping our vaccination against COVID-19 and yours truly is one of the makunadon just now it was announced that all cities and municipality in the national capital region each one has at least one delta variant case so that's the situation right now that's the breaking news from Dr. Dagnilan is that the leptospirosis alam niyo po sa mga nanunod po ngayon ngayong puntaggunan may tinatawd tayong wild diseases W, waterborne diseases diarrhea I influence another respiratory tract infection L, leptospirosis at saka ang di dengin napagusapan na po yun pero tandaan po natin na ka-ICQ po tayo maliban sa national capital region kasaman dyan ng iluilo kagayang tiyoro ingoog at laguna yung po ay dapat yung malaman sa pagkata alam namin maramin na gato-dilisegot ayon na ayon nyo itong ACQ so bali ito ang tangin paraan yung modeling ko natin lumalabas na ako hindi tayo mag-AACQ baka sa September ka lahating ngayong kaso ang madadagdag na COVID pa dyan sa mga napagusapan ngayon na nagkaparoon na napagtaas sa leptospirosis matapos po kasi ang pagbaha dalawanggang habat na dinggo nakikita natin ang pagtaas yun ito po ay isang babala sa pagkat maliban sa COVID-19 ang hirap hirap po madifferentiay ng lepto dengin at ang SISTI pa pwede po may co-infection at ngayong hapong po tayo po ay pinalad sa ganun ay mantindiyan natin ng lepto sa kontekso po ng COVID-19 Over Raymond, Susie Thank you very much, that's Dr. Eric Tayag and thanks for the updates and for joining us despite your very busy schedule we cannot imagine how busy you are but thank you for joining us at the Stop COVID Deaths Webinar Okay, so it's very interesting Raymond pag naiisip ko these are two diseases with very different modes of transmission one is waterborne, leptospirosis and the other one is through droplet spread in some cases it's airborne in certain conditions where you have very bad ventilation and yet it seems that we will continue to see to see these multiple and I think Mahar used the word ascading disasters these multiple threats to health so I'm just thinking a lot of these problems come about because of congestion yung siksikan yung mga tao siksikan yung tinitirahan nila para our cities are so jam packed so congested no matter what we do this is really going to be a continuing problem for us because we have more people living together than all of these threats are magnified by the sheer number of people who are living close to each other so of course this is a bit of a provocative question for Mahar and for the others I'd just like it to also give an opinion, Mahar is it time for us to start moving to the provinces? Actually mahirap talagang ng disaster kapag overpopulated or densely populated yung community um meron kami ginagawa ngayon sa Manila dyan sa may coastal area we calculated bahwa magkaroon ng chulami may inundate yung lugar na yun yung barangay it will take them one hour para dapat maka-alist na sila dun sa lugar parang lumalabas na kailangan within one hour makapag 6x6 trucks sila na napakadami that virtually impossible mangyari yun parang daandaan na 6x6 trucks just to take them take them all out of that area so that only goes to show na pag maraming tao hindi madali especially sa response and all of these things kailangan maganda talagay yung plano including yung development the growth of the community going back to your question kailangan nabatay yung pumunta sa mga provincia yun ang gusto ko saan nang i-recommend pero hindi naman masap umalis ka dun umalis ka sa Manila tapos nilipat ka dun ay masosod na yung problema mas madali lang kung mangyari yung problema na hazards may impacts ay mamamanage na mas maganda pero the best way really to manage natural hazards is to plan the community well get all of the development yung mga settlements and plans across all sectors eh the growth of the community is where there are no hazards kasi mayro naman in fact parang binilang namin nya 40% of the country say from these floods landslides and storms or jests yung earthquakes as long as mabantayan natin yung building code that it is well implemented and we follow it and we avoid the fault rupture zone kung nasa ang yung mga faults will be okay when the hazards strikes and the people are out of harm's way kasi wala dun yung development ay we will be alright as well parang because we have to live with all of these natural hazards ngayon lang natin nagagamit itong science and technologies to show us where all of these flood prone areas are where all of these landslide potential areas are but we have to mainstream science into the plants of the community obviously metromanila alam naman natin ako sa sabihin ko na it's not well planned it was not well planned you can see it ang overpass na parang makiat ng Mount Everest yung mga overpass na nilalakalan you see that yung makiat ng timbukto yung soko taas taas noon it's not well planned yung it's not well planned it's not enough space so with community planning good comprehensive land use plans disaster reduction management plans climate and disaster risk assessments all of those cities and municipalities should be planned with such that going back to your question if we move there people will be out of harm's way and there will be no disasters right thank you Mar Dr. Nina Glurian usually to comment a little on congestion I mean again right from a public health point of view and you showed us the different occupations of people who are affected go ahead Mamina yung congestion that's a very important factor in transmission the more congested hindi lang yung mga respiratory illnesses yung congestion also would breed yung mga problems in sanitation so lahat halos ng infections will be affected makatama nga I don't know some of us will have to be going back to the provinces or decongest Manila or do not allow people kaming in kasi mas-must double yung ating worries ang concerns in all of this a lot of people will get more infected especially with the respiratory illnesses and by the way ang left talk na nakita namin sa aming yung ating yung left call ang mas marami doon although our clinicians can tell us marami doon may mga lang pulmonary hemorrhages sa baga iba din yung root pero still yung congestion will be playing a big big role in these problems I'd like to ask Jean also because Jean recently you've been talking about tuberculosis and how it has increased during this pandemic would you like to share a little bit more information on that? Thank you Dr. Suzino We have observed a lot of we have three groups of patients with TB and COVID those who are still on medication early part or the intensive phase of medication and they get COVID in the community those who have previous TB and has been completed treatment they have COVID and then those with HIV who have TB and with COVID so these are the three groups that we have in our most of our hospitals and they really present with severe manifestations in the group of HIV and TB with COVID okay I think the most predominating symptom is the HIV and the TB and the usual clinical presentation is expiratory failure but they usually don't present with the bilateral, the ground glass and severe immunocompromise those with the history those with during the intensive phase of TB and then at COVID these are the patients that really present with the plurid manifestations of COVID so in a way I think the message here is that when you have these co-infections some or one of the infections there can dominate over the other like for example if I can take with lepto and COVID this data presented by Dr. Daniela those lepto patients whose age group are in the younger age group they may present with they may be positive with COVID but I think the most dominant presentation is still lepto because of the acuteness and then you have more of the load of the leptospires which really triggers more of the pulmonary hemorrhage and the renal failure over that of the COVID infection right, yeah Penji, would you like to comment on that on other infections? I mean I guess in terms of infections that later turn into kidney disease what are your thoughts on this? Penji, you're on mute that's very true Susie it's been shown in the literature that if a patient develops acute kidney injury even without any other comorbid factors the fact of getting acute kidney injury if you follow them forward a good percentage of them will develop chronic kidney disease so as in COVID we're seeing that it's producing permanent lung damage, the long COVID sort of type of patient with the kidneys we're also seeing the same thing so it's very important to really try to prevent getting acute kidney disease it's so important with lepto that we do our prophylaxis with exposure it's something that's what we are really trying to bring that out in the media so that with prophylaxis you can prevent these very severe complications of having acute kidney injury and requiring dialysis so I would like to comment on the comments of Dr. Solante I agree with him that the younger people will tend to manifest mainly with leptospirosis so you can see from our data that their mortality wasn't that high but if your patient has very severe acute deterioration in their lung findings then they will probably be manifesting more of the COVID and probably be a little bit older elderly people again that will help us but the way we treat them is probably very similar because we're very aggressive with steroids in all of these patients of course the pulmonary support again also very aggressive so but we're happy to see that the co-infection although inflammation wise the markers may be higher for the co-infection their survival is better in a lot of these patients thank you Eric did you want to comment on this? Yes Susie not every area in the country will have facilities like the NKTI so the physicians will be encumbered with deciding if this is COVID-19 or something else okay it's good that and Dr. Benji we're able to share some parameters as well as Dr. Nina but in other areas this is going to be difficult they're not going to get fever at thin levels they're not going to get they will not determine a cytokine storm they just have to have that experience that the NKTI at Nasurang Hospital should have established their telemedicine so that the other areas can benefit and they can have telemetering so that in their situation even without these parameters they can actually make a diagnosis and treatment so that not everyone goes to the National Canadian Transplant Institute this is going to be really for us especially if there's really will be a surge of the Delta virus over Susie thank you very much Eric, I think that that suggestion is going to you Raymond as the head of the National Telehealth Center Baja this is time for us to think through with the PGH group and Chan's dementia is with us also maybe she can comment on it later but to think through how do we bring the expertise I like the idea of telemetering sort of helping our doctors out there who don't have the facilities of NKTI and San Lazaro so Raymond that suggestion is for you very timely rin po kasi I think PhilHealth has already worked out a telehealth related package po for reimbursement so that's something to think about there are also enabling policies na together with the DILG that the DOH and PhilHealth have moved forward so that's something that will be helpful for the future especially even after wala na po COVID na meron po tayo I think since we're talking about it and there is seemingly an increase in leptospirosis cases maybe offline we can have conversation with Benji and Gene and see what we can do but anyway Raymond let's go to the answers to the questions of our fun quiz okay thank you so much TVUP may we have the well at least the Mentimeter po yan okay thank you so much dalawa po ang ating katanungan for today I don't know if ating mga regulars notice I think this is the very first time that we have two questions na in Filipino maybe it's the buwan ng wika effect but it's something of course buwan ng wika at may effect ko ang dalawang katanungan po ay anong hayop ang nagdadala ng leptospirosis so the options that we have here rats, dogs, cows, pigs, carabaus, goats all of the above and none of the above there's at least 9% respondents who answered all of the above but the overwhelming majority chose rats and then for our second question our second question po there we go our second question ano ang mga sin tomas ng leptospirosis nakatulad ng COVID-19 ito na po it's a little bit disperse but 86% chose all of the above followed by 8% ng fever and then medyo tayo na po yung iba joint pain muscle aches, chills, headaches and none of the above so who would like to give po I mean just a reiteration of the answer the first question po I think si Dean Nina Gloryani should answer the first question okay ano lahat as I presented earlier but of course ang talagang main maintenance house kasi ito mga rats kaya healthy sila lalo silang dumadami dala nila sa kidney sila sa ihinila yung leptom but all the others we found may antibody some exposure ito ito mga dogs especially yung siguro baka yung mga ascal kasi yung mga na sa private yung mga may mga breed na dogs may mga bacuna at least actually protected dahil nga hindi kasama yung mga si reverse that we have may partial protection but those around us lalo yung mga nakita yung sa mga flood panghawak-hawak nila na do so flood na paihisi si dong yun naman yaya makakarun ng environmental contamination and then do sa rural areas we found especially yung goat na actually may na isolate kami na isang siro bar sa region 6 and then sa carabaus matahas ang positivity nila so if you handle these animals it is possible yung mga aba 12 workers yung mga occupational occupationally at least we have to be very careful with our people Doc Nina meron mga nagtatanong dito ay yung cats now hindi namin na pesay although may counting reports na pwede ring positive ang cats Susi ayana natin yung pusa habulin yung rats ang ngayon, importante yung pinag-uusapan niyan sa pagkat kung rats yun alam na natin yung intervention kasi baka mamaya aso ang nakikita nyo po napat yung basura po natin na didikpit po natin ng mga ayos yung po hinahanap ng rats over Susi Raymond Thank you very much Eric and I wanted to ask again going back to Dean Nina you were saying that the rats don't get sick so yung mga daga hindi po sinagkakasakit parang maligalig lang sila daladala nila yung leptospira na yan pero hindi sinagkakasakit pero Dean Nina yung mga aso ba kalabau ba ka kambing na kakasakit ba sila yes, kakasakit sila although merong mga parang mild infection I will go un-detected as I mentioned pero itong dogs, they get sick yung sinabi ko yung reproductive drug can be affected meron din yung liver nila kidneys din nila affected siyempe di naman ako vet pero may tumingin sa ang penis na on meron silang signs and symptoms na parang human din Okay, thank you very much Alright, so I think we all learned a lot of things today Let's go to the second question, Raymond Second question po, thank you TVUP, second question Who do we throw this to, Dr. Susie? Maybe to Jean or Pengie Ano mga symptoms na katulad na lep ng COVID Let's ask both of them So let's go to Dr. Jean Solante Yeah, I think although the most common is fever but they also have joint pain, it's also part of that and then, all of these all of the above is the answer Okay, Pengie, would you like to add something to that or you have any comment on this question? Yeah, although it's common in both I would say if a patient complains more of myalgia, especially in standard myalgia and then conjunctival subfusion, that's more of lepto So the polypata orange cord Okay Very painful, tender muscles So that's way more of lepto The way we're looking at it here Okay, great Raymond, let's go to our upvoted questions Meron ba tayo from the audience? We have a couple, Dr. Susie but I'd like to get this one This one comes from our regular Dr. Joseph Tortona It's about convincing the general populace of strict COVID-19 protocols plus strict lepto health protocols How how should the government do this against the well, in a context na may problema sa vaccination, I think a lot of us have seen viral videos and photos laspinyas, manila, et cetera on how it became a little bit rowdy kong baga and is there any role for the private sector in terms of disseminating that information to help Okay Maybe that goes to Eric Eric, go ahead Thank you, Raymond. Thank you, Susie It's about repeating the same messages again and again and again. They heard it They have to hear it again and again again. So for our ECQ masking not going outdoors if it's unnecessary and of course if you have the symptoms, you really have to have yourself tested and if you have any doubts this is the DOH COVID-19 hotline 1555 so that we can make things easier for you. That's for your teleconsultation UPPJ also has medicine services and many are having this and it's going to be difficult unless people are actually listening and we have to show them how it's done that's how behavior are changed. It takes time but people can get very anxious and they will put their guard down especially those who have been fully vaccinated. That's a no-no so you still have to think of social distancing going only outdoors if necessary, indoors is a no-no if these indoors are settings do not have the ventilation Over to see Raymond. Thank you Raymond. Do you have one more question because I think we're approaching the top of the hour so any quick question we can throw at our time. So I'll be combining this question and this is our most upvoted question and with one of similar questions that we have outside of the zoom and it's about prophylaxis for taking doxycycline any particular message that our doctors may need to impart just be very clear as to prophylaxis intake of the drugs Raymond, can I get the Go ahead Dr. Jin Actually that's part of the prevention and I think we have emphasized as much as possible if we can prevent from waiting in the flood areas that's the most important prophylaxis or protecting ourselves. The antibiotic prophylax just have to be careful with this and it should be guided by a prescription or it should be monitored by a doctor because of possible side effects Sometimes we tend to take more than what is prescribed something like that. So you just also don't want to escalate problem of drug resistance. That's all Raymond. Thank you Jin Eric did you want to add to that? You're in mute Eric. Okay I mean now what we can do is that not to actually recommend this strongly without prescription because this can easily be abused and so we want to warn everyone that using the antibiotics there are contraindications especially to children less than 8 years old and women who are pregnant and it needs prescription and several studies have shown that giving this prophylaxis favors those persons at high risk like those involved in rescue and relief. Okay over Susie Thank you very much Eric. So again no let's not self-medicate but I think the deeper message there is relax lang tayo. Let's still come because if we I understand people are anxious they're worried they're seeing people get infected with COVID but we have a role to play I think in just helping people calm down because if you're not calm you won't be able to think right and start doing things that might not really help you but actually could be damaging. So you know take a deep breath when you're with people who are very anxious ask them to breathe with you and this just calm down. Yilipas din ito, huhuparin ito pero nasa sa atin ang frontliners bahagi tayo ng pagpapakalaman ng tao kasi pagkagpanik ang mga tao ko ano-ano naisip nilang gagawin out of fear so we don't want that. We want people to have information but we want people to stay steady and calm. Alright so we're going to ask our panelists to give their questions from Penji Dangilan from the National Kidney Institute. Penji go ahead. Yeah so it's really left to see so now so it was because of the floods maybe a week two weeks ago so everyone please be careful if you're exposed to floods or you're in an area where or like you work in a specific place where you have a lot of exposure please see your doctor you might need prophylaxis and it will help prevent severe disease we see a lot of patients going into acute kidney failure needing dialysis, needing a respirator going on ECMO and we don't want to see this so please take care where the proper clothes know if you want to wear a raincoat boots to do work please do so also we want everybody to take care because it's COVID as mentioned by everyone stay at home if you don't really have to go out and you'll really be helping your family if you stay safe and stay hope together thanks so much Suzy and Reibon thank you very much that's Dr. Dangilan from the National Kidney Institute let's go to Dean Nina Gloriani please your parting words para ang dapat sabihin stay home kahit left to yan, kahit COVID-19 coming from the vaccine expert panel sa yung bakuna so I'm glad na do on the street they still want to get vaccinated and that's really very good kasing atong Delta variant ang kalaba natin dito, unahan natin siya do not want it to take over us and any other variant that will come in so yan, left to end COVID ayaw natin yan stay home stay home thank you very much Dr. Jean Solante of San Lazaro thank you, sundan ko na yung sinasabi ng boss ko sa VEP so tutuwa tayo na maraming magpapapakuna pero alalahan nandin natin we have to remind everyone kung magpapakuna kayo tapos may baha you can always prevent from getting left so mas maigin na magingat pa rin especially for this time na mataas pa rin ang tagulan at marami pa rin pwede ang magkasakit ng left thank you very much Dr. Jean Solante of San Lazaro Hospital will go to Maharlagmay of the UP Resilience Institute Maharlagmay let's see what's happening to Dr. Maharlagmay okay, I was prevented from unmuting and showing my video anyway ang problema ng disasters ay problema na harapin natin hindi lang ngayon in the next years and in the next generations so kailangan natin talagang gawing part ng culture natin na maging maalam na palaging iniintindi and conscious tayo sa mga problema sa mga natural hazards and we need to plan we need to always plan know our neighborhood and we have to be educated on all types of hazards na kailangan natin malaman so very long process I think education is very very important in getting all of the Filipinos to be able to contribute to the disaster management efforts of the country because it's not just the problem of government it's everybody's problem so the solution also will come from the people so lahat na mga ating early warning actions early warning systems as well need to be people centered we need to be engaged all of us need to be engaged and it's very important to anticipate even the bigger events than what we have experience or what we know we have to incorporate it in the planning process from the city municipality or LGU level down to barangay level even up to family level so dapat nag-usap usap tayo palagi na hala answers questions about hazards where they are ma-affectuhan ba kayo and all sorts of other information that we can get pagwala hiniin sa goberno hiliin sa mayor pag meron, kailangan alam natin and all of us have a role to play kung alam na natin we have to tell our cousins, our relatives of the information that we were able to learn so we must develop a culture of safety because hazards will always be here in the Philippines we are in a country that is in the typhoon belt in the pacific ring of fire and we have all sorts of hazards that we know of except probably for snow related hazards and we really need to develop that kind of culture for us to survive thank you ok, thank you very much as Dr. Mahar Lagmay of the Resilience Institute and let's have our final words also from Dr. Eric Tayag Eric, please go ahead Susie, thank you Professor Mahar, Dr. Jean Dr. Nina and everyone including Raymond and everyone who is watching now we can do this dun sa mga kababayan natin biglang na niniwala po at hindi nyo alam ko nyan ay fake news, ay chismis ang may papayo po namin sa inyong po ay kumuha kayo na information sa trusted sources andami-dami po nyan ang hiratira po kasi malina nga po yung puwan yung information hindi po maganda behavior at practice hindi po natin yung kailangan hindi po makakatudong dito sa webinar nito ayyan, takakawa kayo nantamang information pero magiisip pa rin tayo at huli ko masasabi po ang information po namin yun, baka bukas luma na so hindi to disclaimer ganun tu talagang information nagbabago magkakalan na magkakaruntayon ng Delta variant so ito po ay nantabayanan natin kumukata yung information kailangan po itas natin yung science literacy hindi po nakakalungkod po na marami sa atin ayang mababao ang science literacy kaya ayyan magkakaruntayon ng problema sa messaging over Susie Raymond, before we call on Chansey Manchit, I think you want to do the evaluation. Go ahead. Thank you and thank you for the wonderful parting words from each of our speakers po. As shown on the screen, I don't know who close the poll but there are five questions here for those who are asking, I will try to figure out how to reopen it, but the five questions are as follows, the panelists demonstrated thorough knowledge of the topic the panelists were well-prepared and organized the panelists spoke clearly and audibly the panelists used appropriate language with technical medical jargon adequately explained and number five, the panelists contributed to new perspectives and knowledge on managing various key COVID-19 health issues it's a Likert scale so I'm just looking at na po ano except for one, I think all of them reached 90% and we're very happy because it's that's very consistent with our previous 63 webinars that we have had so far. Over to you, Dr. Suzie. Once we will keep that open or it's closed na? Someone closed it so that's why we were able to share the results. Okay, let's try moksan yan. Let's go now to our closing remarks from Chancellor Manila Manchit, please go ahead. Thank you, Dr. Suzie. Dr. Mahalagmay started, opened our session today and he discussed the commonly encountered natural and man-made disasters in the Philippines and note that the Philippines is part of the Pacific Rim of Fire and the Typhoon Belt. For the natural hazards, he mentioned the volcanic eruptions earthquakes and the heavy rains leading to flooding. For the man-made disaster, I think it's worthy to note that he mentioned that even the reduction of the Lameza Dam water level is considered a man-made disaster. So Dr. Mahalagmay wanted us that planning must be anticipatory and we should not only plan for the phenomena but also plan for the consequences of the hazards. It's just like when you have your earthquake drill, you just stop planning for the drill but actually also for what will be the consequences of an earthquake after the phenomenon. So Dr. Mahalagmay reminds us be anticipatory in planning. We've got to know our place of residence and work and over all part of a city, he said that we've got to be planning should be at the level the city or municipality level because all sectors must be involved. And it is in this kind of meetings where hazard maps are discussed and Dr. Mahalagmay mentioned that they will soon upload these maps in their website at the Resilience Institute so that we can plan as a team. But I'd like you to go back to the replay because he actually showed the lessons from past disasters and I think learning from the past is so important and it is a reminder on how we can prepare better. So Dr. Mahalagmay actually ended his sharing by reiterating that we need the whole of society approach for disaster and that we must use science-based solutions. Now our next two speakers are next to doctors Dr. Salantin and Dr. Dinglin actually shared a couple of data so allow me to present their points together in this part. One, they share their experiences in their respective hospital, San Lazaro Hospital at MKTI. I really appreciated the data when Dr. Salantin said in San Lazaro they had a 13% increase in leprospirosis this year compared to last year and the fatality rate that's also slightly higher of 11.4%. Now of course MKTI being a highly specialized hospital for kidney diseases had additional challenges of having a lot of patients undergoing dialysis. But what was actually interesting for us now and I'd like to go back and review them wherein they show the differences between the similarities rather and the differences between the two conditions. In other words, COVID alone leprospirosis alone and then COVID and lepto together. But what is clear when there is a history of waiting in the flat then of course you first think of leprospirosis. Now from both presentations they show the challenges of the overlapping symptoms like fever, myalgia, head ache and ARDS. But there are certain clues both of them mentioned this. When you have the contriomtival suffusion the cuff tenderness when you've got anuria, oliguria elevated VUN priatinate somehow it tells you that you probably are dealing with a leptospirosis. There were excellent discussions I'd like to go back to the replay and look at the presumptive diagnosis definitive diagnosis and as well as there were tips on what will be the indications for admission. Now for management it's important to see how they're managed individually and together. But what I've heard from Dr. Daniela and Dr. Solante is that treatment is always aggressive because of the complexity of both conditions. Now the mention by Dr. Daniela in biomarkers is probably a good clue for us clinicians and other health workers in the audience because what they've shown is that the additional biomarkers like LDH, ferritin, CRP and so on show that they actually have higher values with the higher values. So I'd like you to go back to the replay go back to this part about the symptoms the treatment, admission and so on but what is clear from both is that what is important for us clinicians for us health workers in the audience is that early recognition and early treatment will improve survival. Now the next reactor actually is Dr. Dr. Nina Gloriani who talked about the connectedness of disasters and infectious diseases and instead of just limiting it to flooding she did mention that there are occupational exposures both a person at risk for leptospirosis and that will be some exposures of some occupations where in you're exposed to animals and of course there are leisure also that are included so it's not just flooding and also from her lecture we learned that it's not just the rats they have enough data they have looked at other animals cows, dogs, pigs, caribals and goats showing to also levels of leptospirosis so when you are exposed to these animals who are infected and you have a cut for abrasion in the skin of course there is the risk for that infection I do want to mention the three modes of control for leptospirosis and she talks about control of the source of transmission number two is controlling transmission through vaccinations of the animals and number three is control at the level of the humans and that's for the early diagnosis and treatment so you've got to look at these three angles of control to have an effective approach to the control of leptospirosis now Dr. Eric Tyag reminded us when you're in the province you will not be able to get all of these biomarkers on hand to help you make a diagnosis and for that Dr. Eric Tyag recommended actually that we establish the telemetering for the provinces so that they will have the opportunity of actually engaging with specialists who will tell them how to manage these patients with joint infection COVID-19 leptospirosis and I'm going to challenge doctors to take this on as a a successful project to make sure that we are able to help them and I think there are efforts now both at the Department of Health as well as UP Manila and feel to make sure that the telehealth becomes a regular component in the care of our patients so in closing let us remember that COVID-19 may eventually be resolved leptospirosis can eventually be eradicated but the Philippines will continue to be a disaster from country so let us keep the messages of Dr. Mahar anticipate, plan, be engaged regardless of what your profession is all of us have a role to play to make sure that regardless of what infection comes our way it will not complicate the presence of a disaster in our country so sa araw na ito hindi lang bakuna para sa COVID ang dapat pandaan meron din bakuna laban sa lepto para sa mga hayo Back to you Susie and Raymond Thank you very much UP Chancellor UP Manila Chancellor Manchit Padilla I think we had a great webinar I'd like to thank everyone thank all of our panelists our presenters for excellent presentations alam nyo yung mga speakers natin kinakarir nila yung mga powerpoint nila to get you the latest data because we want to continue community for you bringing you the best speakers and next week we have another very exciting topic we are going to talk about COVID-19 and teen age pregnancy bakit naman pag-usapan nyo alam nyo ba na itong 2020 there were 70,000 70,000 teen age deliveries for the whole year that's like if we average 991 girls at the ages of 10 to parang 10 to 50 eong ko anong age po itong but teen age so teen age means up to 16, 17, 18 may teen pero karamiyan dito yung 10 to 14 years old and they project that this will double in 2021 that means about deliveries of young girls who got pregnant during this pandemic the lockdown what are the circumstances for this we will find out bakit nangyayari ito and as frontliners what are we supposed to do when you have a teen age a pregnant teen age who probably let's say has COVID symptoms what are you going to do so we're going to have very good experts some of you have already met secret nalang di ko sa sabihin po ang sino pero tapik po natin COVID-19 and teen age pregnancy so don't miss it and invite your teams to watch lalo na yung team natin sa barangay mga midwives et cetera kasi ang dami para dam natin problema hindi kaya natin ito okay remod over to yung thank you doctor Susie well really quick sneak peek into our episode for next week we will have well it's a little bit different na naman po in terms of how the structure will be pakaiabangan na lang po kung sino po ang ating resource persons who will be attending and hope this is of interest especially to everyone this will be co-sponsored by the Philippine obstetrics and gynecology society so before before we conclude I'd like to acknowledge po the very hard working team behind the stop COVID-19's webinar series thank you to each and everyone maraming salamat po also for those who are asking about the certificates of attendance yes we are still sending out certificates and only those who have attended 50% of the time sa webinar po at least in the zoom duration sa webinar duration po will be eligible to receive a certificate of attendance so please take note that you can also watch all of these sa playback po in all of the social media accounts that we have especially in Facebook but also in the YouTube channel of TVUP you will see on the screen po all 63 and will be 64 po no either tonight or tomorrow you can watch po later will be very interesting how we have evolved through the last 64 weeks sa ating webinar series so this brings our webinar for this week to a close we look forward to your company again next week it's a date together we can stop COVID-19 so keep safe, keep healthy and see you online thank you oh god how long is this going on and if you're here to keep me strong I'm here to hold the line oh keep my hands until my hands say his name to real just hold on to the word he gave this time will come to pass because this salvation makes a last you'll carry you to see the break up the others pained the others laughs before my tears but right behind the mask look into myself and ask do I have strength to carry on oh god how long is this going on and if you're here to keep me strong I'm here to hold the line oh keep my head word until my hands die my fears before my tears but right behind the mask look into myself and ask do I have strength to carry on or be strong out of pain before my tears pushing on the spite of tears these things through another day