# data[].attributes.headline
During the fourth year of American War, on November 1902 lasted till early of February 1904.

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During the fourth year of American War, on November 1902 lasted till early of February 1904.

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April 16, 1902 - General Malvar surrendered to put an end of his countrymean.

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April 16, 1902 - General Malvar surrendered to put an end of his countrymean.

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During the 1902-1904 Epidemic: 166, 252 cases and 109,461 estimated deaths were reported 

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During the 1902-1904 Epidemic: 166, 252 cases and 109,461 estimated deaths were reported 

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https://jamanetwork.com/journals/jama/article-abstract/462583

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Shortage of food and medical supplies because of borderline quarantine

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Shortage of food and medical supplies because of borderline quarantine

# data[].attributes.headline
 In Farolla, a barrio near Pasig River. 

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 In Farolla, a barrio near Pasig River. 

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First chorela case. Farolla a barrio near Pasig River.This was because of the incoming vessels that is coming from Hong Kong that is been transported in rivers of Pasig.

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In April 12 1902 U.S Commander at Calamba, Laguna 

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In April 12 1902 U.S Commander at Calamba, Laguna 

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In April 12 1902 U.S Commander at Calamba, Laguna witnessed a suspected first case of Cholera in a bario and they decided to burned the nipa hut of the suspected person to stop the spread of virus.

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Government Order 66 was implemented which stipulated,among other things, that nipa houses of cholera cases were to be burned, while houses constructed of wood were to be disinfected.

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It is evident that the impacts of containment measures are critical in preventing the spread of infectious diseases. The analogy between COVID-19 and cholera illustrates how urgently and comprehensively measures must be implemented in order to contain outbreaks and protect public health. It is critical that individuals, organizations, and governments work together to maintain containment measures including social distancing, testing, contact tracing, and immunization in order to halt the spread of illnesses and decrease their impacts. By thinking about the experiences with cholera and COVID-19, we can obtain vital insight into the effectiveness of containment techniques and the necessity of early and well-coordinated actions in handling public health emergencies.

Having to deal with both COVID-19 and cholera as public health professionals is an extremely difficult aspect of their job in protecting our health. Similar to frontliners, they continue to be responsible even when others pass away or do so quickly. The people who conduct experiments and create vaccinations deserve our gratitude because, despite their hard job, they genuinely care about us. Therefore, one of the public health officials and I should collaborate to stop this spiral of chaos.

As a people, we ought to be ready for anything since we have no idea what will occur after this. Always be mindful of your surroundings, try to keep your space as sterile as possible, and understand how to communicate effectively when handling public health emergencies. Exercise extra caution, research reliable sources, interact with the community, and be informed about public health emergencies. In actuality, epidemics aid public health officials in being more vigilant and ready for any future health emergencies.

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During 1902 in Tondo where there is a lot of corpses laying in ground, American Government are worried if they will just bury the corpses on the ground that water tables would be infected. Instead they come up with a solution of cremation and the burial of corpses inside a metal coffin and bury them 7 feet deep.

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As we can see, the Philippines and other countries are mostly concerned about cholera and COVID-19. The cholera virus, which can spread through tainted food and water supplies, can cause diarrhea and dehydration. The government is working to improve access to clean water, food, and sanitation infrastructure in the Philippines, which is suffering from poor sanitation and a lack of clean water. This is being done to stop the spread of cholera, which is spread by COVID-19 and is contracted through the respiratory system. The Philippines is indeed going through a pandemic, and in order to stop the virus from spreading, health authorities are implementing lockdowns, testing, contact tracing, and vaccine drives.

To effectively address COVID-19 and cholera, it is imperative that the health authorities in the Philippines employ techniques for surveillance, prevention, and response. Public awareness, accessibility to healthcare facilities, and a dedication to preventative measures are essential in the fight against these diseases. To learn more about COVID-19 and cholera in particular, we could contact the Philippine Department of Health or our local health authorities.

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Inside Manila, infected homes were marked with a red flag to signal people to stay away while loved ones were cared for.

https://www.edwardianpromenade.com/colonies/philippinescholera/#:~:text=Any%20houses%20found%20to%20be,carrying%20the%20disease%20with%20them.

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On December 31, 2019, was the first ever recorded Covid-19 case and it was located at Wuhan, China.

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Gianfranco Spiteri, ¹ James Fielding, ² Michaela Diercke, ³ Christine Campese, ⁴ Vincent Enouf, ⁵ Alexandre Gaymard, ⁶ Antonino Bella, ⁷ Paola Sognamiglio, ⁸ Maria José Sierra Moros, ⁹ Antonio Nicolau Riutort, ¹⁰ Yulia V. Demina, ¹¹ Romain Mahieu, ¹² Markku Broas, ¹³ Malin Bengnér, ¹⁴ Silke Buda, ³ Julia Schilling, ³ Laurent Filleul, ¹⁵ Agnès Lepoutre, ¹⁶ Christine Saura, ¹⁷ Alexandra Mailles, ⁴ Daniel Levy-Bruhl, ⁴ Bruno Coignard, ⁴ Sibylle Bernard-Stoecklin, ⁴ Sylvie Behillil, ⁵ Sylvie van der Werf, ⁵ Martine Valette, ⁶ Bruno Lina, ⁶ Flavia Riccardo, ⁷ Emanuele Nicastri, ⁸ Inmaculada Casas, ¹⁸ Amparo Larrauri, ¹⁹ Magdalena Salom Castell, ²⁰ Francisco Pozo, ¹⁸ Rinat A. Maksyutov, ²¹ Charlotte Martin, ²² Marc Van Ranst, ²³ Nathalie Bossuyt, ²⁴ Lotta Siira, ²⁵ Jussi Sane, ²⁶ Karin Tegmark-Wisell, ²⁷ Maria Palmérus, ²⁸ Eeva K. Broberg, ¹ Julien Beauté, ¹ Pernille Jorgensen, ² Nick Bundle, ¹ Dmitriy Pereyaslov, ² Cornelia Adlhoch, ¹ Jukka Pukkila, ² Richard Pebody, ² Sonja Olsen, 2, ²⁹ and Bruno Christian Ciancio 1, ²⁹

Abstract

In the WHO European Region, COVID-19 surveillance was implemented 27 January 2020. We detail the first European cases. As at 21 February, nine European countries reported 47 cases. Among 38 cases studied, 21 were linked to two clusters in Germany and France, 14 were infected in China. Median case age was 42 years; 25 were male. Late detection of the clusters' index cases delayed isolation of further local cases. As at 5 March, there were 4,250 cases.

Keywords: COVID-19, Novel coronavirus, SARS-COV-2, SARS, coronavirus disease 2019

A cluster of pneumonia of unknown origin was identified in Wuhan, China, in December 2019 [ 1]. On 12 January 2020, Chinese authorities shared the sequence of a novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) isolated from some clustered cases [ 2]. Since then, the disease caused by SARS-CoV-2 has been named coronavirus disease 2019 (COVID-19). As at 21 February 2020, the virus had spread rapidly mostly within China but also to 28 other countries, including in the World Health Organization (WHO) European Region [ 3- 5]. Here we describe the epidemiology of the first cases of COVID-19 in this region, excluding cases reported in the United Kingdom (UK), as at 21 February 2020. The study includes a comparison between cases detected among travellers from China and cases whose infection was acquired due to subsequent local transmission.

Surveillance in the WHO European Region

On 27 January 2020, the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe asked countries to complete a WHO standard COVID-19 case report form for all confirmed and probable cases according to WHO criteria [ 6- 8]. The overall aim of surveillance at this time was to support the global strategy of containment of COVID-19 with rapid identification and follow-up of cases linked to affected countries in order to minimise onward transmission. The surveillance objectives were to: describe the key epidemiological and clinical characteristics of COVID-19 cases detected in Europe; inform country preparedness; and improve further case detection and management. Data collected included demographics, history of recent travel to affected areas, close contact with a probable or confirmed COVID-19 case, underlying conditions, signs and symptoms of disease at onset, type of specimens from which the virus was detected, and clinical outcome. The WHO case definition was adopted for surveillance: a confirmed case was a person with laboratory confirmation of SARS-CoV-2 infection (ECDC recommended two separate SARS-CoV-2 RT-PCR tests), irrespective of clinical signs and symptoms, whereas a probable case was a suspect case for whom testing for SARS-CoV-2 was inconclusive or positive using a pan-coronavirus assay [ 8]. By 31 January 2020, 47 laboratories in 31 countries, including 38 laboratories in 24 European Union and European Economic Area (EU/EEA) countries, had diagnostic capability for SARS-CoV-2 available (close to 60% of countries in the WHO European Region), with cross-border shipment arrangements in place for many of those lacking domestic testing capacity. The remaining six EU/EEA countries were expected to have diagnostic testing available by mid-February [ 9].

Epidemiology of first cases in the European Region

As at 09:00 on 21 February 2020, 47 confirmed cases of COVID-19 were reported in the WHO European Region and one of these cases had died [ 4]. Data on 38 of these cases (i.e. all except the nine reported in the UK) are included in this analysis.

The first three cases detected were reported in France on 24 January 2020 and had onset of symptoms on 17, 19 and 23 January respectively [ 10]. The first death was reported on 15 February in France. As at 21 February, nine countries had reported cases ( Figure ): Belgium (1), Finland (1), France (12), Germany (16), Italy (3), Russia (2), Spain (2), Sweden (1) and the UK (9 - not included further).

COVID-19: coronavirus disease 2019; WHO: World Health Organization.

a Four cases were reported by Germany with unknown date of onset and unknown symptomatology. Belgium and France reported one asymptomatic case each. These cases are displayed according to their date of notification.

b The figure does not include nine cases reported in the United Kingdom.

The place of infection (assessed at national level based on an incubation period presumed to be up to 14 days [ 11], travel history and contact with probable or confirmed cases as per the case definition) was reported for 35 cases (missing for three cases), of whom 14 were infected in China (Hubei province: 10 cases; Shandong province: one case; province not reported for three cases). The remaining 21 cases were infected in Europe. Of these, 14 were linked to a cluster in Bavaria, Germany, and seven to a cluster in Haute-Savoie, France [ 12, 13]. Cases from the Bavarian cluster were reported from Germany and Spain, whereas cases from the Haute-Savoie cluster were reported from France and Spain. Cases linked to the Haute Savoie cluster were also detected in the UK, including the index case of this cluster, who was infected in Singapore before travelling to France [ 14]. The index cases for the cluster in Bavaria was reported to be infected in China [ 15].

The median age of the 38 cases was 42 years (range: 2-81 years) and 25 were male ( Table ). The proportion of male cases was higher among cases acquired in Europe (14 males of 21 cases) compared with those acquired in China (8 males of 14 cases) although the difference was not statistically significant (chi-squared test: p = 0.6). There was no difference in median age by sex (males: 45 years; females: 38 years, k-sample median test, p = 1.0) or by whether infection was acquired in Europe or not (acquired in Europe: 47 years; acquired in China: 38 years, p = 0.2).

Table

Characteristics

Number of cases overall

Number of cases infected in Europe

Number of cases infected in China

p valueb

Age range in years

Sex

Hospitalised

Symptoms c (31 cases with available information)

Mean days from onset to hospitalisation
(29 cases)

3.7

4.6

2.5

ND

Mean days from onset to first positive laboratory test
(16 cases)

5.1

6.5

5.2

ND

All but two cases were hospitalised (35 of 37 where information on hospitalisation was reported), although it is likely that most were hospitalised to isolate the person rather than because of severe disease. The time from onset of symptoms to hospitalisation (and isolation) ranged between 0 and 10 days with a mean of 3.7 days (reported for 29 cases). The mean number of days to hospitalisation was 2.5 days for cases imported from China, but 4.6 days for those infected in Europe. This was mostly a result of delays in identifying the index cases of the two clusters in France and Germany. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six took only a mean of 2 days to be hospitalised.

Symptoms at the point of diagnosis were reported for 31 cases. Two cases were asymptomatic and remained so until tested negative. The asymptomatic cases were tested as part of screening following repatriation and during contact tracing respectively. Of the remaining 29, 20 reported fever, 14 reported cough and eight reported weakness. Additional symptoms reported included headaches (6 cases), sore throat (2), rhinorrhoea (2), shortness of breath (2), myalgia (1), diarrhoea (1) and nausea (1). Fever was reported as the sole symptom for nine cases. In 16 of 29 symptomatic cases, the symptoms at diagnosis were consistent with the case definition for acute respiratory infection [ 16], although it is possible that cases presented additional symptoms after diagnosis and these were not reported.

Data on pre-existing conditions were reported for seven cases; five had no pre-existing conditions while one was reported to be obese and one had pre-existing cardiac disease. No data on clinical signs e.g. dyspnea etc. were reported for any of the 38 cases.

All hospitalised cases had a benign clinical evolution except four, two reported in Italy and two reported in France, all of whom developed viral pneumonia. All three cases who were aged 65 years or over were admitted to intensive care and required respiratory support and one French case died. The case who died was hospitalised for 21 days and required intensive care and mechanical ventilation for 19 days. The duration of hospitalisation was reported for 16 cases with a median of 13 days (range: 8-23 days). As at 21 February 2020, four cases were still hospitalised.

Laboratory diagnosis

All cases were confirmed according to specific assays targeting at least two separate genes (envelope (E) gene as a screening test and RNA-dependent RNA polymerase (RdRp) gene or nucleoprotein (N) gene for confirmation) [ 8, 17]. The specimen types tested were reported for 27 cases: 15 had positive nasopharyngeal swabs, nine had positive throat swabs, three cases had positive sputum, two had a positive nasal swab, one case had a positive nasopharyngeal aspirate and one a positive endotracheal aspirate.

Discussion

As at 09:00 on 21 February, few COVID-19 cases had been detected in Europe compared with Asia. However the situation is rapidly developing, with a large outbreak recently identified in northern Italy, with transmission in several municipalities and at least two deaths [ 18]. As at 5 March 2020, there are 4,250 cases including 113 deaths reported among 38 countries in the WHO European region [ 19].

In our analysis of early cases, we observed transmission in two broad contexts: sporadic cases among travellers from China (14 cases) and cases who acquired infection due to subsequent local transmission in Europe (21 cases). Our analysis shows that the time from symptom onset to hospitalisation/case isolation was about 3 days longer for locally acquired cases than for imported cases. People returning from affected areas are likely to have a low threshold to seek care and be tested when symptomatic, however delays in identifying the index cases of the two clusters in France and Germany meant that locally acquired cases took longer to be detected and isolated. Once the exposure is determined and contacts identified and quarantined (171 contacts in France and 200 in Germany for the clusters in Haute-Savoie and Bavaria, respectively), further cases are likely to be rapidly detected and isolated when they develop symptoms [ 15, 20]. In the German cluster, for example, the first three cases detected locally were hospitalised in a mean of 5.7 days, whereas the following six were hospitalised after a mean of 2 days. Locally acquired cases require significant resources for contact tracing and quarantine, and countries should be prepared to allocate considerable public health resources during the containment phase, should local clusters emerge in their population. In addition, prompt sharing of information on cases and contacts through international notification systems such as the International Health Regulations (IHR) mechanism and the European Commission's European Early Warning and Response System is essential to contain international spread of infection.

All of the imported cases had a history of travel to China. This was consistent with the epidemiological situation in Asia, and supported the recommendation for testing of suspected cases with travel history to China and potentially other areas of presumed ongoing community transmission. The situation has evolved rapidly since then, however, and the number of countries reporting COVID-19 transmission increased rapidly, notably with a large outbreak in northern Italy with 3,089 cases reported as at 5 March [ 18, 19]. Testing of suspected cases based on geographical risk of importation needs to be complemented with additional approaches to ensure early detection of local circulation of COVID-19, including through testing of severe acute respiratory infections in hospitals irrespectively of travel history as recommended in the WHO case definition updated on 27 February 2020 [ 21].

The clinical presentation observed in the cases in Europe is that of an acute respiratory infection. However, of the 31 cases with information on symptoms, 20 cases presented with fever and nine cases presented only with fever and no other symptoms. These findings, which are consistent with other published case series, have prompted ECDC to include fever among several clinical signs or symptoms indicative for the suspected case definition.

Three cases were aged 65 years or over. All required admission to intensive care and were tourists (imported cases). These findings could reflect the average older age of the tourist population compared with the local contacts exposed to infection in Europe and do not allow us to draw any conclusion on the proportion of severe cases that we could expect in the general population of Europe. Despite this, the finding of older individuals being at higher risk of a severe clinical course is consistent with the evidence from Chinese case series published so far although the majority of infections in China have been mild [ 22, 23].

This preliminary analysis is based on the first reported cases of COVID-19 cases in the WHO European Region. Given the small sample size, and limited completeness for some variables, all the results presented should be interpreted with caution.

With increasing numbers of cases in Europe, data from surveillance and investigations in the region can build on the evidence from countries in Asia experiencing more widespread transmission particularly on disease spectrum and the proportion of infections with severe outcome [ 22]. Understanding the infection-severity is critical to help plan for the impact on the healthcare system and the wider population. Serological studies are vital to understand the proportion of cases who are asymptomatic. Hospital-based surveillance could help estimate the incidence of severe cases and identify risk factors for severity and death. Established hospital surveillance systems that are in place for influenza and other diseases in Europe may be expanded for this purpose. In addition, a number of countries in Europe are adapting and, in some cases, already using existing sentinel primary care based surveillance systems for influenza to detect community transmission of SARS-CoV-2. This approach will be used globally to help identify evidence of widespread community transmission and, should the virus spread and containment no longer be deemed feasible, to monitor intensity of disease transmission, trends and its geographical spread.

Additional research is needed to complement surveillance data to build knowledge on the infectious period, modes of transmission, basic and effective reproduction numbers, and effectiveness of prevention and case management options also in settings outside of China. Such special studies are being conducted globally, including a cohort study on citizens repatriated from China to Europe, with the aim to extrapolate disease incidence and risk factors for infection in areas with community transmission. Countries together with ECDC and WHO, should use all opportunities to address these questions in a coordinated fashion at the European and global level.

Acknowledgements

We are grateful for the essential work of a large number of public health experts, clinical microbiologists, practitioners and clinicians who have been involved in the investigations at national and regional level including all the professionals of the Canarian Health Service and the Balearic Islands Health Service. We acknowledge the work of ECDC data manager, particularly Zsolt Bartha, and country cooperation teams in rapidly establishing the online reporting system in TESSy by 26 January 2020. We thank also the efforts of Catalin Albu, Adrian Prodan, Skaidra Kurapkiene, Per Rolfhamre and Anca Dragnea. ECDC also thanks the Epidemic Intelligence team that provides vital and timely data on global cases of COVID-19. WHO thanks Ka Yeung (Calvin) Cheng, Silviu Ciobanu, Gudrun Freidl, Lauren MacDonald, and Miriam Sneiderman for assistance with data management.

Funding statement: No specific funding.

The authors alone are responsible for the views presented in this manuscript and they do not necessarily reflect the views, decisions or policies of the institutions with which the authors are affiliated.

Notes

Conflict of interest: None declared.

Contributed by

Authors' contributions: EB and BC developed the surveillance system and reporting protocol. GS, JB, EB, CA, NB and BC initiated and developed the initial outline of the manuscript. GS performed the analysis. GS, BC, JB, NB, CA, EB wrote the first draft of the manuscript. JF, PJ, DP, JP, RP, SO contributed extensively to additional versions of the manuscript. MD, CC, VE, AG, AB, PS, MJSM, ANR, YVD, RoM, MBr, MBe, SBu, JS, LF, ALe, CS, AM, DLB, BC, SBS, SBe, SvdW, MV, BL, FR, EN, IC, ALa, MSC, FP, RiM, CM, MVR, NB, LS, SJ, KTW, MP were involved in national clinical, microbiological and public health investigations as well as data collection and reporting. All authors provided input to the outline, multiple versions of the manuscript and gave approval to the final draft.

References

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6. European Centre for Disease Prevention and Control (ECDC). 2019 novel coronavirus (nCoV) disease data Reporting Protocol Version 1, 27 Jan 2020.

9. Reusken CBEM, Broberg EK, Haagmans B, Meijer A, Corman VM, Papa A, et al.On Behalf Of Evd-LabNet And Erli-Net Laboratory readiness and response for novel coronavirus (2019-nCoV) in expert laboratories in 30 EU/EEA countries, January 2020. Euro Surveill. 2020;25(6):2000082. 10.2807/1560-7917.ES.2020.25.6.2000082 [[ PubMed] [ CrossRef] PMC free article] [ Google Scholar]

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Articles from Eurosurveillance are provided here courtesy of European Centre for Disease Prevention and Control

# data[].attributes.attachment_link.title
First cases of coronavirus disease 2019 (COVID-19) in the WHO European Region, 24 January to 21 February 2020

# data[].attributes.attachment_link.description
In the WHO European Region, COVID-19 surveillance was implemented 27 January 2020. We detail the first European cases. As at 21 February, nine European countries reported 47 cases. Among 38 cases studied, 21 were linked to two clusters in Germany and ...

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In 1902 during the peak of Cholera, the Americans organized their cholera hospitals by race: the tent line marked street A was “Chinatown,” street B was for the Spanish, street C for white Americans, street D for black Americans, and E through G for Filipinos

https://www.edwardianpromenade.com/colonies/philippinescholera/#:~:text=Any%20houses%20found%20to%20be,carrying%20the%20disease%20with%20them.

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On the 30th of January 2020 the Department of Health(DOH) recorded the first Covid-19 case in the Philippines and it was a Chinese National.

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Abstract

Background

Assessing the current understanding of future health care workers about the COVID-19 is very important in order to identify gaps that affect their perceptions and responses, which they can integrate into the people in the community.

Objective

This study aimed to investigate the knowledge, attitude, and practice towards COVID-19 of student nurses in Manila, Philippines.

Methods

This study utilized a descriptive cross-sectional survey of 314 individuals from October 2020 to December 2020 to evaluate the association of different factors to knowledge, attitude, and practice towards COVID-19. Frequency, percentage, mean, standard deviation, t-test, and one-way ANOVA were used to analyze the data gathered.

Results

The survey revealed that the respondents have a mean knowledge score of 18.76 ( SD = 1.64), a mean score for attitude of 26.58 ( SD = 2.71) and a mean score for practice of 4.26 ( SD = 0.93). A significant different were noted in terms of year level with level 3 having a higher mean score ( M = 19.01, F = 2.696, p = 0.046) compared to other levels and type of school, with public university students having a higher level of knowledge ( M = 18.97, t = 2.070, p = 0.039). In terms of attitude, females have higher mean scores ( M = 26.85, t = -2.630, p = 0.009 and students from public university have higher scores ( M = 2.81, t = -4.406, p = 0.000) than students from private university. For practice, a significant difference was noted in terms of year level, with level 3 students having a higher mean score ( M = 4.42, F = 3.180, p = 0.024) compared to other year levels.

Conclusion

Filipino student nurses have a high level of knowledge about COVID-19 and are mainly optimistic about controlling the pandemic. Nevertheless, having constant reminder from the authorities and health care professionals are the solution to aid public knowledge and comprehension relating to COVID-19.

Keywords: COVID-19, nursing, students, knowledge, attitude, practice, Philippines

A new strain of flu-causing coronavirus has been spreading and affecting the lives of many. Reports showed that the first case was discovered in Wuhan, China, in December 2019, making Wuhan its place of origin (World Health Organization, 2020a). Formerly known to be 2019-nCoV, this new strain named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causes the illness coined as the Coronavirus disease 2019 (COVID-19) having mild symptoms of fever, dry cough, and tiredness to many severe symptoms of chest pain, shortness of breath or difficulty of breathing (World Health Organization, 2020b).

Experts believe that the virus can easily be transmitted when susceptible hosts inhaled small droplets that contain the virus, which is expelled from an infected person's nose or mouth through coughing, sneezing, or speaking. But as the experts continue to study more about this pathogen, it turns out that there are other ways how this is being transmitted (World Health Organization, 2020b). The virus began to spread rapidly, even having cases outside China, making the World Health Organization's Director-General declaring the outbreak a Public Health Emergency of International Concern. It spreads so fast that it became a pandemic just more than a month after the previous declaration (World Health Organization, 2020a).

As the virus continues to spread worldwide, the Philippines was not able to contain the virus outside its borders. On 30 January 2020, the Philippine Department of Health (DOH) recorded the first case of COVID-19 in the country with a Chinese national. On 7 March 2020, the first local transmission was reported (World Health Organization, 2020c). Precisely months have passed since the primary affirmed COVID-19 case was reported within the Philippines. The government executed numerous actions, including adherence to the guidelines and health protocols released by the WHO, contact tracing to immediately detect and isolate those who have close contacts with carriers, and strict community isolation in Metro Manila extending to Luzon as well as other parts of the country closing almost all establishments, such as shopping centers, hoping to contain the rapidly increasing cases within the bounds of the Philippines (World Health Organization, 2020d).

But despite these numerous actions, the country's situation seems to worsen as time goes by. Ten months after the first recorded case, the country has reported a total of 431,630 confirmed cases with total deaths of 8,392 (Elflain, 2020; Philippine Department of Health, 2020; World Health Organization, 2020e). This makes the Philippines the 2 nd country in Southeast Asia with the most number of confirmed cases and ranks 27 th globally (Elflain, 2020; Petterson et al., 2020; World Health Organization, 2020e). According to experts, a significant factor why COVID-19 cases persist to increase is due to faulty human behavior (Lee, 2020; Maragakis, 2020) and Filipinos are no exceptions. On 25 October 2020, Manila Bulletin released an article announcing that over 100,000 quarantine violators were arrested by the Philippine National Police (Chavez, 2020).

This shows that the success of the efforts of the government depends on people's adherence to preventive measures, which is affected by their knowledge, attitude, and practices. A study revealed that public knowledge is vital in response to outbreaks (University of Surrey, 2018), which means that public health educators are as crucial as other front liners, including student nurses.

In the Philippines, the Bachelor of Science in Nursing (BSN) is a four-year program that includes general and professional courses. Professional courses are threaded from the first year through the fourth year, emphasizing the concepts with corresponding Related Learning Experience (RLE). The BSN curriculum includes an intensive nursing practicum designed to improve nursing skills further and ensure that the BSN program results expected of an entry-level nurse are met (Commission on Higher Education, 2017). As early as in their 2 nd year in the BSN program, student nurses are taught how to educate people in the community. Assessing their current awareness and knowledge about this virus and its prevention can identify gaps that affect their perceptions and responses, which they can integrate into those people in the community.

COVID-19 is a new strain of infectious virus that has had a catastrophic effect on every individual within the short time it was first detected. Thus far, only a few published articles evaluate the knowledge, attitude, and practice of nursing students towards COVID-19. The novelty of this virus, together with its precariousness and serious threats, made it hard for health professionals and authorities to plan strategic action to stop the spread of the virus. To the best of our knowledge, this is the first study to examine COVID-19 knowledge, attitude, and practice related sociodemographic characteristics among student nurses in the Philippines. Thus, this study aims to determine the knowledge, attitude, and practice towards COVID-19 among student nurses in Manila, Philippines.

Methods

Study Design

This study utilized a descriptive cross-sectional survey to determine the level of knowledge, attitude, and practice towards COVID-19.

Participants

An online survey using the Likert scale was used to gather the necessary data for this study. Total enumeration of students from two Colleges of Nursing in Manila was included with a total of 314 student nurses. The inclusion criteria include: (1) nursing students studying in a college or a university, either public or private, in Metro Manila; (2) currently enrolled in the academic year 2020-2021; (3) have access to internet connection; (4) understands the English language; (5) and of legal age (18 years old and above) who can give informed consent.

Measures

This study utilized the questionnaire developed by Al-Hanawi et al. ( 2020) in order to measure the knowledge, attitude, and practice towards COVID-19 among nursing students. Respondents were asked about their knowledge using the 22-item Dichotomous questions where the questions were answered by yes or no with Cronbach's alpha coefficient of 0.71. In terms of attitudes, respondents were asked to answer six attitudinal statements and scored as 1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, and 5 = strongly agree. It has a Cronbach's alpha coefficient of 0.81. In the section of practice, respondents five practice statements to be answered by "yes" or "no" were asked, and a score of one was given for answers that denote a good practice, and a score of zero was given for answers that denoted bad practice. The total score ranged from zero to five, with high scores indicating better practices. The instrument was administered using the English language translation of Al-Hanawi et al. ( 2020). No translation was conducted since English is the medium of instruction in the BSN program in the Philippines.

Data Collection

This study involved the use of primary data collection using a self-administered questionnaire. Prior to data gathering, the researchers got approval from the College Dean through a letter of request to conduct this study. Permission to utilize the COVID-19 knowledge, attitude, and practice instrument was secured from the developer of the tool. Further, with the Dean's approval and a clearance from the ethics board, the researchers then collected the data using Google Forms. Given the physical distancing measures and other restrictions implemented, data were collected online to avoid face-to-face interactions during the course of the collection from October 2020 to December 2020.

Data Analysis

This study used frequency, percentage, mean, standard deviation, independent t-test, and one-way ANOVA to analyzed the data gathered from the respondents. The Shapiro Wilk test indicated that the data were normally distributed. The alpha level of significance was set at 0.05.

Ethical Considerations

This study was conducted in accordance with the established ethical standards of conducting research with human participants. The researchers obtained ethical clearance from San Beda University - Research Ethics Board with Protocol Number 2020-040. It was made sure that respondents were informed regarding the study's objectives, associated risks, and benefits of participation and encouraged to ask any questions regarding the study. Written consent was also secured when the respondents decided to participate.

Results

Table 1 shows the socio-demographic characteristics of the participants, which displays the mean knowledge score of 18.76 ( SD = 1.64), the mean attitude score of 26.58 ( SD = 2.71), and the mean practice score of 4.26 ( SD = 0.93). Of the total individuals, 77 (24.5%) were males and 234 (74.5%) were females, aged between 18 and 31. More than half of them were enrolled in private schools totaling 177 (56.4%) individuals, and the majority came from Level 1 with 122 (38.9%). These participants were also categorized according to their family's monthly income in Philippine peso (Php), with 112 (35.7%) in the less than Php 20,000 bracket, 59 (18.8%) in the Php 20,000-30,000 bracket, 29 (9.2%) in the Php 30,000-40,000 bracket, 26 (8.3%) in the Php 40,000-50,000 bracket, and 88 (28%) in the more than Php 50,000 bracket. The content of the next tables, Table 2 - ​-4, 4 , shows the participants' responses about knowledge, attitude, and practice towards COVID-19.

Table 1

Variable

Mean (SD)

n (%)

Knowledge

18.76 (1.64)

Attitude

26.58 (2.71)

Practice

4.26 (0.93)

Age

19.80 (1.54)

Gender
Male
Female

77 (24.5)
234 (74.5)

Year Level
1 st year
2 nd year
3 rd year
4 th year

Type of School
Public
Private

137 (43.6)
177 (56.4)

Income
Less than Php20,000
Php20,000 to Php30,000
Php30,000 to Php40000
Php40,000 to Php50,000
More than Php50,000

Table 2

Statements

n (%)

Correct Answer

Incorrect Answer

Table 3

Statement

n (%)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Table 5 shows the comparison of the characteristics of the participants with the level of knowledge, attitude, and practice. In terms of knowledge, a significant difference noted in terms of year level, with 3 rd year having a higher mean score ( M = 19.01, F = 2.696, p = 0.046) compared to other levels and type of school, with public university students having a higher level of knowledge ( M = 18.97, t = 2.070, p = 0.039) as compared to private university students.

Table 5

Variable

Knowledge score

Attitude score

Practice score

Mean

SD

F/t

p

Mean

SD

F/t

p

Mean

SD

F/t

p

Gender
Male
Female

18.62
18.80

1.97
1.52

-0.732

0.406

25.94
26.85

3.21
2.44

-2.630

0.009*

4.11
4.31

1.03
0.89

-1.594

0.112

Year Level
1 st year
2 nd year
3 rd year
4 th year

2.696

* 0.046

1.447

0.229

3.180

* 0.024

Type of School
Public
Private

18.97
18.59

1.64
1.63

2.070

* 0.039

25.83
27.15

2.81
2.49

-4.406

0.000*

4.22
4.29

0.94
0.93

-0.704

0.482

Income
Less than 20,000
20,000 to 30,000
30,000 to 40000
40,000 to 50,000
More than 50,000

0.780

0.539

1.396

0.235

1.327

0.260

In terms of attitude, females have higher mean scores ( M = 26.85, t = -2.630, p = 0.009 and students from public university have higher scores ( M = 2.81, t = -4.406, p = 0.000) than students from private university. For practice, a significant difference was noted in terms of year level, with 3 rd year students having a higher mean score ( M = 4.42, F = 3.180, p = 0.024) compared to other year levels.

Discussion

The objective of the study is to determine the significance of assessing the level of knowledge, attitude, and practice to be measured can serve as a guide (Azlan et al., 2020). These circumstances stipulate the necessity of public adherence to preventive and control measures, which is influenced by their knowledge, attitudes, and practices (Al-Hanawi et al., 2020).

The survey on 314 student nurses showed that the majority of the participants were aware of COVID-19 related knowledge, exhibit a positive attitude and dynamic practice throughout the outbreak showing the effect of massive public education campaigns, such as social media (Peng et al., 2020). Although this study shows that the participants were very much acquainted with the precautions, symptoms, and transmission of the virus, it also manifests that more than half of the participants were still convinced that having close contact or eating wild animals causes COVID-19. A total of 169 or 53.8% of the participants erroneously answered on this item. This exhibits that these participants still adhere to the claims that the virus came from bats that were ingested by people in a marketplace in Wuhan despite the fact that several reports are claiming that there may have animals that tested positive for this virus, but there is still no evidence to suggest that animals are capable of transmitting the infection to humans (Ohio State University, 2020; Centers for Disease Control and Prevention, 2021). Another significant error was 178 (56.7%) of the respondents believe that children are at higher risk for COVID-19 compared to adults who may be due to thinking that children have a weaker immune system, but experts believe that children are not at higher risk but is equally susceptible to the virus as adults do (Beusekom, 2020).

Several factors were also incorporated to see if there would be any differences in the knowledge of participants. Among the characteristics of the respondents, the year level and the type of school appear to have a significant difference. The study revealed that third-year students have a higher mean score than other levels. This is different from other studies that show a higher level of knowledge in fourth and fifth-year students (Noreen et al., 2020). This reflects the effectiveness of the new nursing curriculum where the nursing subject for communicable diseases is now embedded in the third year, giving them more opportunities to have further information about such diseases at an earlier time. It also came to light that students from public schools have a higher mean score than students from private schools, congruent with other studies (Peng et al., 2020). This may be rooted in private schools' inferiority in terms of numbers, including quantity and quality of students and teachers, as well as support from authorities (The World Bank, 2011).

The result for assessment of the participants' attitude exhibits notable data. Although almost all of them have a positive attitude in following measures to address the spreading of the virus, 39.2% of them think that the current situation will not be controlled anytime sooner. Nearly half of them (47.1%) also think that the country's austere measures will not be able to control this pandemic. These outcomes show a remarkable number of individuals who are not assertive in the government's movement and immediate response, including austere lockdowns, suspension of public transports, school classes, leisure activities, and implementation of a curfew in disparate cities. However, some of the participants have been pessimistic regarding this issue owing to the fact that people tend to experience negative emotions, such as panic and anxiety, throughout the time of the pandemic that could influence their attitude. Further, gender and the type of school were showed to have a significant difference. The results showed that women tend to be more optimistic and have a positive attitude towards this crisis which is also reflected in several studies (Noreen et al., 2020).

Overall, the majority of the participants abides by the control and preventive measures that the health workers along with the authorities enacted. This showed beyond doubt the eagerness of the participants to adjust and undergo behavioral changes in the face of the COVID-19 pandemic. The participants espoused good and safe practice for the reason that the government's palpable campaign towards the disease influenced the behavioral change of the individuals.

Based on our knowledge, this is the first study conducted to analyze the knowledge, attitude, and practice related to COVID-19 among student nurses in the Philippines. For that reason, it offers valuable information about public health education and prevention in Philippine universities during the COVID-19 pandemic. Our findings show that most Filipino undergraduate students have a basic understanding of COVID-19, though their performance varies by school type and year level. There is a difference based on gender and type of school based on the attitude towards COVID-19. These findings indicate that gender, year level, and type of school can influence students' responses to the COVID-19 outbreak and acquisition of public health education, which should be brought to the attention of educators and health officials. These factors should also be considered when developing contingency plans or preparation for students in the event of potential public health emergencies.

Conclusion

The current study was able to lay out an extensive exploration concerning the knowledge, attitude, and practice of the student nurses in the Philippines towards COVID-19. Knowledge about COVID-19 is pondered to be the first step in overcoming infectious disease. In addition, being educated about its basic information, such as its transmission and causes, increased the possibility of people being mindful of the spread of communicable diseases. The outcome proves that Filipino student nurses have a justifiable level of knowledge in the said disease and are mainly optimistic in their perspective in controlling the pandemic. Nevertheless, having constant reminder from the authorities and health care professionals are the solution to aid public knowledge and comprehension relating to COVID-19.

Acknowledgment

The authors would like to express their sincerest gratitude to all the students who participated in the study.

Declaration of Conflicting Interest

The authors have no conflict of interest to disclose.

Funding

This research did not receive any specific grant from funding agencies.

Author Contribution

All the authors have made a substantial contribution from conception to the finalization of this study. EZQ was involved in the conception of the study, data collection, and revising the article for important intellectual content. RRT was involved in the conception of the study, the collection of data, and editing the article for important intellectual content. GPS was in charge of the conception and design of the study, analysis and interpretation of data, and revising the article for important intellectual content. All authors approved the final version of the article.

Author Biographies

Earl Zedrick S. Quisao and Raven Rose R. Tayaba are Bachelor of Science Nursing students at San Beda University, College of Nursing, Manila, Metro Manila, Philippines.

Gil P. Soriano, MHPEd, RN is an Assistant Professor at San Beda University, College of Nursing, Manila, Metro Manila, Philippines, and at Wesleyan University Philippines, Graduate School, Cabanatuan City, Nueva Ecija, Philippines.

Data Availability Statement

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

References

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Noreen, K., Rubab, Z.-e., Umar, M., Rehman, R., Baig, M., & Baig, F. (2020). Knowledge, attitudes, and practices against the growing threat of COVID-19 among medical students of Pakistan. [[Plos One, 15(12), e0243696. 10.1371/journal.pone.0243696 PubMed] [CrossRef] PMC free article] [Google Scholar]

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Articles from Belitung Nursing Journal are provided here courtesy of Belitung Raya Foundation

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Knowledge, attitude, and practice towards COVID-19 among student nurses in Manila, Philippines: A cross-sectional study

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Assessing the current understanding of future health care workers about the COVID-19 is very important in order to identify gaps that affect their perceptions and responses, which they can integrate into the people in the community.This study aimed to ...

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In southwestern Luzon the situation became dire because of the war and epidemic that caused famine into their society.

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First case of Covid-19 death was recorded on February 1st of 2020. It was recorded by Department of Health(DOH).

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Edna M. Edrada, ¹ Edmundo B. Lopez, ¹ Jose Benito Villarama, ¹ Eumelia P. Salva Villarama, ¹ Bren F. Dagoc, ¹ Chris Smith, 2, ³ Ana Ria Sayo, ¹ Jeffrey A. Verona, ¹ Jamie Trifalgar-Arches, ¹ Jezreel Lazaro, ¹ Ellen Grace M. Balinas, ¹ Elizabeth Freda O. Telan, ¹ Lynsil Roy, ¹ Myvie Galon, ¹ Carl Hill N. Florida, ¹ Tatsuya Ukawa, ² Annavi Marie G. Villaneuva, ² Nobuo Saito, ⁴ Jean Raphael Nepomuceno, ² Koya Ariyoshi, ⁵ Celia Carlos, ⁶ Amalea Dulcene Nicolasora, ⁶ and Rontgene M. Solante ¹

Abstract

Background

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

Case presentation

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

Conclusions

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

Keywords: Case report, COVID-19, SARS-CoV-2, Coronavirus, Philippines, Manila

Background

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

Case presentation

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

History prior to hospitalisation

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

Clinical course of patient 1

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

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

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

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

Clinical course of patient 2

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

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

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

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

Table 1

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

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

Discussion and conclusion

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

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

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

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

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

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

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

Acknowledgements

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

Abbreviations

Authors' contributions

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

Availability of data and materials

N/A

Ethics approval and consent to participate

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

Consent for publication

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

Competing interests

The authors declare that they have no competing interests.

Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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9. Yoshida L, Suzuki M, Nguyen HA, Le MN, Vu TD, Yoshino H, et al. Respiratory syncytial virus: co-infection and paediatric lower respiratory tract infections. Eur Respir J. 2013;42:461-469. doi: 10.1183/09031936.00101812. [[ PubMed] [ CrossRef] Google Scholar]

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11. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet (London, England) 2020;6736(20):1-7. [[ PMC free article] [ PubMed] Google Scholar]

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13. Lopez J. Severe Acute Respiratory Syndrome (SARS) control and surveillance :The Philippine experience. In: 4th Health Rsearch For Action National Forum. Manila; 2003.

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

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The novel coronavirus (COVID-19) is responsible for more fatalities than the SARS coronavirus, despite being in the initial stage of a global pandemic. The first suspected case in the Philippines was investigated on January 22, 2020, and 633 suspected ...

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Due to lockdown and limited physical interaction, individuals resort to technology to lessen their boredom and keep up with their folks into the new normal world.

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Pew Research Center: Internet, Science & Tech

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90% of Americans say the internet has been essential or important to them, many made video calls and 40% used technology in new ways. But while tech was a lifeline for some, others faced struggles

Pew Research Center has a long history of studying technology adoption trends and the impact of digital technology on society. This report focuses on American adults' experiences with and attitudes about their internet and technology use during the COVID-19 outbreak. For this analysis, we surveyed 4,623 U.S. adults from April 12-18, 2021. Everyone who took part is a member of the Center's American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP's methodology.

Chapter 1 of this report includes responses to an open-ended question and the overall report includes a number of quotations to help illustrate themes and add nuance to the survey findings. Quotations may have been lightly edited for grammar, spelling and clarity. The first three themes mentioned in each open-ended response, according to a researcher-developed codebook, were coded into categories for analysis.

Here are the questions used for this report, along with responses, and its methodology.

The coronavirus has transformed many aspects of Americans' lives. It shut down schools, businesses and workplaces and forced millions to stay at home for extended lengths of time. Public health authorities recommended limits on social contact to try to contain the spread of the virus, and these profoundly altered the way many worked, learned, connected with loved ones, carried out basic daily tasks, celebrated and mourned. For some, technology played a role in this transformation.

Results from a new Pew Research Center survey of U.S. adults conducted April 12-18, 2021, reveal the extent to which people's use of the internet has changed, their views about how helpful technology has been for them and the struggles some have faced.

The vast majority of adults (90%) say the internet has been at least important to them personally during the pandemic, the survey finds. The share who say it has been essential - 58% - is up slightly from 53% in April 2020. There have also been upticks in the shares who say the internet has been essential in the past year among those with a bachelor's degree or more formal education, adults under 30, and those 65 and older.

A large majority of Americans (81%) also say they talked with others via video calls at some point since the pandemic's onset. And for 40% of Americans, digital tools have taken on new relevance: They report they used technology or the internet in ways that were new or different to them. Some also sought upgrades to their service as the pandemic unfolded: 29% of broadband users did something to improve the speed, reliability or quality of their high-speed internet connection at home since the beginning of the outbreak.

Still, tech use has not been an unmitigated boon for everyone. " Zoom fatigue" was widely speculated to be a problem in the pandemic, and some Americans report related experiences in the new survey: 40% of those who have ever talked with others via video calls since the beginning of the pandemic say they have felt worn out or fatigued often or sometimes by the time they spend on them. Moreover, changes in screen time occurred for Americans generally and for parents of young children. The survey finds that a third of all adults say they tried to cut back on time spent on their smartphone or the internet at some point during the pandemic. In addition, 72% of parents of children in grades K-12 say their kids are spending more time on screens compared with before the outbreak.

For many, digital interactions could only do so much as a stand-in for in-person communication. About two-thirds of Americans (68%) say the interactions they would have had in person, but instead had online or over the phone, have generally been useful - but not a replacement for in-person contact. Another 15% say these tools haven't been of much use in their interactions. Still, 17% report that these digital interactions have been just as good as in-person contact.

Some types of technology have been more helpful than others for Americans. For example, 44% say text messages or group messaging apps have helped them a lot to stay connected with family and friends, 38% say the same about voice calls and 30% say this about video calls. Smaller shares say social media sites (20%) and email (19%) have helped them in this way.

The survey offers a snapshot of Americans' lives just over one year into the pandemic as they reflected back on what had happened. It is important to note the findings were gathered in April 2021, just before all U.S. adults became eligible for coronavirus vaccines. At the time, some states were beginning to loosen restrictions on businesses and social encounters. This survey also was fielded before the delta variant became prominent in the United States, raising concerns about new and evolving variants.

Here are some of the key takeaways from the survey.

Some Americans' experiences with technology haven't been smooth or easy during the pandemic. The digital divides related to internet use and affordability were highlighted by the pandemic and also emerged in new ways as life moved online.

For all Americans relying on screens during the pandemic, connection quality has been important for school assignments, meetings and virtual social encounters alike. The new survey highlights difficulties for some: Roughly half of those who have a high-speed internet connection at home (48%) say they have problems with the speed, reliability or quality of their home connection often or sometimes.

Beyond that, affordability remained a persistent concern for a portion of digital tech users as the pandemic continued - about a quarter of home broadband users (26%) and smartphone owners (24%) said in the April 2021 survey that they worried a lot or some about paying their internet and cellphone bills over the next few months.

From parents of children facing the " homework gap" to Americans struggling to afford home internet, those with lower incomes have been particularly likely to struggle. At the same time, some of those with higher incomes have been affected as well.

Affordability and connection problems have hit broadband users with lower incomes especially hard. Nearly half of broadband users with lower incomes, and about a quarter of those with midrange incomes, say that as of April they were at least somewhat worried about paying their internet bill over the next few months. And home broadband users with lower incomes are roughly 20 points more likely to say they often or sometimes experience problems with their connection than those with relatively high incomes. Still, 55% of those with lower incomes say the internet has been essential to them personally in the pandemic.

At the same time, Americans' levels of formal education are associated with their experiences turning to tech during the pandemic.

Those with a bachelor's or advanced degree are about twice as likely as those with a high school diploma or less formal education to have used tech in new or different ways during the pandemic. There is also roughly a 20 percentage point gap between these two groups in the shares who have made video calls about once a day or more often and who say these calls have helped at least a little to stay connected with family and friends. And 71% of those with a bachelor's degree or more education say the internet has been essential, compared with 45% of those with a high school diploma or less.

More broadly, not all Americans believe they have key tech skills. In this survey, about a quarter of adults (26%) say they usually need someone else's help to set up or show them how to use a new computer, smartphone or other electronic device. And one-in-ten report they have little to no confidence in their ability to use these types of devices to do the things they need to do online. This report refers to those who say they experience either or both of these issues as having "lower tech readiness." Some 30% of adults fall in this category. (A full description of how this group was identified can be found in Chapter 3.)

These struggles are particularly acute for older adults, some of whom have had to learn new tech skills over the course of the pandemic. Roughly two-thirds of adults 75 and older fall into the group having lower tech readiness - that is, they either have little or no confidence in their ability to use their devices, or generally need help setting up and learning how to use new devices. Some 54% of Americans ages 65 to 74 are also in this group.

Americans with lower tech readiness have had different experiences with technology during the pandemic. While 82% of the Americans with lower tech readiness say the internet has been at least important to them personally during the pandemic, they are less likely than those with higher tech readiness to say the internet has been essential (39% vs. 66%). Some 21% of those with lower tech readiness say digital interactions haven't been of much use in standing in for in-person contact, compared with 12% of those with higher tech readiness.

As school moved online for many families, parents and their children experienced profound changes. Fully 93% of parents with K-12 children at home say these children had some online instruction during the pandemic. Among these parents, 62% report that online learning has gone very or somewhat well, and 70% say it has been very or somewhat easy for them to help their children use technology for online instruction.

Still, 30% of the parents whose children have had online instruction during the pandemic say it has been very or somewhat difficult for them to help their children use technology or the internet for this.

The survey also shows that children from households with lower incomes who faced school closures in the pandemic have been especially likely to encounter tech-related obstacles in completing their schoolwork - a phenomenon contributing to the " homework gap."

Overall, about a third (34%) of all parents whose children's schools closed at some point say their children have encountered at least one of the tech-related issues we asked about amid COVID-19: having to do schoolwork on a cellphone, being unable to complete schoolwork because of lack of computer access at home, or having to use public Wi-Fi to finish schoolwork because there was no reliable connection at home.

This share is higher among parents with lower incomes whose children's schools closed. Nearly half (46%) say their children have faced at least one of these issues. Some with higher incomes were affected as well - about three-in-ten (31%) of these parents with midrange incomes say their children faced one or more of these issues, as do about one-in-five of these parents with higher household incomes.

Prior Center work has documented this " homework gap" in other contexts - both before the coronavirus outbreak and near the beginning of the pandemic. In April 2020, for example, parents with lower incomes were particularly likely to think their children would face these struggles amid the outbreak.

Besides issues related to remote schooling, other changes were afoot in families as the pandemic forced many families to shelter in place. For instance, parents' estimates of their children's screen time - and family rules around this - changed in some homes. About seven-in-ten parents with children in kindergarten through 12th grade (72%) say their children were spending more time on screens as of the April survey compared with before the outbreak. Some 39% of parents with school-age children say they have become less strict about screen time rules during the outbreak. About one-in-five (18%) say they have become more strict, while 43% have kept screen time rules about the same.

More adults now favor the idea that schools should provide digital technology to all students during the pandemic than did in April 2020

Americans' tech struggles related to digital divides gained attention from policymakers and news organizations as the pandemic progressed.

On some policy issues, public attitudes changed over the course of the outbreak - for example, views on what K-12 schools should provide to students shifted. Some 49% now say K-12 schools have a responsibility to provide all students with laptop or tablet computers in order to help them complete their schoolwork during the pandemic, up 12 percentage points from a year ago.

The shares of those who say so have increased for both major political parties over the past year: This view shifted 15 points for Republicans and those who lean toward the GOP, and there was a 9-point increase for Democrats and Democratic leaners.

However, when it comes to views of policy solutions for internet access more generally, not much has changed. Some 37% of Americans say that the government has a responsibility to ensure all Americans have high-speed internet access during the outbreak, and the overall share is unchanged from April 2020 - the first time Americans were asked this specific question about the government's pandemic responsibility to provide internet access.

Democrats are more likely than Republicans to say the government has this responsibility, and within the Republican Party, those with lower incomes are more likely to say this than their counterparts earning more money.

Video calls and conferencing have been part of everyday life

Americans' own words provide insight into exactly how their lives changed amid COVID-19. When asked to describe the new or different ways they had used technology, some Americans mention video calls and conferencing facilitating a variety of virtual interactions - including attending events like weddings, family holidays and funerals or transforming where and how they worked. From family calls, shopping for groceries and placing takeout orders online to having telehealth visits with medical professionals or participating in online learning activities, some aspects of life have been virtually transformed:
"I've gone from not even knowing remote programs like Zoom even existed, to using them nearly every day." - Man, 54 "[I've been] h"I ... use Zoom for church youth activities. [I] use Zoom for meetings. I order groceries and takeout food online. We arranged for a 'digital reception' for my daughter's wedding as well as live streaming the event." - Woman, 44 andling ... deaths of family and friends remotely, attending and sharing classical music concerts and recitals with other professionals, viewing [my] own church services and Bible classes, shopping. ... Basically, [the internet has been] a lifeline."
- Woman, 69

When asked about video calls specifically, half of Americans report they have talked with others in this way at least once a week since the beginning of the outbreak; one-in-five have used these platforms daily. But how often people have experienced this type of digital connectedness varies by age. For example, about a quarter of adults ages 18 to 49 (27%) say they have connected with others on video calls about once a day or more often, compared with 16% of those 50 to 64 and just 7% of those 65 and older.

Even as video technology became a part of life for users, many accounts of burnout surfaced and some speculated that "Zoom fatigue" was setting in as Americans grew weary of this type of screen time. The survey finds that some 40% of those who participated in video calls since the beginning of the pandemic - a third of all Americans - say they feel worn out or fatigued often or sometimes from the time they spend on video calls. About three-quarters of those who have been on these calls several times a day in the pandemic say this.

Fatigue is not limited to frequent users, however: For example, about a third (34%) of those who have made video calls about once a week say they feel worn out at least sometimes.

These are among the main findings from the survey. Other key results include:

Some Americans' personal lives and social relationships have changed during the pandemic: Some 36% of Americans say their own personal lives changed in a major way as a result of the coronavirus outbreak. Another 47% say their personal lives changed, but only a little bit.About half (52%) of those who say major change has occurred in their personal lives due to the pandemic also say they have used tech in new ways, compared with about four-in-ten (38%) of those whose personal lives changed a little bit and roughly one-in-five (19%) of those who say their personal lives stayed about the same.

Even as tech helped some to stay connected, a quarter of Americans say they feel less close to close family members now compared with before the pandemic, and about four-in-ten (38%) say the same about friends they know well. Roughly half (53%) say this about casual acquaintances.

The majority of those who tried to sign up for vaccine appointments in the first part of the year went online to do so: Despite early problems with vaccine rollout and online registration systems, in the April survey tech problems did not appear to be major struggles for most adults who had tried to sign up online for COVID-19 vaccines. The survey explored Americans' experiences getting these vaccine appointments and reveals that in April 57% of adults had tried to sign themselves up and 25% had tried to sign someone else up. Fully 78% of those who tried to sign themselves up and 87% of those who tried to sign others up were online registrants.

When it comes to difficulties with the online vaccine signup process, 29% of those who had tried to sign up online - 13% of all Americans - say it was very or somewhat difficult to sign themselves up for vaccines at that time. Among five reasons for this that the survey asked about, the most common major reason was lack of available appointments, rather than tech-related problems. Adults 65 and older who tried to sign themselves up for the vaccine online were the most likely age group to experience at least some difficulty when they tried to get a vaccine appointment.

Tech struggles and usefulness alike vary by race and ethnicity. Americans' experiences also have varied across racial and ethnic groups. For example, Black Americans are more likely than White or Hispanic adults to meet the criteria for having "lower tech readiness." Among broadband users, Black and Hispanic adults were also more likely than White adults to be worried about paying their bills for their high-speed internet access at home as of April, though the share of Hispanic Americans who say this declined sharply since April 2020. And a majority of Black and Hispanic broadband users say they at least sometimes have experienced problems with their internet connection.

Still, Black adults and Hispanic adults are more likely than White adults to say various technologies - text messages, voice calls, video calls, social media sites and email - have helped them a lot to stay connected with family and friends amid the pandemic.

Tech has helped some adults under 30 to connect with friends, but tech fatigue also set in for some. Only about one-in-five adults ages 18 to 29 say they feel closer to friends they know well compared with before the pandemic. This share is twice as high as that among adults 50 and older. Adults under 30 are also more likely than any other age group to say social media sites have helped a lot in staying connected with family and friends (30% say so), and about four-in-ten of those ages 18 to 29 say this about video calls.

Screen time affected some negatively, however. About six-in-ten adults under 30 (57%) who have ever made video calls in the pandemic say they at least sometimes feel worn out or fatigued from spending time on video calls, and about half (49%) of young adults say they have tried to cut back on time spent on the internet or their smartphone.

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Pew Research Center has a long history of studying technology adoption trends and the impact of digital technology on society. This report focuses on American adults' experiences with and attitudes about their internet and technology use during the COVID-19 outbreak. For this analysis, we surveyed 4,623 U.S. adults from April 12-18, 2021.

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During the Epidemic in 1902, local Filipinos were being suppressed by colonial authorities and because of that, their normal lives and rituals are being disrupted.

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What a way to start the day, catching a TV interview with Metro Manila's chief of police, birthday boy Debold Sinas, explaining the government's latest anti-COVID-19 operations in Navotas, which has been placed on total lockdown. In the background were armored personnel carriers that had been brought in, prompting a newscaster to ask, with a noticeable tinge of sarcasm, "Sino ang kalaban? Bayrus?" (Who's the enemy? A virus?)

Earlier, the government announced there would be house-to-house searches for COVID-19 patients. Home quarantine has apparently been banned, and patients-heaven knows how they will be detected simply by house searches-will be sent to barangay quarantine centers.

From the very beginning of the lockdown, I've worried about how we've been using police/military models to control COVID-19, a bad way to start the quarantine. But, instead of learning from the futility of these measures, we're now intensifying them.

We should be learning from the experiences of Americans, who first introduced this police model of public health during their colonial occupation of the Philippines. Here, I draw rich materials from Warwick Anderson's book "Colonial Pathologies." Anderson is a physician and a historian who worked on the Americans' public health policies as his doctoral dissertation.

The Americans occupied the Philippines in 1898, plunging straight into the Philippine-American War as Filipino guerrillas resisted the new colonial power. Early on, the Americans realized they had to face another "insurrection," that of disease.

Try to imagine how the Americans felt with the new, unfamiliar, and uncharted territory before them. They saw dangers everywhere. The guerrillas were foremost, but there was more. One American official wrote that "even the dogs seemed trained to bark peculiarly at an American."

Danger came from everywhere, even the tropical weather. In sum, "air, water, soil, the whole earth and its sundry encumbrances (living and dead) were reeking it seems in germs."

Remember, the germ theory of disease had just been accepted late in the 19th century, displacing early theories about miasmas or vapors of the earth as the main causes of disease.

The most feared enemy then, as it is today, was invisible.

A cholera epidemic that broke out in Manila in 1902 became a nightmare with its rapid spread. The Americans responded by going house to house, rounding up suspected patients and putting them in detention camps. The nipa houses of the poor were then burned down. Wooden houses of the middle- and upper classes were deemed "less dangerous" and simply sprayed with disinfectants.

The result? People fled from Manila, and the epidemic quickly spread out to the rest of the country. The Board of Health (the equivalent of our health department today) had to fan out to the rest of the country. By then, the American colonial government had learned from their mistakes and were allowing home quarantine instead of using detention centers, and had stopped burning houses down.

But people had lost trust in both the Americans and the Filipinos in the Board of Health. They continued to flee from their homes, or would hide infected relatives and bury their dead secretly.

The Board of Health blamed Filipinos for the spread, calling them superstitious and ignorant. Health inspectors armed themselves with rifles. "Pasaway" had not been coined yet at that time, but if it had been, I can imagine the Americans would have learned it right away, albeit with the pronunciation "pe-se-way."

Dr. Trinidad Pardo de Tavera, one of only two Filipinos in the Philippine Commission administering the country, called out the Americans for their atrocities and said Filipinos "fear the Board of Health more than they fear the epidemic."

The Americans had to become more conciliatory in their tactics. The epidemic came under control after more than a year. More than 100,000 people perished in that epidemic out of a population of 8 million. Manila, where it all started, had 5,000 deaths.

Similar fiascos happened a few years later, for example in the way the Americans tried to handle malaria, a problem that never really went away.

Meanwhile, a mental health problem called "philippinitis," first reported in 1898 and that seemed to affect only Americans, administrators in particular, began to spread. Even the American head of the Philippine General Hospital came down with philippinitis and had to be sent to recover in Baguio, which was built, in part, to handle this new affliction.

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What a way to start the day, catching a TV interview with Metro Manila's chief of police, birthday boy Debold Sinas, explaining the government's latest anti-COVID-19 operations in Navotas, which has been placed on total lockdown. In the background were armored personnel carriers that had been brought in, prompting a newscaster to ask, with a noticeable tinge of sarcasm, "Sino ang kalaban?

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Because of the implementation of lockdown and limited social interaction in 2020, physical interactions decreased and virtual/online interactions increased.

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Enhance Community Quarantine & General Community Quarantine 

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Enhance Community Quarantine & General Community Quarantine 

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ECQ & GCQ was introduced to the world. refers to “the implementation of temporary measures limiting movement and transportation, regulation of operating industries, and presence of uniformed personnel to enforce community quarantine protocols.”

https://www.moneymax.ph/lifestyle/articles/new-normal-guide#:~:text=Outdoor%20exercise%20like%20jogging%20and,masks%20and%20practice%20social%20distancing.

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New Normal in the Philippines: Quarantine Guidelines

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The COVID-19 pandemic is changing the way we live in more ways than one. Here is a guide and the changes you need to expect in "the new normal."

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Nine typologies of PHSMs that emerged such as (1) physical distancing, (2) border controls, (3) personal protective equipment requirements, (4) transmission monitoring, (5) surge health infrastructure capacity, (6) surge medical supplies, (7) surge human resources, (8) vaccine availability and roll-out and (9) social and economic support measures.

https://gh.bmj.com/content/7/11/e009863

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WHAT IS ALREADY KNOWN ON THIS TOPIC

The COVID-19 pandemic had driven countries to implement an array of Public Health and Social Measures (PHSMs), which aim to mitigate the spread of the virus and minimise economic fallout. Most modelling studies highlight the effectiveness of one PHSM as a standalone measure but do not emphasise the interplay between PHSMs and the key indicators that determine their overall effectiveness.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

We found that for PHSMs be effective, national responses will need to place the most vulnerable first by centring PHSMs around an equity lens with strong governance and community engagement as key tenets at all levels of the health system.

As the world moves towards living with the virus endemically, coupled with waning vaccine immunities, newer variant strains and the reopening of economies, health systems need to be made resilient and nimble to readily redeploy PHSMs. Such policy actions will help curb any spike in infections in order to protect the lives and livelihoods of populations.

Country selection criteria

This study focuses on six countries in Asia that introduced different levels of PHSMs at different stretches of the pandemic. Although this study has a Asian regional focus, the selected countries differed in terms of income status, level of devolution and centralisation of governance, population density, mortality rates from COVID-19, health systems attributes, Universal Health Coverage Service Coverage Index and Global Health Security Index which give us a comprehensive picture of how PHSMs evolved and impacted national responses in a variety of six Asian countries. Table 1 provides a backdrop of country profiles, including key country indicators.

Literature search and case studies

The team of researchers from the six countries performed desk reviews of literatures relevant to PHSMs applied by their home countries. To that end, we used the literature review methodology set by Webster and Watson by harnessing scientific online data bases such as PubMed, EMBASE and Scopus as a starting point. 17 Keywords during the initial search included 'national responses to COVID-19', 'Public Health Measures', 'Social Support Measures' and names of individual countries. We also performed a deeper dive into each PHSMs by repeating certain searches with the relevant PHSMs that we have identified after the initial thematic analysis. After the relevant articles have been sieved out, we selectively performed a backwards review of the pertinent citations from the articles to help address any missing data which we thought were applicable to our area of research. 17 We also performed searches for national health accounts, government reports and policy executive summaries on the topic through digital government domains, mainly from ministries of health websites. To plug any remaining gaps, we performed a search of university databases where permitted, the websites of international development organisations and traditional and non-traditional media outlets (primarily through Google search). This provided us with a relatively complete census of the relevant literature made publicly available on PHSMs in the six countries. Data extracted in the local languages and English were included. Snapshots of the key PHSMs implemented from 2020 to 2022 are summarised in the results section and detailed in tables 2-10.

Data analysis and presentation

The research team extracted key themes from the literature obtained from countries by performing an inductive thematic analysis whereby theoretical insights are generated from data, 18 and thereafter drew comparisons across case studies which include all salient themes as typologies of PHSMs. 19 Multiple rounds of iterative feedback between team members were performed to ensure the typologies correctly represented the themes that surfaced from the data to ensure reliability and accuracy. Any disagreement was resolved through discussions till a consensus was reached. Thematic saturation was reached when no new themes emerged.

Physical distancing

All countries reviewed implemented physical distancing measures to prevent viral transmission between people in close proximity. Common methods include school closures, work from home (WFH) arrangements or limitations applied to public gatherings. School closures vary in duration and intensity, with countries such as Indonesia, Thailand, the Philippines and Vietnam facing challenges of remote learning due to limited internet coverage and availability of learning devices. Similarly, despite digital challenges when shifting to WFH arrangements, all countries pushed for minimal office presence if offsite options were available. In addition, all countries reviewed introduced restrictions on public gatherings, most commonly implemented by controlling the size of group gatherings based on a tiered system, with lockdowns implemented only as a last resort. Singapore, for example, initiated its Circuit Breaker lockdown in response to massive outbreaks within foreign worker dormitories and to rapidly suppress community transmission. In larger countries, stringency of physical distancing differs based on epidemiological performance at sub-national levels, such as the Community Activity Restrictions (known as 'PPKM') in Indonesia, which tailored these restrictions based on local hospital capacity and caseloads.

Border controls

The imposition of travel bans to stem the inflow of infections by countries was commonplace after the WHO declared a public health emergency of international concern. For inbound travellers, strict quarantine at designated facilities was required, with the need to monitor health status through various applications. South Korea, for example, mandated inbound travellers to quarantine in dedicated facilities while a Global Positioning System tracking function was used to monitor compliance. As the pandemic continued into its second year, countries relying heavily on tourism trialled calibrated reopening of their borders to the fully vaccinated through sandbox pilots such as the Phuket Sandbox in Thailand and Phu Quoc Island in Vietnam. By the end of 2021, certain countries had shifted from a static close all borders approach to a more dynamic one based on epidemiology in sending and receiving countries, vaccination statuses and to some extent, reciprocity. As vaccination coverage expanded, countries such as Singapore and South Korea commenced vaccinated travel lanes (VTLs), with vaccination and negative test requirements for inbound travellers. However, with the resurgence of more virulent strains such as Delta and Omicron, these countries retightened their borders iteratively.

PPE requirements

Countries reviewed adjusted their requirements for mask-wearing based on the stage of the pandemic that they are in. For example, in the early stages of the pandemic in Singapore, mask-wearing was only for the unwell, but subsequently, everyone was required by law to wear one. Eventually, all countries implemented mandatory mask-wearing, with penalties imposed for non-compliance, such as in Indonesia, where police and military personnel meted out fines to those who flouted these mandates. However, amid increasing vaccine coverage, South Korea altered their masking requirements such that vaccinated people need not wear a mask outdoors by July 2021, but this was suspended amid a spike in numbers, while the Philippines had mandated everyone to wear both face shields and masks while in public. In some Western countries, mask-wearing had been a point of contention between policymakers and citizenry. 20 However, this was not the case in countries reviewed due to cultural and environmental factors, such as in Vietnam, where wearing face masks was common due to air pollution in the cities.

Transmission monitoring

Countries reviewed implemented extensive testing, surveillance and contact tracing strategies since the beginning of the pandemic to detect and isolate potential and confirmed cases quickly. PCR testing remains the gold standard for diagnosing COVID-19. Chiefly, PCR testing is coupled with other more efficient testing methods such as rapid antigen tests (RAT) when laboratory testing capacities became overwhelmed by high caseloads brought about by multiple epidemic waves and testing requirements.

Testing strategies are in tandem with contact tracing protocols which aim to identify cases to break transmission chains. Contact tracing teams were rapidly mobilised in all countries, embarking on a manual tracing process initially. As transmissions intensified, digital tools were used to accelerate the tracing process. In Singapore, the TraceTogether mobile application and Safe Entry QR code were created by the government technology office and adopted by the population to aid in contact tracing, while South Korea leveraged CCTV footage, cellular geolocation and credit card histories for the same purpose. However, uptake of such digital strategies faced challenges due to privacy concerns. For the Philippines, an additional hurdle was the parallel development of multiple information systems and digital platforms that were not immediately interoperable. Generally, passive surveillance was already in place for most countries with a system to detect underlying infectious diseases prior to COVID-19, and since 2020, was augmented with active and sentinel surveillance protocols through healthcare providers, routine rostered testing for workers or wastewater testing.

Surge health infrastructure capacity

Health infrastructure such as laboratories, isolation facilities and negative pressure rooms in medical facilities are needed to identify and care for patients and suspected cases as well as parameterise them from the community to reduce transmission. Countries expanded laboratory testing capacities by setting up new laboratories or authorising private laboratories to provide testing services. In South Korea, novel testing protocols such as drive-through and walk-through testing were deployed in car park spaces. In Vietnam and Thailand, the distribution of testing laboratories proliferated across the country in order to reach all provinces. This was done by expediting accreditation of government and private laboratories, commonly under a national laboratory network system. Nonetheless, as more transmissible variants emerged, even this expanded capacity faced difficulties with the swelling demand, making RATs an acceptable means to triage patients for RT-PCR tests. As for quarantine and isolation facilities, countries partnered with the private sector and converted hotels and other large public facilities such as convention centres into quarantine or isolation facilities. Designated hospitals were also retrofitted to serve as respiratory split hospitals to segregate prospective COVID-19 patients from the general patient pool, such as those in South Korea. Initially, the focus was on the quarantine of contacts and isolation of cases in dedicated facilities resulting in a large emphasis on creating such facilities. However, countries such as Singapore and South Korea which had high population vaccination coverage had progressively moved towards a more home-based quarantine and isolation approach for patients with milder symptoms to be managed at home to preserve hospital capacity for more severe cases.

Surging health supplies

At the early stages of the pandemic, countries preserved health supplies by easing import regulations while restricting the export of certain medical products, which were subsequently lifted after domestic production was increased through the use of innovative technologies and approaches. For example, garment factories in Thailand, the Philippines and Vietnam were retrofitted to manufacture PPEs while approvals for manufacturing or sale of certain health products were expedited. For instance, Thailand reclassified hand sanitisers as medical products to prevent production delays. Price controls and regulations to deter hoarding were implemented to ensure the population had access to available stocks. South Korea had initially limited weekly masks sales by retailers, while hoarders faced imprisonment and financial penalties. In addition, countries such as Singapore and South Korea maintained a national stockpile of medical supplies that could be rapidly deployed in times of health emergencies.

Human resource capacity

Having a sufficient and healthy healthcare workforce is imperative to treating, isolating, testing and contact tracing during a pandemic. Across reviewed countries, healthcare workers were overburdened as case numbers increased while taking on heightened risks when managing COVID-19 patients, at times with uncertain access to PPE necessary to provide care safely. To mobilise more human resources, some countries activated their 'reserves' which predominantly came from former or retired healthcare workers, medically or non-medically trained volunteers, medical and paramedical students, or the military. In countries such as Vietnam, the military and public security forces were rapidly mobilised and trained to perform contact tracing. In Singapore, nursing students answered the call for volunteers by joining mobile serology teams, while Thailand successfully mobilised their pool of village health volunteers for public education activities and community surveillance.

Vaccine availability and roll-out

Mass vaccination has been touted as a key exit strategy from this pandemic. However, vaccine supply chains must be secured, high-risk groups prioritised and distribution plus access within communities ensured through robust cold chains. Vaccine drives commenced at the beginning of 2021 for countries reviewed. As Singapore ramped up its vaccination drive, it unveiled its VacciNationSG Campaign to address misconceptions, debunk misinformation about vaccinations and promote uptake. Other strategies to promote vaccine uptake are allocation and affordability. In terms of allocation, all countries reviewed had prioritised high-risk groups such as the elderly and front-line workers for vaccination, with the costs of vaccination borne by the government. However, access to vaccines at the country level posed a hurdle for countries failing to secure sufficient advance purchase agreements with pharmaceutical companies. Donations from other countries and the COVAX facility had provided vaccine doses to countries such as the Philippines, Indonesia and Vietnam, although only for a marginal proportion of their population, while others such as Indonesia and Thailand produced their own. Most countries also implemented vaccine differentiated measures, such as Singapore, South Korea and Vietnam, which necessitate a digital vaccination certificate to be presented for entry into certain venues. As more transmissible variants circulated, countries began recommending booster doses, with Singapore only considering those with a booster dose as fully vaccinated.

Social and economic support measures

All countries had provided support packages to the vulnerable groups and businesses, but the level and type of support for the general population varied. These included financial relief packages, skills upgrading to increase employability, measures that cover basic necessities, insurance premium waivers and utility subsidies. To revitalise the economy, Singapore issued vouchers to the general public to spend on local businesses, while Indonesia, Philippines and Vietnam provided tax incentives and reductions in corporate tax for selected businesses. Vulnerable groups such as low income and migrant workers were supported with cash transfers, unemployment protection and free COVID-19 treatment services. Some countries such as the Philippines saw the emergence of ground-up initiatives like food pantries, and Indonesia expanded its cash transfer initiative under Programme Keluarga Harapan for low-income households. Support packages were reportedly extended due to poor economic outlook and prolonging of PHSMs in the face of new waves of infection.

The dynamic interplay among PHSMs

PHSMs cannot function alone and must be implemented strategically and synergistically to maximise the protection of the health of populations and livelihoods. Synergies across different PHSMs can achieve their intended outcomes and withstand unintended consequences. Three nested interactions that emerged from this study will be discussed.

First, transmission monitoring through testing and contact tracing must be followed by citizens' compliance with quarantine and isolation to stem community transmission. Ringfencing cases and contacts require alignment with social and economic support measures so that these individuals possess the resources to remain temporarily segregated from the rest of the community. 21 This may come in the form of food delivery services as seen performed by village health volunteers in Thailand and allowances or income replacement given to isolated individuals in Singapore. This is especially integral for informal economy workers or daily waged earners, who are disproportionately affected by these quarantine measures, making physical distancing measures difficult to adhere to. 22 The need for such support is more evident in low-income and middle-income countries (LMICs), where a large proportion of their population belongs to informal sector and is impoverished. 23 24 However, vulnerable groups also exist in upper-middle-income and high-income countries, which are disproportionately affected by COVID-19 who also need government support. This dilemma further adds to the complexities between the protection of the health of the population and livelihoods.

Second, a more complex interaction network between various PHSMs entails interactions between health worker capacity, health infrastructure, border controls, vaccination roll-out and testing requirements, to name a few. To elaborate, human resources are needed to expand health services provision capacities to respond to the pandemic and to maintain other essential routine services at health facilities, which can be accomplished by mobilising military personnel and volunteers to refurbish non-clinical facilities and erect field hospitals and vaccination centres. During vaccination roll-out, human resources are required for inoculation services and facilitation of the cold chain. Private sector providers are commonly engaged to augment government service personnel to conduct laboratory tests, treatment and quarantine services. In Thailand, public and private healthcare providers were contracted on the same terms, conditions and fees, which had to an extent, prevented patient denials by private facilities. 25 26 To that end, hotels were also converted into isolation amenities for returning travellers and close contacts during the initial peaks. Closely related are sandbox pilots for travel, where vaccine campaigns were accelerated to reach a certain level of population coverage before reopening of borders, which was determined by the availability of vaccines, manpower capacity to vaccinate and relevant supporting infrastructure.

Third, the availability of PPE, medical supplies and human resources also need to complement one another to maximise their effectiveness. Specifically, in certain countries with initial supply shortfalls, mask coverage for the general population was low during the early stages of the pandemic. These mismatches between PHSM objectives and medically related supplies were alleviated after rapid market approvals were authorised and domestic manufacturing capacities bolstered. Similarly, adequate PPEs for healthcare workers must be preserved to safeguard essential workforces to render COVID-19 related services while maintaining other essential health services. The severe lack of PPEs had endangered the lives of health workers and, in some cases, precipitated into healthcare worker mortality, further straining the countries' test, trace and test capabilities. 27 28

The list of interlinkages, complementation and synergies between different PHSMs are non-exhaustive, as depicted in the framework by the different permutations represented by the intersecting black lines in figure 1. Fundamentally, the mantra that PHSMs do not operate in silos and one PHSM should not substitute but complement another must be amplified at all levels of the health system. 29

Key indicators influencing the dynamism of PHSMs

As the pandemic wore on, vaccines became more available and with the emergence of the more virulent strains in 2021, most countries adjusted their PHSM based on these emerging contexts as well as the impact of prolonged PHSMs on the economy. Policies had to balance between the health of the population and livelihoods. In general, the key indicators that govern the scale and duration of PHSMs are similar across the six countries. For example, Vietnam had used five explicit metrics to achieve this. Specifically, during the early stages of vaccination roll-out, a proportion of the population over the age of 50 fully inoculated was the most important indicator, as older persons were more predisposed to severe symptoms and overburden the health system, followed by the percentage of people over 18 who receive at least one vaccine dose. Next, the health system capacity indicator was predicated on the number of oxygen tanks at commune health stations to be used as a precaution for managing milder cases in the community along with the districts' plan of deploying mobile health stations to provide care for hard-to-reach populations. Another indicator existed during the peak of demand for critical services, where the government earmarked ICU beds for the most severe COVID-19 cases based on an estimation of the percentage of total COVID-19 cases as potential demand. The number of community infections was also incorporated when calibrating the magnitude of PHSMs. Broadly, in all countries reviewed, parameters for decision-making towards scaling up PHSM include: community spread (indicator 1), number of severe cases and mortality (indicator 2) and health system capacity (indicator 3). For most countries, excluding Singapore, decisions were also made at the subnational level, and PHSMs tailored based on subnational key indicators.

n addition, a country's fiscal capacity (indicator 4) and vaccination coverage (indicator 5) also act as important indicators (25). Countries that depend heavily on tourism, with large informal economies or insufficient budget reserves, might find themselves reopening their economy prematurely. 30 Countries such as Thailand whose economy relies on tourism cautiously reopened borders at selected destinations, contingent on high vaccination coverage. Moreover, of the total government debt, 59.5% of GDP in 2022, 98.14% were internal borrows and were used to finance social and economic support and recovery from the pandemic. 31 In 2022, vaccine policy changes were influenced by demand for booster doses in the light of waning vaccine immunity, breakthrough infections, new vaccines and existing fiscal space. When Omicron circulated towards the end of 2021, huge waves of infections threatened to overwhelm health systems. As a result, Thailand recommended a fourth dose to health workers, while Singapore mandated a booster dose to be considered fully vaccinated. 32 33 However, despite high vaccination rates in countries such as Singapore, increased community transmission resulted in reclosing of borders in December 2021 and January 2022, with the temporary ceasing of VTLs to preserve hospital capacity. 34 Concomitantly, these policy decisions and the prolonging of PHSMs require an enlarged fiscal space for health. 35

The availability of technology (indicator 6) is a quintessential element to guide the intensity and duration of PHSMs. This is evident in countries such as Indonesia, Thailand, the Philippines and Vietnam, whereby a large proportion of their student population might not have access to the internet for remote online learning. Despite having measures to support students, it is reportedly insufficient to meet the immense demand. The long-term closure of schools and the digital divide threaten the quality of education and exacerbate inequity gaps. 36 Access to technology can determine a population's capacity to maintain physical distancing measures such as WFH arrangements and provision of telehealth services. 37 38 Furthermore, leveraging digital technologies such as mobile applications to perform check-ins at locations by scanning QR codes and generating proximity notifications when in close contact to a suspected or positive case using Bluetooth technology in addition to alerting individuals and authorities for contact tracing and follow-up management proved vital to reducing the transmission in countries such as Singapore, South Korea and Thailand. 21 39 40

PHSMs centred on equity require governance and community engagement to balance the protection of health of population and livelihoods

The phasing introduction of PHSM, either sequentially or concurrently in a comprehensive manner, synergise and complement each other, reflects the decision-making agility of the government based on evidence from the field of what works and vice versa. The up-scaling and down-scaling of PHSMs are mostly guided by epidemiological evidence, the effectiveness of interventions and unintended consequences of policies, reflecting the governments' adaptability. Therefore, governance structures need to take into account key indicators to derive a plan of action which involves the evaluation of the effects of PHSMs on health of population vs incomes. On another level, strong and coordinated governance is imperative at subnational levels, where local governments are devolved the authority to make decisions while maintaining a coordinated national response at all levels of government. 41 Instrumentally, governments need to emulate transparency and uphold political accountability regarding decision-making processes, which can come in the form of community engagement as populations need to understand the rationale behind PHSMs, their stringency and duration due to PHSMs' impacts on their health and livelihoods. 42 43 Effective and transparent community engagement strategies can help mobilise the general public to action, such as mobilising volunteers to augment the health workforce or to educate and advocate for behavioural changes that promote adherence to PHSMs. This can be achieved through engaging community leaders to promote compliance with physical distancing and mask-wearing measures, leveraging on pre-existing trust fostered within the community. 44 This is seen in Vietnam, where community COVID-19 supervision groups comprising village health workers, youth or women union volunteers were responsible for sharing information and promoting compliance to PHSMs. 45 In Singapore, the government also launched both WhatsApp and Telegram chat groups to directly engage the public and provide accurate updates on the evolving situation, modifications to regulations and dispel misinformation. 46 Notably, there is a need for clear communication channels by the government to clarify vaccine efficacy and safety, and timely management of vaccine misinformation in the Philippines, where vaccine hesitancy was spreading during the initial stages of vaccination roll-out. 47 Chiefly, community engagement can strengthen governance by providing feedback channels to understand the local sociocultural context, enabling iterative tailoring and cocreation of PHSMs that fit the needs of the population. 48

All PHSMs seek similar objectives of curbing onward transmission, reducing mortality and preserving livelihoods. The unintended consequences of PHSMs can be seen through widening income gaps, increased gender-based violence and forecasted lowering of educational attainment, among other social and health indices. 49-51 These inequities and inflictions on population health outcomes will not only impact the present but future health of a population and its national economy. Hence, PHSMs need to place equity at the core at all stages of the pandemic and can only be achieved when governance structures put the most vulnerable first while simultaneously balancing the dichotomous trade-offs between the health of population and livelihoods. 52 53

Charting an equitable and resilient recovery

As more variants and subvariants such as Omicron BA.1 and BA.2 continue to emerge, the need for contextually appropriate PHSMs that will augment vaccines due to waning of immunity in the population remains. 54-56 Henceforth, governments must remain vigilant and steadfast by executing regular risk assessments through surveillance strategies and reintroducing evidence-based and cost-effective PHSMs. 53 Although PHSMs serve to safeguard the lives and livelihoods of all populations, including the vulnerable, governments need to redress the existing vulnerabilities and societal inequities. The pandemic has put a wedge on and expanded the current fissures between the have and have-nots and amplified the inequities in all dimensions, not only in LMICs but in high-income countries as well. 57 58 This is observed in countries reviewed, whereby support packages were offered to vulnerable populations such as migrant workers, as most of them are socially marginalised, lack social protection and are more predisposed to getting infected. 59 This is also seen in high-income countries such as Singapore, whereby massive outbreaks in crowded foreign worker dormitories led to the implementation of a nationwide Circuit Breaker for 2 months. 60 Therefore, countries that do not offer vaccines to migrants and non-residents, might observe a persistence of epidemic waves, dampening the effectiveness of other PHSMs. The instance of such oversight is also reported in other vulnerable groups such as internally displaced people and refugees. 61

Essentially, the level of disproportionate impacts on the poor and vulnerable groups is determined by the level of existing structural inequality on the one hand, the size of social capital and resilience on the other hand, calling on national and global solidarity. 62 63 In particular, inadequate vaccine coverage and lack of resilient health system pillars can prolong the pandemic as low-income countries continue to fight outbreaks, permitting the emergence of new variants and spread across the world due to international travel. 64 Increasingly, as more viable and effective antivirals are developed and authorised for use, their equitable access has also come under scrutiny. 65 Therefore, countries need to focus on equitable distribution of vaccines, antivirals and other resources to strengthen health systems globally and narrow the gap between the global North and South. 66 67

Lastly, countries must harness this pandemic as an ephemeral window to strengthen health system capacities by investing in three interlocking pillars: (1) capacity to rapidly detect and react to emerging infectious diseases, (2) capacity to absorb infected individuals while maintaining care continuity for routine management of other diseases and (3) foster an enabling climate for the nurturance of healthy lifestyle and behaviours to promote healthier populations resilient towards diseases. 68 Only through these steps can populations and health systems become more resilient and steadfast in the face of a prolonged pandemic.

Strengths and limitations

An in-depth analysis of the interlinks and synergies across nine typologies of PHSMs applied by six Asian countries enabled us to rapidly synthesise a framework for PHSMs where key indicators play a significant role in shaping PHSMs as the pandemic unfolds. Importantly, this study confirms a prior study that explores the major negative impacts on social inequity and vulnerability, and that universality principles prevail in the effective containment of the pandemic. 69 However, this study captures snapshots of policy responses from January 2020 to January 2022 in the context of data incompleteness. Given the ongoing and rapid changes to contextual environments, it is likely that many of the policies highlighted above may have changed considerably since the time of writing. Certain information on policies might also be unavailable and inaccessible from public domains. It is, however, beyond the scope of this study to assess the full range of PHSMs and ascertain the effectiveness of implementation.

Patient consent for publication

Not applicable.

# data[].attributes.attachment_link.title
COVID-19 public health and social measures: a comprehensive picture of six Asian countries

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The COVID-19 pandemic will not be the last of its kind. As the world charts a way towards an equitable and resilient recovery, Public Health and Social Measures (PHSMs) that were implemented since the beginning of the pandemic need to be made a permanent feature of health systems that can be activated and readily deployed to tackle sudden surges in infections going forward.

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Declaration of ECQ in other parts of Philippines where virus is most prominent by Former President Rodrigo Duterte. This is to mitigate the spread of the virus. Physical activities where banned at this point.

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GUIDE:What's the difference between ECQ and GCQ?

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Confused about the difference between ECQ and GCQ? Want to know which establishments will be allowed to operate under ECQ and GCQ? Get the answers here.

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The declaration of GCQ, were other physical activities from other parts of Philippines are allowed but it has strict limitations.

# data[].attributes.attachment_link.title
GUIDE:What's the difference between ECQ and GCQ?

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Confused about the difference between ECQ and GCQ? Want to know which establishments will be allowed to operate under ECQ and GCQ? Get the answers here.

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On April 2, 2020, Former President Rodrigo Duterte mandated the wearing of face mask to prevent the spread of the virus.

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MUSE - Science Museum, Trento, Italy

Faculty of Croatian Studies, University of Zagreb, Zagreb, Croatia

Croatian Institute for Brain Research, University of Zagreb School of Medicine, Zagreb, Croatia

Institute for the Study of Science, Technology and Innovation, The University of Edinburgh, Edinburgh, United Kingdom

Business Information Systems, Cork University Business School, University College Cork, Cork, Ireland

Communication and Society Research Centre, University of Minho, Braga, Portugal

University Hospital Medical Center "Bežanijska kosa", and University of Belgrade Faculty of Medicine, Belgrade, Serbia

Department of Health Economics, Faculty of Medicine, University of Szeged, Szeged, Hungary

Department of Political Science, Centre for the Study of Contemporary Solidarity (CeSCoS), University of Vienna, Vienna, Austria

Department of Global Health & Social Medicine, King's College London, London, United Kingdom

Wearing face masks is recommended as part of personal protective equipment and as a public health measure to prevent the spread of coronavirus disease 2019 (COVID-19) pandemic. Their use, however, is deeply connected to social and cultural practices and has acquired a variety of personal and social meanings. This article aims to identify the diversity of sociocultural, ethical, and political meanings attributed to face masks, how they might impact public health policies, and how they should be considered in health communication. In May 2020, we involved 29 experts of an interdisciplinary research network on health and society to provide their testimonies on the use of face masks in 20 European and 2 Asian countries (China and South Korea). They reflected on regulations in the corresponding jurisdictions as well as the personal and social aspects of face mask wearing. We analyzed those testimonies thematically, employing the method of qualitative descriptive analysis. The analysis framed the four dimensions of the societal and personal practices of wearing (or not wearing) face masks: individual perceptions of infection risk, personal interpretations of responsibility and solidarity, cultural traditions and religious imprinting, and the need of expressing self-identity. Our study points to the importance for an in-depth understanding of the cultural and sociopolitical considerations around the personal and social meaning of mask wearing in different contexts as a necessary prerequisite for the assessment of the effectiveness of face masks as a public health measure. Improving the personal and collective understanding of citizens' behaviors and attitudes appears essential for designing more effective health communications about COVID-19 pandemic or other global crises in the future.
To wear a face mask or not to wear a face mask? Nowadays, this question has been analogous to the famous line from Shakespeare's Hamlet: "To be or not to be, that is the question."
This is a bit allegorical,
but certainly not far from the current circumstances
where a deadly virus is spreading amongst us... Vanja Kopilaš, Croatia.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic is currently perceived as one of the greatest global threats, not only to public health and well-being, but also to global economic and social stability. While the first two decades of the third millennium were characterized by crisis-most notably the economic downturn of 2008 and the looming climate change-the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus originating from China has given rise to most drastic societal and political responses. These included measures as severe as states forbidding citizens from leaving their homes and effectively shutting down all social and economic activities ( 1). In Europe, Italy was the first country to officially detect the presence of COVID-19 in its territory, and it swiftly adopted measures to contain its spread ( 2- 4). Within a few weeks, the epidemic progressively spread across Europe. Because of the novel situation and the contradictory opinions of experts, including representatives of the scientific community and World Health Organization (WHO), the level of threat caused by the disease appeared unclear ( 5). The assessment of the perceived risks of the disease varied in the public discourse-some considered it just as "a stronger influenza"; others drew parallels with the very deadly Spanish Flu outbreak in the 1918-1920, and many were simply not sure what to believe. Nevertheless, most felt the novel and unpleasant feeling of being vulnerable to the invisible threat of the infection (i.e., to be the ones in danger) or to be contagious themselves (i.e., to be the danger).

A variety of public health and hygiene measures have been initiated; the most visually noticeable perhaps is the wearing of face masks. The medical research on the use of face masks as personal protective equipment (PPE) against SARS-CoV-2 transmission was interpreted very cautiously, and the initial guidance from health officials was conflicting ( 6). The WHO advice was conceived to avoid unnecessary paternalism and at the same time be comprehensive in discussing different medical aspects of mask use. However, it was updated several times, shifting from initial statements that face masks are not to be worn by healthy individuals toward gradual adoption of face masks as useful in slowing community transmission. In particular, "...WHO has updated its guidance to advise that to prevent COVID-19 transmission effectively in areas of community transmission, governments should encourage the general public to wear masks in specific situations and settings as part of a comprehensive approach to suppress SARS-CoV-2 transmission" ( 7). Gradually, face mask use has been recognized as a suitable measure within the scientific community ( 8- 12), if nothing else due to the application of the "precautionary principle" in the face of an acute crisis ( 13, 14). This has since been backed up by empirical observations ( 15, 16).

Materials and Methods

The invitation to write their views about face mask wearing was sent by e-mail to 97 experts, all members of the interdisciplinary research network Navigating Knowledge Landscapes (NKL; http://knowledge-landscapes.hiim.hr/). The invitation was sent on May 11, 2020, and the responses were collected until May 26, 2020 (over 16 days' period). The experts were asked to contribute a single-page narrative structured in four parts, framed as follows:

* Part 1: What are the rules adopted in your country about face mask wearing? What would be the overall approach for use of the face masks in your community (government instructions, availability, the citizen compliance)?

* Part 2: What is your individual/personal attitude and practice in relation to face masks? If applicable, start with good practice and end with what you consider to be mistakes.

* Part 3: How do you judge the behavior of people you encounter? Face masks (or no face masks) and interpersonal interactions. Again, start with positive and end with negative.

* Part 4 (optional): free to say whatever you think is important to the practices of your community in relation to face masks.

Twenty-nine scholars responded (30% of those invited), providing 27 contributions (two contributions were coauthored). They were from 22 countries, 20 from Europe (Albania, Austria, Bosnia and Herzegovina, Croatia, Czechia, Estonia, Hungary, Italy, Ireland, Norway, Poland, Portugal, Romania, Serbia, Slovenia, Spain, Sweden, Turkey, Ukraine, and United Kingdom) and two from Asia (China and South Korea). The contributors belonged to the following academic disciplines: biology (2), economics (1), engineering (2), information systems (1), law (1), medicine (6), philosophy (5), psychology (1), and sociology (10).

The contributors as experts are all highly educated (Ph.D., holders or Ph.D., students), and most of them are employed in academic institutions and perform research activities in their respective disciplines. The authors of this study were among the contributors.

The testimonials were based on the aforementioned open-ended questions and narrative in style. "Face mask" was used as the umbrella term for all types of face coverings, from the custom-made cotton scarves to disposable surgical masks and medical-grade N95 respirators. This was done to preserve the authenticity of these narratives without going into detail about the medical or microbiological features of the different types of face coverings. In the same way, grammatical or vocabulary use of non-native English speakers was kept as it was. The contributions received were collected and published as a citable open-source dataset at Mendeley Data repository ( 22).

Concerning the thematic analysis, we divided testimonials in three categories. The first category captured the situation in the respondent's country; the subcategories we were interested in were the regulatory framework and the supply situation in each respective country. The second category captured experts' own use of masks. Here we focused in particular on whether and in which situations they reported to wear (or not wear) masks, what kind of face covering they used, and the meaning they ascribed to masks (e.g., mask wearing as a symbol of social cohesion). Third, we categorized the participants' accounts regarding the practices and attitudes of mask wearing they observed in others. We created an MS Excel file in which we collected the respondents' statements on these different categories. In a subsequent step, we analyzed the data for patterns and recurring topics. We looked for country-specific differences and similarities in regulations and practices. Moreover, we also paid close attention to how the experts made sense of their experiences with mask wearing and how the issues addressed were expressed (e.g., experts referring to folk stories, metaphors, or past incidents). When presenting our research results, we focused on the topics we identified as prevalent through our inductive analysis, and we contextualized it based on the published research.

Ethics

The narratives analyzed in this study were given with the full consent of the people who wrote them and were made available for public access as an open-source repository for the research purpose ( 22). All the authors provided their consent that the narratives are published in the repository under their full name and affiliation and that they can be used for research purposes. The authors were cited here under their full names, recognizing their authorship of the narratives and their contribution to the dataset collection. The study received ethical approvals from the Ethical Committees of the University of Edinburgh, Scotland, UK and the University of Zagreb, Faculty of Croatian Studies, Croatia.

Results

Face Mask Wearing From Medical to Public Settings

The use of a face mask-of various specifications according to the required degree of protection/function-is part of the PPE required in several professional activities, most noticeable in healthcare. One of the participants in this study, who works in healthcare, described her own experience in terms of the caring features of the face masks from medical to communal setting.

" As an obstetrician-gynecologist, I am used with the mask, I feel it a part of my professional life, and I am trying to convince people that there is no way of considering the mask as an enemy but as a protection-like and umbrella against the rain, like a coat against the cold-and as a sign of civilization to protect our colleges and people around." [Iuliana Ceausu, Romania]

The contextual transfer of face mask use from healthcare settings to public spaces is precisely the aspect of making the "outside world" closely resemble scientific apparatus. This includes measuring its success as a feature of the social power derived from the accuracy of the scientific prediction. For instance, Latour ( 25) specifically examines the public nature of Pasteur's demonstration of the efficacy of the process of animal vaccination by making a "prophecy" that vaccinated cattle on a pilot farm will survive, while other infected animals will perish. In the same way, the (anecdotally) apparent success of the use of face masks reinforces the belief in their utility and efficacy:

" The people working in the shops would use the masks too... I see familiar faces of the employees all the times of lockdown, although they spend all time in the shop with many different customers, obviously they did not get sick. This was for me a major reassuring fact that the danger is not so high as it could be seen from the media." [Srećko Gajović, Croatia]

It is worth remembering here the significant number of deaths of inadequately protected healthcare workers during the COVID-19 epidemic in various countries, mainly due to the lack of the appropriate PPE supplies ( 26).

The Politics of a Face Mask

Following initial confusion around the utility of face masks for slowing down the spread of COVID-19 pandemic, there is increasing scientific evidence to support citizens' wearing of face coverings, albeit the public health advice and legislation vary from country to country. A recent study in Germany indicated that a mandatory approach to face mask wearing achieved better compliance than voluntary one, and it was perceived as an effective, fair, and socially responsible measure ( 27).

In our study, accordingly, the reported country policies differed across rather a wide spectrum of approaches-ranging from legally mandated instructions to cover one's face in all public spaces reinforced by financial penalties (i.e., payable fines), to recommendations only, official indifference, or advice against this practice ( Table 1). We were interested how these policies related to the concurrent COVID-19 situation expressed as total number and increase of cases per million people in these countries during the period when experts made their contributions. We observed an obvious trend showing that the countries with more strict rules had better epidemiological situation than those not mandating the face mask usage ( Table 1).

Table 1. Perception of the official policies on face mask usage in May 2020.

In some countries, face mask-related policies did not need to be prescribed as this was part of existing established habits; in the same way, no fines are necessary to get people to wash their hands. In particular, since the SARS epidemic in 2003, in many Asian countries, masks are customary wear used to protect against seasonal flu and the common cold. In China and South Korea, they are also employed to protect citizens from pollutants ( 17, 29).

" In South Korea, it is common to wear a mask to keep the cold from getting worse in the winter and to prevent the spread of cold to others. Also, as the yellow dust from China and fine dust became much severe, it was common for many people, especially children, to wear masks even before the corona crisis. For this reason, many families even had a lot of masks in their homes before the corona crisis. Personally, I'm familiar with wearing a mask, and I'd like to wear it in order not to harm other people, as I may be a potential patient." [Jiwon Shim, South Korea]

In contrast, in the West, the use of face masks is rare in social settings. Hence, because of the public visibility of face mask usage, face masks became an ideological symbol in some countries, with divergent political mindsets governing their adaption or rejection ( 17). Political dividing lines were particularly apparent in the United States, where the President refused to wear a mask until the last days of July 2020, when the floundering poll numbers and the increasing numbers of COVID-19 cases prompted the need to recommend this health protection device ( 30). Thus, in the United States and elsewhere, face masks were used by citizens to express their opinions in public.

" At the beginning of the pandemic, the use of masks had political connotations: since the government advised against their use, their wearing was even considered a form of political opinion." [Iñigo de Miguel Beriain, Spain]

The public statement made by wearing (or not wearing) the face mask did not only address the political standpoints but have also been used to communicate various societally relevant statements, i.e., stating ethnical, religious, or cultural affiliations ( 31). For instance, many countries that before COVID-19 banned face coverings in public spaces are now mandating it, supporting the idea that the past bans were motivated on the basis of religious/cultural beliefs ( 17).

" Ethical and moral dilemmas have already risen, especially in countries where Muslim minorities live. If you ban a burka covering the face due to security reasons, how would you deal with massive usage of face masks?" [Gentian Vyshka, Albania]

" The decision to wear a face mask is not an easy one. Traditionally, face coverings are an indicator of political persuasion and religious belief. I perceive that the widespread covering of one's face in public is a significant cultural and social shift in Ireland." [Ciara Heavin, Ireland]

"To Wear a Face Mask, or Not to Wear a Face Mask, That Is the Question..."

The collected narratives indicated that the contributors had a clear standpoint on their own face mask usage and developed arguments to support their decisions to wear or not to wear face masks.

" As soon as I leave the house and find myself in the supermarket or in public places, I wear a mask. However, I do not wear a mask when I take a walk in the forest. I started wearing it even before it became mandatory. I think it is important to wear masks, especially to avoid endangering others, e.g., elderly people. I find it unspeakable when people who wear masks are ridiculed by those who do not wear masks. At least that's what happened to me in the beginning, before the mask duty... Many thought that the people wearing masks would want to protect themselves in particular. Very few thought that people wearing masks wanted to protect their social environment." [Melike Sahinol, Turkey]

" My personal view is that as long as the spread of the virus is under control (as it currently is), there is no need to make the masks obligatory. I personally have not worn a mask (have not purchased any either) with the exception of when I visited healthcare institution (provided by them). I must also say, though, that none of my family members are considered a vulnerable population. If my grandmother would live with us, I might think differently." [Kadri Simm, Estonia]

What was exemplified in many narratives is that individual usage is not meant predominantly for an individual's self-protection, but the decision was based on people's relationship to others. The citizens' question "should I protect myself" evolved into "can I protect the others?"

" I wear disposable masks, understanding they protect others from me, more than me from others. I wear them to demonstrate responsible behavior and attitude to benefit of society." [Predrag Pale, Croatia]

The experiences of interaction with others in relation to face mask wearing were mentioned frequently, indicating the importance of the social context of individual behavior.

" I experienced cases when my request to keep distance or to take on a mask properly was treated offensively or as a sign of mistrust..." [Christina Nasadyuk, Ukraine]

" I put it on when I go to the grocery store because at the early stage of the pandemic, I was warned by the lady working at the counter that I am putting her life 'in danger by not wearing a mask.' Obviously, I did not want to take chances with her life again, so I purchased one of those cloth masks." [Vanja Kopilaš, Croatia]

However, many testimonies pointed out that masks have not been used properly. The health risks of incorrectly wearing a face mask represent an important argument against the use of face masks as a public health measure ( 32).

" ...25% wore masks improperly, on their necks, or covering only their mouths, but not noses. ...They do not know how to put the mask on, and when they remove their masks, they touch the outside of the mask, which is inappropriate and wrong." [Izet Mašić, Bosnia and Herzegovina]

" Also, one can observe many cases of half-compliance or sham compliance. For instance, people do wear masks, but slide them down onto their chins or take them off completely while talking to someone on the street or speaking on the phone. And this is all a performance, keeping their masks somewhere within reach in case of the sudden emergence of police officers, who are indeed issuing fines for not wearing a mask." [Aleksandra Głos, Poland]

This is even more complicated in situations when face masks were scarce (the stocks gradually improved through time in all examined locales).

" During the early stages of disease progression, mask wearing was not a common practice, mainly due to the complete absence and highly inflated prices in stores." [Rostyslav Bilyy, Ukraine]

" I do not use face mask. In the early stage of the COVID-19 epidemic in Norway, my understanding was that available masks should be reserved for people in the health and caring sector." [Anna Lydia Svalastog, Norway]

" I think the biggest concern is that the mask has been in short supply for a long time, and that its trade has not been subject to official pricing, so prices have been uncontrolled... The mask was in short supply when emergency was announced, but it is now available in many places and can be obtained at the checkout of almost every grocery store if someone started shopping without it." [Norbert Buzas, Hungary]

The shortage of masks ignited a burst of creativity in producing homemade masks, with a proliferation of tutorials for their production on the Internet and social media.

" Nowhere was possible to come to the face masks. Typical situation: the government did announce decree, but it did not provide the means for its implementation. We as ordinary citizens need to improvise with needlework of masks at home as well. Taking in regard that immediately rapacious war profiteers did appear by selling masks the needlework of masks at home was even not the worst solution." [Franc Mali, Slovenia]

" Although during the first weeks there was lack of masks and respirators, it was great how many people proved their creativity. It concerned not only the textile reusable masks, but also design and development of respirators with higher level of protection. They were mostly printed on 3D printers. Later on, some of the approved types were taken by larger producers, and mass production started." [Lenka Lhotska, Czechia]

Mask Wearing at the Interface of Personal and Social Responsibility

Besides being shaped by public discourse and social norms, risk perception also has a strong personal element. Some people seem like they do not care; others are quite relaxed, and some are more cautious. As for COVID-19, conflicting perspectives and emotions and even the psychological entrapment syndrome known as "cabin fever" (i.e., referencing long winter isolation in a small cabin) have been reported ( 33). Here, restricted microenvironments and quarantine are felt as secure places. The additional challenges were noticeable during the shift from the lockdown phase and the beginning of the so-called "phase 2" or "reopening" when people were allowed to leave their home again.

" 'Convivere,' i.e., 'live together with' the virus is the expression used by experts and media, to describe the phase 2, but this narrative could result quite distressing: how glad would someone be when living with a submicroscopic entity, that is such dangerous?" [Lucia Martinelli, Italy]

During this second phase, going back to living with "the others" demands new social behavior/etiquette combined with increased safety measures. The face masks start to be part of the new everyday rituals of saying hello, having a coffee together, and protecting each other. The role of peers in shaping the behavior of others is significant. People not committed to wearing mask can feel peers' pressure to comply. Moreover, "a collapse between the status of being at risk and being a risk" was noted ( 34- 36).

" The face mask, I realize, signals both positions, at the same time as it doesn't provide a definite answer: are you the risk object or the object at risk? Saying this, my individual attitude toward face masks cannot be pried apart from the social acceptance and use of the same. As long as the nonuse of face masks constitutes the norm, I will most likely interpret the usage as deviant and worrying. On the other hand, if the vast majority of the Swedish population would wear face masks, I would most likely start wearing a face mask as well. Here, the mass effect kicks in." [Jennie Olofsson, Sweden]

" The massive use of the masks among Albanian citizens... has become a normal well-adopted ritual of surviving, implemented as of a social significance for 'not letting the virus in.' This social cohesion on the intrapersonal view as 'to scare the virus" and 'fear of an enemy' comes close to a group approach of 'control and stability.' This ritual of social cohesion vis-à-vis the 'fear of death' or 'fear of the unknowing' is a similar to a psychological regression, when the individual survival depended largely from the herd." [Gentian Vyshka, Albania]

" For me, unlike other measures to contain the spread of the virus, the wearing of masks is predominantly a symbol of social cohesion and complying with the rules and not so much a measure to effectively protect myself and others from infection. The few times I saw someone without a mask entering a supermarket or the metro, my first thoughts were about social deviance and the arrogance of ignoring a commonly agreed-upon practice, and not about the risk of infection." [Mirjam Pot & Barbara Prainsack, Austria]

" In general, there seems to be a relatively wide acceptance of government recommendations, but a very patchy uptake. Though the Scottish Government advice is trusted more than that from the UK Government, significant generational and cultural differences can be seen as to its implementation... in a multicultural society such as Scotland, there are some subtle differences between people from different cultural backgrounds and traditions who are either more accustomed to follow stricter government instructions, or from cultures where face mask wearing is more commonplace." [Matjaž Vidmar, Scotland, UK]

" Finally, as an anecdote, I would mention the recent case of expelling an opposition MP from the Assembly because he did not have a mask on his face, although the Prime Minister who warned the MP did not have a mask either." [Zoran Todorović, Serbia]

The pandemic also seems to have reminded many people about the responsibility of humanity toward the preservation of all the living organisms and, as recognized by the Centers for Disease Control and Prevention ( 40), that our health is closely connected to the health of whole environment.

" We should see ourselves as the most important participants and the biggest beneficiaries of public health, so we should take expert advice-wear mask. In other word, under this special situation, we need to work with medical experts, government to co-build a safe, harmonious and orderly living world with 'One Health' concept, rather to resist or despise it." [Bie Ying Long, China]

The Face Mask: A New Barrier Affecting Social Relations?

If we assume that in the near future we will be used to living with the pandemic, or even a series of pandemics, we are currently developing new norms for social interaction. Being with other people and enjoying their company are essential for our mental and physical well-being. How do these interactions include face mask usage? What will socializing look like in the era of physical distancing (i.e., "keeping a safe space between yourself and other people who are not from your household") ( 41)? These issues are being recognized as particularly challenging.

" We must reinforce the message that face masks do not remove (or even reduce) the need for social distancing as well as excellent hand and respiratory hygiene. We need to avoid a situation where face masks become a weapon that could negatively impact our fight against this invisible enemy." [Ciara Heavin, Ireland]

" I believe the benefits of face masks may be overestimated and lead us into a false sense of security in which we take unwarranted risks-such as touching more objects and neglecting handwashing or going outside when suffering from a cough or cold. Therefore, my preference would be to give greater attention to other steps such as providing screens and visors for workers in public facing roles and reinforcing protective mechanisms around social distancing." [Helena Webb & Sue Ziebland, England, UK]

" Since the use of a mask started to become widespread, people seem to feel safer and unfortunately are more at risk, for example, not maintaining physical distance, making appointments with extended family and friends, etc." [Helena Machado, Portugal]

Not all evidence is in support of above assessments that face masks bring about a (false) sense of security. In a recent study conducted in the Italian Venice metropolitan area, wearing a mask has proven to be a visual factor strengthening physical distancing as a public health measure ( 3). Between February 24 and April 29, 2020, distances have been measured by an operator wearing an exclusive sensor-based "social distancing belt." They were interchangeably "unmasked," "masked," "do it yourself (DIY)-masked," "goggles masked," and "goggles DIY-masked." Results show that people tended to stay closer to an unmasked person, while mask wearing tended to increase the physical distance. This paradox is explained by considering humans' intrinsic social nature that favors social vs. antisocial behaviors ( 3). Wearing a mask thus can turn unconscious social behavior into conscious antisocial behavior.

" I believe that due to the extraordinarity of wearing face coverings in public spaces in Scotland, these do not encourage an undue feeling of 'safety' by their use, rather the reverse. Hence, with full awareness that the evidence for being protected by this measure is not there, rather, I hope that by wearing a face covering, I may remind (or even deter) others from breaking social distancing rules." [Matjaž Vidmar, Scotland, UK]

Marchiori's study ( 3) also suggests that distance increases with face mask wearing, thus supporting the importance of visual stimuli as a signal of danger. This fact recalled in the mind of our colleague, Bie Ying Long, the ancient Chinese tale of "The Blind Man Who Lights a Lantern While He Walks in the Night," which proposes a "wise" interpretation of action as interplay of altruism and self-interest ( 42). When people asked a blind man for the reason why was he carrying a large lantern when he traveled at night, he replied that while day and night were not different to him, carrying a lantern while walking in the night was for the sake of everyone. For him, the lantern provided protection from other people, allowing them to avoid bumping into him. For others, carrying a lantern shone a light on them and let them walk more securely.

" In the present, we should learn the kind of survival wisdom of the blind man in the story. To wear a mask proactively does not mean 'I'm infected with the virus,' rather to protect my own health. At the same time, it is a reminder to others that we are still in a time of crisis; we need to pay highly attention to our health and life safety very seriously." [Bie Ying Long, China]

However, face mask use may have adverse systemic effects, as well:

" The use of a mask is seen as an act of responsibility and altruism. However, I notice that people with masks tend to avoid personal interaction and to decrease the time they talk to each other. They avoid looking at others." [Helena Machado, Portugal]

" The syntagm social distancing is problematic because it symbolically transforms the rule of physical distance into the subversion or deconstruing of social ties. Face masks are strongly related to this implicated meaning. The human estrangement as a part of the 'COVID-19 regime' is the reason I have been more annoyed by some people strongly emphasizing the need for masks and physical distance than by those exhibiting the lack of interest for the personal protection against the infection." [Renata Šribar, Slovenia]

In this framework, institutional health communication plays a crucial role in motivating citizens to wear face masks and use them properly (i.e., how to handle it and how to cover one's mouth and nose), as well as to respect physical distancing and hygiene procedures. Here, the choices of narratives by public health system officials play a crucial role. Accordingly, the expression "social distance" tends to be avoided nowadays. "Physical distancing" has been adopted by the WHO, which they define as keeping a distance and avoiding spending time in crowded places or in groups ( 43). More distressing expressions such as "avoiding all unnecessary contacts" and "unnecessary contacts with the others" are used in some official advices ( 44). These messages may appear authoritarian, by intruding in the personal space of what is "unnecessary" and about who are "the others" when considering social contacts and human relations.

Conversely, an interesting example for motivating the correct use of face masks is the communication campaign "Per tornare tutti insieme a sorridere" [To get back to smiling together] by the Italian Health Ministry ( 45). This message designed to stimulate feelings of mutual protection and solidarity among relatives, as well as among strangers. Motivation is crucial because, as we have demonstrated, a face mask can be perceived as both a physical and psychological barrier, particularly in countries where covering one's face is not a common habit.

" When I walk and nobody is around me, I do not have my mask on the mouth and nose; however, when I'm approaching people, I pose it in the proper way and smile (with my eyes): I consider this a sort of 'greetings and courtesy nod,' a way to say 'I care for your health, do not be afraid by me, we will help each other.' I consider it as a message of solidarity." [Lucia Martinelli, Italy]

Discussion

Although a "simple" face mask may not be considered in or of itself a sophisticated technological artifact, its systemic use in healthcare settings, its past adopted use in certain social contexts, and the current significant expansion of its application to public health measures (as evidenced through the testimonies and literature outlined above), it can be understood as a facet of a substantial technoscientific project. Importantly, face mask use in the case of COVID-19 has an obvious medical/healthcare connotation, even though face masks are used in many professions to protect the workers against inhaling dust or harmful substances. In fact, many mask types worn during the pandemic come from non-medical supplies (the standard "filtering face-piece" or FFP1 and FFP2 models). However, it is the medical-grade masks that serve as a reference point for all other (varieties of) face coverings.

The aim of this exploratory study was to understand face mask wearing in terms of public policies, individual behaviors and attitudes, and the collective experiences of the affected communities. The main results of our study highlight that the societal and personal practices of wearing (or not wearing) face masks are influenced by ( 1) individual perceptions of infection risk, ( 2) personal interpretations of responsibility and solidarity, ( 3) cultural traditions and religious imprinting, and ( 4) the need of expressing self-identity.

First, even for individuals who might not be concerned for their personal health and safety, the wearing of a face mask often indicates a level of care and respect toward others. The decision about wearing a face mask is mediated by standpoints on utility of face masks based on scientific knowledge and/or in the absence of scientific consensus also on political beliefs ( 17).

Second, the behaviors of others were described in the collected testimonies in terms of societal responsibilities and rituals of social interaction, highlighting the role of peers in shaping the individual behavior. The narratives shine a light on the perceived balance between protecting oneself and social responsibility, reasserting the notion "If the people wearing masks are protecting you, isn't it right that you should protect them in return?" ( 17). However, this leads to inherent contradictions in the behavioral change required. The interchangeability of being at risk and being a risk is particularly striking ( 34- 36), making face mask wearing both an act of self-interest as well as altruism ( 42). In a similar vein, what could be perceived previously as anti-sociable behavior may now be beneficial for societal well-being (protection against the pandemic) and, in fact, preferred ( 3).

Fourth, the use of face masks preventing the spread of the virus is complemented or even upgraded by the use of face mask as a visual communication tool during times of lockdown and isolation providing a new way to communicate during a pandemic. This covers both political statements in relation to states' public health measures, as well as personal expression of raising awareness, collective solidarity, or just as a part of new pandemic-related esthetic.

We hope that this research will help develop new frameworks to guide a more holistic approach to understanding and enabling behavioral change among citizens, as well as enabling new models for non-verbal communication, noting specific challenges such as disability ( 46, 48). Recent articles highlight the need to develop new ways to communicate while wearing face masks through body language, particularly in terms of using eye contact to communicate emotion ( 52, 53). Also, there is an opportunity to develop new ethical frameworks to guide collective and individual decision making around face coverings. For health policy makers, our study highlights that public messaging plays a crucial role in institutional health communication and that in-depth knowledge of various cultures and ethics concerning health habits are relevant to informing and developing reliable information resources and policies for citizens during a global health pandemic.

However, this study was not without limitations. We acknowledge that our sample is yet representative of a group of intellectuals with a higher level of education, and therefore, the data cannot be generalized to the whole society. The methods we applied for data collection and analysis, however, fit the aim of our research: to explore the broad range of personal and social meanings of mask wearing in different countries. Furthermore, our sample combines the professional and personal observations by health and other experts providing a unique interdisciplinary perspective on face masks. Although we asked standard questions, we let people answer them in freestyle. We did not ask our authors to alter, explain, or correct their narratives in any way.

From a purely medical perspective, the effectiveness of measures to contain the spread of the virus is independent of the geographic area where these measures are implemented. From a social scientific perspective, however, individual and public health is always embedded, in particular social, cultural, and political contexts. Because of these influencing factors, health measures and devices are imbued with particular meanings that differ across countries. The specific meaning of a device, such as a mask, acquires also shapes how people deal with it and how they integrate it (or not) into their everyday routines and practices ( 55). Ultimately, this implies that studying the personal and social meaning of mask wearing in different contexts is also necessary for the assessment of the effectiveness of face masks as a public health measure.

In conclusion, our study points out the need of an in-depth understanding of the various social, cultural, religious, and ethical considerations on health habits and attitudes in a time of pandemics. Additional knowledge about the variety of personal and collective understanding of face mask wearing is essential for designing more effective health communication during and beyond the COVID-19 pandemic.

Data Availability Statement

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: http://dx.doi.org/10.17632/9s6fm7vdbc.1 ( 22).

Ethics Statement

The studies involving human participants were reviewed and approved by Ethical Committees of the University of Edinburgh, Scotland, UK and the University of Zagreb, Faculty of Croatian Studies, Croatia. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author Contributions

LM, VK, SG, CH, HM, NB, MP, and BP: designed the study. LM, VK, and SG: performed data acquisition, organization and analysis and wrote the first version of the manuscript. VK, MV, CH, HM, ZT, NB, MP, and BP: contributed to the interpretation of the results and critically revised manuscript. All authors approved the submission to the journal.

Funding

SG and VK acknowledge EU European Regional Development Fund, Operational Programme Competitiveness and Cohesion, grant agreement No.KK.01.1.1.01.0007, CoRE-Neuro, and awarded to University of Zagreb School of Medicine for financial support.

Conflict of Interest

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

Acknowledgments

We are grateful to the University of Zagreb, Faculty of Croatian Studies for covering Ph.D. tuition fees for VK. We thank Navigating Knowledge Landscapes Network for providing the framework for the study.

References

34. Hilgartner S. (1992). The social construction of risk objects: or, how to pry open networks of risk. In: Short JF, Clarke L, editors. Organizations, Uncertainties, and Risk. Boulder, CO: Westview Press (1992). p. 39-53.

# data[].attributes.attachment_link.title
Frontiers | Face Masks During the COVID-19 Pandemic: A Simple Protection Tool With Many Meanings

# data[].attributes.attachment_link.description
Wearing face masks is recommended as part of personal protective equipment and as a public health measure to prevent the spread of coronavirus disease 201...

# data[].attributes.body
Many Filipinos lost jobs and  food shortages and difficulties accessing health care.

# data[].attributes.attachment_link.readable_text
For Vilma Campos, a Quezon City resident and mother of five, life has improved since her family received their vaccinations. "My daughter has resumed working, so has my husband," she said. "Life is no longer that difficult."

Before COVID-19 hit, Vilma's job was taking care of children. When the authorities started implementing quarantine restrictions, she, her daughter, and her spouse lost their jobs. Vilma said her family was always wondering where to get the next meal. "What gave us hope was the arrival of vaccines," she said. "Things have improved and I really wish we can all overcome this pandemic."

Challenge

The Philippines was one of the countries hit hardest by COVID-19 in the East Asia and Pacific region. To manage the spread of the virus, authorities implemented strict quarantine restrictions and health protocols, restricted mobility of people as wells as the operational capacity of businesses. As a result, the Philippine economy suffered. In 2020, GDP contracted 9.5 percent, driven by significant declines in consumption and investment growth, and exacerbated by the sharp slowdown in exports, tourism, and remittances. Many Filipinos lost jobs and experienced food shortages and difficulties accessing health care. Due to global shortages, procurement of COVID-19 vaccines, medical supplies, personal protective equipment (PPE), reverse transcription polymerase chain reaction (RT-PCR) test machines, and test kits proved challenging in the early phases of the pandemic.

Approach

The project supported the country's efforts to scale up vaccination across the national territory, strengthen the country's health system, and overcome the impact of the pandemic especially on the poor and the most vulnerable. Besides vaccines, the project supported procurement of PPE, essential medical equipment such as mechanical ventilators, cardiac monitors, portable x-ray machines; laboratory equipment and test kits; and ambulances. The project also supported construction and refurbishment of negative pressure isolation rooms and quarantine facilities, as well as the expansion of the country's laboratory capacity at the national and sub-national levels for prevention of and preparedness against emerging infectious diseases. It funded retrofitting of the national reference laboratory - the Research Institute for Tropical Medicine (RITM) - as well as six sub-national and public health laboratories in Baguio, Cebu, Davao, and Manila, and the construction and expansion of laboratory capacity in priority regions without such facilities.

Results

During year1 to year 2, the following results were achieved:

The project supported the procurement and deployment of 33 million doses of COVID-19 vaccine across the country. The project supported pediatric vaccination for 7.5 million children. With the support of development partners including the World Bank, Asian Development Bank, and Asian Infrastructure and Investment Bank, the Philippines administered more than 137 million vaccines (more than 126 million first and second doses, and more than 10 million booster doses) by March of 2022.

The project helped scale up testing capacity from 1,000 RT-PCR tests per day to 24,979 per day.

The project supported the procurement of 500 mechanical ventilators, 119 portable x-ray machines, 70 infusion pumps, 50 RT-PCR machines, and 68 ambulances.

As a result of the strong vaccination rates and strengthened health response capacity, the Philippines is now much better able to manage the pandemic.

Bank Group Contribution

The World Bank through the International Bank for Reconstruction and Development (IBRD) provided $900 million of funding in total for the emergency response project. The project provided $100 million for medical and laboratory equipment and supplies; $500 million for primary vaccine doses, ancillaries, and end-to-end logistics; and $300 million for boosters and additional doses, and end-to-end logistics.

Partners

The World Bank collaborated with the Asian Development Bank (ADB) and the Asian Infrastructure and Investment Bank (AIIB) on project preparation and vaccines financing. The Bank worked with the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the United States Agency for International Development (USAID) on the Vaccine Introduction Readiness Tool (VIRAT) and Vaccine Readiness Assessment Tool (VRAF) Tool 2.0, which is used to assess status, gaps, and issues in four domains: planning and management, supply and distribution, program delivery, and supporting systems and infrastructure. Australia, through the AGaP Trust Fund, provided a US$300,000 grant to support implementation. The World Bank also collaborated with UNICEF to address vaccine hesitancy and with the WHO to procure RT-PCR machines and test kits.

Looking Ahead

The Philippine government is considering additional support for scaling up testing capacity. Equipment has been acquired and civil works commissioned through the project are now in use. An action plan is being developed for continued implementation of environmental and social safeguards employed in the project, such as COVID-19 waste management and assessment of accessibility of vulnerable groups to health care services. These will be institutionalized using the manuals developed and through directive issuances by the Department of Health. The project also supports the development of National Action Plan Towards Increased Accessibility of Health Care Facilities for Vulnerable Groups. The World Bank is also supporting the Department of Health and priority LGUs in strengthen local health systems for Universal Health Coverage.

# data[].attributes.attachment_link.title
Supporting the Philippines' COVID-19 Emergency Response

# data[].attributes.attachment_link.description
When the COVID-19 pandemic struck in the Philippines, the World Bank supported the country's efforts to scale up vaccination, strengthen its health system, and counter the impact of the pandemic, especially on the poor and the most vulnerable.

# data[].attributes.body
Due to global shortages, procurement of COVID-19 vaccines, medical supplies, personal protective equipment (PPE), reverse transcription polymerase chain reaction (RT-PCR) test machines, and test kits proved challenging in the early phases of the pandemic.

# data[].attributes.attachment_link.readable_text
For Vilma Campos, a Quezon City resident and mother of five, life has improved since her family received their vaccinations. "My daughter has resumed working, so has my husband," she said. "Life is no longer that difficult."

Before COVID-19 hit, Vilma's job was taking care of children. When the authorities started implementing quarantine restrictions, she, her daughter, and her spouse lost their jobs. Vilma said her family was always wondering where to get the next meal. "What gave us hope was the arrival of vaccines," she said. "Things have improved and I really wish we can all overcome this pandemic."

Challenge

The Philippines was one of the countries hit hardest by COVID-19 in the East Asia and Pacific region. To manage the spread of the virus, authorities implemented strict quarantine restrictions and health protocols, restricted mobility of people as wells as the operational capacity of businesses. As a result, the Philippine economy suffered. In 2020, GDP contracted 9.5 percent, driven by significant declines in consumption and investment growth, and exacerbated by the sharp slowdown in exports, tourism, and remittances. Many Filipinos lost jobs and experienced food shortages and difficulties accessing health care. Due to global shortages, procurement of COVID-19 vaccines, medical supplies, personal protective equipment (PPE), reverse transcription polymerase chain reaction (RT-PCR) test machines, and test kits proved challenging in the early phases of the pandemic.

Approach

The project supported the country's efforts to scale up vaccination across the national territory, strengthen the country's health system, and overcome the impact of the pandemic especially on the poor and the most vulnerable. Besides vaccines, the project supported procurement of PPE, essential medical equipment such as mechanical ventilators, cardiac monitors, portable x-ray machines; laboratory equipment and test kits; and ambulances. The project also supported construction and refurbishment of negative pressure isolation rooms and quarantine facilities, as well as the expansion of the country's laboratory capacity at the national and sub-national levels for prevention of and preparedness against emerging infectious diseases. It funded retrofitting of the national reference laboratory - the Research Institute for Tropical Medicine (RITM) - as well as six sub-national and public health laboratories in Baguio, Cebu, Davao, and Manila, and the construction and expansion of laboratory capacity in priority regions without such facilities.

Results

During year1 to year 2, the following results were achieved:

The project supported the procurement and deployment of 33 million doses of COVID-19 vaccine across the country. The project supported pediatric vaccination for 7.5 million children. With the support of development partners including the World Bank, Asian Development Bank, and Asian Infrastructure and Investment Bank, the Philippines administered more than 137 million vaccines (more than 126 million first and second doses, and more than 10 million booster doses) by March of 2022.

The project helped scale up testing capacity from 1,000 RT-PCR tests per day to 24,979 per day.

The project supported the procurement of 500 mechanical ventilators, 119 portable x-ray machines, 70 infusion pumps, 50 RT-PCR machines, and 68 ambulances.

As a result of the strong vaccination rates and strengthened health response capacity, the Philippines is now much better able to manage the pandemic.

Bank Group Contribution

The World Bank through the International Bank for Reconstruction and Development (IBRD) provided $900 million of funding in total for the emergency response project. The project provided $100 million for medical and laboratory equipment and supplies; $500 million for primary vaccine doses, ancillaries, and end-to-end logistics; and $300 million for boosters and additional doses, and end-to-end logistics.

Partners

The World Bank collaborated with the Asian Development Bank (ADB) and the Asian Infrastructure and Investment Bank (AIIB) on project preparation and vaccines financing. The Bank worked with the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the United States Agency for International Development (USAID) on the Vaccine Introduction Readiness Tool (VIRAT) and Vaccine Readiness Assessment Tool (VRAF) Tool 2.0, which is used to assess status, gaps, and issues in four domains: planning and management, supply and distribution, program delivery, and supporting systems and infrastructure. Australia, through the AGaP Trust Fund, provided a US$300,000 grant to support implementation. The World Bank also collaborated with UNICEF to address vaccine hesitancy and with the WHO to procure RT-PCR machines and test kits.

Looking Ahead

The Philippine government is considering additional support for scaling up testing capacity. Equipment has been acquired and civil works commissioned through the project are now in use. An action plan is being developed for continued implementation of environmental and social safeguards employed in the project, such as COVID-19 waste management and assessment of accessibility of vulnerable groups to health care services. These will be institutionalized using the manuals developed and through directive issuances by the Department of Health. The project also supports the development of National Action Plan Towards Increased Accessibility of Health Care Facilities for Vulnerable Groups. The World Bank is also supporting the Department of Health and priority LGUs in strengthen local health systems for Universal Health Coverage.

# data[].attributes.attachment_link.title
Supporting the Philippines' COVID-19 Emergency Response

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When the COVID-19 pandemic struck in the Philippines, the World Bank supported the country's efforts to scale up vaccination, strengthen its health system, and counter the impact of the pandemic, especially on the poor and the most vulnerable.

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DAZA, CZAN KYLE M.

GARCIA, APRIL KURSTEIGN

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Implementing of Virtual/Online Learning 

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Implementing of Virtual/Online Learning 

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The implementation of online learning was introduced in March 2020 in response to strict lockdown measures in the Philippines.

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INTRODUCTION:

In March 2020, the coronavirus disease 2019 (COVID-19) pandemic forced medical schools in the Philippines to stop face-to- face learning activities and abruptly shift to an online curriculum. This study aimed to identify barriers to online learning from the perspective of medical students in a developing country.

METHODS:

The authors sent out an electronic survey to medical students in the Philippines from 11 to 24 May 2020. Using a combination of multiple-choice, Likert scale, and open-ended questions, the following data were obtained demographics, medical school information, access to technological resources, study habits, living conditions, self-assessment of capacity for and perceived barriers to online learning, and proposed interventions. Descriptive statistics were calculated. Responses were compared between student subgroups using nonparametric tests.

RESULTS:

Among 3670 medical students, 93% owned a smartphone and 83% had a laptop or desktop computer. To access online resources, 79% had a postpaid internet subscription while 19% used prepaid mobile data. Under prevailing conditions, only 1505 students (41%) considered themselves physically and mentally capable of engaging in online learning. Barriers were classified under five categories technological, individual, domestic, institutional, and community barriers.

DISCUSSION:

Medical students in the Philippines confronted several interrelated barriers as they tried to adapt to online learning. Most frequently encountered were difficulty adjusting learning styles, having to perform responsibilities at home, and poor communication between educators and learners. By implementing student-centered interventions, medical schools and educators play a significant role in addressing these challenges during the COVID-19 pandemic and beyond. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s40670-021-01231-z.

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Barriers to Online Learning in the Time of COVID-19: A National Survey of Medical Students in the Philippines. | Med Sci Educ;31(2): 615-626, 2021 Apr. | MEDLINE

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In March 2020, the coronavirus disease 2019 (COVID-19) pandemic forced medical schools in the Philippines to stop face-to- face learning activities and abruptly shift to an online curriculum. This study aimed to identify barriers to online learning from the perspective of medical students in a developing country.

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The World Health Organization (WHO) has announced some basic sanitation practices to help prevent the spread of the virus. These practices include:

- Wearing a properly fitted mask

- Practicing social distancing by maintaining a distance of at least 6 feet from others

- Washing hands frequently

- Covering your mouth when coughing and your nose when sneezing