Mixed signals can be ‘bad for health’

This week, many stakeholders in public health and the media noticed the mixed signals DOH Secretary Ted Herbosa sent out regarding the state of dengue during a media briefing last Monday and during an interview with Karen Davila of ANC.

As reported in The Philippine STAR by Rhodina Villanueva and Artemio Dumlao, Sec. Ted Herbosa stated that “dengue cases in the country have soared and may have already reached outbreak levels, … based on a conversation with our epidemiology bureau director, our dengue cases are of outbreak levels already.” The secretary went on to share that current cases are 33 percent higher compared to last year.

“Forewarned is forearmed” and that statement from the secretary himself is important and helpful. But it was short of a formal declaration of a “dengue putbreak.” Failure to formally declare a “dengue outbreak” limits public health officials and LGUs in terms of what actions and expenditures can be used to combat dengue.

Health workers pointed out that the level of response, resources, stocks to be deployed or prepared immediately is dependent on the declaration of the secretary. Considering that the Philippine Red Cross made an announcement encouraging Filipinos to donate blood in response to the dengue situation on the same day, the secretary may end up being “too late the hero.”

Secretary Herbosa was probably still waiting for an official endorsement from his epidemiologist or team before committing himself to a full declaration. However, the delay has placed Herbosa in a “damned if you do/damned if you don’t” situation.

In a related matter, I saw a video clip of the interview of Secretary Herbosa where Karen Davila asked him to talk about a dengue vaccine that is different from the controversial Dengvaxia.

Herbosa stated, “Let me make it clear before people misunderstand, yes, it is dengue season, the vaccine has no use during the dengue season because you need two or three doses of vaccine to get the immunity. Number two, we only give the vaccine to those who are already infected.”

“I think the mistake of the previous implementation of the dengue vaccine which actually is available in other countries is that it was given to all kids regardless.” (Davila interjected and asked who should have been given the Dengvaxia vaccine?)

“The dengue vaccine is a post-exposure vaccine, that means you must have had dengue once, because dengue is more serious in the second infection. So, if you have had dengue before and you get antibody enhancement which causes the severe bleeding and all the hemorrhagic that can cause death.”

“So (yun yung) pini-prevent nung previous vaccine. Pero naibigay sa lahat, so nag karoon ng parang second infection so they became worse. So, we have about 160 alleged people that could have died from the implementation of the vaccine. And they pulled out. The company that made that, pulled out of this country and I think there is an ongoing lawsuit on that.”

Ordinary Filipinos might not pick up on the nuances of the conversation but as someone who has given media training for many years, I noticed that Secretary Herbosa rushed to reply and missed Karen Davila’s first question or request about “the other vaccine.”

Davila was referring to a different vaccine undergoing evaluation with the Food and Drug Administration for approximately 18 months and but comparatively languished to other applicants because FDA officials are avoiding a political controversy similar to Dengvaxia from happening.

Secretary Herbosa was correct to point out that a vaccine at this time would be ineffective because vaccines need to be injected/introduced six weeks to two months ago before it can have any effect. But that was not the question.

The question was: “about the new vaccine different from Dengvaxia.” Is the new vaccine the same or different in composition and effect? What is the status of the FDA evaluation, etc. and when will it be available?

As far as Dengvaxia is concerned, the manufacturer Sanofi voluntarily reported cases of “adverse reaction” based on a belated discovery and subsequently suggestion that Dengvaxia be used only for individuals who have already had dengue to prevent them getting it a second time when it is more dangerous.

After further evaluation, their license to manufacture and distribute was revoked by the FDA as a regulatory action leading to the pullout of the product. Since Dengvaxia is no longer in the market and not the topic, Secretary Herbosa should not have talked about it at all.

What Secretary Ted should not have done was dig a deeper ditch to sink in by making references to “the mistake in implementation” and “the 160 cases of people that could have died” because it was not the topic.

As per my sources, back then (2016) as per WHO, “serotesting” was not required in “highly endemic areas.” The Dengvaxia Investigative Task force of the DOH evaluated the death of 14 children who received the vaccine. While three showed potential causal association, the reports emphasized there is no evidence directly attributing those deaths to the vaccine.

The matter of alleged deaths or “people who could have died” is still in court. The Court of Appeals dismissed the homicide charges while the case continues with the Sandiganbayan.

Secretary Ted Herbosa needs to know that several public health advocates are now asking if the DOH secretary is anti-vaccine? Does he have an axe to grind with former DOH officials? Why does he keep raising possible obstacles to a new vaccine in the face of an outbreak he has almost declared? Is he trying to convince or confuse the media?

Secretary Herbosa deserves credit for engaging the media and stakeholders in public health. But now that he holds a national position, such activities require professional training and preparation.