The COVID-19 scorecard for Duque and DOH


By Rafael Castillo M.D.


Last week, at least 15 senators urged Health Secretary Francisco Duque III to resign because of the Department of Health’s (DOH) perceived failure to handle the new coronavirus disease (COVID-19) pandemic.

A resolution decried the secretary’s “failure of leadership, negligence, lack of foresight and inefficiency,” as well as “poor planning, delayed response, lack of transparency, and misguided and flip-flopping policies and measures.”

I may have criticized the DOH a number of times, but I think overall, the DOH, with Duque at the helm, did fairly well in keeping the outbreak at bay. That’s the bottom line at this point, which the good senators should have considered.

In retrospect, Duque could have recommended an earlier travel ban to China and other countries with already alarming COVID-19 incidence. He could have anticipated the need and stockpiled on test kits and personal protective equipment (PPE) for health-care workers. He could have proposed the lockdown a day or two earlier—but it’s a lot easier to argue on hindsight.

Everyone is a genius on hindsight. But when you’re confronted with a tough situation and have to make a call, the demarcation between a prudent decision and a heedless one is often a blur. But you need to choose the lesser evil.

It’s no different during medical audits when we assess how the attending physician has managed a serious case. With the advantage of hindsight, many consultants lambast their colleagues because of some perceived oversights. But a problem like COVID-19 can humble any health official, and make him or her clutch at straws.

COVID-19 is a public health problem like no other. It was and remains uncharted territory. Nobody can claim to be an expert on it. There’s no previous reference experience that can guide anyone on how to deal with it.

Duque and the DOH may have looked a bit overwhelmed at the start, but who wouldn’t be, with a vicious and unseen enemy like COVID-19? But I think the DOH got up quickly enough.

We would have been a lot worse off if they did not react the way they did, despite limited resources and logistical challenges. After all, it’s not a purely public health problem. It has ramified into a complex socioeconomic, political and governance crisis that requires a whole-of-government and whole-of-society approach. The health secretary has no absolute control over this crisis situation.

Gold standard

One of the decisions Duque made that was taken against him was not recommending rapid antibody test kits for mass testing. He stood pat on his recommendation to use only polymerase chain reaction (PCR)-based testing to diagnose COVID-19 patients, which he rightfully called the gold standard.

He was just defending the science, which, if misinterpreted, could jeopardize the country more. Now that Duque was apparently overruled on this, the country could be facing a risk if mass testing with the rapid antibody test kits is pursued on a regional or nationwide basis.

We explained in last week’s column that antibody testing is ideal only for epidemiological research, if the government would like to determine the prevalence of those who may have had COVID-19 in the population or in a certain locality.

The risk is when the result of the antibody testing is used to determine who has active or infective disease as part of mass screening. In that case, we wrote, tossing a coin would be relatively more reliable.

The sensitivity of the antibody test to identify those with infective COVID-19 is less than 50 percent. That means every other COVID-19 positive case would be missed, and would be likely to spread the virus in their community or household because they thought they were COVID-19-free.

In some news reports, it was claimed by some proponents of the rapid antibody test that its sensitivity is more than 90 percent. That is a half-truth, actually, and I hope the manufacturers of these kits are not intentionally spreading it. The sensitivity goes up to 90 percent by the second week, especially at around 14 days. But on the first week of infection, especially during incubation and the asymptomatic phase of the infection, it’s dismally low.

I heard that this test is being used extensively by local government units (LGUs) to clear balikbayan overseas Filipino workers (OFWs) now coming home in droves before they’re allowed to go back to their communities. It’s a useless test for that, and is more of a psychological crutch to make the LGU officials feel more comfortable that they did something.

There should be a more scientific and rational way to screen returning OFWs, so not all of them have to be quarantined for two weeks before rejoining their families. I think the greatest injury from COVID-19 is not the physical harm, but the exaggerated paranoia that has afflicted many of us.

Big relief

Back to the DOH scorecard. As of this writing, they have reported 6,981 confirmed cases, 722 recoveries and 462 deaths. My estimate is that the number of actual cases should be at least three times this number, or more than 20,000 cases.

It’s only lately that our capacity has increased to more than 5,000 tests daily. So the ones tested are those with relatively more serious disease or who are symptomatic. The far bigger majority of around 80 percent had mild or maybe asymptomatic COVID-19 infection, and didn’t bother to get tested.

But when we look at the DOH statistics—and the DOH should guide the public more on how to interpret the data—we should look more at the pattern, rather than the actual number.

One pattern is the doubling rate of confirmed cases. Before the quarantine last month, the doubling time of confirmed cases was three to four days. Undersecretary Maria Rosario Vergeire recently announced that the doubling time has increased to five days, but I think it’s a lot more than that; I’d say it’s around 14 days now, which is a big relief.

Does that mean that we’re flattening the curve? If we can maintain a more than 15-day doubling time for a month, we can say that we’ve flattened the curve somehow, just enough to buy our health-care system more time to ramp up its capacity to handle a potential surge in cases.

We’re just delaying the surge, but we cannot escape it. We’ll have to confront it, hopefully much later than sooner.

We’re still far from the goal of eradicating this pestilent coronavirus. That will happen—and we’re not even too sure it would happen—only if we’ve developed herd immunity to it. This happens when 70 percent of the population is already immune to COVID-19, either by getting infected or by being vaccinated.

Since the earliest we can expect the vaccine is a year from now, despite the hype that it would be available this year, that means we have to delay and prevent any surge till then.

A modest surge within the capacity of our health-care systems to absorb is allowable. But if we have more cases than our hospitals could accommodate, our health-care system will choke and collapse.

The DOH should be monitoring the admissions and discharges so that at any given point, it knows if we’re nearing tipping point or not. I pegged a doubling time of 15 days as good enough to cut us some slack, because in a small study we did last month up to early this month, the average hospital stay of COVID-19 patients was 13 days. Among those we gave high-dose melatonin to as adjuvant therapy to the other empirical treatments, the average hospital stay was reduced to 8.6 days, including for three patients with adult respiratory distress syndrome (ARDS).

So, with a doubling time of 15 days, we can maintain the number of people who need to be hospitalized to a manageable level. The previous batch of COVID-19 patients shall have been discharged when a new batch comes for admission.

Overstaying

The hospitals should also prevent overstaying of patients. Sometimes, the patients must stay several more days in the hospital waiting for the result of the repeat COVID test. Previously, the guidelines recommended that a patient must test negative twice before discharge.

In a recent tele-meeting, we explained to Secretary Duque that this guideline was unnecessarily keeping COVID-19 patients in the hospital when their rooms could have been vacated to accommodate others. He immediately called another DOH official to revise the guidelines and allow discharge based on clinical parameters. The test could still be done before discharge, but the patient can just be advised of the results later on.

One thing good with the secretary is that he listens to feedback and is able to discriminate between the good and the pragmatic, the not-so-good and the impracticable.

The 15 senators should probably step back a bit to have a better perspective of how Duque and the DOH are managing the pandemic. They should assess it not on a piecemeal basis, but on the totality of the decisions made and how they impact outcomes.

So far, the outcomes are relatively better than those in other countries, including the United States, Italy and Spain, with far better technologies and much more resources. We may not be on top in terms of performance, but we’re somewhere in the middle of the pack.

There are definitely areas for improvement, like the lack of PPE which could be a cause of the high infection rate of our health-care workers, and the lack of accredited facilities to conduct the more accurate PCR-based testing—but these are being addressed and should be improved soon.

Some senators have likened it to a basketball game and argued that we should change the team captain lest we lose the ball game. It’s a tight ball game, we fumbled at the start, but we’re starting to score now and narrowing the gap, as shown by more recoveries than deaths.

The pandemic is a precarious learning curve for any health official. Duque had his, learned some humbling lessons, but I think he’s on top of the curve now. Everything he learned would be put to waste, and it would be quite a tragedy for the country to replace him at this stage.

Who knows? When this is over, the 15 senators might just withdraw the Senate resolution they passed last week, and pass instead another commending Duque and the DOH for helping the President shepherd us through this crisis.

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