In the second part of our Online Kapehan, I am still joined by Ph. D. candidates and fellow PIKO members Erica Españo (Life Science in Pharmacy, Korea University Sejong Campus), Paula Cammayo (Preventive Veterinary Medicine, Gyeongsang National University), and Rey Anthony Sanjorjo (Applied Life Science, Gyeongsang National University) to discuss what mass testing is, why mass testing alone isn’t enough, and why the Philippines seems to encounter a lot of issues pertaining to mass testing. WATCH HERE.

Jubert: While we are on the subject of COVID-19 in the Philippines, I would like to ask your thoughts regarding an opinion piece published in Esquire a few weeks ago by a medical doctor regarding mass testing. The gist of his piece was “mass testing shouldn’t be the priority in the Philippines right now but rather people who are probable COVID-19 cases as well as those who have had contact with them.” Do you agree with him? Why or why not?

Erica: Can we first define what we mean by mass testing? I think there’s this wrong belief that it means untargeted testing – like we test everyone. Most people who suggest mass testing actually mean expanding the testing capacity, meaning accrediting labs faster, training testing personnel faster, so that we can test a lot of samples in a single day. We’ve had cases of people dying before they got their results, and that suggests how much backlog we have. I think the recent increase in testing capacity has cut down the collection to results timeline, but I’m not sure if testing labs have caught up with the backlogs yet, so we might not be seeing the number of cases in real-time just yet.

Having said that, I’d like to ask, how exactly are we going to identify probable COVID-19 cases, trace their contacts, and isolate them if we’re not going to test them in the first place? The thing with untargeted isolation (meaning everyone is kept isolated because you don’t even know who’s positive because you’re not testing) is that we keep people in quarantine longer than we probably should, and we isolate more people than we probably should. I am not an economist, but I don’t think we can keep paralyzing human movement, hence paralyzing the economy, for months because of the lack of capacity to test people.

Jubert: Which is exactly what Korea did: they did not impose any lockdown even during the height of COVID-19 infections here, but rather imposed strict social distancing measures coupled with widespread surveillance using their technology which led to targeted mass-testing of possible infected patients.

Erica: Yes, exactly. Instead, Korea employs a less stringent but prolonged social/physical distancing measure by imposing guidelines on mass gatherings. There was a study published in Science on April 14, 2020, suggesting that widespread surveillance should be performed regularly to help governments make informed decisions regarding social distancing measures (which are tied with the isolation of cases). Surveillance is doing testing for those infected and (and, in the future, if it’s possible or applicable to COVID-19) for those who have already been infected. If, for example, we perform surveillance and find that a certain locality, say a barangay, has a sudden spike in cases, then we can put that specific community on quarantine instead of isolating an entire city or, worse, the entire region. That, I think, is more sustainable. We shouldn’t have to fight blind. If we would also know how big the outbreak is at a locality at a given time, we would know whether we should put up stringent or looser measures when and where.

Also, how would we define “probable” cases? Are they defined as symptomatic and close contacts? Several studies have already suggested that a good portion (50 and even up to 80%) of COVID cases are asymptomatic, and presymptomatic (those who test positive and get symptoms within 7 days after the test) shed the virus and are infectious, suggesting that we should also be looking at them. If we limit the tests to the symptomatic cases or wait till they develop symptoms, these people may have had contact with several people days before they got the symptoms, and days before we have successfully isolated them. We could go back and trace the contacts, but early diagnosis (even before the symptoms or early into the symptom onset) would help us isolate them early, preventing the spread, and lessening the people we need to go back to for contact-tracing, which also means less work for contact-tracing. As Larry Brilliant, one of the people who helped end smallpox said: “Early detection, early response” should be the mantra for ending disease. Time is essential in mitigating the spread of COVID-19, and a proactive, expansive testing capacity is going to be a very, very big tool in helping us catch up.

Jubert: But we also have to consider that the Philippines isn’t as well-equipped compared to Korea. So wouldn’t it also affect the efficiency of contact-tracing back home?

Erica: Right, right. As you pointed out, our contact-tracing capacity is not as efficient as, say, Korea’s. The transactions in Korea are easily traceable because of their ICT. Most people here do card transactions, which makes it easier to track their movement. Relying on COVID-19 cases to report their whereabouts is not going to give you a full picture of the contacts these people have been with. Most people would forget where they’ve been, and, as in some unfortunate cases, some people actively lie. As one of the coronavirus experts in Germany has pointed out, we have to try to do contact-tracing electronically. Given this, our contact-tracing is not as tight, so relying on it heavily might leave some loose threads.

Loose threads, like Korea’s Patient 31, and what happened in Singapore where the cases in the dormitories of foreign workers have spiked, can undo all the effects of the ECQ, so we have to stay vigilant. I think, if we perform expanded testing and contact-tracing to identify infected people, we’ll do better. We have to understand that testing, isolation, and contact-tracing are not independent of each other and, instead, go hand in hand. Understandably, the biggest limitation we have for testing is the lack of finances: we can’t buy test kits for everyone. But I think we just have to be very strategic with our testing approach, identify the targets, and use all the available techniques we have so that we still cover a lot of people in a short time despite the obvious limitations to finances and kit supply. There are recommendations like pooling samples strategically that might be worth looking into. I think Germany and New Zealand are looking into it now.

Jubert: Your thoughts, Paui, and Rey?

Paui: I’m okay with mass testing as long as the laboratories, health centers, and hospitals have the capacity in terms of having trained personnel and equipment to do large scale testing. If we are after epidemiological surveillance, also we need to push for mass testing.

Regarding having false-negative results, it may either be due to how the sample was acquired or maybe a problem with how the samples were processed. Either way, if a person shows obvious symptoms linking to COVID-19, the doctor may recommend retesting, or the patient may request for another one to verify the previous test.

Rey: I agree with Dr. Salvana who wrote that article. Mass testing that is not necessarily targeted is expensive and impractical. The Philippines is in a tricky position. We have a privacy data act and a bank secrecy law that doesn’t allow the government to look and track our financial transactions and conduct digital surveillance without consent, but that exactly is what is done in Korea that had proven to be essential in effectively monitoring and isolating COVID19 suspected and confirmed individuals. Mass testing at the scale and speed similar to Korea is also quite impossible right now in the Philippines. We never had the infrastructure, manpower, and resources similar to Korea, considering that we have 2x the population, 1/5 of the economic size and along with logistical challenges due to geography. Hence, we should optimize what we have, and that means creating a more bureaucratic checklist before proceeding to the actual testing. Even the US had an issue with scarcity on test swabs that were used for nasopharyngeal sampling and on test kit components including an enzyme called TaqPath for RT-qPCR tests.

Part 3 will discuss treatment options and updates regarding clinical trials for COVID-19 candidate drugs.

Note: The transcribed interview was edited for brevity.