Case 2: Situation Appraisal of the Covid Testing Process in Metro Manila

Scope:
COVID - 19 testing (RT-PCR) in Metro Manila (16 cities: Manila, Quezon, Caloocan, Las
Piñas, Makati, Malabon, Mandaluyong, Marikina, Muntinlupa, Navotas, Parañaque,
Pasay, Pasig, San Juan, Taguig, and Valenzuela, as well as the municipality of Pateros.)

This case study’s COVID testing process will cover the following steps (Philippine
Genome Center, 2020).
1. “Customer” sets appointment
2. Swab test
3. Transport tests to lab
4. Process tests
5. Get result
6. Contact “customer” for results

I. Government Concerns for COVID-19 Testing

1. There is a shortage of a trained clinical laboratory workforce; diagnostic
centers are forced to hire additional personnel who have limited experience
and technical knowledge and skills of molecular assays (Albano, 2020).
a. Explanation of the concern
● Specimen Collection: When collecting specimens, it is important to properly
identify the sample, collect adequate amount or volume as well as practice
standard protocols in the transport and proper storage of biological
materials to be tested.
b. KPIs
● Number of COVID-19 tests conducted within a day. Currently, there are 79
licensed covid-testing laboratories located in Metro Manila (HFSRB, 2020).
c. Data supporting the concern
● Analytical Issues: Confirmatory laboratory tests through nucleic acid
amplification assay is performed for suspected cases. The use of RT-PCR
remains the gold standard for testing wherein unique sequences of the
SARS-CoV-2 genome are detected. However, RT-PCR is labor-intensive
and is an inherently complex assay requiring experience in all aspects of
testing, and thus limiting the capacity for quick turnaround time from sample
collection to the availability of results. This bottleneck may lead to long wait
periods and an exponential demand for testing. With the increasing number
of suspected cases needing confirmatory diagnostic testing, laboratory
personnel are forced to work under severe pressure in high-throughput
 settings with an insurmountable workload and with limited access to
personal protective equipment (PPE).
● RT-PCR is a multi-procedural process which makes it susceptible to cross-
contamination. Another possible source of cross-contamination is the
pipetting of patient samples into the PCR plate or strip. Possibly, samples
can also be misidentified as positive due to sample misplacement.

2. Test kit supply won’t be able to cope with the demand of Metro Manila
a. Explanation of the concern
● It is only through timely and accurate data can the government properly
strategize. That being said, a shortage of test kits will limit the data that the
government can work with as well as potentially create panic within the
public. When England and Scotland ran out of test kits, it forced people to
travel long distances to get tested thus increasing the chance of their
exposure. As seen in this article, people will act on their own once they
believe their government is lacking (Halliday, 2020).
b. KPIs
● No. of COVID-19 testing labs that can run at full capacity. An average daily
testing capacity of 27,800 individuals was recorded by the DOH (DOH,
2020).
c. Data supporting the concern
● In a statement, the DOH said that as of August 4, a total of 1,643,539
individuals have been tested for COVID-19, having an average of 28,938
tests per day within the last week (Hallare, 2020).
● According to the World Health Organization (2020), over 222,055 were run
from Nov. 10 to Nov. 18 and 12,348 new cases were confirmed from these.
With Metro Manila having a population of over 12 million people, this may
be a struggle considering there may be errors in the tests when it comes to
rapid covid testing (Radcliffe, 2020). PCR tests for example are not always
accurate and 29% of the time there are false negatives.
● Senior policy adviser of Thinkwell Philippines Marife Yap, a private
consulting agency to the Department of Health, said laboratories are only
using one kind of reverse transmission-polymerase chain reaction (RT-
PCR) test kit, which is imported from abroad and usually takes two to three
weeks before they arrive. There are laboratories with machines that require
only one type of RNA extraction kit or PCR kit. Not everything available in
the market can be used by our laboratories. As more local government units
conduct target testing, laboratories are getting overwhelmed with the
number of samples they receive (Ferreras, 2020).
 3. Length of processing time 24-48 hrs
a. Explanation of the concern
● At this rate, it would be difficult to test a number of patients who have
experienced symptoms of the disease since there is an increase in demand
for community testing, leaving the system overwhelmed and unable to
accommodate all patients, thus taking it weeks to remedy. According to
Dougan (2020), it is vital that one must get his/her test results sooner to
prevent the disease from being transmitted any further. In addition, Salva et
al (2020) determined the trend of symptom to death duration and found that
this ranges from 8 to 18 days. Prolonged determination of COVID-19 results
may also affect this trend since infected individuals are not given prompt
and proper treatment.
b. KPIs
○ The fastest processing time of COVID-19 testing of other countries,
specifically China, is only 30 minutes (Global Times, n.d.). In addition, China
has focused some of their COVID-19 research to developing rapid testing
kits such that a total of 44 different testing kits have been approved to be
usable. This just proves that the current testing kit capacities used in the
Philippines are very much lacking and that current technology already
supports fast COVID-19 testing.
c. Data supporting the concern
● The RITM (2020), which is the national reference laboratory for emerging
infectious diseases, said that results will be expected 48 hours after results
were taken. However, it may take longer if the sample taken does not pass
their criteria for “acceptable specimen”.
● Depending on the area of where the test was taken and the type of test run
by the testing site, the length of time it takes to receive the results can vary
between a few hours to several days (Barrell, 2020). Usually, symptoms of
COVID-19 are experienced 2 weeks after getting infected, which means that
as one is unaware of being infected, he/she can unknowingly transmit the
disease to anybody. Thus, if they have other speculations like being near a
person coughing or experiencing other symptoms of Covid, whether they
have it or not, one can suspect that he/she has been infected, and thus must
get a test.

II. Prioritization of the Concern

1. Design of Rubric for Prioritization
 Score Timeliness (30%)

5 Processing time takes a week or longer due to concern

4 Processing time takes 4-6 days due to concern

3 Processing time takes 1-3 days due to concern

2 Processing time takes 12-24 hrs due to concern

1 Processing time takes 12 hrs or less due to concern

Score Hazard (70%)

5 Problem affects both the individual and the population such that severe
repercussions(e.g. Increased mortality rate) are felt due to the problem.

4 Problem affects both the individual and the population and the adverse
effects are not related to the mortality rate.

3 Problem only affects both the individual and a small portion of the
population.

2 Problem is individual centric and does not affect the whole population.

1 Problem does not contribute any adverse effects to the individual and/or
population.

2. Explanation of Rubric Design

a. Timeliness
● This concerns the time that is wasted due to the concern. This measures
the potential loss in terms of time to an individual test.
b. Hazard
● This concerns the gravity of the effects when the concern is not resolved.

3. Use this Rubric to Prioritize the Concern

WO Concern Timeliness (30%) Rate Hazard (70%) Rate Weighted Final

T Score Ranking

W1 1 Lack of skilled and well trained 2 The limited number of lab 2 2 3rd
personnel leads to delay technicians hinders the process
 results. of obtaining the results.
Nonetheless, the results will still
come although taking longer than
the average amount of time
specified.

W2 2 Delayed test kits will also 5 Proper medication is delayed for 5 5 1st
delay results. Regardless of symptomatic carriers. This
how accurate the tests can be, increases the mortality rate of the
if the results take too long to individual. Asymptomatic carriers
be received, it may be too late are less likely to obtain testing
for the person to self-isolate due to insufficiency such that
(Radcliffe, 2020). proper distancing protocols
outside and in the house are not
likely to be observed.

W3 3 Factoring in the time it takes to 4 Rate of testing increases 3 3.3 2nd

send the results from the lab it
thus takes more time before
returning to the tested
individual. However, some
medical facilities (Gavilan,
2020) offer “express lanes” for
faster processing times to
those willing to pay more.
susceptibility to backlog and
delayed medication. Since many
individuals have enough funds to
avail “express” testing, then
mortality rates tend to increase
for these individuals due to faster
medication as compared to the
individuals availing the regular
COVID-19 testing.

III. Problem Statement

A lack of test kit supplies will stop the covid-testing process indefinitely, thus it is a
priority that test kit supplies are readily available at all times to accommodate heavy
demand.

IV. Bibliography
Albano, P. (2020). Cross-contamination in molecular diagnostic laboratories in low- and
middle-income countries: A challenge to COVID-19 testing. Philippine Journal of
Pathology, 5(2). doi:https://doi.org/10.21141/PJP.2020.08
Barrell, A., (2020, Sep 8). Coronavirus (COVID-19) Test Results: How Long Do They
Take?. [online] Medicalnewstoday.com.
https://www.medicalnewstoday.com/articles/coronavirus-covid-19-test-results-ho
w-long
China’s COVID-19 testing capacity leading the world. (2020, August 5). Global Times.
https://www.globaltimes.cn/content/1196804.shtml
Doh.gov.ph. 2020. PHILIPPINES NOW HAS 100 LICENSED TESTING LABS – DOH.
https://www.doh.gov.ph/doh-press%20release/PHILIPPINES-NOW-HAS-100-LIC
ENSED-TESTING-LABS-%E2%80%93-DOH
Ferreras, V. (2020, May 18). Lack of test kits, manpower slow down testing capacity for
COVID-19. CNN Philippines
Gavilan, J., (2020, August 4). LIST: How Much A COVID-19 PCR Test Costs In Metro
Manila Private Facilities. Rappler.
https://www.rappler.com/newsbreak/iq/list-prices-covid-19-pcr-tests-metro-manila
Hallare, K. (2020, August 6). PH has highest COVID-19 testing capacity in SE Asia —
DOH. Inquirer
Halliday, J. (2020, August 24). Coronavirus home test kits 'run out' in England and
Scotland. The Guardian.
Hfsrb.doh.gov.ph. (2020). LIST OF LICENSED COVID-19 TESTING LABORATORY IN
THE PHILIPPINES | HFSRB. https://hfsrb.doh.gov.ph/?page_id=1729
Modesto, C. (2020, Mar 20). How COVID-19 testing is conducted in PH. CNN
Philippines. Reference in:
https://cnnphilippines.com/news/2020/3/20/coronavirus-testing-in-philippines.html
Philippine Genome Center. (2020, November 27). Updated rates for COVID-19
testing following the DOH & DTI JAO No. 2020-0001 starting Nov. 27, 2020.
https://pgc.up.edu.ph/updated-rates-for-covid-19-testing-following-the-doh-dti-
jao-no-2020-0001-starting-nov-27-2020/
Radcliffe, S., (2020). Here’S Why We Can’T Rely On Rapid Coronavirus Testing.
https://www.healthline.com/health-news/fast-isnt-always-better-experts-worry-
abo
ut-rise-of-rapid-covid-19-testing#Less-accurate-tests-can-still-help
Salva, E. P., Villarama, J. B., Lopez, E. B., Sayo, A. R., Villanueva, A., Edwards, T.,
Han, S. M., Suzuki, S., Seposo, X., Ariyoshi, K., & Smith, C. (2020).
Epidemiological and clinical characteristics of patients with suspected COVID-19
admitted in Metro Manila, Philippines. Tropical medicine and health, 48, 51.
https://doi.org/10.1186/s41182-020-00241-8
Sciencemediacentre.org. (2020). Expert Comment About COVID-19 Testing Issues.
https://www.sciencemediacentre.org/expert-comment-about-covid-19-testing-
issues/?cli_action=1606489015.085