Rapid testing conducted in Pasig, a city that has one of the highest COVID fatality rates in the country. Photo from Mayor Vico Sotto's FB account
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Lipa, San Juan, Muntinlupa, and Pasig have the highest COVID death rates among PH cities

Our resident expert suggests that more testing should be done in areas with high death rates, but low positive cases. This suggests they are not testing enough nor are they doing ample contact tracing. BY BENJAMIN CO MD
ANCX | Jun 06 2020

Infectious diseases and clinical pharmacology expert Dr. Benjamin Co has been thankfully breaking down coronavirus numbers in his personal blog since the outbreak started. The perspective he provides is informative, and comforting in those who are craving for a clear picture of how we are faring against the virus. Dr. Co will share daily updates and analysis of the Department of Health reported numbers with ANCX. 

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Refer to the link DOH.gov.ph  or up-to-date data or to COVID19.gov.ph. (The latter is not a secure site.) The new site for the Department of Health is user friendly, provides more information where a COVID19 tracker is seen. Readers can check their official site where Data Drop for raw data can be found. 

One useful site is COVID19Stats.ph, where one can see the dashboard of information from the DoH website. Unfortunately, because of the migration of the data drop into COVID Kaya, no one is able to break down the numbers to the finer details as in the previous posts. 

 

Good news. Bad news: The wrap for the day

After one day of relief, our numbers up once more. 

There are 714 new confirmed cases today compared to the 244 yesterday—and expectedly so. Since we’re doing an average of 10,000 tests a day, and the positivity rate is around seven percent, (assuming that the positive rate is constant), we should have an output of approximately 700 positive cases a day (not including backlogs). Only when the positivity rate begins to decline (in spite of increased testing), will we see an actual “bending” of the curve. It is now clear that as all the data sets come in, the backlogs and lower testing early on in the pandemic were the primary reasons why the number of cases were low but the death rates were high in the beginning. 

Of the 714 total cases, 350 are “fresh” and 364 are “late.” Of the 350 “fresh cases,” 171 came from Region VII, 104 came from NCR, and 75 came from other areas. 

Of the 364 “late cases,” 140 came from NCR while 224 came from other areas. 

Fresh or late, NCR had 244 cases, Region VII had 171, and other areas had 224. 

With more backlogs coming in, the numbers are expected to rise. The good news is that the deaths remain low in spite of the increase in number of positive cases. Whether these remaining positive cases are retests from previously positive patients who are recovering or have recovered are unknown. 

As of today, the Philippines still adopts the criteria of having two negative consecutive tests to be considered a recovery. This most likely accounts for the low recovery rate because many patients don’t take the initiative to have retesting done, especially when they are mild or asymptomatic and have clinically recovered. Other patients who are retested over and over but remained positive in spite of clinical recovery past the clinical course of illness are probably included in the count on positive tests. 

With continuous testing of clinically ill or exposed individuals to positive patients through contact tracing, the number of positive patients will remain in an upward trajectory for the meantime. 

Today’s total brings the case fatality rate of the Philippines to its lowest of 4.66 percent (good news) and recovery rate is a tad lower at 20.8 percent as the number of total cases increased significantly today. The low recovery rate is probably due to the reporting system of recoveries in the country with the LGUs having different data from the national agency.

According to the Department of Health, based on the remaining 15,309 active cases remaining as of June 05, 2020, 94.3 percent (14,439 cases) are mild while the remaining 5.2 percent (793 cases) are asymptomatic. Only 0.5 percent of the remaining active patients are severe (58) or critical (19).

With the current data, the growth rate has increased back up to 3.5 percent but the doubling time remains approximately 10 days. While Indonesia has a higher case fatality rate compared to the Philippines (5.9 percent vs 4.66 percent), recovery rates in Indonesia are far better than ours (32.5 percent vs 20.8 percent). Overall, 81 percent of all cases in the Philippines are recoveries, while 19 percent lead to death. This makes us the lowest among the Southeast Asian countries in terms of recoveries-to closed cases ratio. 

 

Testing capacity

As more RT-PCR laboratories are being licensed, we’re having more tests conducted. At least 3,735 test/million population are being carried out per day. As of June 4, a little over 1,000 samples are left in the backlog. Hopefully, this closes in toward the middle of next week. 

Of the 408,945 total tests conducted in 376,341 individuals, the positivity rate is now lower at 7.1 percent from a previous 7.3 percent. This means that we are testing enough to see the prevalence of the pandemic in the country. The number of positivity is also going down in spite of the higher testing capacity. This is an important issue to discuss as certain areas in the country have a very high death rate compared to the overall case fatality rate. It is recommended that those areas with high death rates (>10-12 percent) should have more aggressive testing and contact tracing done.

For example, if there is one death in 1 case in one community, its case fatality rate is 100 percent. Because the virus is highly infectious, there must be other cases undetected within the community. Targeted aggressive contact tracing should be done within that community so that those that are positive can be quarantined or isolated, in order to contain a potential outbreak. 

Majority of the patients tested (~93 percent) were negative. This means for every 13 patients, 1 would most likely test positive. 

 

Breakdown the day before

Yesterday, of the 244 new cases announced by the Department of Health, 204 had residence information. Fifty-two cases were reported in Luzon, 138 in Visayas, and 14 in Mindanao. There was no report among repatriates.

Based on cases per region, the NCR still has the most number of cases followed by Region VII and Region VI-A. While Region VII may have more than 3,100 cases, it has the lowest fatality rate. 

Based on cases per city, nine of the top 10 cities are within the NCR. Quezon City ranks first, followed by Cebu City and then Manila. While most of the cities has seen a growth in cases over the past week, the highest increase in growth rate goes to Cebu City with 4.40 percent.

Cities with the highest fatality rate (for those with more than 50 cases reported) include Pasig (10 percent), Muntinlupa (10 percent), San Juan (13 percent), and Lipa, Batangas (15 percent). 

More testing should be done in areas that have reported a high case fatality rate (>10-12 percent) compared to the number of cases they have reported. The mere fact that there are reported deaths in these areas due to COVID-19 but report low positive cases, means that they are not testing enough in these communities. This is a long and exhaustive list which covers many cities in the archipelago. This is the ideal target for the expanded testing and contact tracing that others in the NTF on COVID-19 should be focusing on.

To get in touch with the Department of Health, the COVID hotline is (02)894-COVID loc 1555.

Disclaimers on the data: 

(1) These three parameters (new confirmed cases, new recoveries, new deaths) are not real-time data. The data provided by the Department of Health is the date of public announcement. Even global data will vary in time of reporting, depending on the reporting capacity of that country. To date, the latency period of the Department of Health on reporting recoveries averages almost 10 days (with more than 50 percent reported after eight days and more) and deaths averaging almost 12 days (with more than 50 percent being reported after eight days or more).

(2) Depending on where testing is done, RT-PCR test results take an average of 12 hours to two days to process. Barring any delays, all tests done should ideally be released within 48 hours (the earlier the better). However, the test results released from government facilities range from three to 30 days (based on Data Drop), probably due to an overwhelming number of tests being conducted when compared to private hospitals where fewer number of tests are performed.

 

Global statistics

Update as of 7PM 06 June (Saturday)

TOTAL CONFIRMED CASES: 6,867,463

TOTAL DEATHS: 398,585 (case fatality rate: 5.8 percent)

TOTAL RECOVERED: 3,362,943 (case recovery rate: 49 percent)

Total cases worldwide

Note that every reference has its own cut-off time for reporting. For the global data, WorldOMeters is used as its reference.

The global statistics now approached the seven million mark, and almost half the total cases recovered. Of the more than 6.8 million cases, more than half already have an outcome: 89 percent have recovered while 11 percent died. Only a little more than 45 percent of the cases remain active.

These are good numbers because they indicate that while the number of cases continue to increase (mainly driven by more testing), majority of them already had an outcome and the fatality rate is generally lower now. With the revision on the criteria for recoveries now being implemented in several countries, the global recovery rates have dramatically gone up.

The global data shows that the average cases is still more than 100,000 case per day. The highest number of cases globally was reported yesterday: 130,529. 

Daily confirmed cases since December 31, 2019. The last time we looked back at the lowest numbers was on February 24, 2020. It has been an upward trajectory since and has plateaued at >80,000 confirmed cases per day since April 5.

And while the daily new cases saw a surge, the number of deaths declined from 5511 yesterday to 4906 today.

Daily deaths as of May 30, 2020

The United States of America continues to lead globally in the number of total confirmed cases at 1,965,912 (up by more than 25,000 cases overnight) with a case fatality rate (CFR) lower today at 5.67 percent with 111,394 total deaths recorded. Among the states, New York leads with 396,699 total confirmed cases and 30,372 total deaths with a lower 7.66 percent case fatality rate (CFR) as the number of deaths slows down for the last week. 

Brazil remains in second with a lower CFR at 5.42 percent with a haul of over 30,000 cases. Total cases are now at 646,006. Russia is in third with a CFR of 1.25 percent and total cases of 458,689. India is now in sixth spot with 237,395 cases and a CFR steady at 2.8 percent. The South American countries are now the hotbeds in terms of cases for the last two weeks. Brazil tops the list at number two in the world, Peru has moved up from ninth to eighth today, and Chile is close at 13th place. These three countries combined make up almost one million cases in the world. 

In Southeast Asia, Singapore slips down to 28th in the world with Indonesia remaining at 34th spot and the Philippines at 38th.

As several countries ramp up testing in various degrees, more new confirmed cases are being reported. With more testing and aggressive targeted contact tracing, more patients who may be asymptomatic or pre-symptomatic and are potentially infective to the vulnerable population are being identified. With more testing, we see a better picture of the extent of the pandemic. There are, however, some countries who may not be performing a lot of contact tracing and/or testing, but have better outcomes than others that do. 

For a discussion on how much testing is “enough” testing, you may click here

There are multiple factors that determine how outcomes of pandemics play out. Policy responses include school and workplace closures, cancellation of public events and gatherings, restrictions on public gatherings, public information campaigns, stay-at-home restrictions, international and domestic travel (public transport, restrictions on internal movement and international travel controls), and of course, testing and contact tracing. 

The median average of case fatality rates worldwide has further declined to 5.8 percent (from 5.86 percent yesterday). For the past two to three months, over 89 percent of patients are either asymptomatic or have mild disease and have recovered. 

The good news? Recoveries far outnumber the deaths with a ratio of approximately 8.45:1. (The ratio of recoveries continues to increase, and will reassuringly do so, over deaths because of increased testing and better minimum healthcare standards.)