 Afternoon, everyone, and welcome to the fifth installment of the University of the Philippines, the Philippine Health Insurance Corporation's webinar series on Stop COVID Vets. I'm Dr. Raymond Sarmiento from the National Telehealth Center of the National Institutes of Health. From the University of the Philippines, Amanila, it is always a pleasure for us to be able to share the floor and this platform with all of you during our regular Friday lunch date. With me is my co-host and my partner in crime, so to speak. My mentor, Dr. Susie Pineda Mercado, who is also a board member of the Philippine Health Insurance Corporation. Dr. Susie. Thank you so much. We'd like to welcome you to the fifth in a series of webinars for improving our knowledge and our understanding of clinical management of COVID. I know all of you who are listening out there are eager to hear our speaker. There's so much information that's changing so rapidly. So we thought that this platform would be a good way to reach out to everybody. Salamat po sa lahat ng sumama ngayon, sa lahat po na nunud sa playback at sana po marami kayong matutunan sa aron ito. Raymond. Thank you so much, Dr. Susie. So indeed, we have featured po na a renowned pulmonologist, infectious disease experts, and also one of the top renal specialists in the country. And for today, we have the head of the adult infectious diseases section at San Lazaro Hospital. And before we go into an introduction of our resource speaker, I would like to call on Dr. Susie Mercado for an introduction po of our speaker who will give our opening remarks. Dr. Susie. Before I introduce our guest speaker and our opening remarks speaker, I just wanted to say that, you know, Raymond, the rain is starting to come and people are getting worried about dengue and other infections. So I think I'll ask you for a moment. That's our new normal. People are getting worried about new infections. So we're going to be talking about infections. Before we go into our main speaker, it's my pleasure to introduce to you someone who's also been at the forefront of all of the response on COVID. And they've actually done an amazing job in terms of getting the research agenda sorted out and also helping expand the testing capability in the Philippines. So I'd like to welcome our opening remarks speaker who is the Executive Director of the National Institutes of Health and she's also Vice Chancellor of Research for UP Manila. Let's welcome Dr. Eva Maria Kutionko Dela Pass. Welcome Eva. Hi Eva, good afternoon to you. Hello, that was a thunder that stopped our webinar series but thunder or no thunder, good afternoon to all our attendees from the academia, government and private sectors. The National Institutes of Health University of the Philippines is very honored to co-host this important webinar series with our partner, the Philippine Health Insurance Corporation. So every week we are privileged to have attendees join us in this weekly webinar from all over the Philippines as well as from abroad. I'd like to thank the team so are making this weekly webinar series successful, namely the UP Office of the President represented by Executive Vice President Dr. Teodoro Herbosa, Office of the Vice President for Public Affairs led by Dr. Elena Pernia and also represented by AVP Rika Abad and Director Timi Cabana, TVUP led by Dr. Professor G.G. Alfonso, ITDC led by Director Paolo Paje and from the National Institutes of Health National Telehealth Center, it's director Dr. Raymond Cermiento and of course Dr. Susy Pineda Mercado, the lead person and the Fail Health Insurance Corporation. On this fifth session of the webinar series, we have one of the top infectious disease experts in the country who will talk about the impact of COVID on the control of dengue, tuberculosis, HIV and other infections from the San Lásaro experience. Allow me to just briefly share some important contributions of the National Institutes of Health UP Manila during this time. The National Training Center for Biosafety and Biosecurity has been officially designated by the Department of Health as training provider for biosafety and biosecurity. NTCBB offers online biosafety education and awareness training called the BEAT COVID-19 program. This self-paced and student directed training modules has now a total of 2,471 graduates. This certification program is an important component of the lab accreditation process of RITM. Together with UP Delimands National Institute of Molecular Biology and Biotechnology with Dr. Pia Bagamasbad as lead faculty, we are also offering hands-on training for SARS-CoV-2 testing. And we have trained 21 private and government institutions not only from NCR but also from Eastern Visayas, Takloban and Ilocos. These institutions have now set up their own molecular labs and some are still in the process of having their lab accredited. Special thanks to Dr. Susy Pineda Mercado who was the driving force to create such a program to assist laboratories. And lastly, the NIH COVID-19 testing laboratory has to date provided testing for 8,331 patients from PGH, a COVID referral center, and 29 other hospitals and community quarantine areas in the cities of Manila, Mandaluyong, Makati San Juan, as well as Cavite, free of charge, surviving on donations from UP, PGH, VOH, RITM, as well as generous donors from the private sector. The National Institutes of Health values the importance and transformative role of research in informing national policies and supports the University of the Philippines and the Philippine Health Insurance Corporation in disseminating the state-of-the-art in terms of clinical management of COVID-19 cases. May this webinar series, such as what we have today, contribute to our knowledge on diagnosis, management, and prevention measures and allow us also to find sustainable solutions to fight COVID together. Maraming salamat po at magandang hapong po sa inyong lahat. Thank you so much. Executive Director Eva Cotronco de La Paz who is my boss over at the National Institutes of Health. It really is a huge body of work that the NIH has been doing and it's really inspiring for all of us, not just at UP Manila but for everyone who is at the forefront of fighting the COVID-19 pandemic. Thank you Dr. Eva for that inspiring speech. And then before we go to an introduction of our research speaker for today, I would like to enjoy our attendees right in front of your screen spot would be our pre-test questions. Although it might show post-webinar questions right now, these are actually pre-test questions and then after the webinar we will be answering them. Actually our research speaker will be providing the correct answers for these questions. The first question it reads, simultaneous testing for both pulmonary tuberculosis and COVID-19 will be indicated for three main reasons except option A, simultaneous exposure to both diseases, option B, presence of a risk factor for poor outcomes to either pulmonary tuberculosis or COVID-19, option C, clinical manifestations are common to both diseases and option D, previous history of BCG vaccine and pulmonary calcification. So the answers are slowly tripling in. Currently we have on this Zoom webinar 144 attendees to date but we also have other attendees joining us in YouTube and in other means. So nearly half of the attendees answered for question number one, previous history of BCG vaccine and pulmonary calcification. We will ask our research speaker kung ano po ang tamangs kasagutan dito po sa question number one. And then for question number two, it reads, the following are the precautionary measures that people living with HIV should adhere to prevent the spread of COVID-19 infection except option A, avoid close contact with anyone who has fever or cough, option B, clean hands frequently with alko gel, option C, cover your mouth and nose with a tissue when coughing or sneezing, and option D, if feeling ill, wear a surgical mask and practice self-isolation. So again nearly half of our attendees chose option B naman po na clean hands frequently with alko gel. So just put in po your answers and towards the end of this webinar we will ask our research speaker to provide the correct answers. And I'll turn over the mic over to my partner and co-host Dr. Susie Pineda-Markado for the introduction of our research speaker for today, Dr. Susie. Thank you very much, Reymood. Parang mahirap yat ang mga tanong na. Anyway, I hope you're on please because we just really wanted to have a sense of trying to get the audience to say what are the things I took away or what did I learn from the webinar. So I hope you enjoy the little poll questions we have. Anyway, as you know, there are more than 12,000 cases reported of COVID-19. Possibly more as our testing capability increases. Over 800 deaths have been reported. But at the same time, as I mentioned earlier, we know that the rains are coming. Last year we had 400,000 cases of dengue, about 1,500 deaths. Tuberculosis kills 70 people every day. And we have one of the highest increases, rates of increase in the world for HIV AIDS. So now when you bring all of that together with COVID-19, what are we going to do? How do we handle this situation? And what do we do if we're looking at possible infections from multiple microbes, et cetera? Of course, best to get information from an expert in infectious disease. And what we're seeing and learning from the San Lazaro Hospital, I think is something that's worth learning across all hospitals, across all clinical facilities, and from practitioners, doctors, nurses, medical technologists, and so on. So it's my pleasure to welcome today our guest speaker. He's the head of the Adult Infectious Disease Unit of the San Lazaro Hospital. We'd like to welcome Dr. Jean Solante to our webinar. Welcome, Jean. First of all, I would like to thank Dr. Susie again for inviting me and to share our experience here in San Lazaro Hospital. And it's true, it's really challenging if you are in a hospital that caters most of these common infectious diseases. So this is the scope of my discussion. We'll go through the current situation now here in San Lazaro Hospital. And we'll also give you an update on how are we doing with our patients with COVID, especially with the use of these interrogational drugs. But the main focus here is we'll be on the other co-infections that we do encounter among our COVID patients, particularly those with HIV and those with tuberculosis. And the last part will be about the healthcare worker since we also do a regular surveillance or testing among our healthcare workers in this hospital for us to know who are really carriers or who are infected. So San Lazaro Hospital is a 500 bed capacity and infectious disease referral hospital. And it's also one of the 31 national or subnational referral laboratory for COVID-19. And we have two accredited training programs by the Adult Infectious Disease and then the Family and Community Medicine. In terms of programs of the Department of Health, we are one of the HIV confirmatory referral laboratory, the ACCL. And then we also have here our HIV treatment hub, the DOTS referral hospital and the multi-drug resistant tuberculosis referral. So you look at this particular facility, everything is here from drug susceptible to drug resistant common infectious disease. So we are also the first hospital to diagnose the first two cases of COVID cases in the Philippines last January 23. And currently we are one of those centers participating in the WHO solidarity trial. Okay, so let's start first with the cases here in San Lazaro Hospital. This is a data from January to May. And if you'll notice the number one infectious disease admission that we have is still dengue. And then this is followed by tetanus. Then you have community acquired pneumonia. You have snake bite, rabies, tuberculosis, varicella. Including those patients with opportunistic infections, CNS infection and the other. But this data compares with the previous months is really very low. And I think the majority here can explain because we focus on the management of COVID. And that's why comparing it with our number of cases admitted because of COVID, we have a total of 240 since May. And this is the breakdown of the cases. Then what are the most common symptoms among these patients? So this is quite challenging for us because anybody who comes in with fever, we have to do screening and test them for COVID. As long as they are not, we have to look into the risk of exposure, the history and the findings of lower respiratory drug infections. Then we can focus on COVID, but still we have to rule out tuberculosis. We have to rule out other pneumonia that can also be present. We do encounter a lot of these patients prior to COVID-19. But focusing on COVID since January, we now have a total of 88 cases confirmed among those patients that were tested. And this is our data in terms of the mortality. Now, this is also the same as what we are reporting now in the country that the male is the most common or the common sex that is confirmed with higher risk of death. In this group of patients, the most common cause of death is usually 50-50. Either they die of severe sepsis or the die of the severe pulmonary complications in the form of the acute respiratory disease syndrome. But look at our data here. Among the 19 mortalities that we have, more than 68% of these are the age group of 50 years old and above. And this can only tell you how high is the risk for mortality based on age because of what we call age-dependent effect in T cell and B cell function. And in this case, we need to really prioritize close monitoring and early intervention among this group. But this is not also to say that we should forget also those patients with HIV and those with concomitant immunocompromised status, especially those patients with tuberculosis. Our data is a bit better in terms of the confirmed death in the country because in the DOH situation, 86% of those who died because of COVID or confirmed death are 50 years old and above. So again, this is something to do with the elderly, the age as an important and major risk factor for determinant of survival. Now, among the cases that we documented and who died, then majority of those also had comorbidities. But if you look at some of these comorbidities, it may not be typical comorbidities that you have encountered in some of the data. Like, yes, hypertension is one of those, the most common, then we have diabetes militants, but we also have here. Those patients who died of TB, those patients who died of HIV, concomitant COVID and those patients who died because of the presence of HIV and the presence of tuberculosis, the double infection. So, I mean, they have three infections, COVID, HIV, and pulmonary tuberculosis. And this really is very challenging for us as clinicians on how to go about in this group of patients. And this is just the data coming from China that the presence of an underlying medical condition, which did not also mention about the significance of other infectious diseases as a comorbidity and contributor of mortality like HIV and tuberculosis. This is a snapshot of the other presence of co-infections among our patients. And one of the most common co-infections that we encountered among those select group of those mortality are patients with COVID at the same time with seasonal influenza B. And then you also have here is septococcus pneumoniae. One of the patients died because of a concomitant septococcus pneumoniae. And then you have interococcus fecalis, septococcus ominous bacterimia. So, to say this are the secondary infection that during the course of treatment probably these are also hospital acquired that at risk or higher risk also of mortality. If you look at some of the significant laboratories that are found in most of our patients, this is in relation to how good is the immune response in patients with a natural infection. Usually we do have what we call elevation of the WBC, but in most patients that we encounter, particularly those associated with higher mortality, most of the WBC here is really normal. And in fact, the mean value is 8000 and most of them also have decreased lymphocytes even with the presence of a superimposed bacterial infection. So, meaning there is a dominance here of the COVID-19 over that of the other bacterial infections because if you look at data for COVID-19 patients only, most of those really had lymphopenia and leukopenia. And in fact, if you review the diagnostic testings and the different typical abnormalities aside from the elevation of the different inflammatory markers that is very characteristic, particularly for those patients with cytokine storm. Now, the most important part here is that most of those has leukopenia and relative lymphopenia. So, the implication here is that COVID-19 is really causing this immunosuppression plus the fact that you have a patient that is elderly. You have a patient with concomitant tuberculosis or concomitant HIV and that really brings down the immune response and then it is also related with higher rate of mortality and that is now what we are experiencing in our patient. This is data coming from our list of mortality and if you look at the radiologic characteristics, this is the common radiographic findings that is suggestive of positive patients with COVID. Consolidation is still the most common, followed by ground glass opacity. So, this is chest X-ray, this is not chest C, this gun. And the distribution is more or less bilateral in involvement. If you look at our data, most of those patients who died, in fact 90% of those had bilateral pneumonia and only two of these had lower pneumonia. And so, this means that the majority of those who died of COVID really has what we call significant involvement of the pulmonary organ. And that's the reason why most of them end up complication of hypoxemia and acute respiratory distress syndrome. Now, we're looking at how can we utilize chest X-ray in terms of predicting severity or even making it as a tool to assess improvement. So, we have here, we're using this severity scoring system in COVID-19 and this entails the assignment of percentage of each of the lungs to percentage and the higher the number of lung involvement, the higher also is the percentage here. So, here if there is more than 75% involvement, then this is also related with the higher risk of mortality and somehow we observe that in some of our patients. I'll give you one example. Remember, this is not a 50-year-old individual. This is a 39-year-old male and this patient is also impacted with HIV. So, if you look at the chest X-ray upon admission and then comparing it from day 12 to day 15 to day 17. So, this is the time that the patient became toxic, progressive disnia and we tried to do the scoring. So, you have involvement here of two lobes and you have 50%. And then on day 15, there was the need for intubation. So, this patient's respiratory status became progressive and to the point that when we repeated the chest X-ray, it's now more than 75% involvement. And we know that at this point in time, the mortality is really very high. And then it's just a matter of time. On day 17, two days after, we saw this particular pattern which we call ARDS. So, progressive increase in the bilateral infiltrates up to the day of demise. And this patient was RTPCR positive even until the ninth day of illness. So, you just can imagine the viremia occurring in this particular patient and then before the patient died on the 17th day. The other end of the radiographic findings here, this is a 53-year-old male confirmed COVID and the first time that he first detected on the 10th day of illness. And I think this is also in relation that viremia is usually very high after or during the first week or later part of the or early part of the second week. So, this is consistent with this particular patient. So, again, there was 75% involvement of the lungs. And then significantly when the RTPCR was detected on the 15th day prior to the undetected result, you notice there is also improvement in the chest x-ray. So, the value here of correlation of your RTPCR with that of the chest x-ray can also be another tool for us to develop and use in the assessment of the prognosis among this patient. So, more or less we do regular RTPCR every two to three days among our critically ill patients and we also correlated with the clinical manifestations, meaning even if they have symptoms but they are progressively deteriorating, we do repeat the PCR until such time it is negative. And we found out that most of those who had a higher rate of mortality, the RTPCR positivity is really continuous to be positive until their demise. So, the other tool that we've been using here in our hospital is also the chest CT. And for us this is more or less it somehow supplement the findings in the chest x-ray. There are three patterns of findings in the chest CT that you need to look at. Very characteristic is the ground glass opacity. And ground glass opacity is not only specific for COVID. In fact, patients with tuberculosis, patients with pneumocystis gerobacon pneumonia, which is also seen in most of our patients also have ground glass opositis. And this is where the challenge for us clinicians because if you see that ground glass opacity in your patient, you suspect patient is STB, you suspect that the patient is HIV, with opportunistic infection, the only way to really diagnose them is the use of an RTPCR the patient is COVID positive. The second most common findings in a chest CT in patients with COVID is the crazy paving pattern ground glass pacification with interlobular septal thickening with interlobular lines. And this appears like this. And then the last one is consolidation. So, meaning it doesn't always mean that the absence of ground glass opacity you will be able to rule out COVID-19. Consolidation is common among those patients with bacterial pneumonia but we have seen a lot of our COVID-19 even without co-infection with bacterial pneumonia they also have pure consolidation on chest CT. So, in terms of the chest CT findings in our hospital, you'll notice that the most common is still the ground glass opacity and then you also have a combination of a ground glass opacity and consolidation in this group of patients. But there are also patients in which the chest CT findings may not be what we call this diagnosis. That's why you cannot use chest CT findings as confirming the presence of your COVID-19. And I'm saying that because there are some of those who ask us that in the absence of an RT-PCR and patient has symptoms can we diagnose them without an RT-PCR and just looking at chest CT findings? No, you should also do your RT-PCR. Now I'll go to the interventions using investigational drugs. So, we use the management algorithm that is being recommended by the Philippine Society for Microbiology and Infection Diseases. And if you go through this algorithm, it starts with the symptom-based screening and then the presence of comorbidities and age. So, if these are present, if you have less than 60 years old or more than 60 years old and the presence of comorbid conditions, then you directly will consider this patient as having moderate risk pneumonia. Then if they have hemodynamic alteration with progressive hypoxemia, then you will categorize them as having severe or high risk. And these are the two patients, group of patients that we always have to admit. And once admitted, we either give them any of these investigational drugs either in the form of chloroquine or hydroxychloroquine if they are illegible, meaning if they don't have any contraindications like cardiac abnormality or acuity interval prolongation. And then we also consider giving a combination using either Lupinavir-Ritunavir, which is an HIV drug. So, this is where we also another challenge because if you're giving an LPV-Ritunavir in a patient that you will not screen as having HIV, then chances are you will be also promoting drug resistance. So that's the reason why that when we have patients with COVID, we always ask, are there risk factors for HIV? Okay, multiple sex partners or have they been diagnosed with HIV in the past? And then once they are in severe respiratory distress or the beginning of the cytokine-related syndrome, then one drug that we consider very important also is the monoclonal antibody drug or anti-inflammatory drug in the form of Tocillizamab. So, this is a slide that will tell us the different potential drug targets of the different investigational drugs, okay? Either in the form of inhibiting the replication of the virus. And this is where Remdesivir and Lupinavir-Ritunavir will act and then inhibit viral entry. This is where chloroquine and hydroxychloroquine will be an important drug and then prevention of activation of the inflammatory molecules. And this is where your Tocillizamab will also act. So, this is how we should be doing this and understand why are we giving a combination or single drug or two drugs and what is the effect of this intervention and looking at it since these are all investigational drugs then it has to be used in the context of a clinical trial that we're doing here in San Lazaro Hospital. So, currently as part of the solidarity clinical trial out of the 24, we're one of those hospitals. We are also randomizing our patients either to receive Remdesivir or Lupinavir-Ritunavir or a combination of your Lupinavir-Ritunavir with interferon beta 1 alpha and or those will be randomized alone using your chloroquine and hydroxychloroquine. Okay, so, when we reviewed our mortality and the interventions that were given so majority of those that patients we admit especially those with severe and moderate severe COVID we always start with antibiotic before the result of the COVID-19 test result will come in because that's part of the guideline that anybody who is critically ill and will present with more severe type of pneumonia we also have to give antibiotic at the onset. Now, the other spectrum of these interventions we gave there was one patient we also gave Seltamivir since this patient was positive for influenza B and then patients with some of them were given hydroxychloroquine and then four patients received Lupinavir-Ritunavir and then combination three patients with really critical clinical manifestations we combined the chloroquine with that of the Lupinavir-Ritunavir and then, of course, most of those that had severe ARDS are on mechanical ventilation while those that did not require mechanical ventilation was able to tolerate oxygen via face mask. These are the interventions that we've been giving lately since Tosilizumab is already available in the hospital after approval by the FDA and by the Department of Health so if you look at some of the combined interventions here aside from antibiotic, we do give chloroquine, Lupinavir and including that of Tosilizumab so it's part of the standard of care depending on the severity and depending also if they have contraindications of those drugs but what I would like to share with you here our experience with the use of Tosilizumab among patients with COVID-19 and in fact, we have a very good experience with Tosilizumab among those patients who survived although this is still very small data but we continue to observe how good these drugs are since they are investigational. Hydroxychloroquine and chloroquine you'll notice in this slide these are the survivors and then the blue one is the survivors and the red one is the non-survivor meaning there is really not so significant but the trend here is that given among those who survived you have higher patients that were given the investigational drugs. Sharing with you some of the cases that we put on the anti-inflammatory drug Tosilizumab so this is a 40-year-old male confirmed severe case who also has diabetes and this is the sixth day of illness before Tosilizumab was given if you notice that the chest x-ray may not be that bad but if you look at the clinical presentation of the patient it begins to be in the storm clinical manifestations the inflammatory markers were already elevated and the oxygen requirement which is the most important initial findings among those who decide to find storm if you have a patient with increasing oxygen requirement in a few days or in a few hours then that's the start of the storm. We gave Tosilizumab and then this is two days after Tosilizumab you'll notice that there was not significant clearing but there was really what we call an improvement in the clinical status and the slight improvement also in the radiologic appearance after the use of the anti-inflammatory drug and another same patient when we did the chest CT because one of our protocol here part of the protocol is that if you're giving Tosilizumab you also need to monitor the chest CT findings so this is the chest CT of a patient after four days receiving the Tosilizumab meaning you'll notice that there is really decrease in the ground glass appearance of the chest CT and the consolidation has also decreased and then another patient this is again a 37 year old male and with some of the comorbidities that I have mentioned and this is the chronology of the improvement this is before the Tosilizumab and then after the Tosilizumab you'll notice that comparing this one this is before Tosilizumab 13th day, this is 7th day after Tosilizumab you'll notice that this part here of the lungs bilateral consolidation and ground glass appearance more or less has decreased, significantly decreased and this is also associated with improvement in the clinical status of the patient so this is just some of the success solely that we have among our patients who are critically ill now, what are the other co-infections that we have encountered since I have mentioned streptococcus pneumoniae influenza B one of the other important co-infections that we have been we have experienced among our patients are those patients with mycobacterium tuberculosis and HIV so if you look at some of these articles that were based on those patients infected with SARS-CoV-1 in the past this is the interrelationship between the virus, the host and the bacterial infections which will be a determinant of the severity and eventually outcome so you have here some of the changes or the pathology you have more inflammation you have increased in the number of the viral load of the virus at the same time when you have increased the viral load there is also higher opportunity for this microorganism to stimulate your macrophage and produce more chemokines your interferon which are the determinant of your cytokine storm and then once you have cytokine storm there is also increase in apoptosis so increase cell stress cell death and necrosis and at the same time at the level of the alveolar cells you have here increase in hypoxia so it's no wonder that if you have a patient with multiple infections with COVID-19 you also expect a higher rate of mortality just to share with you this is the first COVID-19 infection in the Philippines that was documented here in San Lazaro Hospital this patient doesn't have any comorbidities he's a 44-year-old male a Chinese tourist who visited the Philippines now when we did examine the respiratory tract specimen aside from being COVID positive this patient also has influenza B and at the same time streptococcus pneumoniae so remember again this patient doesn't have any comorbidities so does this two infection contributed to the demise of this patient that remains to be a question that we don't know but if you look at the rationally there when you have bacterial co-infections in the setting of the patient with COVID-19 then most likely the presence of two other infections can also increase the risk of poor outcome now this is something that the first time we did have a patient with COVID-19 and at the same time TB so this is a 54-year-old male who presented with sudden onset of fever for 14 days and this was accompanied by difficulty of breathing and body weakness and remember this patient developed PTB treatment for eight months in 2018 so when we admitted this patient this is the HSX-ray and it looks like that we really suspect that this is purely tuberculosis but when we look at the area here it seems that this infiltrate is new so this patient initially consulted in the outpatient but when this patient was found to be positive the patient was advised admission and from this day up to this date an interval of eight days look at the infiltrate here it's really progressive but if you are looking at this area here you will say this is TB but would I suspect also COVID in this patient with tuberculosis it's a tough question but to go to the history this patient was asymptomatic for how many months and only had complaint of fever for 14 days so this is an acute onset manifestation and probably this can be the result of his previous TB treatment or previous TB infection so you have here a destroyed lung so this is new one positive for TB so that's why we labeled him as TB relapse and at the same time eventually this patient turned out to be COVID-19 positive so in that perspective what is the difference and how do we approach a patient with TB and at the same time with COVID-19 in terms of mortality rate of course your PTB has a higher risk of mortality especially if TB occurs in those who are untreated or those who are immunocompromised but the risk factor for both of this are more or less the same they can be elderly they can have comorbidities they can have immunocompromise and more or less the same as that with the TB risk factor so meaning if you highly suspect that these are risk factors present in your patient it's difficult to rule out one over the other and it's really better to also get specimen and test not only for COVID-19 but also test them for PTB using your gene expert those patients with co-infection with COVID-19 and TB both of them can exacerbate the natural symptoms of the other so going back to our patient this patient has had TB in 2018 it could be possible that the presence of your COVID-19 has activated a new onset of tuberculosis or it could also be possibility that patient already has resistant TB since this patient has been exposed to previous medication and that will really have a negative impact on the person's health meaning risk of mortality is really very high so what is the risk of TB TB and risk of getting infected with COVID-19 currently there's no data according to the union among those TB and COVID-19 but they surmise that so this then outcome could be or should be worse and TB disease may put patients at increased risk also developing more severe COVID-19 symptoms so that's also been observed in one of our patients patients with TB lung diseases should consider limiting their exposure to high risk environment this is what we always emphasize among our patients with TB also have the OTS and MDR TB as much as possible the prevention that we use for those patients with COVID-19 should also apply among them but the more important part here is you always have to see to it that you also not be doing something to really decrease the immune function of your lungs and one of that is stop using tobacco or any tobacco products like vaping so for the TB program one of the recommendations never discontinue the drug the TB program should always provide the drug to their patients during this lockdown so there's no lockdown in terms of TB that's provision of medication procurement and supply management system should always be in place so that there will be no interruption in the treatment of TB because once this patient will develop resurgence of TB then that puts them again a higher risk of getting COVID-19 there were models that were exemplified here that will involve the social distancing one is self administered therapy meaning the patient can take his medications while not going to the DOTS facility but the DOTS facility can also follow up every day by calling through a mobile phone and then checking on if the patient is taking the medication regularly the other evidence here that the patient should be taking the anti-TB medication is a video observed therapy so this is very important in terms of instead of going to the clinic higher risk of exposure then they will be staying in the area to take the video they are taking the medication now in those areas where there is a lockdown the local government should also prioritize that they should be given the medication so some of the some of these healthcare workers are going to this area and distributing the medication if the patient is in a community where there is an ongoing lockdown to say TB programs should have a system in place to continue to support people on TB treatment so this is just a comparison of TB and COVID-19 more or less how this two infection compares in terms of infectiousness prevention and treatment so for TB there is treatment but for COVID-19 there is only supportive treatment so if there is drugs that we are giving now these are all investigational the next challenging case this is a COVID-19 and HIV positive so this is 35 year old from this area who complains again of fever this patient was diagnosed with HIV since 2015 so see the patient was on antiretroviral treatment but he stopped in 2018 and was lost to follow up so again he manifested with the following manifestations and upon examination these were our findings so this patient is really in cardiorespiratory distress so if you look at the HSX-ray it may seem to be normal but if you look at the detail here there is really an interstitial infiltrates and the patient is hypotensive tachycardic and tachypne since we have an idea here that this patient is HIV positive since 2015 and presented with fever what usually will you think of this patient will you think of COVID or will you think of an opportunistic infection of course we always prioritize if this is COVID because we are now in the community transmission but at the outset we also have to rule out if this patient also has pneumocystis gerobakendomonia because the radiologic appearance of PCP and that of your COVID-19 can also be the same being interstitial and bilateral and at the same time this patient is also hypoxemic, hypotensive and tachypne so we treated a patient that's having PCP severe the same time when we did examination patient also have oral candidiasis meaning the CD4 count of this patient is really very low because he stopped the medication but if you're in HIV and you continue your ARV that in itself is the protection that your risk of acquiring COVID will be the same as that with the general population so that's why but if you are in HIV positive and you will stop your antiretroviral medication then that's very dangerous because that will also increase your risk of getting COVID because you'll be immunocompromised based on several of this study the clinical characteristic of COVID-19 in patients with HIV appeared to be similar to those without HIV meaning you have the cough, you have the fever you have the difficulty of breathing meaning it's difficult to rule out one over the other now among those HIV if they are on effective antiretroviral treatment meaning they have a very good viral load count undetectable and their CD4 count is very high then that again decreases the risk that they will get so meaning when you have patients who suspect HIV you always have to get the CD4 count you always have to get the viral load count when you suspect that they have COVID-19 because these are the parameters that will also help you prognosticate because the higher the viral load count the lower the CD4 count in the presence of an opportunistic infection in the presence of your COVID-19 then the risk is very high so prevention is always important among this population so aside from the usual precautionary measures like hand hygiene, face mask and physical distancing the current management prevention now is also to give them the pneumococcal and influenza vaccine so I think this is not only with HIV but also for our elderly patients since we are also now entering in the influenza season this is where you need to maximize the giving of your vaccine despite this pandemic what about those clinicians who will be managing patients with HIV and at the same time with COVID-19 number one ART should not be discontinued you have to continue the anti-retroviral therapy look at some of the drug-drug interactions if you are giving what we call investigational drugs you have to look at what are the drug interactions among this individual when they will be receiving the anti-retroviral therapy okay and then at the same time clinicians should ask providers to waive drug supply quantity restriction so meaning as long as the patient the patient should have access to this anti-retroviral treatment if they will be in another admitted in another center not in the treatment hub that they used to have this follow up then they have to communicate with a treatment hub that can give them the anti-retroviral therapy so that it will not be discontinued okay so avoid drug substitutions or ARB drug substitutions as much as possible procure the ARB that the patient is currently being given and then clinician must assess potential for drug interactions if they are receiving investigational drugs and of course social distancing and isolation may exacerbate mental health and issues for some persons with HIV so we have some patients with newly diagnosed HIV may have some issues with their mental health and then that should also be closely followed up and closely monitored by the clinicians who are in the treatment hub okay the third case that I would like to show here is the triple infection we have a COVID-19 confirmed HIV positive and you also have tuberculosis okay very challenging case but eventually this patient I think this patient did not make it so this is the chest x-ray when this patient was initiated on anti-retroviral treatment whose baseline CD4 count was 87 during the time January 16 and at the same time this also at this period that the intensive phase of treatment was initiated with TB treatment okay and the patient presented with decreased insulin soryong for the past two weeks there was progressive fever body malay, decreased in appetite cough and productive diagnosed with HIV 2019 and newly diagnosed with PTB in November 2019 okay so there are a lot of dilemma here this is a confirmed case of HIV he only started with this with his ART in January so meaning fourth month you don't expect immune system will improve and that's another risk for acquiring COVID-19 so this patient at a very low WBC count and look at the lymphocyte count is only three so this is severe lymphopenia so these are the patients that are higher risk of mortality another patient with triple infection 27 year old again complaining of fever and diagnosed newly diagnosed with HIV in January 2020 came in because of severe dry cough and high fever diagnosed both with TB and HIV in January and the patient came in because of hypertension and increase in the temperature the oxygen saturation is 95% at room air and look at the CD4 count of this patient it's only four so chances are you will really get COVID while you are still starting your treatment on ARV but unfortunately this patient has not been started on antiretroviral therapy why? because he was diagnosed with HIV in January 2020 the lockdown was much he was not able to follow up with the treatment because of the fear that he will acquire COVID-19 and that fear became a reality and that's why he was admitted because of severe COVID and severe tuberculosis this is the last part healthcare workers we always value our frontliners in terms of their service in terms of taking care of COVID-19 but they're also the most at risk in acquiring the infection so we also do what we call regular surveillance among our healthcare workers every three weeks the first wave of the healthcare workers we were able to test 196 of them and seven became positive if you look at the rundown of those infected one was a doctor, three were nurses and three were laboratory personnel what are the common comorbidities among these healthcare workers who were positive for COVID majority of them had obesity, hypertension or a mix of your diabetes and asthma most common symptoms they have cough, sore throat ranorrhea, loss of smell, loss of taste headache, myalgia and fatigue so you'll notice most of this patient doesn't have fever so again the bottom line here doesn't need that you have to have fever if you have all of this symptom in your healthcare worker especially Malay, myalgia, fatigue or even headache chances are that you need to investigate need to investigate and do some history taking if there was really bridge of the use of PPE or exposure in the community then you have to scream them for COVID-19 this is the department of health tracker on healthcare workers with confirmed COVID-19 and you'll notice that the peak of the healthcare workers getting infected was between March and April and it has gone down since May and I would like to share with you here some of the risk how does a healthcare worker acquire this COVID-19 in the performance of their duties one of that that was been identified is the lack of PPEs for physicians when interacting with patients positive for COVID-19 second is performance of a high risk procedures such as tracheal intubation pekyosamela ringoscope or other airway procedures that's why you have to be very careful when you are doing aerosol generating procedures in most of your patients although wearing PPE is a protection but it will not guarantee also that it is 100% that will protect you now existing comorbidities including that of Patim are also factors that increases the risk of us healthcare workers to get COVID okay so in summary COVID-19 cases remain the bulk of our admitted cases here in San Lazaro hospital with clinical teachers comorbidities and outcome the same as most reported cases in the Department of Health based on the review of the interventions no interventions significantly associated with the survival to those who did not survive no trend favor those who receive posilisimab and most of these investigational drugs we utilize chest radiograph and chest CT not only to diagnose but also to prognosticate and at the same time use them to assess response to treatment now this is the most important challenge to presence of co-infections we have presented here patients with TB presence with HIV that among them if they have risk of mortality or risk of poor outcome has been demonstrated among our patients especially for those patients who have active tuberculosis and active HIV so the bottom line here is always situate that when this patients have ongoing treatment they should not discontinue the treatment they should have a close follow up with the different Department of Health programs that they will be given the medications especially for those patients with HIV and the same protection the same precautionary measures we always have to implement among these patients as that with the general population and lastly healthcare workers is a highly vulnerable population that measures to monitor them by regular testing is imperative thank you very much for your kind of attention thank you so much Doctor Jean from the San Lazaro Experience and it was really an eye-opener on how you have been addressing all of these issues and concerns regarding COVID-19 just to share that we are now at 195 Zoom webinar participants and I'm pretty sure marami pa rin po pomaaten, pwapaso at nakikinood po through TVUP and also through our YouTube streaming po and to share po we have attendees who have been joining us from as far as Bukidnon Provincial Medical Center in Malay Balay City, Northern Mindanao we have one from Dakaraga, Tuberculosis Reference Laboratory in Butuan City in Agusan del Norte we have the Northern Summer Provincial Hospital in Kataraman Northern Summer Apayo Kagayan Medical Center from Abulog Kagayan Valley Ilocosur Provincial Health Office from Vegan Ilocos Region from RITM obviously po and from other countries international ako kayo Doctor Solante from Singapore from Masuda, Japan and from North York in Canada so yung po ang ating demographics for today and right now being flash on the screen is our post presentation questions for its traditional po just to be able to give a rapid assessment of how our presenter did and I'm pretty sure Barami po it Doctor Solante, Doctor Jean gets high marks for this presentation as evidence po so 90% of our attendees strongly agree that the presenter demonstrated thorough knowledge as well as he was well prepared and organized the presenter was also speaking clearly and audibly during the presentation the presenter also used appropriate language with technical medical jargons and also used appropriate webinar techniques so I think this is the time wherein we ask the questions to Doctor Solante maybe I could start ahead with the first question so for our first question po Doctor Jean it is related to the risk factors associated to higher mortality in COVID-19 would you know kung meron po anything that you could cite as a definitive or maybe slightly correlated po the risk factors? Most of the if I'm going to look at our patients here I think one of that is the age those patients whose age is like 60 or 70 and above regardless of whether they have comorbidities but most of them also have comorbidities higher risk factors but I'm looking also now that HIV and TB can be an important risk factors among this group of patients what we've seen in most of our patients although these are still small number of patients but if they have low CD4 count or if they are still in the ongoing treatment of tuberculosis and has not yet been in the finished treatment higher risk also for mortality among this group we haven't seen any cases like dengue with COVID or the other infections but so to say these are some of the TB and the HIV are really for me I think are important risk factors for morbidity or mortality first to see on your end Raymond I wanted to say something muna first Jean thank you so much for your presentation very very informative for me personally I really enjoyed seeing all the x-ray slides and the CT scans because this also helps our audience who are in practice get a sense of the cases and how you're using the drugs and all of that very very important very very informative Jean I think for me before we go into the other questions given the number of people who have tuberculosis in the country I think this is very helpful also for Philly out that you're saying that we really need to continue treatment for TB dots and vots I thought that was very cute having video video of drugs but this is the new normal so I was just going to say Jean I mean we call it a risk but maybe I don't know somewhere in the guidelines when we're looking now at diagnosing patients with COVID we really need to screen and consider tuberculosis in HIV and I'm very happy to hear your presentation because it just gives you all the evidence to say that look we're not looking for hypertension and asthma here there's so many people who have tuberculosis and possibly HIV and we may miss that in in the history so can you just talk a little bit more about how the doctors need to I mean apart from asking the history especially for TB as you mentioned one of your cases they were on TB meds they're off it we know that it's a problem they're on it then they're off it and they're on it again and then they're off it and then they're resistant so how do we approach in general practice in primary facilities in districts how will we now approach understanding that TB comorbidity I think it's more than risk I think it's a comorbidity because it is really an illness Thank you doctor Susie and that's a very important question Now in most of the experience especially for the for some laser experience one, it's difficult to diagnose a patient with TB at the same time with COVID because they can also present with the same clinical manifestation the important part here is that exposure second if you there are what we call they come from an area where there is also history of exposure to tuberculosis and I think that will be the same as that when you investigate a patient with tuberculosis most important do you have patient at home that was diagnosed with tuberculosis or do you have patient at home diagnosed with previously treated with tuberculosis second is the physical examination particularly with HIV when you look at some of those patients newly diagnosed with HIV they already have what we call kakeksha, they have muscle wasting and in fact most of these patients have what we call the skin eruption, the popular proritic eruption the third most important part here is the sexual history, don't be afraid of asking the sexual history even if it's a COVID-19 probably it's really out of the what we call the usual questions that we ask from our patients with COVID-19 but sexual history is very important if you want to rule out HIV in a patient with concomitant COVID-19 if you have a patient with multiple partners you have to do the test also while they are in your facility thank you very much thank you very much very very helpful and I think as we progress we begin to to ask more questions along these lines because the question about exposure even on COVID sa dami kasi nang mga tinitay sa dami nagpapatingin wala na and also at the end of the day it's going to boil down again to clinical history and the physical examination so all this talk about the testing we still go back to very basic clinical skills in history taking and having that clinical eye and trying to think about is there exposure Jean, there are some questions here let me read one of them and then the others I think Raymond will want to do ok na hondami ng question how many days po ang interval to do a swab test so when you have patients confined in San Lazaro and they are COVID positive how often do you do a PCR on them ok so during the first few months of the pandemic ok we always because it is what the DOH recommended do it every 48 hours until the time the patient is asymptomatic ok we changed that since there was decrease in the number of the testing kids so we changed it and also in accordance with the DOH recommendation we only repeat the test once the patient has absence of symptoms for 3 days ok so if the patient is asymptomatic at 17 hours then we do repeat the rtpcr test ok thank you very much Raymond you have questions yes other questions po Doctor Solante maybe we could get something I don't know if it's easy or controversial po kong bagan ang tanong po since there is still high community transmission would you recommend or is it advisable to reopen outpatient clinics ok so that's not controversial very good question what are you doing for OPD ok so it's not controversial difficult question because we promote that social distancing should also be observed no but I think the point here is that once we once we go down to the ok I'll give you an example we are our HIV clinic we still open until now and in fact we did not have any holiday in terms of the procurement of the medications because we have a lot of these cases so they still go here like every Tuesday Thursday but the point here is that you have to schedule your patients that they should not be in one day only no so there should be appointment with the HIV treatment hub manager same as that also with the program ok so you have to up that schedule and then for new cases ok there is also a day allotted for the new cases compared to those who are going to be on follow up patients ok so I think I'll give a breather po muna kay Dr. Solante and maybe I could ask our opening remarks speaker my boss Dr. Delapas mam Eva mam there's a question po here there are those who are interested po do sa training po na ba nang geto po mam kanina how do they enroll po ba or how do they register thank you so much for that question po right now I closely coordinate this training program with RITM and the department of health yun po sa biosafety training which is an online course they just have to email the national training center for biosafety and biosecurity I can provide that email if they are already in the stages of building a lab so that their laboratory personnel can have the proper biosafety training do naman po sa hands-on training which is done in coordination with UP deliman NIMBB molecular biology and biotechnology ito po, I closely coordinated with RITM and the reason for that is many institutions need training but we have to prioritize yung mga laboratories that are already in the stage 4 stage 5 of building a lab they're given priority so that they can be given the hands-on training because after that po they're already asked for the proficiency panel as long as they've also completed all the requirements of RITM to acredit their lab bi begin po sila ng proficiency panel testing okay, thank you Dr. Eva ma'am to recap lang po the NTCBB training is online, tama po ba ma'am that's correct, that is online I can just another one that's correct so you cannot move on to the hands-on without the biosafety training because it's vital that people know how to protect themselves from this infectious agent if they are laboratorians okay thank you Dr. Eva so to the one who asked the question po it's very important po that you are able to complete training by the national training center for biosafety and biosecurity before moving on to the actual hands-on in person na training po thank you Dr. Eva for Dr. Solante there's a question po with regards to the increased mortality among patients with COVID-19 and concomitant infections what is the current stance po for patients undergoing immunosuppressive therapy such as those that need serotherapy or kailang po na transplant po yun po sir okay, it's a very good question because there are also part contraindications to this investigational drugs if you are immunocompromised or if you are immunosuppressed and if you have a patient with concomitant malignancy just an example patients with HIV with a CD4 count of less than 200 anti-inflammatory drugs because we don't know for example, some of these patients the patients with HIV and TB it was so tempting to give them the anti-inflammatory drugs but they have HIV, they have TB obviously we can't give them because that can only aggravate the ongoing infection and that's I think one of the area here inside to find storm because of COVID-19 with a concomitant TB and HIV and that will be put them at higher risk of mortality okay, thank you ah, tako mo na meron ako nakita dito Raymond kasi Doc Geno is already talking about inflammation rosa a question here around blood clotting and and strokes no I'm looking for it anyway for those who are asking we're going to send the PowerPoint to you on YouTube sorry, on email and then you can go to tvup on YouTube to watch it again or to use this for your own training okay, so here's the question Gen there have been reports in the US of blood clotting leading to stroke and embolism in COVID patients are we seeing this in our patients as well what do you suggest as clinical interventions that's from Lester okay, so thank you for that ah, question Lester no in our experience we haven't seen those cases with thrombotic related or thrombosis related complications but just the same when we have patients like elderly with comorbidities like hypertension these are also the patients higher risk of developing thrombosis related complications that's why part of the team in the management of this severe critical COVID we always have the cardiologist the interventional or the intensive care physician part of the team because this is already outside of the realm of infectious diseases may be for pulmonologist but it entails multidisciplinary sub-specialty management to really address all these issues okay, Gen, there's another one here I wanted to talk about this I think this is the moment Pedro is asking doctor based on your patients were they with flu and or pneumococcal vaccination and was there some kind of protection provided so I know you wanted to talk a little bit more about adult vaccinations so in the patients that you've seen did we know whether or not they had flu vaccination or pneumococcal vaccination so the patients that had infection with influenza B and streptococcus did not receive any of those vaccines and that's why I think the importance here of giving the vaccination okay let's just have to point this out the vaccine for influenza and streptococcus pneumonia and it's not for COVID-19 why are we recommending the use of this vaccine because if you had this patients HIV, TB, elderly there are hires also of developing influenza and pneumococcal complication what if they had this infection and at the same time you also have a COVID-19 infection and that again increases the risk of mortality because we did not gave the opportunity for these patients to be given the vaccine so to say that they should have been protected with the vaccine less of the complications of the superimposed or secondary bacterial infection okay thank you for that answer Dr. Jean there's another practical shall we say question po, no sir based on Sennlaser experience po sir do you do like do well ba by the actual screening for COVID-19 and tuberculosis yes we do that initially during the first the two months the second month when we had one nurse okay when we have one healthcare worker would turn out to be positive in the TB unit okay so the infection control committee decided to do screening for all the patients we admitted because of TB screen them for COVID-19 and fortunately I think only one patient turned out to be positive and the clinical manifestation was really more on TB and it's not much of the COVID-19 mm okay and then I think marami po sa ating mga attendees po represent the pharmacist sector po and then there are clamors po for future webinar proposed webinar topics po in the future but for now I think important question po sa kaila any significant drug interactions regarding any of the proposed therapies for COVID-19 anti-tuberculosis medication naman po yes there is no so you're the pin of ear return of ear okay we'll have a very high rate of drug-drug interaction with your I'm talking about the patients with TB if you have a patient with tuberculosis we have to have a COVID-19 patient with tuberculosis are you going to give the looping of ear return of ear which is one of the investigational drugs I should not be giving that because that will also decrease the concentration of your rifampicin which is important in this patient okay thank you. Other questions from your end Dr. Susi? Ayman there's a related question here about the use of chloroquine and hydrochloroquine I mean if we use it for patients with COVID is there a possibility that you have CQ resistance in relation to malaria this is a question from Alhora in fact our chloroquine resistant malaria is really very high that's why we're not using it anymore so to speak we have eliminated chloroquine in the regimen for malaria but I just don't know if there is a chloroquine cross resistance with the current anti-malaria drugs okay so Raymond I think in the future this thing about drug interaction as has been mentioned by one of the participants is something we need to talk about because we've heard this also in previous webinars we're trying to give the medications that are available on the other hand when you have high comorbidity senior giving all kinds of other medicines so this is sort of an important continuing discussion for us there's another question here which I think is interesting there was a question here about those who if they test negative so you said Dr. Jean that they you test every 72 hours every 3 days and if they test negative how many times do you have to get a negative PCR and do you have patients who actually test continue to test positive and become asymptomatic or are they there are some questions together okay so in our protocol here we do the criteria for discharge is one the patient should be asymptomatic second the patient should be RT-BCR negative twice twice okay now we have experience in fact we go to 20 to 30% of our patients they have RT-PCR negative and then they have RT-PCR positive again and they are already asymptomatic so the question then are you going to discharge them since they also are fully asymptomatic and one is negative and only the latest one is positive so again it depends on you but again our consensus then is we have to develop negative so we don't discharge them as long as they have an RT-PCR positive they should have negative RT-PCR before we can discharge them we have another page yes yes Jean would there be any room for using an antibody test I mean not necessarily the rapid test kit but I've heard already about some antibody tests that are being used using architect for example where they take 2 ML of blood it's the same test that they use for HIV for blood screening and for hepatitis C so is there any potential because the thing about the RT-PCR is that it can also pick up virus fragments that are dead right how about antibody what do you think of them yes very good question because right now we are now submitting our proposal for an antibody testing parallel with RT-PCR among our patients here at San Lazaro Hospital and we now we do serobanking so we keep the serum of those patients the initial diagnosed when the RT-PCR positive until they were negative so we keep those and hopefully once this antibody test not necessarily the rapid antibody test but the true antibody test that higher sensitivity and higher specificity hopefully we can also materialize that and test the utility of this antibody test among our patients with COVID-19 and has recovered ok thank you very much Raymond na namin pang question dito let's take a few more maybe more dohan daming question i'm telling you it's been a very fascinating discussion Raymond go ahead you choose so for Dr. Solante Poulut sir anything that you could share in terms of the use of a convalescent plasma therapy from the San Lazaro experience po so my answer to that we don't have any patient yet given the convalescent plasma ok sir ok other questions naman po is related naman po sa patients who are suspect COVID and suspect TV is there po ba in terms of test that you will need to conduct what will be the protocol ok so the current protocol now if you have patient COVID-19 suspect and you also suspect this patient is TV we do first the COVID-19 RTPCR and then after that we do also the gene expert TV so we prioritize first the COVID-19 before we do the gene expert for TV thank you sir doctor Susie ok so i think just a few more a few more questions here um trying to look at something ok precautions for HIV AIDS patients would be the would they be the same for for COVID yes in terms of the prevention i think we have mentioned that one already terms of social distancing and wearing of face mask we have an HIV ward just above the COVID unit ward so the people there are not allowed to go down and be in the COVID unit so we always make sure that there will be the traffic of the visitors will be very different with the COVID unit and that of the tuberculosis ok another question of a systems question but it's good to get your opinion on it so they're asking if the diagnostic capability for co-infections is ok so the question is from Ryan is the current COVID-19 testing affect the laboratory capacity in the country i mean i know there's a lot of there are many issues around this on the one hand we want to build laboratory capability like and do more testing for COVID and the gene expert machine is one of the machines that we want to use and then at the same time we still don't have enough gene expert machines for tuberculosis either so how do we i know it's a systems question it's not about clinical management but what are your thoughts on improving diagnostic capability for infections in the country coming from San Lazaro seeing what you're seeing on the ground in the field what does the country need to do to improve our capability for diagnostics on infections ok so tough question but i'll have to base it on what i have seen and what i have experienced one is you have to have manpower you have to have enough people who really can do those tests because if you have all those machines if you have all those gene experts but the question then is i only have three four medtechs in my laboratory how can i develop this system how can i develop a very good laboratory capability given those limitations so you have to have one manpower second you have to have a very good leader in your hospital that can really create harmonious what we call capability open to collaboration open to networking open to training because it's only that's the only way we can also expand our capability in terms of expansion to other diagnostic tests and number three you should have a very good support from the department of health ok thank you very much gene i think on that note we're going to ask Dr. Eva to respond to that and maybe to just give her insights on on the lecture and what do you think was discussed that has some research leads for everyone we could probably pursue Eva over to you thank you Dr. Susie i think what we have seen is the richness of experience that san lasaro has i mean this is like over the years not only during this COVID 19 pandemic and right now what Dr. Solante has given us is many also the richness of his experience dealing with COVID 19 cases in the last three months since the start because they actually took care of the first patient who was identified in the first ever case identified in the Philippines so we appreciate the way that he has given us a very good and comprehensive explanation or discussion of their management strategies from diagnosis to clinical presentation and as you said Dr. Mercado he also gave us a good good illustrations on CT scans, x-rays that probably will help many of our colleagues in different parts of the Philippines to help them in their cases and more importantly because HIV, TB they're here to stay and did I get it right Dr. Solante this are not going to go away and so being able to recognize that the emerging infection the emerging viruses while we battle those emerging viruses this other conditions that have been plaguing our country are also important to recognize that they are part of us and that their management should also be given due importance and I think he did mention that they're going to start studies on antibodies I think many of the institutions who deal with cases of COVID at COVID referral hospitals as well as the research institutions like San Lassaro, RITM and the Philippine General Hospital right now everyone's cooperating to come up with researchers that will help us improve our diagnostic capability as well as our therapeutic management so the solidarity trial for sure is going to make a big impact in management in the next months to come and I think Dr. Suzie, I think we also need to think about doing research on how the government measures to like do the ECQ how has it affected what has its impact been in society not only health but also affecting our socioeconomic status as well as the psychological impact of the measures that the government has undertaken to fight COVID-19 many different sectors of society not only the health care providers as well as health researchers can actually embark in studies to answer the many questions that we have for for our present pandemic I think a better understanding of what we are dealing with our unknown enemy will actually help us move things forward yun lang pa Raymond you want to go to the answers to the yes so that we can ask Dr. Solante what the what the correct answer is well first and foremost thank you so much to NIH Executive Director Dr. Eva for for that closing remarks and we appreciate all the insights that you shared with us based on the presentation by Dr. Solante and then for Dr. Jean sir first question how about testing for both PTB and COVID-19 will be indicated for three main reasons except I think for me is the previous history of BCG vaccine and pulmonary calcification which has been answered by 63% of our attendees pasando mo, pasando ayan ok and then for the second question is just a question ok game and then for the second question the following are the precautionary measures that people living with HIV should adhere to to prevent the spread of COVID-19 infection except yeah the alcohol gel ok po ne kasi sir para po yung po which has been answered by 68% of our attendees anything open water yes so it's the soap and water I think we have to go back to the very very basic public health may assures just wash your hands frequently with soap and water so I'm very happy for that question Dr. Jean, maganda yung trick question ok po any last questions for Dr. Suzy for Dr. Jean or for Dr. Eva no I don't have any questions I want to thank our guests I want to thank Eva for your time and for all the things you've been doing for the country as well my goodness I can't imagine what it's like to be working in San Lazaro at the time like this but here you are you were able to get all the cases together and show them but I know Jean you should know that there are people watching from all over the country and this webinar gets replayed on YouTube through TVUP and the University of the Philippines has been amazing at getting all of this together in a way that is interesting for everyone and so we just want to want to thank you both for your time now next week we're going to have very interesting speaker we're going to have Dr. Antonio Ramos from the Philippine Lang Center and he's going to talk about protecting health workers from infections again another warrior at the frontline who will have many many interesting insights to share with you at the Philippine Lang Center so that nobody gets infected I think that's a very top of mind concern for all of you who are on the webinar but on behalf of the whole team that's worked together I would like to thank Dr. Jean Eva thank you so much for all that you're doing for us and on behalf of the Philippine Health Insurance Corporation that is now in the new normal trying to reach out to everybody share information partnerships I'd just like to thank all of our participants on the webinar and all of you who are watching on the playback over to you Raymond Thank you so much Dr. Suzie and with that we conclude our fifth installment of the University of Philippines and Philippine Health Insurance Corporations Webinar Series on Stop COVID Deaths magsama-sama ko tayo ulit for our next webinar which has been already described by Dr. Suzie and we will have a resource speaker from the Lang Center of the Philippines which is a COVID-19 referral hospital for everyone I think everyone knows that already up to this time we still have 160 plus attendees with us so marami salamat and that is how engaging the presentation of Dr. Solanti has been and also the questions and the answers given by Dr. Jean to the questions that were posed so marami salamat po magkita kita ko tayo ulit like I mentioned, keep safe keep healthy and see you online marami salamat