 For the past several months, Filipino doctors have hurriedly thought themselves how to diagnose and treat COVID-19 patients. Many of the protocols, diagnostics, therapies, and discharge criteria have been arbitrarily set up. As newer knowledge came, this rapidly changed. Today, we will tackle the clinical issues in the care of COVID-19 patients. Welcome to TVUT. This is your host, Dr. Teddy Herbosa. For today's episode, we have as our special guest, Dr. Anthony Leachon. Dr. Leachon studied medicine at the Pontifical University of Santa Tomas and graduated in 1985. He subsequently took his fellowship in cardiology at the Department of Internal Medicine at the University of the Philippines, Philippine General Hospital. He became the medical director of Pfizer Philippines. Later, he joined us as a syntax advocate and became president of the Philippine College of Physicians. He also became an independent board member of the PhilHealth and is now a special advisor to the National Task Force against COVID-19. Dr. Leachon, welcome to Health Issue. Hi, Ted. Thank you very much for the opportunity to share knowledge and expertise to our stakeholders. Thank you very much. And indeed, the hospital where you practiced vanilla doctor's hospital was one of the first hospitals to actually receive a lot of COVID-19 patients and several of our doctor colleagues were also infected with COVID-19. How was your clinical practice in cardiology affected by this entry of COVID-19 in the Philippines? Well, my cardiology practice has changed a lot, not only my clinical practice, but the entire medical staff of the vanilla doctor's hospital. In fact, there is a criteria that if you are above 60 and you have hypertension and you have diabetes, you are not allowed to go on duty. So there was this particular time when the residents and the fellows were on duty and supported by younger consultants from age 35 up to about 50 because they don't want the senior consultants to be affected by COVID. So for the last 60 days, I have not been holding clinic, but I have been resorting to telemedicine and have been working with you daily at the National Task Force. Correct. So we served the country after we were called to be special advisors of the National Task Force. But tell me more about the vanilla doctor's hospital was the recipient of some of the initial cases in vanilla. And how did the healthcare workers at the hospital feel at that time? How did your colleagues feel about managing this very new disease, COVID-19? You know, vanilla doctor's hospital is a strategic area where a lot of cases are being referred. And you know that vanilla doctors is almost the extension of the UPPJs. Most of our consultants about 80% are coming from the Philippine General Hospital. You see the best and the brightest physicians are practicing in our hospital. That's the reason why some of the high-profile cases were seen at the vanilla doctor's hospital because of their expertise. And during the initial stages of the COVID, of course, we did not recognize that it was first COVID. And only after a flurry of deaths, then we recognized it. And as you can see, some of our dear colleagues, one of your classmates, perish during this particular period before we can actually adjust. So we're right now adjusting and we're doing well. So far, the younger consultants are not on duty right now. And the residents and the fellows are back right now. And we have adjusted to the situations right now. But your clinic is still not open, correct? Right. We'll be open next week, June 1. Actually, the vanilla doctor is as open as right now. They doors to some patients, elective cases, but mostly are actually on telemedicine. Next week on June 1, next week, we will be holding clinic on a gradual basis twice a day, twice a week and for a limited period of time, two to four hours. And the rest will be on telemedicine. Wow, very interesting. And really our health system has totally changed because of COVID-19. Now, Sonya, let's talk about the clinical course of COVID-19 patients. What are the clinical or historical findings that make you suspect that you are treating a patient with COVID-19? Based on my readings and experience at the Manila Doctors' Hospital, you would trace it to a patient who traveled abroad in areas with COVID. We had cases from returning Filipinos from the US and Australia and confined at the Manila Doctors' Hospital. And of course, infecting some of our medical staff and even our consultants mostly are basically those exposed from endemic areas. But in the second week of the infection, most are actually local transmission coming from some of the patients and, of course, the medical staff. So these are the basic things. What do they usually complain about? They usually complain about fever, cough, and the shortness of breath. And then initially, the first strategy was to close down the outpatient department. And we only have the emergency room as the entry point and for the triaging system. And that triggered actually the closing of our clinics because we don't want forest borders. And then we adjusted and then assigned certain floors as COVID area and then for PUI cases and then separated the clinical patients. So that was the strategy before. And the initial presentations of the patients are basically upper respiratory symptoms. But the more severe ones would present with fever, cough, and difficulty of breathing with classic pneumonia. But the pneumonia here is quite different from the usual pneumonia. We see this white lung in medicine when we see white lungs are already distressed syndrome. And they would require very high oxygenation leading to intubation. That is to put the putting on a tube right there from your throat down to your lungs and then would need to hook to a mechanical ventilator. And sadly, 70 to 80% of these patients who are hooked to a mechanical ventilator would expire because of the severe pneumonia and other cardiovascular as well as renal complications or kidney complications. So what was the percentage of the critically ill versus those that would recover with COVID? There were more that actually recovered than those that became critically ill and died, right? Right. 80% of the patients would present with mild symptoms and they usually are confined in the floors. And then about 10 to 20% of cases would present with severe symptoms and they will be confined in the ICU. Mostly they would require ventilator. But eventually we adjusted to the system because of our readings. We would like to prevent mechanical ventilation given the high incidence rate of dying because of the ventilation in hospital acquired pneumonia. So we would use a high-flow nasal cannula in order to avert using the mechanical ventilator and put the patients on what we call a prone position rather than the usual supine or anterior position because of the compression of the diaphragm on the lower portion and then decreasing of course the compliance of the lungs. So we see a lot of patients improving with the prone position and averting of course the intubation as well as the mechanical ventilator. And with readings and webinars listening to our Chinese counterparts, we were able to master it and eventually out of the particular respiratory failure. And the batting outbreaks right now when we are treating patients would be about 70 to 80% would be recovering. During the initial period, there was this controversy on the use of certain drugs for compassionate use. For the information of the public, when we mean compassionate use, there are drugs that are used for certain indications that are in the market but may be used based on certain small studies that will save the patient. So we usually ask the relatives and the family to explain that this particular use may be on a compassionate basis or experimental use in order to save the patients. Now we know for a fact that during the initial period, we use anti-malarial drugs like hydroxychloroquine or chloroquine together with acetromycin and then we use some other drugs. And as of late, we know already that the hydroxychloroquine or chloroquine based on the latest FDA announcement that you cannot use this because of the propensity to develop irregular heart beats or cardiac arrhythmia because of the prolongation of their QT interval. That's a cardiologist's language or term, but it means that when you use that drug, it may compromise the patient's cardiac condition by creating more problems like arrhythmia and that can lead to sudden cardiac death. So there are certain other drugs that may be used like some HIV drugs and antiviral. The remdesivir has been approved in the United States for use. The problem here is that we have some problems in the supply chain but eventually you might have that in the market. And of course, the last resort of course is the vaccine but which may not be available until one and a half years from now. Okay. Okay, so we've described several of the therapies that are all being undergoing trials still, right? And let's talk about testing. How do you diagnose and confirm that you are indeed treating a COVID-19 patient? Okay. What are the different tests available to you? The gold standard is actually the RT-PCR. We call it the nasopharyngeal swab. And usually you request this when the patients would present with respiratory symptoms like cough or sore throat or those with fever. And because of the bottleneck situation during the first time, the results would come out after seven days. And then that may be a problem. So we start with usually with our empirical and other drugs to be used by the patient. So can you repeat that? You do a test. We usually repeat that twice. RT-PCR, you get a sample inside the notes. But you start treatment already. We put a note in the throat. And then we put that particular specimen in a tube. And then we send this out to a center accredited by the Department of Health. And during that time, there was only one center at that time. It's our ITM. Right now we have about more than 30 laboratories accredited by the Department of Health. So that is the usual scenario. So our hospital is not considered a COVID hospital. We're not also a hospital with this particular laboratory. The other alternative tests that we usually do, particularly in areas without the RT-PCR. So we went around with Secretary Galvez and Dr. Erboza and our team. And in the countryside when you don't have RT-PCR, the rapid antibody test might be handy. It's a point of care of this. Where usually you will defect the antibody. The first antibody to rise is the IgM. That is about one or one to seven days during the time of the viral shedding. And then this will go down, the IgM. And then you will see a rise in your IgG. And that would mean a past infection or recovery or have immunity. But we would like to emphasize that we would use this together with the RT-PCR. Just in case we would like to validate whether this patient had really the coronavirus infection. So we're using this. The third one is the gene expert, which you can use using the test for tuberculosis. The test would run for about 45 minutes. The main problem is that it is not available in other areas. So in our discussion here at the National Task Force, we would recommend the RT-PCR in areas where there are centers where you can use it. In other areas, then you can probably use it. Particularly for contact tracing, those for clearance, let's say from our overseas workers that will be going to their final destination after quarantine of 14 days. Those would require a medical clearance before they return to work. These are the certain medical conditions. I want to explain that to the employers and to the employees and the patients that in the absence of the RT-PCR, rather than not using anything, then perhaps the rapid antibody test might be used. So this is the way we do it right now. We are not in a business as usual mode. We are in a crisis situation knowing that we believe science and of course research. But we need to be flexible because of this particular crisis. Thank you. There's been a lot of controversy with this testing. They talk of what they call mass testing. And then there's what they call the RT-PCR, which is a nucleic. It tests for the virus, right? It looks for the RNA of the virus. And the other one, the antibody, looks for the antibodies produced by the patient. So why are there shectors or doctors who refuse to use the antibody test? And what are their claims to this? Well, basically because as epidemiologists or researchers, they may actually focus on their expertise to use that. But as a public, not only the medical aspect, but the socioeconomic impact of your certain diagnostic tools. For example, when I was at PGH, there was no CT scan. There was no MRI scan. But we were able to manage cases clinically. And I learned this from you about the syndromic diagnosis that you can actually blend using clinical symptoms and signs together with the minimum diagnostic tool to arrive at a diagnosis. We were instructed by Secretary Galvez to use available diagnostic tools in order to save lives. In a crisis situation, this is very important. We don't want to, of course, to stay away from science and research. But this is the issue right now. And we need to be adaptive and, of course, calibrate our mood space on the present situation. So you feel that the use of the antibody test and PCR test are complementary to each other? Absolutely. And we discussed this at the Philippine College of Physicians that though the medical societies have issued this particular statement, one particular caveat here is that they will not enforce or perhaps influence the employers to use whatever diagnostic tools in order to protect their patients and their employees. And as we speak right now, this morning, Secretary Ed Año of the DILG said that he would conduct a Zoom meeting together with the local government units in order to explain the use of the RTPCR and the rapid antibody test, depending on the situations. And eventually, he would advise the IADM through the technical, through the Task Force Strat Communications to issue a final statement so that we will not confuse, of course, the Filipino population. So let's talk about the antibody test. There are like three bars to call it a lateral flow test. You can also test the antibody using the ELISA, which is a machine or a lab. But in the lateral flow, it diagnoses there are three bars in that kit. In that kit, there is like a control and then there's the IgM and IgG. So what does it mean when you have a positive IgM? When you have a positive IgM, it means that you are in the first week. Usually the incubation period is about 14 days. And then you have a pre-symptomatic case. The symptomatic case is defined as, this is the absence of symptoms. The difference between coronavirus and SARS is that in SARS, you can actually be contagious during the time of the symptoms. But the main difference is that coronavirus, you can be contagious or can infect another person, even if you're asymptomatic or you're in the pre-symptomatic case. Now, the IgM would rise during the first seven days, usually about three to seven days. That is the first antibody response. That is the response of the body because of the infection. The increase right now of the immunoglobulin G, which would mean that you actually develop immunity. Of course, we don't know yet the full force of the disease because we are right now in the midst of crisis. We don't know yet whether we will have full immunity with this particular virus or we would have total herd immunity once 70 to 90% of the population is exposed. So a lot of things are not sure right now. So therefore, what we would like to advise is to keep, of course, the social distancing measures in the population. While we unveil some of the studies related to this particular problem. So we visited Baguio City and in Baguio City, Mayor Magalong and Baguio General Hospital implemented this artificial intelligence together with the city scan findings. Can you tell us more about use of AI in the diagnosis of the pneumonia of patients with COVID-19? Absolutely, I did that in the country. For example, the proponent of the prone position CT scan of the chest and they can do the chest CT scan in order to see whether there are ground glass opacities. Now, this particular gadget or technology that is sponsored by Huawei can actually have the results in seven minutes and even in the absence of the RT-PCR results, you can actually manage the cases of COVID-19. And according to Mayor Magalong, the correlation rate after extracting the specimen and then the results of the chest scan is actually about 80 to 90%. That's a very good diagnostic rate. And in terms of efficiency, I would say that this is accurate. Now, we have the same experience at the Manila Doctors' Hospital. Since the turnaround time will be about five, seven days, we usually use the chest X-ray, the syndromic diagnosis and the chest CT scan. And this is one of the success stories, of course, of using multiple diagnostic tools in order to save a patient and not be too dependent on one diagnostic tool, which is the RT-PCR, which is considered the gold standard. Good, very good. Can you tell us more about a research program of the WHO called the Solidarity Trial? I think they're trying to study all the proposed therapies out there. The Solidarity Trial is a multi-study led by the World Health Organization and that includes, of course, the Philippines. The lead proponent in the Philippines is the president of the Philippine Society of Microbiology and Infectious Disease. In order to tell us and find out whether those drugs use for compassionate use or for experimental use and this would be comprised of the anti-malarial drugs together with your antiviral drugs together with your HIV drug and, of course, some medications, of course, for your connective tissue diseases and the results will be out in a few months. But as you can see, the FDA has announced that the hydrocyclerophen may not be effective and it may be deleterious to your patients. Without waiting for the Solidarity Trial, you can actually be following this particular guideline. Then remdesivir has been found to be effective in reducing drugs and can actually more be deleterious rather than use for the patient. My idea has discussed with you, Ted, is that we don't want the patients to be admitted in the hospital because it's very expensive. As you can see, based on my patient's experience, one patient would spend about 1.5 million and I heard about many patients spending so much on this. So you don't want to be confined for two reasons. One, it's very expensive. Number two, the prolonged hospitalization can lead to intubation and use of your mechanical ventilator. Number three, you cannot visit your relatives and the other reason is that the members of the family may actually be affected as well. So you should focus more on the preventing aspect and the idea is to have more testing centers to detect and isolate and trace the patients rather than be confined and overwhelm the healthcare system. So in the new normal, the idea is to be more focused on the preventive or absolute cases, more on detection, isolation, racing, rather than treating the patients in the hospital and overwhelm the healthcare system. There's another form of therapy that's going around in a few of the hospitals in Manila and it's called plasma therapy. You know, you get a patient who already had COVID-19 and recovered and they get their plasma to plasma patients. Can you explain the principle behind plasma therapy for COVID-19? The plasma therapy has been used as well in Manila Doctors' Hospital and some other local hospitals. The principle is that once the patient has recovered, then the patient who was then affected with COVID had a period of time of recovery. Then you can actually donate or the white, they call it the white of the blood or the plasma and then this usually will be extracted from you and then bunk in the laboratory of, let's say, I think there are only a few hospitals offering this, the Philippine General Hospital and St. Luke's at this moment. And then when there are security cases of COVID, for example in the ICU, then this particular plasma can be used in order to induce of course success, but we need to understand that we need a clinical trial to find out whether these patients would have other side effects aside from its efficacy. We want to test here the efficacy rate as well as the safety, but based on our understanding and based on the stories of those our patients who recovered, plasma therapy has a role, of course, in the treatment regimen of the patients. Thank you, Tony. One last and final question. What is your fear less forecast on the vaccine? Coming from the pharmaceutical industry, I was connected with Pfizer for two decades and we produce the best drugs as well as vaccines. Usually in order to launch a product in the market, you need a billion dollars to launch a product in the market. And based on our projection, this is vaccine, you might need one and a half years minimum, minimum to two years to launch a vaccine in the market, particularly with this kind of virus when you have other problems. So, and therefore based on this assumption, the new normal may be actually from today and then the next two years before we can see the light at the end of the tunnel. Thank you very much. That's been a very good discussion. Any final words for our viewers? I think we need to be resilient and relentless in trying to pursue the vaccine for this particular pandemic. I would like to advise everyone as we open the economy next week from ECQ to MECQ to GCQ, we must maintain our social distancing measures and I would actually enjoy everyone, every Filipino, to have a culture of discipline and commitment. Thank you very much, Ted, for the opportunity to enlighten our viewers. Thank you very much, Tony. That is a very interesting discussion in the COVID-19 creation. Like you, I do hope that we will find the right therapy to the solidarity trials and in a year or two be able to commercially produce vaccines against COVID-19. Thank you very much, ladies and gentlemen. This is your host, Dr. Teddy Herbosa. Stay home, stay safe.