Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

__
April 9, 2020

DEPARTMENT CIRCULAR
No. 2020-_ 06/4

TO: ALL UNDERSECRETARIES AND ASSISTANT

SECRETARIES; DIRECTORS OF BUREAUS, SERVICES AND
CENTERS FOR HEALTH DEVELOPMENT; MINISTER OF
HEALTH — BANGSAMORO AUTONOMOUS REGION _IN
MUSLIM MINDANAO; EXECUTIVE DIRECTORS OF
SPECIALTY HOSPITALS AND NATIONAL NUTRITION
COUNCIL; _DIRECTOR GENERAL OF PHILIPPINE
INSTITUTE OF TRADITIONAL MEDICINE AND
ALTERNATIVE HEALTH CARE; CHIEFS OF MEDICAL
CENTERS, HOSPITALS, SANITARIA AND INSTITUTES:
PRESIDENT OF THE PHILIPPINE HEALTH INSURANCE
CORPORATION: DIRECTORS OF PHILIPPINE NATIONAL
AIDS COUNCIL SECRETARIAT AND TREATMENT AND
REHABILITATION CENTERS AND ALL OTHERS
CONCERNED

SUBJECT: Reiteration of Department Memorandum No. 2020-0151 dated

March 31, 2020 entitled “Interim Guidelines on Expanded Testing
for COVID-19”

cases
With the increasing COVID-19 in
the country, there is also a subsequent increase in the
demand for RT-PCR testing all over the country. In order to maximize the current testing
capacity, the Department of
Health reiterates Department Memorandum No. 2020-0151 dated
March 31, 2020 entitled “Interim Guidelines on Expanded Testing for COVID-19” as
attached.

Dissemination of the information to all concerned is requested.

FRANCISCO TY’
DUQUE III, MD, MSc
Secvetary of Health

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1108, 1111, 1112, 1113
Direct Line: 711-9502; 711-9503 Fax: 743-1829 @ URL: http://www.doh.gov.ph; e-mail: ftduque@doh.gov.ph
>
Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY
March 31, 2020

DEPARTMENT MEMORANDUM
No. 2020 - 015)

TO: ALL _UNDERSECRETARIES AND ASSISTANT SECRETARIES;

DIRECTORS OF BUREAUS AND CENTERS FOR HEALTH
DEVELOPMENT; MINISTER OF HEALTH — BANGSAMORO
AUTONOMOUS REGION MUSLIM___ MINDANAO; __IN_

EXECUTIVE DIRECTORS OF SPECIALTY HOSPITALS AND

NATIONAL NUTRITION COUNCIL: CHIEFS OF MEDICAL
CENTERS, HOSPITALS, SANITARIA _AND_ INSTITUTES:
PRESIDENT OF THE PHILIPPINE HEALTH INSURANCE
CORPORATION; DIRECTORS PHILIPPINE NATIONAL OF

AIDS COUNCIL AND TREATMENT AND REHABILITATION

CENTERS AND ALL OTHERS CONCERNED

SUBJECT: Interim Guidelines on Expanded Testing for COVID-19

INTRODUCTION

Coronavirus disease 2019 (COVID-19) was first reported in Wuhan City, China in
December 2019 as a cluster of pneumonia cases of unknown etiology. With the increasing
number of cases and deaths in various territories, the World Health Organization declared
COVID-19 as a pandemic last March 11, 2020.

With the increasing COVID-19 cases in the country, there is also a subsequent
increase in the demand for RT-PCR testing all over the country. In order to maximize the
limited testing capacity, the Department of Health issues these guidelines on risk-based
testing for COVID-19.

GENERAL GUIDELINES
1. COVID-19 Expanded Testing is defined as testing all individuals who are at-risk of

contracting COVID-19 infection. This includes the following groups: (1) suspect
cases or (2) individuals with relevant history of travel and exposure (or contact),
whether symptomatic or asymptomatic, and (3) health care workers with possible
exposure, whether symptomatic or asymptomatic.
a. The following exposures should have happened during the two (2) days before or
14 days after the onset of symptoms of
a confirmed or probable case:
1) Face-to-face contact with a confirmed case within | meter and for more than
15 minutes
2) Direct physical contact with a confirmed case
3) Direct care for a patient with probable or confirmed COVID-19 disease
without using proper personal protective equipment
b. Indiscriminate testing beyond close contacts of a confirmed COVID-19 case
recommended.
not is
2. The following reflects the sub-groups of at-risk individuals arranged in order of
greatest to lowest need for testing:

= Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1108, 1111, 1112, 1113

Direct Line: 711-9502; 711-9503 Fax: 743-1829 e URL: http://www.doh.gov.ph; e-mail: ftduque@doh.gov.ph
 a. Subgroup A: Patients or healthcare workers with severe/eritical symptoms,
relevant history of travel/contact
b. Subgroup B: Patients or healthcare workers with mild symptoms, relevant
history of travel/contact, and considered vulnerable
c, Subgroup C: Patients or healthcare workers with mild symptoms, relevant history
of travel/contact
d, Subgroup D: Patients or healthcare workers with no symptoms but relevant
history of travel/contact
Due to global shortage of testing kits and limitation in local capacity for testing, there
is a need to rationalize available tests and prioritize subgroups A and B.
However, in view of the expansion of testing capacity and to ensure healthcare
workforce safety, subgroup C will be tested and health workers prioritized.
All subnational laboratories are directed to allocate between 20-30% of their daily
testing capacity for health workers and the remaining 70% for patients.
Based on current available evidence, real-time polymerase chain reaction (RT-PCR)
test
testing is the confirmatory test, In the Philippines, this pertains to using RT-PCR
kits that are approved by the Food and Drug Administration (FDA), and validated by
the Research Institute for Tropical Medicine (RTIM).
Pending results of local studies, use of point-of-care rapid antibody-based test kits
shall not be used as standalone tests to definitively diagnose or rule out COVID-19,
Because these must be used in conjunction with RT-PCR, care must be exercised to
not unduly consume RT-PCR test kits for the sake of confirmation.
Expanded use of point-of-care rapid antibody-based test kits shall be explored
through validation and sero-epidemiological studies particularly for use in Subgroup
D, as testing all asymptomatic contacts of confirmed COVID-19 cases using RT-PCR
is not recommended until there is surplus testing capacity.
Results of such studies shall be submitted to the Health Technology Assessment
Council (HTAC) for their review and consideration. DOH and PhilHealth may only
finance or reimburse COVID-19 test kits that have been positively recommended by
the HTAC as required by RA No, 11223.
10. Only one RT-PCR test with negative results is enough to clear a COVID-19 positive
patient.

II. SPECIFIC GUIDELINES

.

A. The following guidelines shall apply once the FDA-approved antibody-based test kits
have been validated through local studies.

Only licensed medical practitioners may prescribe and administer antibody-based tests.
l, The medical practitioner shall be responsible for:
a. wearing appropriate personal protective equipment provided by the health
institution, prior to administering test;
b. following DOH published guidelines on case management;
c. filling online Case Investigation Form for all and coordinating with regional
epidemiological surveillance unit;
d. monitoring and reporting adherence to case managementon
a daily basis
e. referring antibody-based test positive cases which belong to Subgroup A and B
for possible admission to hospital and confir matory testing for RT-PCR; and
f. Issuing official receipt to the patient for the services rendered,
Zs Failure to comply with the above mentioned responsibilities may be considered
violation of RA 11332, which penalizes “non-cooperation of persons and entities that

2
 should report and/or respond to notifiable diseases or health events of public
concern”, penalty of which is fine not less than Php 20,000 but not more than Php
50,000 or imprisonment of not less than one month but not more than 6 months, or
both such fine and imprisonment, and other applicable laws, rules and regulations

C. For Health Care Workers

1. All symptomatic healthcare workers should be isolated and tested with RT-PCR.
a, All symptomatic healthcare workers who test positive using RT-PCR must be
hotne-quarantined or hospitalized depending on the severity of symptoms,
ii After 14 straight days without symptoms, the healthcare worker can be
subjected to antibody testing.
1. IfIgG is positive, the health worker can return to work and do
not need repeat testing unless they develop symptoms,
2. IfIgG remains negative, an RT-PCR can be done:
a. Ifnegative, the healthcare worker can return to work,
b, All symptomatic healthcare workers who test negative using RT-PCR may
retutn. to work upon resolution of symptoms, then be subject to guidelines for
asymptomatic healthcare workers

2. All asymptomatic healthcare workers with unprotected exposure should be isolated

and tested with RT-PCR. If
there is no available RT-PCR due to
limited availability,
they can be tested using antibody-based tests every 14 days until IgG develops, but the
healthcare worker should remain isolated for 14 days unless RT-PCR tests are
available.
a. Exposure is defined as working in a healthcare facility with confirmed
COVID-19 patients within the last 14 days without appropriate PPE.
b. All IgM positive but IgG negative healthcare workers who are asymptomatic
can be tested with RT-PCR, if and when the testing capacity becomes available.
i. If cleared using a negative RT-PCR, they are allowed to return to duty
granted that they have recovered from all symptoms, They can be
retested with an antibody test after 14 days for development of If
IgG.
IgG remains negative, continue antibody testing every 14 days as long as
exposure is occuring,
ii, If they develop symptoms, they shall be prioritized for RT-PCR testing
and shall follow protocol indicated in Section IILC.1,
c. All IgG positive healthcare workers, whether IgM positive or negative, can
return to work, provided they be retested with an RI-PCR if they develop
symptoms.

3. Test all healthcare workers with unprotected exposure every 14 days. If symptomatic,
follow the protocol in Section IILC.1. If asymptomatic, test with an antibody-based test
every 14 days until IgG develops. All IgM positive but IgG negative healthcare workers
who are asymptomatic shall follow the protocol indicated in Section IIL.C.2.b,

D. For Symptomatic Non-Health Care Workers

1. Testing of symptomatic patients who are close contacts of a known or probable case
with rapid antibody-based test kits alone is not recommended, and can be dangerous
not done with proper Personal Protective Equipment. Isolate the patient and conduct
if
RT-PCR testing as recommended,
 2. If there available RT-PCR due
is no to
limited availability, rapid antibody-based testing
can be used, but the patient should remain isolated for 14 days regardless of result
(See Annex A).
a. If IgM negative, collect samples for RT-PCR testing
i. If RT-PCR negative, the patient is not a COVID-19 case but has to
complete the 14-day quarantine.
ii. If RT-PCR positive, the patient is a confirmed COVID-19 case and shall
be treated and undergo isolation accordingly.
iii. If RT-PCR testing is not available, isolate the patient for 14 days. Repeat
rapid antibody-based testing once asymptomatic, and follow protocols
indicated in Section E for asymptomatic patients.
b. If IgM _positive, the patient is a probable COVID-19 case. Collect swab for
RT-PCR testing.
i. If RT-PCR positive,
the patient is a confirmed COVID-19 case and shall
be treated and undergo isolation accordingly.
ii. If RT-PCR negative, the patient has to complete the 14-day home
quarantine and repeat rapid antibody-based test.
iii. If RT-PCR testing is not available, isolate for 14 days. Repeat rapid
antibody-based testing once asymptomatic, and follow protocols
indicated in Section E for asymptomatic patients.

E. For Asymptomatic Non-Health Care Workers : Rapid antibody testing may be used
for asymptomatic non-health care workers, particularly for close contacts of confirmed
COVID-19 cases (See Annex B).
1. If the patient tests negative for both IgM and IgG, there is no need to isolate, unless

the patient becomes symptomatic. However, they shall strictly observe the quarantine
procedures in
their locality.
2. If the patient tests positive IgG only, the patient is considered a presumed recovered
case, and there is no need to isolate. However, they shall strictly observe the
quarantine procedures in their locality.
3. Patients who test IgM_positive shall be isolated at home or at a community
quarantine facility for 14 days. If they become symptomatic, they will be treated as
probable COVID-19 cases and shall follow the protocol indicated in Section D.

For strict compliance.

FRA CO A.
DUQUE III, MD, MSc
of Health
Secr¢tary
ANNEX
A.Algorithm on the Use of Rapid Antibody Tests as Adjunct Test for Testing
COVID-19 among Symptomatic Patients and Healthcare Workers with Relevant History
of Travel/Exposure

PURO ee)
HEALTHCARE WORKERS
AS OF APRIL 7, 2020
eee 10) eR eo
FOR TESTING COVID-19 AMONG SYMPTOMATIC PATIENTS AND
WITH RELEVANT HISTORY OF TRAVEL/EXPOSURE

SYMPTOMATIC
Warning: Do not attempt to test symptomatic
patients without adequate PPE
|

lgM
ol jo (-)

PRESUMPTIVE COVID-19 CASE

SWAB FOR RT-PCR
SWAB FOR RT-PCR. Ifno RT-PCR available, isolate
If no RT-PCR available, isolate for
for 14 days and repeat IgM/IgG
14 days and tepeal IgM/IgG once
once asymptomatic and follow

|
asymptomatic and follow asymptomatic algorithm
asymptomatic algorithm

Toa
or none

PRESUMPTIVE
| RT-PCR(-)

COVID-19 CASE
Isolate for 14 days and Retest at NOT A COVID-19 CASE
Observe local
the end and follow
asymptomatic algorithm quarantine procedures

If patient worsens, repeat swab

RT-PCR(+) RT-PCR(+)

COVID-19 CASE
Treat and isolate
per protocol

f OfficialDOHgov w @DOHgovph @doh.gov.ph (02) 894-COVID

ANNEX
B. Algorithm on the Use of Rapid Antibody Tests for Testing COVID-19 among
Asymptomatic Patients and MHealthcare Workers with Relevant History of
Travel/Exposure

eee
ALGORITHM ON THE USE
OF RAPID ANTIBODY TESTS FOR TESTING

Ye ae eV
OER We
eS
Ce
UAT ACO MeeeVEE
AS OF APRIL 7, 2020
tO Meme ed

ASYMPTOMATIC
Close contacts of
known case only

IgM
co [io (-)

PRESUMPTIVE NOT AN ACTIVE

COVID-19 CASE COVID-19 CASE

IgG (+) IgG (+)

IgG (-) IgG (-)

PRESUMPTIVE
COVID-19 CASE
Isolate for 14 days and Retest at NOT A COVID-19 CASE
the end and follow algorithm Observe local
quarantine procedures
If patient develops symptoms,
do nasal swab

Vv Vv

PRESUMPTIVE
RECOVERED
COVID-19 CASE

f OfficialDOHgov w@DOHgovph @dohgov.ph VL (02) 894-COVID