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Taiwan man suffers with coronavirus for 8 days after test vial snafu

One man goes untreated, another lives in fear after test results mixed up for over a week

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Chen Shih-chung. 

Chen Shih-chung.  (CNA photo)

TAIPEI (Taiwan News) — A test tube mixup led to one Taiwanese man languishing in quarantine for over a week without knowing he had the coronavirus and another living in fear thinking he had been infected with the deadly disease.

During his weekly press conference Wednesday afternoon, Minister of Health and Welfare and CECC head Chen Shih-chung (陳時中) announced that a snafu in the lab had resulted in coronavirus case no. 530's test results being mixed up with case No. 536's. As case no. 530, who had been working in China, was found to be negative, he will be removed from the list of "confirmed cases," and China will be notified of the change via a World Health Organization's National IHR Focal Point.

Chen stated that deep throat saliva specimens collected from case no. 530 at the airport showed a "strong positive result" for COVID-19. However, the specimen taken the next day came back negative, with an upper respiratory tract specimen and an antibody test taken later also yielded negative results.

Given the huge discrepancy between the first and subsequent tests, the Centers for Disease Control (CDC) initiated an investigation on Oct. 15, including the details of the tests taken on the day case no. 530 arrived in Taiwan: Oct. 11. The CDC then followed up with all 30 passengers who were tested that day.

Among the 30, who had been tested for the virus on Oct. 11, only case no. 536 later tested positive for COVID-19 — on Oct. 16. Chen explained that after a human DNA analysis had been carried out on the sample from case no. 530, the results showed it had actually been taken from case no. 536.

Chen indicated that the investigators had found that a "misplacement" had taken place between case no. 530 and case no. 536's specimens. The CECC stated that according to the investigation, the misplacement occurred while different test tubes for different testing instruments were being manually operated and transposed.

Chen pledged that after the review process is carried out, the COVID-19 inspection network will establish stronger "error-proofing mechanisms," encourage inspection agencies to increase laboratory manpower, strengthen the comparison of samples in experimental steps, and actively introduce nucleic acid inspection models with a higher degree of automation to reduce the need to manually write labels and transfer samples.

The CECC head then patted the inspection network on the back for being "an important part of Taiwan's COVID-19 epidemic prevention network" by testing more than 100,000 people. Chen said that the CECC will use this experience to humbly reflect on and continuously refine the inspection process.

Case no. 536 is a Taiwanese man in his 20s who worked in France for an extended period of time and most recently departed Taiwan in August of last year. Upon returning to Taiwan on Oct. 11, he proactively informed quarantine officers that he had begun to experience a sore throat on Oct. 9.

However, an initial test administered on the man yielded a negative result. While undergoing home quarantine from Oct. 12 to 13, he began to suffer a cough, diarrhea, general fatigue, and shortness of breath.

The health department arranged for him to undergo another test on Oct. 16. He was diagnosed with the disease on Oct. 19 and placed in a hospital isolation ward.

As a result of test tube blunder, Case no. 536 had suffered for eight days before being correctly diagnosed with the virus and receiving proper treatment.

Case no. 530, is a Taiwanese man in his 40s who went to work in Jiangsu, China, in February and returned to Taiwan on Oct. 11. He underwent a test for the virus that day, and on Oct. 13 he was informed he had tested positive for the disease (based on case no. 536's sample).

The CECC said the health unit has identified 17 people who came in contact with the man during his flight to Taiwan, including 10 passengers who sat in the rows directly in front of and behind him, as well as seven crew members. The 10 passengers were told to begin home isolation, while the seven crew members, who did not enter the country that day, were asked to start self-health monitoring, as they were deemed to have been wearing adequate protective equipment.

Therefore, due to the foul-up, case no. 530 was subjected to additional testing, unnecessary hospitalization, and 15 days of anxiety believing that he had the coronavirus. In addition, 17 people were told to either begin home isolation or self-health quarantine unnecessarily.