Fragile Success
Long hard look at DOTS effort
By Mike Gomez
Despite the headway made in combating tuberculosis in the Philippines, the prevalence and general state of the epidemic seem to have remained the same after several decades. Most Filipinos have been exposed in some degree to the TB bacilli, and an unacceptably large number are suffering from the disease.
The one great promising initiative against TB in the last decade is the Directly Observed Therapy Short-course or DOTS, a treatment approach that requires community mobilization and counseling or training of caregivers to ensure compliance with daily chemotherapy by supervising and monitoring drug intake. This approach seemed particularly important in the Philippines where treatment failures have been traced to poor compliance with or early discontinuance of treatment when symptoms ceased to bother the patient.
DOTS was instituted in the Philippines in 1996 through the initiative of the Philippine Coalition against Tuberculosis (PhilCAT) and the Department of Health. The targets set at the time were to detect at least 70 percent of existing smear, positive cases, and cure at least 85 percent of these cases.
While these seemed ambitious vis-a-vis other public health efforts of similar magnitude, DOTS advocates were confident of attaining them because DOTS was designed to dovetail directly into an existing health care network. Unlike other health campaigns, DOTS did not require any huge financial investment in health infrastructure, technology, or operational expense. The DOTS treatment regimen was no different from that already being used against TB before its introduction.
After a year of instituting DOTS, only 10 percent coverage was attained. From 1997 to 2001, however, the reported figure rose to an impressive 97 percent. By then, PhilCAT reckoned the National TB Program would be entering its second phase from 2002 to 2003, which would focus on maintaining and improving the quality of DOTS in the Philippines.
Propitious
Before venturing into the second phase of its nationwide effort, PhilCAT deemed it necessary to review the progress and make an impartial assessment of the current situation. Coincidentally, the Global TB Program of the World Health Organization was also in the process of organizing TB DOTS Program Reviews in countries where the disease is still considered a major problem. WHO lists the Philippines among the top 22 member-states in TB burden.
Thus, in early July, 31 participants convened at the National Tuberculosis Reference Laboratory at the Research Institute for Tropical Medicine in Alabang to look into the policy environment, case finding, case management, supervision and monitoring, drug supply, laboratory network, training, advocacy, health education, and finance aspects of the National TB Program.
Taking part were representatives from several international bilateral and multilateral agencies including the World Bank, United States Agency for International Development, US Centers for Disease Control and Prevention (CDC), Canadian International Development Agency, Japan International Cooperation Agency, Research Institute for Tuberculosis (RIT-Japan), World Vision, Medicos del Mundo, and WHO.
With technical support from WHO, field visits were undertaken by teams sent to six areas: Caraga, Southern Mindanao, Western Visayas, Southern Tagalog, Central Luzon, and the National Capital Region. Team members were assisted by personnel from the DoH central office and regional offices.
Dr. Leopold Blanc, WHO Global TB Program Manager, told MEDICAL OBSERVER that the call for review arose when concerns were raised that the expansion of DOTS was "not moving fast enough at global level." It was becoming evident that the targets were not going to be achieved. Had the Philippines not requested for the review, WHO would have recommended one just the same along with other countries targeted for program review, said Dr. Blanc.
Success Story
"The Philippines is a success story in terms of DOTS expansion," Dr. Blanc said, marveling at the achievement amid the difficulties of coping with the decentralization of health services. "Now, DOTS is available everywhere in the Philippines-in all public health facilities, and in some NGO facilities where the Philippine Tuberculosis Society is present," he noted.
The WHO official expressed some concern though over the remaining difficulties in the program, particularly in ensuring sustainability at the local level. "Many of the activities of the TB program depend on the commitment of the local authorities," he noted. Local government units are responsible for the actual conduct of activities and for augmenting supply of medicines for minimal TB. The DoH supplies drugs for infectious patients.
"So this makes this program a little bit fragile," Dr. Blanc commented. "If the local authority changes, the commitment may also change; then the support for TB control would be difficult."
The situation notwithstanding, the devolved system of health care delivery is not without advantages to the DOTS program. Dr. Blanc cited the benefit of the proximity of the TB patients to the health service delivery system in a decentralized structure.
But the greatest obstacle is having to convince local officials and gatekeepers of the benefits of the new strategy. With the centralized system, the Health Secretary's political will was sufficient to get a nationwide program in motion since directives are simply passed down through the network. With the autonomous system, project proponents need to educate leaders in each locality, get them to implement the program, and secure the much-needed commitment for its sustainability. After all these have been established, the rest is easy, Dr. Blanc said.
Upon reviewing data gathered by the monitoring teams dispatched to the six sites, the assembly concluded that the DOTS strategy is indeed available countrywide. The most encouraging finding of all is that out of all the patients who begin DOTS, more than 85 percent are treated successfully.
Not out of the Woods
Still, the long-standing issue of proper case finding and confirmation continue to merit concern. Dr. Blanc disclosed that TB case finding in the Philippines is a matter of "question." In the last three years, there has been a decline in the number of cases detected. The cause of this requires further investigation-looking at data from different regions and considering new strategies in case finding.
Officials often take epidemiologists to task when they find more disease cases, even if the increase is due to improved diagnosis and surveillance rather than actual increase in prevalence. In looking at national TB prevalence, however, the number of cases that need to be detected is calculated using 1997 prevalence survey data as basis.
In the 1990s, WHO aimed at detecting 70 percent of the theoretical number of existing TB cases in the country. Dr. Blanc lamented that the Philippines has still not attained this target. In 2001, the proportion of expected TB cases detected was only 60 percent.
At the same time quality control, particularly in laboratory capability and case finding, is an issue requiring constant vigilance. PhilCAT issues protocols for TB in the industrial setting. It establishes guidelines on the examination and treatment of employees and job applicants. Such matters may also need some overseeing by local officials to ensure they are being done rationally so as to uphold labor rights while also safeguarding public health.
First Things First
Having surveyed DOTS programs all over the world, Dr. Blanc cautioned health systems not to put the cart before the horse. "It is important to know that until you have a health system or service that is performing well and able to implement the DOTS strategy well, you cannot look for more patients," he said. It is first, essential to set up a good service that can effectively cure patients before thinking of increasing demand for service.
He stressed though that the Philippines is indeed ready to go all-out in case finding and advocacy. "So now is the time-and only now-that the Philippines can think of increasing the social demand for TB services," he declared.
The network of laboratories is one key factor in ensuring a workable system for finding and curing TB patients in the community. Smear microscopy, wherever available, remains the gold standard. "If you see bacilli, it is TB," Dr. Blanc quipped. He admitted though that a better diagnosis tool would be advantageous to the program since sputum smear examination is not very easy to do.
Ongoing is the development of diagnostic kits that do not require a microscope. However, since it relies on the PCR method of confirmation and is therefore expensive, it is not appropriate for field use in the Philippines.
In some sites, a high-powered diagnosis committee convenes periodically to review each case and make decisions on whether or not it is TB, and what intervention should be given. With such a system, issues involving questionable radiologic findings, sputum negatives, clinical manifestations, and the like can be better assessed to ensure improved diagnosis. Some places have been found guilty of making up 50-percent false diagnoses of tuberculosis.
Fortunately, Dr. Blanc noted, the incidence of HIV in the Philippines remains low and slow-growing, thereby having no discernible effect on the trend of TB. It is only in countries where a large percentage of the population is afflicted with HIV/AIDS that an increase in HIV/AIDS-TB related is experienced. Some African countries have seen their TB prevalence multiplied four times in only eight years time due to the spread of HIV. We can only be thankful that the Philippines is far from being at risk of suffering such catastrophe.
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