TB BURDEN; DOTS

Victoria Dalay, MD, MSCCTM, DTM&H

CURRENT UPDATES ON TB BURDEN DIAGNOSIS AND TREATMENT

OUTLINE:
DIAGNOSIS:
• Facts About TB
 Go to Health Facility
• Transmission
 Smear Microscopy
• Signs and Symptoms
 Chest X-ray
• TB Diagnosis
• TB treatment and Drug Resistant TB  TB Culture
• Prevention and Control  Gene Expert
• Burden of TB
TREATMENT:
 4-5 TB Drug Regimen
FACTS ABOUT TB
 DSTB: 6-12 months
AGENT:  DRTB: 18-24 months
• Caused by a “rod-shaped” bacteria = NOTE: Tuberculosis is curable and can be treated with a
 Mycobacterium tuberculosis six-month course of antibiotics which are available in
• Commonly affects the lungs*** (pulmonary TB) DOTS facilities for FREE. BUT it can also kill if not properly
• Can also cause extra-pulmonary disease (such as in treated!
lymph glands***, bones, joints, abdomen, brain,
kidney etc.)
DRUG RESISTANT TB (DRTB)
• Contagious disease
Two Classifications of Drug Resistant TB: ***
TRANSMISSION: Multi drug-resistant TB (MDR-TB)
Transmitted from  A form of TB that does NOT respond to the standard
person to person by treatment using first-line drugs, specifically
inhalation of infectious rifampicin and isoniazid
droplet nuclei
 Coughing Extensively drug-resistant TB (XDR-TB)
 Sneezing  Occurs when resistance to second-line drugs
 Talking develops
 Spitting
Resistant TB develops due to improper use of anti-TB drugs
TB is NOT spread by:  Improper treatment regimens
 Shaking someone’s hand o Wrong dosage, wrong time,
 Sharing food, drink or spoon /fork  Patient does not complete whole course of
 Touching bed linens or toilet seats treatment
 Sharing toothbrushes or towels PREVENTION AND CONTROL ***
 Kissing
 Practice Healthy Lifestyle
NATURAL HISTORY OF TUBERCULOSIS  Proper and healthy diet
 Avoid smoking and other vices
 Enough rest and exercise
 BCG vaccination (Infants)
For the prevention and control of TB:
 ALWAYS cover your mouth when you cough and
sneeze
 Do NOT spit anywhere
 WASH hands properly
 Protect your family and friends from TB — take the
correct kind and quantity of drugs and complete the
treatment!
*see bigger picture at the last page

SIGNS AND SYMPTOMS

Pulmonary TB is suspected if a person has:
 Cough for 2 weeks or more
With or without:
 fever
 chest and back pain
 poor appetite
 weakness
 weight loss
 night sweats blood in sputum or phlegm
Page 1 of 8
 BURDEN OF TB TB BURDEN IN THE PHILIPPINES, 2007

OUTLINE: • 6 billion of annual income lost due to TB morbidity

• Global Situation • 27 billion pesos lost (foregone wages) annually
• National Situation • 8 billion pesos in actual wages lost
• Local Situation: Region IV-A
NOTE: Economically productive individuals who have the
disease make them unfit to work and must also impose
GLOBAL TB STATUS
themselves to self-quarantine due to the highly
infectiousness/contagiousness nature of TB. This has a very big
impact economically because according to Peabody and
colleagues at least 27 billion pesos is lost annually due to
premature deaths and around 8 billion in actual wages are lost
(due to TB morbidity and mortality).

MAGNITUDE OF TB
• 43 million lives saved between 2000 and 2014
• 3 million people who fall ill with TB still unreached
A Comparison of the (3) National TB Prevalence Surveys
every year

NOTE: Three National TB Prevalence Surveys have been

performed: in 1983, 1997 and last 2007. A comparison among
END TB STRATEGY the 3 surveys was done and the data shows that the prevalence
of smear positive cases per 1000 population decreased from 6.6
cases per 100 populations in 1983 to 2 cases per 1000
population in 2007. But the new cases of MDR-TB slightly
increased from 1997 to 2007 which may pose a threat to the
on-going efforts to control TB.

Region 4A has the highest burden of TB in the country

*see bigger image at the last page

3 Provinces in Region 4A belongs to the
TB BURDEN IN THE PHILIPPINES, 2015 top 10 provinces in the country with
the highest TB burden
• 9th among the 30 TB High burden countries***
• 6th in the MDR-TB high burden countries
Cavite has the highest TB burden in the
• 6th leading cause of Morbidity and Mortality
region!
• 115,000 per year (New ss+ cases)
• 98 Filipinos die daily
NOTE: In the Philippines, we are among the 22 high burden
th nd
countries and is ranked 9 . We are 2 among the Western
th
Pacific countries. TB is also the 6 leading cause of morbidity THE NATIONAL TUBERCULOSIS CONTROL
and mortality according to the 2007 FHSIS data. There are an PROGRAM (NTP)
estimated 115,000 new Sputum smear positive cases per year.
Among those who have the disease, almost 98 Filipinos die
OUTLINE:
daily (this was computed based on the data found in the Global
TB control report of 2009 which states that there are 36,000
• TB in the END TB strategy
recorded TB deaths of all forms last 2007 when divided by 365 • History of TB Control in the Philippines
days gives us 98 deaths due to all forms of TB). • DOTS Strategy
• Commitment for change in NTP
Page 2 of 8
 END TB STRATEGY
NOTE: SUMMARY
VISION: A COUNTRY (PHILIPPINES) FREE FROM TB BASED ON
GLOBAL END TB STRATEGY 5 ELEMENTS OF DOTS

• Political commitment sustained

• Quality-assured TB sputum microscopy is accessible
• Regular and uninterrupted supply of quality assured
drugs
• Treatment under direct supervision of Treatment
Partner or DOT
• Systematic Recording and reporting system

TARGETS FOR FIGHTING TUBERCULOSIS

NTP:
• Detect at least 90% of the estimated all forms of TB
*see bigger image at the last page
cases.
NOTE: One-third of the world’s population or around 2 billion • Achieve more than 90% Treatment Success Rate
are infected with tuberculosis and that 1 in every 10 of those Global:
people will become sick with active TB in his or her lifetime. • Reduce TB Mortality by 95% and incidence rate of
<10/100,000 population by 2035
DOTS STRATEGY 2015 NTP ACCOMPLISHMENT- OUTCOME
WHY D.O.T.S.?
• Direct observed treatment shortcourse ***
• Cost effective
• Proven to reduce morbidity and mortality (e.g. Peru)
• Science and evidence based
• Shortest and most effective chemotherapy we have
• Interrupts TB infection in populations since it treats
as a priority the sputum smear (+) cases
• Can successfully and permanently treat > 90% of
identified TB cases
• Can add years of life to an HIV-positive individual
• DOTS prevents new infections and development of
MDR-TB

FIVE KEY ELEMENTS ARE ESSENTIAL FOR THE DOTS

STRATEGY TO BE SUCCESSFUL: ***
1. Sustained political commitment means to increase
human and financial resources and make TB control a
nationwide activity as part of a national health
system. The government must ensure continuous
monitoring and improvement of the quality of DOTS
implementation.
2. Access to quality-assured TB sputum microscopy for
case detection among people with, or found through
screening to have, symptoms of TB (most importantly
prolonged cough). Special attention is necessary for
case detection among HIV-infected people and other
high-risk groups, e.g. people in institutions. Since
sputum microscopy remains to be the most cost
effective way to detect pulmonary TB, there must be
sufficient number of laboratories to carry out quality
microscopy services.
3. Standardized short-course chemotherapy to all cases
of TB under proper case-management conditions,
including the direct observation of treatment.
4. Uninterrupted supply of high quality drugs with
reliable drug procurement and distribution systems.
TB drugs must always be made available, accessible
and affordable.
5. Recording and reporting system enabling outcome
assessment of each and every patient and
assessment of the overall program performance.
Records and reports are the source of statistics on TB
that are used to guide programs.
NOTE: The 2007 NTPS conclusions on the national TB disease
burden based on data gathered tells us that:
 The burden of TB disease in the country has declined
over the past 10 years since the launching of the
DOTS program.
 There is a significant decline in TB disease
 35.5% decline in sputum smear +
Pulmonary TB
 42.0% decline in sputum culture + PTB
TO PHILIPPINE NTP IN 2016!
 End of Millennium Development goals
 Start of the Sustainable Development Goals
 Start of the new Presidential administration!
2017-2022 NTP NATIONAL STRATEGIC PLANS
1. One national plan but locally adopted
2. Led by DOH with strong Public-Private Sector
Collaboration
3. Active participation of patients and communities
4. Promotion of human rights and equity
5. Efficient resource utilization
COMMITMENT FOR CHANGE 2017-2022

Page 3 of 8
 • The NTP adopted the DOTS strategy in 1996 which is
proven to be the most successful and cost-effective
treatment strategy.
• DOTS strategy focuses on the following operational
targets:
 detect at least 70% of the new smear-positive TB
cases and
 Cure at least 85% of these cases.
• Five key elements that are essential for the DOTS
strategy to be successful: political commitment;
sputum microscopy; directly observed treatment;
uninterrupted supply of drugs; and recording and
reporting
• Since the 100% DOTS coverage of the public sector,
the Philippines has achieved the global MDG targets
for TB prevalence and TB mortality in 2011 and
surpassed these targets since 2008.
• Among the 22 high-burden countries with
Tuberculosis in 2007, the Philippines is within the
“target zone” together with China and Vietnam. This
TRENDS OF CDR, CURE AND TREATMENT SUCCESS, indicates that not only have we achieved the set
2003 – 2008 targets for CDR and TSR, but also surpassed the given
targets.

THE NEED FOR PUBLIC-PRIVATE COLLABORATION

OUTLINE:
• the PPMD strategy
• Structure of PPM DOTS Implementation
• PPMD Installation
• PPMD Accomplishments
• Future direction of PPMD

NTP EXTERNAL EVALUATION

NOTE: This graph shows the trends since the 100% DOTS July 2002 by WHO, JICA, USAID, CIDA-World Vision and
coverage of the public sector of the operational targets namely Medicos del Mundo
the Case Detection Rate (CDR), Cure and Treatment Success Findings:
rate of Tuberculosis from 2003 to 2008.  Acknowledged the remarkable expansion and
For CDR (indicated by blue line), there was an increase from
coverage of public sector DOTS
61% in 2003 to 76 % in 2008.  Need to focus on quality-control as far as DOTS
While for the Cure Rate (indicated by red line), there was an implementation is concerned
increase from 2003 to 2006 then slightly decreased from 2006  Correct some problems in drug supplies
to 2008.  Focus on promoting private-public mix (PPM) in DOTS
The Treatment Success Rate (indicated by green line), shows an
implementation
increasing and high TSR.
From the given data, it shows that we have achieved the Global
targets in CDR and Treatment Success Rate in 2004. WHY ENGAGE THE PRIVATE SECTOR

Treatment outcome (%), 2007 (n=84,715)

Treatment success rate: 90%

NOTE: Data gathered last 2007 for the Treatment Outcome NOTE: This pie chart represents the Action Taking Behavior of
shows in this pie chart that 81% were cured using the DOTS TB Symptomatic in 1997. According to this chart, a large
strategy while 9% completed the chemotherapy which gives a proportion approximately 36% of TB patients seek the care of
total of 90% for the Treatment Success Rate. private MDs followed by those seeking care in health centers.

SUMMARY
• The National Tuberculosis Control Program (NTP) was
established to address the problem of TB in the
Philippines.

Page 4 of 8
 TB CASE LOAD IN THE PRIVATE SECTOR (2000) What are the Objectives of the PPMD?
• Increase case detection and synchronize
management of TB among all health care providers
• Ensure compliance to the National Tuberculosis
Program policies for case finding, case holding,
recording and reporting by all health care providers
What are the Approaches for a PPMD?
 Public-initiated PPMD
 Private-initiated PPMD

A PPM DOTS unit shall implement the NTP in consonance

with its existing operational policies, standards and guidelines.

NOTE: Further evidence of the significant role played by the
private sector is shown in this table which estimates TB drug
sales. Studies have shown private MD tend to over diagnose
and over treat TB patients but that perhaps half of TB patients
default after going through treatment and so for the Philippines
easily we can probably double the figure of 83,000 as far as
private sector is concerned
PPMD ACCOMPLISHMENTS
The total Coordinating structures and PPMD units that have
been established in the country as of 2009 are: 1 NCC, 16
RCCs, and 221 PPMD units with a coverage of 36 million or
around 40% of the total population.

SURVEY OF KAPS OF PRIVATE PRACTITIONERS PPMD Contribution to CDR in Areas Covered (2004 – 2008)

NOTE: This table shows two surveys that were independently

NOTE: Since the implementation of the PPMD strategy from
conducted about the Knowledge, Attitudes, and Practices
2004 to 2008, there has been a significant contribution to the
(KAPs) of Private Physicians regarding Tuberculosis. These
Case Detection Rate (CDR) of TB. This graph basically shows
surveys were conducted by Medicos, which did a telephone
that there is an increase in CDR from 7% in 2004 to 14% last
survey of over 1300 private physicians, and PhilCAT which did a
2008.
more limited study in the NCR and Cavite areas covering 188
MDs.
PPMD Contribution to National CDR (2004 – 2008)
Both studies showed similar findings in that private MDs see an
average of 5-10 new TB patients per month, 88 to 95% use X-
rays and only 17 to 59% use sputum microscopy as a method to
diagnose TB.

Adherence to NTP guidelines ranges from 10.7-16% and

practice treatment variations can be as much as 64 to 80
variations.

NEED FOR PRIVATE SECTOR INVOLVEMENT

• As government reaches almost 100% coverage in the
public sector, it is apparent that global and national
targets of 70% detection rate cannot be reached
without active involvement of the private sector;
• The Philippines has a large private sector (for profit NOTE: This graph shows the PPMD contribution to the National
CDR from 2004 to 2008. There is an increase in CDR as the
and non-profit );
number of installed PPMD units also increases.
• Private sector is a valuable resource available and
widely utilized even by the lower income groups.
Trend of CDR: Public and with PPMD (2004 – 2008)
THE PPMD STRATEGY

What is PPMD?
• PPMD stands for Public-Private Mix DOTS;
• A strategy adopted by the DOH in partnership with
the Philippine Coalition Against Tuberculosis
(PhilCAT) and other various private organizations;
• PPMD is broadly defined as “any initiative or
collaboration involving the public and private sector
working towards TB Control”.

Page 5 of 8
 NOTE: The trend of CDR when combining the public and with
PPMD shows that the PPMD (represented by the red line) by
itself has contributed an additional 6% to the total CDR of the
country last 2008. This illustrates the important role of the
PPMD in the control against TB.

What is the Direction of PPMD in the Country?

• Country wide engagement of health care providers
even the hospitals using the ISTC 2014 and MOP
2013;
• Expand TB services to cover TB in vulnerable
populations like inmates, children & MDR-TB.

NOTE: Through the PCC Core Team and the committees, the
engagement of non-NTP care providers becomes a step-by-step
process. On this diagram, the engagement process is
symbolized by the horizontal arrow pushed forward by steps 1
through 8, with each step mostly prepared and performed by
the core teams.

Step 1: the preparatory visit by central/regional teams, is done

to explore possibility of partnership with LGU to establish
Provincial Coordinating Committee for PPM DOTS.

Step 2 follows, which trains the committees on situational

assessment for their respective provinces—this is in
preparation for PCC members to learn competencies in
NOTE: This slide illustrates the proposed PPMD expansion sites conducting the situational assessment phase, which is step 3 of
shown by the yellow dots while the purple areas represent the this process.
proposed 44 Provincial Coordinating Committee Sites or PCCs
for PPMD which will be discussed next. Once data has been gathered and analyzed, step 4—the
strategic planning workshop—follows. This aims to incorporate
THE PROVINCIAL COORDINATING STRUCTURE FOR what data has been gathered from the situational assessment
PPMD with strategies for the engagement of non-NTP providers.
*launched: December 2009 Next is step 5, which is the DOTS advocacy symposium to
Objectives of the PCC promote awareness on the global, local, and provincial
• General situations on TB control and care. This targets DOTS providers
– Help reduce the prevalence, incidence and and private care providers.
mortality of TB by 50% in 2015 and beyond
Step 5 precedes step 6, which is a DOTS training for referring
50% from a baseline established in 2000 in
physicians and also includes an LOA signing.
support of the Millennium Development
Goals (MDG) for poverty alleviation. Step 7 is the launching of Provincial PPM Initiatives and the
• Specific signing of their respective Memorandums of Understanding.
– Detect an additional 6% of smear (+) TB Lastly would be step 8: the monitoring and evaluation of
cases existing nationwide and maintain a provinces.
treatment success rate of 85%.
Strategy
• Establish a Provincial Coordinating Committee who
will initiate and sustain the engagement of all non-
NTP care providers both in the public and the private
sectors using the International Standards of TB care
(ISTC);
• Link existing DOTS facilities and all care providers to
ensure universal access to quality DOTS services by
all TB patients and
• Generate political commitment towards the
attainment of Millennium Development Goals for TB
control.

NOTE: The Regional Coordinating Committee, in accordance

with NCC directions, policies, and standards, oversees the
establishment of the PCC, providing technical advice to the PCC
as necessary in conduct of their functions and plans, along with
enforcing the policies, guidelines, and standards set in their
respective regions while ensuring that these are consistent with
the direction, strategy, and policies of the NTP DOTS. This is
illustrated in the diagram shown.

Page 6 of 8
 Reasons why HOSPITALS should be involved in TB control
efforts

• TB is a major public health problem in the

Philippines.
• Hospitals are major providers of TB care.
• However, majority of TB cases seen by hospitals are
NOT managed according to national policies and
ISTC.
• The hospitals’ mission is to provide quality in-patient
and out-patient care.
• TB patients will greatly benefit from hospital
involvement in TB control.
It is needed to sustain the Private sectors’ contribution from
Private hospitals!

Why the Update?

NOTE: The PCC is comprised of a chair- an LGU representative
 Policy issuances of WHO &
who is also the province’s PHO, co-chaired by the province’s
ISTC
private health sector representative. On one hand, the chair
leads in identifying, targeting, and engaging all public health • Expanded participation of
practitioners in the province, while on the other hand, the co- non-NTP facilities (PPMDs,
chair does the same with the target focused on soliciting hospitals (government &
commitment from the private health services, NGOs targeting private), clinics, prisons &
vulnerable sectors as beneficiaries, medical schools, jails)
pharmacies, practitioners of traditional/alternative medicines,  New initiatives such as
and other organizations that can help in attaining the over-all intensified case finding
goal and purpose of the NTP. Both share equal status and are
and infection control
supported by a vice-chair, who is elected by, and from among,
 Roll-out of rapid diagnostic tools
the representatives of the national governments, a secretariat
made up of the NTP provincial team from one’s PHO, and a  Updated Philippine Plan of Action to Control
secretary—who is the provincial NTP medical coordinator. Tuberculosis (PhilPACT) 2010-2016

Key Challenges:
• Innovate to solve the problem
NOTE: The PCC has three principal functions to be able to
• Develop a roadmap toward sustainability of private
achieve the project’s goals.
sector’s engagement
Primarily, the PCC engages all non-NTP care providers in the • Embrace and scale up new technologies, medicines
province, both public and private using the International and approaches
Standards of TB Care by developing a plan for the engagement • Act on the new TB law ( Republic Act No. 10767-
of all non-NTP care providers and monitor this. The PCC also Comprehensive TB elimination Act of 2016)
reports on the non-NTP care providers engaged and address
issues related to sustaining the said engagement.
Expected Changes No. 2
The PCC will also provide all TB patients access to quality TB
care by linking existing DOTS facilities and all care providers by
developing strategies to provide vulnerable and special
population groups, like indigenous people and prisoners, to
access quality TB care and its monitoring. The Committee also
ensures the availability of laboratory supplies and anti-TB
drugs—and ensures the overall quality of DOTS services
provided.

Also, the PCC generates political commitment to sustain PPM

initiative beyond the project life by developing a PPM
sustainability plan and the mobilization of resources from
private and public sectors as well as the community and the
monitoring of sustainability direction.

Page 7 of 8
Expected changes No. 4 END OF TRANSCRIPTION

“In the end, we only regret the chances we didn’t take.”

Transcription Team 2019

Transcribed by: Heidi Cruz

References: Dra. Dalay’s PPT used

during the symposium

Remarks: Lahat ng may “***”,

natanong sa past
evaluations. Study
well! God Bless <3 

Page 8 of 8