1. Programmatic Management of Drug-resistant TB (PMDT) in the Philippines
DR. IRMA ASUNCION
National Center for Disease Prevention and Control
Department of Health 1

2. Outline Latest estimates on MDR-TB burden Background on PMDT
Program Performance
Case Finding/Case Holding Strategy on PMDT
Plans/Challenges 2

3. Latest Global TB estimates - 2012
Magnitude:
Latest Global TB estimates
Estimated no. of cases
Estimated no. of deaths
In 2012, 8.6 M developed TB, 1.3 M died ( incl. 320,000 deaths among HIV +)
Without treatment, 70% die within 10 years among sm +, HIV -; % die within 10 years among culture +, sm -
Treatment success rate for all new smear + and all new TB cases in 2011 was 87%
530,000 TB cases among <15 y/o with 75,000 deaths among HIV -
13% or 1.1 M who dev TB were HIV + (75% of which were in the African region)
6.1 M cases notified of which 5.7 M were newly diagnosed and 0.4 M were prev diagnosed TB patients
Of the 2.9 M missed cases, 75% were in 12 countries: India (31%), South Africa, Bangladesh, Pakistan, Indonesia, china, democratic republic of Congo, Mozambique, Nigeria, Ethiopia, Philippines, Myanmar
405,000 dev MDRTB with 170,000 deaths; 9.6% of MDRTB have XDRTB; 48% success rate among MDRTB
92 countries have reported XDRTB: 94,000 notified globally but only 77,000 (82%) were started on treatment
Overall TSR is 48% but 34/107 countries have already reached the 2015 goal of 75%
All forms of TB Greatest number of cases in Asia; greatest rates per capita in Africa
8.6 million
1.3 million
Multidrug-resistant
TB (MDR-TB)
~450,000
~170,000
Extensively drug- resistant TB (XDR-TB)
~ 50,000
~ 30,000 3

4. 7,100
islands 99
million 17
geographic regions 4

5. Formulate policies and guidelines Provide technical assistance
DOH – NCDPC (NTP)
Formulate policies and guidelines
Provide technical assistance
Provide drugs/laboratory supplies
Monitor and evaluate implementation
17 Centers for
Health Development
Monitor and supervise implementation
Distribute drugs/supplies to the city/mun
QA Centers
80 Provincial/129 City
Health Offices
Manage TB patients
Store anti TB drugs
Microscopy services
3,074 Rural Health Units
(DOTS Facilities)
16,038 Barangay
Health Stations
Identify TB symptomatics
Do DOT 5

6. Vision MDGoals TB FREE Philippines 2015 2050 2010 2020 2030 2040
1 active case/1M population
MDGoals
2010
2015
2020
2030
2040
2050
Prevalence rate: 500/100,000 (2012: 450)
Death rate: 29/100,000 (2012: 23)
CDR: 84 (2012) Treatment Success Rate 2011: 90 6

7. Mission Program Targets
Ensure that TB DOTS services are available, accessible, and affordable to the communities in collaboration with the LGUs and other partners
Program Targets
Treatment Success of at least 90%
Case Detection Rate of All Forms of TB at least 90% 7

8. Prevalence and Mortality Rates from Tuberculosis, Philippines, 1990 - 2015 (per 100,000 population)
(SOURCE: WHO Global Tuberculosis Control )
This is where
we are
500
450 29 23 29 8

9. Trends of CDR, Cure and Treatment Success
90%
83%
84% 9

10. Number of Cases Detected vs. Estimated Number of All Forms of TB
64,440 missing cases 10

11. CDR and Treatment Success Rate, Philippines11

12. Current Status: Philippines
7th among the 22 high TB burdened countries (HBCs) worldwide (with high number of All Forms of TB) – Global TB Control Report 2013
One of the 27 high MDR-TB burden countries – Global TB Control Report 2013
TB is 6th in mortality and 8th in morbidity – FHSIS Report 2010 12

13. Estimated Proportion of TB Cases that Have MDR - TB
Estimated % of New TB cases with MDR – TB
Estimated % of Retreatment TB cases with MDR – TB
Global
3.6
20.2
Western Pacific Region (WPR)
4.7 22
High
MDR – TB Burden Countries
4.2 21
Philippines
4.0 13
Global tuberculosis control: WHO report 2013

14. Priority countries in the Western Pacific Region
High-burden countries
China
Philippines
Viet Nam
Cambodia
Lao PDR
Mongolia
PNG
22 HBCs: Afghanistan, Bangladesh, Brazil, Cambodia, china, democratic republic of Congo, Ethiopia, India, Indonesia,Kenya, Mozambique, Myanmar, Nigeria, Pakistan, Philippines, Russian federation, South Africa,Thailand, Uganda, united republic of Tanzania, Vietnam, Zimbabwe
Top 10: 1. India 2. china 3. South Africa 4. Indonesia 5. Pakistan
6. Bangladesh 7. Philippines 8. Ethiopia 9. dem. rep. Of Congo
10. Myanmar
Intermediate- burden countries
Brunei
Hong Kong (China)
Japan
Macau (China)
Malaysia
Republic of Korea
Singapore 14

15. Estimated MDRTB burden 201215

16. Treatment Failure* Rate (Smear +) DOTS Center at MMC
The beginning…..1999
Start of management of drug resistant TB in a private DOTS clinic- Makati Medical Center through the Tropical Disease Foundation (TDF) and was the 1st GLC approved pilot project worldwide
Treatment Failure* Rate (Smear +) DOTS Center at MMC
This was in 1999 and support were from
Private PPMD
Year
Among NEW
(%)
Among Re- Treatment (%)
1999
22.2
2000
4.3
6.7
2001
2002
15.4
2003
14.3
* All turned out to be MDR-TB 16

17. Phases of Implementation
# of patients
Geographical coverage
Support
1999
Pilot Phase 7
200 (165)
Metro Manila - Makati Medical Center DOTS Clinic
NGOs, GOP, PTSI
Global Fund
Expansion Phase
500
Metro Manila – FBOs, NGOs, DOTS facilities, satellite TCs
Mainstreaming
2500
Metro Manila, 1 region in the south
Scale up Phase
19,500
Nationwide
Global Fund, GOP 17

18. Source of DR-TB Suspect Referrals Screened at selected PMDT TC, 2011 (n=1788)
Based from 2011 TB Symptomatics Masterlist of CHD 1, 4A, 7, 6, 9, 11, 12 & CAR 18

19. Case Finding Strategy TC or STC
Govt. DOTS facilities
Pvt. facilities/ referring health providers
Hospitals
TC or STC
Quality Assured Laboratory
Confirmed DR-TB
Identification and referral of suspects
Category IV treatment
DSSM, TB Culture, DST
Screening, assessment, sputum collection 19

20. Case Holding Strategy
Strict DOT for the entire course of treatment (18 – 24 months)
Default Tracing
Decentralization to local health facilities
Management of adverse drug reactions and other co-morbidities
Monthly monitoring of treatment
DSSM monthly
TB Culture monthly during intensive phase then every 2 months
CXR & Blood Chemistry every 6 months
Special diagnostics
Other TC Interventions
Psychosocial activities/GA
Enabler Support 20

21. PMDT Facilities Treatment Centers Satellite Treatment Centers
Stand alone PMDT specific treatment facilities, attached and networked to DOTS facilities catering to patients within a region
Satellite Treatment Centers
DOTS facilities where PMDT services are available catering to the catchment area of the facility
Treatment Sites
PMDT trained DOTS facilities, recognizes and refers presumptive DRTB patients, continuation of patient’s treatment upon decentralization 21

22. Satellite Treatment Center
Region
Treatment Center
Satellite Treatment Center
NCR
1.KASAKA – QI
2.LCP – NCPR DOTS clinic
3.DJNRMH –TALA PPMD
4.PTSI – Tayuman PPMD
5.San Lazaro Hospital DOTS Clinic
Lagrosa DOTS clinic, Pasay City
Gat Andres MMH , Tondo, Mla
Tondo foreshore , Tondo Mla
Moonwalk ,DOTS clinic Paranaque City
Super Batasan, QC
Grace Park DOTS clinic , Caloocan
Lacson DOTS Clinic, Mla.
QC BJMP DOTS clinic ,QC 7
Eversley Child’s DOTS clinic
Vicente Sotto Med.Center, Cebu City 1
Ilocos Training Regl Medical Center
Region 1 Medical Center,Pangasinan 4A
1.De La Salle Health Sciences Inc
2.Batangas Regional Hospital
Cainta PPMD, Gumaca District PPMD Los Banos DOTS Clinic, Laguna 4B
Ospital ng Palawan DOTS clinic 5
SMMGHHC
Bicol Medical Center 10
German Doctors , XU-Community
Iligan Specialty Internist , PPMD 11
Davao Southern Phil. Medical Center
Davao Regional Hospital ,Tagum City
Location of PMDT Facility 22

23. Satellite Treatment Center
Location of PMDT Facility
Region
Treatment Center
Satellite Treatment Center 6
Western Visayas Medical Center
Don Pablo O Torres Medical Hospital
(Riverside PPMD DOTS clinic)
Roxas CHO 8
Schistosomiasis General Hospital 9
Zambo. City and Medical Center
Dr. Jose Rizal Mem Hospital,
Dapitan City 12
Koronadal CHO PPMD
Cotabato Regional and Medical
Center DOTS clinic
CAR
Baguio General Hospital & Medical
Center 2
Cagayan Valley Regional Hospital
CARAGA
CARAGA PPMD DOTS
Total 20 23

24. 16 GeneXpert Center (3 TBC/DST; 10 TBC; 3 PMDT facility)
REgion
GX center
Facility description
Date of Operation
NCR
National TB Reference Laboratory (2 units)
Culture/DST center
September 2011
Lung Center of the Phil (2 units)
October 2011 1
ITRMC
Culture center 9
Zamboanga City Medical Center 5
SMMGH
(private facility) 4A
Dela Salle Health Sciences Institute 6
Western Visayas Medical center
November 2011 7
Cebu Reference Laboratory
December 2011 24

25. REgion GX center Facility description
Date of Operation 10
XU-CHCC (German Doctors)
Culture Center
(private)
December 2011 11
Davao TB reference lab 12
Koronadal CHO PPMD
PMDT Treatment Center
CAR
Baguio General and Medical Center
NCR
PTSI-QI Laboratory(2 units)
Dr. Jose N. Rodriguez Memorial Hospital
CARAGA
Caraga Regional Hospital
San Lazaro Hospital
October 2012 25

26. Examples of PMDT Treatment Centers
Private facility
Public PPMD in a regional hospital
Public PPMD in a DOH-retained hospital
Lung Center of the Phils.-PHDU, QC (2005)
KASAKA-QI MDR-TB
Housing Facility, QC (2004)
Dr. Jose N. Rodriguez
DOTS Center, Caloocan
City (Mar 2008)
Private PPMD
Private Hospital
Gov’t PPMD: regional hosp
Eversley-Childs Sanitarium PMDT TC the South
Mandaue, Cebu (Sept 2008)
SMMGHHSC
Sorsogon (July 2009)
PTSI-Tayuman,
Manila (Sept 2008) 26

27. Examples of Satellite Treatment Centers
Roxas City CHO
Bicol Medical Center
Lob Baños RHU
Gumaca District Hospital 27

28. Examples of Treatment Sites
Public DOTS Facility
Private DOTS Facility (PPMD) 28

29. Expansion of PMDT Services
LUZON
Region TC
STC GX 1 2
CAR 3
NCR 5 11 4A 4B
VISAYAS
Region TC
STC GX 6 2 1 7 8
MINDANAO
Region TC
STC GX 9 1 10 11 12 2
CARAGA
ARMM *
2007 = 3 facilities
2009 = 10 facilities
2011 = 25 facilities
2013 = 44 treatment facilities 29

30. DOTSFacilities as PMDT Treatment Sites (Partial ,as of January 2013)
NCR
CAR 1 3 4A 4B 5 6 7 8 10 11 12
CARAGA
TOTAL
RHU
LGU
479 23 71
138 36 52 4 20 30
887
Hospital 22 2 29
Jail 17
Other private
513 24
142 37 16 57 34
940 30

31. GeneXpert equipment 31

32. Enrollment of DRTB patients
Trend of MDRTB cases from 1999
470% increase noted in 2000 to 2001
350% increase noted in 2003 to 2004
195% increase noted in 2010 to 2011, the time when the cases totaled more than a thousand
As of July 1, 2013 32

33. Enrollment of DRTB Patients33

34. Treatment Success Rate per Year 1999 to 200934

35. MDG: To reduce prevalence and mortality by half by the year 2015
PMDT 35

36. Trainings of different health workers on PMDT
Administrative
Order No, : Guidelines for the Implementation of Programmatic Management of Drug-resistant TB signed by the Secretary of Health
Trainings of different health workers on PMDT 36

37. 2010 – 2016 Enhanced Philippine Plan of Action to Control Tuberculosis (PhilPACT)
Reduce local variations in TB Control Program performance (Governance)
Scale-up and sustain coverage of DOTS implementation (Service delivery, Health Info, Human Resource)
Ensure provision of quality TB services (Regulation)
Reduce out-of-pocket expenses related to TB care (Financing) 37

38. 8 Strategies of PhilPACT
Localize implementation of TB control
Monitor health system performance
Engage all health care providers
Promote and strengthen positive behavior of communities
Address MDR-TB, TB-HIV and needs of vulnerable populations
Regulate and make available quality TB diagnostic tests and drugs
Certify and accredit TB care providers and facilities
Secure adequate funding to improve allocation and fund utilization 38

39. STRATEGY 5. Address MDRTB, TB-HIV and needs of vulnerable populations
Performance Targets
5.1) A total of 19,500 MDR TB cases have been detected and provided with quality assured second-line anti-TB drugs
5.2) At least 75% of enrolled MDR TB patients are successfully treated 39

40. PMDT Subplan of the PhilPACT
Integration of PMDT services in Basic DOTS Services of Health Facilities
Building the capacity and capability of Basic DOTS facilities to provide quality PMDT services
Empowerment of the Patient and support groups
Enhancing PMDT management
Support systems strengthening
Operations researches and studies
Resource mobilization 40

41. Today 3 DST Centers 18 Culture Centers 44 TCs and STCs 887 HCs
For the structures, a total of 11 treatment centers have been established and more treatment sites have been involved in the decentralization of patients.
2,565 labs
1 lab with line probe assay 41

42. 2016 7 DST Centers 29 Culture Centers 100 STCs centers
All HCs are ready
By 2015, a cumulative number of 15,000 MDR-TB patients will detected and provided with SLDs
35 treatment centers have been established
37 Culture centers culture centers and
5 DST centers.
By this time, all Treatment sites will be ready to accept decentralized patients 42

43. PMDT Challenges Challenge Addressing the challenge
Cost and Sustainability
High cost of quality second line anti-TB drugs
High cost of laboratory needs and infrastucture
Estimated cost of Php 200k – 280k per patient put on MDRTB treatment for months treatment
Almost all MDRTB funds are GFATM sourced
Global Fund Presence until because of the “New Funding Model” $75M for to 2016
DOH to ensure sustainability of PMDT beyond 2016
Philhealth currently developing DRTB package
Expansion and inclusion of PMDT in DOTS facilities
Advocating for LGU support for indigent patients 43

44. PMDT Challenges Accessibility Challenge Addressing the challenge
44 facilities across 16 of the 17 regions
99 M population, estimated MDRTB patients
Provinces still without access to PMDT
Implementation of the PMDT scale-up and expansion plan
Continuous advocacy and expansion to all CHD’s and potential treatment facilities
PMDT expansion to every province, 2 or more facilities in big provinces
PMDT services to be available in all cities of the national capital region
Continuous training for all CHD’s for capacity building
Roll-out of GeneXpert facilities 44

45. PMDT Challenges Challenge Addressing the challenge
Decreased MDRTB enrollment and increasing burden
Non adherence to DOH approved treatment guidelines and regimens
Poor referrals from private practitioners
Not all health workers are oriented on MDRTB
Poor health seeking behavior
Revised NTP-MOP
Enhanced PhilPACT
Rollout of TB/HIV strategic plan and AO
All HIV+ to be screened for DRTB
All DRTB for Provider Initiated Counseling and Testing
Intensifying Contact Tracing not just to include household
Establishment of PMDT services in Jails and Prisons
Private physician advocacy and involvement 45

46. PMDT Challenges Difficulty to treat patients Challenge
Addressing the challenge
Difficulty to treat patients
18 to 24 months treatment
ADR’s from second line drugs
High defaulter rate
Competing priorities to treatment (work, finances, etc.)
Decentralization of PMDT services and expansion
Introduction of the 9 month regimen
Introduction of new available drugs - Bedaquiline
Enabler and psychosocial support
Default tracing mechanisms
LGU financial support for indigent patients 46

47. PMDT Challenges Awareness of MDRTB Challenge Addressing the challenge
Self medication
Improper treatment of MDRTB
Private practitioners treating DRTB suspects
Stigma of MDRTB patients
Revision of MOP, PMDT Training Manuals
PhilPACT Revision and Dissemination
Continued training to all NTP service providers
Advertisements and educational references (ACSM) 47

48. Thank you for your attention....48