1. ADDRESSING MDR-TB: The PHILIPPINE EXPERIENCE
For the APEC Conference on
Prevention, Control and Care of MDR-TB
And Supply of 2nd Line Anti-TB Drugs
Taiwan, June 29, 2016
ROSALIND G. VIANZON, MD, MPH
Division Chief, IDPCD
Disease Prevention and Control Bureau
Department of Health
Philippines

2. Philippines 2014 - Impact Indicators
Incidence
Prevalence
Mortality
288/100,000
290,000 Filipinos
417/100,000
410,000 Filipinos
10/100,000
10,000 Filipinos

3. 30 countries with High TB Burden
Each list contains 30 countries (top 20 in terms of absolute numbers of cases plus 10 countries with the most severe burden in terms of case rates per capita (not part of top 20) and meet minimum threshold of absolute numbers of cases ( per year for TB, and 1000 per year for TB/HIV and MDR-TB).
Each list accounts for 85–89% of the global burden.

4. Global Burden of MDR-TB
Est. Deaths from MDR-TB
190,000
>50% Missing DR-TB Cases
Treatment Success Rate
50%

5. Global Burden of MDR-TB
Estimated MDR-TB Cases
New TB Cases: 3.3%
Previously Treated TB Cases: 20%
Estimated New MDR-TB Cases Worldwide
480,000
Mortality
190,000
Estimated MDR-TB Cases among Notified TB Cases
300,000
RR/MDR-TB Notified
123,000 (41%)
RR/MDR-TB Enrolled
111,000
Treatment Success Rate
50%
Source: WHO Global TB Report 2015

6. How Big is the MDR TB Burden in the Philippines?
Drug Resistance Survey
% of Notified Cases with MDR-TB
2004
2012
Among New TB cases 4% 2%
Among Re-treatment TB cases
21%

7. How Big is the MDR TB Burden?
Drug Resistance Survey
% of Notified Cases with MDR-TB
2004
2012
Among New TB cases 4% 2%
Among Re-treatment TB cases
21%
2015 notified New TB cases
2015 notified Re-treatment TB cases
28,404
5,419
5,965

8. How Big is the MDR TB Burden?
Drug Resistance Survey
% of Notified Cases with MDR-TB
2004
2012
Among New TB cases 4% 2%
Among Re-treatment TB cases
21%
2015 notified
New TB cases
2015 notified
Re-treatment TB cases
11,384
MDR-TB
28,404
5,419
5,965

9. National TB Control Program
Case detection rate: > 90%
Success rate: > 90%
Localized implementation of TB
Monitor health system performance
Engage both public & private health care providers
Promote and strengthen positive behavior of the community
Secure adequate funding and improve
allocation and efficiency of fund utilization
Certify and accredit TB care providers
Regulate and make available quality TB diagnostic tests and drugs
Address MDR-TB, TB/HIV, and needs of
vulnerable population
Detect and Treat 19,500 MDR-TB Cases ( )
MDR-TB Notification of 62%
Treatment Success of 75%
2010 – 2016 Philippine Plan of Action to Control Tuberculosis. Department of Health, Philippines

10. PhilPACT Objectives Strategies
Reduce local variation in TB control program performance
Localize implementation of TB control
Monitor health system performance
Scale up and sustain coverage of DOTS implementation
3. Engage both public and private health care
providers
Promote and strengthen positive
behaviour of the communities
Address MDR-TB, TB/HIV, and needs of
vulnerable population
Ensure provision of quality TB services
Regulate and make available quality TB
diagnostic tests and drugs
7. Certify and accredit TB care providers
Reduce out-of-pocket expenses related to TB care
Secure adequate funding and improve
allocation and efficiency of fund utilization

11. Trend of Enrollment and Treatment Success Rates
9-MTR OR
ETAP
Food Pckg
NTPMO
iDOTS
ComPCare
MAIP
Xpert MTB/RIF test
TSR 41%
TSR 49%
SRDR
TSR 46%
Started in the private sector in NCR
Expansion outside NCR
TSR 64%
TSR 57%
In 1999, a non-government organization (Tropical Disease Foundation), started providing diagnostic and treatment services to DR-TB patients. This was continued through a Green Light Commitee-approved DOTS-Plus Pilot Project. In 2003, the Global Fund to Fight against AIDS, Tuberculosis and Malaria initiated giving financial support to the country to expand services to DR-TB patients. In 2007, there were 3 PMDT treatment facilities, all located in the National Capital Region. 
In 2008, the number of DR-TB cases increased as compared to the previous years. This may be attributed to the expansion  of DR-TB services.  A PMDT treatment facility (Eversley Childs Sanitarium Treatment Center, Cebu) outside the National Capital Region was established. In the same year, the Department of Health (DOH) issued Administrative Order "Guidelines for the Implementation of the Programmatic Management of Drug Resistant Tuberculosis (PMDT). This paved the way for mainstreaming PMDT to other regions of the country. Treatment Success Rate was 64%.
In 2009, the treatment success rate was 57%. 
In 2010, there were more DR-TB cases and again, the increased in enrollment was mainly due to continuous expansion of DR-TB services. In April, 2010, PMDT management was transferred from a private sector to a government institution (Lung Center of the Philippines). Treatment regimen was revised from individualized to standardized treatment regimen (Standard Regimen Drug Resistant/SRDR). TSR was low at 46% due to increase in the lost to follow-up rate.
In 2011, there was a dramatic increased in the number of enrolled DR-TB but the TSR was only 41%. In the last quarter of 2011, rapid molecular diagnostic tool (Xpert MTB/RIF test) was adopted by the program initially to 16 sites.
There was an improvement of the TSR in 2012 but still below the global TSR of 50%.
Various initiatives were introduced and implemented to overcome the challenge of poor treatment success rate due to increase in the lost to follow-up such as the Milestone Achievement Incentive Package (MAIP) in 2013 wherein, enrolled DR-TB patients were provided financial support (total amount of P20,000) for good compliance to treatment. 
In 2014, integration of PMDT services into the basic DOTS services of health facilities with community based PMDT care was piloted in the National Capital Region. In the same year, PMDT has been integrated within the NTP at the national, regional and provincial/city levels and services have been expanded to all the 18 regions of the country.
In 2015, together with partners, initiated the 9-month treatment regimen operational research in selected PMDT treatment facilities. This aims to test the country-specific operational feasibility, and to measure the effectiveness and safety of a shorter, 9-month MDT-TB regimen in the Philippines. Other initiatives to ensure treatment compliance of DR-TB patients are:
Enhance Treatment Allowance Package (ETAP) – this is basically enhancing the financial scheme being provided by increasing the amount from P75.00 to P and is being done on a front-loading scheme to avoid out-of-pocket expense from the patients.
Food package – on top of the treatment allowance, the program is also providing food package worth P100.00

12. Cascade for PMDT Care
88% of identified has been enrolled – 578 not enrolled
For every 15 tested, 1 positive

13. Trend of Treatment Outcome of Patients under PMDT, 1999 to 2012

14. Analyzing Case Notification
PhilPACT Target: 62%
No access to health care
Access to health facilities, but don't go
Undiagnosed cases
Presenting to health facilities, but undiagnosed
All TB cases
Diagnosed by public or private providers, but not notified
Systematic screening for active TB is predominantly provider-initiated. It may target people who do not seek health care because they do not have or
recognize symptoms, because they do not perceive that they have a health problem that warrants medical attention, because there are barriers to
accessing care, or for other reasons. It may also target people seeking health care who do or do not have symptoms or signs compatible with TB and who
may not be identified by “passive case-finding” as possibly having TB.
People seeking care who may be eligible for TB screening include people with medical conditions that constitute risk factors for TB (such as people living
with HIV and people with diabetes mellitus) who may seek care for reasons other than symptoms compatible with TB
Poor or no access to health care – delay in diagnosing TB and initiating appropriate treatment
Increse sensitivity of current case-finding approach by expanding current definition of TB symptomatics from 2 wks symtoms to any period of symptoms and signs, and we would like to see how many additional TB cases are idendified and see if this new approach is cost effective, affordable, acceptable and feasible and to get more beneficial than doing harm such as putting false positives on unnessary treatment. (potential benefits and harms of screening)
Target three different groups of people (missed, delayed or problems with access to high-quality care)
Who seek health care with or without symptoms and signs compatible with TB
Who do not seek care because they do not perceive that they have a health problem that warrents medical attention
Who do not seek care because barriers such as financial/geographicial or cultureal barries, which make it difficult to access health care
- Barriers to early case detection may occur at each step, and the poorest people are at highest risk of not completing, or delaying, each step.
They have the least access to high-quality services, and face the highest costs from illness and for health care.24 Screening groups who have limited access
to health care may help reduce delays. However, other interventions to improve health-seeking and access may be equally or more relevant and cost effective, depending on the local situation.
Diagnosed but not notified cases
Diagnosed by NTP
or collaborating providers
Recorded in NTP notification data
Notified cases

15. Findings (Joint Program Review March 2016)
Implementation and scaling-up of PMDT depends heavily on external funding and project-hired staff
Gap between diagnosis v.s. notified v.s. treatment cohorts are wide
Low Treatment Success on MDRTB is due to High Lost to follow-up
Current regimen for pre-XDR-TB and XDR-TB do not include new anti-TB drugs
(Bedaquiline and Delamanid)

16. Burdens of MDR-TB On Service Delivery:
- Complexity on the needed preparations and high cost of expanding PMDT services
- Limiting the capacity of DOTS facilities; capable only for basic TB services
On Health Systems:
- More expensive
- More workload for the health workforce

17. Burdens of MDR-TB On Patients: - Onset of ADRs
- Long treatment duration
- Absence from work
- Far from the family

18. Tropical Disease Foundation
Most frequent self-reported reasons for stopping treatment among LTFU patients (based on qualitative analysis) Tupasi, et. al, LTFU Study 2014
Tropical Disease Foundation

19. NTP’s Actions to “Unburden” MDR-TB
Pillar 1: Integrated, Patient-Centered
Care and Prevention
Service Delivery :
Expand PMDT services: i-DOTS with CompCare
Decentralize services -closer to patients and family
- Lessen travel time; no need for re-location
Strengthen capability of HCWs; upgraded facilities
Provide Nurses “AIDERs” based at GIDA areas
Patient Support Group (KAP) per Satellite/Tx Center
Use RMDT (Xpert MTB/RIF test); includes Sm-CXR+
Conduct Contact Tracing strategies
Offer PICT to enrolled DR-TB patients 15y/o &above

20. Integrated DOTS (i-DOTS)
Hospital: DOTS Center
Identification & referral of presumptive DR-TB
DSSM
RHU: DOTS Center
Identification & referral of presumptive DR-TB
DSSM
Treatment: continuation
RHU: iDOTS Center
Screening & sputum collection
DSSM
Treatment: initiation, intensive, continuation, post
RHU: DOTS Center
Identification & referral of presumptive DR-TB
DSSM
Treatment: continuation
RHU: iDOTS Center
Screening & sputum collection
DSSM
Treatment: initiation, intensive, continuation, post
RHU: DOTS Center
Identification & referral of presumptive DR-TB
DSSM
Treatment: continuation
RHU: PMDT STC
Screening & sputum collection
DSSM & GX
Treatment: initiation, intensive, continuation, post
RHU: DOTS Center
Identification & referral of presumptive DR-TB
DSSM
Treatment: continuation
Hospital: Laboratory
DSSM GX
TBC and DST
Hospital: PMDT TC
Screening & sputum collection
Treatment: initiation, intensive, continuation, post

21. Community – Based DOT for PMDT Community Treatment Partners
Key Components
iDOTS FACILITY
Community Treatment Partners
i-DOTS Staff
DR – TB Patient

22. NTP’s Actions to “Unburden” PMDT
Pillar 2: Bold Policies and Supportive Systems
Needed Resources (Human and Monetary)
TB Law RA.10767”Comprehensive Tuberculosis Elimination Plan Act”
- mandatory reporting of TB cases
PMDT sub-plan under the NSP (PhilPACT)
Includes workforce-specific needs, budget, fund source
Private Sector support – PMDT policies in CPGs of MDs
Decentralized TB services to reduce costs (already in 18 reg)
Priority on available domestic funds for sustainable services
Initiative to advocate with new National Leadership to expand current insurance financing scheme (TB OPB Pckge)

23. NTP’s Actions to “Unburden” PMDT
Pillar 2: Bold Policies and Supportive Systems
DOMESTIC (GOVERNMENT)
EXTERNAL RESOURCE (GFATM)
Consumables Needed;
Microscopy supplies, CXR films,
Xpert cartridges
Equipment needed:
Microscopes, some CXR machines
Xpert units
First line anti-TB drugs;
IPT for Children and PLHIVs
Second-line anti-TB drugs;
Ancillary drugs
Entire drug chain processes
Mainly on procurement; partly on distribution/delivery to periphery
60-70% of Program budget on logistics (primarily drugs)
70-75% of Project budget on PMDT implementation
NTP - biggest budget amongst the Infectious Disease Programs
GF-TB Project has the biggest budget amongst the 3 GF Projects

24. NTP’s Actions to “Unburden” PMDT
Pillar 3: Intensified Research and Innovation
Patient Condition
Conduct researches to address patient issues:
- Long treatment duration (e.g. 9-MTR)
- ADRs (e.g. new treatment regimens?)
Assess/Evaluate incentives
- Milestone Incentive Package

25. Basic Lessons Learnt Prevent DR-TB generation Sustain GOOD basic DOTS
Prevent DR-TB transmission
Expand to
Patient-centered DOTS

26. Let us all support the NTP; Let’s contribute to the economy!
TB/DR-TB is a socio economic disease.
It contributes to the country’s economic burden
It affects the economically-productive age group;
Our economic workforce.
A well-planned and effective
National TB Program, the NTP,
can help sustain the growing economy
of the country.
Let us all support the NTP;
Let’s contribute to the economy!

27. Thank You…