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TB: The battle goes on

For a TB-free future: Dr. Ana Marie Garfin, DOH national TB control program manager; Dr. Jose Morfe, national chairman of the Philippine Coalition Against Tuberculosis (PhilCAT); Dr. Vivian Lofranco, PhilCAT overall chair for World TB Day 2015; and Ma. Cristina Brigaste, TB survivor and president of patient group Samahan ng Lusog Baga, lead the observance of World TB Day in the country.

You probably think that tuberculosis (TB) is a thing of the past. That in this day and age, nobody dies of TB anymore, as Manuel Quezon, the second president of the Philippines did in 1944. The grim news is, TB “remains to be a serious health concern all over the world.” So serious that the World Health Organization (WHO) has included it in the list of major diseases that it hopes to eradicate as part of its Millennium Development Goals for 2015.

The chilling truth is that TB ranks as the sixth leading cause of death in the Philippines, based on the Philippine Health Statistics of 2009, and counts as the eighth leading cause of illness as of 2010. A cause for concern is that the Philippines is eighth among the 22 high-burdened countries in the world in terms of number of TB cases.

Thus, the battle vs. TB rages on. The government continues its relentless drive to educate Filipinos about TB and, most importantly, encourages those stricken with the disease to get treatment which is now readily available and effective, provided the procedures are properly observed. It is spot on with its DOTS (directly observed treatment, short-course) TB control strategy recommended by WHO.

With the battle cry “Stop TB,” and the significant decrease of TB incidence in the country, we hope to help in winning this global war versus TB. Last March 23, to observe World TB Day, various sectors of society and the healthcare industry gathered to throw their support behind the Department of Health’s TB advocacy.  

 “The success of the DOTS program depends largely not just on the efforts of the government in terms of disease monitoring, but also on vigilance and support from doctors and healthcare professionals, from the patients themselves and most especially from the private sector,” said Dr. Jose Hesron D. Morfe, national chairman of the Philippine Coalition Against Tuberculosis (PhilCAT).

This year’s campaign, dubbed “Stop TB: Hanapin, Gamutin, Pagalingin,” highlights the strategy of the DOTS method in ensuring “an effective and holistic battleplan against the disease — from diagnosis and proper treatment to availability of drugs, as well as monitoring and assessment of treatment results.”

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Joining PhilCAT are patient group Samahan ng Lusog Baga and global research-based pharmaceutical company Pfizer. “Pfizer is committed to continuously innovating healthcare solutions through research and development, and making these accessible to more Filipinos,” remarked corporate affairs director Gerrard Anthony Paez.

“With continued support, we are on track in helping the government meet or even exceed the WHO Millennium Development Goal of eradicating tuberculosis as one of the important global health concerns,” Dr. Morfe stressed.

Excerpts from The Philippine STAR interview with Dr. Morfe:

PHILIPPINE STAR: Mere mention of TB is enough to make us shrink in fear. How much of a dreaded communicable disease is TB today?

DR. JOSE HESRON D. MORFE: Actually, a lot of people do not want to be diagnosed with TB because it has a lot of implications in the sense that persons with TB are not eligible for employment because they are likely to transmit the disease to co-workers, for example. So the thing about TB is that, it does not only involve the single individual but usually the entire household. Thirty to 40 percent of the time when a patient consults, he has already managed to transmit the disease to other household members.

So, all of these contribute to the fact that prolonged treatment, for example, makes one dread the possibility of having TB; people will shy away from you, you will be ostracized somehow because of the stigma associated with TB. What we’re trying to bring out every World TB Day is that there is no need for people to be afraid because TB is curable; that there are available free medicines in government health centers and, at the same time, it’s easy to diagnose TB these days. We have modern diagnostics that can help physicians decide if it’s TB or not, and on top of that, we need to be concerned because drug resistance is increasing. If you don’t treat it the first time around, the likelihood of a more difficult treatment is increasing.

What are the recent developments in the treatment of TB?

We’re still offering the same regimen; we’re just trying to make sure that it’s standardized in the sense that the international standards say that we should treat TB with at least four drugs for two months’ intensive phase, followed by two drugs of a four-month continuation phase. So, that is assuming that the bacteria strain is sensitive or susceptible to the drugs.

In our drug resistance surveillance in the country in 2012, it turned out that 1.96% of those that receive treatment will turn out to be MDR (or multi-drug-resistant TB). So, that is a very good figure in the sense that it means that if it’s your first time to be diagnosed, the likelihood of having a drug-susceptible TB is 98%... so gagaling ka.

MDR — that means that isoniazid or rifampicin will not work on your TB. The standard is you need to have four drugs on board, as I’ve said. If you get treated for at least a month and you do not finish it, the likelihood of you having a multi-drug -resistant TB is magnified up to 21.4%. So, that means one out of five individuals who gets treated for TB but does not complete it, or is not receiving the right dose or the right regimen, will likely come back with a multi-drug-resistant TB.

And the problem is, it’s not your ordinary drugs now. You will be spending for drugs that are not commercially available and the treatment duration is 18 to 24 months. So, it costs the government about P250,000 to 700,000 per case. And the drugs are more toxic so we don’t want that. We want to make sure that if you get treated for TB, you get treated right away, with the right regimen, with the right duration and then you are documented to have responded to treatment because at any point that you do not convert from mere positive to negative, if you continue to worsen, at least the government can immediately offer you the free second-line drugs for multi-drug-resistant TB.

The other development is that it’s easier to diagnose multi-drug-resistant TB now because we have the gene expert machines or what you call expert MTB/RIF machines. They detect the DNA of the TB bacilli and the sputum, and within two hours, you will find out if you have TB and if you have a drug-resistant strain. We initially started the program, I think, in 2011 with just having about 20 machines. By the end of 2014, we have already acquired an additional hundred, and then we’re acquiring 80 for 2015 and by the end of 2016, almost all provinces, highly urbanized  centers, even island municipalities would have had their own machines in order to make diagnosis very easy.

Why do we need to diagnose them immediately?

Because if left untreated, a single case will be able to infect 10 to 15 individuals each year. And that magnifies our problem. So, we need to treat everyone and that was the theme in fact of our campaign for the World TB Day: Hanapin, Gamutin, Pagalingin. So, we need to intensify our case finding; we need to not be satisfied with just the index case; we need to screen the family members, the household members, those with risk factors … like if you’re diabetic, you’re three times more likely to have TB; if you have HIV, all the more, about 27 to 30 times more.

Who are at high risk of TB?

Basically those with immuno-compromised states. Those who cannot generate a good resistance against the disease. Because normally, in ordinary cases, about 90% will remain healthy. It will remain dormant and will go into a state we call latent TB infection. Only 10% will proceed to the disease and out of those 10%, 90% will get cured. If you get treated under directly observed treatment (DOT) — and that’s what we’re trying to promote, DOTS; we added the ‘S’ for short course because six months of right treatment will get you cured. So, who are at high risk? First of all, a Filipino. Two out of three Filipinos will have TB infection at least once in their lifetime. The poor definitely, those with diabetes, those with cancer, those with gastrointestinal surgeries. Those other risk factors — the alcoholics; the smokers are twice more likely to have TB compared to non-smokers; vegetarians — because their immune response is slightly blunted because you need protein in order for you to have those anti-bodies or to have that proper immune response, so maybe that’s the reason.

The most important risk factor is exposure. The reason people think it’s hereditary is because you are able to transmit it to family members. It only takes three feet for you to inhale the air droplet of the one beside you. So, a single bacilli can multiply in your body immediately and then, if left unchecked, you will have the disease. So, the immuno-compromised state further increases your chance because it’s just one bacilli, for example — you can expectorate it, you have other defenses in your body. But chronic exposure means that you have a bacilli deposited serially and then if left unchecked, it will multiply.

How can we protect children from TB?

In the first place, children get it from the adults. So, it’s very important that we try to cure all of the infectious cases so that children do not get infected. Now, once the child becomes infected, if less than five years of age, we can offer them INH preventive therapy. That means their infection will not progress to the disease because you have INH somehow already addressing the infection. The chance of the infection progressing into the disease at five years old and above would have been less than .5% already. This is why we don’t run after the latent TB infection beyond that. So, in children, we just make sure that they get preventive therapy during the ages of 0 to less than five.

But thereafter, all children, exposed, for example, to an active case among adults or adolescence, and then, for example, they already have the manifestation because they can contract it from schools, they can get it from any other environment that is enclosed. So, we make sure that the children themselves are also given the right diagnosis, the right treatment, so the DOH now has an integrated program that actually combines the same approach for children and for adults. So, we are able to synchronize the programs in a sense that we are after all forms of TB, whether adult or for pedia, and, at the same time, whether it be pulmonary or in other organs.

How can adults protect themselves from TB?

The avoidable risk factor is don’t smoke, because smoking actually paralyzes the mucocilliary apparatus. These are the hair-like projections from your cells in the respiratory tree that actually bring out the mucus or the sputum. So, if they get paralyzed, all the more the secretions will stay inside and they are good culture medium for the bacteria. If you are diabetic, you control your blood sugar. Definitely, you try to be cautious about being exposed to people who are also coughing. And if you are coughing, make sure you cover your mouth or you practice cough etiquette so you don’t spread the infection to other people. Of course, the best way to prevent it is to get diagnosed immediately — that will minimize transmission, especially if you are offered the right treatment immediately.

Do you see the day when TB will be totally eradicated?

Right now, we are actually decreasing the case burden of the country. From 1990, we have managed to actually decrease it by 50%. To the extent that right now, the target is for us to further improve our performance by targeting an additional 75% decrease from the 2015 rate by 2025 for both mortality and prevalence of tuberculosis. So much so that by 2035, if we’re going at the same rate as we are right now, it is projected that we would have managed to contribute to the TB elimination for the rest of the world. So, we are on the right track.

But we need to really engage everyone and that is the purpose in fact of this World TB Day advocacy. We want everyone to become aware. We want them to think of TB as something that requires their attention. Because a lot of people think that it’s controlled; “I don’t have that.” But on the contrary, just because you live, for example, in a posh village doesn’t mean that you are immune or you are not likely to get TB. Remember, those under you are also exposed. If you ride the FX, if you watch in a cinema, for example, you might be beside someone who is already coughing and you have the risk of getting the disease.

Any message to the public?

As PhilCAT (Philippine Coalition Against Tuberculosis), we enjoin the private sector in particular to participate in the government’s national TB control program, to observe the standard diagnostic algorithm, the standard treatment regimen, and to document the treatment and its cure in order for us to be able to make sure that everyone around us would be TB-free in the future.


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