Philippine Standard Time
Monday, August 26, 2019
The US Food & Drug Administration (FDA) has approved Pretomanid. They approved this new drug as part of a three-drug, six-month, all-oral regimen for the treatment of people with extensively drug-resistant TB (XDR-TB) or multidrug-resistant TB (MDR-TB) who are treatment-intolerant or non-responsive. Note: The WHO is currently updating its guidelines on the programmatic management of drug-resistant TB. This drug and regimen may be included in that document.
James Sherpa (our ex-WHO intern) has published this research article recently. Abstract: Private providers in Metro Manila perceived their clientele as loyal and their services as distinct from public services, with unique attractions of convenience and quality of service. The private sector saw value in engaging with the public sector for knowledge exchange, access to public-sector commodities, and access to public sector assistance with public health tasks related to tuberculosis. However, their proposed ways of engaging were more centred on the private sector role, in ways that are not currently being pursued by the public sector. It is of the utmost importance to recognize that private provider perspectives are essential to build effective engagement models and, thus, to reach all clients with quality TB care.
Note: The WHO retains the copyright to this article. Therefore, please feel free to distribute it to anyone who may benefit from it.
Abstract: In 2016, the Viet Nam National Tuberculosis Programme (NTP) conducted the first national TB patients cost survey. This survey aimed to identify the main cost drivers to help guide cost mitigation policies and reduce financial barriers to the treatment of TB patients. The survey findings were widely disseminated and the NTP defined a roadmap. The major components of the roadmap included (1) advocating for patients to be covered by social health insurance; (2) creating a charity fund for TB patients; (3) strengthening the collaboration between the Ministry of Health and Ministry of Labour and Social Affairs; and (4) advocating for donor support. The survey findings led to policy changes and new practices in Viet Nam. The Viet Nam NTP plans to conduct a second national TB patients costing study in 2020 to measure the impact of policy change with the help of the multisectoral roadmap.
Note: Let us hope that the Philippines can also continue to find similar and/ or other ways and design a roadmap to mitigate the catastrophic costs that over one-third of Filipino TB patients face, as per the 2017 Patients’ Cost Survey of the Philippines.
Here is a paper that I co-authored on people-centred tuberculosis care. In this paper, we emphasise on how the language we use to refer to people with TB often place limits on the care that we provide to them.
Here is a fact sheet on the Multisectoral Accountability Framework on TB that can help support the process of defining who is accountable, what they are accountable for, and how they will be held accountable, at country and local levels, as well as at regional and global levels. MAF has four components: Commitments -> Actions -> Monitoring and Reporting -> Review.
This declaration mentions 22 rights of people affected by tuberculosis, which includes the rights to life, dignity, health, freedom from degrading treatment, equality, liberty, freedom of movement, privacy, confidentiality, information, informed consent, education, work, food, housing, water and sanitation, social security, freedom of expression, freedom of assembly and association, participation, justice and science.
This document has the following modules:
Globally, TB programmes are missing people who: (1) Do not access care, either due to vulnerability, stigma, poverty, remote location, or ongoing conflict; (2) Access care, but are not diagnosed with TB due to deficient screening, diagnostic and referral systems, long waiting times, and overburdened health systems; and (3) Are diagnosed, but may not be started on proper treatment and notified. These 10 Field Guides are organized around these three broad gaps in TB case finding.
Field Guide I: Introduction: Planning and managing interventions to reach more people with TB
Field Guide 1: TB case finding with key populations
Field Guide 2: Strategies for TB case finding in prisons and closed settings
Field Guide 3: Finding missing people with TB in communities
Field Guide 4: Intensified case finding at facility level
Field Guide 5: Scaling up interventions to find children with TB
Field Guide 6: Using contact investigation to find the missing people with TB
Field Guide 7: The role of laboratory systems in TB case detection
Field Guide 8: The role of chest X-ray screening in TB case detection
Field Guide 9: Finding missing people with TB by engaging the private sector
Field guide 10: Strengthening TB information systems and linkages to care
This is a "seminar" article on A-to-Z about tuberculosis, including many interesting updates.
Given the new recommendations on the hierarchy of multidrug-resistant tuberculosis drugs, the authors of this article find it surprising that WHO continues to recommend the shorter “Bangladesh” regimen, which includes several drugs that are low in the current hierarchy of multidrug-resistant tuberculosis drugs (e.g., amikacin, ethionamide, and isoniazid). According to them, national tuberculosis programmes must choose between sticking with the obsolete Bangladesh regimen or new, shorter all-oral regimens that are likely to be more effective and safer.
This paper analysed patient-based national surveillance data to investigate the epidemiology of reported tuberculosis among children (aged 0–9 years), adolescents (aged 10–19 years) and young adults (aged 20–24 years) to better understand the burden of disease and treatment outcomes in these age groups.
The study prospectively retested sputum from 238 patients, irrespective of current symptoms, who were previously diagnosed to be Xpert positive and treated successfully. Patients who retested as Xpert positive and culture negative were exhaustively investigated (repeat culture, chest radiography, bronchoscopy with bronchoalveolar lavage, long-term clinical follow-up). A total of 229/238 (96%) of patients were culture negative. All patients who initially retested as Xpert positive and culture negative ("Xpert false positive") were clinically well without treatment after follow-up. Conclusion: Patients with previous TB retested with Xpert can have false-positive results and thus not require treatment.
Results. The paper included a total of 40 studies that were conducted in 20 countries. The overall pooled prevalence rates of the most common mental health disorders were 25% for depression, 24% for anxiety, and 10% for psychosis. The prevalence of psychosis was 4% before MDR-TB treatment commencement, and 9% after MDR-TB treatment commencement. The most common social stressors reported were stigma, discrimination, isolation, and a lack of social support. Health-related quality of life was significantly lower among MDR-TB patients when compared to drug-susceptible TB patients.
Conclusion. [We need to screen all MDRTB patients for mental health and social issues using simple and short tools. Then, we need to refer those who require mental health services, social protection and/or social support for appropriate care.]
The target audience for these guidelines includes national and subnational policymakers; frontline health workers; health system managers for TB, HIV and highly prevalent non-communicable disease programmes; managers of IPC services in inpatient and outpatient facilities; managers of congregate settings and penitentiary facilities; occupational health officials; and other key TB stakeholders.
This report of DOLE mentions that more than 35,000 people develop silicosis every year within the Philippines. Exposure to silica dust and silicosis are among the strongest risk factors for TB, with a relative risk of 2.8 – 39 for silicosis, depending on the severity of the disease. Silicosis is common in miners, which is the main reason for the high incidence of TB among them.
At this website, you can find many materials about WHO TB Day 2019, from the WHO, including an animated logo, social media tiles and posters .
This resource provides practical guidance for front line health workers responsible for the diagnosis, management and care of patients with these two diseases. The Union has published this guide in collaboration with the World Diabetes Foundation.
This interesting article describes methods for constructing care cascades for active TB.
A new report has revealed the world\'s heaviest internet users: the Philippines, where people spent an average of 10 hours and two minutes a day online in 2018. Brazil came in second, with nine hours and 29 minutes of internet usage, followed by Thailand with nine hours and 11 minutes, Colombia with nine hours, and Indonesia with eight hours and 36 minutes.
The Stop TB Partnership’s TB REACH has launched its Wave 7 round of funding to improve TB case finding and treatment outcomes with an emphasis on the empowerment of women and girls to lead key approaches in TB response. Interested agencies may apply. The WHO Country Office (Philippines) would be happy to provide technical assistance during the writing of the concept note.
Results. This systematic review included 25 studies published between January 2000 and December 2017. Individual counselling support and home visits by health workers, provided throughout treatment, were associated with fewer losses to follow-up than when they were provided only at the start of treatment, or not at all. The findings are consistent with those reported in a recent Cochrane systematic review (link: http://bit.ly/2SfZVr8), which found that daily DOT did not improve TB cure rates, compared to self-administered therapy, when the frequency of contact with providers during self-administrated therapy was every 2 weeks or more frequently than that. This review also provides evidence to support the effectiveness of financial compensation for rent or travel expenses, as well as lost wages, but not of group counselling, involvement of family in counselling sessions or nutritional support, on improving retention in care.
During this study, the researchers used "any-one-of-four" symptom screening. But they used Xpert test for all visitors of the primary health clinics. They found that about 5% of those who had at least “any-one-of-the-four TB symptoms” had Xpert positive TB. They also found that about 2% of those who were visiting the clinics for other reasons had Xpert positive TB. The research findings suggest that the primary health clinics of South Africa used to miss 62.9–78.5% of TB patients attending primary health clinics for TB-related symptoms. The clinics also used to miss 89.5–100% of TB patients attending the clinics for other non-TB symptoms. [Now, South Africa has started using "screen all" policy in all clinics of the country. To find all TB patients among clinic visitors, X-ray screening may be done, if available. If X-ray is not available, "any-one-of-four" symptom screening will also find many missing TB patients.]
In this advisory, the National Privacy Commission has clarified to the DOH that "the Data Privacy Act does not prohibit the DOH from collecting and processing personal data for purposes necessary to its mandate". This advisory is useful for facilitating mandatory notifications by the private providers.
This new report shows that the incidence rate of the Philippines did not change between 2016 and 2017. The main reason for the no-change is that the treatment coverage rate fell from 58% in 2016 to 55% in 2017. To achieve the SDG target of 80% reduction of incidence rate by 2030 (compared to 2015), we need to increase our treatment coverage rate to over 90% within the next 2-3 years, rapidly.
Here is the full 2018 Global TB Report:
Here is a one-page comparative global and Philippines data based on the report:
Here is a one-page extract for the Philippines from the report:
Here is a one-page infographic for the Philippines based on the report:
For the health aspects of the Act, the focus is on tuberculosis, hepatitis and HIV. Here is a nice DOLE-primer, although a little outdated:http://bit.ly/2N7a8I1DOLE is now in the process of writing the “implementing rules and regulations” for this Act. Engaging DOLE and the formal sector for health in the context of this new Act will help us to reach out to almost 26% of the general population who are in the formal sector.
Here is Republic Act 11058, drafted in 2017 and signed in 2018
This toolkit is for developing, strengthening and integrating specimen referral networks globally.
Volunteers, mostly ex-TB patients, screened 650,000 people at the cost of US$0.29 per person screened and US$ 44 per person diagnosed. The intervention resulted in an additional 4,300 sputum-smear-positive pulmonary tuberculosis diagnoses, 42% (4,300/10,247) of the provincial total for that period.
This new guideline mentions that National TB Programs need to focus on TB contacts who are above five-year of age too, and not just under-five contacts and PLHIV. It recommends shorter regimens to treat Latent TB Infection, e.g., INH + Rifampicin daily for three months and INH + Rifapentine weekly for three months.
The systematic review suggests that the WHO’s four-symptom screening rule has lower sensitivity among people with HIV (PLHIV) who are on ART. Hence, chest radiography may be offered to PLHIV who are on ART to improve the sensitivity of the four-symptom screening rule, provided it does not pose a barrier to preventive treatment. The WHO guideline on Latent TB Infection (above) mentions this too.
This is a technical guide to help TB programs and partners measure levels of TB stigma in specific settings and populations.
17 August 2018 | GENEVA - Major improvement in treatment outcomes and quality of life of patients with multidrug-resistant tuberculosis (MDR-TB) are expected, following key changes in MDR-TB treatment announced by WHO today.
The first important change is a new priority ranking of the available medicines for MDR-TB treatment, based on a careful balance between expected benefits and harms. Treatment success for MDR-TB is currently low in many countries. This could be increased by improving access to the highest-ranked medicines for all patients with MDR-TB.
The second important change is a fully oral regimen as one of the preferred options for MDR-TB treatment, with injectable agents proposed to be replaced by more potent alternatives such as bedaquiline (the first-ever medicine to be developed specifically for the treatment of MDR-TB). Injectable agents cause pain and distress to patients, with many experiencing serious adverse effects that often lead to treatment being interrupted.
"The treatment landscape for patients with MDR-TB will be dramatically transformed for the better with the announcement today," said Dr Soumya Swaminathan, WHO Deputy Director-General for Programmes. "Building on the available new data, and with the involvement of a large number of stakeholders, WHO has moved forward in rapidly reviewing the evidence and communicating the key changes needed to improve the chances of survival of MDR-TB patients worldwide. Political momentum now needs to urgently accelerate, if the global crisis of MDR-TB is to be contained."
This is the latest version of the End TB Compendium, with many new things that are relevant for the Philippines. If you are too busy to read the whole document, then please just try to skim through the WHO’s 33 standards of care (words in bold letters) – from page # 9 to 39.
This is a great policy, with a potential to revolutionise the health sector in the Philippines. Everyone needs to read and adopt it in their work.
The Compendium has been developed as a clear and concise instrument to facilitate the understanding and planning of delivery of high-quality care for everybody affected by TB. It incorporates all recent policy guidance from WHO; follows the care pathway of persons with signs or symptoms of TB in seeking diagnosis, treatment and care; and includes key algorithms and cross-cutting elements that are essential to a patient-centred approach in the cascade of TB care. The Compendium is structured into 33 WHO standards. It consolidates all current WHO TB policy recommendations into a single resource, with electronic links to the individual, comprehensive WHO policy guidelines. This Compendium will be updated annually, including in its digital format, to allow incorporation of new evidence emerging from the rapidly evolving TB diagnostic and treatment landscape. Read More
A team of officers from all three levels of the WHO (headquarters, regional office and country office) conducted a “screening-diagnosis” review mission along with key partner agencies on 02-06 October 2017. The mission recommended three approaches to find the missing cases: (1) ‘Screen all’ at all public health facilities and congregate settings, irrespective of their symptoms (2) ‘Screen high risk groups’ in communities and (3) ‘Link all’ who already have chest X-rays in private and corporate sectors to Xpert MTB/RIF, as required. For more details, please read the report by following the above-mentioned link. Read More
This course will provide a knowledge base that goes from the basics of TB to the current state of knowledge on various aspects of tuberculosis: the clinical picture, epidemiology, paediatric TB, factors affecting susceptibility to the disease, including HIV, diabetes and human genetics, immunology, vaccines, diagnosis, current and future ways to detect drug resistance, and how to treat drug sensitive and multi-drug resistant strains. This online course is organized over six weeks. Each week is composed of 4 to 6 sequences. In each sequence, you will find a 10 minute video and two multiple choice questions (MCQ) to help students check their understanding. A weekly evaluation is performed using about 10 MCQs and, at the end of the course, a final evaluation is performed with 30 MCQs. Classes will start on Jan 29 2018 and end on Apr 02 2018. Estimated effort required: 02:30 hours per week. Read More
Stop TB Partnership’s CFCS is a unique small grants mechanism that, since 2007, supports innovative community responses to fight tuberculosis (TB). The theme for this latest round of funding is “Communities for Impact”. The overall aim of CFSC Round 8 is to contribute to expanding access to quality TB prevention and care services to community- and hard-to-reach settings. The application period has started on 4 December 2017. Applications should be completed by Friday, 12 January 2018 (18:00 hrs Geneva time). Read More
“Opportunity: 72049218RFA00001 - TB Platforms for Sustainable Detection, Care and Treatment Activity” This funding opportunity is open to all US and non-US organizations. Closing date for applications: January 03, 2018 Estimated total program funding: $20,000,000. Read More
The report shows no significant progress against all important indicators. If we want to end TB by 2030, we need to launch historically unprecedented efforts against TB, starting now. Here are the full and extracted reports.
One-page Comparative Analysis of the Philippines vs the World
Two-page Extract Report of the Philippines including SDGs
Global TB Report 2017 (a link to the WHO website)
Stop TB Partnership wants to fund innovative and out of the box ideas, strategies, initiatives, and technologies, which aim to increase the number of people diagnosed and treated for TB, to decrease the time to appropriate treatment and to improve treatment success rates. The Philippines is one of the 12 countries that they will prioritise for this funding. Applicants from the Philippines are encouraged to submit proposals that link to, inform or support their country’s case detection or notification activities funded under their Global Fund grants. Please read this dedicated information note to understand how TB REACH funding needs to be linked to Global Fund Catalytic Funding on ‘finding the missing cases’: http://bit.ly/2zv31PN Read More
Specimen referral systems can reduce catastrophic costs and treatment delays. Besides, they can help to engage the private sector more easily by providing them the incentive of quality-assured laboratory services. This guide has many interesting indicators, formats, and nine case-studies. Read More
Community-based care for drug-resistant TB patients is superior to facility-based care. This guide provides practical, step-by-step guidance on how to organize, implement, and monitor community-based care for DR TB. It is equally useful for program planning or supervision. Read More
This modular training package has been developed to guide programme and laboratory managers and their implementation partners on key topics for diagnostic network strengthening. The modules are in PowerPoint format for country customization, and are accompanied by facilitator guides and worksheets for participants. Read More
This is an excellent document. Please read it carefully. If we implement what is mentioned in the document, and keep the interest of the patients as paramount, the treatment success rate will rise to 80-90% rapidly. The most critical sections that you need to read are about the 3Ps:
USAID Philippines has posted a Request for Application (RFA) for eligible U.S. non-profit non-governmental organization (NGOs) for-profit NGOs willing to forego their fee, private voluntary organizations (PVOs), Philippine-based NGOs, universities, foundations, consortiums, and international organizations for a Cooperative Agreement to implement a $30 million, five-year activity entitled, "Tuberculosis Innovations and Health Systems Strengthening." To see details regarding this RFA, click the link below: Read More
MDR and XDR tuberculosis were forecasted to increase in all four countries, including the Philippines. Additional control efforts beyond improving acquired drug resistance rates are needed to stop the spread of MDR and XDR tuberculosis in countries with a high burden of MDR tuberculosis. Read More
Factors associated with fewer losses (in the cascade of care for LTBI) were immune-compromising medical indications, being part of contact investigations, and use of rifamycin-based regimens (e.g., Rifapentine). Read More
Stigma and challenges regarding access to health care were identified as barriers to tuberculosis diagnosis and treatment uptake, whereas support from nurses, family, and friends was a facilitator for treatment adherence. Read More
The analysis showed that tuberculosis screening by (mobile) chest radiography improved screening coverage and tuberculosis identification, reduced diagnostic delay, and was cost-effective among several hard-to-reach populations... Monetary incentives improved tuberculosis identification and management among drug users and homeless people. Read More
The pooling analysis indicated that diabetes mellitus was an independent risk factor for MDR-TB, especially for primary MDR-TB. Read More
Shift away from (just) asking: What is the matter with you? What matters to you? In other words, ask your patients this one question: How can I improve your care?. Read More
The Global Laboratory Initiative (GLI) has released a guide on the new XpertÂ® MTB/RIF Ultra cartridges based on recommendations of the WHO. The sensitivity of these Ultra cartridges is about 5% higher than that of Xpert MTB/RIF (87.8% vs 82.9%). However, as expected, this increase in sensitivity is at the cost of specificity, which is about 3.2% lower (94.8% vs 98%). Hence, the GLI has suggested a revision of the algorithm. You may refer to the revised algorithm on page 11 of the document. This revised algorithm would be useful only after the Philippines starts procuring and supplying these new Ultra cartridges. Read More
The Patient-centred TB Care project will focus on improving patient-centered TB care by bolstering tuberculosis services at the regional, provincial, local government unit, and community levels. It is a five-year project (September 2017-August 2022) under a cooperative agreement award that is estimated at $20 million. Applications will close on June 15, 2017. Read More
The category II regimen is no longer recommended for patients who require TB retreatment and drug-susceptibility testing should be conducted to inform the choice of treatment regimen. Patient care and support (for drug susceptible and drug resistant tuberculosis).
Community- or home-based directly observed treatment (DOT) is recommended over health facility-based DOT or unsupervised treatment.
Decentralized model of care is recommended over centralized model for patients on MDR-TB treatment.
The revision is in accordance with the WHO requirements for the formulation of evidence-based policy. Read More
The Technical Expert Group of the WHO agreed that the Ultra is non-inferior to the Xpert MTB/RIF assay. The group agreed that the greatest benefit was in the increased yield for the detection of MTB in smear-negative culture positive specimens, pediatric specimens, extra-pulmonary specimens (notably cerebrospinal fluid), and especially for HIV positive individuals whose specimens are frequently paucibacillary. Read More
The WHO and UNICEF have urged all national TB programmes to discontinue and replace the previously used medicines for children weighing less than 25 kg with the child-friendly dispersible TB FDCs as soon as possible. Read More
This guide includes the use of four new WHO-recommended model TB diagnostic algorithms. In addition, it describes the most recent guidance in key technical areas, including quality assurance and quality management systems, specimen collection and registration, procurement and supply-chain management, biosafety, diagnostics connectivity, data management, human resources, strategic planning, and other topics. Read More
This handbook provides four model diagnostic algorithms. (These are the same algorithms as in the above-mentioned GLI Practical Guide). These algorithms graphically depict the most up-to-date WHO recommendations on use of TB diagnostics. The algorithms include the use of Xpert MTB/RIF, line probe assays for 2nd line drugs, the lateral flow urine lipoarabinomannan (LF-LAM) assay and the loop-mediated isothermal amplification (TB-LAMP) test, together with conventional tools including microscopy and phenotypic culture and DST. Read More
A year-long mass communications initiative was deployed in a section of Karachi, Pakistan (the intervention area). This initiative encouraged people with prolonged cough (>2 weeks) to seek care at local family clinics or Indus Hospital, a 150-bed, private hospital. The initiative included billboards, local cable television ads, posters, and flyers, as well as deployment of local residents as TB screeners in over 50 local private sector family clinics. Screeners were provided a mobile phone, then given a monthly stipend and small conditional cash transfers via phone bank transfer for such activities as submitting a daily report, procuring an acceptable sputum sample, and identifying a smear-positive case. Between 2010 and 2011, pulmonary tuberculosis notifications increased by about four times for adults and about seven times for children. Read More
This short guide is for activists as well as others who want to know about TB diagnostics in a very simple language. Read More
In 95 studies from low- and middle-income settings, the prevalence of active TB in all contacts was 3.1%, microbiologically proven TB was 1.2%, and latent TB infection was 51.5%. The prevalence of TB among contacts of patients with multidrug-resistant or extensively drug-resistant TB was 3.4%. Incidence was greatest in the first year after exposure. Read More
In Palawan (Philippines), the DetecTB project implemented an active case finding strategy that offered a one-stop diagnostic service with a mobile unit equipped chest X-ray and Xpert. The highest yield (in percentage) with lowest number needed to screen (NNS) to get one TB patient was found in prison (6.2%, NNS: 16), followed by indigenous population (2.9%, NNS: 34), the rural poor (2.2%, NNS: 45), and the urban poor (2.1%, NNS: 48). Read More
This paper describes how to use analysis of cascades of care to address quality of TB care. Please check the diagrams within it. Read More
The Framework has 12 core indicators to measure programmes\' capacity to detect TB accurately and rapidly using new diagnostics, provide universal DST, and ensure the quality of testing. These indicators will be monitored globally by WHO as countries progress towards reaching the targets, and they complement the broader top 10 indicators for monitoring the End TB Strategy. Please refer to a link at the bottom of that webpage for a downloadable MS Excel file. Read More
Residents of Quezon City can no longer self-medicate for tuberculosis, after Mayor Herbert Bautista recently signed into law an ordinance preventing drugstores from selling anti-TB drugs without a doctor\'s prescription. District 3 Councilor Eufemio Lagumbay authored Ordinance No. 2545, titled the â€œNo Prescription, No Dispensing of Anti-TB Drugs Policy, to enforce locally a national policy in dispensing prescription medication, which includes anti-TB drugs, over the counter. The measure also makes it imperative for pharmacies to equip their personnel with the necessary skill and competence to help TB patients get access to the correct and complete TB treatment. Read More