Monday, March 9, 2009

Profile of Tuberculosis in the Philippines

The Philippines has the ninth highest burden of tuberculosis in the world, according to the WHO Global TB Report 2006. TB is the sixth greatest cause of morbidity and mortality in the country. Approximately 78 Filipinos die from the disease every day, but significant strides have been made in recent years in increasing case detection and treatment. By 2004, the country achieved a TB case detection rate of 73 percent, exceeding the national and global target of 70 percent. The national TB treatment success rate is currently at 88 percent, above the national target of 85 percent. While the national performance levels are already high, many locales are still below target levels, given the difficulty of breaking down the stigma of TB that keeps many of those infected from seeking care.

USAID Approach and Key Activities
USAID is helping to fight TB in the Philippines on two fronts – enhancing the public sector National TB Control Program (NTP) and strengthening the private sector’s capacity to implement Directly Observed Therapy, Short-Course (DOTS). Between 2000 and 2005, USAID funds for TB programming in the Philippines averaged $1.9 million per year. USAID assistance has contributed significantly to increasing the availability of quality DOTS in the National Capital Region and in five provinces of the country where service delivery is especially difficult.
In the Philippines, people with TB symptoms are more likely to seek treatment from private providers than from public providers. Implementation of DOTS among private sector practitioners is thus critical to reducing TB prevalence. Between 2002 and 2005, the USAID-supported Philippines Tuberculosis Initiatives in the Private Sector (PhilTIPS) project improved cooperation with the NTP and strengthened TB diagnosis and treatment by private providers in 25 selected sites nationwide. In 2005, the private sector expanded provision of quality TB services to 30 service delivery points, including multispecialty clinics, hospital-based public-private physician practices, clinics, and workplace models; an additional public-private TB control project has also recently begun.

USAID’s assistance includes the following activities and interventions:
Enhancing national-level planning, monitoring, and supervisory capacity
Ensuring that health personnel are knowledgeable in all aspects of DOTS, policy reform, and advocacy
Strengthening TB surveillance, laboratory capacity, and quality control
Improving TB drug management
Implementing information, education, and communication activities
Providing microscopes, laboratory equipment and reagents, and vehicles to enable supervisors to monitor program activities
Conducting operations research
Providing grants to nongovernmental organizations to carry out TB education and replicate private sector efforts at the local level

USAID Program Achievements
USAID’s program has contributed to substantial improvements in human and infrastructure capacity and includes the following achievements:
Met its fiscal year 2005 target of 73 percent of participating units (facilities accredited in DOTS) achieving an 85 percent TB success rate
Assisted the Department of Health (DOH) in increasing the use of a community-based management information system by 18 percent in public and private clinics, thus enabling local government units (LGUs) to identify people with TB symptoms who are not consulting any health care provider
Improved case detection rates from 54 to 73 percent between 2000 and 2004

Facilitated substantial improvements in health worker capacity to implement DOTS by training 470 LGU health workers; 3,314 barangay (administrative unit) health workers; and 3,000 private sector physicians
Implemented through a DOH order a certification system for accrediting public and private sector DOTS centers by the Philippine Health Insurance Corporation (PHIC), with 303 centers certified to date and 200 of these accredited by PHIC, of which 20 percent are private clinics
Facilitated the establishment of 30 public-private mix DOTS service delivery points providing quality services with high patient satisfaction ratings
Assisted PHIC in developing a TB-DOTS outpatient benefit package, thus enabling accredited public and private centers to generate reimbursements from PHIC
Assisted the Department of Labor and Employment in implementing an order promoting TB control in the workplace
Developed a TB/DOTS core curriculum for medical schools and integrated DOTS into the curriculum at 10 major medical schools
Established 48 fully equipped TB microscopy centers in regional health units and quality control centers in three provinces and cities, coupling this with improved practice of 51 LGU medical technologists in laboratory diagnosis and 15 staff in laboratory management
Strengthened DOTS program monitoring and supervision as well as field management by personnel at the regional, provincial, and city levels

USAID partners in TB control include WHO, the Philippines NTP, the U.S. Centers for Disease Control and Prevention, the Philippines Coalition Against TB, the Tropical Disease Foundation, Inc., Chemonics International, the ReachOut Foundation International, and the New Tropical Medicine Foundation, Inc. WHO leads the technical collaboration of external partners. In addition to USAID, other key donors include the World Bank, the Canadian International Development Agency, and the Japan International Cooperation Agency. In 2003 and 2006, the Global Fund to Fight AIDS, Tuberculosis and Malaria approved the Philippines’ TB proposals for funding of $58.6 million over five years.


the following are the resources that we utilized in order to complete this blog:

synthesis & summary

Tuberculosis is a bacterial infection that can be fatal. The body's immune system can usually fight the infection and confine it successfully.

When the immune system is weak, confined tuberculosis bacteria can become active and spread to other parts of the body. This is called active tuberculosis.

Due to the recent milestones in medicine, treatment for active tuberculosis is now available and easily accessible. It is very important for the patient to follow the course of treatment religiously and completely to completely eradicate the bacteria and to prevent the illness from worsening or recurring.

The aforementioned illness can be prevented by practicing good hygiene including good ventilation, isolation of patients and suspected patients, and covering the mouth when coughing. The universal precaution for this is proper handwashing and isolation of infected patients.



In general, TB is preventable. From a public health standpoint, the best way to control TB is to diagnose and treat people with TB infection before they develop active disease and to take careful precautions with people hospitalized with TB. But there also are measures you can take on your own to help protect yourself and others:

  • Keep your immune system healthy. Eat plenty of healthy foods including fruits and vegetables, get enough sleep, and exercise at least 30 minutes a day most days of the week to keep your immune system in top form.
  • Get tested regularly. Experts advise people who have a high risk of TB to get a skin test once a year. This includes people with HIV or other conditions that weaken the immune system, people who live or work in a prison or nursing home, health care workers, people from countries with high rates of TB, and others in high-risk groups.
  • Consider preventive therapy. If you test positive for latent TB infection, your doctor will likely advise you to take medications to reduce your risk of developing active TB. Vaccination with BCG isn't recommended for general use in the United States, because it isn't very effective in adults and it causes a false-positive result on a Mantoux skin test. But the vaccine is often given to infants in countries where TB is more common. Vaccination can prevent severe TB in children. Researchers are working on developing a more effective TB vaccine.
  • Finish your entire course of medication. This is the most important step you can take to protect yourself and others from TB. When you stop treatment early or skip doses, TB bacteria have a chance to develop mutations that allow them to survive the most potent TB drugs. The resulting drug-resistant strains are much more deadly and difficult to treat.

To help keep your family and friends from getting sick if you have active TB:

  • Stay home. Don't go to work or school or sleep in a room with other people during the first few weeks of treatment for active TB.
  • Ensure adequate ventilation. Open the windows whenever possible to let in fresh air.
  • Cover your mouth. It takes two to three weeks of treatment before you're no longer contagious. During that time, be sure to cover your mouth with a tissue anytime you laugh, sneeze or cough. Put the dirty tissue in a bag, seal it and throw it away. Also, wearing a mask when you're around other people during the first three weeks of treatment may help lessen the risk of transmission.


Treatments and drugs

Medications are the cornerstone of tuberculosis treatment. But treating TB takes much longer than treating other types of bacterial infections. Normally, you take antibiotics for at least six to nine months to destroy the TB bacteria. The exact drugs and length of treatment depend on your age, overall health, possible drug resistance, the form of TB (latent or active) and its location in the body.

Several promising new TB drugs are in development, and some may become available within the next 10 years.

Treating TB infection (latent TB)
If tests show that you have TB infection but not active disease, your doctor may recommend preventive drug therapy to destroy bacteria that might become active in the future. You're likely to receive a daily or twice-a-week dose of the TB medication isoniazid. For treatment to be effective, you usually take isoniazid for nine months. Long-term use of isoniazid can cause side effects, including the life-threatening liver disease hepatitis. For this reason, your doctor will monitor you closely while you're taking isoniazid. During treatment, avoid using acetaminophen (Tylenol, others) and avoid or limit alcohol use. Both increase your risk of liver damage.

Treating active TB disease
If you're diagnosed with active TB, you're likely to begin taking four medications — isoniazid, rifampin (Rifadin), ethambutol (Myambutol) and pyrazinamide. This regimen may change if tests later show some of these drugs to be ineffective. Even so, you'll continue to take several medications. Depending on the severity of your disease and whether the bacteria are drug-resistant, one or two of the four drugs may be stopped after a few months. You may be hospitalized for the first two weeks of therapy or until tests show that you're no longer contagious.

Sometimes the drugs may be combined in a single tablet such as Rifater, which contains isoniazid, rifampin and pyrazinamide. This makes your treatment less complicated while ensuring that you get all the drugs needed to completely destroy TB bacteria. Another drug that may make treatment easier is rifapentine (Priftin), which is taken just once a week during the last four months of therapy, in combination with other drugs.

Medication side effects
Side effects of TB drugs aren't common, but can be serious when they do occur. All TB medications can be highly toxic to your liver. Rifampin can also cause severe flu-like signs and symptoms — fever, chills, muscle pain, nausea and vomiting. When taking these medications, call your doctor immediately if you experience any of the following:

  • Nausea or vomiting
  • Loss of appetite
  • A yellow color to your skin (jaundice)
  • Dark urine
  • A fever that lasts three or more days and has no obvious cause
  • Tenderness or soreness in your abdomen
  • Blurred vision or colorblindness

Treating drug-resistant TB
Multidrug-resistant TB (MDR TB) can't be cured by the two major TB drugs, isoniazid and rifampin. Extensive drug-resistant TB (XDR TB) is resistant to those drugs as well as three or more of the second line TB drugs. Treating these resistant forms of TB is far more costly than is treating nonresistant TB.

Treatment of drug-resistant TB requires taking a "cocktail" of at least four drugs, including first line medications that are still effective and several second line medications, for 18 months to two years or longer. Even with treatment, many people with these types of TB may not survive. If treatment is successful, you may need surgery to remove areas of persistent infection or repair lung damage.

Treating children and pregnant women
Treating TB in children is largely the same as treating adults, except that ethambutol is not used for young children because of the possible side effect of vision problems. Instead of ethambutol, children may take streptomycin.

For pregnant women with active TB, initial treatment often involves three drugs — isoniazid, rifampin and ethambutol. Pyrazinamide isn't recommended because its effect on the unborn baby isn't known. Some second line TB medications also aren't recommended.

Completing treatment is essential
After a few weeks, you won't be contagious and you may start to feel better. It might be tempting to stop taking your TB drugs. But it is crucial that you finish the full course of therapy and take the medications exactly as prescribed by your doctor. Stopping treatment too soon or skipping doses can allow the bacteria that are still alive to become resistant to those drugs, leading to TB that is much more dangerous and difficult to treat. Drug-resistant strains of TB can quickly become fatal, especially if your immune system is impaired.

In an effort to help people stick with their treatment, a program called directly observed therapy (DOT) is recommended. In this approach, a nurse or other health care professional administers your medication so that you don't have to remember to take it on your own. Sometimes clinics provide incentives, such as food coupons or transportation, for people to show up for their appointments.

methods of diagnosis

Tests and diagnosis

If your doctor suspects TB, you will need a complete medical evaluation and tests for TB infection.

Skin test

The most commonly used diagnostic tool for TB is a simple skin test. Although there are two methods, the Mantoux test is preferred because it's more accurate.

For the Mantoux test, a small amount of a substance called PPD tuberculin is injected just below the skin of your inside forearm. You should feel only a slight needle prick. Within 48 to 72 hours, a health care professional will check your arm for swelling at the injection site, indicating a reaction to the injected material. A hard, raised red bump (induration) means you're likely to have TB infection. The size of the bump determines whether the test results are significant, based on your risk factors for TB.

The Mantoux test isn't perfect. A false-positive test suggests that you have TB when you really don't. This is most likely to occur if you're infected with a different type of mycobacterium other than the one that causes tuberculosis, or if you've recently been vaccinated with the bacillus Calmette-Guerin (BCG) vaccine. This TB vaccine is seldom used in the United States, but widely used in countries with high TB infection rates.

On the other hand, some people who are infected with TB — including children, older people and people with AIDS — may have a delayed or no response to the Mantoux test.

Blood tests
Blood tests may be used to confirm or rule out latent or active TB. These tests use sophisticated technology to measure the immune system's reaction to Mycobacterium tuberculosis. These tests are quicker and more accurate than is the traditional skin test. They may be useful if you're at high risk of TB infection but have a negative response to the Mantoux test, or if you received the BCG vaccine.

Further testing
If the results of a TB test are positive (referred to as "significant"), you may have further tests to help determine whether you have active TB disease and whether it is a drug-resistant strain.

These tests may include:

  • Chest X-ray or CT scan. If you've had a positive skin test, your doctor is likely to order a chest X-ray. In some cases, this may show white spots in your lungs where your immune system has walled off TB bacteria. In others, it may reveal a nodule or cavities in your lungs caused by active TB. A computerized tomography (CT) scan, which uses cross-sectional X-ray images, may show more subtle signs of disease.
  • Culture tests. If your chest X-ray shows signs of TB, your doctor may take a sample of your stomach secretions or sputum — the mucus that comes up when you cough. The samples are tested for TB bacteria, and your doctor can have the results of special smears in a matter of hours.

    Samples may also be sent to a laboratory where they're examined under a microscope as well as placed on a special medium that encourages the growth of bacteria (culture). The bacteria that appear are then tested to see if they respond to the medications commonly used to treat TB. Your doctor uses the results of the culture tests to prescribe the most effective medications for you. Because TB bacteria grow very slowly, traditional culture tests can take four to eight weeks.

  • Other tests. Testing called nuclear acid amplification (NAA) can detect genes associated with drug resistance in Mycobacterium tuberculosis. This test is generally available only in developed countries.

    A test used primarily in developing countries is called the microscopic-observation drug-susceptibility (MODS) assay. It can detect the presence of TB bacteria in sputum in as little as seven days. Additionally, the test can identify drug-resistant strains of the TB bacteria.

What if my test is negative?
Having little or no reaction to the Mantoux test usually means that you're not infected with TB bacteria. But in some cases it's possible to have TB infection in spite of a negative test. Reasons for a false-negative test include:

  • Recent TB infection. It can take eight to 10 weeks after you've been infected for your body to react to a skin test. If your doctor suspects that you've been tested too soon, you may need to repeat the test in a few months.
  • Severely weakened immune system. If your immune system is compromised by an illness, such as AIDS, or by corticosteroid or chemotherapy drugs, you may not respond to the Mantoux test, even though you're infected with TB. Diagnosing TB in HIV-positive people is further complicated because many symptoms of AIDS are similar to TB symptoms.
  • Vaccination with a live virus. Vaccines that contain a live virus, such as the measles or smallpox vaccine, can interfere with a TB skin test.
  • Overwhelming TB disease. If your body has been overwhelmed with TB bacteria, it may not be able to mount enough of a defense to respond to the skin test.
  • Improper testing. Sometimes the PPD tuberculin may be injected too deeply below the surface of your skin. In that case, any reaction you have may not be visible. Be sure that you're tested by someone skilled in administering TB tests.

Diagnosing TB in children
It's harder to diagnose TB in children than in adults. Children may swallow sputum, rather than coughing it out, making it harder to take culture samples. And infants and young children may not react to the skin test. For these reasons, tests from an adult who is likely to have been the cause of the infection may be used to help diagnose TB in a child.

signs & symptoms


Although your body may harbor the bacteria that cause tuberculosis, your immune system often can prevent you from becoming sick. For this reason, doctors make a distinction between:

  • Latent TB. In this condition, you have a TB infection, but the bacteria remain in your body in an inactive state and cause no symptoms. Latent TB, also called inactive TB or TB infection, isn't contagious.
  • Active TB. This condition makes you sick and can spread to others.

Signs and symptoms of active TB include:

  • Unexplained weight loss
  • Fatigue
  • Fever
  • Night sweats
  • Chills
  • Loss of appetite

Tuberculosis usually attacks your lungs. Signs and symptoms of TB of the lungs include:

  • Coughing that lasts three or more weeks
  • Coughing up blood
  • Chest pain, or pain with breathing or coughing

Tuberculosis can also affect other parts of your body, including your kidneys, spine or brain. When TB occurs outside your lungs, symptoms vary according to the organs involved. For example, tuberculosis of the spine may give you back pain, and tuberculosis in your kidneys might cause blood in your urine.

When to see a doctor
See your doctor if you have a fever, unexplained weight loss, night sweats and a persistent cough. These are often signs of TB, but they can also result from other medical problems. Your doctor can perform tests to help determine the cause. TB can be diagnosed by your primary care doctor or by a doctor who specializes in lung diseases (pulmonologist) or by an infectious disease specialist. If you don't have a doctor, your local public health department can help.