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Drug resistant TB cases rise in the Philippines

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By Wilson Chua

Tuberculosis (TB) is one of the top 10 causes of death worldwide. Ten million people contracted TB and 1.6 million died from it in 2017. And MDR-TB (multidrug-resistant) is now fast becoming a public health crisis and threat. Especially in the Philippines. We now have one of the highest rates of MDR-TB in the world. Despite Government TB clinics that can treat this, fully 4% of new cases are MDR-TB.

To understand why, I turned to 2016 study from mClinica.

Patients are not getting the WHO standard treatment

The first graph below shows the percentage of patients on mono vs combination therapy. Combination therapy is the WHO standard of care. This is confirmed by Dra Jennifer Ann Wi (Dagupan Doctor’s Villaflor Hospital), “We have been using fixed dose combination for TB therapy since 2000.

And yet, 1 in 3 patients are still on Monotherapy. Please note that Monotherapy is sub-standard treatment. Patients on monotherapy are more likely to develop antimicrobial resistance. When resistance develops, the bacteria no longer responds to existing medicines.

1tb

 

The graph above is based on drugs that are dispensed (as opposed to prescribed) and digitized by mClinica in its 2016 pilot study. By showing that 36% of patients still take monotherapy, the graph “might explain why the Philippines has one of the highest incidences of MDR in the world”. Dra Anne Marie Garfin (DOH) reveals that a 2016 National TBN Prevalence Survey found that 40% of those who have symptoms of TB are self-medicating.

In contrast to monotherapy, combination therapy consists of an initial two-month phase of isoniazid, rifampicin, pyrazinamide, and ethambutol (quadtab combined therapy). This is followed by a four-month phase of isoniazid and rifampicin (dual tab combined therapy).

Patients are not completing the 6 months dosage

Beth Ann Lopez, director of Public affairs at mClinica explains her deepening concerns with this second graph below:

2tb

Remember: the standard of care is six months of continuous antibiotic treatment.

“However, the average number of TB tablets dispensed at the pharmacies was 2.4 tablets per visit. You can see that more than one in five patients received a single tablet on their visit to the pharmacy.”

One possible explanation: “Most likely, the patient couldn’t afford to buy many drugs at the same time and took only a small amount. This is the textbook case of where antimicrobial resistance comes from – patients not completing a full course of antibiotics.”

Why do patients buy when it’s free?

Dra Garfin also confirms that the Philippine Government is providing free fixed dose combination of anti-TB drugs for patients. As to why patients are not availing of the free combination therapy, Beth Ann Lopez says “Lots of reasons – convenience, better privacy (Directly Observed Therapy or DOT is a common standard of care in which clinicians actually watch the patient take their medicine every day. If they don’t, a community health worker might be sent to their house to follow up. It’s effective but invasive. Also, there is stigma around TB – it’s considered a disease of poverty), lack of knowledge that they can get treated at public facilities, maybe they don’t like public facilities because they are crowded or not high quality, maybe they don’t trust public doctors, etc.”

Dra Wi offers another insight: “The reason patients shy away from the government TB clinics is distance from their homes and (physical) weakness.”  Hence the need for government field workers to visit and make follow ups.

Silver linings

There may be another explanation to the 2.4 average tablet. Dra Wi shares “A Patient that completed a course of TB treatment gets a recurring cough. The patients “believe” that they have relapsed. So, they go to the pharmacy to buy the TB medicine. But in fact, it isn’t recurring TB, it may be a post TB bronchiectasis and no longer a TB disease.”

With the use of a DOH diagnostic kit called MTB GENXPERT given to all TB clinics, doctors can now fast track the diagnosis and start treatment within the first day of visit. This kit costs 2,000 to 4,000 in private clinics but is free in DOTS clinics.

More about mClinica’ s data.

The eDSS mobile app captures prescription data and converts them into text. Pharmacists use the app to take a picture of the prescription. According to Farouk Meralli, mClinica founder, eDSS uses advanced analytics to do image recognition. It then converts the handwritten prescriptions into digitized data.

 

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