Strategies for tuberculosis control from experiences in Manila : the role of public-private collaboration and of intermittent therapy

It is estimated that 8.5 million new tuberculosis cases occurred in the year 2001
and that 1.8 million people died of TB. Operational research to improve the use of
existing tools is vital. Studies in Manila, Philippines were carried out to exami ne TB
illness experience and help seeking of TB patients. Apart from patient interviews,
focus group discussions with non-affected urban poor residents and group discussions
with public health care providers were carried out. The TB illness burden was found
to be substantial; ill-defined suffering, such as emotional and social distress as well as
social stigma, was common. Non-affected urban poor residents expressed
ambivalence towards TB patients: fear of getting infected contrasted with feelings of
concern and support. Interaction with the health care providers was found to be
problematic. Misconceptions have the potential to increase the burden of TB. Giving
health information, interpersonal skills and other aspects of clinical care need to be
improved. The patient interviews also inquired about case finding. Only 29% of the
respondents had gone first to a health centre after onset of TB-related symptoms, and
53% had initially consulted a private doctor. Two-thirds of the patients (66%) had
received a prescription for drugs, and 29% had purchased and taken anti-TB drugs for
at least three weeks before they came to a public health centre. The health seeking
delay after symptom onset was relatively short – 64% of the respondents said they
went to a health facility within one month. With these findings as a background, we examined the TB-related practices of
the private practitioners and approaches to public-private collaboration and assessed
the feasibility, acceptability and effectiveness of thrice-weekly therapy in comparison
to daily therapy. Forty-five private practitioners of Malabon who treat adult TB patients were interviewed in their clinics. For diagnosis, most private practitioners
relied on clinical presentation and result of an X-ray and 96% used X-ray as a tool to
monitor treatment. Sixty percent of the respondents prescribed in accordance to
international guidelines a regimen consisting of isoniazid, rifampicin, pyrazinamide,
and ethambutol. However, over-dosage was common and length of treatment not
always correct. For re-treatment cases, none prescribed the recommended retreatment
regimen. The private practitioners perceived the main reasons for patient
non-adherence to be the patients' lack of finances to buy drugs and patients' perceived
well-being after a certain period of treatment. Patients' lack of money was seen as the
main obstacle to treatment adherence. The only case holding mechanism mentioned
was occasional visits of the TB patients to the clinic. Our findings of the private
practitioner's unsatisfactory quality of care and of the limitations of the public sector
indicate the need for collaboration between public and private sectors. The private
practitioners were therefore asked about their felt needs for additional knowledge on
clinical management of tuberculosis and their views on the public TB programme and
collaboration with the public health sector. And discussions with personnel of the
public health centres inquired about collaboration with private practitioners. The
private practitioners' most frequently mentioned needs for updated clinical knowledge
were about appropriate use of sputum microscopy, how to tell patients that household
contacts need a check-up, and motivating the patients to adhere to treatment. There
was considerable interest to receive and follow the national TB guidelines. The main
perceived problems they identified with the public TB programme were insufficient
drug supply, poor quality of the TB drugs, and lack of health education. Two
suggestions on how to establish public-private collaboration (mandatory referral of
poor TB patients to the public TB programme and allowing private practitioners to
use the governmental TB drugs) were generally welcome, but they expressed
reservation concerning feasibility of the latter suggestion. The personnel of the public health centres were positive about mandatory referral of poor TB patients to the
public TB programme but sceptical about allowing private practitioners to use the
governmental TB drugs. Our findings suggest steps to facilitate public-private
collaboration. The public programme needs to be strengthened and collaboration
prioritised. Public-private collaboration has great potential to make TB care that is
based on the principles of DOTS, the internationally recommended treatment
strategy, accessible to more people with TB. While our studies on the private practitioners and public-private collaboration
aimed to see DOTS being used more widely, the randomised controlled trial that
compared thrice weekly with daily therapy aimed to make the main tool of DOTS,
namely short-course chemotherapy, more efficient and patient- as well as providerfriendly.
Intermittent regimens (twice weekly and thrice weekly regimens) are
recommended, but the evidence base regarding their effectiveness in comparison to
daily therapy is not very strong. We carried out a randomised controlled trial: thriceweekly
therapy was randomly assigned to 10 of the 20 health centres of a
municipality in Manila. All TB patients of the other 10 health centres received daily
therapy. Patients were interviewed three times. Drug susceptibility tests were
performed. A total of 806 patients (451 under thrice-weekly and 355 under daily
therapy) were interviewed shortly after treatment start. 18.5% were re-treatment
cases. Multidrug-resistant TB was found among 2% of the new and 26% of the
previously treated patients. Under thrice-weekly therapy, directly observed therapy in
the health centres was more common than when treatment was daily. Thrice-weekly
therapy was more popular among patients and health personnel and resulted in
savings of about 40% of the cost of drugs. There were also some disadvantages of
thrice-weekly therapy compared to daily therapy: gastro-intestinal disturbances were
reported more frequently. And sputum conversion rate assessed after two months of treatment was lower (74% vs. 81%; p = 0.03). Treatment outcome was similar, but
treatment failure and default due to side effects was more common among those
treated thrice weekly (p = 0.08 and p = 0.04, respectively). In a multivariate model,
adverse treatment outcome (failure and relapse) was not associated with mode of
treatment (p = 0.7). In the light of the potential benefits of intermittent therapy, its
equivalence to daily therapy should be established more firmly and if confirmed,
fully thrice-weekly therapy should be used more widely. Our research indicated approaches of how to improve TB control in terms of
more appropriate practices in the private sector, better access to proper TB care, and
more efficient and patient-friendly use of treatment. Resources and commitment for
further operational research and for pilot projects are needed to further test and
implement outlined approaches to public-private collaboration and to clarify the role
of intermittent therapy.